UnitedHealthcare Medicare Advantage Cardiology Prior Authorization Program
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1 Electrophysiology Implant Classification Table The table below contains the codes that apply to our UnitedHealthcare Medicare Advantage cardiology prior Description Includes Generator Placement Includes Lead Placement Includes Removal of Existing Device Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); atrial Yes Yes No Pacemaker Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); ventricular Insertion of new or replacement of permanent pacemaker with transvenous electrode(s); atrial and ventricular Device Type Yes Yes No Pacemaker Yes Yes No Pacemaker/ CRT Insertion of pacemaker pulse generator only; with existing single lead Yes No No Pacemaker Insertion of pacemaker pulse generator only; with existing dual leads Yes No No Pacemaker Upgrade of implanted pacemaker system, conversion of single chamber system to dual chamber system (includes removal of previously placed pulse generator, testing of existing lead, insertion of new lead, insertion of new generator) Yes Yes Yes Pacemaker Insertion of pacemaker pulse generator only; with existing multiple leads Yes No No CRT Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, w/ attachment to previously placed pacemaker or implantable defibrillator pulse generator (including revision of pocket, removal, insertion, and/or replacement of existing generator) Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertion of implantable defibrillator or pacemaker pulse generator (eg, for upgrade to dual chamber system) (List separately in addition to code for primary procedure) generator; single lead system generator; dual lead system generator; multiple lead system Yes Yes Yes CRT Yes Yes No CRT Yes No Yes Pacemaker Yes No Yes Pacemaker Yes No Yes CRT Insertion of implantable defibrillator pulse generator only; with existing dual leads Yes No No ICD Insertion of implantable defibrillator pulse generator only; with existing multiple Yes No No CRT Insertion of implantable defibrillator pulse generator only; with existing single lead Yes No No ICD Insertion or replacement of permanent implantable defibrillator system, with transvenous lead(s), single or dual chamber pulse generator; single lead system pulse generator; dual lead system pulse generator; multiple lead system Insertion or replacement of permanent subcutaneous implantable defibrillator system, with subcutaneous electrode, including defibrillation threshold evaluation, induction of arrhythmia, evaluation of sensing for arrhythmia termination, and programming or reprogramming of sensing or therapeutic parameters, when performed. Yes Yes No ICD/CRT Yes No Yes ICD Yes No Yes ICD Yes No Yes CRT Yes Yes Yes ICD 1
2 Diagnostic Catheterization Classification Table The table below contains the codes that apply to our UnitedHealthcare Medicare Advantage cardiology prior Description Left heart catheterization including intraprocedural injection(s) for left ventriculography, imaging supervision and interpretation, when performed Combined right and left heart catheterization including intraprocedural injection(s) for left ventriculography, imaging supervision and interpretation, when performed supervision and interpretation supervision and interpretation; with catheter placement(s) in bypass graft(s) (internal mammary, free arterial venous grafts) including intraprocedural injection(s) for bypass graft angiography supervision and interpretation; with right heart catheterization supervision and interpretation; with catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) including intraprocedural injection(s) for bypass graft angiography and right heart catheterization supervision and interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed supervision and interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed, catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) with bypass graft angiography supervision and interpretation; with right and left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed supervision and interpretation; with right and left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed, catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) with bypass graft angiography 2
3 Stress Echocardiography Classification Table The table below contains the codes that apply to our UnitedHealthcare Medicare Advantage cardiology prior Description Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report; including performance of continuous electrocardiographic monitoring, with supervision by a physician or other qualified health care professional 3
4 Diagnostic Catheterization Crosswalk Table The following table contains codes that are interchangeable for prior authorization. Substitution is appropriate if a care provider obtains prior authorization for a procedure that corresponds with this Crosswalk Table. You can verify if prior authorization is required or initiate a request by calling Diagnostic Catheterization Crosswalk Prior Authorization Given With This Description Left heart catheterization including intraprocedural injection(s) for left ventriculography, imaging supervision and interpretation, when performed Claim Submitted With This Will Be Allowed Combined right and left heart catheterization including intraprocedural injection(s) for left ventriculography, imaging supervision and interpretation, when performed angiography, imaging supervision and interpretation 93452; ; angiography, imaging supervision and interpretation; with catheter placement(s) in bypass graft(s) (internal mammary, free arterial venous grafts) including intraprocedural injection(s) for bypass graft angiography ; angiography, imaging supervision and interpretation; with right heart catheterization ; angiography, imaging supervision and interpretation; with catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) including intraprocedural injection(s) for bypass graft angiography and right heart catheterization ; angiography, imaging supervision and interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed ; angiography, imaging supervision and interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed, catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) with bypass graft angiography angiography, imaging supervision and interpretation; with right and left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed ; ; angiography, imaging supervision and interpretation; with right and left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed, catheter placement(s) in bypass graft(s) (internal mammary, free arterial, venous grafts) with bypass graft angiography Please note: There are no substitute codes for electrophysiology implant procedures. 4
5 UnitedHealthcare Medicare Stress Echocardiogram Crosswalk Table The following table contains codes that are interchangeable for prior authorization. Substitution is appropriate if a care provider obtains prior authorization for a procedure that corresponds with this Crosswalk Table. You can verify if prior authorization is required or initiate a request by calling Stress Echocardiogram Prior Authorization Given With This Description Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation Claim Submitted With This Will Be Allowed descriptions see Page descriptions see Page 3. Please note: There are no substitute codes for electrophysiology implant procedures. 5
UnitedHealthcare, UnitedHealthcare of the River Valley and Neighborhood Health Partnership Cardiology Notification and Prior Authorization Program:
Notification and Prior Authorization Program: Electrophysiology Implant Classification Table The following chart contains the codes that require notification or prior authorization as part of UnitedHealthcare
UnitedHealthcare, UnitedHealthcare of the River Valley and Neighborhood Health Partnership Cardiology Notification and Prior Authorization Program:
UnitedHealthcare, UnitedHealthcare of the River Valley and Neighborhood Health Partnership Cardiology Notification and Prior Authorization Program: Electrophysiology Implant Code Classification Table The
evicore cardiology procedures and services requiring prior authorization
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