2018 MDwise HIP Medical Services that Require Prior Authorization
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1 2018 MDwise HIP Medical Services that Require Prior Authorization Medical services that require Prior Authorization Type of Service Requires PA Coding All Out of Network services Facility to facility ambulance transport (non-emergent transport) Air Ambulance Elective/emergent/urgent medical, surgical inpatient admissions, and skilled nursing facility services Inpatient Rehabilitation With the exception of ER, Ambulance, Urgent Care Center services, Immunizations, Family planning services, chiropractic services, podiatry, and ologists, except if service is otherwise listed on PA list. A0426, A0428 A0430, A0435, A0431, A0436 Subacute admission POS 21 Transplants Accidental dental services (other than ER) including the work up/ evaluation for transplant POS 21, 22, 24, 51,61, 31, 32 Maternity stays are notification only and no prior authorization number is issued. POS 21 or 61 and accommodation codes 024, POS 21 or POS 61. Revenue code 024 POS 21 - Heart/lung Liver Pancreas Bone Marrow/Stem cell: Pancreas: Intestine: , D0100-D0999. Please contact DentaQuest for prior authorization of dental services Bariatric Surgery Roux-en-Y , Gastroplasty , Gastric banding sleeve Gastrectomy , 43847, 43848, 43886, 46887, 43888, Duodenal switch , 43845, Revision: Cochlear Implants surgery (See DME for device) Hysterectomy 45126, 51925, 51597, , , , , Mastectomy reconstructive surgery Same as breast reconstruction below Maxillofacial surgeries/tmj -including Arthroplasty, Arthroscopy, Reconstruction, Discectomy (with or without disc replacement), trigger point injections, Arthrocentesis, and mandibular orthopedic repositioning appliances (MORA) 21010, , 21050, 21060, 21070, 21073, 21116, , , , 21255, 29800, 29804, D7000-D7999 HIPP0215 (4/17) Revised January
2 Type of Service Requires PA Coding Non-cosmetic reconstructive surgery Included in potentially cosmetic Potentially cosmetic procedures in addition to other procedures listed separately: blepharoplasty, septoplasty/rhinoplasty, port wine stain removal, otoplasty, breast reconstruction, breast enlargement, breast reduction/mammoplasty, mammoplasty for gynecomastia, breast implant removal, excision of excess skin due to weight loss including panniculectomy/abdominoplasty, lipectomy or excess fat removal, varicose vein treatment, cleft lip/palate surgery, congenital craniofacial anomaly surgery, surgical treatment of congenital chest wall deformity (pectus excavatum), breast congenital anomaly (i.e. polymastia) 11200, 11201, (with criteria) , , 11971, ,15847, , , , ,19499, , , , , 37500, , 37799, , , 54660, , , S2066, S2067, S2068, Breast congenital anomaly (i.e. polymastia) Included in Breast Reconstruction Breast enlargement (same as Augmentation) Same as Augmentation above Congenital craniofacial anomaly surgery Included in Maxillofacial above Tonsillectomy & Adenoidectomy, if age18 or older Uvulopalatoplasty including laser assisted Vision surgery - Laser in-situ keratomileusis (LASIK), laser epithelial keratomileusis (LASEK), Photorefractive Keratectomy (PRK), Photostigmatic keratectomy (PARK/PRK-A), Epikeratoplasty 42820, 42821, 42825, 42826, 42830, 42831, 42835, non-covered Implantation of a total replacement heart system (artificial heart) with recipient cardiectomy Replacement or repair of thoracic unit of a total replacement heart system (artificial heart) Replacement or repair of implantable component or components of total replacement heart system (artificial heart), excluding thoracic unit Insertion or replacement of permanent subcutaneous defibrillator system/ Insertion of subcutaneous implantable defibrillator electrode/ Removal of subcutaneous defibrillator electrode/ Repositioning of previously implanted subcutaneous implantable defibrillator electrode/programming device evaluation (in person)/ Interrogation device evaluation (in person)/electrophysiologic evaluation of subcutaneous implantable defibrillator 0051T 0052T 0053T 33270, 33271, 33272, 33273, 93260, 93261,
