medicare_prior_authorization_requirements

Policy Overview

This document is the Fidelis Care Medicare prior authorization matrix — Part 1 of 2. It specifies services that require prior authorization and documents program delegations, code-level requirements, and limited exceptions for certain licensed in‑state behavioral health/substance use facilities.

High‑level scope includes: authorization requirements for inpatient admissions (medical, substance use, behavioral health, rehabilitation, and transplants); selected outpatient surgeries; behavioral health outpatient services and testing; DME/orthotics, imaging, home health and outpatient therapy; and pharmacy/injectable drugs including oncology and certain Part B injectables. The matrix lists specific CPT and HCPCS code groups and place‑of‑service/bill‑type conditions tied to PA requirements.

Delegated prior authorization programs are identified: the Musculoskeletal/Radiology/Radiation/Oncology reviews are delegated to Evolent (NIA) (effective for certain programs as noted), and TurningPoint Healthcare Solutions, LLC handles delegated ENT and Cardiac surgical procedure reviews; when a CPT group is delegated the associated HCPCS device codes are reviewed by the same delegate.

Key timing and review notes: all inpatient admissions require authorization except emergent stabilization (post‑stabilization inpatient admissions do require PA and medical necessity review). OASAS licensed in‑state inpatient SUD and OMH licensed in‑state pediatric inpatient mental health have specified notification/concurrent‑review carve‑outs when the facility complies with the required two‑day notifications and LOCADTR/OMH processes. Out‑of‑state or out‑of‑network behavioral health/substance use facilities must request prior authorization and are subject to concurrent review.

Effective / last review metadata from the source: last_review: 2024-10-01; effective date fields are program‑specific within the matrix (examples in text include programs effective 01/01/2020 and program transitions effective 1/1/24 and therapy/effective dates noted 9/20/2021 for services on/after 10/1/2021).

Inpatient Admissions — Requirements and Exceptions

Inpatient Admissions and Exceptions

Covered when ALL of the following are met:

ALL of the following

All inpatient admissions require prior authorization unless otherwise noted (see exceptions below).
All facility admissions are reviewed for medical necessity.
Exceptions
- Emergency stabilization: Emergency room services and emergent stabilization do not require authorization; however, post-stabilization services and subsequent inpatient admissions after the emergency visit do require authorization.
- Transplant evaluations: All solid organ and bone marrow/tissue transplants require authorization at the time of the transplant evaluation. (See transplant CPT list branch below.)

Delegated Prior Authorization Programs

Prior Authorization

Delegate program PA routing

Submit prior authorization requests to the delegated vendor when a CPT is delegated—follow the vendor’s submission path for Evolent (NIA) or TurningPoint as indicated.

Evolent (NIA): Musculoskeletal Management, Radiology, Radiation Therapy, Oncology programs — submit to Evolent per their portal/process (delegated scope includes associated HCPCS devices when CPTs are delegated).
TurningPoint Healthcare Solutions, LLC: ENT and Cardiac delegated CPTs — submit to TurningPoint for delegated ENT and cardiac procedures; associated HCPCS devices are reviewed by TurningPoint when CPTs are delegated.
If CPT delegation applies, HCPCS device reviews follow the same delegate (HCPCS devices follow CPT delegation).
See pharmacy/oncology and radiology sections for additional portal/contact details (Evolent portal referenced elsewhere).

Outpatient Surgery — Services Requiring Prior Authorization

Transplant and major surgery CPTs requiring authorizationCPTCovered

32850
32851
32852
32853
32854
32855
32856
33930
33931
33932

1–10 of 72

1/8

Outpatient surgery CPTs requiring authorization (selected groups)CPTCovered

43770
43771
43772
43773
43774
43888
15820
15821
15822
15823

1–10 of 139

1/14

Billing Rule

Freestanding ASC preauthorization (bill type 0831)

Obtain preauthorization when the listed CPTs are performed in a freestanding ambulatory surgery center billed with bill type 0831.

Affected CPTs (when billed as bill type 0831): 10060, 11100, 11900, 17000, 20600, 20605.
Confirm billing as freestanding ASC (bill type 0831) before submitting PA.

Behavioral Health — Outpatient and Partial Hospitalization

Note

Most outpatient behavioral health services — no PA

Most outpatient behavioral health services no longer require prior authorization; however specified testing and higher‑level services still need authorization.

