Evolent Prior Authorization Updates, Effective April 1, 2026
Date: 03/30/26
As part of Sunshine Health, in partnership with Evolent Specialty Services to manage utilization management, certain prior authorization requirements will be removed effective April 1, 2026.
As part of our ongoing work to improve the prior authorization (PA) process for providers and members, Sunshine Health is removing PA requirements for select Radiology & Diagnostic Cardiology & Cardiology codes.
Radiology & Diagnostic Cardiology (RBM = High Tech/Cardiac Imaging) Codes: 70480,70481,70482, 70487,70488, 70486, 76380, 71250, 71260, 71270, 71271, 73200, 73201, 73202, 73218, 73219, 73220, 73700, 73701, 73702, 74712, 74713, 75557, 75559, 75561, 75563, 75573, 77046, 77047, 77048, 77049, 77078, 77084, 78472, 78473, 78494, 93312, 93313, 93314, 93315, 93316, 93317, 93318
Cardiology Codes: 36218, 36253, 36254, 75580, 75736, 76937, 35583, 35585, 35587, 35621, 35646, 35654, 35656, 35661, 35666, 35671, 35556, 35558, 35566, 35571, 93451, 93505, 93563, 93565, 93566, 93567, 93568, 93571, C1759, 33820, 33215, 33217, 33223, 33405, 35305, 35884, 93580, 93583, 93650, C1732, C1895, 33202, 33218, 33220, 33222, 33224, 33225, 33226, 33227, 33228, 33229, 33233, 33234, 33235, 33236, 33271, 33274, 33275, 33286, 92960, 92961, C1722, C1760, C1785, C1882, C1900, C2621, 93292, K0606, 93662, C1730, 35700, 35881, 35883, 37765, 37766, 33418, 92987, 92997, 93581, 93590, 93591, 36836, 36837, 33475, 33477, 35001, 35011, 35141, 35151, 33361, 33362, 33363, 33364, 33365, 33366, 33369, 93745, 35301, 35302, 35303, 35351, 35355, 35371, 35372, 33465
These updates will create a more uniform set of PA requirements across all health plan offerings, simplify processes, reduce provider confusion, and support future efforts to expand real-time responses to requests. Each of the affected codes provided in this communication is managed on behalf of Sunshine Health by Evolent Specialty Services, our utilization management partner.
If you have questions about specific prior authorization codes or how these changes affect your practice, please reach out to your local Provider Engagement Account Manager (PEAM).
As of April 1, 2026, the following codes for RBM will no longer require PA and will be removed from the Evolent Utilization Review Matrix.
Modality | Allowable Billing Group | CPT |
|---|---|---|
CT ORBIT/EAR/FOSSA WITH O DYE | 70480,70481,70482 | 70480 |
CT MAXLOFCE AREA; W/O CONTRAST MATL | 70487,70488, 70486, 76380 | 70486 |
DIAGNOSTIC COMPUTED TOMOGRAPHY THORAX W/O CNTRST | 71250, 71260, 71270, 71271 | 71250 |
CT UPPER EXTREMITY WITH O DYE | 73200, 73201, 73202 | 73200 |
MRI UPPR EXTREMITY WITH OAND WITH DYE | 73218, 73219, 73220 | 73220 |
CT LOWER EXTREMITY WITH O DYE | 73700, 73701, 73702 | 73700 |
MRI FETAL SNGL/1ST GESTATION | 74712, 74713 | 74712 |
CARDIAC MRI MORPHOLOGY & FUNCTION W/O CONTRAST | 75557, 75559, 75561, 75563 | 75557 |
CT HRT WITH 3D IMAGE CONGEN | 75573 | 75573 |
MRI BREAST WITHOUT CONTRAST MATERIAL UNILATERAL | 77046, 77047, 77048, 77049 | 77046 |
CT BONE MINERL DENSITY STUDY 1/> SITS AXIAL SKE | 77078 | 77078 |
MRI BONE MARROW BLOOD SUPPLY | 77084 | 77084 |
GATED HEART PLANAR SINGLE | 78472, 78473, 78494 | 78472 |
ECHOCRDGRPHY RL TM W/2D W/WO M-MODE, TRANSESOPHAGEAL | 93312, 93313, 93314, 93315, 93316, 93317, 93318 | 93312 |
As of April 1, 2026, the following codes for Cardiology will no longer require PA and will be removed from the Evolent Utilization Review Matrix.
| Modality | Impacted CPT |
|---|---|
ANGIOGRAPHY | 36218, 36253, 36254, 75580, 75736, 76937 |
BYPASS GRAFT IN-SITU VEIN | 35583, 35585, 35587, 35621, 35646, 35654, 35656, 35661, 35666, 35671 |
BYPASS GRAFT VEIN | 35556, 35558, 35566, 35571 |
CARDIAC CATHETERIZATION | 93451, 93505, 93563, 93565, 93566, 93567, 93568, 93571, C1759 |
CONGENITAL HEART DISESE SURGERY | 33820 |
CORONARY ARTERY DISEASE SURGERY | 33215, 33217, 33223, 33405, 35305, 35884, 93580, 93583, 93650, C1732, C1895 |
DEVICE IMPLANTATION/ELECTRICAL CARDIOVERSION | 33202, 33218, 33220, 33222, 33224, 33225, 33226, 33227, 33228, 33229, 33233, 33234, 33235, 33236, 33271, 33274, 33275, 33286, 92960, 92961, C1722, C1760, C1785, C1882, C1900, C2621 |
DEVICE MONITORING | 93292, K0606 |
ELECTROPHYSIOLOGY STUDIES (EPS) | 93662, C1730 |
EXCISION EXPLORATION REPAIR REVISION | 35700, 35881, 35883 |
INTERRUPTION/LIGATION/STRIPPING ETC. | 37765, 37766 |
INTERVENTIONAL CARDIOLOGY | 33418, 92987, 92997, 93581, 93590, 93591 |
INTERVENTIONAL RADIOLOGY | 36836, 36837 |
PULMONARY VALVE SURGERY | 33475, 33477 |
REPAIR/EXCISION FOR ANEURYSM OCCLUSIVE DISEASE ETC. | 35001, 35011, 35141, 35151 |
TAVR | 33361, 33362, 33363, 33364, 33365, 33366, 33369 |
THERAPEUTIC SERVICES | 93745 |
THROMBOENDARTERECTOMY | 35301, 35302, 35303, 35351, 35355, 35371, 35372 |
TRICUSPID VALVE SURGERY | 33465 |
SH_11471