Aetna Health Management HMO Products SouthEast Region (Including Arkansas) Medical and Non-Medical Approvals and Denials from 01/01/2018 to 03/31/2018

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1 Aetn Helth Mngement HMO Products SouthEst Region (Including Arknss) Medicl nd Non-Medicl Approvls nd Denils from 0/0/208 to 03/3/208 Code 5840 Inptient Medicl nd Non-Medicl Approvls nd Denils Top 0 Provider/Fcility Types Internl Medicine 688 Obstetrics & Gynecology 43 Fmily Prctice 33 Psychitry 9 Surgery 95 Surgery, Orthopedic 92 Generl Prctice 78 Acute Short Term Hospitl 55 Peditrics 47 Surgery, Neurologicl 44 Top 0 Codes nd Descriptions Code Description MYOMECTOMY, EXCISION OF FIRBROID TUMORS OF UTERUS; ABDOMINAL APPROACH 2 Ambultory Medicl nd Non-Medicl Approvls nd Denils Top 0 Provider/Fcility Types Internl Medicine 59 Applied Behviorl Anlysis 30 Psychitry 27 Surgery, Orthopedic 20 Clinicl Psychologist 9 Surgery, Plstic 9 Fmily Prctice 6 Crdiovsculr Disese 6 Optometrist 4 Surgery 3 Gstroenterology 3 Top 0 Codes nd Descriptions Code Code Description G0379 DIRECT ADMISSION OF PATIENT FOR HOSPITAL OBSERVATION CARE TOTAL KNEE ARTHROPLASTY ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS,LASER, FIRST VEIN TREATED INITIAL HOSPITAL CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A DETAILED OR COMPREHENSIVE HISTORY; A DETAILED OR COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING INJECTION PROCEDURE DURING CARDIAC CATHETERIZATION INCLUDING IMAGING SUPERVISION, INTERPRETATION, AND REPORT; FOR SELECTIVE LEFT VENTRICULAR OR LEFTATRIAL ANGIOGRAPHY H005 ALCOHOL AND/OR DRUG SERVICES; INTENSIVE OUTPATIENT REDUCTION MAMMAPLASTY 3 Pge of 7

2 G INSERTION OF NEW OR REPLACEMENT OF PERMANENT PACEMAKER WITH TRANSVENOUS ELECTRODE(S); ATRIAL AND VENTRICULAR LARYNGOSCOPY, DIRECT, WITH INJECTION INTO VOCAL CORD(S), THERAPEUTIC; WITH OPERATING MICROSCOPE OR TELESCOPE MONITORING FOR LOCALIZATION OF CEREBRAL SEIZURE FOCUS, BY CABLE OR RADIO 6 OR MORE CHANEL TELEMETRY COMBINED ELECTROENCEPHALOGRAPHIC (EEG) AND VIDEO RECORDING AND INTERPRETATION,(EG, PRESURGICAL LOCALIZATION) EACH 24 HOURS AMNIOCENTESIS; THERAPEUTIC AMNIOTIC FLUID REDUCTION (INCLUDES ULTRASOUND GUIDANCE) OBSERVATION OR INPATIENT HOSPITAL CARE, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT INCLUDING ADMISSION AND DISCHARGE ON THE SAME DATE, WHICH REQUIRES THESE 3 KEY COMPONENTS: A DETAILED OR COMPREHENSIVE HISTORY; A DETAILED OR COMPREHENSIVE EXAMINATION DIRECT ADMISSION OF PATIENT FOR HOSPITAL OBSERVATION CARE LAMINECTOMY, FACETECTOMY AND FORAMINOTOMY (UNILATERAL OR BILATERAL WITH DECOMPRESSION OF SPINAL CORD, CAUDA EQUINA AND/OR NERVE ROOT(S), SINGLE VERTEBRAL SEGMENT; EACH ADDITIONAL SEGMENT,CERVICAL, THORACIC OR LUMB HEMILAMINECTOMY; LUMBAR Top 0 Dignosis Codes nd Descriptions ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, RADIOFREQUENCY; FIRST VEIN TREATED H2036 ALCOHOL AND/OR DRUG TREATMENT PROGRAM, PER DIEM PSYCHOLOGICAL TESTING (INCLUDES PSYCHODIAGNOSTIC ASSESSMENT OF EMOTIONALITY, INTELLECTUAL ABILITIES, PERSONALITY AND PSYCHOPATHOLOGY, EG, MMPI, RORSCHACH, WAIS), PER HOUR OF THE PSYCHOLOGIST'S OR PHYSICIAN'S TIME, BOTH FACE-TO-FACE TIME ADMINISTERING TEST 9 BLEPHAROPLASTY, UPPER EYELID; WITH EXCESSIVE SKIN WEIGHTING DOWN LID 8 J8499 PRESCRIPTION DRUG, ORAL, NON CHEMOTHERAPEUTIC 8 J0585 INJECTION, ONABOTULINUMTOXINA, UNIT 7 S9480 INTENSIVE OUTPATIENT PSYCHIATRIC SERVICES, PER DIEM OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF A NEW PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A PROBLEM FOCUSED HISTORY; A PROBLEM FOCUSED EXAMINATION; STRAIGHTFORWARD MEDICAL DECISION MAKING. COUNSELING AND/OR COORDINATION UNLISTED EVALUATION AND MANAGEMENT SERVICE 7 Top 0 Dignosis Codes nd Descriptions Pge 2 of 7

