Acute inpatient and inpatient rehabilitation — Prior authorization & notification

Prior authorization is required prior to acute inpatient hospitalization and prior to admission for inpatient rehabilitation. Concurrent review may be required for additional days. Notification within 24 hours of admission is required for acute inpatient medical, mental health and substance use disorder admissions; a discharge summary must be sent upon discharge (within 72 hours for acute inpatient notifications). Failure to obtain required authorization in advance may result in claim denial.

• Acute inpatient hospitalization (medical, mental health, substance use disorder): prior authorization required; concurrent review as indicated; discharge summary required upon discharge.
• Inpatient rehabilitation: prior authorization required prior to admission; concurrent review for additional days; discharge summary required upon discharge.
• Notification for acute inpatient medical, inpatient mental health, and inpatient substance use disorder admissions: notify within 24 hours; send discharge summary within 72 hours; fax numbers provided on forms.

Artificial disc and back/spine surgery — Prior authorization required

Prior authorization is required prior to artificial disc replacement procedures and for specified back/spine surgeries. Certain emergent indications (trauma, acute transverse myelopathy, tumors) and specified cervical/thoracic surgeries are excluded from authorization requirements. Medical necessity is determined using InterQual and applicable Medicare LCD/NCD criteria.

• Artificial disc replacement: CPT/HCPCS 22856, 22857, 22858 — PA required prior to service.
• Back/spine surgeries: PA required prior to service. Affected codes include: 22533, 22534, 22558, 22585, 22586, 22612, 22614, 22630, 22632, 22633, 22634, 22808, 22810, 22812, 22840–22844, 27279, 27280, 64628, 64629.
• Medical necessity criteria references: InterQual Procedures (Artificial Disc Replacement; Lumbar Spinal Fusion/Decompression; Neuroablation; MIS SI Joint Fusion) and Medicare LCDs where applicable.

Durable medical equipment (DME) — Prior authorization required

Prior authorization is required before delivering or dispensing DME items that require authorization. Aspirus reserves the right to determine rental vs purchase; repair or replacement of rental equipment is the provider's responsibility. Miscellaneous HCPCS E1399 requires authorization when billed charges exceed $1,500.

• Examples of DME items requiring authorization include: E0483, E0652, E0748, E0749, E0764 (rental only), E0766 (rental only).
• Authorization required prior to delivery/dispensing; Medicare NCD/LCD and InterQual Medicare DME criteria will be applied as appropriate.
• Aspirus may determine rental vs purchase; providers are responsible for repair/replacement of rental equipment.

Formula and nutritional services — Prior authorization required

Prior authorization is required prior to provision of formula and enteral nutritional services unless the formula is administered via a feeding tube. Medical necessity is determined using InterQual enteral nutrition criteria.

• Codes requiring authorization include B4102, B4103, B4105, B4149, B4150, B4152–B4155, B4157–B4162.
• Authorization not required when formula is administered through a feeding tube.
• Medical necessity determined using InterQual Medicare: Enteral Nutrition.

Genetic and molecular diagnostic testing — Prior authorization required

Prior authorization is required prior to ordering specified genetic and molecular diagnostic tests, including cancer panels and sequencing. Medical necessity will be evaluated using InterQual Molecular Diagnostics and applicable Medicare coverage determinations.

• Affected indications include testing for breast, colorectal (excluding fecal DNA), ovarian, pancreatic, prostate cancers, and all cancer panels (gene sequencing, whole genome/exome).
• Representative CPT codes requiring authorization include: 0037U, 81162–81167, 81210, 81212, 81215–81217, 81288, 81292–81301, 81317–81319, 81415–81416, 81432–81438, 81445, 81460, 81500–81506, 81518, 81520–81521, 81523, 81525, 81535–81536, 81539–81541, 81551.
• Providers may request the criteria used for medical necessity determinations via Aspirus' Authorization page.

Microprocessor lower limb prosthesis — Prior authorization required

Prior authorization is required prior to provision of microprocessor-controlled lower limb prostheses. Medical necessity will be determined using InterQual prostheses criteria.

• Affected HCPCS/L-codes include L5856, L5857, L5858, L5859, L5930, L5961.
• PA required prior to service; InterQual Medicare Procedures: Lower Limb Prostheses will be applied.

Orthognathic surgery — Prior authorization required (non‑emergent)

Prior authorization is required prior to orthognathic surgery except for emergency trauma surgery. Photographs are not required with initial authorization requests for cosmetic/reconstructive procedures unless requested by the Utilization Review Specialist. Breast reconstruction related to breast cancer does not require authorization.

