Medical Pre-Authorization and Notification Requirements

Transcription

1 Medical Pre-Authorization and Notification Requirements NOTICE CHANGE IN PRE-AUTHORIZATION PROCESS EFFECTIVE JANUARY 14, 2019 The Health Plan has entered into a partnership with Palladian Health to improve outcomes for musculoskeletal conditions and spine pain management, effective January 14, This pre-authorization and review process does not include services provided to participants in self-funded plans please check plan benefits for coverage and prior auth requirements. Palladian Health will be performing all pre-authorizations and medical necessity review for the following services on all enrollees in all commercially insured fully-funded plans (including HMO, PPO and POS plans), all Medicaid plans, and all Medicare Advantage plans: All services related to spine care management (including injections, spinal surgeries, and spinal stimulation) require pre-authorization and medical necessity review. All PT and OT all services after initial evaluation require pre-authorization and medical necessity review. Ø No referral or pre-authorization is required for the initial evaluation (members may self-refer for evaluation). Ø Palladian Health will complete medical necessity review after the initial evaluations. All chiropractic care all services after initial evaluation require pre-authorization and medical necessity review. Ø No referral or pre-authorization is required for the initial evaluation (members may self-refer for evaluation). Ø Palladian Health will complete medical necessity review after the initial evaluations. Ø All X-rays performed in the chiropractic setting require pre-authorization. Pre-authorization may be completed through The Health Plan online portal at via fax at , or telephonically at Periodic retrospective review will be completed to assure compliance with standards of care and medical appropriateness guidelines. Effective January 14, 2019.

2 Medical Pre-Authorization and Notification Requirements Below is a list of services that require notification, pre-authorization and/or medical appropriateness review. Please check plan benefits for network limitations. PLEASE NOTE: There are additional procedures that require pre-authorization for Self-Funded Employer Groups. Please contact The Health Plan Customer Service Department at for assistance on handling of authorization for Self-Funded Employer Groups. Out-of-Network Care All out-of-network care per plan design Tertiary Care All services require pre-authorization per plan design Inpatient Care All elective inpatient care. Notification of urgent and emergent admission is expected within 48 hours or as soon as reasonably possible Skilled nursing and rehabilitation inpatient care Out-of-network / out-of-area care Long-term acute care (LTAC) All elective C-sections and all elective inductions Diagnostic Testing and Studies MRI of the shoulder, knee, hip, extremity, elbow, ankle, foot, wrist, and the spine (cervical, thoracic, lumbar) Low-dose CT for lung cancer screening CT / MRI / MRA Pre-authorization is required by all non-physician practitioners only CT angiography for CAD SPECT MPI (myocardial perfusion imaging) Pre-authorization is required by all non-cardiologists only PET scan / PET/CT fusion scan Virtual colonoscopy CT colonography Urine Drug Testing: Ø Medicaid member - definitive urine drug testing (G0483, G0659) for all services. Ø Medicaid member - all other urine definitive and presumptive codes have service limits. Preauthorization for medical necessity is required beyond established limits. Ø All other lines of business member - urine definitive drug testing (G0481-G0483, G0659) for all services. Ø All other lines of business member - urine definitive and presumptive codes have service limits. Pre-authorization for medical necessity is required beyond established limits. Procedures Automatic implantable cardiac defibrillator / wearable cardioverter defibrillator / CRT-D Bariatric and weight loss surgery Bone anchored hearing aid (BAHA)/ cochlear implants Periodic retrospective review will be completed to assure compliance with standards of care and medical appropriateness guidelines. Effective January 14, 2019.