3 Dignosis code Dignosis Code Description J8.9 PNEUMONIA, UNSPECIFIED ORGANISM 54 R07.9 CHEST PAIN 53 R0.9 UNSPECIFIED ABDOMINAL PAIN 52 F0.20 ALCOHOL DEPENDENCE 35 R50.9 FEVER, UNSPECIFIED 30 MAJOR DEPRESSIVE DISORDER, RECURRENT SEVERE WITHOUT F33.2 PSYCHOTIC FEATURES 30 I63.9 CEREBRAL INFARCTION, UNSPECIFIED 28 F32.9 MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE, UNSPECIFIED 27 A4.9 SEPSIS, UNSPECIFIED ORGANISM 23 N39.0 URINARY TRACT INFECTION 23 I2.4 NON-ST ELEVATION (NSTEMI) MYOCARDIAL INFARCTION 23 Top 0 Denil Resons Post - Coverge for the requested dmission is denied - member does not meet criteri 43 Abdominl Pin- Coverge for the requested dmission is denied - member does not meet criteri 28 Chest Pin- Coverge for the requested dmission is denied - member does not meet criteri 24 Cellulitis- Coverge for the requested dmission is denied - member does not meet criteri 6 Pneumoni- Coverge for the requested dmission is denied - member does not meet criteri 6 Systemic or Infectious Condition- Coverge for the requested dmission is denied - member does not meet criteri 2 Asthm - Adult/Peds- Coverge for the requested dmission is denied - member does not meet criteri 8 Dignosis code Dignosis Code Description F84.0 AUTISTIC DISORDER 39 I87.2 VENOUS INSUFFICIENCY (CHRONIC) (PERIPHERAL) 28 F0.20 ALCOHOL DEPENDENCE 8 R07.9 CHEST PAIN, UNSPECIFIED 5 F.20 OPIOID DEPENDENCE 2 B8.2 CHRONIC VIRAL HEPATITIS C N62 HYPERTROPHY OF BREAST 8 Z63.6 DEPENDENT RELATIVE NEEDING CARE AT HOME 7 VARICOSE VEINS OF BILATERAL LOWER EXTREMITIES WITH I OTHER COMPLICATIONS 7 Z85.3 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF BREAST 6 F33.2 MAJOR DEPRESSIVE DISORDER, RECURRENT SEVERE WITHOUT PSYCHOTIC FEATURES 6 Top 0 Denil Resons Network Adequcy Denil: No Out of Network Benefits 8 Not Mediclly Necessry 5 Brest Reduction: Brest Tissue Surfce Are 4 Cervicl lminectomy nd/or ACDF 2 Vricose Veins 2 Uvulopltophryngoplsty (UPPP) Adult 2 GCSF (grnulocyte colony-stimulting fctor) for primry prophylxis Pge 3 of 7

