Transcription of MEDICARE ADVANTAGE AUTHORIZATION REQUIREMENTS
1 MEDICARE ADVANTAGE AUTHORIZATION REQUIREMENTS For dates of service on or after October 1, 2023. These AUTHORIZATION REQUIREMENTS apply to all Cigna Healthcare MEDICARE ADVANTAGE markets. This document lists services, items and medications that AUTHORIZATION REQUIREMENTS require AUTHORIZATION prior to being provided or When required, it is the provider's responsibility to obtain administered to Cigna Healthcare MEDICARE ADVANTAGE AUTHORIZATION prior to services being rendered. Facilities are Plan customers. encouraged to verify that a prior AUTHORIZATION has been Any code included on this list requires AUTHORIZATION approved before providing a service or item, unless the regardless of how it is classified on this document. service is urgent or emergent care. Payment may be denied AUTHORIZATION is not required for emergency or for services rendered without AUTHORIZATION . urgent care. All final decisions concerning coverage and payment are Some services are managed by our external delegate, based on plan, customer eligibility, the customer's benefits, eviCore.
2 Please see the eviCore website for more details: the care provider's contract and applicable state law at the time of service delivery. An AUTHORIZATION number or referral number is not a guarantee of payment. Please always All SNF, IRF, LTAC and home health requests are managed verify benefits. by eviCore. Please visit for more details. AUTHORIZATION requests can be submitted by phone, by fax or Exception: Arizona home health requests are managed via web-based HS Connect (HSC) (HSC not currently by Professional Health Care Network available for Arizona). For an overview of capabilities and instructions for obtaining access, visit the HSC section of the All DME requests (with the exception of Arizona) are Provider Manual at managed by eviCore. Please visit medicareproviders-cigna-com/docs/medicar e-provider- Cigna for more details. Services must be provided according to MEDICARE coverage guidelines established by the CMS.
3 According to the guidelines, all medical care, services, supplies and equipment must be medically necessary. You may review Refer to the online directory at Provider MEDICARE coverage guidelines at Search Online Directory. To locate an in-network health care Arizona Delegated Vendors professional or facility, please call the provider The Arizona market has specially delegated vendors for customer service line for your market. certain services. Please contact these vendors for their Arizona: delegated services: American Specialty Health (ASH) Chiropractic and All other markets: acupuncture eviCore Cardiology, high-tech radiology, nuclear cardiology and radiation therapy Coram Home Infusion Home infusion services Professional Health Care Network (PHCN) Home health care 979322 10/23 2023 Cigna Healthcare. Some content provided under license. PCOMM-2023-1610. Referral policy Cigna Healthcare values the relationship between the patient, the primary care physician (PCP) and other providers involved in the patient's medical care.
4 Our network of specialty physicians are contracted to work closely with our referring PCPs to coordinate and improve the quality of care provided to your Cigna Healthcare MEDICARE ADVANTAGE patients. In 2023, a referral may or may not be required for a patient to see a specialist. Please refer to the 2023 Provider Manuals to determine if a referral is required for your patient. For easy searching, hit Ctrl+F on your keyboard and type the five-digit code you are searching for. Universal AUTHORIZATION REQUIREMENTS All inpatient admissions, including: AUTHORIZATION is not required to visit an out-of-network provider for PPO customers; however, any services and procedures listed on this Inpatient medical and document still require AUTHORIZATION regardless of provider network behavioral health status Inpatient rehabilitation Supplemental Benefit Transportation requests for travel more than LTAC. 60 miles; Requests for travel less than 60 miles do not require prior Inpatient observation AUTHORIZATION unless specified on this grid SNF All transplant requests All home health care Behavioral Health Partial Hospitalization Program Out-of-network requests for HMO and POS Genetic testing customers, unless at urgent care, emergency room or behavioral health NONSURG ICAL.
5 Emergency setting Ambulance A0430 A0431 A0435 A0999. Cardiology Catheter Procedures 0793T 93451 93452 93453 93569. 93573 93574 93575 93593 93594. 93595 93596 93597 C7516 C7517. C7518 C7519 C7520 C7521 C7522. C7523 C7524 C7525 C7526 C7527. C7528 C7529 C7552 C7553. Devices 0571T 93590 93591 93799. Stress 93350 93351. Diagnostic Services Cardiovascular 0076T 0807T 0808T 35400 78429. 78430 78431 78432 78433 78434. Gastrointestinal 0780T 0108U 0114U 48400 91110. 91111 91112. Genitourinary 0546T. Invasive 0075T 36660 42975 93456 93461. 93619 93620 93624 93644 93653. 93654 93656. Neurologic 0358U 95999. 2. Diagnostic Services (continued). Other 0113U 0120U 0129U 0130U 0131U. 0132U 0133U 0134U 0135U 0794T. 81162. Durable Medical Equipment All DME is managed by eviCore. Please visit for more details. Arizona plans: Please contact the health plan. Home Health Home health is managed by eviCore. Please visit for more details.
6 Arizona plans: Please contact the appropriate vendor listed on page 1 of this document. Laboratory (Includes Genetic Testing). 0001U 0005U 0008U 0010U 0011M. 0012M 0012U 0013M 0014U 0016M. 0018U 0019U 0022U 0026U 0029U. 0036U 0037U 0045U 0047U 0048U. 0050U 0053U 0055U 0056U 0060U. NONSURG ICAL. 0068U 0070U 0071U 0079U 0080U. 0084U 0086U 0087U 0088U 0089U. 0090U 0094U 0096U 0097U 0101U. 0102U 0103U 0111U 0152U 0153U. 0156U 0170U 0172U 0175U 0179U. 0203U 0204U 0207U 0211U 0212U. 0213U 0214U 0215U 0217U 0231U. 0234U 0236U 0237U 0238U 0239U. 0242U 0244U 0245U 0250U 0258U. 0295U 0301U 0302U 0315U 0337U. 0344U 0361U 0378U 0403U 0537T. 0538T 0539T 0540T 81120 81121. 81161 81163 81164 81165 81166. 81170 81173 81175 81176 81177. 81178 81179 81180 81183 81184. 81191 81194 81201 81203 81206. 81207 81208 81210 81216 81218. 81219 81220 81223 81225 81226. 81227 81228 81229 81230 81231. 81232 81233 81235 81236 81238. 81240 81241 81242 81245 81246.
