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Authorization will be required for commercial EPO, PPO members
April 15, 2022

This article is for providers caring for our members

We’re expanding prior authorization requirements for certain services listed in our medical policies to members in our commercial EPO and PPO plans as of June 1, 2022. These requirements will align with those currently in place for our commercial HMO and POS members.

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Who will need authorization for coverage?

Commercial EPO and PPO plan members who are:

  • Currently using a service listed below and need an approved authorization for continued coverage on or after June 1, 2022
  • Receiving the service on or after June 1, 2022

We’ll accept prior authorization requests up to 30 days before June 1, 2022, so that you can have an approved authorization for any services taking place after the effective date.

We previously communicated this change last September and delayed the effective date until this June.

Which services will require authorization?
For these services Please request authorization
Continuous glucose monitors
(Codes: A9277, K0553, S1036)
Following the same method you use today for HMO/POS members.

Refer to our Continuous or Intermittent Monitoring of Glucose in Interstitial Fluid and Artificial Pancreas Device Systems medical policy 107.

Remember: Authorization is required on an annual basis.
Spine surgeries using InterQual SmartSheets for:
  • Anterior Cervical Discectomy and Fusion (ACDF)
  • Discectomy, Percutaneous, Lumbar
  • Fusion (with Laminectomy), Cervical
  • Fusion (with Laminectomy), Lumbar
  • Fusion (with Laminectomy), Thoracic
  • Fusion, Cervical Spine
  • Fusion, Lumbar Spine
  • Fusion, Thoracic Spine
  • Hemilaminectomy (Laminotomy) +/- Discectomy, Cervical
  • Hemilaminectomy (Laminotomy) +/- Discectomy, Lumbar
  • Laminectomy (with Fusion), Cervical
  • Laminectomy (with Fusion), Lumbar
  • Laminectomy (with Fusion), Thoracic
  • Laminectomy, Cervical
  • Laminectomy, Lumbar
  • Laminectomy, Thoracic

Following the same method you use today for HMO/POS members.

Other services (refer to list of codes) Following the same method you use today for HMO/POS members.
Instructions for using Authorization Manager

As always, we recommend checking member benefits and eligibility to determine any authorization requirements. You can use Authorization Manager, available on Provider Central, to check any authorization requirements by entering the procedure code.  

You can learn more about how to request authorization on our Authorization Manager page (scroll to our Guides and video demonstrations section) or view our Authorization Manager User Guide.

  • If you have questions about whether a service requires prior authorization, use Authorization Manager to look it up by CPT or HCPCS code first.
  • If you aren’t able to get the information using Authorization Manager, you may call Clinical Intake at 1-800-327-6716.

As always, thank you for the care you provide to our members.