Effective April 7, 2014 UTILIZATION MANAGEMENT STANDARD CLINICAL REVIEW PREAUTHORIZATION LIST The following services require clinical review preauthorization for commercial managed care products, Medicare, Medicaid, Family Health Plus and Child Health Plus and certain PPO products. Please review the column that applies to the member s specific health benefit program regardless of place of service. IMPORTANT This list represents services that require preauthorization with a clinical medical necessity review. It is NOT inclusive of all products and procedures requiring preauthorization. There may be services which require preauthorization/-notification that do not require clinical review. Please verify specific coverage requirements before rendering service. The following services require preauthorization regardless of place of service. Clinical Review Abdominoplasty and Panniculectomy Acoustic Cardiography Adult Day Care Health Care NOT COVERED (Plus Med Only) Air Ambulance (Non-Emergent) Anesthesia for Dental Autism Spectrum Services (ABA with ICD-9 diagnosis codes 299.00, 299.10 or 299.80 or ICD- 10 diagnosis codes F840, F843, F845 or F848) (Excludes Medicare Advantage) Balloon Sinuplasty Bariatric Procedures Biofeedback BRCA Testing Blepharoplasty (Child Health Plus Only)
Breast Reconstruction, including but not limited to Implant Insertion, Removal, Reinsertion (except for breast cancer diagnosis) Breast Reduction, including surgery for Gynecomastia Cardiovascular Telemetry, Wearable; Mobile Chelation Therapy Clinical Trials * Cochlear Implants and Auditory Brain Stem Implants Collagenase; Clostridium Histolyticum; Xiaflex Comfort; Convenience, Cosmetic or Custodial Services or Procedures Computer Assisted Navigation for Knee and Hip Arthroscopy Commercial only * For Medicare Advantage members, Medicare approved clinical trials are covered by original Medicare or FFS Medicare and should be billed directly to your fiscal intermediary. Crossover claims will be sent directly to the plan by the intermediary. Be sure to use the correct clinical trial codes. Contact Lenses Not Cranial Orthotics Cryosurgical Tumor Ablation Day Treatment (Behavioral Health) Deep Brain Stimulation Dermabrasion Developmental Testing Not Durable Medical Equipment for all equipment listed below or when member contract requirements dictate: Airway Clearance Ambulatory Traction BiPAP Machines Bone Growth Stimulators Continuous Glucose Monitoring Systems Functional Neuromuscular Stimulators Gait Trainers Hospital Beds (including Air Fluidized Beds) Insulin Pumps for all equipment listed below or when member contract requirements dictate: Airway Clearance Ambulatory Traction BiPAP Machines Bone Growth Stimulators Continuous Glucose Monitoring Systems Functional Neuromuscular Stimulators Gait Trainers Hospital Beds (including Air Fluidized Beds) Insulin Pumps
Intrapulmonary Percussive Pneumatic Cervical Traction Pneumatic Compressors (Lymphedema Pumps) Speech Generating Stander / Standing T.E.N.S. units Wheel Chairs and Power Operated Vehicles Intrapulmonary Percussive Pneumatic Cervical Traction Pneumatic Compressors (Lymphedema Pumps) Speech Generating Stander / Standing T.E.N.S. units Wheel Chairs and Power Operated Vehicles Experimental and Investigational Procedures and /or Services Gastric Neurostimulation Genetic Testing Mental Health Group Therapy Hearing Aids Not Hip Replacement (including total and resurfacing) Home Care and Home Infusion Nursing Visits Home Tele-Monitoring (this is not Cardiac Surveillance) Not Covered Home Uterine Monitoring Hospital to Hospital Transfers Hyperbaric Oxygen Therapy Hyperhidrosis (excludes Child Health Plus and Family Health Plus) Inpatient Admissions (except routine maternity) to any facility including hospital, elective and direct admit, acute rehab, SNF, mental health, chemical dependency and hospital to hospital transfers. * Emergency admissions require notification to the Health Plan. Intensity Modulated Radiation Therapy (IMRT)
