MDwise HIP Prior Authorization and Drug List
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1 MDwise HIP Prior Authorization and Drug List Services that require Prior Authorization Type of Service Requires PA Coding All Out of Network services 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. Facility to facility ambulance transport (nonemergent transport) A0426 & A0428 Air Ambulance A0430, A0431, A0435, A0436 Elective/emergent/urgent medical, surgical inpatient admissions and observation stays Inpatient Rehabilitation POS 21, 22, 24, 51, 61 Skilled nursing facility services POS 31 Subacute admission POS 21 POS 21 or 61 and accommodation codes 024, POS 21 or POS 61. Revenue code 024 Transplants Accidental dental services (other than ER) Bariatric Surgery excluding the work up/evaluation for transplant POS 21 - For outpatient need to have the following: S9975, Solid: Heart/lung liver , pancreas , Bone Marrow: Heart valve tissue transplants: 33933, Stem cell: Pancreas: Intestine: , D0100-D0999. Please contact Dentaquest for prior authorization of dental services , , , or Cochlear Implants surgery (See DME for device) General anesthesia for dental procedures D D9248 Hysterectomy 51925, , , , , Mastectomy reconstructive surgery Same as breast reconstruction below
2 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, S8262 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) , , , , , 15847, , , , , , , 30520, , 37785,37799, , , 54660, , 69300, S2066-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 Uvulopalatoplasty including laser assisted Vision surgery - Laser in-situ keratomileusis (LASIK), laser epithelial keratomileusis (LASEK), Photorefractive Keratectomy (PRK), Photostigmatic keratectomy (PARK/PRK-A), Epikeratoplasty S0800, S0810, S0812, Home health services POS 12 with the following codes, G0151, G0152, G0153, G0155, 99600, TE, TD, 99601, 99602, 92610, S9349, S9127, 97001, 97003, Initial evaluation codes for PT, OT, ST in home and all subsequent therapy visits in home requires PA.
3 Home IV infusion S9349 Tocolytics, Home oxygen Hospice (inpatient and outpatient) Nutritionals and Supplements, Enteral/Parenteral Nutrition and services Outpatient ST/OT/PT Outpatient cardiac rehab Outpatient Pulmonary rehab CORF- comprehensive outpatient rehabilitation facilities, regardless of total claim cost A4615- A4616, A7046, E0424-E0455, E0460-E0461, E0463, 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 -B , 97004, , , , G G HX CP 943 G G HX G G HX G0237-G0239, 948, G0424 Included in PT, OT, ST including all POS 62 Cochlear Implants (device) L8614- L8619 Durable Medical equipment all DME and supplies >$500 (total claim) including rental or purchase requires prior authorization ALL DME codes Electric breast pump, rental or purchase of $500 or more per claim Hearing Aids V V5263, V5267 Orthotics L0100-L4631 Prosthetics of $500 or more per claim L5000 L9900 TENS (see pain management) A A HX A4595 A A HX E E HX E E HX
4 Bone Density study for members under 65 years of age Botox Injections Chiropractic Clinical trials for cancer treatment Dialysis Genetic testing Hyperbaric oxygen PET Scan- All MRA- ALL G G HX CP CP CP J0585-J0588 Please refer to Drugs that Require Prior Authorization below Prior Authorization is required for all services billed by the Chiropractor Provider Specialty (150). Chiropractor services are only prior authorized based on medical necessity. Rev codes 082x, 083x, 084x-, 085x 81228, 81229, 88230, 88367, 88291, 80502, 88262, 88289, 88230, 72090, C1300, A4575, E , , , 78459, , G0219-G , 73225, 71555, , 73725, , 72198, 72159, 72159, MR Spectroscopy MRI- Abdomen MRI - Pelvis MRI - Lower Extremity MRI- 3D MRI - Brain MRI - Chest MRI - Cervical, Thoracic, lumbar spine MRI - Breast
