CurrentModa HealthPolicy N/A

Procedures and services requiring prior authorization

Governs which procedures, services, drugs, and durable medical equipment require prior authorization, notification, or review for Moda Health Medicare Advantage members; affects providers and facilities submitting claims or seeking authorization.

Policy Summary

PayerModa Health

PolicyProcedures and services requiring prior authorization

Policy CodePolicy N/A

Change TypeNo material change noted

Effective DateN/A

Next Review DateN/A

Key ActionNotify Moda Health within 48 hours for all urgent/emergent inpatient admissions and obtain prior authorization for elective inpatient admissions and listed services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

48 hoursnotification timeframe

PA requiredelective inpatient admissions

eviCore / Prime / Modaauthorization vendors

hundredslisted codes

0412T,0413Tnon-covered codes

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High-level coverage criteria and referral

Covered when the conditions below are met; many listed services require prior authorization, notification, or are reviewed at claim submission per referenced Medicare guidance and vendor channels.

Urgent/emergent inpatient admissions: notification to Moda Health within 48 hours and must meet the definition of an 'emergency medical condition'.

Elective inpatient admissions: prior authorization is required for all inpatient elective admissions to an acute care facility.

Skilled Nursing, Inpatient Rehabilitation, and Long Term Acute Care admissions: prior authorization required prior to patient admission.

Transplant evaluation and transplant events: prior authorization required.

Advanced imaging / procedural vendor authorization: Select advanced imaging, echocardiography, musculoskeletal, pain intervention and cardiology procedures require prior authorization via eviCore (www.eviCore.com or 844-303-8451).

Drug authorization channels: Select specialty drugs require prior authorization through Prime Therapeutics Management (https://gatewaypa.com/); self-injectable drugs require prior authorization through the Moda Health Pharmacy Benefit (Pharmacy Customer Service 888-361-1610).

Claim-submission medical necessity review: Therapeutic drug monitoring / urine drug testing (80305, 80306, 80307, G0480–G0483): prior authorization not required but will be reviewed with claim submission for medical necessity per Medicare LCD L36707.

Referenced coverage guidance and medical necessity sources

Coverage or review instructions reference specific Medicare LCDs/NCDs, MCG, and other manuals; providers must follow those sources for medical necessity determinations.

Dynasplint / JAS / Mechanical Stretching Devices (E1800–E1841): follow AFO/KAFO LCD (L33686), MHMNC Mechanical Stretching Devices guidance and Medicare Program Integrity Manual Chapter 3.6.2.2 Reasonable and Necessary Criteria.

Bariatric surgery (examples 43659, 43999, 43770, C9748, C9785): follow Bariatric Surgery Coverage LCA (A53027) and Bariatric Surgery NCD (100.1); specific inpatient-only codes are identified in the policy.

Home Infusion Services (S-codes listed): S codes are statutorily non-covered by Medicare except for select contracted providers — check provider contract and follow instructions in the Medicare Benefit Policy Manual Chapter 7 Section 10.

Implantable neurostimulators and related devices (e.g., L8678, L8681–L8689, 95970): follow Electrical Nerve Stimulators NCD (160.7), MCG A-0716, and other cited NCDs as applicable for patient suitability and coverage determination.

Coverage criteria and operational instructions

Operational instructions: certain code groups require prior authorization or external contractor review; some listed codes are non-covered under Medicare.

Interventional pain and many related spinal/neuraxial procedure codes (e.g., 62320–64636, 63650, 63655, 63685) are subject to eviCore review and must follow eviCore, NCD/LCD, Moda Health and Milliman (MCG) guidance.

Intravenous immune globulin (J1562, 90281, 90283, 90284 and related J-codes) and certain specialty J-/L-/Q-/V- HCPCS require prior authorization and may be reviewed by Prime Therapeutics or Moda Health per instructions.

Non-covered items: Specific CPT/HCPCS codes are identified as Non‑Covered by Medicare (see non-covered lists and CMS Non‑Covered Items references); these should be treated as non-covered per Medicare guidance.

Prior authorization and non-coverage criteria

Lists of CPT/HCPCS with PA and non-coverage notes; follow the item-specific rules below.

Large groups of J-, L-, Q-, V- HCPCS and many Category III CPT codes require prior authorization; refer to the specific code lists in the policy (representative codes appear in the non-covered/prior auth lists).