3 Medical Pre-Authorization and Notification Requirements Cosmetic procedures (reduction mammoplasty, rhinoplasty, blepharoplasty, sclerotherapy, otoplasty, scar revision, abdominoplasty, panniculectomy, etc.) Hysterectomy Kyphoplasty / vertebroplasty (As of January 14, 2019 will be reviewed for medical necessity by Palladian Health see Page 1). Continuous intraoperative neurophysiological monitoring Prophylactic mastectomy All sleep apnea surgeries Podiatry surgical procedures other than in-office Photographic surveillance of malignant melanoma Transplant and all related services Balloon sinuplasty Ambulatory Services Ambulatory blood pressure monitoring Cardiac outpatient monitoring / mobile real-time and Notification Capsule endoscopy esophageal ph monitoring (Bravo) Continuous glucose monitoring Requirements All genetic, genomic, pharmocogenetic, pharmacogenomics, and pharmacodynamic testing Cologuard Infertility treatment Oncotype DX assay / MammaPrint gene expression assay Skin substitutes (e.g., Dermagraft, Apligraft) Surgical / invasive varicose vein treatment TMJ diagnostics and treatment All tertiary care / out-of-network / out-of-area care Urinary / fecal incontinence clinic and therapies, including percutaneous tibial nerve stimulation Hyperbaric oxygen Ancillary Providers and Services Medical Pre-Authorization Ambulance/ambulette non-emergent Audiologists (independent practices) all evals and testing Chiropractic care all ages requires pre-authorization (Effective January 14, 2019 will be reviewed for medical necessity by Palladian Health see Page 1). Home health services will no longer require pre-authorization during the first certification period. If services are to extend past the first certification period (60 days), pre-authorization is required to the start of the second certification period Hospice/private duty nursing Infusion therapy Insulin pumps Initial order for insulin pump supplies Speech therapy- all visits Periodic retrospective review will be completed to assure compliance with standards of care and medical appropriateness guidelines. Effective January 14, 2019.

4 Medical Pre-Authorization and Notification Requirements PT/OT outpatient - all services after initial evaluation (Effective January 14, 2019 will be reviewed for medical necessity by Palladian Health after initial evaluation see Page 1). Orthotics or prosthetics $500 as required by The Health Plan fee schedule All molded-to-patient model and custom fabricated prosthetics/orthotics Wheelchairs and accessories Durable medical equipment $500 (rental or purchase) and as required per The Health Plan fee schedule; go to healthplan.org for complete information Unlisted/Miscellaneous Codes Will be reviewed to assess if it is non-covered or an up-coded procedure, service or equipment. New Technology It is imperative that providers contact The Health Plan to verify coverage of all new technology. Investigational services are not covered. Pre-authorization is required for these services: Artificial urinary sphincter Autologous chondrocyte implantation Bioimpendance / biventricular pacemaker / CRT-D Bone morphogenetic protein (BMP) Botulinum toxin injections Carotid artery stenting Chemo-embolization Cryosurgery for renal masses DSEK and DSAEK for corneal endothelial degeneration Enhanced external counterpulsation (EECP) HALO 360 coagulation system Intensity modulated radiation therapy (IMRT) Intrastromal corneal ring inserts (Intacs) Implantable / insertable loop recorder Gamma knife / stereotactic radiosurgery Gastric electrical stimulation Ventricular assist devices (LVAD, RVAD, Pediatric VAD, (percutaneous) pvad) ProstaScint Provenge immunotherapy for prostate cancer Radiofrequency ablation for chronic back pain (Effective January 14, 2019 will be reviewed for medical necessity by Palladian Health see Page 1). Selective internal radiation therapy Sacral nerve stimulation / spinal cord stimulator (Effective January 14, 2019 will be reviewed for medical necessity by Palladian Health see Page 1). Transperineal template guided saturation biopsy of the prostate (CPT 55706) X STOP interspinous process decompression system (Effective January 14, 2019 will be reviewed for medical necessity by Palladian Health see Page 1). Xiaflex injections Periodic retrospective review will be completed to assure compliance with standards of care and medical appropriateness guidelines. Effective January 14, 2019.

5 Medical Pre-Authorization Options Pre-Authorization Line: Elective admissions, non-emergent referrals, diagnostics, imaging and procedure pre-authorization. Available 8:00 am to 5:00 pm, Monday through Friday. FULLY INSURED COMMERCIAL PLANS (HMO, PPO, POS) GOVERNMENT PROGRAMS (MEDICAID & MEDICARE) Available 8:00 am to 8:00 pm, Monday through Friday. SELF-FUNDED (ASO, EMPLOYER-FUNDED) Available 8:00 am to 5:00 pm, Monday through Friday. MEDICARE Available 8:00 am to 5:00 pm, Monday through Friday. MEDICAID Palladian Health Via Portal 24/7: myplan.healthplan.or g/account/login Available 7:00 am to 7:00 pm, Monday through Friday. Telephone: Fax: Admissions: Notification of urgent and emergent admissions to participating facilities (in-plan) available 24 hours a day/7 days a week; Reverts to voice mail notification after regular business hours: Fax: To submit clinical information for review: Physician Access Line: For all EMERGENCY ISSUES, URGENT/EMERGENT TRANSFERS to TERTIARY FACILITIES, and contacting the medical director after hours, call NURSEHP ( ). Available 24 hours a day/7 days a week physician access only Provider Websites: - open website; link to password secure provider website for eligibility, claims, reference materials and provider support information.

