CurrentAmeriHealthPolicy N/A
Precertification requirements for AmeriHealth Medicare Advantage services
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This document lists services and items that require precertification for AmeriHealth Medicare Advantage members for elective, non-emergency care and identifies third-party reviewers for select service categories. It affects providers and facilities submitting precertification requests for Medicare Advantage members.
Policy Summary
PayerAmeriHealth
PolicyPrecertification requirements for AmeriHealth Medicare Advantage services
Policy CodePolicy N/A
Change TypeNo material change
Effective DateJan 1, 2024
Next Review DateN/A
Key ActionObtain precertification from the listed reviewer (Carelon or Magellan where indicated) before elective, non-emergency services; precertification does not guarantee coverage.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
20+service categories
7+genetic test categories
Carelon/Magellanthird-party reviewers
81400-81408flagged CPT range
Services Requiring Precertification
Precertification-required services list
Services and items that require precertification (elective, non-emergency):
Inpatient services: acute rehabilitation admissions; elective surgical and nonsurgical inpatient admissions; inpatient hospice admissions; long-term acute care (LTAC) facility admissions; skilled nursing facility admissions.
Cardiology procedures: arterial ultrasound; diagnostic coronary angiography; percutaneous coronary intervention.
Major procedures and spine surgeries: bone graft substitutes and bone morphogenetic proteins for spine surgery; cervical decompression with or without fusion; cervical disc arthroplasty; cochlear implant surgery; hip arthroplasty; hip arthroscopy and open procedures; knee arthroplasty; knee arthroscopy and open procedures; lumbar disc arthroplasty; lumbar discectomy, foraminotomy, and laminotomy; lumbar fusion and treatment of spinal deformity (including scoliosis and kyphosis); lumbar laminectomy; meniscal allograft transplantation of the knee; obesity surgery; shoulder arthroplasty; shoulder arthroscopy and open procedures; treatment of osteochondral defects; vertebroplasty/kyphoplasty.
Reconstructive and potentially cosmetic procedures: blepharoplasty/ptosis repair; bone graft, genioplasty, and mentoplasty; breast reconstruction, reduction, augmentation, mammoplasty, mastopexy, insertion and removal of breast implants; canthopexy/canthoplasty; cervicoplasty; chemical peels; dermabrasion; excision of excessive skin and/or subcutaneous tissue; gender-affirming interventions; genetically and bio-engineered skin substitutes for wound care; gynecomastia; hair transplant; injectable dermal fillers; keloid removal; lipectomy, liposuction, or any other excess fat-removal procedure; otoplasty; rhinoplasty; rhytidectomy; scar revision; skin grafts, skin flaps, tissue grafts; surgery for varicose veins (including perforators and sclerotherapy).
Interventional pain management services: epidural injection procedures and diagnostic selective nerve root blocks; implanted spinal cord stimulators; paravertebral facet injection/nerve block/neurolysis; regional sympathetic nerve block; sacroiliac joint injections.
Radiology: CT; CTA; echocardiography services (stress echocardiography, resting transthoracic echocardiography, transesophageal echocardiography); MRA; MRI; nuclear cardiology; PET scans.
Prosthetics and orthoses: custom ankle-foot orthoses; custom knee-ankle-foot orthoses; custom knee braces; custom limb prosthetics including accessories/components.
Selected durable medical equipment (DME): bone growth stimulators (including noninvasive and low-intensity ultrasound types); spinal noninvasive electrical bone growth stimulation; bone-anchored hearing aids; cochlear implants; bone conduction hearing aids; CPAP and BiPAP devices and supplies; dynamic adjustable and static progressive stretching devices (excludes CPMs); electric/power/motorized wheelchairs including custom accessories; insulin pumps; manual wheelchairs (except rentals); negative-pressure wound therapy; neuromuscular stimulators; power-operated vehicles (POV); pressure-reducing support surfaces (non-powered advanced pressure-reducing mattress, air-fluidized bed, powered air flotation bed, powered pressure-reducing mattress); push rim activated power-assist devices; repair or replacement of DME items, orthoses and prosthetics that require precertification; speech-generating devices.
Advanced therapies and specialty services: medical foods; hyperbaric oxygen therapy; proton beam therapy; in-lab/facility sleep studies.
Behavioral health and substance use services: inpatient mental illness/serious mental illness care; partial hospitalization programs; intensive outpatient mental illness care; repetitive transcranial magnetic stimulation (rTMS).
Applied behavioral analysis for autism spectrum disorders: precertification review for this service is provided by Magellan Healthcare, Inc.
Genetic and genomic tests: types of genetic and genomic tests that require precertification (see separate genetic test categories for details); consult the complete procedure code list for specifics.
Covered/Listed test types
The document lists categories of genetic tests that are addressed by the policy and indicates billing and precertification considerations.
Test categories enumerated
- Hereditary heart disease testing (e.g., Long QT syndrome, aortic dilation/aneurysm/Marfan syndrome tests).
- Full gene analysis examples (e.g., cystic fibrosis full gene sequencing and deletion/duplication analysis; PMP22 full gene sequencing and deletion/duplication analysis for Charcot‑Marie‑Tooth/hereditary neuropathy).
- Simultaneous multi-disorder panels (expanded carrier screening such as Carrier Status DNA Insight®, Counsyl Family Prep Screen, pan‑ethnic carrier screening; hearing loss panels; intellectual disability panels; Noonan spectrum disorder panels).
