PA and Policy Updates
Prior Authorizations and Policy Update Notifications Since September 1, 2024
For PA's and Policy notifications delivered prior to September 1 please see Updates page.
2025 Policy Updates
Buckeye is committed to continuously improving our overall payment integrity solutions. We previously provided notification in July 2023 that we would begin performing additional prepayment claim reviews using Optum’s Comprehensive Payment Integrity (CPI) tool. This tool continues to evolve so Buckeye remains diligent in reviews and follow industry standards.
If Optum’s review results in a finding, the provider will receive detailed instructions about how to submit requested documentation. Providers who do not submit the requested documentation may receive a technical denial, which will result in the claim being denied until the information required to adjudicate the claim is received.
If it is determined that a coding and/or payment adjustment is applicable, the provider will receive the appropriate claim adjudication. Providers retain their right to dispute results of reviews.
If you have questions please contact Provider Services listed on our home page or your Provider Engagement Account Manager.
Editing Area | Description | Lines of Business |
Trauma Activation with No Ambulance Service | Identifies outpatient claims with revenue codes for trauma response (Rev 681 – 689) w/ no claims for ambulance services with HCPCS codes between A0021 and A0999 for same member, same date of service. | Marketplace, Medicare, Medicaid |
High Dollar Hardware | Identifies outpatient claims billing high dollar pass-through payment for hardware with code C1713 (anchors/screws). | |
Unsupported Lab Tests on High Dollar Claims | Reviews high dollar lab claims potentially unsupported by an order from a qualified healthcare professional. | |
Cross-coder Outpatient Facility Surgical Claims | Identifies outpt facility claims w/ surgical proc codes that do not match prof claim codes for similar services provided to same patient, same date of service. | |
Cross-coder Professional vs. Outpatient Facility Surgery Claims | Identifies prof claims w/surgical proc codes that do not match the outpt facility claim codes for similar services provided to same patient, same date of service. | |
Digital Spike Analysis | Reviews when a Digital Spike Analysis of EEG (95957) is billed in addition to the primary EEG procedure to verify required additional time and extra work was done to support billing this code. | |
Upcoding of Incision and Drainage Codes | Reviews claims billing incision and drainage (I&D) procedure codes suspected to be non-incision or lower-level I&D which may have been incorrectly submitted, reviewing simple I&D procedure codes 10060, 10080, 10140 and complicated/multiple I&D procedure codes 10061, 10081 | |
Misbilling of Third Order Selective Catheter Placement | Records will be reviewed to determine if the coding guidelines required to bill arterial selective catheter placement of the third order are met. |
Policy CC.PP.057: A physician or other qualified health professional may submit both a preventative E&M CPT® code and a problem oriented E&M CPT® code on the same date of service for the same patient. Once clinically validated, if the problem-oriented E&M represents a significant and separately identifiable E&M procedure or service, the problem-oriented procedure code will be reimbursed at a reduced rate.
Policy CC.PP.071: Treatment Room and Specialty Services revenue codes characterize services performed in a facility setting that are represented by a specific procedure reportable in a treatment room setting. The patient receiving these services must be registered through the hospital business office for outpatient services on a hospital campus.
Treatment room services are outpatient services, furnished on hospital premises, which require the use of a bed, and periodic monitoring for a relatively brief episode of time in order to carry out certain procedures. The use of the treatment room is an expected part of a minor procedure and replaces the charge for the operating room and recovery room as patients can also recover in the treatment room. Operating rooms are procedure rooms within a sterile corridor and are used for open or major surgical procedures usually involving general anesthesia.
Payment Policy CC.PP.052: The purpose of this policy is to prevent duplicate payments that occur when a provider is reimbursed for resources not directly consumed during the provision of a service. Furthermore, to define payment criteria for problem-oriented visits when billed on the same day as a surgical procedure with a 0-, 10-or 90-day global period when making payment decisions and administering benefits.
Under modifier -25 correct coding principles, a patient may be seen by the physician for a problem-oriented evaluation and management (E&M) service on the same day of a procedure with a 0-, 10-or 90-day global surgical period if the physician indicates that the service is a significant and separately identifiable E&M service that is above and beyond the usual pre-and post-operative work associated with the procedure.
The purpose of this policy is to ensure that the level of E&M service reported by the provider for emergency department (ED) E&M services reflects the level of services performed. There are three key components providers must consider when selecting the appropriate level of E&M service provided: history taking, physical examination and medical decision making. When selecting the appropriate level of E&M service, all the key components must meet or exceed the stated requirements to qualify for a particular level of E&M service (i.e., office, new patient, inpatient hospital care, office consultations, emergency department services, etc.) See our Policy Website Page for more details.
