Moda Health prior auth list & policy update | OpenPayer
CurrentModa HealthPolicy N/A
Procedures and services requiring prior authorization (Moda Health Medicare Advantage)
Lists procedures, services, codes, and circumstances that require prior authorization or notification for Moda Health Medicare Advantage members; affects providers, facilities, and pharmacy/benefit teams contracting with Moda Health Medicare Advantage.
Policy Summary
PayerModa Health
PolicyProcedures and services requiring prior authorization (Moda Health Medicare Advantage)
Policy CodePolicy N/A
Change TypeNo material changes
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.
No material clinical or coverage changes in this revision.
20+distinct procedure/service categories listed for prior authorization
48 hrsnotification timeframe for urgent/emergent inpatient admissions
eviCorethird-party authorization vendor cited
Prime Therapeuticspharmacy management vendor cited
Severalnon-covered items called out
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hundredsCPT/HCPCS and other codes listed
Coverage Criteria and Decision Rules
Coverage criteria and authorization nodes
Coverage stance varies by service; some services are explicitly non‑covered by Medicare and Moda follows Medicare non‑coverage, while other items require prior authorization or medical‑necessity review per referenced LCD/NCD/MHMNC/MCG guidance.
Services follow Medicare coverage determinations when specified; Moda adheres to Medicare non‑coverage for statutorily non‑covered codes (e.g., 'S' codes) unless a provider contract states otherwise.
Vendor‑managed prior authorization
Advanced imaging, echocardiography, select musculoskeletal and pain procedures require prior authorization via eviCore.
Specialty drugs require prior authorization and are managed via Prime Therapeutics per plan instructions.
Self‑injectable drugs administered in the office require prior authorization via Moda Pharmacy Customer Service or per pharmacy vendor guidance.
Urgent/emergent inpatient admissions: notification to Moda within 48 hours is required and the admission must meet the definition of an emergency medical condition.
Unlisted or unclassified codes: prior authorization is not required but services will be reviewed at claim submission for medical necessity.
Coverage criteria and notes
Coverage stance and review pathways for listed services and codes.
Medicare non‑covered codes
Certain codes are explicitly noted as Non‑Covered by Medicare (examples include select gastric procedures 43842 and DME/light box code E0203); providers should not expect Medicare coverage absent a contract exception.
Inpatient‑only codes: Codes listed in Addendum E are payable only as inpatient for CY 2023 and require inpatient status/authorization for payment.
Vendor and vendor‑managed reviews
Interventional pain management procedures (e.g., 64491–64495, 64633) are reviewed by eviCore per vendor processes and applicable NCD/LCD or Milliman/Moda criteria.
Home infusion and certain specialty drug administrations are managed per vendor instructions; S‑codes for home infusion are statutorily non‑covered except for select contracted providers.
Coverage stance and criteria references
Entries reference external coverage authorities (NCD/LCD, MolDX, MCG, MHMNC) or indicate Medicare non‑coverage; some services require medical necessity review.
Lipectomy and other reconstructive vs cosmetic procedures: review for medical necessity per Plastic Surgery LCD and MCG/MHMNC guidance.
Compounded inhalation/nebulizer solutions and select DME: follow Medicare and Moda Pharmacy/LCD guidance; some items are statutorily non‑covered.
Sleep study authorization rules
Home sleep studies (codes 95800, 95801, 95806, G0398, G0399, G0400) generally do not require prior authorization and will be handled per claim review.
Specified in‑lab sleep study codes (e.g., 95807, 95808, 95810, 95811) require prior authorization per plan thresholds.
Prior authorization and coverage references
Listed items reference external coverage policies/guidance and, in some cases, are non‑covered by Medicare or require medical necessity review per the cited source.
Items requiring medical necessity review or external guidance
Argus II retinal prosthesis (L8608) requires medical necessity review prior to coverage determination.
Spinal cord stimulator procedures (63650, 63655, 63685) are reviewed by eviCore and adjudicated per the Spinal Cord Stimulators for Chronic Pain LCD and vendor criteria.
DME and orthoses (examples: E1031, E0627, E0628, L0622, L0624): prior authorization and LCD/MHMNC guidance apply; follow MHMNC General DME instructions for coverage evaluation.