4 Atril Fibrilltion - Coverge for the requested dmission is denied - member does not meet criteri 8 Precert denil of requested post-surgicl dmission 7 Neurologicl- Coverge for the requested dmission is denied - member does not meet criteri 7 Musculoskeletl- Coverge for the requested dmission is denied - member does not meet criteri 7 Botox for Overctive Bldder Vricose Veins - more thn one first vein bltion Cpsule Endoscopy FAI (femoro-cetbulr) hip impingement surgery ge 5+ Pge 4 of 7

5 Aetn Life Insurnce Compny PPO Products SouthEst Region (Including Arknss) Medicl nd Non-Medicl Approvls nd Denils from 0/0/208 to 03/3/208 Inptient Medicl nd Non-Medicl Approvls nd Denils Top 0 Provider/Fcility Types Internl Medicine 666 Psychitry 232 Surgery, Orthopedic 54 Surgery 3 Fmily Prctice 9 Obstetrics & Gynecology 3 Generl Prctice 87 Peditrics 8 Emergency Medicine 60 Crdiovsculr Disese 54 Top 0 Codes nd Descriptions Code Code Description 9595 MONITORING FOR LOCALIZATION OF CEREBRAL SEIZURE FOCUS, BY CABLE OR RADIO 6 OR MORE CHANEL TELEMETRY COMBINED ELECTROENCEPHALOGRAPHIC (EEG) AND VIDEO RECORDING AND INTERPRETATION,(EG, PRESURGICAL LOCALIZATION) EACH 24 HOURS ARTHRODESIS, POSTERIOR OR POSTEROLATERAL TECHNIQUE, SINGLE LEVEL ; LUMBAR (FUSION) URETERONEOCYSTOSTOMY NEUROPLASTY, MAJOR PERIPHERAL NERVE, ARM OR LEG, OPEN; OTHER THAN SPECIFIED Code Ambultory Medicl nd Non-Medicl Approvls nd Denils Top 0 Provider/Fcility Types Psychitry 9 Internl Medicine 55 Surgery, Orthopedic 43 Surgery 39 Applied Behviorl Anlysis 37 Fmily Prctice 34 Clinicl Psychologist 30 Surgery, Neurologicl 28 Surgery, Plstic 20 Opthlmology 9 Top 0 Codes nd Descriptions Code Description H005 ALCOHOL AND/OR DRUG SERVICES; INTENSIVE OUTPATIENT 59 G0379 DIRECT ADMISSION OF PATIENT FOR HOSPITAL OBSERVATION CARE 57 H2036 ALCOHOL AND/OR DRUG TREATMENT PROGRAM, PER DIEM T TECHNICIAN, FACE-TO-FACE WITH ONE PATIENT; FIRST 30 MINUTES OF TECHNICIAN TIME HEMILAMINECTOMY; LUMBAR RECONSTRUCTION MIDFACE, LEFORT I;TWO PIECES, WITHOUT 242 BONE GRAFT ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS, RADIOFREQUENCY; FIRST VEIN TREATED 36 S9480 INTENSIVE OUTPATIENT PSYCHIATRIC SERVICES, PER DIEM 33 Pge 5 of 7