Physician medical records should chronologically report the care a patient received and record pertinent facts, findings, and observations about the patient’s health history. See our Policy Website Page for details.
Payment Policy CC.PP.067: Renal Hemodialysis
Providers furnishing hemodialysis services are reimbursed up to three times per calendar week. If the provider bills for treatments in excess of this frequency, either in units or visits, the applicable service line will deny any units or visits above the three times per week limitation.
If a provider receives a claim denial for additional hemodialysis beyond the usual weekly maintenance dialysis due to the Member’s underlying condition, the dialysis provider may request a reconsideration or appeal accompanied by a medical justification. See Policy Website Page.
The purpose of this policy is to define payment criteria for newborn inpatient stays to be used in making payment decisions and administering benefits. Newborn inpatient stays are reimbursed by the Health Plan based on Medicare Severity Diagnosis Related Groups (MS-DRGs).
For newborn inpatient stays, assignment of a NICU-level DRG is dependent upon the exclusive billing of NICU revenue codes. When a claim reflects only non-NICU revenue codes (170/171 normal newborn stay), it will be reclassified and reimbursement adjusted to MS-DRG 795 in accordance with health plan policy requirements. See Policy Website.
Medicaid: EXfz (Retain Pay): Healthy Newborn Claim paid per policy, remit records for reconsideration.
Marketplace: EXhn (Retain Pay): Healthy Newborn Claim paid per policy, remit records for reconsideration
We are committed to continuously improving our overall payment integrity solutions to prevent overpayments due to waste or abuse. On July 1, 2023, we notified you that we would begin performing additional prepayment claim review using Optum’s Comprehensive Payment Integrity tool. This tool continues to evolve, so we remain diligent in reviews and follow industry standards. The latest edit areas are shown below.
Optum CPI Amisys X0097 P0335
Effective 9/1/2025 Optum will include edits for the following.
Editing Area | Description | Lines of Business |
Critical Care Coding Requirements | Review seeks to ensure appropriate critical care billing for illnesses or injuries. | Marketplace, Medicare, Medicaid |
Percutaneous Nephrostolithotomy (PCNL) Procedures | Review of professional and outpatient claims seeks to ensure documentation supports billing a complex Percutaneous Nephrostolithotomy (PCNL) Procedure. |
If Optum’s review results in a finding, the provider will receive detailed instructions about how to submit requested documentation. Providers who do not submit the requested documentation may receive a technical denial, which will result in the claim being denied until the information required to adjudicate the claim is received.
If it is determined that a coding and/or payment adjustment is applicable, the provider will receive the appropriate claim adjudication. Providers retain their right to dispute results of reviews.
If you have questions please contact Provider Services listed on our home page or your Provider Engagement Account Manager if you have any questions.
2025 Prior Authorizations - Effective in 2025
Service Category | PA Rule | Services | Procedure Codes |
Behavioral Health | PA Required | Treatment Services | 90867, 90868 97157 |
Cardiovascular | PA Required | Heart Surgery | 93656 |
DME Services | PA Required | Incontinence Supplies | T4521, T4522, T4523, T4524 |
Drug Codes | PA Required | Injections | J1437, J3490 |
Genetic Analysis | PA Required | Genetic Testing | 81220 |
Hearing Services | PA Required | Implants and Supplies | L8614, V5261 |
