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Effective January 1, 2022, Prior Authorization will be required for the following Medicare services: 

 

Service Category

Services/Procedures

Comments

Acupuncture An alternate form of medicine in which thin needles are inserted into the body. Medicare doesn't cover acupuncture (including dry needling) for any condition other than chronic low back pain. Limit to 20 visits. Prior Authorization May Be Required.
Ambulance Nonemergent Fixed Wing Nonemergent fixed wing ambulance transfers Requires prior authorization before transport
Behavioral Health Services Day Treatment
Electroconvulsive Therapy (ECT)
Inpatient Psychiatric
Intensive Outpatient Therapy
Neuropsychological Testing
Partial hospitalization
Psychological Testing
Substance Use Disorder
Therapeutic Repetitive Transcranial Magnetic
Stimulation (TMS) Treatment
Treatment/Rehabilitation
Added: Therapeutic repetitive transcranial magnetic stimulation treatment
Bronchial Thermoplasty Outpatient procedure for the treatment of asthma  
Chiropractor Services  Medicare coverage for chiropractic services extends only to treatment by means of manual manipulation of the spine to correct a subluxation, provided such treatment is reasonable and medically necessary Prior Authorization May Be Required.
Clinical Trials: Notification Only A clinical trial is one type of clinical research that follows a pre-defined plan or protocol  
Cochlear Implants & Surgery Provides direct electrical stimulation to the auditory nerve, bypassing the usual transducer cells that are absent or nonfunctional in deaf cochlea  
Cosmetic Procedures/ Dermatology Includes any surgical procedure directed at improving appearance, except when required for the prompt (i.e., as soon as medically feasible) repair of accidental injury or for the improvement of the functioning of a malformed body member Including, but not limited to the following:
Chemical exfoliation
Dermabrasion/chemical peel
Laser Treatment
Skin injections and implants
 
Drug Testing Quantitative tests for drugs of abuse  
Durable Medical Equipment (DME) Ambulatory Infusion Pumps
BIPAP
Bone Growth Stimulator
Continuous Glucose Monitor
Hospital Bed/Mattreess
Implantable Neurostimulator
Lift Devices including Hoyer
Lymphedema Pumps and Supplies
Oxygen Concentrators
TENS Unnits
Vagus Nerve Stimulator
Ventilators
Wheelchairs, Custom & Power
 
Enhanced External Counterpulsation (EECP) The noninvasive outpatient treatment for patients with coronary artery disease (CAD)  
Experimental/Investigational Services Any item or service potentially considered investigational or experimental must be authorized in advance  
Gender Reassignment General term to describe a surgery or surgeries that affirm a person's gender identity  
Genetic Counseling and Testing Genetic testing is a type of medical test that identifies changes in chromosomes, genes, or proteins  
Home Health Services Home Health Aide
Occupatioinal Therapy
Physical Therapy
Skilled Nursing Visits
Social Work Visits
Speech Therapy
 
Hospice: Notification only Home or Inpatient  
Hospital Admission Acute Inpatient Hospital
Inpatient Rehabilitation Hospital
Long Term Acute Care Hospital (LTAC)
Skilled Nursing Facility (SNF)
 
Hyperbaric Oxygen Therapy Includes HBO therapy administered in a chamber  
Infertility Drug Therapy, Testing, Treatment  
Neuropsychological Testing Evaluations for members with a history of psychological, neurologic or medical disorders known to impact cognitive or neurobehavioral functioning  
Nutritional Supplements and/or services Formula administered via a enteral feeding tube  
Observation Stay     Prior Authorization required if >48 hours
Orthotics/Prosthetics Prosthetic devices needed to replace a body part or function
Limited coverage options for orthotic shoes and devices, including artificial limbs and eyes as well as braces for arms, legs, back, or neck, penile prosthetics
 
Outpatient Therapy
* Occupational Therapy
* Physical Therapy
* Speech-Language Therapy
Therapeutic treatment: as a remedial treatment of mental or bodily disorder or an agency (as treatment) designed or serving to bring about rehabilitation or social adjustment Requires authorization after 12 combined visits
Pain Management Epidural Injections
Facet Injections
Median Branch Block
Radio Frequency Ablation
Sacroiliac joint injection (SI)
Trigger Point
 
