Prior authorization list. Integrity Home Care + Hospice. Mercy Care Management Prior Authorization Guide with procedure code
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1 Integrity Home Care + Hospice Mercy Care Management Prior Authorization Guide with procedure code Medical Observation admits greater than 23 hours. Surgical Observation admits where the procedure requires Prior Authorization, or greater than 23 hours All Inpatient Hospital, Behavioral Health, Chemical Dependency, Skilled Nursing, Long-term Acute care and Rehabilitation admissions require Prior Referral/Authorization. Maternity admissions require Prior Referral/Authorization under the following circumstances: Maternity Vaginal Delivery; > 48 hours from delivery Cesarean Delivery; > 96 hours from delivery Vaginal delivery after previous cesarean section; > 48 hours from delivery Cesarean delivery following attempted vaginal delivery after previous cesarean delivery; > 96 hours from delivery Mental health services call Mercy Managed Behavioral Health at or Neuropsychological testing Nutritional Support (enteral feeding) Home Health, except for Physical Therapy, Occupational Therapy and Speech Therapy. Hospice Durable Medical Equipment (DME) over $ single line item purchase price, or cumulative rental of a single item (does not include oxygen and oxygen equipment). In addition the following items, including but not limited to: o CPAP units (not supplies) o TENS units (not supplies) o Bone growth or neuromuscular stimulators o Hospital beds o Wheelchairs
2 o All custom made items o Insulin pumps (not supplies) o Continuous Glucose Monitors Orthotics over $1000, all foot orthotics or any custom orthotic Non emergent ambulance transfers Air ambulances Phototherapy Clinical trials Transplants Prosthetic > $1000 Accidental dental services All CPT codes ending in 99 All CPT codes ending in T Genetic testing (except codes ) Integumentary System Tattooing, intradermal Insertion of tissue expander(s) for other than breast, including subsequent expansion Replacement of tissue expander with permanent prosthesis Removal of tissue expander(s) without insertion of prosthesis Removal, implantable contraceptive capsules Insertion, removal, non-biodegradable drug delivery implant ** Blepharoplasty, upper eyelid 15830, Excision, excessive tissue skin and subcutaneous tissue Graft for facial nerve paralysis; free muscle graft; free muscle flap; regional muscle transfer Mastectomy for gynecomastia **19316 Mastopexy **19318 Reduction mammaplasty ** Mammaplasty, augmentation; with and without prosthetic implant Removal of intact mammary implant Removal of mammary implant material ** Immediate/ delayed insertion of breast prosthesis following mastopexy, mastectomy, or in reconstruction Nipple reconstruction Breast reconstruction ** Revision of reconstructed breast; preparation of moulage for custom breast implant Musculoskeletal System
3 Electrical stimulation to aid bone healing; noninvasive; invasive Low intensity ultrasound stimulation to aid bone healing Unlisted procedure, musculoskeletal system, general Arthrotomy, temporomandibular joint Condylectomy/ Menisectomy; temporomandibular joint Coronoidectomy Impression and custom preparation; maxillofacial prosthesis Unlisted maxillofacial prosthetic procedure Application of halo type appliance for maxillofacial fixation, includes removal Interdental fixation for other than fracture Injection procedure for temporomandibular joint arthrography Genioplasty ** Augmentation, mandibular body or angle; prosthetic material, with bone graft, onlay or interpositional Reduction forehead ** Reconstruction midface, LeFort I, II, III ** Reconstruction of orbital rims, forehead, cranial bones, mandibular rami ** Osteotomy, mandible, segmental; with genioglossus advancement ** Osteoplasty, facial bones; augmentation ** Graft bone; nasal, maxillary or malar areas; rib cartilage, autogenous, to face, chin, or nose; ear cartilage, autogenous, to nose or ear Arthroplasty, temporomandiular joint; autograft, allograft, prosthetic joint replacement ** Reconstruction of mandible or maxilla **21255 Reconstruction of zygomatic arch and glenoid fossa ** Reconstruction of orbit with osteotomies; periorbital osteotomies; orbital repositioning **21270 Malar augmentation, prosthetic material **21275 Secondary revision of orbitocraniofacial reconstruction Unlisted craniofacial and maxillofacial procedure Reconstructive repair of pectus excavatum or carinatum Partial excision vertebral component or vertebral body Osteotomy spine Percutaneous vertebroplasty, kyphoplasty IDET (Intradiscal electrothermal therapy) Musculoskeletal System (continued)