Home sleep study vs in-lab polysomnography: no authorization required for home sleep study CPTs 95800, 95801, 95806, G0398, G0399, G0400; prior authorization required for in-lab polysomnography CPTs 95807, 95808, 95810, 95811.

Certain services are designated Non‑Covered by Medicare (see grouped non-covered service lists, e.g., 92145, 93702, 97026 and many Category III codes) and will be treated accordingly.

Some procedures are identified as Inpatient Only (example: CPT 54438 for penile replantation) — inpatient stays for these procedures require appropriate authorization per policy notes.

Penile replantation/repair coverage notes

Coverage stance and instructions for penile repair/replantation procedures.

Repair/Replantation of penis (complete) — CPT 54438 (inpatient only): listed as Inpatient Only; refer to MHMNC Gender Reassignment Criteria for instructions and prior authorization requirements.

Repair of traumatic corporeal tears / penile repair (CPT 54437) references MHMNC Gender Reassignment Criteria and is subject to the policy's prior authorization and inpatient-only guidance when applicable.

Contractility modulation removal coverage

Coverage stance for removal of cardiac contractility modulation systems.

Removal of permanent cardiac contractility modulation system: CPT codes 0412T and 0413T are identified as Non‑Covered by Medicare in this policy and should be treated as non‑covered under Medicare guidance.

Prior authorization is referenced for removal procedures generally, but where codes are designated Non‑Covered by Medicare they are not payable per Medicare guidance.

Medical necessity and reference-driven coverage

Devices and procedures that require medical necessity review or reference to other coverage criteria.

Argus II Retinal Prosthesis (L8608) requires medical necessity review (prior authorization).

Rhinoplasty (CPTs 30400–30465): coverage determinations reference the Plastic Surgery LCD (L37020), associated coverage article (A57222), and Milliman/Moda Health criteria; follow those references for medical necessity decisions.

Spinal cord stimulator review: Spinal cord stimulator implantation/related codes (63650, 63655, 63685) are reviewed by eviCore and must follow Spinal Cord Stimulators for Chronic Pain LCD (L36204) and related MCG guidance.

Coverage references and review processes

Coverage is determined per the referenced sources; some items may be non-covered or require external review and prior authorization.

Follow MCG rules (examples cited throughout the policy such as S-330, S-810, S-820 series) where referenced for surgical and device coverage guidance.

Follow applicable LCDs, LCAs, and NCDs cited (examples include Speech Generating Devices LCD L33739, Spinal Cord Stimulators LCD L36204, CPAP LCD L33718, etc.) for Medicare-aligned coverage rules.

Codes specifically marked as 'Non‑Covered by Medicare' in the policy are treated as non-covered per Medicare guidance and Moda Health aligns with those determinations.

Certain services (e.g., spinal cord stimulator codes) are routed to external reviewers (eviCore, Prime Therapeutics, MolDX) for prior authorization or medical necessity review per the policy instructions.

Prior authorization and coverage note items

Representative items requiring prior authorization or subject to special coverage notes; follow the item-specific instructions and referenced guidance.

Vacuum erection devices (L7900, L7902): listed as Non‑Covered by Medicare — follow the Vacuum Erection Devices policy article and treat per Medicare guidance.

Vagus nerve stimulators (multiple L/CPT codes listed, e.g., L8680, L8682–L8687, 61885–61886, 64553, 64568–64569, 95970): prior authorization required; follow Vagus Nerve Stimulators NCD (160.18).

Ventilators (E0450, E0460–E0467): prior authorization required; follow Ventilators NCD (280.1) and MAC guidance/Respiratory Assist Devices LCD (L33800) for coding and coverage.

Virtual reality cognitive behavioral therapy device (E1905): prior authorization required; follow device‑specific instructions in the policy.

Select drugs, biologics and specialty items (examples: J1429/J3490 golodirsen, J1632 Zulresso, J0775 Xiaflex, 90736 Zostavax): prior authorization and Moda Health Pharmacy criteria apply; Zostavax requires medical necessity review for members under age 60.