Home Services | No PA Required | Home Management | S5160, S5161 |
Laboratory | No PA Required | Pathology | 81270 |
Other Medical Services
| PA Required | Surgical Supplies | A4554 |
Physical Medicine | PA Required | Orthotic and Prosthetic | Q4101, Q4121, Q4160, Q4186, Q4195, Q4196 |
Physician Services | No PA Required | Education Services | S9140 |
Skin Procedures | PA Required | Muscle Flap Procedures | 15734 |
Surgery Procedures
| PA Required
| Cardiovascular System
| 33285, 37220, 37221, 37225, 37228, 37229 37230, 37231, 37243 |
Transportation Services | PA Required | Medical Transportation | A0428, A0431, A0436 |
Service Category |
PA Rule | Services | Procedure Codes |
DME Services | No PA Required | Equipment Accessories | E0953, K0019, K0044, K0045, K0046, K0047, K0051, K0052 |
Wheelchairs | E0954, E0956, E0957, E0973, E1028, E2209, E2210, E2365, E2366, E2367, E2603, E2604, E2615, E2616, K0733, K0739 | ||
Home Services | No PA Required | Home Management | G0156 |
Other Medical Services | No PA Required | Other Services | 97010, 97012, 97024, 97033, 97035, 97150 G0283 |
Sleep Medicine | No PA Required | Sleep Studies | 95805 |
Surgery Procedures | No PA Required | Vascular | 36471, 37765, 37766 |
Transportation Services | PA Required | Medical Transportation | A0431, A0436 |
No PA Required | Medical Transportation | A0434 | |
Skin Substitutes & Wound Dressings
| PA Required | Skin Substitutes & Wound Dressings | C9358, C9360, C9363, Q4111, Q4115, Q4117, Q4118, Q4125, Q4134, Q4135, Q4136, Q4139, Q4145, Q4162, Q4165, Q4166, Q4167, Q4168, Q4170, Q4171, Q4174, Q4176, Q4177, Q4179, Q4180, Q4181, Q4182, Q4205, Q4206, Q4208, Q4209, Q4211, Q4212, Q4214, Q4216, Q4217, Q4218, Q4219, Q4220, Q4221, Q4222, Q4226, Q4227, Q4229, Q4230, Q4232, Q4233, Q4234, Q4235, Q4237, Q4238, Q4239, Q4240, Q4241, Q4242, Q4244, Q4245, Q4246, Q4247, Q4248, Q4251,Q4252, Q4253 |
Service Category |
PA Rule | Services | Procedure Codes |
DME Services | No PA Required | Wheelchairs | K0739 |
Drug Codes | PA Required | Medications | Q0138, Q0139 |
Surgery Procedures | PA Required | Digestive System | 43281, 43282, 49329 |
As of October 1, 2025, codes S5000 and S5001 will require prior authorization on any billed charges that exceed $500.
A breakdown of the S5000 and S5001 codes is as follows for your reference:
- HCPCS code S5000 is a temporary national code used to identify a generic prescription drug. Part of the HCPCS level II codes, which are codes used for billing and reimbursement for healthcare services and supplies, the S5000 code is specifically used for generic medications that have been prescribed by a healthcare provider.
- HCPCS code S5001 is a billing and insurance code used for brand name prescription drugs only, prescribed by a healthcare provider. It falls under the category of “miscellaneous medications and therapeutic substances,” as maintained by the Centers for Medicare & Medicaid Services (CMS).
Codes S5000 and S5001 should only be used when a more appropriate or specific code is not available.
As of October 1, 2025, prior authorization is required for Ambetter by Buckeye Health Plan providers billing HCPCS code H0019 (BHVAL HLTH; LNG-TERM RES PER DIEM).
Evolent (formerly New Century Health) manages prior authorizations for Centene for Medical Oncology, Radiation Oncology, Pediatric and Dose Optimization, and Cardiology.
Beginning October 1, 2025, the procedure codes included in this bulletin will require prior authorization through Evolent. This change applies to all Ambetter (Marketplace), Medicaid, and Medicare products offered by Centene.
If you have any questions regarding this update please contact your Provider Engagement representative.