- Specialty oncology tests (cancer gene expression or protein signature tests such as OncotypeDX®, MammaPrint®, Afirma®, Prosigna®, HeproDX™; tumor molecular profiling such as FoundationOne®, neoTYPE™, OncoPlexDx®; tissue of origin testing; PCA3 testing for prostate cancer).
- Pharmacogenomic tests (CYP2D6, CYP2C9, CYP2C19 metabolism gene testing; specialized drug response gene panels such as Assurex GeneSight®; warfarin response testing; MGMT methylation analysis for glioblastoma).
- Other specialty tests (coronary/heart disease risk testing such as CorusCAD®, CardioIQ®, APOE, ACE, KIF6; heart disease risk testing including MTHFR where listed).
- Genome-wide tests (microarray studies; whole exome testing; whole genome testing; mitochondrial genome or nuclear testing; any genetic test for more than one gene or condition—often named 'panel' or 'comprehensive').
Note: This list is a guide; due to the volume of tests, not every test is listed. See the complete procedure code list for details and to determine whether a specific test requires precertification.
Billing/Precertification criteria
Billing and administrative criteria
Precertification for genetic tests billed with the non-specific/unlisted codes above must be obtained from Carelon (an independent company); precertification review benefit varies based on the member's employer group.
Codes and Code Groups
Precertification code list referencemixed
| The document references a separate published list of medical procedure codes for services that require precertification (available on the Medical Policy Portal for Medicare Advantage members). |
Provider Precertification Responsibilities
Prior Authorization
Prior Authorization Required
Precertification applies to elective, non-emergency services. Because a service or item is subject to precertification, it does not guarantee coverage — the member's benefit plan terms and exclusions must be reviewed to determine actual coverage.
- Applies to services performed on an elective, non-emergency basis.
- Precertification does not assure payment or coverage; confirm benefits and exclusions in the member's plan.
Note
Carelon Precertification Review
Carelon performs precertification reviews for certain services listed by AmeriHealth. Providers should submit precertification requests to Carelon for the applicable services and confirm whether the member's employer group decision affects review benefits.
- Carelon is an independent company handling precertification for listed services.
- Precertification review benefit may vary based on the member's employer group decision.
Note
ABA Precertification by Magellan
Precertification review for Applied Behavioral Analysis (ABA) for autism spectrum disorders is handled by Magellan Healthcare, Inc., an independent company. Providers should direct ABA precertification requests to Magellan as indicated.
- Applies to Applied Behavioral Analysis for autism spectrum disorders.
- Magellan Healthcare, Inc. conducts the precertification review for ABA services.
Prior Authorization
Precertification for Nonspecific / Unlisted Genetic Tests
Any genetic test billed with a non-specific or unlisted procedure code requires precertification. Examples include broad genetic CPT ranges and common unlisted genetic procedure codes.
Definitions and Test Type Details
Precertification — definition and coverage caveat
DefinitionPrecertification is the requirement to obtain approval prior to elective, non-emergency services; it does not guarantee coverage and the member's benefit plan terms must be reviewed to determine coverage.
Applies toServices performed on an elective, non-emergency basis for AmeriHealth Medicare Advantage members.
Coverage caveatA precertification determination is not a guarantee of coverage; plan terms and exclusions must be checked.
Third-party precertification reviewers
Primary reviewersCarelon and Magellan Healthcare, Inc. are independent companies that perform precertification review for specified services.
Carelon roleCarelon performs precertification review for selected services; benefit review may vary by member's employer group.
Magellan roleMagellan Healthcare, Inc. provides precertification review for applied behavioral analysis services (autism spectrum disorders).
Genome-wide tests / multi-gene panels — definition and examples
DefinitionGenome-wide tests are assays such as microarray studies, whole exome testing, whole genome testing, and mitochondrial or nuclear genome testing; any genetic test for more than one gene or condition (often called a 'panel' or 'comprehensive').
ExamplesMicroarray studies; whole exome testing; whole genome testing; mitochondrial genome testing; nuclear genome testing.
Naming noteOften identified by terms like 'panel' or 'comprehensive' in the test name when multiple genes or conditions are assessed.
Specialty oncology tests — examples and scope
ScopeSpecialty oncology tests include assays used for cancer characterization, prognostication, and treatment selection; they are a distinct category requiring precertification.
ExamplesCancer gene expression or protein signature tests (OncotypeDX, MammaPrint, Afirma, Prosigna, HeproDX); tumor molecular profiling (FoundationOne, neoTYPE, OncoPlexDx); tissue of origin testing for cancer of unknown primary; PCA3 testing for prostate cancer.
PurposeUsed for gene expression/protein signatures, tumor molecular profiling, tissue of origin identification, and specific biomarkers (e.g., PCA3) in oncology.
Pharmacogenomic tests — examples and gene examples
DefinitionPharmacogenomic tests assess genetic variants that affect drug metabolism or response to guide medication selection or dosing.
Gene examplesCytochrome P450 metabolism genes (CYP2D6, CYP2C9, CYP2C19).
Test examplesSpecialized drug response gene panels (Assurex GeneSight, GeneTrait, Genecept, Millennium PGT); warfarin response testing; MGMT methylation analysis for glioblastoma.
Policy Summary
PayerAmeriHealth
PolicyPrecertification requirements for AmeriHealth Medicare Advantage services
Policy CodePolicy N/A
Change TypeNo material change
Effective DateJan 1, 2024
Next Review DateN/A
Key ActionObtain precertification from the listed reviewer (Carelon or Magellan where indicated) before elective, non-emergency services; precertification does not guarantee coverage.
SourceLink
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