April 8, 2018 UTILIZATION MANAGEMENT STANDARD CLINICAL REVIEW PREAUTHORIZATION LIST

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A nonprofit independent licensee of the BlueCross BlueShield Association April 8, 2018 UTILIZATION MANAGEMENT STANDARD CLINICAL REVIEW PREAUTHORIZATION LIST The following services require clinical review preauthorization for commercial managed care products, Medicare, Medicaid, Child Health Plus and certain PPO products. Preauthorization means that you or the physician in charge of your care must notify us in advance of plans for you to undergo a specific course of care (such as a hospital admission, or a complex diagnostic test) so that we can determine whether it is medically necessary. Please review the column that applies to your specific insurance plan. These services require preauthorization regardless of whether the service is provided while you are in the hospital, in an outpatient department, in your doctor s office or at home. For some PPO products, you are responsible for notifying us for certain services. Please check your ID card to see if any Prior Authorization Requirements are listed and follow the instructions. Be aware that this document includes medical and technical language. That s why it is important for you to review this information with your health care provider if you have questions. Payment is based on the benefits in your contract, eligibility and medical necessity at the time of service. Claims will process according to your 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. Column A applies to our to: HMO, EPO and Healthy Blue PPO, and Exchange. Column B applies to our managed Safety Net products (Medicaid and Child Health Plus). Envolve-New York Inc. handles most preauthorization requests on behalf of Excellus for these products. NOTE: This list is not inclusive of all insurance products and procedures requiring pre-authorization. Some member contracts may have other restrictions. Not all contracts include all benefits. Excellus has delegated responsibility for the preauthorization of some services to other vendors. Please call the Customer Care phone number listed on your identification card to verify specific coverage requirements before having services rendered if you have any questions.

and Exchange Abdominoplasty and Panniculectomy Ablative techniques for treating Barrett s Esophagus and treating Not primary and metastatic liver malignancies Acoustic Cardiography Not Adenoidectomy NOT REQUIRED Air Ambulance (Non-Emergent) Anesthesia for Dental Surgery Aqueous Drainage Devices Not Assisted Reproductive Technology (ART)/Tubouterine Implantation Not Balloon Sinuplasty Bariatric Procedures BRCA Testing Blepharoplasty Breast Reconstruction, including but not limited to Implant Insertion, Removal, Reinsertion (except for breast cancer diagnosis) Breast Reduction Surgery, including surgery for Gynecomastia Cardiac Catheterization (elective) Not Cardiac Devices; Implantable Cardiovascular Telemetry Devices, Wearable; Mobile through evicore through evicore Not Chelation Therapy Cholecystectomy, Laparoscopic Not

Clinical Trials * and Exchange 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. Cochlear Implants and Auditory Brain Stem Implants Collagenase; Clostridium Histolyticum; Xiaflex Comfort; Convenience, Cosmetic or Custodial Services or Procedures Not Compression Garments Not Computer Assisted Navigation for Knee and Hip Arthroscopy Contact Lenses Not Contact Lenses; Gas Permeable Scleral Cosmetic Services (refer to published procedure code list) Not Cranial Orthotics Cryosurgical Tumor Ablation Deep Brain Stimulation Dermabrasion

Durable Medical Equipment and Exchange for all equipment listed below or when member contract requirements dictate: Airway Clearance Devices Ambulatory Traction Devices BiPAP / CPAP Machines Bone Growth Stimulators Continuous Glucose Monitoring Systems Continuous Passive Motion Device (in home setting) Functional Neuromuscular Stimulators Gait Trainers Home Automatic External Defibrillators Hospital Beds (including Air Fluidized Beds) Insulin Pumps Intrapulmonary Percussive Devices Non Invasive Positive Airway Ventilator Pneumatic Cervical Traction Devices Pneumatic Compressors (Lymphedema Pumps) Speech Generating Devices Stander / Standing Devices T.E.N.S. units Wheel Chairs and Power Operated Vehicles Wound Vac for all equipment listed below or when member contract requirements dictate: Airway Clearance Devices Ambulatory Traction Devices BiPAP / CPAP Machines Bone Growth Stimulators Functional Neuromuscular Stimulators Gait Trainers Hospital Beds (including Air Fluidized Beds) Insulin Pumps and External Insulin Delivery systems Intrapulmonary Percussive Devices Oxygen Equipment Pneumatic Cervical Traction Devices Pneumatic Compressors (Lymphedema Pumps) Speech Generating Devices Stander / Standing Devices T.E.N.S. units (excludes supplies) Wheel Chairs and Power Operated Vehicles Wound Vac Other Select DME items refer to published Preauthorization Code List Electromagnetic Navigation Bronchoscopy Not Enteral and Parenteral Therapy Not Experimental and Investigational Procedures and /or Services Fecal Bacteriotherapy Gastric Neurostimulation Genetic Testing Hearing Aids and Services Not Home Care and Home Infusion Nursing Visits