Service Category |
PA Rule | Services | Procedure Codes |
DME Services | No PA Required | Equipment Accessories | E0953, K0019, K0045, K0052 |
Wheelchairs | E0954, E0956, E0957, E0973, E1028, E2209, E2210, E2365, E2366, E2367, E2603, E2604, E2615, K0733, K0739 | ||
Home Services | No PA Required | Home Management | G0156 |
Sleep Medicine | No PA Required | Sleep Studies | 95805 |
Surgery Procedures | No PA Required | Vascular | 36471 |
Transportation Services | PA Required | Medical Transportation | A0431, A0436 |
No PA Required | Medical Transportation | A0434 |
Service Category |
PA Rule | Services | Procedure Codes |
DME Services | No PA Required | Wheelchairs | K0739 |
Drug Codes | PA Required | Medications | Q0138, Q0139 |
No PA Required | Injections | J0640 | |
Genetic Analysis | PA Required | Genetic Testing | 81420 |
Surgery Procedures | PA Required | Digestive System | 43281, 43282, 49329 |
Male Genitalia | 55866 | ||
Musculoskeletal System | 28308 | ||
No PA Required | Facial, Cranial and TMJ Procedures | 21230 | |
Vascular | 36476 |
Service Category |
PA Rule | Services | Procedure Codes |
Behavioral Health | PA Required | Treatment Services | 90867, 90868 |
No PA Required | Treatment Services | 97157 | |
Cardiovascular | PA Required | Cardiovascular Tests | 93623 |
Heart Surgery | 93656 | ||
DME Services | PA Required | Incontinence Supplies | T4521, T4522, T4523, T4524 |
Nutritional Services | B4158, B4159, B4160, B4161 | ||
Orthotic and Prosthetic | L1833 | ||
No PA Required | Equipment and Accessories | E1392, K0043 | |
Drug Codes | PA Required | Injections | J1437, J3490 |
Medications | Q0138, Q0139 | ||
Genetic Analysis | PA Required | Genetic Testing | 81220, 81420 |
No PA Required | Genetic Testing | 81244, 81331 | |
Hearing Services | PA Required | Implants and Supplies | L8614, V5261 |
Home Services | No PA Required | Home Management | S5160, S5161 |
Infusion Services | S5498, S9500, S9501, S9502 | ||
Laboratory | No PA Required | Pathology | 81270 |
Other Medical Services
| PA Required | Surgical Supplies | A4554 |
No PA Required | Acupuncture | 97810, 97811, 97813 | |
Other Services | 97010, 97014, 97032, 97035, 97150 | ||
Speech Therapy | 92508 | ||
Wound Care | A6549 | ||
Physical Medicine | PA Required | Orthotic and Prosthetic | Q4101, Q4121, Q4160, Q4186, Q4195, Q4196 |
Physician Services | No PA Required | Education Services | S9140 |
Skin Procedures | PA Required | Muscle Flap Procedures | 15734 |
No PA Required | Skin Grafts | 14020, 14021 | |
Surgery Procedures
|
PA Required
PA Required | Cardiovascular System | 33285, 37220, 37221, 37225, 37228, 37229 37230, 37231, 37243 |
Digestive System | 49329, 49505, 49591, 49593, 49595, 49650 | ||
Female Genitalia | 58661, 58662 | ||
Integumentary System | 19301 | ||
Male Genitalia | 54360 | ||
Nervous System | 64999 | ||
No PA Required | Vascular | 36479 | |
Transportation Services | PA Required | Medical Transportation | A0428, A0431, A0436 |
Buckeye Health Plan is continuously reviewing our Prior Authorization requirements and work to ensure our provider partners find our processes straightforward. Buckeye wanted to announce that the Prior Authorization is being turned OFF for S5000-Script drug generic for Medicaid.
It is also important to note that there is a prior authorization in place for all providers for S5001-Script drug brand name. The Health Plan sees this code come through our claims system without a Prior Authorization often, which will lead to unnecessary denials, and this newsletter is serving as a reminder that S5001 DOES require a Prior Authorization for All providers.
Updated Prior Authorization requirements for code G0483 - DRUG TEST DEF 22+ CLASSES. Buckeye health Plan will align with OAC rule 5160-11-11, stating prior authorization is needed. Currently, our system is set up as a conditional Prior Auth above 12 visits per year and this will be changed from the conditional Prior authorization requirement to “yes” for all providers. This change will take effect 10/1/2025.
Important change to our pre-authorization requirements for certain laboratory codes, effective immediately.
Updated Pre-Authorization Guidelines
CPT Codes 80305–80307 (Presumptive Drug Testing):
- Non-Participating Providers: Pre-authorization is required for all services.
- Participating Providers: Pre-authorization is required after 30 visits per calendar year.
HCPCS Codes G0480–G0483 (Definitive Drug Testing):
- Non-Participating Providers: Pre-authorization is required for all services.
- Participating Providers: Pre-authorization is required after 12 visits per calendar year.
These updates are being implemented to support appropriate utilization and ensure the delivery of high-quality, cost-effective care.
Action Required
Please ensure your practice management and billing teams are aware of these changes and incorporate the updated requirements into your pre-authorization workflows.
Questions?
If you have any questions regarding this update or how it may affect your practice, please contact our Provider Services team at (866) 246-4356.
In April of 2025, we previously notified you that the Prior Authorization Code Updates listed below effective July 1, 2025. The effective date for this Prior Authorization Code Updates is now September 1, 2025.