Part B Drugs Added for Step Therapy:
Lutetium LU 177 dotatate therapeutic 1 MCI
Injection darbepoetin alfa, 1 micogram (non-ESRD use)
Injection epoetin alfa, (for noin ESRD use), 1000 units
Injection cemiplimab-RWLC 1 mg
Injection lurbinectedin 0.1 mg
Injectiion pembrolizumab 1 mg
Injection nivolumab 1 mg
Injection polatuzumab vedotin-PIIQ 1 mg
Injection ado-trastuzumab EMT 1 mg
Injection daratumumab, 10 mg and hyaluronidase-fihj
Injection epoetin alfa, 100 units (for ESRD on dialysis)
Injection darbepoetin alfa, 1 microgram (for ESRD on dialysis)
Lisocabtagene maraleucel per therapeutic dose
Injection rituximab-arrx biosimilar 10 mg
See Appendix A for complete list
Radiation Therapy Intensity modulated radiotherapy (IMRT)
Neutron beam therapy
Proton beam therapy
Stereotactic radiotherapy
 
Radiology MRI, MRA, PET Scan, CT, Cardiac Imaging All Health Plans Excluding Medicare Advantage from MHS Health Wisconsin visit www.radmd.com
Sleep Studies Hospital/Facility Sleep Study  
Surgeries, regardless of place of service Abortion
Bariatric Surgery
Blepharoplasty
Breast Augmentation (except  following mastectomy)
Breast Reduction
Capsule Endoscopy
Chondrocyte Implants
Cochlear Implant
Facial Osteotomy
Hysterectomy
Joint Replacements
Mastectomy for Gynecomastia
Otoplasty
Reconstructive and Plastic Surgery
Rhinoplasty
Sacral Nerve Neuromodulation
Scar Revision
Septoplasty
Spinal Surgeries, including Fusion, Stabilaztion, Discectomy
Temporomandinbular Joint Surgery
Transcatheter implantation of wireless pulmonary artery pressure sensor
Uvolopharyngoplasty
Uvulopalatopharyngplasty
Veins (ablation, ligation, stripping, sclerotherapy)
X-stop: Spinal Surgery
 
Transplants All transplant evaluations and procedures, including, but not limited to, evaluation, transplant consult visits, HLA typing, donor search and transplant procedure  

On June 1, 2021, Plan Waivers for Applicable COVID-19 Treatment and Telehealth Services Expire

As we continue to address the COVID-19 pandemic, we want to update you on important changes for our Medicaid and Medicare plans. Last year, we instituted temporary prior authorization waivers for both plans for select services to ensure critical care could be quickly delivered to our members during a time of heightened need. In addition, we instituted temporary member cost share liability on our Medicare plan. On June 1, 2021, these temporary waivers expire. Please see our COVID website page within for full details for each plan.

Behavioral Health Providers

[Applicable to all Medicaid and Medicare Providers]

Thank you for being a valued partner and providing outstanding care to our members, your patients. In our efforts to streamline the prior authorization process and remove some administrative burden, we are implementing the following changes related to behavioral health services:

  • Effective 3/15/20 forward, providers are no longer required to obtain a prior authorization for ACT (H0040) and IHBT (H2015) for the first six months of treatment.
    • After 6 months of treatment/billed services, a prior authorization will be required for both ACT (H0040) and IHBT (H2015) services. All billed services after 6 months without an authorization will deny.

If you have any questions or concerns about the policy changes above, please outreach your local provider relations team member or contact our provider services team at 866-296-8731.

 

MyCare Home Health RN Assessment Extension

In our ongoing efforts to make working with Buckeye as easy as possible, we are modifying our Home Health RN assessment billing policy.

  • Buckeye’s current policy allows for 1 RN assessment, without authorization, to be billed every 60 days. If there is significant change in condition, we allow an additional authorized RN assessment(s) during that time period.
  • Buckeye’s new policy: allows for 1 RN assessment, without authorization, to be billed every 60 days and we allow an additional RN assessment, without authorization, in the time period of 56 to 60 days.

All other aspects of the Home Health RN assessment billing policy remains the same.

We have updated our claims system configuration to allow for this additional assessment as of April 19, 2021, with an effective date back-dated to January 1, 2019. Buckeye will work with our contracted providers to reprocess claims for one RN assessment falling in the 56-60 day timespan for reimbursement.

Please contact Provider Services with any questions.