Evolent
Sunshine Health has contracted with Evolent for Musculoskeletal Surgical Procedures for Ambetter (Marketplace), Allwell and Wellcare (Medicare), Medicaid and Children’s Medical Services (CMS) Health Plan.
The program is designed to work collaboratively with physicians to promote patient safety through the practice of high quality and cost-effective care for our members.
Sunshine Health oversees the Musculoskeletal Surgical Quality and Safety Management Program and is responsible for claims adjudication. Prior Authorization for medical necessity and appropriate length of stay (when applicable) has been delegated to Evolent. and will be required for the following surgical procedures (and CPT codes) in both inpatient and outpatient settings.
Musculoskeletal
Orthopedic Surgical Procedures
Including all associated partial, total and revision surgeries
- Knee Arthroplasty
- Unicompartmental/Bicompartmental Knee Replacement
- Hip Arthroplasty
- Shoulder Arthroplasty
- Acromioplasty and Rotator Cuff Repair
- Anterior Cruciate Ligament Repair
- Knee Arthroscopy
- Hip Resurfacing
- Meniscal Repair
- Hip Arthroscopy
- Femoroacetabular Arthroscopy
- Shoulder Fusion
- Osteochondral Defect Repair
Spinal Surgical Procedures
Including all associated partial, total and revision surgeries
- Spinal Fusion Surgeries
- Cervical
- Lumbar
- Thoracic
- Sacral
- Scoliosis
- Disc Replacement
- Laminectomy/Discectomy
- Kyphoplasty/Vertebroplasty
- Sacroiliac Joint Fusion
- Implantable Pain Pumps
- Spinal Cord Neurostimulator
- Spinal Decompression
NOTE: The coding sets identified below are subject to quarterly additions/deletions per CMS guidelines. To account for these changes, or any inadvertent omissions directly related to the procedures on the Evolent Clinical Scope of Services, codes may be added or deleted throughout the term of the program.