Benefit Guidelines for Generating or Updating Referrals

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Benefit Guidelines for Generating or Updating Referrals How to Use these Guidelines Physicians should follow these guidelines to determine the maximum number of visits to allow when generating patient referrals for Blue Choice, Premier Health Plan, and ViaHealth Plan members. If a condition is not listed below but is a covered benefit, the physician should use his or her own discretion to determine the number of visits to assign. Please note that some guidelines are different for certain health care plans. Referral Guidelines by Type of Service/Procedure Acne/Rosacea Six visits for acne or rosacea. Maximum of 10 visits for cystic acne or patients undergoing Accutane treatment. Air Ambulance The Provider must contact Provider Services for prior approval by a Alopecia One visit for initial evaluation. Additional visits at the PCP's discretion for the diagnosis of alopecia areata. Definitive treatment plan for all other diagnoses is required. Annual Body Checks Artificial Insemination See Infertility. Benign Lesion Three visits and removal of up to five lesions per calendar year with documented medical necessity. Diagnoses considered benign include: fibroma, keratoderma, lipoma, mole, nevus, papilloma, skin tag, and solar/seborrheic keratosis. Blepharoplasty Breast Reduction Coverage provided with documented medical necessity. Removal of 1,000 grams required bilaterally. When done post-mastectomy to match prosthesis size, removal of 250 grams is required. Breast Implant Insertion, Removal or Reinsertion

Bunion Three visits initially. Additional visits allowed with treatment plan inclusive of surgery or injections. Cardiac Rehabilitation Coverage is only provided for the monitored program (Phase II); maximum of 36 visits allowed. Benefit is limited to patients with acute MI, Coronary Bypass Surgery, Heart Transplant, or Angioplasty with Stent placement within the previous 12 months; Coronary Angioplasty within the previous six months; or patients with Stable Angina Pectoris or Valvular Disease. Note: Only one episode of Cardiac Rehabilitation for a diagnosis of Angina Pectoris allowed per lifetime. Any request for additional coverage requires special consideration by a Chemical Dependence No referral necessary to a participating outpatient facility. Note: For Lifetime Health members, contact Center Relations at (585) 338-1400. Chiropractic Services No referral is required for non-senior members. Blue Choice Senior/SeniorCare members do require a referral and have a benefit of 12 visits per calendar year. X-rays are not reimbursed separately if done in the chiropractic office. Chorionic Villus Sampling Chronic Vagus Nerve Stimulation Corns/Calluses Coverage provided with documented medical necessity. Coverage for six visits per calendar year with a vascular impairment or diabetes. Developmental Disabilities A school evaluation is required for children age three and over prior to treatment. Deviated Nasal Septum Visits are at the PCPs discretion. For treatment via Rhinoplasty or Septoplasty, the Specialist must contact Provider Services for Prior Justification and approval by a Dexa Scans Coverage is provided for any member who has undergone long term steroid therapy, females over age 45 for a diagnosis of osteoporosis or males who are hypogonadal. All other requests, including repeat scans, require prior approval by a Diabetes

No referral is necessary for diabetic education or teaching at a participating outpatient facility. Dietary consult benefit is four visits initially. For additional visits, the referring Provider must contact Provider Services. Insulin teaching benefit is two visits to a participating outpatient facility and does require a referral. The diabetic routine foot care benefit provides coverage up to six visits per calendar year. Eye exams/visits are covered when medically necessary and visits are at the Specialist s discretion. Diabetic Teaching No referral necessary. Covered for four visits per year for services rendered by a facilitybased Certified Diabetes Educator. Dietary Consultation Maximum of two visits per year. For additional visits, the referring Provider must contact Provider Services for approval by a Dyschromia, Vitiligo, Pigmentary Changes Dyshidrosis The PCP must contact Provider Services for approval by a Exostosis Three visits initially. Additional visits allowed with treatment plan inclusive of surgery or injections. Eye Clinic Referral required only for the 24-hour post-trauma visit at the outpatient department. Foot Pain One visit initially. Additional visits require definitive diagnosis and appropriate treatment plan. Gastric Bypass Genetic Counseling No referral is necessary for amniocentesis. For all other testing, the specialist must contact Provider Services for prior justification and approval by a Gynecomastia One visit initially. Additional visits require the Specialist to contact Provider Services with definitive treatment plan for approval by a There is no coverage for cosmetic purposes. Hammertoe Three visits initially. Additional visits allowed with treatment plan inclusive of surgery or injections.

