PRIOR AUTHORIZATION LIST Call Paramount's Provider Inquiry Department at or toll free at
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- Maximillian Everett King
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1 PRIOR AUTHORIZATION LIST Call Paramount's Provider Inquiry Department at or toll free at Electronic submission is preferred. Fax prior authorization request to the appropriate fax number or toll free at Prior authorizations can be ed to Paramount's Utilization Management staff at PHCReferralManagement@ProMedica.org. Imaging procedures can be submitted through the web based prior authorization submission tool (McKesson's Clear Coverage), via MyParamount.org as of 2/1/18. Note: All products/benefit packages may not require prior authorization. Providers: Please call Provider Inquiry at or toll free at Members: Please call Member Services at or toll free TTY service for the hearing impaired is available at or toll free at Hours of operation are Monday through Friday (excluding holidays) are: Commercial products 8am to 5pm; Paramount Advantage 7am 7pm; Paramount Elite 8am to 8pm. NOTE: Prior Authorizations are required for payment for primary, secondary, or tertiary coverage. Retro authorization reviews/provider appeals for denied claims for failure to follow precertification requirements will be considered for review for the following exception: the member represented as a self pay. As a registered user to the Paramount Portal, you may also verify Paramount eligibility on MyParamount.org. Call Paramount 's Utilization/ Case Management Department at or toll free at Updated 3/15/2018 PRIOR AUTHORIZATION REQUIRED = SERVICE/PROCEDURE HMO/ Individual Marketplace PPO ELITE ADVANTAGE CODES MEDICAL POLICY ACTIGRAPHY NON-COVERED NON-COVERED PG0198 Actigraphy and Accelerometry ACUPUNCTURE NON-COVERED NON-COVERED NON COVERED Treatments beyond five Effective (5) visits without proven success & 10/01/17 treatments beyond twenty (30) visits per calendar year PG0382 Acupuncture ALL OUT OF NETWORK SERVICES (ECEPT ER) 95950, 95951, 95953, 95956, AMBULATORY EEG MONITORING REQUIRES PRIOR AUTHORIZATION FOR requires prior authorization for > 3 >3DAYS days. PG0333 Ambulatory EEG Monitoring CHILDREN'S INTENSIVE BEHAVIORAL SERVICE & APPLIED BEHAVIORAL PG0335 Applied Behavioral Analysis NON-COVERED NON-COVERED , 0359T-0374T ANALYSIS (ABA) (ABA) ARTIFICIAL INTERVERTEBRAL DISC REPLACEMENT - CERVICAL ARTIFICIAL PG0027 Artificial Intervertebral Disc DISC REPLACEMENT AT MORE THAN ONE LEVEL Replacement ARTIFICIAL INTERVERTEBRAL DISC REPLACEMENT - LUMBAR ARTIFICIAL PG0027 Artificial Intervertebral Disc NON-COVERED DISC REPLACEMENT AT ONE LEVEL Replacement AUTISM TREATMENT (MICHIGAN MEMBERS ONLY) AVISE PG NON-COVERED NON-COVERED NON-COVERED PG0194 Avise PG BINAURAL HEARING AIDS NO NO NO V5014, V5030, V5040, V5060, V5070, V5080, V5130, V5140, V5150, V5160, V5170, V5180, V5190, V5200, V5210, V5220, V5230, V5240, V5252, V5253, V5260, V5261, V5264, V5266, V5267, V5298 PG0141 Hearing Aids