6 Medical Pre-Authorization Options ADDITIONAL SERVICES MAY REQUIRE PRE-AUTHORIZATION. Due to changes in medical technology, the accessibility of diagnostic equipment and services in an office/outpatient setting, as well as updated methods of performing procedures, there may be additional services that will require pre-authorization. Please contact The Health Plan prior to performing services related to new technology. Periodic review of provider utilization data may eliminate or require the need for medical appropriateness review and pre-authorization of additional services and diagnostic studies.

7 20552 Inj trigger point 1/2 muscl Injection Inject trigger points 3/> Injection Sp bone algrft morsel add-on Sp bone algrft struct add-on Sp bone agrft local add-on Sp bone agrft morsel add-on Sp bone agrft struct add-on Electrical bone stimulation Electrical bone stimulation Remove part of neck vertebra Remove part thorax vertebra Remove part lumbar vertebra Remove extra spine segment Remove part of neck vertebra Remove part thorax vertebra Remove part lumbar vertebra Remove extra spine segment Incis spine 3 column thorac Incis spine 3 column lumbar Incis spine 3 column adl seg Incis 1 vertebral seg cerv Incis 1 vertebral seg thorac Incis 1 vertebral seg lumbar Incis addl spine segment Incis w/discectomy cervical Incis w/discectomy thoracic Incis w/discectomy lumbar Revise extra spine segment Treat spine fracture Treat neck spine fracture Treat thorax spine fracture Treat each add spine fx Percutaneous vertebroplasty cervicothoracic Percutaneous Percutaneous vertebroplasty lumbosacral Percutaneous Percutaneous vertebroplasty add-on Percutaneous Percutaneous vertebral augmentation thoracic Percutaneous Percutaneous vertebral augmentation lumbar Percutaneous Percutaneous vertebral augmentation add-on Percutaneous Percut kyphoplasty add-on Percutaneous Idet single level Percutaneous Idet 1 or more levels Percutaneous Lat thorax spine fusion 1 Obtaining a pre-authorization does not guarantee payment

8 22533 Lat lumbar spine fusion Lat thor/lumb addl seg Neck spine fusion Neck spine fuse&remov bel c Addl neck spine fusion Neck spine fusion Thorax spine fusion Lumbar spine fusion Additional spinal fusion Prescrl fuse w/ instr l5-s Spine & skull spinal fusion Neck spinal fusion Neck spine fusion Thorax spine fusion Lumbar spine fusion Spine fusion extra segment Lumbar spine fusion Spine fusion extra segment Lumbar spine fusion combined Spine fusion extra segment Post fusion </6 vert seg Post fusion 7-12 vert seg Post fusion 13/> vert seg Ant fusion 2-3 vert seg Ant fusion 4-7 vert seg Ant fusion 8/> vert seg Kyphectomy 1-2 segments Kyphectomy 3 or more Insert spine fixation device Insert spine fixation device Insert spine fixation device Insert spine fixation device Insert spine fixation device Insert spine fixation device Insert spine fixation device Insert spine fixation device Insert pelv fixation device Remove spine fixation device Remove spine fixation device Device, with fusion, with or without integrated anterior fixation Device to fill a corpectomy defect, with fusion, with or without integrated anterior fixation Remove spine fixation device Cerv artific diskectomy Lumbar artif diskectomy Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection); single interspace, cervical, second level, cervical 2 Obtaining a pre-authorization does not guarantee payment