Codes and billing categories

Behavioral health / ABA / TMS CPT/HCPCSmixedCovered

H0010	Residential mental health
H0011	Inpatient chemical
H0012	Residential chemical dependency
H0013	Residential chemical dependency
H0017	Residential mental
H0018	Residential mental
H0019	Residential mental
H0035	Partial hospitalization program mental health / chemical dependency
S9480	Intensive outpatient treatment - mental health
0362T	Applied behavioral analysis (example)

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Orthoses / DME HCPCSHCPCSCovered

L2330	Ankle-foot orthosis, posterior
L2335	AFO component
L2340	AFO, solid
L2350	AFO, articulating
L2360	AFO, molded
L2370	AFO, custom
L2380	AFO, other
L2390	AFO
L3000	Orthotic adjunct

Endoscopy / GI / Capsule EndoscopyCPTCovered

91110	Capsule endoscopy, esophagus
91111	Capsule endoscopy, small intestine
91113	Capsule endoscopy interpretation
91299	Unlisted endoscopy procedure
44799	Unlisted intestinal procedure

Non-covered DME / examplesHCPCSNot Covered

E0200	Heating pad, non-covered example
E0205	Heating pad, non-covered example

Inpatient Only Codes (Addendum E) - representative listCPT

00176	Example inpatient-only code
00604	Inpatient-only example
20500	(representative)
33405	Cardiac valve procedure (inpatient-only)
49596	Hernia repair - inpatient only example
54438	Repair of traumatic corporeal tear(s) - inpatient only
41130	Head/neck inpatient code example
43300	Spinal/instrumentation inpatient example
50010	Abdominal surgery inpatient example
58999	Unlisted gynecologic procedure (inpatient example)

Cardiac / Thoracic / Vascular representative codesCPTCovered

33916	Cardiac procedure example
33920	Cardiac procedure example
33944	Cardiac procedure example
92941	Percutaneous coronary intervention code example
93583	Hemodynamic monitoring/injection

Selected inpatient surgical codesCPTCovered

35565	Vascular surgery example
35600	Peripheral vascular procedure
38562	Lymph node excision - inpatient example
39501	Cardiac surgery - inpatient example
63101	Neurosurgical inpatient example

Molecular Pathology / MolDX — covered with criteriamixedCovered

0031U	Molecular pathology assay (example)
0032U	Molecular pathology assay
0364U	Molecular pathology - MolDX reviewed
81105	Molecular pathology panel
81230	Cystic fibrosis testing
81362	EGFR mutation analysis

Non-covered CPT/HCPCS (examples)mixedNot Covered

0054T	Computer assisted navigation - non-covered example
0055T	Computer assisted navigation - non-covered example
0235T	Category III / novel tech - non-covered example
0274T	Herniated disc treatment - non-covered example
0232T	Platelet rich plasma - non-covered by Medicare
0412T	Removal of permanent cardiac contractility modulation system - non-covered example
0413T	Removal of permanent cardiac contractility modulation system - non-covered example

DME / Devices / Sleep study examplesHCPCSCovered

E0747	Osteogenesis stimulator
L8699	Cochlear implant, miscellaneous
E0650	Pneumatic compression device
E0675	Home sleep device - non-covered example
G0398	Home sleep study (no auth required)
G0399	Home sleep study
95800	Home sleep study - no authorization required

Penile replantation / repair — inpatient codesCPTCovered

54438	Repair of traumatic corporeal tear(s) - replantation, penis, complete (inpatient only)
54437	Repair of traumatic corporeal tear(s) - repair (not complete replantation)

Cardiac contractility modulation removal — non-coveredCPTNot Covered

0412T	Removal of permanent cardiac contractility modulation system - Non-Covered by Medicare
0413T	Removal of permanent cardiac contractility modulation system - Non-Covered by Medicare

Mixed HCPCS / CPT / J-codes examplesmixed

L8608	Argus II retinal prosthesis
J9213	Roferon A
G0415	Inpatient rehabilitation HCPCS
L8699	Miscellaneous prosthetic - L8499/L8699 examples

Unlisted / Miscellaneous & representative unlisted codesCPT

39499	Unlisted procedure, thorax
40799	Unlisted procedure, jaw
43289	Unlisted endoscopic procedure
44799	Unlisted intestinal procedure
49999	Unlisted procedure, abdomen
51999	Unlisted procedure, male genital
69949	Unlisted procedure, nervous system
81479	Unlisted molecular pathology/other lab
81599	Unlisted multianalyte assay
95999	Unlisted neurophysiology procedure

Provider responsibilities and authorization workflow

Prior Authorization

Prior Authorization / Notification Overview

All urgent/emergent inpatient admissions must be notified to Moda Health within 48 hours of admission and must meet the definition of an emergency medical condition. Prior authorization is required for all elective inpatient admissions to an acute care facility, and for admissions to Skilled Nursing Facilities, Inpatient Rehabilitation Facilities, and Long-Term Acute Care prior to patient admission. Transplant evaluations and transplant events require prior authorization. Advanced imaging, echocardiography, musculoskeletal, pain intervention and select cardiology procedures require prior authorization through eviCore. Specialty drug prior authorization is managed by Prime Therapeutics. Self-injectable medication prior authorization is managed through the Moda Health Pharmacy Benefit. Therapeutic drug monitoring (urine drug testing codes 80305, 80306, 80307, G0480–G0483) does NOT require prior authorization but will be reviewed at claim submission for medical necessity.