3 Type of Service Requires PA Coding Home health services POS 12 with the following codes, G0151, G0152, G0153, G0155, 99600, TE, TD, 99601, 99602, 92610, S9349, S9127, , , Initial evaluation codes for PT, OT, ST in home and all subsequent therapy visits in home requires PA. Home IV infusion S9349 Tocolytics, Home oxygen Hospice (inpatient and outpatient) Nutritionals and Supplements, Enteral/Parenteral Nutrition and services Outpatient ST/OT/PT Outpatient Pulmonary rehab, regardless of total claim cost The initial evaluation does not require prior auth. Prior authorization is required for all PT or OT. No PA required for ST for the first 12 visits or hours within a calendar year. A4615- A4616, A7046, E0430-E0459, E0465, E0466, E1352-E1392, E1405, E1406, K0738 All POS 34, For POS 12, the following should pend: 651, 652, 655 and 656 with HCPCS codes Q5001-Q5010 B4034 -B9998 Cochlear Implants (device) L8614- L8619 Durable Medical equipment Electric breast pump Hearing Aids Orthotics all DME and supplies >$500 (total claim) including rental or purchase requires prior authorization, rental or purchase of $500 or more per claim for orthotics of $250 or more PT - Revenue codes - 420, 421, 422, 423, 429, and 97164, 97168, , , 97750, OT - Revenue codes , 439 ST - Revenue codes 440,-443, 449, 92507, 92508, ST - Revenue codes 440, 441, 442, 443, G0237-G0239 ALL DME codes. Please also refer to the orthotics category of this document for other items that may be considered DME that require prior authorization. Left and Right ear- V5030,V5040,V5050, V5060, V5070, V5080, V5095, V5100, V5120, V5130, V5140, V5150, V5170, V5180, V5190, V5210, V5220, V5230, V5242-V5261, V5263, V5267 Bilateral- V5100, V5120, V5130, V5140, V5150, V5248, V5249, V5250, V5251, V5252, V5253, V5258, V5259, V5260, V5261 L0100-L4631 3
4 Type of Service Requires PA Coding Prosthetics Botox Injections Chiropractic Clinical trials for cancer treatment Dialysis Genetic testing,, urine drug testing-limit to 10 presumptive and 10 definitive tests (G0480 only) per calendar year without prior authorization. of $500 or more per claim L5000 L9900 J0585, J0586, J0587, J0588 Please refer to worksheet titled Drugs requiring PA 97012, 97014, 97016, 97018, 97022, 97024, 97026, 97028, 97032, , 97039, 97110, 97112, 97113, 97116, 97124, 97139, Rev codes 082x, 083x, 084x-, 085x , , , 88235, 88237, , 88289, 88291, 88299, , 77072, , 82542, , 83789, G0480-G0483 Hyperbaric oxygen 99183, A4575, E0446 PET Scan- All MR Spectroscopy , 78491, 78492, 78608, 78609, MRI- Abdomen 74181, 74182, MRI - Pelvis 72195, 72196, Outpatient procedures , , , , , , 32672, , , , 33548,33641, 33647, 33660, , 47370, , 52601, , , 59076, , 61645, , 61783, , , , 64722, , 65770, 65772, 65775, 66999, 75894, 76940, 77013, , 82785, , 91110,93025, , , , , , ,97799, 0071T, 0072T, 0191T, 0376T, G0297, S2117 MRI Upper/Lower Extremity ,
