Exclusive Precertification Quick Reference Guide Verify Benefits and Eligibility With Customer Service For All Services. There may be differences in coverage at the member or group level. Services listed in this Guide may be governed by Anthem Medical Policies or Clinical Guidelines and may impact coverage decisions even when they do not require precertification. To review Medical Policies and Clinical Guidelines refer to the Provider Manual at www.anthem.com.
Precertification:
Central: (303) 493-7507
North: (970) 224-4600
South: (719)365-5025 or (800) 207-1018
COMMENTS CODES LISTED BELOW ARE REFERENCED IN PROVIDER COMMUNICATIONS AND ARE NOT
Procedure
EXCLUSIVE INCLUSIVE OF ALL CODES REQUIRING PRECERTIFICATION. A pre-determination is offered for codes with a suspend/deny or MRU edit. PLAN * Call Customer Service at the number on the Member's Health Plan ID card to confirm benefits for any and all services.
Ablative techniques (Barrett's Esophagus)
Yes
43228, 43258
Ablative techniques (Liver malignancies)
Yes
47370, 47371, 47380, 47381, 47382
Abortion – elective
Yes
Abraxane(Paclitaxel nanoprotein)
Yes
J9264
Actemra (Tocilizumab)
Yes
J3262
Acupuncture
Yes
Not a covered benefit for Exclusive members
Adcetris (brentuximab)
Yes
J9042
Adcetris (brentuximab)
Yes
J9042
Adenoidectomy
No
Admission- ER, direct admit, elective, scheduled ALL medical & surgical inpatient admissions - except Maternity & Hospice require authorization Aldurazyme (Laronidase)
Yes
Yes
J1931
Alimta (Pemetrexed)
Yes
J9305
Ambulance- Air or Water
Yes
Authorization required as of 7/30/10; no penalty for failure to precert for emergent ambulance services A0430, A0431, A0435, A0436, A0999 J0215
Amevive (alefacept)
Yes
Amniocentesis
No
Anesthesia for Colonoscopy
No
Angiography
No
Angioplasty
No
Angioplasty with or without Stent Placement
Yes
0075T, 0076T, 35475, 37215, 37216, 61630, 61635, 61640, 61641, 61642
Ankle Replaceemnt
Yes
27702
Appendectomy (lap & open)
No
Aralast (Alpha 1 proteinase inhibitor)
Yes
J0256
Aranesp (Darbepoetin alfa)
Yes
Obtain through UC Health Pharmacy for non-dialysis outpatient administration
Arteriography
No
Arthroplasty - Ankle Replacement
Yes
**When OP, no authorization needed
Arthroplasty - Hip or Knee Replacement
Yes
**When OP, no authorization needed
Arthroscopy (knee)
No
Arthroscopy (non knee)
No
Artificial – In Vitro Fertilization
No
Confirm Benefit
Artificial Disc
Yes
22856, 22857, 22864, 22865, 22861, 22862, 0163T
Artificial insemination
No
Confirm Benefit
Artificial Intervertebral Discs
Yes
0092T, 0095T, 0098T, 22856
Aspiration or Decompression procedure
Yes
62287
Auditory Brainstem Implants
Yes
Authorization required as of 7/30/10. S3854 Auth not required for 92640
Avastin (Bevacizumab)
Yes
J9035, C9257
Back surgery - all
Yes
Bariatric Services
Yes
Barium Swallow With or Without Speech Therapy
No
Benign Prostatic Hyperplasia (BPH)
Yes
52450, 52647, 52648, 52649, 55873
Benlysta (Belimumab)
Yes
J0490
Biophysical Profile for OB care
No
Biopsy (any)
No
COMMENTS CODES LISTED BELOW ARE REFERENCED IN PROVIDER COMMUNICATIONS AND ARE NOT
Procedure
EXCLUSIVE INCLUSIVE OF ALL CODES REQUIRING PRECERTIFICATION. A pre-determination is offered for codes with a suspend/deny or MRU edit. PLAN * Call Customer Service at the number on the Member's Health Plan ID card to confirm benefits for any and all services.
