News

Ambetter Prior Authorization

Date: 04/05/23

Ambetter from Sunflower Health Plan 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 Ambetter products offered by Sunflower Health Plan.

Ambetter from Sunflower Health Plan is 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 the Online Prior Authorization Tool on our website.

Effective June 1, 2023, the following are changes to prior authorization requirements:

Audiology

PA Rule	Services	Procedure Codes
No PA Required	Hearing aid, assistive hearing devices, supplies	V5267

Behavioral Health

PA Rule	Services	Procedure Codes
No PA Required	Behavioral health counseling	S9484
No PA Required	Developmental and behavioral screening	96110, 96112
No PA Required	Alcohol and/or drug services	H0004, H0005, H0007, H0014, S9475
No PA Required	Crisis intervention services	H2011

Breast reconstruction

PA Rule	Services	Procedure Codes
PA Required except with breast cancer diagnosis	Breast reconstruction, prosthesis	19316, 19318, 19325, 19328, 19340, 19342, 19350, 19370, 19371, 19499, L8031

Cardiovascular

PA Rule	Services	Procedure Codes
PA Required	Insertion/removal of Cardiac Rhythm Monitor	33285
PA Required	Revascularization	37220, 37221, 37224, 37225, 37226, 37227, 37228, 37229, 37230, 37231
PA Required	Unlisted procedure	37799
PA Required	Wireless pressure sensor	C2624
PA Required	External counterpulsation	G0166
No PA Required	Catheter	C2623
No PA Required	Cardiac rehab program	G0422, G0423, S9472

Diagnostic and Therapeutic Radiology services

PA Rule	Services	Procedure Codes
No PA Required	Indium In-111 ibritumomab tiuxetan	A9542
No PA Required	Ablation Liver Tumor	47382
No PA Required	Radiation therapy	77372, 77373, G0339, G0340
No PA Required	Radiolabeled item	C9898

DME & Supplies

PA Rule	Services	Procedure Codes
PA Required	Osteogenesis stimulator	E0749
PA Required	Supplies for home delivery of infant	S8415
PA Required	Personal care items	S5199
No PA Required	Infusion pumps and supplies	B9002, E0781, K0455
No PA Required	Respiratory equipment	E0550, E0565
No PA Required	Wheelchair and accessories	E2611, K0001

Ears, Nose, and Throat

PA Rule	Services	Procedure Codes
No PA Required	Otorhinolaryngologic Services	92611
No PA Required	Dysphagia screening	V5364

Home Care

PA Rule	Services	Procedure Codes
PA Required	Home health skilled nursing visit	0551
PA Required	Repair/maintenance for home hemodialysis equipment	A4870, A4890
PA Required	Home Care Management Services	G0087
PA Required	Home therapy	G2168, G2169
PA Required	Unskilled respite care	S5150, S5151
PA Required	Home modifications, meals, laundry	S5175
PA Required	In-home telemonitoring	S9110
PA Required	Nursing assessment/evaluation	T1001
No PA Required	End Stage Renal Disease services	90966, S9335, S9339
No PA Required	Prenatal home visit	99500
No PA Required	Home visits post-discharge and care plan oversight	G2001, G2003, G2004, G2005, G2006, G2007, G2008, G2009, G2013, G2014, G2015
No PA Required	Coordinated care – home monitoring	G9006
No PA Required	Remote in-home visits	G9978, G9979, G9980, G9981, G9982, G9983, G9984, G9985, G9986, G9987
No PA Required	Services, supplies and accessories used in the home	Q2052
No PA Required	Management of patient home care	S0271, S0273, S0274
No PA Required	Medical home program	S0280, S0281
No PA Required	BPCI home visit	G9187
No PA Required	Home care training	S5108, S5109, S5110, S5111, S5115, S5116
No PA Required	Home visit – wound care and phototherapy services	S9097, S9098
No PA Required	Home infusion therapy	S5035, S5036, S9347

Hospice

PA Rule	Services	Procedure Codes
No PA Required	Physician supervision	G0182
No PA Required	Counseling Services	G9473, G9474, G9475, G9476, G9477, G9478, G9479, S0255

Laboratory

PA Rule	Services	Procedure Codes
PA Required	Genetic analysis/studies, surgical pathology procedures	81235, 81263, 81265, 81267, 81268, 81270, 81275, 81310, 81315, 88237, 0089U

Nutrition

PA Rule	Services	Procedure Codes
PA Required	Medical food nutritionally complete (oral)	S9433

Orthopedic

PA Rule	Services	Procedure Codes
PA Required	Procedures lower extremities	28285, 28299
PA Required	Endoscopy wrist	29848

Orthotics and Prosthetics

PA Rule	Services	Procedure Codes
PA Required	Lower extremity orthotics	L1851, L1852
No PA Required	Lower extremity orthotics	L2112

Pain management

PA Rule	Services	Procedure Codes
PA Required unless	Injection, anesthetic agent or steroid	62320, 62321, 62322, 62323, 62325, 62327, 64400, 64405, 64415, 64417, 64418, 64420, 64421, 64430, 64445, 64447, 64448, 64450, 64451, 64454, 64479, 64480, 64483, 64484, 64505, 64510, 64517, 64520, 64530
No PA Required	Transversus abdominis plane (TAP) block	64486, 64488
No PA Required	Nerve block	64632

Professional services

PA Rule	Services	Procedure Codes
No PA Required	Inpatient telehealth	G0459
No PA Required	Drug infusion services	G0068, G0069, G0070

Skin substitute

PA Rule	Services	Procedure Codes
PA Required	Skin substitute products and injectables	Q4114, Q4130, Q4137, Q4139, Q4205, Q4206, Q4208, Q4209, Q4210, Q4211, Q4212, Q4213, Q4214, Q4215, Q4216, Q4217, Q4218, Q4219, Q4220, Q4221, Q4222, Q4226

Surgical

PA Rule	Services	Procedure Codes
No PA Required	Complex repair of eyelids, nose and ears	13153

Transplant

PA Rule	Services	Procedure Codes
PA Required	Small intestine and liver allografts	S2053