Exclusive Precertification Quick Reference Guide Verify Benefits and Eligibility With Customer Service For All Services

Exclusive Precertification Quick Reference Guide  Verify Benefits and Eligibility With Customer Service  For All Services.  There may be differences i...
Author: Byron Hardy
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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,