Service Category
| Services/Procedures
|
Acupuncture (CA only)
| An alternate form of medicine in which thin needles are inserted into the body.
|
Ambulance: Non-emergent
Fixed Wing only
| Requires prior authorization before transport
|
Behavioral Health Services
| Day Treatment
Electroconvulsive Therapy (ECT)
Inpatient Psychiatric
Intensive Outpatient Therapy
Neuropsychological Testing
Partial hospitalization
Psychological Testing
Substance Use Disorder Treatment/Rehabilitation
|
Bronchial Thermoplasty
| Outpatient procedure for the treatment of asthma
|
Chiropractor Services
| Medicare coverage for chiropractic services extends only to treatment by means of manual manipulation of the spine to correct a subluxation, provided such treatment is reasonable and medically necessary
|
Clinical Trials: Notification Only
| A clinical trial is one type of clinical research that follows a pre-defined plan or protocol
|
Cochlear Implants & Surgery
| Provides direct electrical stimulation to the auditory nerve, bypassing the usual transducer cells that are absent or nonfunctional in deaf cochlea
|
Cosmetic Procedures/Dermatology
| Includes any surgical procedure directed at improving appearance, except when required for the prompt (i.e., as soon as medically feasible) repair of accidental injury or for the improvement of the functioning of a malformed body member Including, but not limited to the following:
Chemical exfoliation, electrolysis
Dermabrasion/chemical peel
Laser treatment
Skin injections and implants
|
Drug Testing
| Quantitative tests for drugs of abuse
|
Service Category
|
Services/Procedures
|
Durable Medical Equipment (DME)
| BIPAP
Bone Growth Stimulator
Hospital Bed/Mattress
Infusion Pumps
Lift Devices including Hoyer
TENS Units
Vagus Nerve Stimulator
Ventilators
Wheelchairs, Custom
Wheelchairs, Power
Wound Vacuum (Negative Pressure) Devices
Implantable Neurostimulator
Continuous Glucose Monitor
|
Enhanced External Counterpulsation (EECP)
| The noninvasive outpatient treatment for patients with coronary artery disease (CAD)
|
Experimental/Investigational Services
| Any item or service potentially considered investigational or experimental must be authorized in advance
|
Gender Reassignment
| General term to describe a surgery or surgeries that affirm a person's gender identity
|
Genetic Counseling and Testing
| Genetic testing is a type of medical test that identifies changes in chromosomes, genes, or proteins
|
Home Health Services
| Home Health Aide
Occupational Therapy
Physical Therapy
Skilled Nursing Visits
Social Work Visits
Speech Therapy
|
Hospice: Notification only
| Home or Inpatient
|
Hyperbaric O2 Therapy
| Includes HBO therapy administered in a chamber
|
Infertility
| Drug Therapy, Testing, Treatment
|
|
|
|
|
Service Category
| Services/Procedures
|
Hospital Admission