9 22859 Insertion of intervertebral biomechanical device (synthetic cage,mesh, methylmethacrylate) to intervertebral disc space or vertebral body defect Revise cerv artific disc Revise lumbar artif disc Remove cerv artif disc Remove lumb artif disc Insertion of interlaminar/interspinous spinous stabilization/distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; single level Insertion of interlaminar/interspinous spinous stabilization/distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; second level Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; second level Spine surgery procedure Inject sacroiliac joint Injection Arthrodesis, sacroiliac joint, percutaneous or minimally invasive (indirect visualization), with image guidance Fusion of sacroiliac joint Epidural lysis mult sessions Percutaneous Epidural lysis on single day Percutaneous Treat spinal cord lesion Percutaneous Treat spinal cord lesion Percutaneous Treat spinal canal lesion Percutaneous Percutaneous diskectomy Percutaneous Injection of diagnostic or therapeutic substances (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, Injection interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance Injection of diagnostic or therapeutic substances (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, Injection interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance Injection of diagnostic or therapeutic substances (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance Injection 3 Obtaining a pre-authorization does not guarantee payment

10 62323 Injection of diagnostic or therapeutic substances (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, Injection interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance Injection including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance (eg, anesthetic, antispasmodic, opioid, steroid, other Injection solution), not including neurolytic substances, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance Injection including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance Injection Injection including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance (eg, anesthetic, antispasmodic, opioid, steroid, other Injection solution), not including neurolytic substances, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); without imaging guidance Injection including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance (eg, anesthetic, antispasmodic, opioid, steroid, other Injection solution), not including neurolytic substances, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance Implant spinal canal cath Percutaneous Implant spinal canal cath Percutaneous Remove spinal canal catheter Percutaneous Insert spine infusion device Percutaneous Implant spine infusion pump Percutaneous Implant spine infusion pump Percutaneous Remove spine infusion device Percutaneous Analyze spine infus pump Percutaneous Analyze sp inf pump w/reprog Percutaneous Anal sp inf pmp w/reprg&fill Percutaneous Anl sp inf pmp w/mdreprg&fil Percutaneous Endoscopic Decompression of Neural Elements and/or Excision of Herniated Intervertebral Discs Remove spine lamina 1/2 crvl Remove spine lamina 1/2 thrc Remove spine lamina 1/2 lmbr Remove spine lamina 1/2 scrl Remove lamina/facets lumbar Remove spine lamina >2 crvcl Remove spine lamina >2 thrc Remove spine lamina >2 lmbr Neck spine disk surgery Low back disk surgery Spinal disk surgery add-on 4 Obtaining a pre-authorization does not guarantee payment

11 63040 Laminotomy single cervical Laminotomy single lumbar Laminotomy addl cervical Laminotomy addl lumbar Remove spine lamina 1 crvl Remove spine lamina 1 thrc Remove spine lamina 1 lmbr Remove spinal lamina add-on Cervical laminoplsty 2/> seg C-laminoplasty w/graft/plate Decompress spinal cord thrc Decompress spinal cord lmbr Decompress spine cord add-on Decompress spinal cord thrc Decompress spine cord add-on Neck spine disk surgery Neck spine disk surgery Spine disk surgery thorax Spine disk surgery thorax Remove vert body dcmprn crvl Remove vertebral body add-on Remove vert body dcmprn thrc Remove vertebral body add-on Remov vertbr dcmprn thrclmbr Remove vertebral body add-on Remove vert body dcmprn lmbr Remove vertebral body add-on Remove vert body dcmprn thrc Remove vert body dcmprn lmbr Remove vertebral body add-on Incise spinal cord tract(s) Drainage of spinal cyst Drainage of spinal cyst Revise spinal cord ligaments Revise spinal cord ligaments Incise spine nrv half segmnt Incise spine nrv >2 segmnts Incise spine accessory nerve Incise spine & cord cervical Incise spine & cord thoracic Incise spine&cord 2 trx crvl Incise spine&cord 2 trx thrc Incise spin&cord 2 stgs crvl Incise spin&cord 2 stgs thrc Release spinal cord lumbar Revise spinal cord vsls crvl Revise spinal cord vsls thrc Revise spine cord vsl thrlmb Excise intraspinl lesion crv 5 Obtaining a pre-authorization does not guarantee payment