S1040: Cranial remolding orthotic, pediatric, rigid, with soft interface material, custom fabricated, includes fitting and adjustment(s)
37229: Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with atherectomy, includes angioplasty within the same vessel, when performed
37227: Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed
36475: Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; first vein treated
31276: Nasal/sinus endoscopy, surgical, with frontal sinus exploration, including removal of tissue from frontal sinus, when performed
31295: Nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); maxillary sinus ostium, transnasal or via canine fossa
31298: Nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); frontal and sphenoid sinus ostia
31296: Nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); frontal sinus ostium
19371: Peri-implant capsulectomy, breast, complete, including removal of all intracapsular contents
S9123: Nursing care, in the home; by registered nurse, per hour (use for general nursing care only, not to be used when CPT codes 99500-99602 can be used)
E0466: Home ventilator, any type, used with noninvasive interface, (e.g., mask, chest shell)
B4105: In-line cartridge containing digestive enzyme(s) for enteral feeding, each
L5856: Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing and stance phase, includes electronic sensor(s), any type
64555: Percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve)
L5968: Addition to lower limb prosthesis, multiaxial ankle with swing phase active dorsiflexion feature
L0648: Lumbar-sacral orthosis (LSO), sagittal control, with rigid anterior and posterior panels, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf
L0637: Lumbar-sacral orthosis (LSO), sagittal-coronal control, with rigid anterior and posterior frame/panels, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
E0637: Combination sit-to-stand frame/table system, any size including pediatric, with seat lift feature, with or without wheels
15847: Excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (eg, abdominoplasty) (includes umbilical transposition and fascial plication) (List separately in addition to code for primary procedure)
E2370: Power wheelchair component, integrated drive wheel motor and gear box combination, replacement only
E0641: Standing frame/table system, multi-position (e.g., 3-way stander), any size including pediatric, with or without wheels
K0801: Power operated vehicle, group 1 heavy-duty, patient weight capacity 301 to 450 pounds
E2375: Power wheelchair accessory, nonexpandable controller, including all related electronics and mounting hardware, replacement only
The following codes will no longer require prior authorization:
G0268: Removal of impacted cerumen (one or both ears) by physician on same date of service as audiologic function testing
If you have questions, please contact Provider Services.
Procedure Code | Procedure Code Description | New Standard | Line of Business |
S5001 | SCRIPT DRUG BRAND NAME | Prior Authorization will remain in place and claims configuration will align for appropriate payment | Medicaid |
97161 | PHYSICAL THERAPY EVALUATION LOW COMPLEX 20 MINS | Prior authorization for non par providers after 15 visits | Medicaid |
97162 | PHYSICAL THERAPY EVALUATION MOD COMPLEX 30 MINS | Prior authorization for non par providers after 15 visits | Medicaid |
E0784 | EXTERNAL AMBULATORY INFUSION PUMP; INFUSION | Prior authorization for all providers |
|
E0260 | HOSP BED SEMI-ELEC W/ANY RAILS W/MATTRESS | Prior authorization for all providers |
|
Wellcare by Allwell requires prior authorization (PA) as a condition of payment for many services. This Notice contains information regarding such prior authorization requirements and is applicable to all Medicare products offered by Buckeye Health Plan.
We are committed to delivering cost effective quality care to our members. This effort requires us to ensure that our members receive only treatment that is medically necessary according to current standards of practice. Prior authorization is a process initiated by the physician in which we verify the medical necessity of a treatment in advance using independent objective medical criteria and/or in network utilization, where applicable.
It is the ordering/prescribing provider’s responsibility to determine which specific codes require prior authorization.
Please verify eligibility and benefits prior to rendering services for all members. Payment, regardless of authorization, is contingent on the member’s eligibility at the time service is rendered. NON-PAR PROVIDERS & FACILITIES REQUIRE AUTHORIZATION FOR ALL HMO SERVICES EXCEPT WHERE INDICATED.
For complete CPT/HCPCS code listing, please see Online Prior Authorization Tool
Effective July 1, 2025, the following are changes to prior authorization requirements.
| Service Category | PA Rule | Services | Procedure Codes |
| Durable Medical Equipment | No PA Required | Supplies & Devices Neurostimulators
| A9279, A9900 E0184 E0730
|
| Home Services | No PA Required | Dialysis Services | 99512 |
| Medical Supplies | No PA Required | Supplies | A4657 |
| Other Medical Services | No PA Required | Wound Care | 97605, 97606 |
| Physician Services | No PA Required | Dialysis Services Neurological Tests | 90989 95972 |
| Surgery Procedures | PA Required | Skin Grafts | Q4205 |
Effective July 1, 2025, the following codes will require prior authorization to be submitted to Buckeye Health Plan.