Birch (bladder repair)
No
Blepharoplasty
Yes
15820, 15821, 15822, 15823, 67900, 67901, 67902, 67903, 67904, 67906, 67908
Bone Growth Stimulator
Yes
20974, 20975, 20979, E0747, E0748, E0760,
Bone Scan (body part or whole body)
No
Bortezomib(Velcade)_
Yes
J9041
Botulinum toxin (BOTOX)
Yes
J0585, 64633, 64634, 64635, 64636, 64650
Brachytherapy
Yes
19296, 19297, 19298, 205555, 31643, 41019, 43499, 47999, 55860, 55862, 55865, 55875, 55899, 55920, 57155, 57156, 58346, 76873, 76965, 67218, 77326, 77327, 77328, 77761,77762, 77763, 77776, 77777, 77778, 8 86 8 90 Q3001 19499
Breast Ductal Lavage
Yes
Breast Prosthesis
Yes
Breast Reconstruction
Yes
19340, 19342, 19350, 19355, 19357, 19361, 19366, 19367, 19368, 19369, 19380, 19396, C1789, L8600,S2066,S2067, S2068
Breast Reconstruction for Cancer Dx
Yes
Approve 2 day LOS if Inpatient
Breast Reconstruction for Non-cancer Diagnosis
Yes
Not a benefit
Breast Reduction
Yes
Not a benefit
Bronchoscopy
No
Bunionectomy (Foot surgery)
No
CABG (Coronary Artery Bypass Graft)
Yes
Campath (Alemtuzumab)
Yes
J9010
Canaloplasty
Yes
66174, 66175
Capsule Endoscopy
Yes
91110, 91111
Cardiac Catheterization
No
Cardiac Rehabilitation
Yes
Cardiac Resyncronization Therapy
Yes
Cardio Assist - External Counter Pulsation
Yes
Cardioversion
No
Carimune (Immune globulin-powder)
Yes
Carpal Tunnel
No
33202, 33203, 33207, 33208, 33211, 33213, 33214, 33216, 33217, 33224, 33225, 33226, 33249 92971, G0166
J1566
Cataract Surgery
No
Ceredase (Alglucerase)
Yes
J0205
Cerezyme (Imiglucerase)
Yes
J1786
Chin Implants
Yes
21125
Chiropractic
No
CO HMO members- refer to Landmark (800) 638-4557
Cholecystectomy (laparoscopy & open)
No
Chondrocyte Implantation
Yes
27412, S2112, J7330
Cimzia (Certolizumab pegol)
Yes
J0718
Cochlear Implant
Yes
Procedure and external speech processor requires authorization. Auth required: L8614, L8619, L8627, L8628, S2235 Auth not required for 92603, L8615, L8616, L8617, L8618 Contact Anthem for auth (800)735-6072
Colonoscopy – medical
Yes
Colonoscopy – routine
Yes
Colonoscopy – virtual
Yes
Screening colonoscopy over age 50 requires no auth
Colposcopy
No
Communication/Speech Generating Devices
Yes
E1902, E2351
Computer-assisted surgical navigational procedure
Yes
0054T, 0055T, 20985
Corneal Topography
No
Cosmetic – Reconstructive
Yes
11920, 11921, 11922, 11950, 11951, 11952, 11954, 17106, 17107, 17108, 21740, 21742, 21743, 30120, 30400, 36469, 54440, 56800, 56805, 56810, 57291, 57292, 64716, 64732, 64734, 64736, 64738, 64740, 64742, 64864, 64865, 64866, 64868, 64870, 69090, 69300,
Cryablation
Yes
64640
Cryopreservation
Yes
89344, 89346, 89354, 89356
COMMENTS CODES LISTED BELOW ARE REFERENCED IN PROVIDER COMMUNICATIONS AND ARE NOT
Procedure
EXCLUSIVE INCLUSIVE OF ALL CODES REQUIRING PRECERTIFICATION. A pre-determination is offered for codes with a suspend/deny or MRU edit. PLAN * Call Customer Service at the number on the Member's Health Plan ID card to confirm benefits for any and all services.
Cryosurgical ablation
Yes
19105, 50250, 50542, 50593, 55873
CT (Computerized tomography)
Yes
70450, 70460, 70470, 70480, 70481, 70482, 70486, 70487, 70488, 70490, 70491, 70492, 71250, 71260, 71270, 72125, 72126, 72127, 72128, 72129, 72130, 72131, 72132, 72133, 72192, 72193, 72194, 73200, 73201, 73202, 73700, 73701, 73702, 74150, 74160, 74170, 74176, 74177, 74178, 74261, 74262, 74263, 75571, 75572, 75573, 75574, 76376, 76377, 77078
CTA (Computerized Tomography Angiography)
Yes
70496, 70498, 71275, 72191, 73206, 73706, 74174, 74175, 75635
Custom knee braces
No
Cyber Knife
Yes
Cystoscopy
No
Deep Brain Stimulation
Yes
61863, 61864, 61867, 61868, 61870, 61875, 61885, 61886, L8680
Defibrillator (Implantable Cardioverter)
Yes
33202, 33203, 33216, 33217, 33249, C1721, C1722, C1777, C1882, C1895, C1896, 0102T
Defibrillator (Wearable Cardioverter)
Yes
K0606
Delivery (cesarean)
No
Requires notification if member hospitalized longer than 4 days OR if out of network
Delivery (vaginal)
No
Requires notification if member hospitalized longer than 2 days OR if out of network
Dental caries-facility and anesthesia
Yes
Dental-related services
Yes