Hearing Evaluation/Audiogram/Baer Test Maximum of three visits. Referral is necessary at a participating outpatient facility. Infertility Coverage provided as long as neither partner has undergone voluntary sterilization. The benefit for Artificial Insemination is 12 visits for Intrauterine and 24 visits for Non- Intrauterine per pregnancy. The benefits for Pergonal Therapy is four cycles per pregnancy. Insulin Teaching Maximum of two visits. Referral is required to a participating outpatient facility. Keloid Scars One visit initially with documented medical necessity. Additional visits require the Specialist to contact Provider Services with an appropriate treatment plan for approval by a Clinical Reviewer. There is no coverage for cosmetic purposes. Lesion in Mouth Visits at PCP s discretion. When lesion is located on the gumline, one visit for consult. Additional visits require the Specialist to contact Provider services with a definitive treatment plan for approval by a Malignant Lesion Visits at PCP s discretion with confirmed biopsy report. Mental Health Treatment - Outpatient Visits at PCP s discretion up to patient s full annual benefit. Certain mental health providers must submit an Outpatient Treatment Report (OTR) to the BCBSRA Behavioral Health Unit to continue treatment after the initial eight visits (24 units) have been used. When more than one family member is in treatment with the same Behavioral Health Provider, one initial visit (three units) will be allowed for each member. All requests for additional visits will require an OTR to be submitted for review by the Behavioral Health Unit. Motor Vehicle Accident (MVA) The Provider must contact Provider Services. Mycotic Nails Visits at the PCP s discretion. Trimming and shaving covered only with documented medical necessity of a vascular impairment or diabetes. Neuropsychological Testing The referring Provider must contact Provider Services for Prior Justification and approval by a Nonparticipating or Out-of-Area Provider Obesity

Occupational Therapy Maximum of eight visits initially. Additional visits may be approved, with a definitive treatment plan, up to the patient s annual benefit. Otoplasty There is no coverage for cosmetic purposes. Physical Therapy Maximum of eight visits initially. Additional visits may be approved, with a definitive treatment plan, up to the patient s annual benefit. Pierced Ear Laceration Coverage provided for traumatic injury only. There is no coverage for cosmetic purposes. PUVU Treatments Routine Foot Care (trimming and shaving) Coverage provided when medically necessary. Coverage is six visits per calendar year days for patients with a vascular impairment or diabetes. Rhinoplasty Sclerosing Injections There is no coverage for cosmetic purposes. Sebaceous Cyst Maximum of three visits per calendar year. Removal of up to three cysts covered per visit. Septoplasty Skin Tags See Benign Lesion. Sleep Apnea Maximum of three visits initially. Surgical repair via palatoplasty or palatopharyngoplasty requires that the specialist contact Provider Services with sleep study results and definitive treatment plan for prior justification and approval by a Sleep Studies Maximum of three visits for diagnoses of: sleep apnea, narcolepsy, sleep related seizures, or brachiopenile impotence to an approved participating facility.

Speech Therapy One visit initially for evaluation to a participating Provider. For additional visits, the Specialist must contact Provider Services with a definitive treatment plan for Prior Justification and approval by a Transplant, Organ or Bone Marrow Urgent Care Centers One visit for emergent conditions at a participating facility. Varicose Veins One visit initially with documented medical necessity. For additional visits the Specialist must contact Provider Services with a definitive treatment plan for Prior Justification and approval by a There is no coverage for cosmetic purposes. Viscosupplementation The PCP must contact Provider Services for Prior Justification and approval by a Clinical Reviewer. Warts/Molluscum Contagiosum Six visits per calendar year for viral or plantar warts. Maximum of eight visits per calendar year for mosaic warts. Visits for treatment of genital warts are at the PCP's discretion. For surgical removal, see Benign Lesion. Workers Compensation The Provider must contact Provider Services.

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