Changes to prior authorization requirements effective December 1, 2019

Beginning December 1, 2019, we will update prior authorization (PA) requirements for certain services for our Medicare Advantage members. Federal and state law, state contract language and CMS guidelines (including definitions and specific contract provisions and exclusions) take precedence over these rules and must be considered first when determining coverage. We will deny claims that are noncompliant with the new rules.

 

In December, PA will be required for the following services/codes:

 

• T1019 — Personal care services, per 15 minutes, not for an inpatient or resident of a hospital, nursing facility, ICF/MR or IMD, part of the individualized plan of treatment (code may not be used to identify services provided by home health aide or certified nurse assistant)
• C9740 — Cystourethroscopy, with insertion of transprostatic implant; 4 or more implants
• E0953 — Wheelchair accessory, lateral thigh or knee support, any type including fixed mounting hardware
• E1031 — Rollabout chair, any and all types with castors 5 inches or greater
• E1090 — High-strength lightweight wheelchair, detachable arms, desk or full-length, swing-away detachable footrests
• E1130 — Standard wheelchair, fixed full-length arms, fixed or swing-away detachable footrests
• E1140 — Wheelchair, detachable arms, desk or full-length, swing-away detachable footrests
• E1260 — Lightweight wheelchair, detachable arms (desk or full-length) swing-away detachable footrest
• E1285 — Heavy-duty wheelchair, fixed full-length arms, swing-away detachable footrest
• E1290 — Heavy-duty wheelchair, detachable arms (desk or full-length) swing-away detachable footrest
• E2207 — Wheelchair accessory, crutch and cane holder
• E2378 — Power wheelchair component, actuator, replacement only
• K0039 — Leg strap, H style

 

Not all PA requirements are listed here; detailed PA requirements are available to contracted providers by accessing the provider self-service tool at https://www.availity.com.

 

Contracted and non-contracted providers who are unable to access the Availity Portal may call the number on the back of the member’s ID card for PA requirements.

 

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