Destruction of lesion (benign or malignant)
No
Dexascan
Yes
Diabetic (dietitian) education
No
76977, 77080, 77082, 78350, 78351, G0130
Dialysis
No
Dilation & Curettage (D&C)
No
Discogram
No
DME (Durable Medical Equipment) other than as listed as "yes" on this list
No
Contact Anthem for auth of DME (800) 735-6072 INCLUDING CPAP & SUPPLIES
Drainage Devices (Intraocular Anterior Segment)
Yes
0253T
Duplex Scan
No
Dysport (Abobotulinum toxin A)
Yes
J0586
Echocardiogram
Yes
93303, 93304, 93306, 93307, 93308, 93312, 93313, 93314, 93315, 93316, 93317, 93320, 93321, 93325, 93350, 93351, 93352
Echtropion Repair
Yes
67917
Education Classes
No
Confirm benefit
EEG (Electroencephalogram)
No
EGD (Esophagogastroduodenoscopy)
Yes
Egrifta (Tesamorelin)
Yes
EKG (electrocardiogram)
No
Electronic analysis of implanted neurostimulator pulse generator system Electrothermal shrinkage
Yes Yes
S2300, 29999
Embolization - Ovarian, Iliac, Uterine Artery
Yes
37204, 75894
Emergency Room Visit
No
J3490
EMG (Electromyography) Nerve Conduction Test
No
Enbrel (Etanercept)
Yes
Must be obtained through UC Health Pharmacy
Endoscopic Fundoplication
Yes
43257
Enteral Feedings
Yes
Epogen (Epoetin alfa)
Yes
J0885 Q4081 J0886; obtain through UC Health Pharmacy for non-dialysis outpatient use
Erbitux (Cetuximab)
Yes
J9055
ERCP (Endoscopic retrograde cholangiopancreatography)
Yes
ESI (Epidural Steroid Injections)
Yes
Ethmoidectomy
Yes
31200, 31201, 31205
Euflexxa (Hyaluronic Acid)
Yes
J7323
Event Monitor
Yes
Monitor itself does not require auth - but reading requires auth if done by out of network company.
Excision (Nasal Polyps)
Yes
30115, 30110
Pre-cert required if non-pregnancy associated
COMMENTS CODES LISTED BELOW ARE REFERENCED IN PROVIDER COMMUNICATIONS AND ARE NOT
EXCLUSIVE INCLUSIVE OF ALL CODES REQUIRING PRECERTIFICATION. A pre-determination is offered for codes with a suspend/deny or MRU edit. PLAN
Procedure
* Call Customer Service at the number on the Member's Health Plan ID card to confirm benefits for any and all services.
Excision Inferior Turbinate, Partial or Complete, any method
Yes
Excision of Benign Lesion
No
30130
Excision of Malignant Lesion
No
External infusion pumps, including insulin
Yes
A9274
Extracorporeal shock wave therapy (ESWT)
Yes
0019T, 0101T, 0102T, 28890
Eye lid Reconstruction
No
67973
Eylea (Afibercept)
Yes
Q2046, J3490, J0178, C9291
Fabrazyme (Agalsidase Beta)
Yes
J0180
Fasciotomy Fixed wing air mileage, per statue mile
No Yes
A0435
Flatfoot Treatments
Yes
S2117
Flebogamma (Immune globulin-liquid
Yes
J1572
Flolan (Epoprostenol)
Yes
J1325
Foot surgery
No
Forehead Reduction
Yes
21137, 21138, 21139
Functional Electrical Stimulators (FES)
Yes
E0764, E0770
Functional Endoscopic Sinus Surgery (FESS)
Yes
Authorization required as of 7/30/10
Fundoplication, Endoscopic
Yes
43257
Gamma globulin, IM
Yes
J1560, J1460
Gamma Knife – Stereotactic radiosurgery
Yes
Gammagard (Immune globulin-liquid)
Yes
J1569
Gammaplex (Immune globulin, IV)
Yes
J1557
Gamunex (Immune globulin-liquid
Yes
J1561
Gastrectomy
Yes
43632
Gastric Bypass, Laparoscopic; Surgery for Morbid Obesity
Yes
Gastric Pacemaker
Yes
43644, 43645, 43646, 43659, 43770, 43774, 43842, 43843, 43845, 43846, 43847, 43848, 43886, 43887, 43888 43647, 43648, 43881, 43882, 64595
Gel-One (Hyaluronic acid)
Yes
J7326
Gender Reassignment Surgery
Yes
54125, 54520, 54690, 55180, 55970, 56625, 55980, 56800, 56805, 57110, 57291, 57292, 57295, 57296, 54660 C1767
Generator, neurostimulator (implantable)
Yes
Genetic Testing
Yes
Genetic Testing for Cancer Susceptibility (BRCA, HNPCC, and FAP testing)
Yes
81211, 81212, 81213, 81214, 81215, 81216, 81217, 81292, 81293, 81294, 81295, 81296, S3840
Genioplasty
Yes
21120, 21121, 21122, 21123
Genotropin (Somatropin (rDNA origin))
Yes
J2941, SPMM - use profile SPMNOF
Glassia (Alpha 1 proteinase inhibitor)
Yes
J0257
Glaucoma Treatment (Drainage Devices)
Yes
0191T, 0192T
Glossectomy
Yes
41599
Graft, bone (reconstructive surgery)
Yes
21235, 21230
Growth Hormone Therapy (Somatropin) (GENOTROPIN, HUMATROPE, SEROSTIM) Gynecomastia repair
Yes
J2941; self-administered products must be obtained through UC Health Pharmacy.