Psychological/Neuropsychological testing codes requiring PA: 96116, 96121, 96130–96133, 96136–96139, 96146 (submit via testing request form).
Developmental pediatric testing codes requiring PA: 96112, 96113 (96110 is non‑covered).
Outpatient ECT requires PA: 90870.
Partial hospitalization and intensive outpatient programs require PA (relevant revenue/CPT/HCPCS codes listed in source).
Transcranial Magnetic Stimulation (TMS) requires PA for CPTs 90867, 90868, 90869 and meets additional clinical criteria.

Outpatient, DME/Orthotics, Imaging, Home Health & Therapy

Imaging and Diagnostic codes (selected)mixedCovered

91110
91111
91112
91113
87483
43235
43239
43248
45378
45380

1–10 of 20

1/2

DME/Orthotic HCPCS not requiring authorization (selected)HCPCS

A4287
A4341
A4342
A4457
A4468
A4541
A4560
A4604
A6590
A6591

1–10 of 51

1/6

Prior Authorization

Outpatient/home therapy PA timing

Submit prior authorization for outpatient or home therapy services to the appropriate review entity within the timing requirements: Evolent for outpatient/home therapy and Fidelis for inpatient; follow SNF/Sub‑acute fax instructions where applicable.

Outpatient setting: send PA to Evolent (NIA) within 1 business day after initial evaluation for services after the initial evaluation.
Home health setting: send PA to Evolent within 2 business days after initial evaluation (initial evaluation for home therapy requires authorization).
Inpatient settings: submit PA to Fidelis within 1 business day.
Exceptions: CPT codes 92610 and 92611 do NOT require prior authorization.
For therapy in SNF/Sub‑acute (POS 31 & 32) fax PA requests to 833-663-1611.

HCPCS J-/Drug Codes and Injectable Prior Authorization

HCPCS J-codes and associated descriptors (listed)HCPCS

J1460	multiple mappings listed (immune glob (Gamastan); J2327; risankizumab-rzaa; Skyrizi; Zynteglo etc.)
J1551	immune globulin (Cutaquig); J2329; ublituximab-xiiy (Briumvi); J3394; lovotibeglogene autotemcel
J1554	immune glob (asceniv); J2350; ocrelizumab (Ocrevus); Lyfgenia
J1555	immune glob (Cuvitru); J2356; tezepelumab-ekko (Tezspire); J3396; verteporfin (Visudyne)
J1556	immune glob (Bivigam); J2357; omalizumab (Xolair); J3397; vestronidase alfa-vjbk
J1557	immune glob (Gammaplex); J2406; oritavancin (Kimyrsa); J3398; voretigene neparvovec-rzyl
J1558	immune glob (Xembify); J2440; papaverine; J3398; voretigene neparvovec-rzyl
J1559	immune glob (Hizentra); J2503; pegaptanib (Macugen); abeparvovec-xioi
J1560	immune glob (Gamastan); J2506; pegfilgrastim, excludes; J3399; onasemnogene
J1561	immune glob (Gamunex-C); biosimilar (Neulasta); abeparvovec-xioi

1–10 of 154

1/16

Billing Rule

Injectable drug PA submission

Submit PA requests for non‑oncology injectable drugs to the Pharmacy Team via e‑fax (effective 10/1/2023); oncology PA for participating providers goes through the Evolent portal.

Send non‑oncology injectable PA requests to Pharmacy Team e‑fax: 1-844-235-5090 (effective 10/1/2023).
Participating providers: submit oncology medication PA via Evolent portal (my.newcenturyhealth.com) or call 1-888-999-7713, option 1.
Example injectable codes from the list: C9047, J0275, J0599.
Non‑participating providers requesting oncology reviews should fax to the Pharmacy e‑fax noted above as directed.

Therapeutic Services, Pain Management, and Special Procedures

Prior Authorization

Pain Management & Interventional Procedures

Obtain prior authorization for many pain management and interventional procedure codes; check clinical criteria and specialty exceptions when requesting review.

Example pain/interventional codes that commonly require authorization: 20526, 20550–20553, 21073, 27096, 62263–62264, 62273, 62280–62282, 62320–62327, 63622, 64400–64530, 64553–64595, 64600–64610, 64618–64647.
Interventional pain/neuromodulation examples: 63650, 63655, 63661–63664, 63685, 63688 and device codes C1778, C1787, C1883, C1897.
Exception: 63622 does not require authorization when requested by orthopedic specialties.
Not covered for low back pain: prolotherapy and steroid injections into intervertebral discs; topical oxygen is not covered.

Counseling Services — MNT and DSMT

Billing Rule

MNT & DSMT coverage limits

Follow the numeric coverage limits and bill the listed CPT/HCPCS codes for Medical Nutrition Therapy (MNT) and Diabetes Self‑Management Training (DSMT).