2 BARIATRIC SURGERY; REMOVAL OF GASTRIC RESTRICTIVE DEVICE 43644, 43645, 43770, 43771, 43772, 43773, 43774, 43775, 43842, 43843, 43845, 43846, 43847, 43848, 43850, 43886, 43887, 43888, S2083 PG0163 Bariatric Services BLEPHAROPLASTY NON-COVERED BLEPHAROPLASTY PG0007 Blepharoplasty, Reconstructive Eyelid Surgery, and Brow Lift PG0007 Blepharoplasty, Reconstructive Eyelid Surgery, and Brow Lift BROW PTOSIS, UPPER EYELID BLEPHAROPTOSIS REPAIR, LID RETRACTION 67900, , PG0007 Blepharoplasty, Reconstructive Eyelid Surgery, and Brow Lift BRONCHIAL THERMOPLASTY NON-COVERED NON-COVERED NON-COVERED 31660, PG0316 Bronchial Thermoplasty CANDELA LASER - PULSED DYE LASER (PDL) THERAPY FOR CUTANEOUS PG0308 Pulsed Dye Laser Therapy for 17106, 17107, VASCULAR LESIONS Cutaneous Vascular Lesions CARTICEL AUTOLOGOUS CHONDROCYTE TRANSPLANTATION PG0190 Chondrocyte Implantation of the 27412, J7330 (ACT)/AUTOLOGOUS CHONDROCYTE IMPLANTATION (ACI) Knee CARTICEL AUTOLOGOUS CHONDROCYTE TRANSPLANTATION PG0190 Chondrocyte Implantation of the NON-COVERED NON-COVERED S2112 (ACT)/AUTOLOGOUS CHONDROCYTE IMPLANTATION (ACI) Knee FETAL CHROMOSOMAL MICRODELETION NON-COVERED NON-COVERED NON-COVERED PG0287 Cell-Free DNA Tests For Fetal Aneuploidy CELL-FREE DNA TESTING (e.g., MaterniT21, Verifi, Harmony, Panorama ) PG0287 Cell-Free DNA Tests For Fetal Aneuploidy CHIROPRACTIC SERVICES & SPINAL MANIPULATION FOR CHILDREN 0-3 PG0150 Chiropractic Services & Spinal YEARS OF AGE Manipulation COCHLEAR (TRADITONAL) & AUDITORY BRAINSTEM IMPLANTS 69930, L8614, S2235 PG0281 Cochlear and Auditory Brainstem Implants CONTINUOUS BLOOD GLUCOSE MONITORING SYSTEMS LONG TERM A9276, A9277, A9278, S1030, S1031 PG0177 Continuous Blood Glucose Monitoring Services CONTINUOUS BLOOD GLUCOSE MONITORING SYSTEMS LONG TERM NON-COVERED K0553, K0554 PG0177 Continuous Blood Glucose Monitoring Services DRUG TESTING Refer to PG0069 Urine Drug Testing for specifics: G0431, G0434, G0477- G0483, G6030-G6058, , , 80348, , , PG0069 Drug Testing ELECTRICAL STIMULATION THERAPY (NMES, FES) NON-COVERED NON-COVERED NON-COVERED E0744, E0745, E0764, E0770, PG0228 Electrical Stimulation Therapy ELECTRONIC BRACHYTHERAPY NON-COVERED NON-COVERED NON-COVERED 0182T, 0394T, 0395T PG0315 Electronic Brachytherapy ETERNAL COUNTERPULSATION THERAPY (ECP) G0166 G0166, NON-COVERED PG0209 External Counterpulsation ETRACORPOREAL SHOCK WAVE FOR PLANTAR FASCIITIS PG0004 Extracorporeal Shock Wave Therapy (ESWT) FRENECTOMY OR FRENOTOMY OF THE LINGUAL