Yes
19300
Hair transplant
Yes
15775, 15776
HALT procedure
Yes
58578
Hammertoe Repair
No
Hearing Aids
Yes
S2230, 69714 Contact Anthem for prior auth (800) 735-6072
Hearing Aids (Bone Anchored)
Yes
L8690
Heart Monitors
Yes
93228, 93229
Hemorrhoidectomy
No
Herceptin (Trastuzumab)
Yes
Hernia Repair
No
J9355
High Frequency Chest Wall Oscillation
Yes
E0483, A7025
Hizentra (Immune globulin)
Yes
J1559
Holter Monitor
Yes
Monitor itself does not require auth - but reading requires auth if done by out of network company.
COMMENTS CODES LISTED BELOW ARE REFERENCED IN PROVIDER COMMUNICATIONS AND ARE NOT
Procedure
EXCLUSIVE INCLUSIVE OF ALL CODES REQUIRING PRECERTIFICATION. A pre-determination is offered for codes with a suspend/deny or MRU edit. PLAN * Call Customer Service at the number on the Member's Health Plan ID card to confirm benefits for any and all services.
Home Health Care
Yes
Contact Anthem for prior auth (800) 735-6072
Home IV Therapy - all others
Yes
Contact Anthem for prior auth (800) 735-6073
Home IV Therapy - antibiotics & Solumedrol
Yes
Contact Anthem for prior auth (800) 735-6074
Home Uterine Monitoring
Yes
Contact Anthem for prior auth (800) 735-6075
Hospice - Inpatient or Outpatient
No
Hospital beds
No
Humatrope (Somatropin (rDNA origin))
Yes
J2941 must obtain through UC Health Pharmary
Humira (Adalimumab)
Yes
J0135 must obtain through UC Health Pharmary
Hyalgan (Hyaluronic acid)
Yes
J7321
Hyperbaric Oxygen Therapy
Yes
99183
Hyperhidrosis
Yes
32664
Hysterectomy
Yes
Not required for Outpatient Hysterectomy
Hysterosalpingogram
Yes
Hysteroscopy
No
IDET (Intradiscal Electrothermal Coagulation- Annuoplasty)
Yes
Immune Globin (Caramune J1566, Flebogamma J1572, Gamma Globulin J1460, J1560, Gammagard J1569, Gamunex J1561, Hizentra J1559, Privigen J1459, SCIg
Yes
90281, J1599, J1566, J1572, J1460, J1560, J1569,J1561, J1559, J1459, 90284
Implantable Devices for Spinal Stenosis
Yes
0202T
Implantable Infusion Pumps
Yes
36260, 36563, 61215
IMRT- Intermodulated radiation therapy
Yes
0073T, 77301, 77418, 77338
In Vitro Fertilization
No
Not a benefit
Incontinence Therapy
No
Infertility
No
Confirm benefit
Insulin Pump
Yes
E0784
Intradiscal Electrothermal Annuloplasty (IDET)
Yes
22526, 22527
Intrapulmonary percussive ventilation system
Yes
E0481
Intravenous Pyelogram
No
IV Therapy – antibiotics & Solumedrol
Yes
IVIG (generic) (Immune globulin-powder)
Yes
90283, J1566
Ixempra (ixabepilone)
Yes
J9207
Ixempra (ixabepilone)
Yes
J9207
JAS or DYNA Splint
No
Kineret (Anakinra)
Yes
J3490
Kyphoplasty - unlisted procedure, spine
Yes
22999
Laminectomy - any level
Yes
Laparoscopy
No
Laparotomy
No
Laryngoscopy
No
Laser Assisted Uvulopalatoplasty (LAUP)
Yes
LEEP procedure
No
Leukine (Sargramostim)
Yes
J2820
Lipectomy
Yes
15833, 15834, 15835, 15836, 15837, 15838, 15839, 15876, 15877, 15878, 15879, 15832
Liposuction
Yes
Lithotripsy
Yes
S2080
Lucentis (Ranibizumab)
Yes
J2778
Lumizyme (Alglucosidase alfa)
Yes
J0221
Lung Reduction
Yes
Lupron, Lupron Depot (leuprolide)
Yes
J9217, J1950, J9218
Lupron, Lupron Depot (leuprolide)
Yes
J9217, J1950, J9218
Macugen (Pegaptanib)
Yes
J2503
Makena (hydroxyprogesterone caproate)
Yes
Makena (hydroxyprogesterone caproate)
Yes
Malar (cheek) implants
Yes
Mammography (routine & non routine)
No
15828
COMMENTS CODES LISTED BELOW ARE REFERENCED IN PROVIDER COMMUNICATIONS AND ARE NOT
Procedure
EXCLUSIVE INCLUSIVE OF ALL CODES REQUIRING PRECERTIFICATION. A pre-determination is offered for codes with a suspend/deny or MRU edit. PLAN * Call Customer Service at the number on the Member's Health Plan ID card to confirm benefits for any and all services.