12 63266 Excise intrspinl lesion thrc Excise intrspinl lesion lmbr Excise intrspinl lesion scrl Excise intrspinl lesion crvl Excise intrspinl lesion thrc Excise intrspinl lesion lmbr Excise intrspinl lesion scrl Bx/exc xdrl spine lesn crvl Bx/exc xdrl spine lesn thrc Bx/exc xdrl spine lesn lmbr Bx/exc xdrl spine lesn scrl Bx/exc idrl spine lesn crvl Bx/exc idrl spine lesn thrc Bx/exc idrl spine lesn lmbr Bx/exc idrl spine lesn scrl Bx/exc idrl imed lesn cervl Bx/exc idrl imed lesn thrc Bx/exc idrl imed lesn thrlmb Bx/exc xdrl/idrl lsn any lvl Repair laminectomy defect Remove vert xdrl body crvcl Remove vert xdrl body thrc Remove vert xdrl body thrlmb Remov vert xdrl bdy lmbr/sac Remove vert idrl body crvcl Remove vert idrl body thrc Remov vert idrl bdy thrclmbr Remov vert idrl bdy lmbr/sac Remove vertebral body add-on Implant neuroelectrodes Percutaneous Implant neuroelectrodes Percutaneous Remove spine eltrd perq aray Percutaneous Remove spine eltrd plate Percutaneous Revise spine eltrd perq aray Percutaneous Revise spine eltrd plate Percutaneous Insrt/redo spine n generator Percutaneous Revise/remove neuroreceiver Percutaneous N block inj sciatic sng Injection Inj foramen epidural c/t Injection Inj foramen epidural add-on Injection Inj foramen epidural l/s Injection Inj foramen epidural add-on Injection Inj paravert f jnt c/t 1 lev Injection Inj paravert f jnt c/t 2 lev Injection Inj paravert f jnt c/t 3 lev Injection Inj paravert f jnt l/s 1 lev Injection Inj paravert f jnt l/s 2 lev Injection Inj paravert f jnt l/s 3 lev Injection N block lumbar/thoracic Injection 6 Obtaining a pre-authorization does not guarantee payment

13 64633 Destroy cerv/thor facet jnt Percutaneous Destroy c/th facet jnt addl Percutaneous Destroy lumb/sac facet jnt Percutaneous Destroy l/s facet jnt addl Percutaneous Other procedures of the nervous system Percutaneous Radiologic examination, spine, single view, specify level Radiologic examination, spine, cervical; two or three views Radiologic examination, spine, cervical; minimum of four views Radiologic examination, spine, cervical; complete, including oblique and flexion and/or extension studies Radiologic examination, spine, thoracolumbar, standing (scoliosis) Radiologic examination, spine; thoracic, two views Radiologic examination, spine; thoracic, three views Radiologic examination, spine; thoracic, minimum of four views Radiologic examination, spine; thoracolumbar, two views Radiologic examination, spine; scoliosis study, including supine and erect studies Radiologic examination, spine, lumbosacral; two or three views Radiologic examination, spine, lumbosacral; minimum of four views Radiologic examination, spine, lumbosacral; complete, including bending views Radiologic examination, spine, lumbosacral, bending views only, minimum of four views Radiologic examination, sacroiliac joints; less than three views Radiologic examination, sacroiliac joints; three or more views Radiologic examination, sacrum and coccyx, minimum of two views Analyze neurostim no prog Percutaneous Analyze neurostim simple Percutaneous Analyze neurostim complex Percutaneous Spin/brain pump refil & main Percutaneous Spin/brain pump refil & main Percutaneous Application of a modality to 1 or more areas; hot or cold packs Application of a modality to 1 or more areas; traction, mechanical Application of a modality to 1 or more areas; electrical stimulation (unattended) Application of a modality to 1 or more areas; vasopneumatic devices 7 Obtaining a pre-authorization does not guarantee payment

14 97018 Application of a modality to 1 or more areas; paraffin bath Application of a modality to 1 or more areas; whirlpool Application of a modality to 1 or more areas; diathermy (eg, microwave) Application of a modality to 1 or more areas; infrared Application of a modality to 1 or more areas; ultraviolet Application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes Application of a modality to 1 or more areas; iontophoresis, each 15 minutes Application of a modality to 1 or more areas; contrast baths, each 15 minutes Application of a modality to 1 or more areas; ultrasound, each 15 minutes Application of a modality to 1 or more areas; Hubbard tank, each 15 minutes Unlisted modality (specify type and time if constant attendance) Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility Massage Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitt Therapeutic procedure, 1 or more areas, each 15 minutes; aquatic therapy with therapeutic exercises Therapeutic procedure, 1 or more areas, each 15 minutes; gait training (includes stair climbing) Unlisted therapeutic procedure (specify) Manual therapy techniques (eg, mobilization/ manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes Therapeutic procedure(s), group (2 or more individuals) Therapeutic activities, direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance), each 15 minutes Sensory integrative techniques to enhance sensory processing and promot adaptive responses to environmental demands, direct (one-on-one) patient contact Self-care/home management training (eg, activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact 8 Obtaining a pre-authorization does not guarantee payment