FRENULUM FOR PG0407 Frenectomy or Frenotomy for 41010, 41115, ANKYLOGLOSSIA FOR MEMBERS 1 YEAR OF AGE Ankyloglossia FRENECTOMY OR FRENOTOMY NON-COVERED NON-COVERED NON-COVERED 40806, PG0407 Frenectomy or Frenotomy for Ankyloglossia GASTRIC NEUROSTIMULATOR 43647, 43648, 43881, 43882, 64590, 64595, 95980, 95981, 95982, C1767, C1778, E0765, L8680, L8688 PG0235 Gastric Electrical Stimulation (GES) GENDER REASSIGNMENT SURGERY NON-COVERED 55970, PG0311 Gender Reassignment Surgery HOME HEALTH CARE
3 HPV VACCINES - PRIOR AUTHORIZATION FOR ONLY 27YO OR OLDER NON-COVERED 90649, 90650, If the HMO, PPO, Individual Marketplace, or Advantage member began the vaccine series before age 27, but the three part vaccine series is not completed by the time they reach age 27, the additional doses will be covered with prior authorization. This does not apply for the University of Toledo benefit contract. PG0092 HPV Vaccine Gardasil and Cervarix INJECTABLE BULKING AGENTS (SOLESTA) FOR TREATMENT OF FECAL PG0260 Injectable Bulking Agents for NON-COVERED NON-COVERED NON-COVERED L8605, 0377T INCONTINENCE Fecal Incontinence IMPLANTABLE MINIATURE TELESCOPE (IMT) NON-COVERED 0308T PG0351 The Implantable Miniature Telescope (IMT) IMPLANTABLE TESTOSTERONE PELLETS (TESTOPEL) S0189, PG0225 Implantable Testosterone Pellets INPATIENT HOSPITAL ADMISSIONS INTENSIVE OUTPATIENT ADMISSIONS INTERACTIVE DIAGNOSTIC INTERVIEW/PSYCHOTHERAPY FOR MEMBERS 18 YRS AND OLDER INTERSPINOUS PROCESS DECOMPRESSION DEVICE (-STOP) NON-COVERED NON-COVERED , C1821 PG0213 Interspinous Process Decompression Devices INTRASTROMAL CORNEAL RING SEGMENTS (INTACS) 0099T, PG0174 Intrastromal Corneal Ring Segments (INTACS) LEADLESS CARDIAC PACEMAKERS NON-COVERED NON-COVERED NON-COVERED 0387T-0391T PG0395 Leadless Cardiac Pacemakers LIPECTOMY NON-COVERED NON-COVERED NON-COVERED 15876, 15878, LIPOSUCTION/ABDOMINAL SUCTION-ASSISTED LIPECTOMY NON-COVERED NON-COVERED NON-COVERED MAGNETIC SOURCE IMAGING (MSI) NON-COVERED NON-COVERED S8035 PG0104 Cosmetic and Reconstructive Surgery PG0299 Abdominoplasty, Panniculectomy and Liposuction PG0186 Magnetoencephalography (MEG) and Magnetic Source Imaging (MSI) MAGNETOENCEPHALOGRAPHY (MEG) 95965, 95966, PG0186 Magnetoencephalography (MEG) and Magnetic Source Imaging (MSI) MAMMOPLASTY, REDUCTION PG0054 Reduction Mammoplasty MANDIBULAR MAILLARY OSTEOTOMY AND ADVANCEMENT AND/OR GENIGLOSSUS ADVANCEMENT WITH OR WITHOUT HYOID SUSPENSION 21141, 21145, 21196, 21199, PG0056 Surgical Treatments for Obstructive Sleep Apnea (OSA) MANUAL THERAPY Prior authorization required for children 0-3 years of age for all product lines PG0158 Physical Therapy (PT) and Occupational Therapy (OT) MASTECTOMY FOR GYNECOMASTIA PG0221 Mastectomy for Gynecomastia NEW TECHNOLOGY (MEDICAL & BEHAVIORAL HEALTH PROCEDURES, DIAGNOSTICS, DURABLE MEDICAL EQUIPMENT) OCCIPITAL NERVE BLOCK THERAPY Prior authorization is required for seven (7) injections or more per calendar year PG0389 Occipital Nerve Block Therapy for the Treatment of Headache and Occipital Neuralgia ORAL APPLIANCES FOR OBSTRUCTIVE SLEEP APNEA CUSTOM E0486 PG0131 Custom Oral Appliance for OSA
