Medicare AdvantagePrior AuthHigh impact
Evolent Prior Authorization Updates: Effective January 1, 2027
Ambetter·WA · Cardiology, Vascular Surgery·Prior Authorization
Effective date
Jan 1, 2027
We identified it
Aug 26, 2026
Summary
Evolent is adding 24 cardiology procedure codes related to endovascular revascularization (angioplasty, stent placement, and atherectomy) to prior authorization requirements, effective January 1, 2027. These codes cover iliac, femoral/popliteal, and tibial/peroneal vascular territories. All prior authorization requests for these procedures must now be submitted to Evolent Specialty Services through the affected health plans.
Action Required
By December 15, 2026: Billing team must update billing system and prior authorization workflows to require Evolent Specialty Services prior authorization for all 18 cardiology CPT codes (37254, 37256, 37258, 37260, 37263, 37265, 37267, 37269, 37271, 37273, 37275, 37277, 37280, 37282, 37284, 37286, 37288, 37290) when billed to Coordinated Care Medicaid, Ambetter from Coordinated Care Marketplace, or Wellcare Medicare plans. Update encounter templates and provider documentation requirements to flag these codes for mandatory prior authorization. Establish submission process with Evolent Specialty Services contact information. Train all billing and clinical staff on new requirements. Failure to obtain prior authorization will result in claim denials. Contact local Provider Engagement representative for questions about specific codes or implementation.