and Exchange Home Tele-Monitoring (this is not Cardiac Surveillance) Not Covered Home Uterine Monitoring Not Hospice Services Not Hospital to Hospital Transfers Hyperbaric Oxygen Therapy Hyperhidrosis Surgery Hysterectomy (excludes primary female reproductive cancer diagnosis) 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. Inpatient Admission to the Neonatal Intensive Care Unit (NICU) Joint Surgery Procedures including Replacement: Ankle, Elbow, Hip, Interphalangeal, Knee, Metacarpophalangeal, Shoulder, Wrist Notification Hip Knee Shoulder Notification Keloid Scar Revision Ankle Elbow Hip Interphalangeal Knee Metacarpophalangeal Shoulder Wrist Left Ventricular Assist Devices (LVAD) Lung Volume Reduction Surgery Not Magnetic Esophageal Ring for treatment of GERD Maze Procedure for treatment of Atrial Fibrillation Not

and Exchange Medical Specialty Drugs reference ExcellusBCBCs.com/provider for frequently updated list Miscellaneous and Unlisted Codes Muscle Flap Procedures Not Neuromuscular Stimulation for Scoliosis and electrical shock units Neuropsychological Testing Non-Participating Providers (PPO products excluded) Orthopedic / Orthotic Devices for custom knee braces and cranial orthotics only or unless member contract limitations apply for Select Orthopedic Devices Refer to published preauthorization Code list Osteochondral Bone Graft Otoplasty Pain Management Services Not Palatopharyngoplasty/ Uvulopalatopharyngoplasty Personal Care Services (SAFETY NET ONLY) Platelet Rich Plasma for wound healing, each unit NOT COVERED Prolotherapy Prosthetic Devices Radiology (Imaging) Services (excludes imaging performed in the inpatient, observation and emergency room settings) for: Computerized prosthetic legs; C legs Miscellaneous and Unlisted L codes, or unless member contract limitations apply 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: Computerized prosthetic legs; C legs Additional select codes Refer to published Preauthorization Code list 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

and Exchange Radiation Therapy Including but not limited to IMRT, SRS and through evicore through evicore Proton Beam Therapies Refractive Procedures Rhinoplasty Sacral Nerve Stimulation for Pelvic Floor Dysfunction Septoplasty Sexual Reassignment Surgery Skin Substitutes Not Sleep disorders; surgical management of Sleep Disorder Management includes Sleep Studies, PAP Devices and Supplies Spine Surgery Program through evicore for all procedures listed below regardless of place of service: Allograft for Spine Surgery Arthrodesis / Fusion Arthroplasty; Artificial Disc Autograft for Spine Surgery Decompression Procedure(s); Spine Discectomy including Osteophytectomy Intraspinous Distraction (X-Stop) Kyphoplasty Laminectomy Laminotomy/Laminectomy; percutaneous Minimally Invasive Technique for Lumbar Fusion Vertebral Corpectomy Vertebroplasty; Percutaneous through evicore for all procedures listed below regardless of place of service: Allograft for Spine Surgery Arthrodesis / Fusion Arthroplasty; Artificial Disc Autograft for Spine Surgery Decompression Procedure(s); Spine Discectomy including Osteophytectomy Intraspinous Distraction (X-Stop) Kyphoplasty Laminectomy Laminotomy/Laminectomy; percutaneous Minimally Invasive Technique for Lumbar Fusion Vertebral Corpectomy Vertebroplasty; Percutaneous

and Exchange For additional Spine surgery codes please see published code list under Spinal surgery Spinal Cord Stimulation Stereotactic Radiosurgery (SRS) Therapy; Occupational Therapy; Physical Therapy; Speech No Preauthorization required for Medicare Advantage Direct Pay members. These are subject to the Therapy Cap Benefit No Preauthorization required for Medicare Advantage Direct Pay members. These are subject to the Therapy Cap Benefit No Preauthorization required for Medicare Advantage Direct Pay members. These are subject to the Therapy Cap Benefit Not Not Not Tonsillectomy Not Transplants Transportation Not 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 Vulvectomy Not Wound Filler Not Yttruim-90 ; Selective Internal Radiation Therapy (SIRT) Not

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