4 ORTHOGNATHIC/MAILLOFACIAL SURGERY , 21125, 21127, , , 21150, 21151, 21154, 21155, 21159, 21160, , 21188, , 21198, 21199, 21206, , 21215, 21230, 21240, , 21255, 21270, 21275, 21295, PG0226 Orthognathic Surgery OTOPLASTY PG0376 Otoplasty PANCREATIC ISLET CELL TRANSPLANTATION PG0415 Pancreatic Islet Cell Transplantation PANCREATIC ISLET CELL TRANSPLANTATION NON-COVERED NON-COVERED NON-COVERED S2102 PG0415 Pancreatic Islet Cell Transplantation PANNICULECTOMY (15830) AND ABDOMINOPLASTY (15847) 15830, PG0299 Abdominoplasty, Panniculectomy and Liposuction PARTIAL HOSPITALIZATION PEDIATRIC DENTAL GENERAL ANESTHESIA IN AN OUTPATIENT SETTING (OVER AGE 5) PERCUTANEOUS & ENDOSCOPIC SPINAL SURGERY AND THERMAL PG0026 Minimally Invasive Treatment of NON-COVERED NON-COVERED NON-COVERED 22526, 22527, INTRADISCAL PROCEDURES Back and Neck Pain PERCUTANEOUS OR MINIMALLY INVASIVE SACROILIAC JOINT STABILIZATION FOR SACROILIAC JOINT FUSION NON-COVERED NON-COVERED NON-COVERED PG0310 Sacroiliac Joint Fusion PERIPHERAL ARTERY DISEASE (PAD) NON-COVERED NON-COVERED NON-COVERED PG0414 Peripheral Artery Disease (PAD) Rehabilitation POTENTIALLY COSMETIC SURGERY PROPHYLACTIC MASTECTOMY- RISK REDUCTION THERAPY (NO CANCER) V50.41 PG0251 Prophylactic Mastectomy RADIOFREQUENCY THERAPY FOR GERD (STRETTA SYSTEM) NON-COVERED NON-COVERED NON-COVERED 43257, 43284, PG0166 Endoscopic Therapies for Gastroesophageal Reflux Disease (GERD) RADIOREQUENCY VOLUMETRIC TISSUE REDUCTION (RFVTR) OF THE SOFT PALATE, UVULA, OR TONGUE BASE (e.g., Coblation, Somnoplasty ) NON-COVERED NON-COVERED NON-COVERED PG0056 Surgical Treatments for Obstructive Sleep Apnea (OSA) REHABILITATION ADMISSIONS RESPITE BEHAVIORAL HEALTH NON-COVERED NON-COVERED NON-COVERED <21 YO RESPITE MEDICAL CARE NON-COVERED NON-COVERED NON-COVERED <21 YO S5150, S5151 PER MEDICAID REQUIREMENTS S5150, S5151 PER MEDICAID REQUIREMENTS REMOVAL OF MAMMARY IMPLANT 19328, 19330, 19370, PG0012 Breast Implant Removal RHINOPLASTY 30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462, PG0009 Rhinoplasty and Septoplasty RHINOMANOMETRY AND ACOUSTIC/OPTICAL RHINOMETRY NON-COVERED NON-COVERED NON-COVERED PG0045 Rhinomanometry and Acoustic - Optical Rhinometry SKILLED NURSING FACILITY ADMISSIONS SPINAL CORD STIMULATION 63650, 63655, PG0253 Spinal Cord Stimulation SUBTALAR ARTHROERESIS S2117, 0335T PG0321 Subtalar Arthroeresis TEMPORAL BONE OSSEOINTEGRATED IMPLANTS (BAHA) 69710, 69711, 69714, 69715, 69717, 69718, L8690, L8691, L8692, L8693 PG0218 Bone-Anchored Hearing Aid (BAHA) THERAPEUTIC CONTACT LENSES V2520, V2521, V2522, V2523, V2530 PG0403 Therapeutic Contact Lenses THERAPEUTIC CONTACT LENSES NON-COVERED NON-COVERED S0515 PG0403 Therapeutic Contact Lenses