| Acute Inpatient Hospital
Inpatient Rehabilitation Hospital
Long Term Acute Care Hospital (LTAC)
Skilled Nursing Facility (SNF)
|
Neuropsychological Testing
| Evaluations for members with a history of psychological, neurologic or medical disorders known to impact cognitive or neurobehavioral functioning
|
Nutritional Supplements and/or services
| Formula administered via a enteral feeding tube
|
Observation Stay
| Prior Authorization required if >48 hours
|
Orthotics/Prosthetics
| Prosthetic devices needed to replace a body part or function
Limited coverage options for orthotic shoes and devices, including artificial limbs and eyes as well as braces for arms, legs, back, or neck, penile prosthetics
|
Outpatient Therapy
· Occupational Therapy (OT)
· Physical Therapy (PT)
· Speech-Language Therapy (ST)
| Requires authorization after 12 combined visits
|
Pain Management
| Epidural Injections
Facet Injections
Median Branch Block
Radio Frequency Ablation
Trigger Point
Sacroiliac joint injection (SI)
|
Radiation Therapy
| Stereotactic radiotherapy
Intensity modulated radiotherapy (IMRT)
Proton beam therapy
Neutron beam therapy
|
Radiology
| MRI, MRA, PET Scan, CT, Cardiac Imaging
PET
MRA
CT
Cardiac Imaging
Visit www.radmd.com
|
Sleep Studies
| Surgery and treatment
|
Surgeries, regardless of place of service continued
| Abortion
Bariatric Surgery
Blepharoplasty
Breast Augmentation (except following mastectomy)
Breast Reduction
Capsule Endoscopy
Chondrocyte Implants
Cochlear Implant
Facial Osteotomy
Hysterectomy
Joint Replacements
Mastectomy for Gynecomastia
Oral Surgery -- Temporomandibular Joint Surgery
Otoplasty
Reconstructive and Plastic Surgery
Rhinoplasty
Sacral Nerve Neuromodulation
Scar Revision
Septoplasty
Spinal Surgeries including Fusion, Stabilization, Discectomy
Uvulopalatopharyngoplasty/Uvolopharyngoplasty
Veins (ablation, ligation, stripping, sclerotherapy)
X-Stop: Spinal Surgery
|
Transplants
| All transplant evaluations and procedures, including but not limited to evaluation, transplant consult visits, HLA typing, donor search and transplant procedure
|
STEP THERAPY
Medicare Part B Drugs (Biopharmacy)
Prior Authorization
Medicare Part B Drugs (Biopharmacy)
Medicare Part B Drugs (Biopharmacy)
Requiring Prior Authorization
Medicare Part B Drugs (Biopharmacy)
Requiring Prior Authorization
Medicare Part B Drugs (Biopharmacy)
Requiring Prior Authorization
| Procedure Code
| Procedure Description
| C9050
| EMAPALUMAB-LZSG
| J0129
| ABATACEPT INJECTION
| J0178
| AFLIBERCEPT INJECTION
| J0584
| BUROSUMAB-TWZA 1M
| J0585
| ONABOTULINUMTOXINA
| J0717
| CERTOLIZUMAB PEGOL INJ 1MG
| J0718
| CERTOLIBUMAB PEGOL, INJ
| J0800
| CORTICOTROPIN INJECTION
| J0897
| DENOSUMAB INJECTION
| J1300
| ECULIZUMAB INJECTION
| J1428
| ETEPLIRSEN, 10 MG
| J1459
| IVIG PRIVIGEN 500 MG
| J1555
| CUVITRU, 100 MG
| J1556
