Humana PathWays Dual Care (HMO-POS DSNP) Indiana Prior Authorization and Notification List
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Defines the services, codes, and processes that require prior authorization or notification for Humana PathWays Dual Care (HMO-POS DSNP) members in Indiana; affects participating providers and delegated networks handling these members.
No material clinical or coverage changes in this revision.
Services Requiring Prior Authorization or Notification
Service categories requiring prior authorization/notification
Services and specific CPT/HCPCS codes listed below require prior authorization or notification per the PAL. Providers should verify member benefits and follow PA submission processes; urgent/emergent services are exempt.
Includes (examples)
- Ablation (bone, liver, kidney, prostate cancer, irreversible electroporation) — Codes: 20982, 20983, 47370-47384, 50250, 50541-50542, 50592-50593, 51721, 52597, 53850-53854, 55873, 55877, 55881-55882, 0582T, 0600T, 0601T, 0950T; Cardiac ablation/electrophysiology — Codes: 93650, 93653, 93654, 93656.
- Durable medical equipment and DME categories (airway clearance, augmentative/alternative communication, diabetic supplies, OSA devices, electrical stimulators, pneumatic compression, unlisted DME) — Examples: E0469, E0481-E0493, E0627, E2508, E2510, A4238, A4239, E0784, K0900 and many E-/K- HCPCS codes.
- Emerging technologies, outpatient procedures, spinal and neurostimulator devices, NPWT, prosthetics, orthotics, home infusion/home health, hyperbaric therapy, observation and inpatient admissions (see lists) — multiple CPT/HCPCS/L codes enumerated in the PAL.
Prior authorization and notification items (enumerated list)
Items listed require prior authorization or notification as specified; lists include specific CPT, HCPCS, and other procedure/product codes.
Selected enumerated items
- Pneumatic compression — Codes: E0650-E0676 (selected), E0678-E0683 (selected).
- Unlisted DME — Code: K0900.
- Epidural injections (outpatient only) — Codes include 62320-62323, 64479-64484, 64999.
- Facet injections — Codes include 64490-64495, 64633-64635, 64999 and related T-codes.
- Home health/home infusion — Code: 99600.
- Observation notification — Codes: All (observation requires notification).
- Inpatient admissions — Codes: All (inpatient admissions require prior authorization for multiple facility types).
Prior authorization and notification rule set
Providers must obtain prior authorization or provide notification for listed codes and services according to Humana PathWays Dual Care (HMO-POS DSNP) Indiana requirements.
Examples of code-based requirements
- Transplant evaluation and surgeries — Transplant evaluation is Notification Required (Code: 99199*); transplant surgeries require prior authorization — example codes enumerated in the PAL (e.g., 32850-32854, 33927-33929, 33935, 33945, 38205-38206, 38230-38243, 44135, 47133/47135, 48160, 48550/48554/48556, 50300/50320/50340/50360/50365/50370, 50547, 0584T-0586T, G0341-G0343, L8698).
Code Lists and Code-Based Rules
| 15830 | Abdominoplasty |
| 15847 | Abdominoplasty |
| 20982 | Ablation (various organs/types) |
| 20983 | Ablation (various organs/types) |
| 47370 | Ablation (various organs/types) |
| 47371 | Ablation (various organs/types) |
| 47380 | Ablation (various organs/types) |
| 47381 | Ablation (various organs/types) |
| 47382 | Ablation (various organs/types) |
| 47383 | Ablation (various organs/types) |
| 33206-33275 | Cardiac implantable devices and related device codes |
| 33289 | Cardiac implantable devices and related device codes |
| 33340 | Cardiac implantable devices and related device codes |
| 93264 | Cardiac implantable devices and related device codes |
| 0408T | Cardiac implantable devices and related device codes (T-code) |
| 0409T | Cardiac implantable devices and related device codes (T-code) |
| 0410T | Cardiac implantable devices and related device codes (T-code) |
| 0411T | Cardiac implantable devices and related device codes (T-code) |
| 0412T | Cardiac implantable devices and related device codes (T-code) |
| 0413T | Cardiac implantable devices and related device codes (T-code) |
| 38225-38228 | Cellular, gene, tissue and transplant therapies |
| C9399 | Cellular, gene, tissue and transplant therapies |
| J3387-J3394 | Cellular, gene, tissue and transplant therapies |
| Q2041-Q2058 | Cellular, gene, tissue and transplant therapies |
| XW0338A | Cellular, gene, tissue and transplant therapies (example XW codes) |
| 96105 | Behavioral health testing/evaluation codes |
| 96121 | Behavioral health testing/evaluation codes |
| 96131-96139 | Behavioral health testing/evaluation codes |
| 96136-96138 | Selected behavioral testing codes |
| 17106-17108 | Cutaneous vascular lesion removal |
| 55801 | Prostatectomy - CPT code listed |
| 55810 | Prostatectomy - CPT code listed |
