Rocky Mountain Health Plans

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1 Rocky Mountain Health Plans Procedures that Require Prior Authorization Revised 12/29/16 The procedures for which Rocky Mountain Health Plans requires prior authorization include the list below. If you have questions about whether a procedure requires prior authorization, contact a Rocky Mountain Customer Service Representative. PPO and Indemnity Members: The services on the lists require authorization. HMO Members: In addition to the services on the lists, all other non-emergent services that you receive from non-network physicians, laboratories, facilities, or other providers must be approved by RMHP. Other items that require preauthorization are listed under DME and Prescription Drugs. Ambulance Transport that is not an Emergency Obtain authorization before you schedule ambulance transportation. This does not apply to urgent or emergent transportation, but only when services are scheduled in advanced. Behavioral Health Services Medicaid Prime Members: Call the Behavioral Health Organization (BHO) Colorado Health Partnerships at Follow process per Colorado State Department of Health Care Policy & Financing (HCPF). All other Members: You do not need a referral or preauthorization to see RMHP participating behavioral healthcare providers. Certain procedures do require preauthorization. Contact Beacon Health for all services at Services to Preauthorize + Applied Behavioral Analysis (ABA) for treatment of Autism + Intensive outpatient treatment + Electric shock therapy + Psychological or neurological testing - No prior authorization is required for IMPACT test following a head injury + In-home outpatient services for a mental health diagnosis Transcranial magnetic stimulation for depression/other neurologic disorders Cardiovascular + Prolonged cardiac monitoring such as event monitoring, loop recording, implanted cardiac event monitoring, including programming and interrogation of the monitor. 1 rmhp.org

2 + Implantation of catheter-delivered prosthetic pulmonary valve, endovascular approach. + Insertion, removal, repositioning of SQ implantable defibrillator + Partial left ventriculectomy (e.g., Batista Procedure) + Percutaneous transcatheter closure of left atrial appendage w/implant + Photopheresis, extracorporeal + Programming device evaluation and/or adjustment + Signal averaged ECG + Therapeutic apheresis; with extracorporeal selective adsorption or selective filtration and plasma reinfusion + Transcatheter aortic valve replacement + Transcatheter insertion of stent of common carotid artery or innominate artery via percutaneous approach + Transcatheter mitral valve repair with prosthetic valve via percutaneous approach + Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when performed; initial prosthesis. + Transcatheter placement of extracranial vertebral or intrathoracic carotid artery stent(s). + Transcatheter placement of wireless physiologic sensor aneurysmal sac endovascular repair. Valvuloplasty Dental and Orthodontic Related Services All dental and orthodontic services, including surrounding services such as anesthesia, facility, or appliances. Please refer to your Evidence of Coverage or contact Customer Service to determine if dental services are covered. Dermatology + Photodynamic therapy for the treatment of skin lesions other than actinic keratosis or Bowen's Disease (e.g. Levualn Kerastick and Metvix CureLight): Total Body Integumentary Photography, for monitoring of high risk patients with dysplastic nevus syndrome or a history of dysplastic nevi, or patients with a personal or familial history of melanoma. Diagnostic Imaging Breast Tomosynthesis - Submit request to RMHP All other imaging procedures: Use this list when the procedure will be performed outside of Delta, or Montrose county and within Colorado. Submit request to evicore healthcare: Phone: CT Scans + CT Angiography + CT Colonography + Magnetic Resonance Angiography (MRA) 2 rmhp.org

