Pre-authorization Form

Transcription

1 Northwest Montana Schools Consortium 2014 Please verify services not listed below on the pre-authorization list with Benefits and Eligibility (Customer Service) to determine coverage. Preauthorization lists do not reflect benefit limitation information or exclusions. The number for Benefits and Eligibility (Customer Service) is located on the member s ID card. Pre-authorization Form Experimental and Investigational services are not covered except as outlined under the Clinical Trials benefit. If a service could be considered experimental and investigational for a given condition, we recommend a benefit determination in advance. Ambulance Air and inter-facility transport require preauthorization, except in life-threatening circumstances Chemical Dependency and Mental Health Inpatient Admissions Residential Treatment Partial Hospitalization Clinical Trials Any treatment provided under a clinical trial Dental Trauma Services Follow up services Dialysis (All) For chronic kidney disease Durable Medical Equipment, Medical Supplies and Prosthetics Bone Growth Simulators Hospital Beds and Traction Custom Fabricated Braces Notes of care provided in transit (ambulance notes). ER notes of care prior to transit if appropriate. Last 3 days of nursing notes/ physician s orders prior to transfer (for inter-facility). Transfer summary for inter-facility transport why private vehicle is not safe. Physician s orders for ambulance transport. Diagnosis/treatment information (primary diagnosis, proposed treatment(s), procedure(s) or service(s), proposed length of stay. Facility name, location, address. Clinical info as soon as available. Physician s order. Documentation of specific request and clinical reasons for Medical condition/diagnosis related to the Clinical documentation supporting the medical necessity of the request Supporting literature/research related to the Documentation of circumstances surrounding the dental trauma (accidental injury). Documentation of planned treatment, including length of time to complete treatment. Clinical Evaluation. Treatment Plan. Physician s order. Documentation of specific reasons for requested equipment. Medical condition/diagnosis related to the equipment. NW Montana Schools Consortium Page 1 of 9

2 Dynamic Splinting Systems Electrical stimulators- Spinal- external Neuromuscular stimulators and TENS Prosthetics Speech Generating Devices Wheelchairs Scooters Cardiac Devices - selected o Ventricular Assist Device o Implantable and Wearable defibrillators Eyelid Surgery Example: Blepharoplasty Genetic Testing Over $500 Hearing Cochlear Implants (covered under surgical benefit) Bone Anchored Hearing Aid (BAHA) Home Health Care Services Home Health care Visits Home Infusion Therapy Enteral Intravenous Clinical documentation supporting the medical necessity of the Anticipated length of need for DME. In the case of equipment with component parts, i.e., wheelchairs statement of medical necessity for individual components (per HCPCS code). History and physical exam which documents: o Frontal and lateral pupil level photographs (straight gaze and lateral) documenting lid and brow position at rest. o Visual fields conducted with and without brow/lid taping, with clear documentation of angle of visual field limitation in report. Letter of request documenting the functional disorder requiring resolution and justifying the procedure proposed. This should be consistent with the objective record. Specific tests being requested. Supporting clinical documentation. Physician s order with diagnosis. Documentation of specific request and clinical reasons for Medical condition/diagnosis related to the Clinical documentation supporting the medical necessity of the Physician order to include diagnosis. Specific disciplines requested, i.e. (RN, PT, OT) and number of visits requested for each discipline. Duration/frequency of services. Clinical documentation of medical necessity for each discipline (i.e., H&P, discharge summary), if available. Documentation of homebound status. Physician order, to include diagnosis, specific drug, formula, dose, length of treatment, codes for drugs/supplies/discipline. Specific disciplines requested, i.e., RN, RD Clinical documentation of medical necessity for each discipline (i.e., H&P, discharge NW Montana Schools Consortium Page 2 of 9

3 Hospice Care Outpatient Inpatient Respite Care Hyperbaric Therapy Imaging Inpatient Hospital Admissions Chemical dependency and mental health admissions (including residential) Hospice* Rehabilitation* Medical/Surgical (excluding routine delivery Skilled Nursing/LTAC* *See individual entries for specific documentation requirements Inpatient Surgeries Lumbar Fusion Shoulder Arthroplasty Total Ankle Replacement Total Hip Replacement Total Knee Replacement Spinal Surgery (Cervical, Thoracic and Lumbar) Inpatient Rehabilitation Admissions summary), if available. Physician order, to include diagnosis, anticipated length of hospice services (prognosis) Specific disciplines requested, i.e. (RN, PT, OT) number and frequency of visits requested for each discipline Clinical documentation of medical necessity for each discipline (i.e. H&P, discharge summary), if available. Physician s order and plan of care. Documentation of specific request and clinical reasons for Medical condition/diagnosis related to the Clinical documentation supporting the medical necessity of the See PET Scans Patient demographics (name, plan ID number, date of birth). PCP/attending physician name Diagnosis/treatment information (primary diagnosis, proposed treatment(s), procedure(s) or service(s), proposed length of stay. Facility name, location, address. Clinical info as soon as available. Anticipated d/c date. History and Physical Exam to include: indications for procedure conservative treatment prior surgery functional impairment mechanism of injury to include documentation of any connection to an on the job injury or possible subrogation claim, i.e. on-the-job injury, vehicular accident smoking history Office Notes (treatment). Results of Diagnostic Imaging. Physician s order Physiatry evaluation D/C summary from medical unit/facility, if available Documentation of medical necessity of inpatient rehab to include: diagnosis, prognosis, anticipated plan/duration of care Specific disciplines requested, i.e. (RN, PT, OT) number and frequency of visits NW Montana Schools Consortium Page 3 of 9