Urgent/Emergent inpatient admission notification: within 48 hours of admission to Moda Health (must meet emergency medical condition).
Inpatient elective admissions: prior authorization required before admission.
Skilled Nursing, Inpatient Rehab, LTAC: prior authorization required prior to admission.
Transplants: prior authorization required for evaluation and transplant event.
Advanced Imaging / Cardiology / Musculoskeletal / Pain Intervention: authorization via eviCore.
Specialty Drugs: prior authorization via Prime Therapeutics (https://gatewaypa.com/).
Self-Injectable Drugs: prior authorization via Moda Pharmacy Customer Service: 888-361-1610.
Therapeutic Drug Monitoring (80305, 80306, 80307, G0480–G0483): no prior authorization required; claim-level medical necessity review applies.

Note

Authorization Vendors & Contact Information

Authorization vendors and contractor routing: eviCore manages advanced imaging, cardiology and many interventional pain/spine reviews; Prime Therapeutics manages review of select specialty injectables and IVIG-related drugs; Moda Pharmacy manages pharmacy prior authorizations including self-injectables and certain specialty agents. For questions or to obtain authorizations contact the listed vendors directly.

eviCore: www.eviCore.com — 24/7 portal; phone 844-303-8451 (hours may vary by service line).
Prime Therapeutics / Specialty Drug prior auths: https://gatewaypa.com/.
Moda Health Pharmacy / Self-injectable prior auths: Pharmacy Customer Service 888-361-1610.
Certain services (e.g., IVIG J-codes listed) are reviewed by Prime Therapeutics Management; interventional pain and SCS are reviewed by eviCore; other categories are reviewed internally by Moda Health per contract.

Prior Authorization

Gastric Bypass / Gastric Restrictive Procedures

Gastric bypass and gastric restrictive procedures require prior authorization. Some related procedure codes are inpatient-only or non-covered by Medicare; follow the Bariatric Surgery Coverage LCA and the National Coverage Determination.

Prior authorization required for bariatric procedures: see Bariatric Surgery Coverage LCA (A53027) and NCD 100.1.
Covered / PA codes include: 43659, 43999, 43770, C9748, C9785.
Inpatient-only codes: 43644, 43645, 43843, 43845, 43846, 43847, 43848, 43771, 43772, 43773, 43774.
Non-covered by Medicare: 43842, 43290, 43291.

Billing Rule

Prior Authorization Code Lists & Instructions

Prior authorization code lists and instructions: many specific CPT/HCPCS groups require prior authorization or are non-covered; inpatient-only codes must be authorized when provided inpatient. "S" codes and many Home Infusion S-codes are statutorily non-covered by Medicare except where the provider contract specifically includes them. Unlisted codes and certain categories will be reviewed at claim submission for medical necessity when PA is not required.

Therapeutic drug monitoring codes (80305–80307; G0480–G0483): no PA required; claim review for medical necessity.
Home Infusion S-codes (e.g., S5035–S9504 series): statutorily non-covered by Medicare except for select contracted providers — authorization only where contract permits.
Inpatient-only CPTs listed throughout the policy require authorization for inpatient services.
"S" codes are generally non-covered by Medicare; Moda adheres unless contract specifies otherwise.
Non-covered code lists (extensive Category III/T codes and others) are maintained per CMS guidance and referenced Medicare Program Integrity Manual and Noridian resources.

Note

Vendor / Contractor Review Responsibilities

Vendor and contractor review responsibilities: categories of services are routed to external reviewers per contract — eviCore for advanced imaging, interventional pain and spinal cord stimulators; Prime Therapeutics for many specialty drug reviews (including certain IVIGs); Moda Pharmacy for pharmacy-managed drugs and self-injectables. Moda Health conducts internal review for services not contracted to external vendors.

eviCore: advanced imaging, cardiology imaging, interventional pain management, spinal cord stimulator reviews.
Prime Therapeutics: specialty drug prior authorizations and management of certain J-code therapies (e.g., IVIG J-codes listed).
Moda Pharmacy: pharmacy prior authorization, self-injectable drugs, weight-loss/obesity drug reviews.