5 THERAPEUTIC CONTACT LENSES NON-COVERED V2531 PG0403 Therapeutic Contact Lenses TOTAL ANKLE REPLACEMENT 27702, PG0151 Total Ankle Replacement TONGUE BASE SUSPENSION NON-COVERED NON-COVERED PG0056 Surgical Treatments for Obstructive Sleep Apnea (OSA) TRANSCRANIAL MAGNETIC STIMULATION (TMS) NON-COVERED 90867, 90868, PG0294 Transcranial Magnetic Stimulation (TMS) TRANSPUPILLARY THERMOTHERAPY PG0149 Transpupillary Thermotherapy (TTT) TRANSURETHRAL RADIOFREQUENCY NON-COVERED NON-COVERED NON-COVERED PG0191 Transurethral & Transvaginal Radiofrequency for Urinary Incontinence TREATMENT OF OPIOID DEPENDENCE COVERED W/O PA COVERED W/O PA COVERED W/O PA H0016 PG0313 Treatment of Opioid Dependence TUMOR TREATMENT FIELD (TTF) THERAPY (i.e., OPTUNE) E0766 PG0371 Tumor Treatment Field Therapy for Glioblastoma VISION THERAPY PG0318 Vision Therapy WIRELESS CAPSULE ENDOSCOPY (PILL CAM) 91110, PG0028 Wireless Capsule Endoscopy WIRELESS GASTROINTESTINAL MOTILITY MONITORING SYSTEM PG0394 Wireless Gastrointestinal (SMARTPILL) Motility Monitoring System GENETIC TESTING: Prior authorization is required for genetic testing unless otherwise noted in one of our policies. BRCA & BART TESTING FOR BREAST CANCER AND/OR OVARIAN CANCER 81162, 81211, 81212, 81213, 81214, 81215, 81216, 81217, 81432, 81445, BRCA & BART TESTING FOR BREAST CANCER AND/OR OVARIAN CANCER NON-COVERED NON-COVERED NON-COVERED CARDIAC CONDITIONS GENETIC TESTING 81413, 81414, 81439, S3865, S3866 COMPARATIVE GENOMIC HYBRIDIZATION (CGH) GENETIC TESTING & REQUIRES PA/ S3870 is NON- COVERED 81228, 81229, S3870 PG0067 Genetic Testing for Breast and Ovarian Cancers PG0067 Genetic Testing for Breast and Ovarian Cancers PG0280 Genetic Testing for Cardiac Conditions PG0296 Comparative Genomic Hybridization (CGH) CORUS CAD GENETIC TESTING NON-COVERED NON-COVERED NON-COVERED PG0363 CORUS CAD DMD GENE MUTATIONS GENETIC TESTING 81161, PG0411 Genetic Testing for Duchenne and Becker Muscular Dystrophy FAMILIAL ADENOMATOUS POLYPOSIS(FAP) GENETIC TESTING 81201, 81202, PG0302 Genetic Testing for Colorectal Cancer FRAGILE SYNDROME GENETIC TESTING NON-COVERED 81243, PG0360 Genetic Testing for FMR1 Mutations Including Fragile Syndrome GENE EPRESSION ANALYSIS FOR PROSTATE CANCER GENETIC TESTING 81313, GENESIGHT ASSAY FOR REFRACTORY DEPRESSION GENETIC TESTING NON-COVERED NON-COVERED NON-COVERED PG0367 Gene Expression Analysis for Prostate Cancer PG0368 GeneSight Assay for Refractory Depression