6 296 RECONSTRUCTION OF MANDIBULAR RAMUS, SAGITTAL SPLIT; IN INTERNAL RIGID FIXATION H0035 MENTAL HEALTH PARTIAL HOSPITALIZATION, TREATMENT, LESS THAN 24 HOURS 30 J930 INJECTION, RITUXIMAB, 00 MG ESOPHAGOGASTRODUODENOSCOPY, FLEXIBLE, TRANSORAL; DIAGNOSTIC, INCLUDING COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING, WHEN PERFORMED (SEPARATE PROCEDURE) 0359T BEHAVIOR IDENTIFICATION ASSESSMENT, BY THE PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL, FACE-TO-FACE WITH PATIENT AND CAREGIVER(S),INCLUDES ADMINISTRATION OF STANDARDIZED AND NON-STANDARDIZED TESTS, DETAILED BEHAVIORAL HISTORY, PATIENT OBSERVATION 22 ENDOVENOUS ABLATION THERAPY OF INCOMPETENT VEIN, EXTREMITY, INCLUSIVE OF ALL IMAGING GUIDANCE AND MONITORING, PERCUTANEOUS,LASER, FIRST VEIN TREATED ARTHRODESIS, POSTERIOR INTERBODY TECHNIQUE, SINGLE INTERSPACE; LUMBAR (FUSION) 960 PSYCHOLOGICAL TESTING (INCLUDES PSYCHODIAGNOSTIC ASSESSMENT OF EMOTIONALITY, INTELLECTUAL ABILITIES, PERSONALITY AND PSYCHOPATHOLOGY, EG, MMPI, RORSCHACH, WAIS), PER HOUR OF THE PSYCHOLOGIST'S OR PHYSICIAN'S TIME, BOTH FACE-TO-FACE TIME ADMINISTERING TEST THYROIDECTOMY, REMOVAL OF REMAINING THYROID TISSUE FOLLOWING PREVIOUS REMOVAL OF A PORTION OF THYROID Top 0 Dignosis Codes nd Descriptions Dignosis code Dignosis Code Description F0.20 ALCOHOL DEPENDENCE, UNCOMPLICATED 93 F33.2 MAJOR DEPRESSIVE DISORDER, RECURRENT SEVERE WITHOUT PSYCHOTIC FEATURES 63 J8.9 PNEUMONIA, UNSPECIFIED ORGANISM 60 R07.9 CHEST PAIN 46 R0.9 UNSPECIFIED ABDOMINAL PAIN 46 F.20 OPIOID DEPENDENCE 39 A4.9 SEPSIS, UNSPECIFIED ORGANISM 34 I2.4 NON-ST ELEVATION (NSTEMI) MYOCARDIAL INFARCTION 32 F32.9 MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE 3 Top 0 Dignosis Codes nd Descriptions Dignosis code Dignosis Code Description F84.0 AUTISTIC DISORDER 72 F0.20 ALCOHOL DEPENDENCE 67 F.20 OPIOID DEPENDENCE 25 F33.2 MAJOR DEPRESSIVE DISORDER, RECURRENT SEVERE WITHOUT PSYCHOTIC FEATURES 22 I87.2 VENOUS INSUFFICIENCY (CHRONIC) (PERIPHERAL) 20 B8.2 CHRONIC VIRAL HEPATITIS C 7 I VARICOSE VEINS OF BILATERAL LOWER EXTREMITIES WITH OTHER COMPLICATIONS 5 Z63.6 DEPENDENT RELATIVE NEEDING CARE AT HOME 4 M5.6 INTERVERTEBRAL DISC DISORDERS WITH RADICULOPATHY, LUMBAR REGION 0 Pge 6 of 7

7 R50.9 FEVER 24 K85.90 ACUTE PANCREATITIS WITHOUT NECROSIS OR INFECTION 24 I63.9 CEREBRAL INFARCTION 24 Top 0 Denil Resons Post - Coverge for the requested dmission is denied - member does not meet criteri 32 Abdominl Pin- Coverge for the requested dmission is denied - member does not meet criteri 22 Chest Pin- Coverge for the requested dmission is denied - member does not meet criteri 4 Pneumoni- Coverge for the requested dmission is denied - member does not meet criteri 3 Systemic or Infectious Condition- Coverge for the requested dmission is denied - member does not meet criteri 3 COPD- Coverge for the requested dmission is denied - member does not meet criteri 0 Precert denil of requested post-surgicl dmission 0 Inptient Admit Denil Due to Denil by evicore 0 Neurologicl- Coverge for the requested dmission is denied - member does not meet criteri 8 F90.2 ATTENTION-DEFICIT HYPERACTIVITY DISORDER, COMBINED TYPE 9 F2.20 CANNABIS DEPENDENCE 9 Top 0 Denil Resons Not Mediclly Necessry 6 Level of Cre 0 Investigtionl/Experimentl 5 Vricose Veins: No Duplex/Ultrsound 4 No Info Privte Duty Nursing 4 Non Prticipting 4 Syngis - Greter thn 29 wks, no qulifying conditions-st yr of life 3 Brest Reduction: Brest Tissue Surfce Are 3 Behviorl Helth ABA - Tretment Hours 3 Pge 7 of 7