Mammoplasty (Augmentation of breast)
Yes
19324, 19325
Mandibular Osteotomies
Yes
21141, 21142, 21143, 21145, 21146, 21147, 21150, 21151, 21154, 21155, 21159, 21160, 21172, 21175, 21179, 21180, 21188, 21196, 21198, 21199, 21256
Mastectomy - Contralateral or Prophylactic
No
Mastectomy for Breast Cancer
No
Mastectomy for Gynecomastia
Yes
Mastopexy
Yes
19316
Maxillary Osteotomies
Yes
21206
Maxillo-facial surgery (surgery on bones of face, jaw, cheeks)
Yes
Maze Procedure
Yes
33254, 33255, 33256, 33257, 33258, 33259, 33265, 33266
Meniscal Transplantation
Yes
29868
Migraine Headaches- surgical treatment
Yes
Authorization required as of 7/30/10
Misc/Unlisted DME code
Yes
-99 E1399
MRA (Magnetic Resonance Angiography)
Yes
70544, 70545, 70546, 70547, 70548, 70549, 71555, 72159, 72198, 73225, 73725, 74185,
MRI (Magnetic Resonance Imaging)
Yes
70336, 70540, 70542, 70543, 70551, 70552, 70553, 70554, 70555, 71550, 71551, 71552, 72141, 72142, 72146, 72147, 72148, 72149, 72156, 72157, 72158, 72195, 72196, 72197, 73218, 73219, 73220, 73221, 73222, 73223, 73718, 73719, 73720, 73721, 73722, 73723, 74181, 74182, 74183, 77084, 75557, 75559, 75561, 75563, 75565, 77058, 77059, 76376 & 76377
MRI Guided Ultrasound Ablation (Fibroids)
Yes
0071T, 0072T
MRS (Magnetic Resonance Spectroscopy)
Yes
76390
Multiple Sleep Latency Test (MSLT)
Yes
95805
Myelogram
No
62284
Myobloc (Botulinum toxin Type B)
Yes
J0587
Myozyme (Alglucosidase alfa)
Yes
J0220
Myringotomy
No
Naglazyme (Galsulfase)
Yes
J1458
Nasal (Dorsal-external) implants; Functional Endoscopic Sinus Surgery (FESS) Nasal Endoscopy
Yes
21083
Yes
S2342, 31237, 31240, 31254, 31255, 31256, 31267, 31276, 31287, 31288, S2342 31231-31235 no auth required
Nasal Surgery for treatment of sleep apnea
Yes
Nasal/ Sinus Endoscopy (EG, balloon dilation)
Yes
31295, 31296, 31297
Natalizumab (Tysabri)
Yes
J2323
Negative pressure wound therapy
Yes
97605, 97606
Neulasta (Pegfilgrastim)
Yes
J2505, obtain through UC Health Pharmacy for outpatient use
Neupogen (Filgrastim)
Yes
J1440, J1441, obtain through UC Health Pharmacy for outpatient use
Neuromuscular Stimulator
Yes
E0745
Neuropsych Testing
Yes
Neurostimulator Implantation
Yes
L8681, L8682, L8683, L8685, L8686, L8687, L8688, 64561, 64581, 64590, 63685
Norditropin (Somatropin (rDNA origin))
Yes
J2941 Obtain through UCHealth Pharmacy
Norditropin Nordiflex (Somatropin (rDNA origin))
Yes
J2941 Obtain through UCHealth Pharmacy
Nuclear Cardiography (Myocardial Perfusion)
Yes
78451,78452, 78453, 78454, 78466, 78468, 78469, 78472, 78473, 78481, 78483, 78494, 78496
Nutropin/Nutropin AQ/Nutropin Depot (Somatropin (rDNA origin)) OB Care
Yes
J2941 Obtain through UCHealth Pharmacy
Occipital Nerve Stimulation
Yes
64555, 64575
Occupational therapy
Yes
Required for children under age 18
No
Octagam (Immune globulin-liquid)
Yes
J1568
Omnitrope (Somatropin (rDNA origin))
Yes
J2941 Obtain through UCHealth Pharmacy
COMMENTS CODES LISTED BELOW ARE REFERENCED IN PROVIDER COMMUNICATIONS AND ARE NOT
Procedure
EXCLUSIVE INCLUSIVE OF ALL CODES REQUIRING PRECERTIFICATION. A pre-determination is offered for codes with a suspend/deny or MRU edit. PLAN * Call Customer Service at the number on the Member's Health Plan ID card to confirm benefits for any and all services.