Coverage decision workflow
Services listed require prior authorization; coverage decisions rely on referenced LCD/NCD/MCG sources or vendor review (e.g., eviCore) as noted per line item.
Refer to the cited authoritative source (MCG, MHMNC, LCD, NCD, or eviCore) for medical‑necessity criteria that determine coverage for listed procedures (sample codes include 63650, 33285, 01429).
Prior authorization required examples
Thoracotomy/inpatient thoracotomy codes require inpatient authorization even when no additional medical necessity review is specified.
Total disc arthroplasty and select total joint replacement procedures are subject to prior authorization and, when indicated, eviCore review per the referenced guidance.
Codes, Addenda, and Coding Notes
examples of CPT/HCPCS groups referencedmixed
97151-97158,0362T,0373T
Applied Behavioral Analysis and behavior identification/therapy codes listed require review/authorization
C9730,C9731,31660-31661
Bronchial thermoplasty codes
33600-33602,33400-33475
Cardiac valve and related inpatient cardiac procedure codes (authorization required for inpatient services)
Inpatient-only CPT/HCPCS codes (Addendum E excerpt)CPTCovered
00176
Inpatient only procedure code (Addendum E list)
19305
Breast surgery code listed as inpatient-only in list
27132
Orthopedic/inpatient surgical code in inpatient-only list
Durable Medical Equipment examples and coverage notesHCPCS
E0483
High frequency chest wall oscillation device
E0481
Intrapulmonary percussive ventilator (non-covered by Medicare)
Examples of codes noted as Non-Covered by MedicaremixedNot Covered
43842
Gastric procedure - Non-Covered by Medicare (example)
E0203
Light box - Non-Covered by Medicare
Molecular pathology and related codesmixed
0378U
Molecular pathology codes (example)
0379U
Molecular pathology codes (example)
81105
Molecular pathology/sequence analysis
Pneumatic compression devicesHCPCS
E0673
Pneumatic compression device
E0675
Pneumatic compression (non-covered by Medicare example)
Provider Notifications, Prior Authorization, and Vendor Reviews
Prior Authorization
Provider Notifications, Prior Authorization, and Vendor Reviews
Prior authorization is required for many surgery- and device-related procedures, select home monitoring and specialty drug services, musculoskeletal and DME/device items, and spinal cord stimulator procedures. Some high-cost infusions and home infusion administrations are managed by specified vendors and require prior authorization or vendor review. Urgent/emergent inpatient admissions require notification to Moda Health within 48 hours and must meet the emergency definition.
Genetic testing: extensive list of molecular/genetic CPT/HCPCS codes (for example 81161–81190 series, 81200–81299 series, 81302–81349, 81400–81479, plus multiple U-codes) require prior authorization and follow MolDX and Noridian guidance (see MolDX and Noridian policy links).
Home monitoring and specialty drug management: INR home monitor (G0249) and select home infusion and specialty drug administrations (S9497, S9500–S9504; 99601/99602 administration codes) require prior authorization or are managed by vendors. Specialty drugs and IVIG (J-codes such as J1459, J1556–J1569, J1572, J1575, J1599) are reviewed by Prime Therapeutics/Moda Pharmacy; IVIG line items 01562, 90281, 90283, 90284 are reviewed by Moda Health.
Definitions, Vendors, and Instruction References
Urgent/Emergent Admission
Definition of emergency medical conditionAn urgent/emergent admission must meet the definition of an 'emergency medical condition' as specified by policy.
Notification timeframeAll urgent/emergent inpatient admissions require notification to Moda Health within 48 hours of admission.
Reporting requirementAdmissions classified as urgent/emergent must meet the emergency definition and be reported to Moda Health for review/documentation.
eviCore authorization
Prior authorization via eviCoreSelect advanced imaging, echocardiography, musculoskeletal, pain intervention, and cardiology procedures require prior authorization obtained through eviCore (website or phone).
Examples of eviCore‑managed services
Policy Summary
PayerModa Health
PolicyProcedures and services requiring prior authorization (Moda Health Medicare Advantage)
Policy CodePolicy N/A
Change TypeNo material changes
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.
Genetic testing prior authorization: Genetic and molecular testing codes require prior authorization and coverage decisions reference MolDX (Noridian/MolDX guidance) and plan instructions.
Medical necessity vs cosmetic: Multiple surgical procedures are reviewed to distinguish medical necessity from cosmetic exclusion per Plastic Surgery LCDs and MCG/MHMNC criteria.