3 + Magnetic Resonance Imaging (MRI) + Magnetic Resonance Spectroscopy + Magnetic Source Imaging (MSI) somatosensory testing 3D rendering of CT Scan, MRI, US or other tomographic modality + Nuclear Cardiology + Nuclear Medicine + PET Scans Gastrointestinal Endoscopic Ultrasound All other imaging procedures: Use this list when the procedure will be performed in Delta, or Montrose county or outside of Colorado. Submit request to RMHP: Fax: or CT Angiography + CT Colonography + Electron Beam CT Scans + Functional MRI + PET Scans SPECT Scan of the Brain Ear, Nose, or Throat Procedures + Osseointegrated hearing device, implantation or replacement Commercial and CHP+ Members and RMHP Medicare Members only Medicaid Prime Members - Submit per HCPF direction + Cochlear device implant + Rhinoplasty with or without septal repair - except for nasal deformity secondary to congenital cleft lip and/or palate + Nasal/sinus endoscopy, with dilatation (balloon dilatation) + Nasal function studies, e.g., rhinomanometry + Surgeries and Procedures for snoring, obstructive sleep apnea syndrome, and upper airway resistance syndrome in adults Partial glossectomy Hemiglossectomy Repose tongue suspension system Submucosal ablation of tongue base, radiofrequency (radiofrequency assisted uvulopalatoplasty (RAUP); Submucosal radiofrequency uvulopalatoplasty (SRUP), Somnoplasty, Tongue reduction surgery) Uvulectomy; Uvulopalatopharyngoplasty (UPPP) 3 rmhp.org

4 Fetal Surgery + Fetal umbilical cord occlusion + Fetal fluid drainage (eg, vesicocentesis, thoracocentesis, paracentesis) + Fetal shunt placement + Unlisted fetal invasive procedure Other fetal surgeries may be considered to be experimental. Refer to the experimental procedure secton Gastroenterology/General Surgery + Abdominoplasty, Lipectomy, Panniculectomy + Bioimpedance spectroscopy + Breast related procedures: Reconstruction, Reduction, Augmentation, Breast Implant or Removal, Removal or Replacement of tissue expander (No prior authorization required if Member has had a medically necessary mastectomy) + Electrogastrography, diagnostic, transcutaneous OR with provocative testing + Gastric Electrical Stimulation: Implantation, replacement, or removal or gastric neurostimulator electrodes, antrum; laparscopic or open. Insertion, replacement, or removal of peripheral or gastric neurostimulator pulse generator or receiver Electronic analysis of gastric neurostimulator pulse generator/transmitter system. + Gastrointestinal transit and pressure measurement, stomach through colon, wireless capsule, with interpretation and report. + Obesity related surgeries: All surgeries related to obesity, including but not limited to bariatric surgeries, lipectomy, or excision of skin due to weight loss + Optical endomicorscopy + Repair of anorectal fistula with plug (e.g., porcine small intestine submucosa (SIS)) + Transesophageal endoscopic therapies for gastroesophageal reflux disease (Stretta procedure, Gatekeeper device and EndoCinch device) Treatment of varicose veins, including but not limited to, radiofrequency ablation, sclerotherapy, stripping and ligation, endolaser therapy. Genetic Testing Contact evicore healthcare at for genetic testing services listed here. To help ensure that you are receiving the most clinically appropriate care, we have partnered with evicore healthcare to review certain outpatient Molecular and Genomic tests. You or your doctor must contact evicore for prior authorization of the Molecular and Genomic tests associated with the CPT codes that are listed, or your claims will be denied. Other Laboratory Tests: Submit requests to RMHP + Allergen specific IgG, quantitative or semi-quantitative, each allergen 4 rmhp.org