Intensive Outpatient Behavioral Health Treatment Intraspinous Distraction (X-STOP) Keloid Scar Revision Knee Replacement; includes Unicondylar Left Ventricular Assist (LVAD) Medical Specialty Drugs reference ExcelluBCBCs.com/provider for frequently updated list Follow the link to the left to view our medical specialty drug preauthorization requirements Miscellaneous and Unlisted Codes Neuromuscular Stimulation for Scoliosis and electrical shock units Follow the link to the left to view our medical specialty drug preauthorization requirements Neuropsychological Testing Non-Participating Providers Orthopedic / Orthotic (PPO products excluded) for custom knee braces and cranial orthotics only or unless member contract limitations apply Osteochondral Bone Graft for custom knee braces and cranial orthotics only or unless member contract limitations apply Otoplasty Partial Hospitalization (Behavioral Health) Palatopharyngoplasty/ Uvulopalatopharyngoplasty Personal Care Services NOT COVERED (SAFETY NET ONLY) Platelet Rich Plasma for wound healing, each unit Prolotherapy Prosthetic for: for: Computerized Computerized prosthetic prosthetic legs; C legs; C legs legs Prosthetic Eyes; device Miscellaneous and Unlisted L and service codes, or unless member Miscellaneous and Unlisted L contract limitations apply codes, or unless member contract limitations apply
Proton Beam Radiation Psychological Testing Radiology (Imaging) Services (excludes imaging performed in the inpatient, observation and emergency room settings) Refer to Radiology CPT code list: CTs and CTAs MRAs MRIs Nuclear cardiology All PET scans (Positron Emission Tomography) Miscellaneous or unlisted radiology procedure codes Refractive Procedures Rhinoplasty/Septoplasty Sacral Nerve Stimulation for Pelvic Floor Dysfunction Sexual Reassignment Skin Substitutes Sleep Studies Spine Program for Medicare Advantage for all procedures listed below regardless of place of service: Allograft for Spine Arthrodesis / Fusion for all procedures listed below regardless of place of service: Arthroplasty; Artificial Disc Autograft for Spine Decompression Procedure(s); Spine Discectomy including Osteophytectomy Intraspinous Distraction (X-Stop) Kyphoplasty Laminectomy Laminotomy/Laminectomy; percutaneous Refer to Radiology CPT code list: CTs and CTAs MRAs MRIs Nuclear cardiology All PET scans (Positron Emission Tomography) Miscellaneous or unlisted radiology procedure codes for all procedures listed below regardless of place of service: Allograft for Spine Arthrodesis / Fusion for all procedures listed below regardless of place of service: Arthroplasty; Artificial Disc Autograft for Spine Decompression Procedure(s); Spine Discectomy including Osteophytectomy Intraspinous Distraction (X-Stop) Kyphoplasty Laminectomy Laminotomy/Laminectomy; percutaneous
Vertebral Corpectomy Vertebroplasty; Percutaneous Vertebral Corpectomy Vertebroplasty; Percutaneous Spinal Cord Stimulation Stereotactic Radiosurgery (SRS) Surgical Management of Sleep Disorders Therapy; Physical and Occupational Therapy; Speech Transplants Vagus Nerve Stimulation Varicose Vein Treatment Procedures (including, but not limited to: Vein Ligation, Sclerosing Injection, VNUS and Laser procedures) Vision Services Eyewear Not Vision Therapy Yttruim-90 ; Selective Internal Radiation Therapy (SIRT) This list is not inclusive of all products and procedures requiring preauthorization. Please verify specific coverage requirements before rendering service. Some services, including behaviroal health and chemical dependency, are not covered benefits under Healthy New York HMO. Some member contracts may have other restrictions. Not all contracts include all benefits. Payment is based on member contract benefits, eligibility and medical necessity at the time of service. The provider delivering the service is responsible for ensuring that the required pre-authorization has been obtained and contract is active at time of service. Claims will process according to the member s benefit plan on the date of service. Failure to obtain the necessary preauthorization may result in the denial of the claim or reduced payment allowance.