7 81249 81250 81251 81256 81257. 81259 81261 81257 81259 81261. 3. Laboratory (Includes Genetic Testing) (continued). 81262 81263 81270 81272 81275. 81276 81277 81279 81283 81286. 81287 81288 81291 81292 81294. 81295 81297 81298 81300 81301. 81302 81306 81307 81309 81310. 81311 81312 81314 81317 81319. 81321 81323 81324 81325 81328. 81329 81332 81334 81335 81338. 81339 81340 81342 81344 81347. 81350 81351 81352 81355 81363. 81364 81370 81372 81373 81374. 81378 81380 81381 81382 81383. 81400 81401 81402 81403 81404. 81405 81406 81407 81408 81410. 81411 81412 81413 81414 81415. 81416 81418 81420 81422 81425. 81426 81427 81430 81431 81432. NONSURG ICAL. 81433 81434 81435 81436 81437. 81439 81440 81441 81442 81443. 81445 81448 81449 81450 81451. 81455 81456 81460 81465 81470. 81471 81479 81490 81493 81503. 81504 81509 81518 81519 81520. 81521 81522 81523 81525 81529. 81535 81538 81539 81540 81541. 81542 81546 81551 81552 81554.
8 81595 81596 81599 84433 86849. 87468 87469 87478 87484 87467. G9143. Mental Health G0410 G0411. Musculoskeletal Program 0777T 20985 23000 23020 23106. 23120 23130 23145 23155 23172. 23174 23415 23430 23440 23450. 23455 23460 23465 23466 23490. 23802 27033 27331 27332 27333. 27334 27335 27340 27347 27355. 27356 27357 27358 27360 27403. 27405 27407 27409 27412 27415. 27416 27418 27422 27424 27425. 4. Musculoskeletal Program (continued). 27427 27428 27429 27438 27440. 27441 27443 29805 29819 29821. 29822 29823 29824 29825 29826. 29827 29850 29851 29860 29861. 29863 29867 29868 29870 29871. 29874 29875 29876 29877 29879. 29880 29881 29882 29883 29884. 29886 29887 29888 29889 29914. 62280 62281 62282 62324 62325. 62326 62327 62350 62351 64480. 64484 64494 64495 64510 64520. 64634 64636 C1767 C1772 C1778. C1787 C1816 C1820 C1883 C1897. E0782 E0783 E0785 E0786 G0260. L8680 L8681 L8682 L8683 L8685. L8686 L8687 L8688 L8689.
9 OB/GYN. NONSURG ICAL. 0404T 56620 56631 56632 56633. 56634 56637 56640 57111 57156. 57270 57296 57305 57307 57308. 57311 57426 57531 57540 57545. 57700 58140 58146 58152 58180. 58240 58263 58267 58275 58280. 58285 58353 58400 58410 58520. 58552 58540 58572 58671 58578. 58605 58611 58670 58750 58700. 58740 58752 58760 58822 58825. 58940 58943 58950 58951 58952. 58958 59136 59120 59121 59130. 59140 59325 59350 59514 59525. 59852 59620 59830 59850 59851. 59855 59856 59857. Ophthalmology 0402T 0616T 0617T 0618T 65710. 65730 65750 65755 65756 65770. 65772 66175 66840 66850 66852. 66920 66940 66983 66986 66999. 67900 67901 67902 67903 67904. 67908 68360. 5. Opioid Treatment G2067 G2078. Other 0011U 0342T 19296 19298 21240. 21247 21248 21249 21255 21268. 22207 22210 22214 22220 22222. 22224 27590 27591 27592 27596. 27645 27646 27709 27712 27715. 27724 27725 27726 29804 41019. 64910 99478 99479 99480. Pain Management 0440T 0441T 0442T 27096 62263.
10 62360 62361 62362 63650 63685. 64479 64483 64490 64491 64492. 64493 64633 64635. Part B Drugs, Biologics and Diabetic Testing Supplies ^Step therapy: These A4238 A4239 A4253~ C9047 C9157. NONSURG ICAL. codes require the Drugs/ C9353 C9399 E0607~ E0784 E2103. Biologics Part B. Precertification form J0129 J0135 J0172 J0174 J0178^. for Step Therapy at J0179^ J0180 J0202 J0218 J0219. MedicareProviders. J0220 J0221 J0222 J0223 J0224. J0225 J0256 J0257 J0349 J0480. ~No AUTHORIZATION is required for Abbott J0485 J0490 J0491 J0517 J0567. and LifeScan devices. J0584 J0585 J0586 J0587 J0588. All other devices J0596 J0606 J0641 J0642 J0717. for this code require prior AUTHORIZATION . J0725 J0775 J0791 J0801 J0802. J0881 J0882 J0885 J0887 J0888. J0896 J0897 J1300 J1302 J1303. J1305 J1306 J1322 J1437^ J1438. J1439^ J1442^ J1447^ J1448 J1449^. J1458 J1459 J1551 J1554 J1555. J1556 J1557 J1558 J1559 J1561. J1566 J1568 J1569 J1572 J1575.
