CurrentMVP Health CarePolicy N/A

MVP Health Care Inpatient Surgical List

Lists CPT procedures that may be performed in the inpatient setting without prior authorization for all MVP plans; procedures not on the list are expected to be outpatient/office and require prior authorization and proof of medical necessity for inpatient setting.

Policy Summary

PayerMVP Health Care

PolicyMVP Health Care Inpatient Surgical List

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionIf the procedure CPT code is on the MVP Inpatient Surgical List, it may be performed inpatient without prior authorization for all MVP plans.

POLICY UPDATE CHANGES

No material changes — the brief indicates there are no material clinical or coverage changes.

400+CPT codes listed (approximate)

YesListed codes: inpatient without PA

YesNon-listed codes require PA

Coverage Summary

Subject: MVP Health Care Inpatient Surgical List. Status: CURRENT.

This document is an inpatient surgical list of CPT procedures that may be performed in the inpatient setting without prior authorization for all MVP plans. Procedures included on the list may be performed inpatient without prior authorization.

Inpatient Surgical List - Key Facts

Approx. CPT codes listed400+

Authorization status for listed codesListed = inpatient without PA

Non-listed codes require PAYes - require PA and proof of medical necessity

PayerMVP Health Care

Policy scopeLists CPT procedures that may be performed in the inpatient setting without prior authorization for all MVP plans; procedures not on the list are expected to be outpatient/office and require prior authorization and proof of medical necessity for inpatient setting.

Inpatient Setting Authorization Rule

Procedures on the Inpatient Surgical List may be performed in the inpatient setting without prior authorization for all MVP plans. Other procedures not on the list are expected to be performed in the outpatient or office setting; prior authorization and proof of medical necessity are required before inpatient performance.

ALL of the following

Procedure CPT code is included on the MVP Health Care Inpatient Surgical List
If procedure is on the list, no prior authorization is required for inpatient setting

If procedure is NOT on list

Procedure is expected to be performed in outpatient or office setting
Prior authorization and proof of medical necessity are required prior to performing the procedure in the inpatient setting

CPT Codes — Inpatient Surgical List

Inpatient Surgical List - Covered Without Prior AuthorizationCPTCovered

21240	Arthroplasty, temporomandibular joint, with or without autograft
21242	Arthroplasty, temporomandibular joint, with allograft
21243	Arthroplasty, temporomandibular joint, replacement
21245	Reconstruction of mandible, extraoral, with transosteal bone
21246	Reconstruction of mandible, extraoral, with transosteal bone
21247	Reconstruction of mandible, extraoral, with transosteal bone
21248	Reconstruction of mandible or maxilla, endosteal implant
21249	Reconstruction of mandible or maxilla, endosteal implant
21255	Reconstruct lower jaw bone
21268	Revision of orbital rims (eye sockets)

1–10 of 451

1/46

Provider Actions / Authorization Requirements

Prior Authorization

Prior authorization not required for listed procedures

If the procedure CPT code is on the MVP Inpatient Surgical List, it may be performed inpatient without prior authorization for all MVP plans.

Applies to all MVP plans
Applies when the CPT code is included on the MVP Inpatient Surgical List

Prior Authorization

Prior authorization required for procedures not on the list

Procedures not included on the MVP Inpatient Surgical List are expected to be performed in the outpatient or office setting; inpatient performance requires prior authorization and proof of medical necessity prior to the procedure.

Requires proof of medical necessity prior to inpatient performance
Expected to be performed outpatient/office unless prior authorized

Background

This document establishes which CPT-coded procedures may be performed in the inpatient setting without prior authorization across MVP Health Care plans. It is an explicit list of CPT procedure codes and short descriptions that are covered for inpatient performance without prior authorization.

For any procedure that is not included on the MVP Inpatient Surgical List, the procedure is expected to be performed in an outpatient or office setting, and prior authorization and proof of medical necessity are required before performing that procedure in the inpatient setting.

Policy Summary

PayerMVP Health Care

PolicyMVP Health Care Inpatient Surgical List

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionIf the procedure CPT code is on the MVP Inpatient Surgical List, it may be performed inpatient without prior authorization for all MVP plans.

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