| 55812 | Prostatectomy - CPT code listed |
| 55815 | Prostatectomy - CPT code listed |
| 55821 | Prostatectomy - CPT code listed |
| 55831 | Prostatectomy - CPT code listed |
| 55840 | Prostatectomy - CPT code listed |
| 55842 | Prostatectomy - CPT code listed |
| 55845 | Prostatectomy - CPT code listed |
| 55866 | Prostatectomy - CPT code listed |
| K0606 | Wearable Cardioverter Defibrillator |
| K0005 | Wheelchair/scooter example |
| E0986 | Wheelchair/scooter codes |
| E1002 | Wheelchair/scooter codes |
| E1003 | Wheelchair/scooter codes |
| E1004 | Wheelchair/scooter codes |
| E1005 | Wheelchair/scooter codes |
| E1006 | Wheelchair/scooter codes |
| E1007 | Wheelchair/scooter codes |
| E1008 | Wheelchair/scooter codes |
How Providers Request Authorization, Required Info, and Notifications
How to request prior authorization / notification
Providers must obtain prior authorization for services listed on this PAL; notifications are required for certain services but do not constitute approval or denial. Urgent/emergent services do not require prior authorization or notification. Providers may submit requests via fax, phone, mail, or online (Availity Essentials); some PAL services include questionnaires that can enable real-time determinations.
- Urgent/emergent services are exempt from PA/notification.
- Online submissions via Availity Essentials are encouraged and may include questionnaires for potential real-time approval.
Required information for PA/notification
At the time of submission provide complete supporting clinical information and required data elements to support timely adjudication; incomplete information may delay or result in retrospective review or adverse decisions.
- Member PathWays (Medicaid) ID or plan Member ID
- Date of service or hospital admission and proposed procedure date (if applicable)
- Procedure codes (up to 10) and diagnosis codes (up to 6)
- Service and inpatient/outpatient location, provider TIN and NPI, caller/requestor name and phone, attending provider phone, relevant clinical information, discharge plans
Decision timelines
Humana follows CMS and Indiana PathWays timelines: CMS requires decisions within 7 calendar days (72 hours for expedited requests); Indiana PathWays requires five business days (or seven calendar days) for standard requests and 48 hours for expedited requests.
- CMS: 7 calendar days standard, 72 hours expedited
- Indiana PathWays: 5 business days (or 7 calendar days) standard, 48 hours expedited
Inpatient admissions - prior authorization
All inpatient admissions require prior authorization, including acute hospital (including inpatient hospice), acute rehabilitation, long-term acute care, mental health/substance use residential treatment, and skilled nursing facility admissions.
- Codes = All for inpatient admissions
- Authorization applies to multiple facility types listed (acute hospital, inpatient hospice, acute rehab, LTAC, residential MH/SUD, SNF)
Observation - notification
Observation stays require notification to Humana; the PAL indicates Observation notifications are required and applies to all observation codes.
- Codes = All (observation notification required)
General prior authorization/notification requirements
A broad set of services and items require prior authorization or notification per the PAL, including DME, devices, procedures, surgeries, emerging technologies, home health/infusion, hyperbaric therapy, NPWT, neurostimulators, orthopedics, molecular diagnostics, prosthetics, and more; providers should verify the specific CPT/HCPCS/product codes listed.
- Examples include DME codes (E-codes, K-codes), NPWT (97605, 97606, A6550), neurostimulators and spinal devices, molecular diagnostic codes (e.g., 81105, 81479), prosthetics and L-codes, and numerous surgical CPT codes.
- Providers must check the PAL code lists for service-specific PA/notification requirements.
Breast reconstruction exemption
No prior authorization is required for breast reconstruction following a medically necessary mastectomy for the Q-codes specified in the PAL (i.e., certain Q-codes are exempt when used for breast reconstruction after mastectomy).
- Breast reconstruction Q-code exemptions are noted in the PAL (examples cited earlier in the code lists).
Code-based prior authorization list
The PAL contains extensive code-based entries listing procedures, devices, prosthetics, DME and other items that require prior authorization or notification; providers must reference the PAL code lists when submitting requests.
- Examples in the PAL include prostatectomy CPTs (55801, 55810…), spinal device and fusion codes, cardiac device and WCD codes (K0606), wheelchairs/scooters (K0005 and many E/K codes), and numerous L-codes for prosthetics.
- Some entries are flagged specifically as Notification Required or as exempt (see PAL).
Key Terms
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