CurrentFidelis CarePolicy N/A

Medicare Authorization Requirements — Services and Procedures Which Require Authorization

Defines which inpatient, outpatient, behavioral health, DME, imaging, therapy, and other services require prior authorization for Fidelis Care Medicare members; affects Fidelis Care providers and facilities, with special state-specific provisions for New York.

Policy Summary

PayerFidelis Care

PolicyMedicare Authorization Requirements — Services and Procedures Which Require Authorization

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateApr 1, 2020

Next Review DateN/A

Key ActionObtain prior authorization for all inpatient admissions; emergency stabilization services do not require authorization but post-stabilization inpatient care does.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

All inpatientinpatient authorization requirement

8/yrMNT visits without auth

10 hrsDSMT allowance

G2010/G2012telehealth codes requiring auth

RadiologyeviCore authorizations

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Coverage and Authorization Criteria

Authorization criteria summary

High-level coverage and authorization criteria

All inpatient admissions require prior authorization and are reviewed for medical necessity. Emergency room services for stabilization do not require authorization, but post-stabilization inpatient care and facility admissions do require authorization.

State-licensed behavioral health exceptions (NY)

OASAS-licensed inpatient substance use disorder (Inpatient SUD) facilities in New York State that are participating in Fidelis Care's provider network are not subject to authorization review and are not subject to concurrent utilization review for the first 28 days, provided the facility notifies Fidelis Care of the admission and initial treatment plan within two business days and submits the OASAS Appendix A Notification Form/LOCADTR tool as required.
OMH-licensed inpatient mental health treatment for members under age 18 provided by OMH-licensed hospitals in New York State that are participating in Fidelis Care's network are not subject to authorization review and are not subject to concurrent utilization review for the first 14 days, provided the facility notifies Fidelis Care of the admission and initial treatment plan within two business days using the OMH Two-Day Notification and Initial Treatment Plan form and meets the other specified requirements.
Facilities that are outside New York State, not OASAS/OMH licensed, or not participating in Fidelis Care's network remain subject to authorization review and concurrent review throughout the admission.

Imaging and radiology

The first four OB ultrasounds may be performed without prior authorization; five or more ultrasounds for a normal pregnancy require authorization (high-risk pregnancy ultrasounds identified do not require authorization).
Radiology services and radiation therapy require authorization through eviCore Healthcare.

Outpatient therapy

Initial evaluations for physical, occupational and speech therapy do not require prior authorization.
All subsequent therapy visits require prior authorization. Certain plans (e.g. Fidelis Dual Advantage Flex Plan 017) have specified annual dollar limits for therapy services.

DME and orthotics: A specified list of DME and orthotic codes do not require authorization; other DME/orthotic items require prior authorization as indicated in the DME section.

Telehealth and MNT

Authorization is required for specified telehealth codes G2010 and G2012.
Medical Nutrition Therapy (MNT) for diabetes is covered and eight visits per year are allowed without authorization using codes 97802, 97803, G0270, or G0271 for eligible diagnoses.

MNT coverage

MNT coverage without authorization conditions

Medical Nutrition Therapy (MNT) is covered for members with a diabetes diagnosis (examples listed in the policy) and eight visits per year are covered without prior authorization when billed with codes 97802 or 97803 or G0270 or G0271.

DSMT coverage

DSMT coverage conditions

Diabetes Self-Management Training (DSMT) is covered for members for up to 10 hours (20 units) in a continuous 12-month period. These services must be provided by certified providers and do not require prior authorization.

Out-of-network coverage

Out-of-network coverage for specific plans

Out-of-network services are covered with prior authorization for the Medicare Advantage Flex Plan (003) and the Medicare Advantage without RX Plan (001); additional co-pays and deductibles may apply to these out-of-network services.

Codes, Limits, and Coding Rules

Transplant-related CPT codes requiring authorizationCPTCovered

32850-32856	Thoracic transplant codes (includes procedures related to lung/heart-lung)
33930-33945	Cardiac transplant and mechanical circulatory support related codes
38204-38215	Bone marrow harvest/transplant codes
38230-38242	Autologous and allogeneic bone marrow transplant codes
44133-44136	Small intestine transplant codes
47133-47147	Liver transplant codes
48160	Pancreas transplant code
48550-48556	Pancreas transplant and related procedures
50300-50380	Kidney transplant and related procedures
50547	Renal transplant-related code