S1040: Cranial remolding orthotic, pediatric, rigid, with soft interface material, custom fabricated, includes fitting and adjustment(s)
37229: Revascularization, endovascular, open or percutaneous, tibial, peroneal artery, unilateral, initial vessel; with atherectomy, includes angioplasty within the same vessel, when performed
37227: Revascularization, endovascular, open or percutaneous, femoral, popliteal artery(s), unilateral; with transluminal stent placement(s) and atherectomy, includes angioplasty within the same vessel, when performed
36475: Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; first vein treated
31276: Nasal/sinus endoscopy, surgical, with frontal sinus exploration, including removal of tissue from frontal sinus, when performed
31295: Nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); maxillary sinus ostium, transnasal or via canine fossa
31298: Nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); frontal and sphenoid sinus ostia
31296: Nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); frontal sinus ostium
19371: Peri-implant capsulectomy, breast, complete, including removal of all intracapsular contents
S9123: Nursing care, in the home; by registered nurse, per hour (use for general nursing care only, not to be used when CPT codes 99500-99602 can be used)
E0466: Home ventilator, any type, used with noninvasive interface, (e.g., mask, chest shell)
B4105: In-line cartridge containing digestive enzyme(s) for enteral feeding, each
L5856: Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing and stance phase, includes electronic sensor(s), any type
64555: Percutaneous implantation of neurostimulator electrode array; peripheral nerve (excludes sacral nerve)
L5968: Addition to lower limb prosthesis, multiaxial ankle with swing phase active dorsiflexion feature
L0648: Lumbar-sacral orthosis (LSO), sagittal control, with rigid anterior and posterior panels, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf
L0637: Lumbar-sacral orthosis (LSO), sagittal-coronal control, with rigid anterior and posterior frame/panels, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
E0637: Combination sit-to-stand frame/table system, any size including pediatric, with seat lift feature, with or without wheels
15847: Excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (eg, abdominoplasty) (includes umbilical transposition and fascial plication) (List separately in addition to code for primary procedure)
E2370: Power wheelchair component, integrated drive wheel motor and gear box combination, replacement only
E0641: Standing frame/table system, multi-position (e.g., 3-way stander), any size including pediatric, with or without wheels
K0801: Power operated vehicle, group 1 heavy-duty, patient weight capacity 301 to 450 pounds
E2375: Power wheelchair accessory, nonexpandable controller, including all related electronics and mounting hardware, replacement only
The following codes will no longer require prior authorization:
G0268: Removal of impacted cerumen (one or both ears) by physician on same date of service as audiologic function testing
If you have questions, please contact Provider Services.
Effective July 1, 2025, the following codes will require prior authorization to be submitted to Ambetter from Buckeye Health Plan.
31276: Nasal/sinus endoscopy, surgical, with frontal sinus exploration, including removal of tissue from frontal sinus, when performed
31298: Nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); frontal and sphenoid sinus ostia
J1439: Injection, ferric carboxymaltose, 1 mg
31295: Nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); maxillary sinus ostium, transnasal or via canine fossa
31296: Nasal/sinus endoscopy, surgical, with dilation (eg, balloon dilation); frontal sinus ostium
36475: Endovenous ablation therapy of incompetent vein, extremity, inclusive of all imaging guidance and monitoring, percutaneous, radiofrequency; first vein treated
Q0138: Injection, ferumoxytol, for treatment of iron deficiency anemia, 1 mg (non-ESRD use)
If you have questions, please contact Provider Services.
Effective February 1, 2025, Buckeye Health Plan will be changing prior authorization requirements for the following codes:
Procedure Code | Procedure Code Description |
New Standard |
Line of Business |
11042 | Debridement, subcutaneous tissue (includes epidermis and dermis, if performed); first 20 sq cm or less | Pre-authorization is required after 12 visits for All Providers | Medicaid |
11043 | Debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); first 20 sq cm or less | Pre-authorization is required after 12 visits for All Providers | Medicaid |
2024 Policy Updates
New Payment Policy: Leveling of Care: Evaluation and Management Overcoding Effective 12-1-24 (All Products)
Payment Policy CC.PP.066: Physician medical records should chronologically report the care a patient received and record pertinent facts, findings, and observations about the patient’s health history. See our Policy Website Page for full details.
2024 Prior Authorizations Effective in 2024
Procedure Code | Procedure Code Description | New Standard | Line of Business |
19303 | MASTECTOMY, SIMPLE, COMPLETE | Pre-authorization is required for All Providers | Medicaid |