| IMM GLOB BIVIGAM, 500MG
| J1557
| GAMMAPLEX INJECTION
| J1559
| HIZENTRA INJECTION
| J1561
| GAMUNEX-C/GAMMAKED
| J1562
| IMMUNE GLOBULIN 105 5 GRAMS, INJECTION
| J1566
| IMMUNE GLOBULIN, POWDER
| J1568
| OCTAGAM INJECTION
| J1569
| GAMMAGARD LIQUID INJECTION
| J1599
| IVIG NON-LYOPHILIZED
| J1572
| FLEBOGAMMA INJECTION
| J1575
| HYQVIA 100MG IMMUNEGLOBULIN
| J1599
| IVIG NON-LYOPHILIZED, NOS
| J1602
| GOLIMUMAB FOR IV USE 1MG
| J1745
| INFLIXIMAB (REMICADE)
| J1930
| LANREOTIDE INJECTION
| J2323
| NATALIZUMAB INJECTION
| J2350
| OCRELIZUMAB, 1 MG
| J2353
| OCTREOTIDE INJECTION, DEPOT
| J2357
| OMALIZUMAB INJECTION
| J2503
| PEGAPTANIB SODIUM INJECTION
| J2778
| RANIBIZUMAB INJECTION
| J3262
| TOCILIZUMAB, 1 MG
| J3304
| TRIAMCINOLONE ACE XR 1MG
| J3357
| USTEKINUMAB SUB CU 1 MG
| J3380
| VEDOLIZUMAB
| J3396
| VERTEPORFIN INJECTION
| J7318
| DUROLANE 1 MG
| J7320
| GENVISC 850, 1MG
| J7321
| HYALGAN SUPARTZ VISCO-3 DOSE
| J7322
| HYMOVIS INJECTION 1 MG
| J7323
| EUFLEXXA INJ PER DOSE
| J7324
| ORTHOVISC INJ PER DOSE
| J7325
| SYNVISC OR SYNVISC-ONE
| J7326
| GEL-ONE
| J7327
| MONOVISC INJ PER DOSE
| J7328
| GELSYN-3 INJECTION 0.1 MG
| J7329
| HYALURONAN DERIVATIVE; TRIVISC IA 1 MG
| J7331
| HYALURONAN DERIVATIVE;SYNOJOYNT IA 1MG
| J7332
| HYALURONAN DERIVATIVE; TRILURON IA I MG
| J9022
| ATEZOLIZUMAB,10 MG
| J9145
| INJECTION DARATUMUMAB 10 MG
| J9173
| DURVALUMAB, 10 MG
| J9176
| ELOTUZUMAB, 1MG
| J9308
| RAMUCIRUMAB
| J9312
| RITUXIMAB, HYALURONIDASE
| Q2041
| AXICABTAGENE CILOLEUCEL CAR+
| Q2042
| TISAGENLECLEUCEL CAR-POS T
| Q2043
| SIPULEUCEL-T AUTO CD54+
| Q5103
| INFLIXIMAB (INFLECTRA)
| Q5104
| INFLIXIMAB (RENFLEXIS)
| Q5109
| INFLIXIMAB-QBTX BIOSIMILAR 10 MG
|
|
|
Procedure Code
| Procedure Description
| A9513
| LUTETIUM LU 177 DOTATAT THER
| C9035
| ARISTADA INITIO
| C9036
| PATISIRAN
| C9037
| RISPERIDONE
| C9038
| MOGAMULIZUMAB-KPKC
| C9040
| FREMANEZUMAB-VFRM, 1MG
| C9043
| LEVOLEUCOVORIN
| C9044
| CEMIPLIMAB-RWLC
| C9045
| MOXETUMOMAB PASUDOTOX-TDFK
| C9049
| TAGRAXOFUSP-ERZS
| C9051
| OMADACYCLINE
| C9054
| LEFAMULIN XENLETA 1 MG
| C9055
| BREXANOLONE 1 MG
| C9130
| IVIG BIVIGAM
| C9133
| FACTOR IX RECOMBINANT
| C9134
| FACTOR XIII A-SUBUNIT RECOMB
| C9136
| FACTOR VIII (ELOCTATE)
| C9399
| UNCLASSIFIED DRUGS OR BIOLOG
| J0135
| ADALIMUMAB INJECTION
| J0179
| BROLUCIZUMAB-DBLL I MG
| J0180
| AGALSIDASE BETA INJECTION
| J0202
| ALEMTUZUMAB
| J0220
| ALGLUCOSIDASE ALFA INJECTION
| J0221
| LUMIZYME INJECTION
| J0222
| PATISIRAN, 0.1 MG
| J0256
| ALPHA 1 PROTEINASE INHIBITOR
| J0257
| GLASSIA INJECTION
| J0364
| APOMORPHINE HYDROCHLORIDE
| J0490
| BELIMUMAB INJECTION
| J0517
| BENRALIZUMAB, 1 MG
| J0567
| CERLIPONASE ALFA 1 MG
| J0570
| BUPRENORPHINE IMPLANT 74.2MG
| J0584
| BUROSUMAB-TWZA 1 MG
| J0586
| ABOBOTULINUMTOXINA
| J0587
| RIMABOTULINUMTOXINB
| J0588
| INCOBOTULINUMTOXIN A
| J0593