1–10 of 11

1/2

Outpatient surgery codes that require prior authorizationCPTCovered

15820-15823	Blepharoplasty
43770-43888	Bariatric surgery series
S2083	Bariatric related HCPCS/Special code
11920-11971	Breast reconstruction and related procedures
19300	Mastectomy/reconstruction related
19316-19342	Breast reconstruction codes
19355	Breast reconstruction code
19370-19396	Breast reconstruction and reduction codes

Behavioral health testing / ECT codes requiring authorizationCPTCovered

96116	Neurobehavioral status exam - administration and interpretation
96121	Neurobehavioral testing by technician
96130-96139	Psychological and neuropsychological testing series
96146	Psychological test administration scoring and interpretation
96112-96113	Neuropsychological testing by a physician or psychologist
96110	(Note: 96110 is non-covered)
90870	Electroconvulsive therapy (ECT) with anesthesia

DME and orthotic codes not requiring authorization (examples)HCPCS

A4604	Seat cushion
E0130	Crutch, underarm, wood
E0135	Crutch, underarm, other
E0168	Walker accessory
E0182	Walker, small
E0184	Walker, large
E0235	Portable suction
E0274	Transport chair
E0305	Oxygen system
E0310	Oxygen regulator

1–10 of 50

1/5

Telehealth G-codes requiring authorizationHCPCSCovered

G2010	Remote evaluation of recorded video and/or images
G2012	Brief communication technology-based service (virtual check-in)

Selected HCPCS C- and J-code mappings (representative)mixed

C9036	Patisiran (Onpattro) - see medical drug policy
C9047	Caplacizumab and related J-code mappings
J0135	Adalimumab (Humira) mapping examples
J0222	Patisiran mapping
J0270	Alprostadil mapping
J1301	Injectable product example
J0841	Injectable product example

Selected J-codes present in policy listHCPCS

J0593	Therapeutic agent mapping
J1746	Injectable mapping
J1830	CI est inhib recon mapping
J2170	Drug mapping
J0717	Omadacycline (Nuzyra)
J0725	Ravulizumab (Ultomiris)

Additional HCPCS/G-codes referencedHCPCS

G0516	Insertion of implant (example)
G0517	Removal of implant (example)
G0518	Removal/reinsert implant (example)

OB ultrasound limit without authorization

OB ultrasound without authorizationFirst 4 OB ultrasounds per normal pregnancy allowed without authorization; five or more for a normal pregnancy require authorization

BRCA genetic testing limit

BRCA genetic testing limitCPT 81329 and 81336 have a combined limit of 1 per lifetime (authorization required)

DSMT annual allowance

DSMT annual allowanceMembers are allowed 10 hours (20 units) in a continuous 12-month period; no authorization required

MNT visits

Provider Responsibilities and Prior Authorization Workflow

Prior Authorization

Elective Surgical Procedures

Elective surgical procedures that are intended to be inpatient but are completed within 24 hours from the onset of surgery generally will not be approved as inpatient level of care. Procedures performed and billed as outpatient within the Fidelis Care network do not require authorization when performed as outpatient. Examples include certain laparoscopic procedures and thyroid surgery when completed within 24 hours. Providers should verify inpatient-only lists (Medicare inpatient-only list) and plan-specific inpatient admission criteria prior to scheduling.

Inpatient-only procedures follow Medicare inpatient-only guidance
Surgeries completed within 24 hours billed as outpatient do not require authorization when performed in-network

Prior Authorization

Outpatient Diagnostics, Imaging, and Radiation

Radiology and imaging services require prior authorization through Fidelis Care's delegated imaging vendor, eviCore. Obstetrical ultrasound limits: the first four OB ultrasounds may be performed without authorization; additional ultrasounds for a normal pregnancy (five or more) may require authorization. Refer to the eviCore Fidelis Care imaging portal for the full list of CPT codes requiring authorization and any site-of-service rules.

Key Definitions

OASAS-licensed Inpatient Substance Use Disorder Treatment in New York State

DefinitionInpatient detoxification, inpatient rehabilitation and inpatient residential treatment services provided by OASAS‑licensed facilities in New York State

Authorization exceptionThese in‑network OASAS‑licensed Inpatient SUD services are not subject to authorization review by Fidelis Care

Concurrent review exemptionNot subject to concurrent utilization review for the first 28 days if the facility notifies Fidelis Care and submits required forms within two business days

Out‑of‑network/out‑of‑state ruleFacilities outside NY State, not OASAS‑licensed, or not in network must request authorization and remain subject to concurrent review

OMH-licensed inpatient mental health treatment for members under age 18 in NY

Definition