5 + Apolipoprotein + Cell enumeration using immunologic selection and identification in fluid specimen (eg, circulating tumor cells in blood); + Cell enumeration using immunologic selection and identification in fluid specimen (eg, circulating tumor cells in blood); interpretation and report + Cellular function assay involving stimulation (eg, mitogen or antigen) and detection of biomarker (eg, ATP) + Coenzyme Q-10 + Exhaled breath condensate ph + FIBROSpect II, HCV, ASH, or NASH FibroSURETM + EXCEPT when used for evaluation of Hepatitis C (Dx B15.0-B19.9; K70.0-K70.9; K73.0-K75.81; K76.0; K76.89; K76.9) + Galectin-3 + Growth stimulation expressed gene 2 (ST2, Interleukin 1 receptor like-1) + Human epididymis protein 4 (HE4) + Leukocyte Histamine Release (LHRT) + Lipoprotein(a) enzyme immunoassay (Lp[a]) + Lipoprotein, blood; electrophoretic separation and quantitation + Lipoprotein, blood; electrophoretic separation and quantitation + Lipoprotein-associated phospholipase A2 (Lp-PLA2, PLAC) + Measurement of Long-chain Omega-3 Fatty Acids in Red Blood Cell + Nephelometry, each analyte not elsewhere specified + Omega-3 fatty acids + Oncoprotein; des-gamma-carboxy-prothrombin (DCP) + Optical endomicroscopic image(s), interpretation and report + Plasma myeloperoxidase (MPO) Thromboxane metabolite(s), including thromboxane if performed, urine GenitoUrinary (Reproductive System, Kidneys, Urinary System) + Biopsies, prostate, needle,transperineal, stereotactic template guided saturation sampling, including imaging guidance + Insertion or replacement of penile prosthesis Implant of neurostimulator electrodes; sacral nerve; Insertion, replacement, or revision of peripheral neurostimulator pulse generator or receiver + Penile revascularization for impotence + Penile venous occlusion surgery + Percutaneous posterior tibial nerve stimulation Temporary prostatic stent (e.g., Spanner stent) 5 rmhp.org

6 Gynecology (GYN) Laparoscopy, surgical, ablation of uterine fibroid(s) Hearing Aids or Repairs + Hearing Aids or Repairs of Hearing Aids for Children less than 18 years of age Commercial and CHP+ Members under 18 years of age. Medicaid members - submit per HCPF direction Interventional Cancer Treatment + Cytoreduction, hyperthermic intraperitoneal chemotherapy (HIPEC) + Cryosurgical ablation of tumors Cryosurgical ablation of tumors other than liver, kidney (50250, 50593) or prostate Percutaneous cryoablation of tumor of bone without imaging guidance + Radiation Oncology Proton Beam Therapy for uveal melanomas Stereotactic body radiation therapy Thoracic target(s) delineation for stereotactic body radiation therapy High dose rate electronic brachytherapy, skin surface application High dose rate electronic brachytherapy, interstitial or intracavitary treatment Radioembolization with Yttrium-90 Microspheres (e.g. SIR-spheres, TheraSpheres) except for unresectable primary hepatocellular carcinoma (HCC) or unresectable metastatic liver tumors Neurosurgery (Brain or Spine) + Bone or Soft Tissue Healing and Fusion Enhancement Products + Intracranial angioplasty/stenting (Neurolink System, Wingspan TM Stent System) + Laminectomy, cervical or lumbar + Magnetoencephalography (MEG)/Magnetic Source Imaging (MSI) (Preauthorization required prior to 10/1/2016) + Percutaneous lumbar discectomy + Spinal arthrodesis, lumbar and cervical, except when done to treat scoliosis. + Total disc arthroplasty (artificial disc) including revision, removal + Spinal cord stimulation Vagus nerve stimulation Nutritional Products + Medical foods + Enteral nutrition 6 rmhp.org

7 + Home parenteral nutrition (TPN); Lipids Inpatient pediatric feeding program Ophthalmology + Corneal hysteresis determination + Electro-oculography with interpretation and report (Preauthorization required prior to 10/1/2016) + Implantation of intrastromal corneal ring segments + Insertion of anterior segment aqueous drainage device, without extraocular reservoir + Insertion of ocular telescope prosthesis including removal of crystalline lens + Keratoprosthesis for refractive error + Oculoplastic Surgery: Blepharoplasty, Eyebrow Ptosis Repair + Probing Nasolacrimal Duct with transluminal ballon catheter dilatation. Applies only when Member is 10 years of age or older. Transpupillary thermoplasty Orthopedic + Arthrodesis, sacroiliac joint, percutaneous or minimally invasive + Arthroplasty, ankle; with implant (total ankle replacement) + Arthroplasty, hip or hip resurfacing (hip replacement/resurfacing) + Arthroplasty, knee (knee replacement) + Arthroplasty, shoulder (shoulder replacement) + Autologous chondrocyte implant, including harvesting of chondrocytes + Arthroscopy, knee, surgical; Meniscal transplantation, medical or lateral + Bone or Soft Tissue Healing and Fusion Enhancement Products + Core hip decompression + Insertion of posterior spinous process distraction device (Xstop) + Intradiscal electrothermal therapy (IDET) + Laminectomy, cervical or lumbar + Low-intensity ultrasound stimulation to aid bone healing, non-invasive (nonoperative) + Open osteochondral autograft, talus + Percutaneous Intradiscal Radiofrequency Thermocoagulation (PIRFT) + Percutaneous lumbar disectomy + Spinal arthrodesis, lumbar and cervical, except when done to treat scoliosis, and related instrumentation Total disc arthroplasty (artificial disc), including revision/removal. Outpatient Services 7 rmhp.org