• Orthognathic CPT codes requiring authorization include: 21121, 21141–21147, 21193–21196, 21198.
• Authorization required prior to service; InterQual CP Procedures apply for osteotomy, maxillomandibular advancement, LeFort I, sagittal split, TMJ reconstruction, and bone augmentation.
• Emergent trauma surgery is excluded from authorization requirement; breast reconstruction for cancer is not subject to this PA.

Transplant procedures — Prior authorization and admission notification required

Prior authorization is required prior to transplant evaluations and listing for designated organ and cell transplantation. Additionally, providers must notify Aspirus within 24 hours of admission for transplant procedures. Medical necessity will be evaluated using InterQual transplant procedures and applicable Medicare coverage criteria.

• Transplant types requiring prior authorization include: Heart, Heart/Lung, Hematopoietic Stem Cell, Liver, Lung, Pancreas, Pancreas/Kidney, Pancreatic Islet Cell, Small Bowel, Small Bowel/Liver (multivisceral).
• PA is required prior to evaluation and prior to listing. Notification to Aspirus required within 24 hours of any transplant-related admission.
• Representative CPT/HCPCS codes: Heart 33945; Heart/Lung 33935; Hematopoietic Stem Cell 38240, 38241; Liver 47135; Lung 32851–32854; Pancreas/Pancreas-Kidney 48554, 50360, 50365; Pancreatic Islet Cell 48160; Small Bowel/multivisceral 44136.

Vein procedures — Prior authorization required

Prior authorization is required prior to vein procedures. Medical necessity is determined using InterQual Medicare procedures for varicose veins and applicable Medicare LCDs.

• Covered vein procedure CPT codes requiring authorization include: 36465, 36466, 36468, 36470–36471, 36473–36476, 36478–36479, 36482–36483, 37765–37766.
• InterQual Medicare Procedures: Varicose Veins. Medicare LCD: Varicose Veins of the Lower Extremity (L33575) may apply.

Wheelchairs and accessories — Prior authorization required

Prior authorization is required prior to delivering or dispensing wheelchair accessories, power-operated vehicles, power wheelchairs and other high‑charge wheelchair items. Aspirus (or its delegate) may determine rental versus purchase; repair or replacement of rental equipment is the DME provider's responsibility. All rental months for wheelchairs must be authorized.

• Wheelchair accessory codes requiring authorization include numerous E‑codes and K0108, K0669 (authorization required if billed charges > $1,500).
• Wheelchair rental codes (all months must be authorized): K0800–K0890 range and related codes listed.
• Wheelchair purchase requiring prior authorization includes K0005–K0007, E1161 and all power-operated vehicles/power wheelchairs.

Denial risk and coverage verification — Obtain required authorizations/notifications

Failure to obtain required prior authorization or to submit required notifications in the specified timeframes may result in claim denials or noncompliance. Providers should verify member eligibility and benefits before rendering services.

• If a service requires authorization and one is not obtained in advance, the claim may be denied.
• Failure to notify within 24 hours for transplant admissions or to provide required discharge summaries may lead to noncompliance with notification requirements.
• Providers must verify member eligibility and benefit coverage prior to service delivery.

Use of authorization/notification forms and submission instructions

Complete and submit the appropriate Aspirus authorization or notification form with supporting clinical documentation by fax or e-mail as specified on the form. Providers may request the medical necessity criteria used for determinations from the Aspirus Authorization page.

• Use the Aspirus Health Plan Authorization and Notification Forms; fax numbers and email addresses are listed on forms and in contact information.
• For mental health and substance use disorder VNS or related requests, send to the Mental Health and Substance Use Disorder fax line when indicated.
• Providers may request copies of the criteria used for medical necessity determinations via the Aspirus Authorization page.

Prior authorization and supporting criteria — Criteria sources and operational notes

Prior authorization decisions for services subject to PA are based on InterQual (appropriate modules noted per service), Medicare NCDs/LCDs where applicable, and Aspirus-specific criteria. Providers should allow up to 14 calendar days for a non‑urgent authorization decision and confirm that authorization is obtained prior to scheduling or delivering services that require it.

• Medical necessity sources: InterQual (LOC, Medicare Procedures, CP, BH modules) and applicable Medicare NCDs/LCDs are applied depending on service.
• Allow up to 14 calendar days for non‑urgent authorization decisions.
• Authorization does not guarantee eligibility or payment — providers must verify member benefits and network status before scheduling.