5 Type of Service Requires PA Coding MRI- 3D MRI - Brain 70336, , 70540, MRI - Chest, Heart 71550, 71551, 71552, MRI - Cervical, Thoracic, lumbar spine CT scan - Cervical, Thoracic, lumbar spine CT scan -Thorax , CT-Scan -Abdomen , CT Scan Pelvis, upper, lower extremity 3D CT scans, CTA Podiatry (also described as routine foot care per HIP 2.0 benefit plans), after 6 visits Pulse generator 61885, The following radiation therapy requires prior auth: IMRT Vision training therapy PICC line insertion for OB services (i.e. hyperemesis gravidarum) Pain management- including trigger point injection, facet joint and/or facet joint nerve injection, Epidural steroid injection Sacral nerve, Neuro or Spinal Cord stimulator Behavioral Health 72191, 72192, 72193, 72194, , 77061, 77062, 77063, , 72191, 73206, Podiatry visits require prior authorization AFTER the 6th visit. All services rendered during the visit unless otherwise noted on this prior authorization list are included in the visit limit without authorization and the following require prior authorization with listed diagnosis , , , 62290, 62318, 62319, , 64455, , , , 77003, E0744-E0749, E0762, E0766, L8679-L , (for implant) 43647, 43648, (for electrodes) Coding PA requirement as outlined on the following pages. 5
6 Medical Benefit Drugs that Require Prior Authorization Effective 4/1/2018 * Please note that coverage of the greyed-out medications/codes has been transferred to the pharmacy benefit. Therefore, prior authorization requests should be submitted by fax to the MDwise pharmacy benefit manager, MedImpact, at (858) Therapeutic Category Brand Name Generic Name Applicable Code (s) Addiction Management Probuphine buprenorphine J0570 * Vivitrol naltrexone J2315 Antisense Oligonucleotides * Exondys 51 eteplirsen J1428 * Spinraza nusinersin J2326 Botox onabotulinumtoxin A J0585 Botulinum Toxins Dysport abobotulinumtoxin A J0586 Myobloc rimabotulinumtoxin B J0587 Xeomin incobotulinumtoxin A J0588 * H.P. Acthar corticotropin J0800 Endocrine Agents J1725, J1726, Q9985, Makena hydroxyprogesterone caproate Q9986 Enzyme Replacement Therapy Hereditary Angioedema Agents Hormonal Modifiers Aldurazyme laronidase J1931 Cerezyme imiglucerase J1786 Elaprase idurasulfase J1743 Elelyso taliglucerase J3060 Fabrazyme agalsidase beta J0180 Kanuma sebelipase alfa J2840 Lumizyme alglucosidase alfa J0220, J0221 Naglazyme galsulfase J1458 Vimizim elosulfase alfa J1322 VPRIV velaglucerase J3385 * Berinert C1 esterase inhibitor, human J0597 * Cinryze C1 esterase inhibitor, human J0598 * Firazyr icatibant acetate J1744 * Kalbitor ecallantide J1290 * Ruconest C1 esterase inhibitor, human J0596 Eligard, Lupron leuprolide acetate J9217, J9218, J1950 Sandostatin octreotide acetate J2354 Sandostatin LAR octreotide acetate J2353 Supprelin LA, Vantas histrelin acetate J9226 Trelstar / Trelstar Depot / Trelstar LA triptorelin pamoate J3315 Vantas histrelin acetate J9225 Zoladex goserelin acetate J9202 HHW-HIP0498 (6/17) Revised February
7 Therapeutic Category Brand Name Generic Name Applicable Code (s) Bivigam immune globulin, human J1556 Immune Globulins Immunomodulators for Inflammatory Conditions Immunomodulators, Miscellaneous Immunomodulators for Multiple Sclerosis Metabolic Bone Disease Miscellaneous Carimune, Gammagard S/D immune globulin, human J1566 Cuvitru immune globulin, human J1555 Flebogamma / Flebogamma DIF immune globulin, human J1572 Gammagard Liquid immune globulin, human J1569 GamaSTAN S/D immune globulin, human J1460, J1560 Gammaplex immune globulin, human J1557 Gamunex-C, Gammaked immune globulin, human J1561 Hizentra immune globulin, human J1559 Hyqvia immune globulin, human with recombinant hyaluronidase J1575 immune globulin, unspecified immune globulin, human J1599 Octagam immune globulin, human J1568 Privigen immune globulin, human J1459 Actemra (IV only) tocilizumab J3262 Benylsta (IV only) belimumab J0490 Entyvio vedolizumab J3380 Orencia (IV only) abatacept J0129 Remicade infliximab J1745 Simponi Aria (IV only) golimumab J1602 Stelara (IV only) ustekinumab J3358, Q9989 Ilaris canakinumab J0638 * Soliris eculizumab J1300 Sylvant siltuximab J2860 Lemtrada alemtuzumab J0202 Ocrevus ocrelizumab J2350 Tysabri natalizumab J2323 Aredia pamidronate J2430 Boniva ibandronate J1740 Reclast, Zometa zoledronic acid J3489 Prolia, Xgeva denosumab J0897 Xiaflex collagenase, clostridium histolyticum J0775 7