4 Arthrodesis, spine Kyphectomy Exploration of spinal fusion Spinal instrumentation Total disc arthroplasty Revision total shoulder Revision total elbow Under Repair, Revision, and/or Reconstruction Procedures on the Femur (Thigh Region) and Knee Joint Under Repair, Revision, and/or Reconstruction Procedures on the Foot and Toes Under Endoscopy/Arthroscopy Procedures on the Musculoskeletal System Respiratory System ** Rhinoplasty, primary or secondary, including major septal repair ** Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate Repair of nasal vestibular stenosis Septoplasty or submucous resection; repair choanal atresia; lysis intranasal synechia; repair fistula; dermatoplasty; repair nasal septal perforations Bronchoscopy with bronchial thermoplasty Cardiovascular System Thoracoscopy with thoracic sympathectomy Transcatheter aortic valve replacement (TAVH/TAVI) Insertion of ventricular assist device Nikaidoh procedure Insertion/Replace VAD Therapeutic Apheresis (removes cholesterol) HPC Boost External mobile cardiovascular telemetry G0166 Enhanced External Counterpulsation (35 treatments over 9 weeks) Digestive System
5 41512 Tongue suspension Tongue base volume reduction Drainage of abscess, cyst, hematoma; removal of embedded foreign body from dentoalveolar structures Gingivectomy; operculectomy; excision of tuberosities dentoalveolar structures; gingivoplasty Digestive System (continued) Unlisted procedure, dentoalveolar structures Uvulectomy Palatopharyngoplasty Maxillary impression for palatal prosthesis Insertion of pin-retained palatal prosthesis Esophagoscopy with optical endomicroscopy Upper GI endoscopy with optical endomicroscopy Laprascopic paraesophageal hernia repair Unlisted laproscopy procedure, stomach 43647, Gastric neurostimulator electrodes, implanatation, revision, , , replacement, removal Bariatric surgery S2083 Allowed 6 in first 12 months following procedure, 3 in second 12 months following procedure without prior authorization All other visits for S2083 require prior authorization Preparation of fecal microbotia for instillation Placement of interstitial devices for radiation therapy guidance Male/Female Cystourethoscopy with injection(s) fro chemodenervation of the bladder Transurethral radiofrequency micro-remodeling of the female bladder neck and proximal urethra for stress incontinence Penile prosthesis Total abdominal hysterectomy, with or without removal of tube(s) and/or ovary(s) Resection of ovarian, tubal, or primary peritoneal malignancy with bilateral salpingo-oopherectomy and omentectomy; with total abdominal hysterectomy, pelvic and limited para-aortic lymphadenectomy Hysterectomy after cesarean delivery
6 59897 Unlisted fetal invasive procedure, maternity care and delivery Nervous System Stereotactic radiation Stereotactic radiosurgery, cranial lesion Insertion/removal/revision neurostimulator Percutaneous lysis of epidural adhesions Stereotactic radiosurgery, spinal lesion Neurostimulators, spinal Nerve block greater occipital nerve (injection of anesthetic agent) RFA inject rx other peripheral nerve destruction by neurlytic agent, chemodenvervation Neurostimulator, peripheral Chemodenervation of muscle(s); cervical spinal muscle(s) Destruction by neurolytic agent, paravertebral facet joint nerves Nerve repair with synthetic conduit or vein allograft Eye and Ocular Adnexa Keratomileusis Radial keratotomy Photodynamic therapy Chemodenervation of extraocular muscle Reduction of ptosis Correction of lid retraction Ocular surface reconstruction Repair of ectropian Osseointegrated implant, implantation, removal, replacement Cochlear device implantation, with or without mastoidectomy J3396 Visudyne Radiology Temporomandibular joint arthrography