MNT limit: 8 visits per year without authorization; bill with 97802 or 97803 or G0270 and G0271.
DSMT limit: 10 hours / 20 units in a continuous 12‑month period; bill with G0108 and G0109 (no PA required when billed with these codes).
Ensure diagnosis meets covered ICD‑10 indications for MNT (diabetes or specified renal disease codes).

New Technology / Experimental and Oncology Review

New Technology / Experimental Treatment

Requirements for new/experimental treatments.

New/experimental: Prior authorization is required for new technology/experimental treatment and approval is based on medical necessity.

Oncology delegation and Part D/B guidance

Medicare Part D/Part B guidance and oncology delegation highlights.

Oncology delegation emphasis: Oncology medications and supportive agents require prior authorization from Evolent (formerly New Century Health) for participating providers before dispensing or administration; PA requests via Evolent portal (my.newcenturyhealth.com) or phone 1-888-999-7713, option 1.

Out-of-Network Coverage Conditions

Out-of-network coverage for specified MA plans

Out-of-network services coverage conditions:

OON coverage conditions: Out-of-network services may be covered with an authorization when the member is enrolled in Medicare Advantage Flex Plan (003) OR Medicare Advantage without RX (001); an authorization must be obtained and additional co-pays and deductibles may apply.

Prior Authorization

Authorization required for out-of-network services

Obtain authorization for out‑of‑network services when coverage is sought under the specified Medicare Advantage plans; note additional member cost‑sharing may apply.

Affected plans: Medicare Advantage Flex Plan (003) and Medicare Advantage without RX (001).
Authorization is required for out‑of‑network coverage and additional co‑pays/deductibles may apply.

Utilization Management — Documentation & Communication Requirements

Documentation Required

Voicemail & UM contact requirements

Ensure voicemail is HIPAA‑compliant to receive detailed UM messages; UM will make a second direct attempt to contact the provider when notifying of a UM determination per DOH policy.

Voicemail greeting must identify the mailbox owner and the owner's organization.
Greeting must state the mailbox is confidential and that PHI may be left.
If voicemail is HIPAA‑compliant, UM may leave a detailed message; if not, UM will leave a generic message and request a callback.
UM will make a second direct attempt to reach the provider for UM determinations as required by the Department of Health Reasonable Effort Policy.

Code Lists (Selected groups)

Behavioral health CPTs/HCPCS requiring authorizationmixedCovered

96116
96121
96130
96131
96132
96133
96136
96137
96138
96139

1–10 of 19

1/2

Imaging and Diagnostic codes (selected)mixedCovered

91110
91111
91112
91113
87483
43235
43239
43248
45378
45380

1–10 of 20

1/2

DME/Orthotic HCPCS not requiring authorization (selected)HCPCS

A4287
A4341
A4342
A4457
A4468
A4541
A4560
A4604
A6590
A6591

1–10 of 51

1/6

HCPCS J-codes and associated descriptors (listed)HCPCS

J1460	multiple mappings listed (immune glob (Gamastan); J2327; risankizumab-rzaa; Skyrizi; Zynteglo etc.)
J1551	immune globulin (Cutaquig); J2329; ublituximab-xiiy (Briumvi); J3394; lovotibeglogene autotemcel
J1554	immune glob (asceniv); J2350; ocrelizumab (Ocrevus); Lyfgenia
J1555	immune glob (Cuvitru); J2356; tezepelumab-ekko (Tezspire); J3396; verteporfin (Visudyne)
J1556	immune glob (Bivigam); J2357; omalizumab (Xolair); J3397; vestronidase alfa-vjbk
J1557	immune glob (Gammaplex); J2406; oritavancin (Kimyrsa); J3398; voretigene neparvovec-rzyl
J1558	immune glob (Xembify); J2440; papaverine; J3398; voretigene neparvovec-rzyl
J1559	immune glob (Hizentra); J2503; pegaptanib (Macugen); abeparvovec-xioi
J1560	immune glob (Gamastan); J2506; pegfilgrastim, excludes; J3399; onasemnogene
J1561	immune glob (Gamunex-C); biosimilar (Neulasta); abeparvovec-xioi

1–10 of 22

1/3

Definitions

Revision History

2024-10-01document reviewLatest

Policy last reviewed (document-level last_review date).

2023-01-01policy update

Behavioral Health services carve-in effective Jan 2023 (expanded BH services included in MAP plan).

2024-01-01program delegation

Musculoskeletal Management Program delegation to Evolent (NIA) effective 1/1/24 for orthopedic/spinal prior authorization and associated HCPCS review.