Musculoskeletal Management and Interventional Pain Management Program: Transition of Utilization Review to NIA Effective for Service Dates beginning January 1, 2024
All of us at Wellcare are committed to continuous improvement of quality services for our members. With that in mind, Wellcare has entered into an expanded partnership with National Imaging Associates, Inc. (NIA)1, to implement a new Musculoskeletal (MSK) Management program, to include Interventional spine Pain Management (IPM) services.
This MSK program includes prior authorization for non-emergent outpatient IPM services, and inpatient and outpatient hip, knee, shoulder, lumbar, and cervical spine surgeries for Wellcare Medicare members. The decision to implement this program is consistent with industry-wide efforts to ensure clinically appropriate quality of care and to manage the increasing utilization of these services. For complete CPT/HCPCS code listing, please see the Online Authorization Lookup Tool.
There will be no change to claim submission requirements or inpatient notification of facility admission and elective inpatient admission prior authorization requirements.
Under terms of the agreement between Wellcare and NIA:
- Wellcare will oversee the MSK program and continue to be responsible for claims adjudication and medical policies.
- NIA manages IPM services and inpatient and outpatient MSK surgeries through the existing contractual relationships with Wellcare.
Providers may begin contacting NIA on January 1, 2024, to seek prior authorization for MSK procedures scheduled on or after January 1, 2024.
The following outlines the specific procedures requiring prior authorization.
IPM Component: Prior authorization is required for the following non-emergent outpatient IPM services:
- Spinal Epidural Injections
- Paravertebral Facet Joint Injections or Blocks
- Paravertebral Facet Joint Denervation (Radiofrequency (RF) Neurolysis)
- Sacroiliac Joint Injections
- Sympathetic Nerve Blocks
- Spinal Cord Stimulators
MSK Surgeries: Prior authorization will be required for the following non-emergent inpatient and outpatient hip, knee, shoulder, lumbar, and cervical spine:
Hip
- Revision/Conversion Hip Arthroplasty
- Total Hip Arthroplasty/Resurfacing
- Femoroacetabular Impingement (FAI) Hip Surgery (includes CAM/pincer & labral repair)
- Hip Surgery – Other (includes synovectomy, loose body removal, debridement, diagnostic hip arthroscopy, and extra-articular arthroscopy knee)
Knee
- Revision Knee Arthroplasty
- Total Knee Arthroplasty (TKA)
- Partial-Unicompartmental Knee Arthroplasty (UKA)
- Knee Manipulation under Anesthesia (MUA)
- Knee Ligament Reconstruction/Repair
- Knee Meniscectomy/Meniscal Repair/Meniscal Transplant
- Knee Surgery – Other (includes synovectomy, loose body removal, diagnostic knee arthroscopy, debridement with or without chondroplasty, lateral release/patellar realignment, articular cartilage restoration)
Shoulder
- Revision Shoulder Arthroplasty
- Total/Reverse Shoulder Arthroplasty or Resurfacing
- Partial Shoulder Arthroplasty/Hemiarthroplasty
- Shoulder Rotator Cuff Repair
- Shoulder Labral Repair
- Frozen Shoulder Repair/Adhesive Capsulitis
- Shoulder Surgery – Other (includes debridement, manipulation, decompression, tenotomy, tenodesis, synovectomy, claviculectomy, diagnostic shoulder arthroscopy)
Lumbar
- Lumbar Microdiscectomy
- Lumbar Decompression (Laminotomy, Laminectomy, Facetectomy and Foraminotomy)
- Lumbar Spine Fusion (Arthrodesis) with or without Decompression – Single and Multiple Levels
- Sacroiliac Joint Fusion
Cervical
- Cervical Anterior Decompression with Fusion – (Single and Multiple Levels)
- Cervical Posterior Decompression with Fusion – (Single and Multiple Levels)
- Cervical Posterior Decompression (without fusion)
- Cervical Artificial Disc Replacement
- Cervical Anterior Decompression (without fusion)
KEY PROVISIONS:
- It is the responsibility of the ordering physician to obtain prior authorization for all IPM procedures and MSK surgeries managed by NIA.
- The ordering physician must obtain prior authorization with NIA prior to performing the surgery/procedure.
- Facility admissions do not require a separate prior authorization. However, the facility should ensure that an NIA prior authorization has been obtained prior to scheduling the surgery/procedure.
- NIA does not manage prior authorization for emergency MSK surgery cases that are admitted through the emergency room or for MSK surgery procedures outside of those procedures listed above.
Effective April 1, 2024, these additional procedure codes will require prior authorization for outpatient settings.
We appreciate your support and look forward to your assistance in assuring that Wellcare members receive MSK services delivered in a quality, clinically appropriate fashion.
This bulletin serves as notice under your Participating WellCare Provider Agreement of changes to the program.
Should you have questions, please contact Wellcare Provider Services Department at 1-833-444-9088.
Provider Quick Reference Guide can be located in the Overview & Resources section of Wellcare Provider Resources webpage.
Contact National Imaging Associates for authorization: National Imaging Associates Provider Web Portal or phone: 1-800-424-5388.