Prior Authorization

Spinal Cord Stimulator Prior Review

Spinal cord stimulators (SCS) require prior review by eviCore. Follow the Spinal Cord Stimulators for Chronic Pain LCD (L36204) and submit requests to eviCore for medical necessity review prior to implantation.

SCS CPT codes: 63650, 63655, 63685 — reviewed by eviCore.
Coverage guidance: Spinal Cord Stimulators for Chronic Pain LCD (L36204).

Prior Authorization

Selected Items Requiring Prior Authorization

Selected items requiring prior authorization or medical necessity review: this includes a broad set of devices, procedures, and drugs (examples below). Many items reference LCDs, NCDs, MCG or Moda Health criteria and may be routed to external reviewers as noted.

Dynasplint / Mechanical Stretching Devices (E1800–E1841, E1818, etc.): prior authorization required; reference AFO/KAFO LCD (L33686) and Medicare Program Integrity Manual Chapter 3.6.2.2.
Elbow Arthroscopy (29838): prior authorization and refer to MCG S-421.
Vacuum Erection Devices (L7900, L7902): Non-covered by Medicare — review policy article for guidance.
Vagus Nerve Stimulator (L8680, L8682, L8683, L8685–L8788; CPTs 61885, 61886, 64553, 64568–64569): prior authorization and reference NCD 160.18.
Tissue grafts / engineered biologics (C93xx, Q41xx series): prior authorization required; extensive code list in policy.
Virtual reality CBT device (E1905), Vision Therapy (92065, 92066), Voice Prosthesis (L85xx series), Vyondys 53 (J1429, J3490): prior authorization or pharmacy routing as specified.
Wheelchair options & accessories and seating components (E09xx series, E22xx, etc.): follow Wheelchair LCDs and obtain prior authorization where required.
Weight loss / obesity drugs (e.g., orlistat, phentermine, others): prior authorization via Moda Pharmacy.

Definitions, vendors, and references

Urgent/Emergent admission notification

Notification timeframeNotify Moda Health within 48 hours of all urgent/emergent inpatient admissions

Definition requirementAdmission must meet the definition of an 'emergency medical condition'

Elective inpatient admissionsElective inpatient admissions to an acute care facility require prior authorization

Authorization vendors

eviCoreAuthorization obtained through eviCore for select advanced imaging, cardiology, musculoskeletal and interventional pain; www.eviCore.com or 844-303-8451

Prime Therapeutics ManagementPrime Therapeutics reviews select specialty drugs and certain IVIG J-codes (see Prime Therapeutics review instructions)

Moda Pharmacy BenefitModa Pharmacy Benefit handles prior authorization for self-injectable medications (Pharmacy Customer Service 888-361-1610)

S Codes (home infusion)

S Codes statusS Codes for Home Infusion are statutorily non-covered by Medicare except for select contracted providers

Example S Codes listedExamples include S5035, S5036, S5497, S5498 and many others listed in Home Infusion Services section

Provider contract noteThese S codes are non-covered unless the provider contract specifically includes them

Inpatient Only Code List / Addendum E (CY 2023)

Addendum E explanation (CY 2023)Addendum E lists HCPCS/CPT codes that would be paid only as inpatient procedures for CY 2023

Examples includedInpatient-only codes enumerated across the policy (see Inpatient Only Code List / Addendum E sections)

Authorization implicationInpatient-only procedures referenced in Addendum E require appropriate inpatient authorization per policy

Inpatient Only Code List

Inpatient Only Code ListPolicy includes an Inpatient Only Code List identifying CPT/HCPCS codes payable only when performed as inpatient procedures

Location in documentSee 'Inpatient Only Code List' sections enumerating specific CPT ranges and codes

Use for authorizationProviders must follow the inpatient-only designation when requesting authorization and billing

eviCore

eviCore review role (interventional pain)Interventional Pain Management codes listed are reviewed by eviCore (instructions reference eviCore, NCD/LCDs, Moda Health, Milliman)

Examples of codes reviewedCodes such as 62320-62327, 63650, 63655, 63685 and various 644/645 series are identified for eviCore review

