UCare Medicare Prior Auth & Notification Policy Update

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

Back (Spine) Surgery criteria: Prior authorization required; medical necessity determined using InterQual Medicare Procedures and applicable NCD/LCDs

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/Molecular Diagnostic testing criteria: Prior authorization required prior to ordering; medical necessity determined using InterQual Medicare Molecular Diagnostics & Lab and applicable NCD/LCD

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

DME and Wheelchair criteria: Prior authorization required prior to delivery/dispensing of DME, wheelchair accessories, and wheelchairs; medical necessity determined using InterQual Medicare DME and applicable NCD/LCDAuthorization required if billed charges > $1500 for certain miscellaneous codes

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

Medical necessity basis: Medical necessity is determined using InterQual Medicare Durable Medical Equipment appropriate subset or Medicare NCD/LCD based on the requested wheelchair item

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

Prior authorization is required before delivering or dispensing accessories or items that require authorization, including new, replacement, or repaired accessories; repair or replacement of rental equipment is the DME provider's responsibility

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

Power wheelchair rental/purchase: Prior authorization is required prior to delivery or dispensing power-operated vehicles and power wheelchairs for items that require authorization; for rentals all months must be authorized; prior authorization required prior to purchase for K0005-K0007 and E1161

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.

The policy lists two air ambulance HCPCS codes that require prior authorization when services are non-emergent: A0430 and A0435. These codes represent fixed-wing air ambulance services and must have authorization prior to the service unless transport is emergent.

Coding — Codes Requiring Authorization / Notification

Air Ambulance Codes requiring authorizationHCPCSCovered

A0430	Air ambulance, fixed wing, single engine
A0435	Air ambulance, fixed wing, twin engine

Back (Spine) Surgery Codes requiring authorization (partial list)CPTCovered

22533	Arthrodesis, posterior or posterolateral technique, single level; lumbar
22612	Arthrodesis, posterior or posterolateral technique, single level; lumbar interbody

Bariatric Surgery Codes requiring authorization (partial list)CPTCovered

43644	Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy
43848	Revision, gastroenterostomy or revision of gastric bypass

Cranial Nerve Stimulation Codes requiring authorizationCPTCovered

64553

Percutaneous implantation of neurostimulator, cranial nerve

DME and Enteral Nutrition Codes requiring authorization (partial list)HCPCSCovered

E0483	High frequency chest wall oscillation system
E1399	Durable medical equipment, miscellaneous
B4102	Amino acid-based elemental formula, administered enterally

Genetic/Molecular Diagnostic Codes requiring authorization (partial list)CPTCovered

0037U	Genetic test code (example)
81162	APC mutation analysis; full sequence

Microprocessor Lower Limb Prosthesis CodesHCPCSCovered

L5856

Microprocessor knee/shank/foot system, electronic

Orthognathic Surgery Codes requiring authorizationCPTCovered

21121

Genioplasty

Spinal Cord Stimulation Codes requiring authorizationCPTCovered

63650

Percutaneous implantation of neurostimulator electrode array, epidural

Vein Procedure Codes requiring authorizationCPTCovered

36465

Endovenous ablation therapy of incompetent vein, other than greater saphenous

Wheelchair and Accessory Codes requiring authorizationHCPCSCovered

E0986	Seat elevator
K0005	Standard wheelchair, multiple adjustments
K0800	Group 2 power wheelchair base

Wheelchair Accessories - Codes requiring authorizationHCPCSCovered

E0986
E1002
E1003
E1004
E1005
E1006
E1007
E1008
E1009
E1010

1–10 of 33

1/4

Wheelchair - Rental codes requiring authorizationHCPCSCovered

K0800
K0801
K0802
K0806
K0807
K0808
K0812
K0813
K0814
K0815

1–10 of 51

1/6

Wheelchair - Purchase codes requiring authorizationHCPCSCovered

K0005
K0006
K0007
E1161

Authorization charge threshold for miscellaneous DME/wheelchair accessory codes

ThresholdAuthorization required if billed charges > $1500 for miscellaneous DME/wheelchair accessory codes (example: E1399).

Example codes subject to thresholdE1399 (miscellaneous DME).

Operational notePrior authorization must be obtained prior to delivery or dispensing when billed charges for a miscellaneous code exceed $1500.

Provider Actions & Requirements

Prior Authorization

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.

Prior authorization required prior to service for non-emergent fixed-wing air ambulance
Authorization not required for emergent air transport
Codes requiring authorization: A0430, A0435
Medical necessity: Medicare Benefit Policy Manual: Chapter 10

Prior Authorization

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

Definitions

Prior authorization — Definition and operational note

DefinitionPrior authorization: An approval by an approval authority prior to the delivery of a specific service or treatment; requests require clinical review to determine medical necessity.

AuthorityApproval authority is UCare or an organization delegated by UCare to approve or deny prior authorization requests.

Purpose of reviewClinical review by qualified professionals determines medical necessity, eligibility, and that alternatives have been considered.

Notification — Definition and timing requirements

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

Timing requirements

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.

OpenPayer

Authorization and Notification Requirements (UCare Medicare Plans)

Coverage Criteria

Coding — Codes Requiring Authorization / Notification

Provider Actions & Requirements

Definitions

Background