| Medicare Products (MedAdvantage,
Preferred Choice Sixty-Five or First Choice Sixty-Five)
The CPT and HCPCS Code List was developed to help you
identify services we require be pre-authorized. In some
cases no CPT or HCPCS code specifically identifies a
service we pre-authorize. For example, new services
we consider investigational may not yet have a code.
Please refer to the Pre-authorization
List to determine which lines of business the
pre-authorization applies to and information concerning
benefits and eligibility.
Effective January 1, 2006
Inpatient
Mental Health and Chemical Dependency
No pre-authorization for Preferred Choice Sixty-Five
Phone: (800) 547-9718 Fax: (800) 331-3505 |
- MedAdvantage
- First Choice Sixty-Five
|
Durable
Medical Equipment
Phone: (503) 220-4795 or (800) 824-8563 Fax: (503) 547-1192 |
| Equipment purchase or repair with billed
charges over $1,500 for any single line item or
component unless listed as a requirement or exception
below. |
| Equipment rental with billed charges over
$500/month for any single line item or component
unless listed as a requirement or exception below. |
| Extremity prosthetics with billed charges
over $5,000 for any single line item or component. |
Vacuum assisted wound closure devices regardless of line item charges
A6550, A6551, E2402
|
Exceptions (the following
items do not require pre-authorization, regardless
of line item charges)
Apnea monitors, cardiac monitors, CPAP/BiPAP, CPM,
dynamic splints, home dialysis equipment, infusion
pumps, insulin pumps, ocular prostheses, oxygen
and oxygen equipment, psoriasis lights, suction
pumps, ventilators (including maintenance) |
Home Services:
Phone: (503) 220-4795 or (800) 824-8563 Fax: (503) 547-1192 |
Home health services including
initial evaluations
|
G0151, 0152, G0153, G0154, G0155,
G0156, S5180, S5181, S9097, S9098, S9122, S9123,
S9124, S9127, S9128, S9129, S9131, S9208, S9209,
S9211, S9212, S9213, S9214, S9590, 99500, 99501,
99502, 99503, 99504, 99505, 99506, 99507, 99509,
99511, 99512, 99600 |
| Parenteral nutrition |
B4164 through B5200, S5035, S5036,
S9364, S9365, S9366, S9367, S9368 |
Inpatient
Admissions:
Phone: (503) 220-4795 or (800) 824-8563 Fax: (503)
547-1192 |
| Contracted facilities are required
to notify us of all inpatient admissions and discharges
via phone or faxed inpatient census logs (including
patient name, admitting diagnosis and admission/discharge
dates) |
| Rehabilitation |
|
| Skilled Nursing Facility (SNF) |
|
Transplants and ventricular
assist devices (pre-authorization not required
for corneal transplants)
Phone: (800) 560-0749
Fax: (503) 226-8754 |
All other members
Transplants
G0267, G0341, G0342, G0343, S2053, S2054, S2055,
S2060, S2061, S2065, S2102, S2103, S2140, S2142,
S2150, S2152, 32850, 32851, 32852, 32853, 32854,
32855, 32856, 33930, 33933, 33935, 33940, 33944,
33945, 38204, 38205, 38206, 38207, 38208, 38209,
38210, 38211, 38230, 38240, 38241, 38242, 44132,
44133, 44135, 44136, 44715, 44720, 44721, 47133,
47135, 47136, 47140, 47141, 47142, 47143, 47144,
47145, 47146, 47147, 48551, 48552, 48160, 48550,
48554, 48556, 50300, 50320, 50323, 50325, 50327,
50329, 50340, 50360, 50365, 50370, 50380
Ventricular assist devices
33975, 33976, 33977, 33978, 33979, 33980, 0048T,
0049T, 0050T, 0051T, 0052T,0053T |
Other
Services:
Phone: (503) 220-4795 or (800) 824-8563 Fax: (503) 547-1192 |
| Air ambulance |
Non-emergent transfers only |
Cosmetic or potentially cosmetic procedures
(procedures solely intended for the purpose
of feature enhancement) |
Pre-authorization not required for initial
breast reconstruction (1 or 2 stages and nipple/areola
reconstruction) following mastectomy, 19340, 19342,
19350, 19357, 19361, 19364, 19366, 19367, 19368
or 19369
The following codes should be pre-authorized
as potentially cosmetic:
11920, 11921, 11922, 11950, 11951, 11952, 11954,
11960, 11970, 11971, 15780, 15781, 15782, 15783,
15786, 15787, 15788, 15789, 15792, 15793, 15810,
15811, 15820, 15821, 15822, 15823, 15824, 15825,
15826, 15828, 15829, 15831, 15832, 15833, 15834,
15835, 15836, 15837, 15838, 15839, 15876, 15877,
15878, 15879, 17360, 17380, 19140, 19316, 19318,
19324, 19325, 19328, 19330, 19355, 19370, 19371,
19380, 19396, 21235, 21740, 21742, 21743, 30400,
30410, 30420, 30430, 30435, 30450, 30460, 30462,
36468, 36469, 36470, 36471, 36475, 36476, 36478,
36479, 37500, 37501, 37700, 37718, 37720, 37722,
37730, 37735, 37760, 37765, 37766, 37780, 37785,
67900, 69300 |
Investigational or potentially investigational
services
(not accepted by Medicare as reimbursable given
lack of acceptance of standard of care in the community) |
- Acupuncture
- Bladder Stimulators (Pacemakers)
- Cardiointegram (CIG) as an Alternative to
Stress Test or Thallium Stress Test
- Carotid body resection to relieve pulmonary
symptoms
- Carotid sinus nerve stimulator for paroxysmal
supraventricular tachycardia
- Cellular therapy
- Chemoendarterectomy/Chelation therapy
- Cochleostomy with neurovascular transplant
for treatment of Meniere’s disease.