7 Functional MRI brain Radiological supervision, vertebroplasty CT colonography Xray fallopian tubes Cardiac MRI Radiology (continued) CT Heart Magnetic resonance spectroscopy Unlisted MRI 76977, Bone density testing when performed on a woman < 65 yrs age or a , , G0339-G0340 man <70 yrs age, or when more than once every 2 years Stereotactic radiation Breast MRI Myocardial imaging, positron emission tomography (PET), metabolic evaluation Myocardial imaging, positron emission tomography (PET), single or multiple studies Brain imaging, positron emission tomography (PET); metabolic evaluation, perfusion evaluation Tumor imaging, positron emission tomography (PET), metabolic evaluation G0219, G0235, G0252 PET imaging Medicine RSV IG intramuscular Individual psychophysiological therapy Biofeedback GI tract imaging, intraluminal e.g. capsule endoscopy External mobile cardiovascular telemetry Neurofunctional testing Neuropsychological testing battery Actinotherapy (ultraviolet light) Microscopic examination of hairs plucked or clipped by the examiner to determine Photochemotherapy (Goeckerman and/or PUVA) Development of cognitive skills Sensory integrative techniques Community/work reintegratin
8 Work hardening Negative pressure wound therapy Performs testing to return to sports Physician attendance and supervision of hyperbaric oxygen therapy, per session J0585-J0588 Botox J1745 Remicade Cosmetic: Not Covered Subcutaneous injection of filling material (e.g. collagen) Punch graft for hair transplant Dermabrasion, abrasion, chemical peel, and salabrasion Cervicoplasty Blepharoplasty, lower eyelid Rhytidectomy Excision, excessive skin and subcutaneous tissue (including lipectomy); abdomen (abdominoplasty) Suction assisted lipectomy Electrolysis epilation Mastopexy Correction of inverted nipples Osteoplasty, facial bones; reduction Medial canthopexy; lateral canthopexy Reduction of masseter muscle and bone; extraoral, intraoral approach Excision or surgical planing of skin of nose for rhinophyma Single or multiple injections of sclerosing solutions (spider veins); limb, trunk, face, legs Canthotomy Repair of brow ptosis; repair of blepharoptosis; repair of overcorrection of ptosis; correction of lid retraction Canthoplasty Ear piercing Otoplasty, protruding ear, with or without size reduction Infertility: Not Covered Vasovasostomy Vasovasorrhaphy
9 Dental: Not Covered Vestibuloplasty; Anterior Vestibuloplasty; Post Unilateral Vestibuloplasty; Post Bilateral Vestibuloplasty; Entire Arch Vestibuloplasty; COMPLX Unlisted not ending in Unlisted In vivo lab service Unlisted reproductive medicine lab procedure This list excludes xxxxt (Category III s). If a Category III code is available for a given service or procedure, use the Category III code instead of a Category I Unlisted code. If billing with a temporary code, include supporting documentation with the claim.
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Position Statement Treatments that primarily affect the appearance are considered medically necessary only in the following circumstances:
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22110 vertebral segment; cervical vertebral segment; thoracic vertebral segment; lumbar
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Code Description 1999 Unlisted Anesthesia Procedure 15781 Dermabrasion, Chemical Peel 15820 Blepharoplasty and Brow Pitosis repair 15823 Blepharoplasty 15830 Excision, Excessive Skin Subcutaneous Abdomen
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sad EFFECTIVE DATE: POLICY LAST UPDATED:
Medical Coverage Policy Prior Authorization via Web-Based Tool for Procedures sad EFFECTIVE DATE: 09 01 2015 POLICY LAST UPDATED: 12 18 2018 OVERVIEW This policy documents the prior authorization request
1105 two (2) vertebrae... 1, add on per additional vertebra
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sad EFFECTIVE DATE: POLICY LAST UPDATED:
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sad EFFECTIVE DATE: POLICY LAST UPDATED:
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Radiology Codes Requiring Authorization*
70336 Magnetic resonance (eg, proton) imaging, temporomandibular joint(s) 70450 Computed tomography, head or brain; without contrast material 70460 Computed tomography, head or brain; with contrast material(s)
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