2022 Cost Share Tables and Benefits Information

Reference Material

Prior Authorization Grid

Services considered not reasonable and necessary, according to the standards of Original Medicare, are NOT COVERED services.

After copays/coinsurances, Aspire pays the remaining amount of covered charges at 100% of the Medicare Allowable Rate.
Note: Quote Medicare Allowable as stated above when servicing a Provider call and include the information when logging your note.

Benefit Information

Abdominal Aortic Aneurysm Screening

COVERED


Prior Authorization NOT Required


The Following Criteria Must Be Met:

  • Certain risk factors are present

  • A Referral from the member's physician, physician assistant, nurse practitioner, or clinical nurse specialist is on file


Benefit Limit

  • One (1) time screening ultrasound


Cost Share and Authorization Requirements

Acupuncture

COVERED


Prior Authorization NOT Required


Covered Services Include:

Medicare Covered Services

    • For Chronic Low Back Pain

Non-Medicare Covered Services

  • Not for Chronic Low Back Pain


Benefit Limit

Medicare Covered Services

  • 12 visits in 90 days

  • Eight (8) additional visits for patients demonstrating an improvement

  • No more than 20 treatments per year

Non-Medicare Covered Services

  • Dependent on Plan


Additional Information

Chronic Low Back Pain is Defined as:

  • Lasting 12 weeks or longer

  • Nonspecific in that it has no identifiable systemic cause (e.g. not associated with metastic, inflammatory, infectious disease, etc.)

  • Not associated with surgery

  • Not associated with pregnancy


Cost Share and Authorization Requirements - Chronic Low Back

Cost Share and Authorization Requirements - Medicare Covered

Durable Medical Equipment and Related Supplies (DME)

COVERED

Prior Authorization MAY Be Required

All purchases exceeding $500 billed amount

Reference Material

DME Authorization Requirements


Follows Medicare Guidelines.

Covered Services Include, but not limited to:

  • wheelchairs

  • crutches

  • powered mattress systems

  • diabetic supplies

  • hospital bed

  • IV infusion pump

  • speech generating devices

  • nebulizers

  • walkers

  • oxygen equipment (No PA required regardless of billed amount)

  • mobility products: canes, walkers, wheelchairs, and scooters

Medicare Policy on mobility products requires that Medicare Funds are only used to pay for:
  • Mobility needs for daily activities within the home
  • The lowest level of equipment required to accomplish these tasks
  • The most medically appropriate equipment that meets the member's needs, not wants

    • CPAP Supplies and Frequencies

HCPC Description FrequencyA4604 CPA Tubing with Heating Element 1 per 3 moA7027 Combination Oral/Nasal CPAP Mask 1 per 3 moA7028 Replacement Oral Cushion for Oral/Nasal Mask 2 per 1 moA7029 Replacement Nasal Pillows for Oral/Nasal Mask, One Pair 2 per 1 mo


Cost Share and Authorization Requirements


NOT COVERED

Non-Covered DME Items