4 Lumbar Fusion Medical Injectables and other Drugs Abatacept Aflibercept (Eylea ) Alglucosidase Alfa (Lumizyme ) Alpha-1 proteinase inhibitor Bevacizumab (Avastin ) Blood clotting factors Bortezomib (Velcade ) Botulinum toxin (all types and brands) Cetuzimab (Cimzia ) Cytarabine liposome Denosumab (Prolia & Xgeva ) Eribulin mesylate (Halaven ) Epoprostenol (Flolan ) Hyaluronan (all brands such as Synvisc, Orthovisc ) Imiglucerase (Cereyzme ) Infliximab (Remicade ) Intravenous immunoglobulin (IVIG) therapy Ipilimumab (Yervoy ) Iron infusions (all brands) Ixabepilone Natalizumab (Tysabri ) Octreotide Depot (Sanostatin LAR ) Omalizumab (Xolair ) Palivizumab (Synagis) Pegaptanib (Macugen ) Pemetrexed (Alimta ) Ranibizumab (Lucentis ) Rituximab Sipuleucel-T (Provenge) requested for each discipline Clinical documentation of medical necessity for each discipline, i.e., H&P History and Physical Exam to include: indications for procedure conservative treatment prior spinal surgery functional impairment mechanism of injury to include documentation of any connection to an on the job injury or possible subrogation claim, i.e. on-the-job injury, vehicular accident smoking history Office Notes (treatment) Results of Diagnostic Imaging Physician order, to include diagnosis, specific drug, dose, length of treatment, codes for drugs/supplies/discipline. Specific disciplines requested, i.e., RN, Clinical documentation of medical necessity for each discipline, i.e., H&P, discharge summary, if available. NW Montana Schools Consortium Page 4 of 9

5 Tocilizumab (Actemra ) Trastuzamab Ustekinumab (Stelara ) Medical Weight Loss Services Non-surgical Mental Health and Chemical Dependency Inpatient Admissions Residential Treatment Partial Hospitalization Organ and Bone Marrow Transplants Includes evaluation of, services for both recipient and donor, and travel and lodging expenses Clinical evaluation. Documentation of BMI and weight loss history. Treatment plan. Patient demographics (name, plan ID number, date of birth). PCP/attending physician name Diagnosis/treatment information (primary diagnosis, proposed treatment(s), procedure(s) or service(s), proposed length of stay. Facility name, location, address. Clinical info as soon as available. Anticipated d/c date. Solid Organ: Letter from facility or transplant committee stating he/she has met their criteria. Indication for transplant and what type of transplant. The provider notes including nephrologist, transplant surgeon and any consulting physicians. Psychosocial evaluation from MSW. All labs, radiology tests, cardiac tests and procedures that were done in the preevaluation phase. Any follow-up tests or procedures that were a recommendation by the transplant physician or committee that needed to be done before would qualify for transplant. Blood & Tissue: Cover letter from facility or transplant committee stating patient has met their criteria. Indication for transplant. Detailed history and physical, including current meds, physical exam, assessment and plan. If proposed allogeneic HSC transplant: HLA typing and histocompatibility report. Pertinent labs, including serologies, MELD (liver), PRA (if indicated). For alcoholic cirrhosis, proof of successful completion of chem. dep. Program. Biopsy results (showing no malignancy solid; bone marrow biopsy stem cell). Risk factors for CAD: need EKG, echo, stress test, cardiac cath. PFT s (for solid lung or if indicated for NW Montana Schools Consortium Page 5 of 9

6 Orthognathic Surgery (Sleep Apena) pulmonary issues). Results of colonoscopy, UGI, as indicated Mammogram, pap smear, PSA, as appropriate. MSW psychosocial evaluation. Consultations as indicated, e.g. cardiology, anesthesiology, dietary, psych, pulmonology. Dental clearance. Financial/insurance coverage, including drug coverage. Stem cell transplants: the synopsis of the protocol to be used for the proposed transplant. Medical history and physical examination with reference to symptoms and functional impairment related to the orthognathic deformity. Description of the specific anatomic deformity present. Complete reports of lateral and anteriorposterior cephalometric radiographs. Cephalometric tracings when available. Copy of medical records from treating physician documenting evaluation, diagnoses, and previous management of the functional impairment. PET Scans Radiation Therapy Stereotactic Body Radiation Therapy (SBRT) Proton Beam or Helium Radiation Therapy Stereotactic radiosurgery (Gamma Knife, Cyberknife) Reconstructive Procedures All procedures that may be considered cosmetic, including but not limited to: o Breast reconstruction (reduction mammoplasty)* o Eyelid surgery (i.e., blepharoplasty)* o Removal of breast implants* Note: Actual photographs, radiographs, and/or molds may also be requested depending on the individual circumstance of the case. Diagnosis, clinical progress and treatment to date. Dates of prior scans and imaging results (CAT, PET). Staging or re-staging for oncology. Clinical documentation of how the results will impact future treatment decisions. Physician s order. Documentation of specific request and clinical reasons for Medical condition/diagnosis related to the Clinical documentation supporting the medical necessity of the Letter describing the clinical circumstances justifying the medical necessity of the service proposed. Clinical documentation such as H&P and/or office notes related to the Documentation of functional deficit resulting from a congenital anomaly, other o Rhinoplasty* diseases, accidental injury or prior covered NW Montana Schools Consortium Page 6 of 9

