Prior Approval and Investigational Services

Below is our Commercial and Medicare Advantage Prior Authorization CPT/HCPCS Code List for services and procedures. The list is searchable by CPT/HCPCS code, and may be updated quarterly or when new codes are published by the AMA when applicable.

Commercial and Medicare Advantage Prior Authorization CPT/HCPCS Code List

Please Note: Prior authorization information for medical drug, PT/OT/ST/chiropractic treatment, transplant, outpatient radiology and radiation/oncology services are not included in the above CPT/HCPCS code list.

Prior authorization information for these services can be found in the appropriate list below based on the plan-type of the patient/member.

Individual & Family Plans (Commercial Plans)

Medicare Advantage Plans

Notice of Changes to Prior Authorization Process

We are partnering with eviCore healthcare (eviCore) to manage the prior authorization process for radiation oncology services. This applies to our fully insured and self-funded group members, including those in commercial, individual and Medicare Advantage plans.

The effective date for the updated requirements is dates of service on and after Feb. 1, 2022. eviCore will begin accepting reviews on Jan. 17, 2022.

Prior to these dates, there are no changes in requirements and providers should continue to submit requests to Medical Mutual directly, as they do today, for radiation oncology services.

After the effective date, services performed without an authorization will be denied for payment. Seeking reimbursement from members is not permitted.

Please refer to the Current Procedural Terminology (CPT®) code list of expanded radiation oncology services or under the “Solution Resources” tab.

Providers should verify if authorization exists before they provide services. Services performed in conjunction with a 23-hour observation, emergency room visits, or inpatient hospital stays are not subject to prior authorization requirements.

For additional information regarding this change and medically urgent requests, please read the eviCore Quick Reference Guide or visit the eviCore Medical Mutual website. To register for prior authorization requests visit eviCore’s website.

Requesting Prior Authorization through eviCore

To request prior authorization, access the eviCore web portal and build a case. Prior authorizations will be accepted 24 hours a day, seven days a week, excluding planned down time for system maintenance through the eviCore website. You may also call toll free at 1-888-693-3211 or fax to 1-888-693-3210. eviCore will provide a voice message service for telephone requests received outside the normal operating hours of 8 a.m. to 9 p.m. E.T., Monday through Friday.