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Ambetter Prior Authorization Change Summary

Date: 05/16/23

Ambetter requires prior authorization (PA) as a condition of payment for many services.  This Notice contains information regarding such prior authorization requirements and is applicable to all Ambetter products offered by Ambetter.

Ambetter is committed to delivering cost effective quality care to our members.  This effort requires us to ensure that our members receive only treatment that is medically necessary according to current standards of practice.  Prior authorization is a process initiated by the physician in which we verify the medical necessity of a treatment in advance using independent objective medical criteria and/or in network utilization, where applicable.

It is the ordering/prescribing provider’s responsibility to determine which specific codes require prior authorization.

Please verify eligibility and benefits prior to rendering services for all members. Payment, regardless of authorization, is contingent on the member’s eligibility at the time service is rendered. NON-PAR PROVIDERS & FACILITIES REQUIRE AUTHORIZATION FOR ALL HMO SERVICES EXCEPT WHERE INDICATED.

For complete CPT/HCPCS code listing, please see Online Prior Authorization Tool.

Effective June 1st, 2023, the following are changes to prior authorization requirements:

Behavioral Health

PA Rule

Services

Procedure Codes

No PA Required

BH counseling

H0007, H2011, S9484

Breast reconstruction

PA Rule

Services

Procedure Codes

PA Required

Mastectomy, Reconstruction Breast

19300, 19330

PA Required Unless Billed with Breast Cancer Diagnosis

Breast prosthesis

L8031

Cardiovascular

PA Rule

Services

Procedure Codes

PA Required

Insertion/removal of Cardiac Rhythm Monitor

33285

PA Required

Revascularization

37220, 37221, 37224, 37225, 37226, 37227, 37228, 37229, 37230, 37231

PA Required

Vascular embolization

37799

PA Required

Wireless Pressure Sensor

C2624

PA Required

External circulatory counterpulsation

G0166

DME

PA Rule

Services

Procedure Codes

PA Required

Osteogenesis stimulator

E0749

PA Required

Wheelchairs, power operated vehicles, and accessories

E2603, E2604, E2605, E2606, E2607, E2608, E2609, E2613, E2614, E2615, E2616, E2617, E2620, E2621, E2622, E2624, K0813

PA Required

Supplies for home delivery of infant

S8415

PA Required

Electrical Nerve Stimulator

K1023

PA Required

Non-Pneumatic Compression

K1024, K1025

PA Required

Whirlpool tub Walk In

K1003

No PA Required

Infusion Pumps

B9002, E0781, K0455

No PA Required

Wheelchair and accessories

E2611, K0001

No PA Required

Respiratory equipment

E0550, E0565

Gastroenterology

PA Rule

Services

Procedure Codes

PA Required

GI capsule transit and pressure measurement

91112

Home care

PA Rule

Services

Procedure Codes

PA Required

Home Care Services

0551, S5165, S5170, S5175, S9110, S9122, T1022, T1028

PA Required

Home therapy

G2168, G2169, S5180, S5181

PA Required

Chore Services

S5120, S5121

PA Required

Home repairs for hemodialysis

A4870, A4890

PA Required

Respite Care Services- Home

S5150, S5151, S9125

PA Required

Foster Care

S5140, S5141, S5145, S5146

PA Required

Attendant and Companion Care Services

S5125, S5126, S5130, S5131, S5135, S5136

PA Required

Care Management Home Visit

G0076, G0077, G0078, G0079, G0080, G0081, G0082, G0083, G0084, G0085, G0086, G0087

 

Pregnancy Home Services

S9208, S9209, S9211, S9212, S9213, S9214

Laboratory

PA Rule

Services

Procedure Codes

PA Required

Genetic analysis/studies, surgical pathology procedures

81235, 81263, 81265, 81267, 81268, 81270, 81275, 81310, 81315, 88237, 88377

Orthopedic

PA Rule

Services

Procedure Codes

PA Required

Procedures lower extremities

28285, 28299

PA Required

Spine Procedures

62264, 62350, 62362, 63650, 63655, 63685

PA Required

Endoscopy Wrist

29848

Orthotic & Prosthetics

PA Rule

Services

Procedure Codes

PA Required

TLSO Orthotic

L0464

Other Medical Items

PA Rule

Services

Procedure Codes

PA Required

Health club membership, annual

S9970

PA Required

Waiver Services

T1020, T2012, T2013, T2014, T2015, T2016, T2017, T2020, T2021, T2030, T2031, T2032, T2033, T2035

Pain management

PA Rule

Services

Procedure Codes

PA Required

Trigger Point Injection

20552, 20553

PA Required

Sacroiliac Injection

27096, G0260

PA Required

Nerve Block

64490, 64491, 64492, 64493, 64494, 64495

PA Required

Neurostimulator implantation

64555, 64561, 64566, 64590

PA Required

Destruction by Neurolytic Agent

64620, 64624, 64625, 64633, 64634, 64635,64636, 64640, 64650, 64680, 64681

No PA Required

Transversus abdominis plane (TAP) block

64486, 64488

No PA Required

Destruction by neurolytic agent

64632

Preventive

PA Rule

Services

Procedure Codes

No PA Required

Developmental and behavioral screening

96110, 96112

Professional Services

PA Rule

Services

Procedure Codes

PA Required

Plan of Care Management

G0162

PA Required

Respite Care Services not in home

H0045

PA Required

Collection of alcohol and drug testing

H0048

No PA Required

Hospitalist Services

S0310

Radiology Treatments

PA Rule

Services

Procedure Codes

PA Required

Ablation of liver tumor

47382

PA Required

Stereotactic radiosurgery

77372, 77373, G0339, G0340

Skin substitute

PA Rule

Services

Procedure Codes

PA Required

Skin substitute products

Q4205, Q4206, Q4208, Q4209, Q4210, Q4211, Q4212, Q4213, Q4214, Q4215, Q4216, Q4217, Q4218, Q4219, Q4220, Q4221, Q4222, Q4226

Sleep Medicine

PA Rule

Services

Procedure Codes

No PA Required

Home sleep testing

95800, 95806