Obtain prior authorization before back (spine) surgery

Prior authorization must be obtained before scheduling or performing back (spine) surgery; emergency surgery for trauma is excluded from the PA requirement.

• Codes listed that require PA include 22533, 22534, 22558, 22585, 22586, 22612, 22614, 22630, 22632, 22633, 22634, 22808, 22810, 22812, 22840, 22841, 22842, 22843, 22844, 27279.
• Medical necessity determinations will use InterQual Medicare Procedures or applicable Medicare NCD/LCD.
• Submitting a PA does not guarantee payment; failing to obtain PA may result in denied claims.

Obtain prior authorization before bariatric (gastric bypass) surgery

Prior authorization is required before bariatric (gastric bypass) surgery is performed.

• Codes listed that require PA include 43644, 43645, 43770, 43773, 43775, 43842, 43845, 43846, 43847, 43848.
• Medical necessity will be determined per InterQual Medicare Procedures and applicable Medicare NCD/LCD.
• Failure to obtain prior authorization may result in claim denial.

Obtain prior authorization for cosmetic procedures (examples listed)

Prior authorization is required prior to cosmetic procedures listed in the policy; breast reconstruction associated with breast cancer is excluded from PA.

• Examples requiring PA include abdominoplasty, blepharoplasty, breast reduction, mammoplasty, panniculectomy, rhinoplasty, and listed CPT codes (e.g., 11960, 19300, 21137, etc.).
• Photographs are not required with the initial request unless requested by the Utilization Review Specialist.
• PA does not guarantee payment and failing to obtain PA may result in denial.

Obtain prior authorization for cranial nerve stimulation (including VNS)

Prior authorization is required before cranial nerve stimulation services, including vagus nerve stimulation, are provided.

• Codes requiring PA include 64553, 64568, 64569, 64582.
• Medical necessity will be determined using InterQual Medicare Procedures and applicable Medicare NCD/LCD.

Obtain prior authorization before delivering/dispensing specified DME

Prior authorization is required prior to delivery or dispensing of specified durable medical equipment (DME); miscellaneous code E1399 and items with billed charges over thresholds also require authorization.

• DME codes listed include E0483, E0652, E0748, E0749, E0764, E0766, and E1399.
• Aspirus reserves the right to determine rental vs. purchase; repair/replacement of rental equipment is the provider's responsibility when billed charges exceed $1,500.
• Medical necessity determinations reference InterQual Medicare Durable Medical Equipment and applicable Medicare NCD/LCDs.

Obtain prior authorization for formula and enteral nutrition

Prior authorization is required before providing formula or enteral nutritional services.

• Enteral/formula codes requiring PA include B4102, B4103, B4105, B4149, B4150, B4152–B4162 and E1399.
• Medical necessity will be determined using InterQual Medicare: Enteral Nutrition criteria.

Obtain prior authorization for specified genetic/molecular diagnostic tests

Prior authorization is required before ordering specified genetic and molecular diagnostic tests.

• Listed codes include 0037U, 81162–81167, 81210, 81212, 81215–81217, 81288, 81292–81299, 81300–81301, 81317–81319, 81415–81416, 81432–81438, 81445, 81460, 81500, 81503–81504, 81506, 81518, 81520–81521, 81523–81525, 81535–81536, 81539–81541, 81551.
• InterQual Molecular Diagnostics or applicable Medicare NCD/LCD will be used to determine medical necessity.

Obtain prior authorization for microprocessor-controlled lower limb prostheses

Prior authorization is required prior to provision of listed microprocessor-controlled lower limb prosthesis items.

• HCPCS codes include L5856, L5857, L5858, L5859, L5930.
• Medical necessity will be determined using InterQual Medicare Procedures for Lower Limb Prostheses.

Obtain prior authorization before orthognathic surgery

Prior authorization is required before orthognathic surgery; emergency surgery for trauma is excluded from the PA requirement.

• Codes requiring PA include 21121, 21141–21147, 21193–21196, 21198.
• Medical necessity will be determined per applicable InterQual criteria; failing to obtain PA may result in denied claims.

Obtain prior authorization for spinal cord stimulation and submit discharge summary

Prior authorization is required for spinal cord stimulation trials and permanent placement; a discharge summary must be sent upon discharge.

• CPT codes requiring PA include 63650, 63655, 63663, 63664, 63685.
• Send the discharge summary upon discharge; failing to obtain PA may result in claim denial and PA does not guarantee payment.

Obtain prior authorization for TMS (CPT 90867–90869)

Prior authorization is required for transcranial magnetic stimulation (TMS).

• CPT codes requiring PA are 90867, 90868, 90869.
• Medical necessity for TMS is determined using InterQual BH: Behavioral Health Services Transcranial Magnetic Stimulation (TMS).

Obtain prior authorization for transplant procedures and notify for applicable admissions

Prior authorization is required for listed transplant procedures; some transplant admissions require notification within 24 hours and concurrent review.