5 CT scan - Cervical, Thoracic, lumbar spine CT scan - Thorax CT scan - Abdomen CT scan - Maxillofacial CT Scan - Pelvis D CT scans , Podiatry (also described as routine foot care per HIP 2.0 benefit plans), after initial visit All services require PA after initial E&M office visit code or the INITIAL ROUTINE FOOT CARE (codes 11055, 11056, 11057, 11719, 11720, 11721) visit. Pulse generator The following radiation therapy requires prior auth: Proton Beam, IMRT, Neutron Beam 32553, , C1728, C2634-C2699, G0173, G0251 Vision training therapy Routine OB Ultrasounds 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, transcutaneous electric nerve stimulator Sacral nerve, Neuro or Spinal Cord stimulator Behavioral Health, more than 2 OB ultrasounds require prior auth the following require prior authorization (TENS) with Diagnosis codes V22.0-V22.2, V23.0-V23.9, V28.3-V28.4, , , , , with diagnosis of , , , , , , , 76942, 77002, 77003, 77021,72275, E0744-E0749, E0762, E0766, L8679-L8695, A (for implant) 43647, (for electrodes) PA requirements as outlined in HIP BAP 18
6 Drugs that require Prior Authorization Therapeutic Category Brand Name Generic Name Applicable Code(s) Blood Modifiers Botulinum Toxins Enzyme Replacement Therapy Hormonal Modifiers Immuno-modulators for Inflammatory Conditions Immuno-modulators for Multiple Sclerosis Metabolic Bone Disease Aranesp darbepoetin alfa J0881, J0882 Epogen, Procrit epoetin alfa J0885, J0886 Leukine sargramostim J2820 Neulasta pegfilgrastim J2505 Neumega oprelvekin J2355 Neupogen filgrastim J1440, J1441 Botox onabotulinumtoxin A J0585 Dysport abobtulinumtoxin A J0586 Myobloc rimabotulinumtoxin B J0587 Xeomin incobotulinumtoxin A J0588 Cerezyme imiglucerase J1786 Elelyso taliglucerase J3060 VPRIV velaglucerase J3385 Eligard, Lupron leuprolide J9217, J9218, J1950 Sandostatin octreotide J2354 Sandostatin LAR octreotide J2353 Supprelin LA histrelin J9225, J9226 Synarel nafarelin J3490 Trelstar LA triptorelin J3315 Zoladex goserelin J9202 Actemra tocilizumab J3262 Benylsta belimumab J0490 Entyvio vedolizumab None Orencia abatacept J0129 Remicade infliximab J1745 Rituxan rituximab J9310 Simponi Aria golimumab None Tysabri natalizumab J2323 Aredia pamidronate J2430 Boniva ibandronate J1740 Reclast zoledronic acid J3488 Prolia, Xgeva denosumab J0897 Zometa zoledronic acid J3487
7 Therapeutic Category Brand Name Generic Name Applicable Code(s) Euflexxa sodium hyaluronate J7323 Gel-One sodium hyaluronate J7326 Osteoarthritis Hyalgan, Supartz sodium hyaluronate J7321 Monovisc sodium hyaluronate None Orthovisc sodium hyaluronate J7324 Synvisc, Synvisc-One sodium hyaluronate J7325 Respiratory Agents Prolastin, Zemaira proteinase inhibitor J2357 Xolair omilzumab J2315 Toxicologic Agent Vivitrol naltrexone J2315 HIP2P0014 (2/15)
2016 MDwise Excel Network Hoosier Healthwise Medical Services that Require Prior Authorization
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Drug Name. J0129 Injection, abatacept (Orencia ), 10 mg Effective 01/01/2014. J0178 Injection, aflibercept (Eylea ), 1 mg Effective 04/01/2015
J0129 Injection, abatacept (Orencia ), 10 J0178 Injection, aflibercept (Eylea ), 1 J0256 J0257 J0585 J0586 J0587 J0588 J0597 J0641 J0717 J0800 Injection, alpha 1-proteinase inhibitor, human (Aralast NP,
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MEDICAL MANAGEMENT CONTACT INFO- MONDAY - FRIDAY FROM 8:00 AM TO 5:00 PM - (720) 445-9404 *ALL REFERRALS TO SPECIALISTS REQUIRE PRIOR AUTHROIZATION* *ALL OUT OF NETWORK SERVICES REQUIRE PRIOR AUTHROIZATION*
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ABA BEHAVIORAL HEALTH CHEMICAL DEPENDENCY Applied Behavioral Analysis stage 3* Neuropsychological Testing Chemical Dependency/Substance Abuse* (MA Only) 0364T 0365T 0366T 0367T 0373T 0374T H2020 96116
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Abatacept (Orencia) 1, 2, 7, 11, 13, 14, 18, 24, 31, 44, 48, 49, 51, 53, 55, 57 J0129 Alpha 1 - Proteinase inhibitor (Prolastin-C) 5, 6, 10, 12, 40 Medically Necessary (if all the following criteria apply):
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sad EFFECTIVE DATE: POLICY LAST UPDATED:
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See the benefits table below. None. $2,000 per Member per Calendar Year $4,000 per family per Calendar Year
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