8 + Actigraphy testing, recording, analysis and interpretation + Allergy immunotherapy; sublingual, oral + Allergy testing: Conjunctival Challenge Test (ophthalmic mucous membrane test) + Allergy testing: Direct nasal mucous membrane testing + Bone Growth Stimulation for bone healing: Electrical or Low intensity US stimulation + Breath condensate test for asthma and other respiratory disorders + Brachytherapy to reduce risk of a de novo restenosis in conjunction with a PTCA, with or without stent placement + Bronchoscopy, rigid or flexible, with: balloon occlusion, when performed, assessment of air leak, airway sizing, and insertion removal of bronchial valve(s) bronchial thermoplasty + Chelation therapy except when used to treat poisoning or toxicity from heavy metals, e.g. lead, arsenic, mercury + Cineradiography/videography + Hyperbaric Oxygen Therapy, including topical O2 for wound care + Motor and/or sensory nerve conduction, using preconfigured electrode array(s), amplitude and latency/velocity study, each limb, includes F-wave study when performed, with interpretation and report (Automated point-of-care nerve conduction studies) + Ocular Photoscreening (e.g. Photoscreener), except 12 months through 36 months of age. + Orthoptics (eye exercises) for learning disabilities and traumatic brain injury + Sleep studies: Home sleep study, unattended, Polysomnography, Acoustic pharyngometer (SNAP) testing. (Preauthorization required prior to 10/1/2016) + Therapy - RMHP PRIME Members only. Habilitative: Physical, Occupational, or Speech - Habilitative services will help a person retain, learn, or improve skills and functions for daily living. Habilitative Speech Therapy - Preauthorization needed for adults age 21 or older Habilitative Physical and Occupational Therapy - All habilitative PT/OT services require preauthorization. Rehabilitative: Physical or Occupational - Rehabilitative Services will help restore functional ability that has been lost due to injury or illness. Preauthorization needed for Members UNDER age 21 when exceeding 48 units of any combination of rehabilitative PT/OT per 12 month period. DO NOT SUBMIT REQUESTS FOR ADULTS 21 OR OVER. BENEFIT LIMITS APPLY. + Sensory Integration Therapy CHP+, Commercial, and Medicare Members only Vision therapy for the treatment of learning disabilities and mild traumatic brain injury Pain Management - Spinal Pain + Destruction by neurolytic agent, paravertebral facet joint nerve(s) + Injection(s), paravertebral facet joint or nerves innervating the joint 8 rmhp.org