6 GENETIC EPRESSION ASSAYS FOR BREAST CANCER PROGNOSIS: - ONCOTYPE D BREAST CANCER ASSAY (81519) - MAMMAPRINT (81521) - PROSIGNA BREAST CANCER ASSAY (81520, 0008M) - BREAST CENCER INDE (81479) - ENDOPREDICT (81479, S3854) (S3854 IS NON- COVERED) 81479, 81519, 81520, 81521, 0008M, S3854 PG0301 Genetic Expression Assays for Breast Cancer Prognosis GENETIC EPRESSION ASSAYS FOR BREAST CANCER PROGNOSIS: - HERMARK ASSAY (81479) NON-COVERED NON-COVERED NON-COVERED PG0301 Genetic Expression Assays for Breast Cancer Prognosis GENETIC TESTING 81105, 81106, 81107, 81108, 81109, 81110, 81111, 81112, 81120, 81121, 81162, 81175, 81176, 81201, 81202, 81203, , 81225, 81226, 81227, 81228, 81229, 81235, 81238, 81247, 81248, 81249, , 81283, 81287, 81288, , , 81321, 81322, 81323, 81332, 81334, 81335, 81346, , 81420, 81432, 81435, 81436, 81445, 81448, 81450, 81455, 81479, 81509, PG0041 Genetic Testing GENETIC TESTING NON-COVERED NON-COVERED NON-COVERED 81200, 81205, 81209, 81230, 81231, 81232, 81252, 81253, 81254, 81257, 81260, 81290, 81324, 81325, 81326, 81330, 81331, 81410, 81411, 81412, 81415, 81416, 81417, 81425, 81426, 81427, 81430, 81431, 81433, 81434, 81438, 81440, 81442, 81460, 81465, 81470, 81471, PG0041 Genetic Testing GENETIC TESTING NON-COVERED PG0041 Genetic Testing GENETIC TESTING NON-COVERED 81242, 81251, 81258, 81259, 81269, 81302, 81303, 81304, 81328, 81361, 81362, 81363, PG0041 Genetic Testing HEREDITARY THROMBOPHILIA 81240, PG0355 Genetic Testing for Hereditary Thrombophilia HEREDITARY THROMBOPHILIA NON-COVERED NON-COVERED NON-COVERED PG0355 Genetic Testing for Hereditary Thrombophilia LYNCH SYNDROME GENETIC TESTING PTEN GENE TESTING 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81301, 81317, 81318, 81319, , 81432, 81435, 81436, 81445, PG0302 Genetic Testing for Colorectal Cancer PG0336 PTEN Gene Testing
7 SPINAL MUSCULAR ATROPHY (SMA) GENETIC TESTING 81400, 81401, 81403, 81404, 81405, 81406, 81408, PG0398 Genetic Testing for Spinal Muscular Atrophy VERISTRAT GENETIC TESTING NON-COVERED PG0111 VeriStrat Testing IMAGING PROCEDURES: PRIOR AUTHORIZATION IS REQUIRED FOR IMAGING PROCEDURES PERFORMED IN AN ELECTIVE OUTPATIENT SETTING. PRIOR AUTHORIZATION IS NOT REQUIRED FOR IMAGING PROCEDURES PERFORMED IN THESE SETTINGS: EMERGENCY DEPARTMENT FACILITY OBSERVATION SETTING INPATIENT SETTING COMPUTERIZED TOMOGRAPHY (CT) COMPUTERIZED TOMOGRAPHY ANGIOGRAPHY (CTA) OF THE CORONARY ARTERIES MAGNETIC RESONANCE IMAGING (MRI) MAGNETIC RESONANCE ANGIOGRAPHY (MRA) 70450, 70460, 70470, 70480, 70482, 70486, 70487, 70488, 70490, 70491, 70492, 70540, 70542, 70543, 70544, 70545, 70546, 70547, 70548, 70549, 71250, 71260, 71270, 71550, 71551, 71552, 71555, 72125, 72126, 72127, 