CurrentUCarePolicy N/A

Authorization and Notification Requirements - UCare Individual & Family Plans (IFP)

Governs UCare Individual & Family Plans (including with M Health Fairview) requirements for prior authorization and notifications for specified inpatient, outpatient, DME, behavioral health, and procedural services and who must comply (providers).

Policy Summary

PayerUCare

PolicyAuthorization and Notification Requirements - UCare Individual & Family Plans (IFP)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateAug 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization or provide required notification (e.g., notify within 24 hours for transplant admissions) before delivering services listed and submit required documentation per form instructions.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~20+service categories listed

5 daysnon-urgent decision timeframe

$1500misc DME auth threshold

24 hrstransplant admission notification

many K-codeswheelchair codes requiring PA

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Coverage and Medical Necessity Criteria

General medical necessity and authorization logic

Covered when medical necessity is met per referenced criteria and prior authorization obtained where required.

General PA rules: Prior authorization required prior to delivery of services listed; medical necessity to be determined using InterQual or other referenced criteria; concurrent review required for extended stays; discharge summary required upon discharge where noted.

Applies across many service types (acute inpatient, rehab, DME, behavioral health, transplant, procedures)

Transplant procedures

Covered when medical necessity is demonstrated per referenced InterQual criteria and authorization/notification requirements are met

Transplant notification and medical necessity: Notification within 24 hours of admission AND medical necessity evaluated using InterQual Medicare Procedures appropriate subset based on requested transplant service

Applies to codes listed in transplant group

Vein procedures

Covered when ALL of the following are met

Vein procedure authorization and criteria: Prior authorization obtained prior to service AND medical necessity met per InterQual Medicare Procedures or InterQual Care Plan for varicose veins

Applies to vein CPT codes listed

Wheelchair/DME coverage criteria

Covered when ALL of the following are met

Wheelchair accessories prior authorization: Prior authorization obtained before delivering or dispensing accessories/items that require authorization; K0108 and K0669 require authorization if billed charges > $1500

Applies to accessory codes listed

Wheelchair purchase prior authorization: Prior authorization obtained prior to purchase for K0005-K0007, E1161, and all power-operated vehicles/power wheelchairs

Applies to purchase codes listed

Wheelchair rental prior authorization: Prior authorization obtained prior to delivery or dispensing for power-operated vehicles and power wheelchairs rental codes; all months must be authorized

Applies to rental codes listed

Authorization is not required for certain urgent or specifically excluded procedures. Examples explicitly listed include emergency surgery for trauma, acute transverse myelopathy, and surgery for tumors. For cosmetic/reconstructive breast procedures, breast reconstruction associated with breast cancer is also exempt from prior authorization. (See code and procedure lists for services that do require prior authorization.)

This section is reserved for additional coverage criteria or clarifications. When populated, entries will summarize specific clinical requirements, referenced medical necessity criteria, and any prior authorization or documentation instructions that apply to the named service or procedure.

This placeholder is available for medium-priority coverage details. Content added here should state the applicable authorization requirement, reference the InterQual or other clinical criteria used to determine medical necessity, and note any required thresholds or supporting documentation.

Code Lists and Billing Thresholds

Artificial DiscCPTCovered

22856	Artificial disc replacement
22857	Artificial disc replacement
22858	Artificial disc replacement

Back (Spine) SurgeryCPTCovered

22533	Lumbar spinal fusion
22612	Lumbar spinal fusion

Cosmetic Procedures (examples list)CPTCovered

11960	Injection for cosmetic procedure (example)
15780	Skin grafting, cosmetic examples

Cranial Nerve / NeuromodulationCPTCovered

64553	Implantation of neurostimulator lead, cranial nerve
64568	Vagus nerve stimulation

Durable Medical Equipment (DME)HCPCSCovered

E0483	High Frequency Chest Wall Oscillation System
E1399	DME - Miscellaneous

Orthognathic SurgeryCPTCovered

21121

Orthognathic surgery CPT example

Proton Beam TherapyCPTCovered

77520

Proton beam therapy

Sleep Studies and Spinal Cord StimulationCPTCovered

95807	Polysomnography, comprehensive
63650	Spinal cord stimulation trial lead placement

Transplant CPT/HCPTC Codes requiring notification/authorizationmixedCovered

33945	Heart transplant (listed under transplant procedures)
33935	Heart/Lung transplant
38240	Hematopoietic Stem Cell (listed)
38241	Hematopoietic Stem Cell (listed)
47135	Liver transplant
32851	Lung transplant
32852	Lung transplant
32853	Lung transplant
32854	Lung transplant
48554	Pancreas transplant