9 + Percutaneous lysis of epidural adhesions using solution injection or mechanical means (eg, catheter) including radiologic localization, multiple adhesiolysis sessions Spinal manipulation under anesthesia Plastic, Reconstructive, and/or Cosmetic Procedures + Oculoplastic Surgery: Blepharoplasty/Eyebrow Ptosis Repair + Breast related procedures: Reconstruction, Reduction, Augmentation, Breast Implant or Removal, Removal or Replacement of tissue expander (No prior authorization required if Member has had a medically necessary mastectomy). + Abdominoplasty, Lipectomy, Panniculectomy + Laser treatment for inflammatory skin disease, except for diagnosis of psoriasis + Rhinoplasty with/without septal repair - except for nasal deformity secondary to congenital cleft lip and/or palate Treatment of varicose veins, including but not limited to, radiofrequency ablation, sclerotherapy, stripping and ligation, endolaser therapy. Transplant Related Services, Including Initial Consult and Evaluations All transplant services, including artificial heart, beginning with initial physician consultation, transplant evaluation, including testing and transplant procedures (except corneal transplants). Wound Care Clinic + Services provided in a Wound Care Clinic, including but not limited to: Debridement Negative Pressure Wound Therapy Low frequency, non-contact, non-thermal ultrasound Wound Care Products Bioengineered Skin Products, including but not limited to: Affinity, per square centimeter + Alloderm + Allopatch HD; Flex HD + Alloskin + Alloskin AC, per sq cm + Alloskin RT, per sq cm + Allowrap ds or dry, per square centimeter + Amnioband or guardian, per square centimeter + Amnioexcel or Biodexcel, per sq cm + Amniopro, bioskin, biorenew, woundex, amniogen- 45, amniogen-200, per square centimeter + Apligraf + Architect extracellular matrix, per sq cm + Artiss + BioBrane Biosynthetic Dressing + BioDfence, per sq cm + Biovance, per square centimeter + DermACELL, per sq cm 9 rmhp.org

10 + Dermagraft + Dermapure, per square centimeter + DermaSpan + Dermavest, per square centimeter + Epicel + EZderm, per sq cm + GammaGraft, per sq cm + Grafix core, per sq cm + Grafix prime, per sq cm + GRAFTJACKET; GRAFTJACKET Regenerative Tissue Matrix + Helicoll, per square centimeter + hmatrix, per sq cm + Hyalomatirx + Integra Bilayer Matrix Wound Dressing + Integra Dermal Regeneration Template(collagenglycosaminoglycan copolymer + Integra matrix, per sq cm + Integra Meshed Bilayer Wound Matrix + Keramatrix, per square centimeter + Marigen, per square centimeter + Matristem burn matrix + Matristem micromatrix + Matrixtem wound matrix + Mediskin, per sq cm + Memoderm/derma/tranz/integup + Neox 100, per square centimeter + Neox 1k, per sq cm + Neoxflo or clarixflo, 1 mg + Nushield, per square centimeter + Oasis burn matrix, per sq cm + Oasis tri-layer wound matrix + Oasis Wound Matrix + Orcel (bilayered cellular matrix) + Primatrix + Regranex + Revitalon, per square centimeter + Skin substitute, NOS + Talymed + Tensix, per sq cm + Theraskin + TissueMend, per sq cm + TransCyte (allogeneic human dermal fibroblasts) Unite biomatrix Refer to the Potentially Experimental List for additional products Potentially Cosmetic Procedures Surgical procedures often are done to correct a functional defect resulting from an injury, sickness, or surgery, or to correct cleft lip or palate. In many cases, the same procedures might be performed for cosmetic reasons. Procedures that are done for cosmetic reasons are not covered. This includes: + Cosmetic surgery, services or supplies, except to the extent such surgery, services or supplies are provided as a benefit in your Evidence of Coverage. + Reconstructive surgery primarily for improving or correcting a psychological or other non-physical condition. Surgical treatment for obesity or conditions related to obesity. Refer to the prior authorization 10 rmhp.org

11 The Potentially Cosmetic Section of the Prior Authorization List labels the most commonly performed potentially cosmetic procedures so that you will know if the procedures is not covered, requires prior authorization, or will be covered without prior authorization. Review the Potentially Cosmetic Procedures section of the Prior Authorization List. This is not a complete listing of every procedure that could be cosmetic. Procedures that RMHP Considers to be Experimental Review the Experimental Section of the Prior Authorization List. Prior authorization is required for all potentially experimental or investigational procedures. Experimental and/or investigational procedures, items and treatments, including participation in Clinical research studies are generally excluded, but may be covered when mandated by the state or federal law. Treatment and services for complications which are "related to" having received an uncovered experimental or investigational procedure are not covered. "Related to" includes services and supplies that are a part of, made necessary by, or support, the uncovered service or benefit. Rocky Mountain Health Plans reserves the right to change this list at any time without notice. Rocky Mountain Health Plans does not guarantee that this list is complete or current. 11 rmhp.org