Authorization and Notification Requirements (UCare Medicare Plans)
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Defines prior authorization and notification requirements for inpatient and outpatient services for UCare Medicare plans, including provider obligations, timelines, and lists of services and codes that require authorization or notification.
No material clinical or coverage changes in this revision.
Coverage Criteria
Back (Spine) Surgery — Covered when prior authorization criteria per referenced clinical criteria are met
Covered when prior authorization criteria per referenced clinical criteria are met
Authorization not required for emergency surgery for trauma, acute transverse myelopathy, tumors, and cervical/thoracic back surgery
Genetic/Molecular Diagnostic Tests — Covered when prior authorization criteria per referenced clinical criteria are met
Covered when prior authorization criteria per referenced clinical criteria are met
Genetic Testing delegated to Carelon as of 7/1/25
DME and Wheelchair — Covered when prior authorization criteria per referenced clinical criteria are met
Covered when prior authorization criteria per referenced clinical criteria are met
UCare reserves right to determine rental vs purchase; repair/replacement of rental equipment is provider responsibility
Medical necessity determination — Covered when medical necessity is met per the referenced criteria
Covered when medical necessity is met per the referenced criteria
Appropriate subset chosen based on requested item
Authorization for accessories and rental repairs — Authorization requirements for accessories and rentals
Authorization requirements for accessories and rentals
UCare reserves right to determine rental vs. purchase
Power wheelchairs and power-operated vehicles — Authorization requirements for power wheelchairs and purchases
Authorization requirements for power wheelchairs and purchases
UCare reserves right to determine rental vs. purchase
Authorization is not required for breast reconstruction when it is performed in association with breast cancer. This follows the policy's exclusion for reconstructive procedures related to breast cancer and means providers do not need to seek prior authorization for those services.
Emergent air transport is not subject to prior authorization. The policy requires prior authorization only for non-emergent fixed-wing air ambulance (codes A0430, A0435); if transport is emergent, providers should deliver necessary services without prior authorization.
UCare explicitly reserves the right to determine rental versus purchase for durable medical equipment and wheelchairs. Providers should expect that UCare may require rental authorizations to cover all months or may decide purchase is appropriate based on medical necessity and program rules; repair or replacement responsibility for rental equipment remains with the DME provider.
Procedures performed for primarily cosmetic reasons are treated as cosmetic and not covered as medically necessary. Examples listed in the policy include abdominoplasty, blepharoplasty/blepharoptosis, breast reduction, gynecomastia procedures, mammoplasty, panniculectomy, removal or replacement of breast implants, rhinoplasty/septorhinoplasty, and skin peels. Medical necessity determinations for reconstructive versus cosmetic intent will be made using referenced clinical criteria such as InterQual and applicable Medicare NCD/LCD guidance; providers should submit clinical documentation to support medical necessity when requesting authorization.
Coding — Codes Requiring Authorization / Notification
| 64553 | Percutaneous implantation of neurostimulator, cranial nerve |
| L5856 | Microprocessor knee/shank/foot system, electronic |
| 21121 | Genioplasty |
| 63650 | Percutaneous implantation of neurostimulator electrode array, epidural |
| 36465 | Endovenous ablation therapy of incompetent vein, other than greater saphenous |
Provider Actions & Requirements
Air Ambulance (Non-Emergent) — Prior Authorization Required
Air Ambulance (Non-Emergent fixed wing) requires prior authorization before the service is provided. Authorization is not required for emergent air transport.
Wheelchairs and Accessories — Prior Authorization Required
Providers must obtain prior authorization before delivering or dispensing wheelchair accessories, rental or purchase items (including power wheelchairs and power-operated vehicles) that require authorization. UCare reserves the right to determine rental versus purchase. Repair or replacement of rental equipment is the DME provider's responsibility.
- Prior authorization is required before delivering or dispensing accessories or items that require authorization, including new, replacement or repaired accessories
- Miscellaneous codes K0108 and K0669 require authorization if billed charges are greater than $1500
- All months of wheelchair rentals must be authorized
- Prior authorization required prior to purchase for K0005–K0007, E1161, and all power-operated vehicles and power wheelchairs
- Repair or replacement of rental equipment is the DME provider's responsibility; UCare may determine rental vs. purchase
Failure to Obtain Authorization — Claim Denial Risk
Failing to obtain required prior authorization in advance may result in a denied claim. Providers should confirm member eligibility and coverage prior to rendering services that require authorization.
- Authorization decisions for non-urgent requests may take up to 14 calendar days
- If services are rendered without required prior authorization, the claim may be denied
- Providers may request a network exception prior to service if services are not available in-network
Submitting Prior Authorization Requests — Instructions
Complete the appropriate prior authorization request form and include supporting clinical documentation. Submit requests by fax or email per the instructions on the form. Providers may request the criteria used for medical necessity determinations on UCare's Authorization page.
- Complete the appropriate request form with supporting clinical documentation
- Submit forms by fax or email according to the return information on each form
- Providers may request a copy of the criteria used to make a medical necessity determination via UCare's Authorization page
- For non-urgent decisions allow up to 14 calendar days
Definitions
Background
This policy applies clinical criteria from recognized sources when making medical necessity determinations. Specifically, UCare uses InterQual (for example, InterQual Medicare Durable Medical Equipment and InterQual Medicare Procedures) and will apply Medicare NCD/LCDs where appropriate for the requested item or procedure. These referenced criteria sets are the basis for prior authorization and coverage decisions described throughout the document.
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