- Colonic Irrigation
- Computed Tomography to Detect Coronary Artery
Calcification
- Coronary and non-coronary stent in the carotid,
vertebral and cerebral vessels
- Cytotoxic leukocyte food tests
- Diathermy or ultrasound heat treatments for
- Pulmonary conditions
- Dual Photon Absorptiometry
- EEG monitoring during open heart surgery
- Electrosleep Therapy
- Electrotherapy for Treatment of Facial Nerve
Palsy
- Ethylenediamine-Tetra-Acetic (EDTA) Chelation
Therapy for Treatment of Atherosclerosis
- Fabric wrapping of abdominal aneurysms
- Fluorescent Cytoprint Assay/Cancer chemosensitivity
test
- Gastric Ballon
- Gastric Freezing
- Hemodialysis for Treatment of Schizophrenia
- Human Tumor Stem Cell Drug Sensitivity Assays
- Intestinal bypass surgery
- Intrapulmonary Percussive Ventilator
- Laetrile and related substances
- Magnetic resonance imaging:blood flow and
spectroscopy
- Magnetic Resonance Spectroscopy (MRS)
- MRI: Cortical bone calcification
- MRI: Evaluation of neuropsychiatric disorders
- MRI: Evaluation of Parkinson’s Disease
- MRI: Spatial resolution of bone
- Multiple Electroconvulsive Therapy (MECT)
- Pallidotomy using stereotactic radiation e.g.,
Gamma rays
- Partial ventriculectomy
- Photokymography
- Prolotherapy, Joint Sclerotherapy, and Ligamentous
Injections with Sclerosing Agents
- Sentinel node biopsies in breast cancer
- Stereotactic Cingulotomy as a Means of Psychosurgery
- Thermogenic therapy
- Tinnitus masking
- Transcendental meditation
- Transexual surgery
- Transfer Factor for Treatment of Multiple
Sclerosis
- Transillumination light scanning aka diaphanography
- Transpupillary thermotherapy (TTT) for age
related macular degeneration
- Transthoracic Echocardiogram (TTE):ER chest
pain
- Transvenous (catheter) pulmonary embolectomy
- Treatment of Motor Function Disorders with
Electric Nerve Stimulation
- Ultrasound: Monitoring of cardiac output (Doppler)
- Ultrasound:B-Scan for atherosclerotic narrowing
of peripheral arteries
- Vertebral Axial Decompression (VAX-D)
- Vertebroplasty in the treatment of painful
hemangiomas and eosinophilic granulomas of the
spine
- Vitamin B12 Injections to Strengthen Tendons,
Ligaments, etc., of the Foot
|
| Non-participating providers (managed care
only; no pre-authorization for MedAdvantage or for
Preferred Choice Sixty-Five members opting out to
Medicare) |
|
| Obesity services |
Including but not limited to work-up, treatment
and surgery
S2082, S2083, 43655, 43645, 43842, 43843, 43845,
43846, 43847, 43848 |
| Orthognathic surgery |
21120, 21121, 21123, 21125, 21127, 21137, 21141,
21142, 21143, 21145, 21146, 21147, 21150, 21151,21154,
21155, 21159, 21160, 21193, 21194, 21195, 21196,
21198, 21199, 21206, 21208, 21209, 21210, 21215,
21230, D7941 through D7950, D7995, D7996, S8262 |
| Outpatient rehabilitation
after 15 visits by any one discipline |
Including physical therapy, speech
therapy, occupational therapy and manipulation of
subluxation of the spine by osteopaths or chiropractors)
to determine medical necessity of ongoing therapy
subject to Medicare's definition of maintenance
therapy
97010 through 97530, 98925 through 98929, 98940
through 98943, 92506, 92507, 92508, 92510, 92526 |
|