7 o Varicose vein procedures* *See individual entries for specific documentation requirements Reduction Mammoplasty (Breast Reduction) Removal of Breast Implants Rhinoplasty Skilled Nursing Facility/LTAC Admissions surgery. Letter describing the clinical circumstances justifying the proposed services. History and physical exam which documents: o The size of the breasts (including photographs) o Significant functional impairment o Medical records may be requested which demonstrate a minimum of 6 weeks of medically supervised conservative treatment addressing functional conditions leading to the request for reduction mammoplasty. o Height and weight of the patient o Explicit estimates of the amount of breast tissue to be removed from each breast. Letter describing the clinical circumstances justifying the service proposed. History and physical exam which documents: o The presence or absence of evidence of leak of a silicone containing prosthesis. o The clinical circumstances under which the prosthesis was initially implanted. o The clinical justification for recommending the removal of the prosthesis Other supporting material at the discretion of the requesting patient or clinician. Letter describing the clinical circumstances justifying medical necessity. Clinical documentation such as H&P and/or office notes related to the request and prior treatment. Documentation of functional deficit resulting from illness or injury resulting in the need for Rhinoplasty. Patient demographics (name, plan ID number, date of birth). PCP/attending physician name, specialty/ certification status. Diagnosis/treatment information (primary diagnosis, proposed treatment(s), procedure(s) or service(s), proposed length of stay and frequency/duration of service. Facility Information (facility name, telephone/fax number, contact person. Physician s order for Skilled Nursing Facility Admission. NW Montana Schools Consortium Page 7 of 9

8 Spinal Injections (with procedural sedation) Any location Spinal Surgeries Stereotactic Radiosurgery Example: Gamma Knife, CyberKnife Surgery (when covered) Abdominoplasty/panniculectomy BAHA-Bone Anchored Hearing Aid (surgical benefit applies) Breast Surgeries - selected Implant removal, Mastectomy for gynecomastia, Prophylactic mastectomy, Reduction Mammoplasty Cosmetic or reconstructive surgery Cochlear implants (surgical benefit applies) Deep Brain Stimulation Eyelid surgery (i.e. blepharoplasty) Spinal surgery - selected Lumbar fusions Cervical Fusions Artificial Intervertebral Disc History & Physical or transfer summary indicating admission criteria. Diagnosis and Procedure (s) requested History and Physical to include o Duration of pain o Duration and type of conservative therapy o Results of imaging studies o Previous surgery or treatment Diagnosis and Procedure requested. History & Physical Exam and clinical documentation to include: o Duration of back/neck pain o Duration and type of conservative therapy o Results of imaging studies o Previous Back Surgeries Physician s order. Documentation of medical necessity, circumstances surrounding the request, including H&P and office notes, including Karnofsky performance rating (level of function), status of extracranial disease and results of imaging studies related to the Documentation of planned treatment. Physician s order with diagnosis. Documentation of specific request and clinical reasons for Medical condition/diagnosis related to the Clinical documentation supporting the medical necessity of the Orthognathic surgery Rhinoplasty Surgical interventions for sleep apnea TMJ surgery Varicose vein procedures The most recent sleep study report, which must be performed and interpreted by a Surgical Interventions for Sleep Apnea physician specializing in sleep disorders. Documentation of a complete Otolaryngology (ENT) evaluation, including NW Montana Schools Consortium Page 8 of 9

9 Travel Benefit Varicose Vein Procedures a recent history and physical when certification of UPPP or other oropharyngeal surgery is requested. Documentation of the absence of, or presence and severity of daytime hypersomnolence associated with sleep study findings by the requesting physician. When daytime somnolence is present, documentation that other causes of daytime somnolence have been addressed. Any interventions to address CPAP intolerance, if applicable. Completed travel benefit form Evidence of incompetence of saphenous veins by Doppler or Duplex ultrasound (Doppler plus conventional ultrasound) study report. History of specific significant symptoms associated with varicose veins. History of prior conservative treatment (unless clearly demonstrated to be contraindicated). On occasion it may also be necessary to request medical records from the primary care provider (or some other clinician) to document the use of conservative therapy and its impact prior to referral, unless conservative therapy is clearly documented to not be indicated in the letter of NW Montana Schools Consortium Page 9 of 9