OMT (Osteopathic Manipulation Therapy)
No
Oncotype DX test
Yes
Orencia (Abatacept)
Yes
J0129
Organ transplant
Yes
Call to preauthorize: 888-574-7215
ORIF (Open Reduction-Internal Fixation)
No
Orthognathic surgery (upper and lower jaw augmentation)
Yes
Orthotics
No
D7995, D7996
Orthotripsy
Yes
28899
Orthovisc (Hyaluronic acid)
Yes
J7324
Oscillatory Device for Airway Clearance
Yes
Osteochondral Allograph/Autograph
Yes
29866, 29867, 27415
Osteochondral Defects (Treatment)
Yes
27416, 28446, 29892
Osteoplasty, facial bones
Yes
21208, 21209
Pacemaker Implant
No
Penile Implant
Yes
Percutaneous lumbar discectomy
Yes
Not a benefit 54400, 54401, 54405, 54410, 54411, 54416, 54417, L8699
Percutaneous lysis
Yes
62263, 62264
Percutaneous radiofrequency neurolysis (RF)
Yes
62622, 64623, 64626, 64627
Periodontal Mucosal Grafting
Yes
41870
Pessary device
No
PET (Positron Emission Tomography Scan)
Yes
PFT (Pulmonary function Test)
No
Pharmacy
Yes
Self-administered medications and medications administered subcutaneously in the outpatient setting should be obtained through a network Pharmacy. For questions call 720-848-6095
Photocoagulation laser treatment
Yes
67220
Photodynamic therapy
No
77608, 77609, 78459, 78491, 78492 , 78811, 78812, 78813, 78814, 78815, 78816
Physical Therapy
No
Platelet Rich Plasma Injections
Yes
0232T - Considered Experimental/Investigational - Would require auth to be covered
Pneumatic Compression Devices
Yes
E0652
Prialt (Ziconotide)
Yes
J2278
Privigen (Immune globulin-liguid)
Yes
J1459
Procrit (Epoetin alfa)
Yes
J0885 Q4081 J0886, obtain through UC Health Pharmacy for non-dialysis outpatient use
Prokine (Sargramostim)
Yes
J2820
Prolastin (Alpha 1 proteinase inhibitor)
Yes
J0256
Proleukin (Ablesleukin)
Yes
J9015
Prolia (denosumab)
Yes
J0897
Prolia (denosumab)
Yes
J0897
Prolotherapy
Yes
Investigational
Prostate Radioactive Seed Implant
No
Prostatectomy
No
Prosthetics
Yes
Prosthetics (Eye)
Yes
Proton Beam (PBRT)
Yes
77520, 77522, 77523, 77525, 61796, 61797, 61798, 62799, , 63620, 63621, 61800, 77432, 77435, S8030
Psych (Behavioral Health) Inpatient
BH
Call Anthem Behavioral Health (ABH) to preauthorize: 800-424-4014
Psych (Behavioral Health) Outpatient
BH
Call Anthem Behavioral Health (ABH) to preauthorize: 800-424-4014
Pulmonary Rehabilitation
Yes
Radiation Therapy
Yes
(new or replacement) prosthetic L6955
77761, 77326, 77790, Q3001, 43499, 47999, 55899, 67218, 19296, 20555, 41019, 55860, 55920, 31643, 57155, 77418, 77301, 77338, 77520, 61796, 63620, 61800, 77432, 77435, S8030, 77371, 61796, 61800, 77432, 77373, 63620, 77435
RadioFrequency Ablation
Yes
32998, 32982, 50542, 50592
Radiofrequency Ablation (Varicose Veins)
Yes
36475, 36476, 36478, 36479
RadioSurgery/RadioTherapy
Yes
Real- time remote heart monitor
No
COMMENTS CODES LISTED BELOW ARE REFERENCED IN PROVIDER COMMUNICATIONS AND ARE NOT
Procedure
EXCLUSIVE INCLUSIVE OF ALL CODES REQUIRING PRECERTIFICATION. A pre-determination is offered for codes with a suspend/deny or MRU edit. PLAN * Call Customer Service at the number on the Member's Health Plan ID card to confirm benefits for any and all services.