15 Community/work reintegration training (eg shopping, transportation, money management, avocational activities and/or work environment/modification analysis use of assistive technology device/adaptive equipment), direct one-on-one contact Wheelchair management Work hardening/conditioning; initial 2 hours Work hardening/conditioning; each additional hour Debridement (eg, high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel, and forceps), open wound, (eg, fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; first 20 sq cm or less selective debridement with scissors, scalpel, and forceps), open wound, (eg, fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; each additional 20 sq cm or part thereof Removal of devitalized tissue from wound(s), non-selective debridement, without anesthesia (eg, wet-to-moist dressings, enzymatic, abrasion, larval therapy), including topical application(s) for ongoing care, per session Negative pressure wound therapy (eg, vacuum assisted drainage collection), utilizing durable medical equipment (DME), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area less than or equal to 50 square cenimeters Negative pressure wound therapy (eg, vacuum assisted drainage collection), utilizing durable medical equipment (DME), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session; total wound(s) surface area greater than 50 square centimeters Physical performance test or measurement with written report Assistive technology assessment (eg, to restore, augment, or compensate for existing function, optimize functional tasks and/or maximize environmental assessibility), direct one-on-on contact, with written report Orthotic(s) management and training (including assessment and fitting when not otherwise reported) upper extremity(ies), lower extremity(ies) and/or trunk, initial orthotic(s) encounter Prosthetic(s) training, upper and/or lower extremity(ies), initial prosthetic encounter Orthotic(s) prosthetic(s) management and/or training, upper extremity(ies), lower extremity(ies) and/or trunk, subsequent orthotic(s)/prosthetic(s) encounter 9 Obtaining a pre-authorization does not guarantee payment

16 97799 Unlisted physical medicine/rehabilitation service or procedure Chiropractic manipulative treatment (CMT); spinal, one to two Performed in Chiropractor regions Office Only Chiropractic manipulative treatment (CMT); spinal, three to four Performed in Chiropractor regions Office Only Chiropractic manipulative treatment (CMT); spinal, five regions Performed in Chiropractor Office Only Chiropractic manipulative treatment (CMT); extraspinal, 1 or more Performed in Chiropractor regions Office Only 0095T Removal of total disc arthroplasty (artificial disc), anterior approach, each additional interspace, cervical (List separately in addition to code for primary procedure) 0098T Additional interspace revision of cervical disc arthroplasty Total disc arthroplasty (artificial disc), anterior approach, including 0163T discectomy to prepare interspace (other than for decompression), lumbar, each additional interspace 0164T Removal of total disc arthroplasty, anterior approach, lumbar, each additional interspace 0165T Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, each additional interspace, lumbar (List separately in addition to code for primary procedure) 0195T Prescrl fuse w/o instr l5/s1 0196T Prescrl fuse w/o instr l4/l5 0202T Post vert arthrplst 1 lumbar 0213T Njx paravert w/us cer/thor Injection 0214T Njx paravert w/us cer/thor Injection 0215T Njx paravert w/us cer/thor Injection 0216T Njx paravert w/us lumb/sac Injection 0217T Njx paravert w/us lumb/sac Injection 0218T Njx paravert w/us lumb/sac Injection 0219T Plmt post facet implt cerv Percutaneous 0220T Plmt post facet implt thor Percutaneous 0221T Plmt post facet implt lumb 0222T Plmt post facet implt addl 0228T Njx tfrml eprl w/us cer/thor Injection 0229T Njx tfrml eprl w/us cer/thor Injection 0230T Njx tfrml eprl w/us lumb/sac Injection 0231T Njx tfrml eprl w/us lumb/sac Injection 0274T Perq lamot/lam crv/thrc Percutaneous 0275T Perq lamot/lam lumbar Percutaneous 0375T Disc Arthroplasty G0260 Inj for sacroiliac jt anesth Injection G0283 Electrical stimulation (UNATTENDED), to one or more areas for indications other than wound care M0076 Prolotherapy Injection 10 Obtaining a pre-authorization does not guarantee payment