Platelet‑rich plasma and certain regenerative medicine codes: reference Milliman and Moda Health criteria; select PRP codes are non‑covered by Medicare (e.g., 0232T) and will be evaluated per policy.
Addendum E inpatient-only listNumerous CPT/HCPCS codes listed in the Inpatient Only Code List are payable only as inpatient procedures for CY 2023 (see Addendum E excerpt).
Representative inpatient-only codesExamples include: 00176, 19305, 27132 and many others listed in the Inpatient Only Code List.
Instruction referenceAddendum E: HCPCS codes that would be paid only as inpatient procedures for CY 2023
Home sleep study authorization threshold
Home sleep study codes with no prior authorization requiredNo authorization required for home sleep study codes: 95800, 95801, 95806, G0398, G0399, G0400
In‑lab sleep study codes requiring prior authorizationPrior authorization required for codes: 95807, 95808, 95810, 95811
Instruction referencePolysomnography and Sleep Studies LCD (L34040)
Inpatient-only designation
Inpatient-only CPT codes require inpatient authorizationCertain CPT codes designated inpatient-only require inpatient authorization for payment (codes listed in the Inpatient Only Code List).
Examples of inpatient-only/related codesExamples include total disc arthroplasty code 0095T and numerous codes in the Inpatient Only Code List such as 00176 and 33418/33419 referenced as inpatient-only in source.
Instruction referenceMedicare Program Integrity Manual Chapter 3.6.2.2 and Addendum E guidance referenced for inpatient-only designations.
Interventional pain and spine/device vendor reviews: interventional pain procedures (e.g., 64491–64495, 64510, 64520, 64625, 64633–64636) and spinal cord stimulators (63650, 63655, 63685 and related codes) are reviewed by eviCore and require prior authorization per vendor criteria and applicable NCD/LCDs (Spinal Cord Stimulators for Chronic Pain LCD L36204).
Musculoskeletal prior authorization: selected musculoskeletal surgical codes (examples include 27422, 27424–27430, 27435–27447, 27486–27488, 27570, 29805–29807, 29819–29828, 29860–29875) are managed via eviCore and follow eviCore, Medicare NCD/LCDs, and Milliman guidance.
DME and device prior authorization: many durable medical equipment and device items require prior authorization and reference DME LCDs and Policy Articles — examples include patient lifts (E0621, E0630, E0635, E0636, E0639, E0640, E1035, E1036), hospital beds (E0265, E0266, E0296, E0297 non-covered), phototherapy lights and augmentation devices (E0202, E0691–E0694), intrapulmonary percussive ventilator (E0481 non-covered), light boxes (E0203 non-covered), and orthoses (shoulder: L3650–L3677; sacroiliac: L0622, L0624; shoulder-elbow-wrist-hand: L3960–L3978).
Examples of other procedures requiring prior authorization: thoracotomy inpatient services (e.g., 32320,32402,32500,32601–32657; authorization required for inpatient even when no medical necessity review is performed), percutaneous vertebral augmentation (0200T, 0201T — reviewed by Moda Health), tissue grafts/engineered mesh (C93xx/Q41xx series), Luxturna and other high-cost gene therapies per policy articles, stereotactic radiation therapy codes and IMRT planning per applicable LCDs/MCG guidance, and many additional CPT/HCPCS codes listed in Moda Health procedure lists.
Spinal cord stimulator review details: spinal cord stimulator procedures and related codes are reviewed by eviCore and require medical necessity review per the Spinal Cord Stimulators for Chronic Pain LCD (L36204). Some spinal and related device codes may be non-covered by Medicare (for example A4467, L0984) or subject to MCG spine surgery guidelines (lumbar discectomy, laminectomy, fusion).
Vendor contacts and instructions: eviCore for advanced imaging, cardiology, musculoskeletal and interventional pain (www.eviCore.com; 844-303-8451); Prime Therapeutics for specialty drug/IVIG review; Moda Pharmacy/Pharmacy Customer Service (888-361-1610) for self-injectable medications and pharmacy-managed prior authorization. Follow referenced LCDs, NCDs, MolDX, Noridian, MCG and Milliman guidance where indicated.