Reference sourcesInstructions reference eviCore and applicable NCDs/LCDs for review guidance

Prime Therapeutics

Prime Therapeutics review rolePrime Therapeutics Management reviews specified Intravenous Immune Globulin (IVIG) J-codes for medical necessity

Examples of J-codes reviewedJ1459, J1556, J1557, J1558, J1559, J1561, J1566, J1568, J1569, J1572, J1575, J1599 are listed as reviewed by Prime Therapeutics

Instruction actionMedical necessity review is required per the Immune Globulin Intravenous (IVIg) LCD and Prime Therapeutics process

Instruction sources

Medicare NCDs/LCDs and ManualsPolicy references Medicare National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and the Medicare Program Integrity Manual for coverage rules

MCG and MillimanMCG (Milliman) guidance is cited for surgical and device coverage decisions (examples: MCG A-0309, S-330, S-820 series)

Moda Health criteriaModa Health criteria and policy articles are cited alongside external guidance for final determinations

Sleep study authorization guidance

Authorization distinctionHome sleep study CPTs (95800, 95801, 95806, G0398, G0399, G0400) do not require authorization; in-lab polysomnography CPTs (95807, 95808, 95810, 95811) require prior authorization

Policy referenceSee Polysomnography and Sleep Studies instructions in policy for Non-Covered codes and procedural guidance

Action for providersSubmit authorization requests for in-lab PSG codes; home sleep study claims will be reviewed at claim submission per guidance

MHMNC Gender Reassignment Criteria

MHMNC Gender Reassignment Criteria usePolicy references MHMNC Gender Reassignment Criteria for coverage instructions on procedures such as penile replantation/repair and other gender-related surgeries

Application examplesUsed as referenced instruction set for procedures coded 54437/54438 and other gender-related surgical coverage decisions

Cross-referenceFollow MHMNC and Moda Health criteria when requesting authorization for these procedures

Plastic Surgery LCD (L37020) and LCA (A57222)

Plastic Surgery LCD and LCAPlastic Surgery LCD (L37020) and Associated Coverage Article (A57222) are referenced for rhinoplasty coverage guidance

Rhinoplasty CPT examplesRhinoplasty CPTs listed include 30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462, 30465

Reference to Milliman/Moda HealthPolicy directs use of Milliman and Moda Health criteria alongside LCD/LCA for coverage determinations

Non-Covered by Medicare (examples)

Examples of codes non-covered by MedicarePolicy lists examples of codes noted as Non-Covered by Medicare such as 0412T and 0413T and many Category III codes (e.g., 0042T, 0339T)

Non-covered group referenceNon-Covered Items group and instructions reference CMS resources and Medicare NCD manual

Action for billingDo not expect Medicare payment for codes designated Non-Covered by Medicare; follow policy instructions

eviCore (review responsibilities)

eviCore review notationeviCore is the named external reviewer for Interventional Pain Management codes listed in the policy

Associated guidanceInstructions reference eviCore along with NCD/LCDs, Moda Health and Milliman for review criteria

Provider actionSubmit authorization requests to eviCore for the specified interventional pain procedures

MCG

MCG referencesMCG (Milliman) guidance is cited for numerous surgical and device reviews (see MCG references like A-0309, S-330, S-820 series)

Use in determinationsMCG rules inform medical necessity decisions referenced across the policy

Cross-reference sourcesMCG is used alongside LCDs/NCDs and Moda Health criteria for final determinations

Denotes items listed as not covered by Medicare

Non-Covered by Medicare notationPolicy denotes items as 'Non-Covered by Medicare' where indicated (examples: lists in Non-Covered Items group)

ImplicationItems so designated should be treated as non-covered under Medicare guidance and billed accordingly

Reference linkNon-Covered Items instructions reference CMS/Noridian guidance and Medicare NCD manual

External guidance sources

LCDs, NCDs, MCG, Moda Pharmacy, eviCore citedPolicy cites external guidance sources including LCDs/NCDs, MCG (Milliman), Moda Health Pharmacy policies, and eviCore for coverage and clinical review guidance

Examples of useThese external sources are referenced throughout for IVIG review, device policies, sleep studies, and more

Provider expectationProviders must follow referenced external guidance when submitting authorization requests or claims

OpenPayer

Procedures and services requiring prior authorization

Coverage criteria and clinical guidance

Codes and billing categories

Provider responsibilities and authorization workflow

Definitions, vendors, and references