Reclast (zoledronic acid)
Yes
J3487, J3488
Reclast (zoledronic acid)
Yes
J3487, J3488
Reconstructive-Cosmetic
Yes
Confirm benefit
Reduction mammoplasty
Yes
Not a benefit
Remicade (Infliximab)
Yes
J1745
Remodulin (Treprostinil)
Yes
J3285
Removal of Breast Implant
Yes
19328, 19330
Removal of excess skin
Yes
22999
Repair of distasis recti
Yes
Rev: 1/04/2013
Rhinoplasty
Yes
30400, 30410, 30420, 30430, 30435, 30450
Rhytidectomy
Yes
15824, 15826
Rituxin (Rituximab)
Yes
J9310
Rocephin (Ceftriaxone sodium)
Yes
J0696 For treatment of Lyme Disease. Use HHINFU as the WMDS profile
Rotary wing air mileage, per statute mile
Yes
A0436
Routine Lab
No
Routine X ray
No
Sacral Nerve Stimulation
Yes
Saizen (Somatropin (rDNA origin))
Yes
J2941
Sandostatin, Sandostatin LAR (octreotide)
Yes
J2353, J2354
Sandostatin, Sandostatin LAR (octreotide)
Yes
J2353, J2354
Scar revisions
Yes
15781, 15782, 15783, 15787, 15786, 15788, 15789, 15792, 15793
SCIg (Immune Globulin)
Yes
90284
Sclerotherapy
Yes
36468, 36469, 36470, 36471, S2202
Scooters
Yes
Septoplasty
Yes
Septoplasty with rhinoplasty
Yes
Serostim (Somatropin (rDNA origin))
Yes
Sigmoidoscopy
No
Simponi (Golimumab)
Yes
Single photon emission computed tomography (SPECT) scan for specific body part Sinuplasty
Yes Yes
31295, 31296, 31297
Sleep Apnea (Obstructive)
Yes
21685, 41512, 41530, HCPCS Codes C9727, E0485, E0486
Sleep Study (Home Study, In-Lab, CPAP/BPAP, Supplies)
Yes
95800, 95801, 95806,95807, 95808, 95810, 95811, E0485, E0486, E0601, E0470, E0471, E0561, E062, A4604, A7046, A8038, A7030, A7031, A7034, A7035, A7036, A7037, A7039, A7044, A7045, A7028, A7029, A7032, A7033, A7038, G0398, G0399, G0400 HOME STUDIES & SUPPLIES AUTH'D BY ANTHEM J1300
Authorization required as of 7/30/10 30420, 30520, 30620
J2941
Soliris (eculizumab)
Yes
Somatrem (Somatropin (rDNA origin))
Yes
J2940
Somatropin (Somatropin (rDNA origin))
Yes
J2941
Somatuline (lanreotide)
Yes
J1930
Somatuline (lanreotide)
Yes
J1930
Somnoplasty for snoring
Yes
42299
Speech generating device
Yes
Contact Anthem for prior auth (800) 735-6072
Speech Therapy
Yes
Spinal Fusion
Yes
Spinal stimulators
Yes
0196T
Spinal Surgery
Yes
0219T, 0221T, 0222T, 63056
Spine Procedures (Percutaneous)
Yes
22520, 22521, 22522, 22523, 22524, 22525, S2360, S2361
Spine/Joint Manipulation (Requiring Anesthesia)
Yes
22505
Stab Phlebectomy of Varicose Veins, One Extremity
No
37765
Standing Frames
Yes
E0638, E041, E0642
Stelara (Ustekinumab)
Yes
J3357
Stereotactic Body Radiotherapy (SBRT)
Yes
63620, 62621, 77373, 77435, G0173, G0251, G0339, G0340,
Sterilization
No
Steroid Injection - see ESI
Yes
COMMENTS CODES LISTED BELOW ARE REFERENCED IN PROVIDER COMMUNICATIONS AND ARE NOT
Procedure
EXCLUSIVE INCLUSIVE OF ALL CODES REQUIRING PRECERTIFICATION. A pre-determination is offered for codes with a suspend/deny or MRU edit. PLAN * Call Customer Service at the number on the Member's Health Plan ID card to confirm benefits for any and all services.
Sterootactic Radiotherapy (SRS)
Yes
61796, 61797, 61798, 61799, 61800, 77371, 77372, 77432, G0173, G0251, G0339, G0340
Strabismus
No
Stretta or Endocinch procedure, Endoscopic treatment for G d Submucous Resection Inferior Turbinate, Partial or Complete
Yes
43499
Yes
30140
Supartz (Hyaluronic acid)
Yes
J7321
Supprelin LA (histrelin implant)
Yes
J9226
Supprelin LA (histrelin implant)
Yes
J9226
Suprachoroidal injection
Yes
0186T
Synagis (Palivizumab)
Yes
Must obtain through UC Health Pharmacy, administration by home health
Synvisc/Synvisc-One (Hyaluronic acid)
Yes
J7325
T&A (Tonsillectomy/Adenoidectomy)
Yes
Tev-Tropin (Somatropin (rDNA origin))
Yes
Thermography
Yes
Thyroidectomy
No
J2941
Tilt Table
No
Tinnitus Treatment
Yes
TMD (Temporomandibular disorders)
Yes
20605, 21010, 21050, 21060, 21073, 21116, 21210, 21240, 21242, 21243, 29800, 29804, D7810, D7820, D7830, D7840, D7850, D7852, D7854, D7856, D7858, D7860, D7865, D7870, D7881, D7873, D7874, D7875, D7876, D7877 NOT A BENEFIT
TMJ (Temporomandibular joint surgery)
Yes
NOT A BENEFIT
Tonsillectomy
Yes
42820, 42821, 42825, 42826. Applies to members under the age of 18.