Urgent/emergent inpatient admissions: notify Moda Health within 48 hours of admission; inpatient elective admissions, skilled nursing, inpatient rehab, long term acute care and transplant events require prior authorization before admission or service per plan-specific rules.
Interventional pain management and many musculoskeletal procedures are reviewed by eviCore per listed CPT codes (e.g., 64491–64495, 64633).
How to obtain authorizationsAuthorization is obtained through eviCore 24/7 via the eviCore website or by calling the eviCore phone number provided in the policy.
eviCore — vendor reference
Vendor name and roleeviCore — external prior authorization/review vendor referenced for advanced imaging, musculoskeletal, interventional pain, spinal cord stimulators, and related services.
Referenced guidancePolicy references eviCore review along with Medicare NCD/LCDs and Milliman for clinical criteria and decision support.
Contact pathwaysAuthorizations for eviCore‑managed services are obtained via eviCore online or by phone as specified in the policy.
MolDX
Program referencedMolDX — molecular diagnostics program referenced for molecular pathology and multianalyte assay coverage guidance.
Affected code setsMolecular pathology and multianalyte assay CPT/HCPCS codes (examples: 0378U, 0379U, 81535, 81536) reference MolDX for instructions.
Instruction sourceMolDX guidance is cited as the instruction source for molecular diagnostic test coverage decisions.
Addendum E
Addendum E contentAddendum E lists HCPCS/CPT codes that would be paid only as inpatient procedures for CY 2023; it is the source for inpatient-only payment determinations.
Usage in policyCodes in Addendum E are cited throughout the policy as requiring inpatient status for payment and for authorization considerations.
Representative referencesSee Inpatient Only Code List entries (e.g., 00176, 33418, 33419) and Addendum E instructions in the policy.
eviCore — vendor reference (duplicate)
Duplicate vendor citationseviCore is referenced multiple times across the document for review/authorization of different service categories (advanced imaging, musculoskeletal, pain, spinal cord stimulators).
Context of repeatsThe policy repeatedly directs providers to eviCore authorizations and eviCore clinical criteria in several sections and line items.
Guidance alignmenteviCore references are used alongside Medicare NCD/LCD and Milliman criteria for consistent review processes.
MolDX — molecular diagnostic test guidance
MolDX for molecular diagnosticsMolDX is cited as the instruction source for molecular pathology and multianalyte assays (e.g., codes 0378U, 0379U, 81535).
Scope of applicationGenetic and molecular testing codes listed throughout the policy require prior authorization and reference MolDX guidance for coverage decisions.
Cross-referencesMolDX references are used in conjunction with Noridian and other LCD/NCD instructions where applicable.
eviCore — eviCore review referenced
eviCore review referencedThe policy indicates eviCore review for interventional pain management, musculoskeletal procedures, spinal cord stimulator services, and other select procedures.
Associated instruction sourceseviCore references are paired with Medicare NCD/LCDs, Milliman, and Moda Health criteria as the basis for medical necessity determinations.
Examples of reviewed servicesExamples include CPT codes 64491–64495 (interventional pain) and 63650/63655/63685 (spinal cord stimulator), which are reviewed by eviCore.
Argus II
Argus II coverage requirementArgus II retinal prosthesis (HCPCS L8608) requires medical necessity review per the policy.
Instruction noteThe policy explicitly states medical necessity review is required for Argus II (L8608).
Where listedArgus II entry appears in the DME/prosthetics section with explicit instruction to perform medical necessity review.
eviCore — vendor reference
eviCore vendor noted repeatedlyeviCore is referenced across multiple sections as the external reviewer and prior authorization vendor for select advanced procedures and devices.
Services under eviCore reviewIncludes advanced imaging, musculoskeletal, interventional pain, spinal cord stimulators, and select cardiac procedures.
Policy integrationeviCore requirements are integrated with Moda Health authorization workflows and referenced instructions.
Instruction references (MHMNC/MCG/LCD/NCD)
Instruction sources listedPolicy references MHMNC, MCG, LCD and NCD instruction sources for medical necessity and coverage guidance throughout multiple entries.
Examples of instruction referencesExamples include MHMNC General DME, MCG musculoskeletal surgery guidance, and specific LCDs for DME and sleep studies.
ApplicationProviders should refer to the cited MHMNC/MCG/LCD/NCD instructions when seeking authorization or documentation for listed services.