| LANADELUMAB-FLYO, 1 MG
| J0598
| C-1 ESTERASE, CINRYZE
| J0599
| HAEGARDA 10 UNITS
| J0604
| CINACALCET ORAL I MG
| J0606
| ETELCALCETIDE, 0.1 MG
| J0630
| CALCITONIN SALMON INJECTION
| J0638
| CANAKINUMAB INJECTION
| J0641
| LEVOLEUCOVORIN INJECTION
| J0642
| LEVOLEUCOVORIN (KHAPZORY) 0.5 MG
| J0775
| COLLAGENASE, CLOST HIST INJ
| J0881
| DARBEPOETIN ALFA, NON-ESRD
| J0885
| EPOETIN ALFA, NON-ESRD
| J0888
| EPOETIN BETA NON ESRD
| J0894
| DECITABINE INJECTION
| J1190
| DEXRAZOXANE HCL INJECTION
| J1301
| EDARAVONE, 1 MG
| J1324
| ENFUVIRTIDE INJECTION
| J1438
| ETANERCEPT INJECTION
| J1439
| FERRIC CARBOXYMALTOS 1MG
| J1442
| FILGRASTIM EXCL BIOSIMIL
| J1443
| FERRIC PYROPHOSPHATE CIT
| J1458
| GALSULFASE INJECTION
| J1628
| GUSELKUMAB, 1 MG
| J1640
| HEMIN, 1 MG
| J1645
| DALTEPARIN SODIUM
| J1675
| HISTRELIN ACETATE
| J1743
| IDURSULFASE INJECTION
| J1744
| ICATIBANT INJECTION
| J1746
| IBALIZUMAB-UIYK, 10 MG
| J1786
| IMUGLUCERASE INJECTION
| J1817
| INSULIN FOR INSULIN PUMP USE
| J1931
| LARONIDASE INJECTION
| J2170
| MECASERMIN INJECTION
| J2182
| MEPOLIZUMAB, 1MG
| J2212
| METHYLNALTREXONE INJECTION
| J2315
| NALTREXONE, DEPOT FORM
| J2355
| OPRELVEKIN INJECTION
| J2440
| PAPAVERIN HCL INJECTION
| J2505
| PEGFILGRASTIM 6MG
| J2507
| PEGLOTICASE INJECTION
| J2562
| PLERIXAFOR INJECTION
| J2783
| RASBURICASE
| J2786
| RESLIZUMAB, 1MG
| J2793
| RILONACEPT INJECTION
| J2796
| ROMIPLOSTIM INJECTION
| J2797
| ROLAPITANT, 0.5 MG
| J2820
| SARGRAMOSTIM INJECTION
| J2840
| SEBELIPASE ALFA 1 MG
| J2940
| SOMATREM INJECTION
| J2941
| SOMATROPIN INJECTION
| J3095
| TELAVANCIN INJECTION
| J3110
| TERIPARATIDE INJECTION
| J3111
| ROMOSOZUMAB-AQQG 1 MG
| J3140
| TESTOSTERONE SUSPENSION INJ
| J3240
| THYROTROPIN INJECTION
| J3245
| TILDRAKIZUMAB 1 MG
| J3262
| TOCILIZUMAB I MG
| J3285
| TREPROSTINIL INJECTION
| J3316
| TRIPTORELIN XR 3.75 MG
| J3385
| VELAGLUCERASE ALFA
| J3397
| VESTRONIDASE ALFA-VJBK
| J3398
| LUXTURNA 1 BILLION VEC G
| J3591
| ESRD ON DIALYSI DRUG/BIO NOC
| J7170
| EMICIZUMAB-KXWH 0.5 MG
| J7175
| FACTOR X, (HUMAN), 1IU
| J7177
| FIBRYGA, 1 MG
| J7179
| VONVENDI INJ 1 IU VWF:RCO
| J7180
| FACTOR XIII ANTI-HEM FACTOR
| J7181
| FACTOR XIII RECOMB A-SUBUNIT
| J7182
| FACTOR VIII RECOMB NOVOEIGHT
| J7183
| WILATE INJECTION
| J7185
| XYNTHA INJ
| J7186
| ANTIHEMOPHILIC VIII/VWF COMP
| J7187
| HUMATE-P, INJ
| J7188
| FACTOR VIII RECOMB OBIZUR
| J7189
| FACTOR VIIA
| J7190
| FACTOR VIII
| J7191
| FACTOR VIII (PORCINE)
| J7192
| FACTOR VIII RECOMBINANT NOS
| J7193
| FACTOR IX NON-RECOMBINANT
| J7194
| FACTOR IX COMPLEX
| J7195
| FACTOR IX RECOMBINANT NOS
| J7196
| ANTITHROMBIN RECOMBINANT
| J7197
| ANTITHROMBIN III INJECTION
| J7198
| ANTI-INHIBITOR
| J7199
| HEMOPHILIA CLOT FACTOR NOC
| J7200
| FACTOR IX RECOMBINAN RIXUBIS
| J7201
| FACTOR IX ALPROLIX RECOMB
| J7202
| FACTOR IX IDELVION INJ
| J7203