8 Therapeutic Category Brand Name Generic Name Applicable Code (s) Oncology Agents Abraxane paclitaxel, protein bound J9264 Adectris brentuximab vedotin J9042 Aldurazyme laronidase J1931 Alimta pemetrexed disodium J9305 Arzerra ofatumumab J9302 Avastin bevacizumab J9035 Beleodaq belinostat J9032 Blincyto blinatumomab J9039 Cyramza ramucirumab J9308 Darzalex daratumumab J9145 Elspar asparaginase J9020 Empliciti elotuzumab J9176 Erbitux erbituxin J9055 Erwinaze asparaginase erwinia chrysanthemi J9019, J9020 Faslodex fulvestrant J9395 Folotyn pralatrexate J9307 Gazyva obinutuzumab J9301 Halaven eribulin mesylate J9179 Herceptin trastuzumab J9355 Imlygic talimogene laherparepvec J9325 Istodax romidepsin J9315 Ixempra ixabepilone J9207 Kadcyla ado-trastuzumab emtansine J9354 Keytruda pembrolizumab J9271 Kyprolis carfilzomib J9047 Latruvo olaratumab J9285 Marqibo vincristine sulfate liposome J9371 Mytolarg gemtuzumab ozogamicin J9203 Novantrone mitoxantrone hydrochloride J9293 Oncaspar pegaspargase J9266 Onyvide irinotecan liposome J9205 Opdivo nivolimumab J9299 Perjeta pertuzumab J9306 Photofrin porfimer sodium J9600 8
9 Therapeutic Category Brand Name Generic Name Applicable Code (s) Oncology Agents (Continued) Ophthalmic Injections Osteoarthritis Pulmonary Arterial Hypertension (PAH) Agents Respiratory Agents Unclassified Portrazza necititumuab J9295 Rituxan rituximab J9310 Synribo omacetaxine J9262 Torisel temsirolmus J9330 Vectibix panitumumab J9303 Velcade bortezomib J9041 Yervoy ipilimumab J9228 Yondelis trabectedin J9352 Zaltrap ziv-aflibercept J9400 Zinplava bezlotozumab J0565 Eylea afibercept J0178 Lucentis ranibizumab J2778 Macugen pegaptinib J2503 Euflexxa sodium hyaluronate J7323 Gel-One sodium hyaluronate J7326 Gelsyn-3 sodium hyaluronate J7328 GenVisc 850 sodium hyaluronate J7320 Hyalgan, Supartz sodium hyaluronate J7321 Hymovis sodium hyaluronate J7322 Monovisc sodium hyaluronate J7327 Orthovisc sodium hyaluronate J7324 Synvisc / Synvisc-One sodium hyaluronate J7325 Flolan, Veletri epoprostenol J1325 Remodulin treprostinil J3285 Aralast NP, Prolastin, Zemaira proteinase inhibitor J0256 *Cinqair resilizumab J2786 Glassia proteinase inhibitor J0257 *Nucala mepolizumab J2182 *Xolair omalizumab J2357 <various> Unclassified drugs J3490 <various> Unclassified biologics J3590 <various> Immunosuppressive drug, NOC J7599 <various> NOC drugs, other than inhalation drugs, administered through DME J7799 <various> Compounded drug, NOC J7999, Q9977 <various> NOC, antineoplastic drugs J9999 9
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2018 MDwise HIP Medical Services that Require Prior Authorization
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Clinical Utilization Management Guidelines
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Clinical Utilization Management Guidelines
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Clinical Utilization Management Guidelines
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Clinical Utilization Management Guidelines
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Clinical Utilization Management Guidelines
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Pulmonary Hypertension Weight Loss Skin Conditions. Skin Conditions Multiple Sclerosis Endocrine Disorder. Endocrine Disorder.
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