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Vein procedure CPT/HCPTC Codes requiring prior authorizationCPTCovered

36465	Vein procedures
36466	Vein procedures
36468	Vein procedures
36470	Vein procedures
36471	Vein procedures
36473	Vein procedures
36474	Vein procedures
36475	Vein procedures
36476	Vein procedures
36478	Vein procedures

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Wheelchair accessories codes requiring authorizationHCPCSCovered

E0986	Wheelchair accessories
E1002	Wheelchair accessories
E1003	Wheelchair accessories
E1004	Wheelchair accessories
E1005	Wheelchair accessories
E1006	Wheelchair accessories
E1007	Wheelchair accessories
E1008	Wheelchair accessories
E1009	Wheelchair accessories
E1010	Wheelchair accessories

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1/4

Wheelchair purchase codes requiring prior authorizationHCPCSCovered

K0005	Manual wheelchair, standard
K0006	Manual wheelchair, heavy-duty
K0007	Manual wheelchair, other
E1161	Power wheelchair related code

Wheelchair rental HCPCS codes requiring prior authorization (all months must be authorized)HCPCSCovered

K0800	Power wheelchair rental
K0801	Power wheelchair rental
K0802	Power wheelchair rental
K0806	Power wheelchair rental
K0807	Power wheelchair rental
K0808	Power wheelchair rental
K0812	Power wheelchair rental
K0813	Power wheelchair rental
K0814	Power wheelchair rental
K0815	Power wheelchair rental

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1/6

Miscellaneous DME billed charge threshold — Authorization required if billed charges > $1500 for E1399, K0108, K0669

Threshold amountAuthorization required if billed charges exceed $1500

Affected miscellaneous DME codeE1399 (Miscellaneous DME)

Policy actionPrior authorization required prior to delivery or dispensing for DME items that require authorization

Medical necessity referenceInterQual Medicare Durable Medical Equipment appropriate subset will be chosen based on requested DME item

Provider Requirements, Notifications, and Authorization Process

Prior Authorization

Transplant procedures authorization/notification

Prior authorization is required prior to service for the listed transplant procedures. Notification is required within 24 hours of admission for transplant procedures; medical necessity will be evaluated using InterQual Medicare Procedures (appropriate subset selected based on requested transplant service).

Transplant procedure codes: Heart: 33945; Heart/Lung: 33935; Hematopoietic Stem Cell: 38240, 38241; Liver: 47135; Lung: 32851, 32852, 32853, 32854; Pancreas and Pancreas/Kidney: 48554, 50360, 50365; Pancreatic Islet Cell: 48160; Small Bowel/Small Bowel-Liver/Multivisceral: 44136
Notification required within 24 hours of admission; failure to notify within 24 hours may be non-compliant with notification requirements
Medical necessity reviewed using InterQual Medicare Procedures (appropriate subset chosen based on requested transplant service)

Documentation Required

Transplant admission notification

Background and References

This policy uses InterQual and American Society of Addiction Medicine (ASAM) criteria where applicable and selects the appropriate subset based on the requested service, procedure, or diagnosis. For procedural and surgical services, medical necessity determinations reference the applicable InterQual Medicare Procedures subsets or InterQual Care Plans; for behavioral health admissions the policy references the appropriate InterQual BH subsets. Transplant-related admissions and procedures are evaluated using the InterQual Medicare Procedures subset identified for the specific transplant service, and notification requirements (such as the 24-hour inpatient notification for listed transplant codes) apply in addition to medical necessity review.

Key Definitions

Prior authorization definition

DefinitionPrior authorization: an approval by an approval authority prior to the delivery of a specific service or treatment requiring clinical review to determine medical necessity and eligibility.

Who grants approvalUCare or an organization delegated by UCare (approval authority)

PurposeClinical review by qualified professionals to determine medical necessity, eligibility, and whether alternatives were considered

Notification definition

DefinitionNotification: the process of informing UCare or its delegates of a specific treatment or service prior to, or within a specified time period after, the start of the treatment or service.

Timing examplesUsed for inpatient admission notifications (see policy for specific timeframes, e.g., 24 hours for certain transplant admissions)