• Examples of transplant CPT codes listed include 33945 (heart), 33935 (heart/lung), 38240–38241 (hematopoietic stem cell), 47135 (liver), 32851–32854 (lung), 48554, 50360, 50365 (pancreas/pancreas–kidney), 48160, 44136 (small bowel/multivisceral).
• Notification requirements: some transplant admissions require notification within 24 hours of admission and concurrent review for additional days.

Use InterQual BH criteria for TMS medical necessity determinations

InterQual BH criteria must be used to determine medical necessity for TMS prior authorization requests.

• Medical necessity for TMS references InterQual BH: Behavioral Health Services Transcranial Magnetic Stimulation (TMS).
• PA submission must include supporting clinical documentation per the InterQual criteria.

Obtain prior authorization for listed transplant and multivisceral procedures using InterQual/Medicare criteria

Prior authorization is required for the transplant and multivisceral procedure codes listed; medical necessity decisions reference InterQual Medicare Procedures or transplant-specific criteria.

• Providers must follow InterQual Medicare Procedures or transplant-specific criteria when submitting PA requests.
• Some transplant admissions also require notification within 24 hours and concurrent review as indicated.

Obtain prior authorization for vein procedures and wheelchair/DME items

Prior authorization is required before performing vein procedures and before delivering or dispensing wheelchair accessories, rental, or purchase items.

• Vein procedure CPT codes requiring PA include 36465, 36466, 36468, 36470, 36471, 36473–36476, 36478, 36479, 36482–36483, 37765–37766.
• Wheelchair accessories and many HCPCS/K-codes (e.g., E0986, E1002, K0108, K0669, K0800–K0891, K0005–K0007, E1161) require PA prior to delivery; all months must be authorized for rentals.
• Medical necessity will be determined using InterQual Medicare Procedures or InterQual Medicare Durable Medical Equipment and applicable Medicare NCD/LCDs.

Obtain prior authorization for medical injectable drugs per Medical Drug Policy library

Medical injectable drugs listed in the Medical Drug Policy library require prior authorization; formulary drugs are managed under the pharmacy benefit.

• Refer to the Medical Drug Policy library for the list of medical injectable drugs that require PA.
• Covered formulary drugs are available on the Aspirus Health Plan Formulary page.

Step therapy rules not specified

No step therapy rules are specified in this document fragment.

• If step therapy applies it will be defined in the applicable drug or treatment policy; none are listed here.

Use the Aspirus authorization/notification forms and submit required clinical documentation

Complete the appropriate authorization or notification request form and submit supporting clinical documentation by fax or e‑mail using the forms on Aspirus Health Plan's Authorization and Notification Forms page.

• Authorization forms are available at: https://medicare.aspirushealthplan.com/providers/authorizations/.
• Contact Medical Authorizations: phone 715.631.7443 or 855.931.5265; fax 715.787.7316; medical drug auth email medicaldrugauthMA@aspirushealthplan.com.

Submit inpatient notification documentation and discharge summaries within 72 hours

For inpatient notifications (acute medical, mental health, and substance use disorder admissions), send the discharge summary within 72 hours of discharge and use the specified fax numbers.

• Fax Acute Inpatient Medical Admissions discharge summaries to 715.787.7316.
• Fax Inpatient Mental Health and Substance Use Disorder discharge summaries to 715.787.7314.
• Notification is required within 24 hours of admission for certain inpatient admissions (e.g., acute inpatient concurrent review).

Use InterQual/Medicare NCD/LCD criteria and include supporting documentation

Use InterQual Medicare Procedures or InterQual Medicare Durable Medical Equipment and applicable Medicare NCD/LCDs as the medical necessity criteria when preparing PA submissions; the provider is responsible for obtaining authorization and supporting documentation.

• InterQual subsets will be chosen based on the requested procedure or DME item.
• Providers must include clinical documentation that demonstrates criteria are met per the referenced InterQual or Medicare NCD/LCD.

Failure to obtain prior authorization may lead to claim denial

Failing to obtain required prior authorization in advance may result in a denied claim.

• Check member eligibility and benefits before requesting services; not all plans offer out-of-network benefits.
• If unable to obtain services in network, submit a network exception request prior to services.

PA approval is not a guarantee of payment

A prior authorization approval does not guarantee payment by Aspirus Health Plan.

• Inclusion of a CPT/HCPCS code in this policy does not imply member coverage or provider reimbursement.
• Provider qualifications, member eligibility, and benefit coverage still apply.

Ensure PA is obtained for TMS and listed transplant procedures

Prior authorization is specifically required for TMS (CPT 90867–90869) and for the transplant procedures listed in the policy.

• TMS CPT codes: 90867, 90868, 90869.
• Transplant codes include heart, heart/lung, hematopoietic stem cell, liver, lung, pancreas, pancreas/kidney, pancreatic islet cell, small bowel/multivisceral as listed.

Obtain PA for vein procedures and wheelchair/DME prior to delivery or dispensing

Prior authorization is required for vein procedures using the listed CPT codes and for wheelchair accessories, rental, and purchase HCPCS/K-codes prior to delivering or dispensing.

• Vein procedure CPT codes include 36465–36476, 36478–36483, 37765–37766.
• Wheelchair rental requires authorization for all months; purchase and accessories require PA prior to purchase or delivery per listed K- and E-codes.