| FACTOR IX RECOMB GLY REBINYN
| J7207
| FACTOR VIII PEGYLATED RECOMB
| J7208
| JIVI 1 IU
| J7209
| FACTOR VIII NUWIQ RECOMB 1IU
| J7311
| FLUOCINOLONE ACETONIDE IMPLT
| J7312
| DEXAMETHASONE INTRA IMPLANT
| J7313
| FLUOCINOL ACET INTRAVIT IMP
| J7314
| YUTIQ, 0.01 MG
| J7401
| MOMETASONE FUROATE SINUS IMP
| J7518
| MYCOPHENOLIC ACID
| J7527
| ORAL EVEROLIMUS
| J7677
| REVEFENACIN INH NON-COM 1MCG
| J7686
| TREPROSTINIL, NON-COMP UNIT
| J8565
| GEFITINIB ORAL
| J8650
| NABILONE ORAL
| J8705
| TOPOTECAN ORAL
| J9015
| ALDESLEUKIN INJECTION
| J9017
| ARSENIC TRIOXIDE INJECTION
| J9019
| ERWINAZE INJECTION
| J9023
| AVELUMAB, 10 MG
| J9027
| CLOFARABINE INJECTION
| J9034
| BENDEKA 1 MG
| J9035
| BEVACIZUMAB INJECTION
| J9036
| BELRAPZO/BENDAMUSTINE
| J9039
| BLINATUMOMAB
| J9041
| VELCADE 0.1 MG
| J9042
| BRENTUXIMAB VEDOTIN INJ
| J9043
| CABAZITAXEL INJECTION
| J9044
| BORTEZOMIB, NOS, 0.1 MG
| J9047
| CARFILZOMIB, 1 MG
| J9055
| CETUXIMAB INJECTION
| J9057
| COPANLISIB, 1 MG
| J9118
| CALASPARGASE PEGOL-MKNL
| J9153
| DAUNORUBICIN, CYTARABINE
| J9199
| GEMCITABINE HCL INFUGEM
| J9203
| INJ GEMTUZUMAB OZOGAMICIN 0.1 MG
| J9205
| IRINOTECAN LIPOSOME 1 MG
| J9212
| INTERFERON ALFACON-1 INJ
| J9213
| INTERFERON ALFA-2A INJ
| J9215
| INTERFERON ALFA-N3 INJ
| J9216
| INTERFERON GAMMA 1-B INJ
| J9225
| VANTAS IMPLANT
| J9226
| SUPPRELIN LA IMPLANT
| J9228
| IPILIMUMAB INJECTION
| J9229
| INOTUZUMAB OZOGAM 0.1 MG
| J9261
| NELARABINE INJECTION
| J9262
| OMACETAXINE MEP, 0.01MG
| J9264
| PACLITAXEL PROTEIN BOUND
| J9266
| PEGASPARGASE INJECTION
| J9271
| PEMBROLIZUMAB
| J9285
| OLARATUMAB, 10 MG
| J9299
| NIVOLUMAB
| J9301
| OBINUTUZUMAB INJ
| J9303
| PANITUMUMAB INJECTION
| J9305
| PEMETREXED INJECTION
| J9306
| PERTUZUMAB, 1 MG
| J9309
| POLATUZUMAB VEDOTIN-PIIQ 1 MG
| J9311
| RITUXIMAB INJECTION
| J9352
| TRABECTEDIN 0.1MG
| J9354
| ADO-TRASTUZUMAB EMT 1MG
| J9355
| TRASTUZUMAB INJECTION
| J9356
| HERCEPTIN HYLECTA, 10MG
| J9395
| FULVESTRANT
| J9400
| ZIV-AFLIBERCEPT, 1MG
| J9999
| CHEMOTHERAPY DRUG
| Q0138
| FERUMOXYTOL, NON-ESRD
| Q0515
| SERMORELIN ACETATE INJECTION
| Q2026
| RADIESSE INJECTION
| Q2027
| SCULPTRA INJECTION
| Q2028
| SCULPTRA, 0.5MG
| Q2041
| KTE-C19 TO 200 M A ANTI-CD19 CAR POS T CE P TD
| Q2042
| TISAGENLECLEUCEL TO 600 M CAR-POS VI T CE PER TD
| Q2050
| DOXORUBICIN INJ 10MG
| Q3025
| IM INJ INTERFERON BETA 1-A
| Q3026
| SUBC INJ INTERFERON BETA-1A
| Q3027
| BETA INTERFERON IM 1 MCG
| Q4074
| ILOPROST NON-COMP UNIT DOSE
| Q5103
| INFLECTRA
| Q5104
| RENFLEXIS
| Q5107
| MVASI 10 MG
| Q5108
| FULPHILA
| Q5111
| UDENYCA 0.5 MG
| Q5112
| ONTRUZANT 10 MG
| Q5113
| HERZUMA 10 MG
| Q5114
| OGIVRI 10 MG
| Q5115
| TRUXIMA 10 MG
| Q5116
| TRAZIMERA 10 MG
| Q5117
| KANJINTI 10 MG
| Q9991
| BUPRENORPH XR 100 MG OR LESS
| Q9992
| BUPRENORPHINE XR OVER 100 MG
| S0145
| PEG INTERFERON ALFA-2A/180
|
|