Total Hip or knee replacement
Yes
Total Parenteal Nutrition
Yes
Tracheotomy
No
See Benefit Language
Transcatheter Closure
Yes
93580
Transcatheter Uterine Artery Embolization
Yes
37210
Transplants
Yes
Call Anthem Transplant Office to preauthorize: 888-574-7215
Treadmill
No
Trigger Point Injections
No
Tubal ligation
No
Tympanic treatment
Yes
Tympanoplasty
No
E2120
Tympanostomy
No
Tysabri (Natlizumab)
Yes
J2323
Tyvaso (Treprostinil, inhalation)
Yes
J7686
UGI (Upper GI)
Yes
Ultrafast computed tomography (CT), including use for evaluation of the heart
Yes
Ultrasound – 3D & 4D
Yes
Ultrasound – non OB
No
Ultrasound – OB
No
Unlisted codes
Yes
UPPP (Uvulopalato-pharyngoplasty)
Yes
unlisted CPT codes - ending in 99 (sometimes 59, 89)
Urgent Care
No
Uterine Artery Embolization, Transcatheter
Yes
37210
Vagus nerve stimulation therapy
Yes
95974, 95975
Vantas (histrelin implant)
Yes
J9225
Vantas (histrelin implant)
Yes
J9225
Varicose vein stripping and ligation, VNUS EVLT or ELAS, ablation (laser) Vasectomy
Yes No
VCUG (voiding cystourethrogram)
No
Vectibix (Panibumumab)
Yes
J9303
Veletri (Epoprostenol)
Yes
J1325
Ventavis (lloprost Inhalation)
Yes
Q4074
COMMENTS CODES LISTED BELOW ARE REFERENCED IN PROVIDER COMMUNICATIONS AND ARE NOT
Procedure
EXCLUSIVE INCLUSIVE OF ALL CODES REQUIRING PRECERTIFICATION. A pre-determination is offered for codes with a suspend/deny or MRU edit. PLAN * Call Customer Service at the number on the Member's Health Plan ID card to confirm benefits for any and all services.
Ventricular Assistive device (VAD)
Yes
Viadur (leuprolide implant)
Yes
J9219
Viadur (leuprolide implant)
Yes
J9219
Virtual Colonoscopy
Yes
Vision Therapy
No
VPRIV (Velaglucerase Alfa)
Yes
Wheelchair supplies
No
No authorization required as of 7/30/10
Wheelchair, electric, motoized/power
Yes
K0010, K0011, K0012, K0014
Wheelchair, power operated vehicle/wheelchair
Yes
E1230, K0812, K0829, K0850, K0864, K0891,
Wheelchair, Ultra lightweight manual
Yes
K0005
Wheelchair, unlisted procedure
Yes
K0899
Wound pump
Yes
Wound vac
Yes
E2402 Contact Anthem for authorization at (800) 735-6072
Xeomin (Botulinum toxin Type A)
Yes
J0588
Xgeva (denosumab)
Yes
J0897
Xgeva (denosumab)
Yes
J0897
Xiaflex (collagenase clostridium histolyticum)
Yes
J0775
Xiaflex (collagenase clostridium histolyticum)
Yes
J0775
Xolair (Omalizumab)
Yes
J2357
J3385
E1239, K0813, K0830, K0851, K0868, K0898
Yag Laser - after cataract
No
Yervoy (Ipilimumab)
Yes
Zemaira (Alpha 1 proteinase inhibitor)
Yes
J0256
Zoladex (goserelin)
Yes
J9202
Zoladex (goserelin)
Yes
J9202
Zometa (zoledronic acid)
Yes
J3487, J3489
Zometa (zoledronic acid)
Yes
J3487, J3489
Zorbtive (Somatropin (rDNA origin))
Yes
J2941
J9228
E1002, K0814, K0831, K0852, K0869,
E1003,E1004, E1005, E1006, E1007, E1008, K0800, K0801, K0802, K0806, K0807, K0808, K0815, K0816, K0820, K0821, K0822, K0823, K0824, K0825, K0826, K0827, K0828, K0835, K0836, K0837, K0838, K0839, K0840, K0841, K0842, K0843, K0848, K0849, K0853, K0854, K0855, K0856, K0857, K0858, K0859, K0860, K0861, K0862, K0863, K0870, K0871, K0877, K0878, K0879, K0880, K0884, K0885, K0886, K0890,