72128, 72129, 72130, 72131, 72132, 72133, 72141, 72142, 72146, 72147, 72148, 72149, 72156, 72157, 72158, 72159, 72192, 72193, 72194, 72195, 72196, 72197, 72198, 73200, 73201, 73202, 73218, 73219, 73220, 73221, 73222, 73223, 73225, 73700, 73701, 73702, 73718, 73719, 73720, 73721, 73722, 73723, 73725, 74150, 74160, 74170, 74176, 74177, 74178, 74181, 74182, 74183, 74185, 74261, 74262, 74263, 75557, 75559, 75561, 75563, 75571, 75572, 75573, 75574, 76380, 76497, 76498, 78599, C8900, C8901, C8902, C8903, C8904, C8905, C8910, C8911, C8912, C8913, C8914, C8918, C8919, C8920, C8931, C8932, C8933, C8934, C8935, C8936, S8037, S8042, S8080 CT SCREENING FOR LUNG CANCER G0296, G0297 PG0049 CT Screening for Lung Cancer in Heavy Smokers CT VIRTUAL COLONSCOPY PG0182 Virtual Colonoscopy DURABLE MEDICAL EQUIPMENT: ALL DME THAT ECEEDS BENEFIT LIMITS AIR FLUIDIZED BEDS E0194 PG0352 Air Fluidized Bed BONE GROWTH STIMULATORS E0747, E0748, E0749, E0760 PG0232 Bone Growth Stimulating Services-Devices (Osteogenic Stimulators) CRANIAL ORTHOTIC REMOLDING DEVICE NON-COVERED L0112, L0113 PG0120 Cranial Orthotic Devices
8 CRANIAL ORTHOTIC REMOLDING DEVICE NON-COVERED S1040 PG0120 Cranial Orthotic Devices ENTERAL NUTRITION B4102-B4155, B4158-B4161. B4157 & B Prior authorization required PG0114 Enteral and Parenteral Nutrition if NOT diagnosed with inborn errors of metabolism GLUCOSE TESTING SUPPLIES REQUIRE PRIOR AUTHORIZATION FOR COVERED CODES IF ECEEDS BENEFIT LIMITS A4252, A4253, A4255, A4256, A4257, A4258, A4259, E0607, E2100, E2101 S5560, S5561, S5565, S5566, S5570, S5571, S Prior authorization required for glucose testing supplies if benefit limits are exceeded PG0155 Glucose Testing Supplies HOME UVB PHOTOTHERAPY TREATMENT DEVICES E0691-E0693 PG0383 Home Phototherapy for Dermatologic Conditions HOSPITAL GRADE BREAST PUMP POWER OPERATED VEHICLES, INCLUDING POWER OPERATED WHEELCHAIRS E Prior authorization required if utilized for more that 6 months E0985, E1230, E1239, K0010-K0014, K0800-K0802, K0806-K0808, K0812- K0816, K0820-K0831, K0835-K0843, K0848-K0864, K0868-K0871, K0877- K0880, K0884-K0886, K0890, K0891, K0898, K0899 PG0201 Breast Pump Equipment/Supplies and Counseling PG0284 Power Mobility Devices SPEECH GENERATING DEVICES E2500, E2502, E2504, E2506, E2508, E2510, E2511, E2512, E2599 PG0135 Speech Generating Devices WEARABLE CARDIOVERTER DEFIBRILLATORS K0606 PG0224 Cardioverter Defibrillators PROSTHETICS: ALL ORTHOTICS / PROSTHETICS THAT ECEEDS BENEFIT LIMITS INITIAL PURCHASE ONLY INJECTABLES: SEE SPECIALTY DRUG LIST (UNDER PRESCRIPTION DRUG PROGRAM TAB/SPECIALTY DRUG PROGRAM TAB OF THIS SITE) DENTAL PROCEDURES: CLICK HERE FOR PARAMOUNT ADVANTAGE DENTAL PRIOR AUTH LIST
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