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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.