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Preauthorization/Precertification Requirements
First Priority Health
Preauthorizations /Pre-certifications can be requested by members’ First
Priority Health participating providers.
Definitions
CT (Computerized Tomography)Scan that uses X-rays to provide detailed
pictures of internal organs and tissues.
Dye Material used to highlight blood vessels, organs or tissues to make
the pictures clearer.
MRI (Magnetic Resonance Imaging) A scan that uses radio waves and a
strong magnetic field (rather than X-rays) to provide detailed pictures for
viewing internal organs and tissues.
MRA (Magnetic Resonance Angiography) An MRI study of detailed images of
blood vessels.
Magnetic Resonance Spectroscopy Specialized MRI scan which gives chemical
information about tissues or organs.
Radiology Tests Requiring Preauthorization (Effective date 5/1/2007)
|
| MRI of eye socket, face and/or neck with dye |
|
MRI of eye socket, face and/or neck without dye |
|
MRI of eye socket, face and/or neck with and without dye |
|
MRI of the brain with dye |
|
MRI of the brain without dye |
|
MRI of the brain with and without dye |
|
MRI of the neck with dye |
|
MRI of the neck without dye |
|
MRI of the neck with and without dye |
|
MRI of the breast, one breast, with and without dye |
|
MRI of the breast, both breasts, with and without dye |
|
MRI of the upper back with dye |
|
MRI of the upper back without dye |
|
MRI of the upper back with and without dye |
|
MRI of the lower back with dye |
|
MRI of the lower back without dye |
|
MRI of the lower back with and without dye |
|
MRI of the arm, other than joint, without dye |
|
MRI of the arm joint with dye |
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MRI of the arm joint without dye |
|
MRI of the arm joint with and without dye |
|
MRI of the leg, other than joint, without dye |
|
MRI of the leg joint with dye |
|
MRI of the leg joint without dye |
|
MRI of the leg joint with and without dye |
|
MRI of the abdomen with dye |
|
MRI of the abdomen without dye |
|
MRI of the abdomen with and without dye |
|
MRA of the head without dye |
|
CT scan of the heart without dye |
|
CT scan of the heart vessels |
|
Magnetic Resonance Spectroscopy (see definition) |
Additional Radiology Tests Requiring Preauthorization (Effective
date 8/1/2007)
|
MRI of the breast, one breast, with dye |
|
MRI of the breast, one breast, without dye |
|
MRI of the breast, one breast, without dye followed by MRI of the breast, one
breast, with dye |
|
MRI of the breast, both breasts, with dye |
|
MRI of the breast, both breasts, without dye |
|
MRI of the breast, both breasts, without dye followed by MRI of the breast,
both breasts, with dye |
|
CT scan of the heart without dye followed by CT scan of the heart with dye |
Additional Radiology Tests Requiring Preauthorization (Effective date
12/1/2007)
|
MRA of the head with dye |
|
MRA of the head with and without dye |
Additional Focus Outpatient Procedures Requiring Precertification
(Effective date 1/1/2008)
Abdomen/Urogenital
| Procedure |
Explanation |
|
Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable
gastric band
-
Revision of adjustable band
-
Removal of adjustable band
-
Removal and replacement of adjustable band
|
Placement of an adjustable band around the upper part of the stomach using a
scope to reduce the functional capacity of the stomach |
|
Gastric restrictive procedure with partial gastrectomy, duodenoileostomy and
ileoileostomy |
Surgery on the intestines and partial removal of the stomach for purposes of
weight loss |
Focus Outpatient Precertification Listing (Effective date 7/1/2007)
Head and Neck
| Procedure |
Explanation |
|
Reduction, forehead, contouring only |
Reshaping of forehead |
Reduction, forehead, contouring and
application of material or bone graft |
Reshaping of forehead with bone or other material |
Reconstruction by contouring of
benign tumor of cranial bones |
Reshaping of bones of head after removal of non-cancerous growth |
|
Repair of brow ptosis |
Repair of drooping eyebrow |
|
Reconstruction, majority of forehead and/or supraorbital rims |
Reshaping of forehead and upper eye socket with bone or other material |
|
Reconstruction bifrontal orbital rims and lower forehead |
Reshaping of eye socket and lower forehead |
|
Reconstruction orbit with osteotomies or bone grafts |
Rebuilding of eye socket with bone |
|
Reconstruction of orbital walls, rims following excision of benign tumor of
cranial bone |
Reconstruction of eye socket after removal of non-cancerous growth |
|
Medial canthopexy |
Repair of eyelid |
|
Lateral canthopexy |
Tightening of eyelid |
|
Repair of blepharoptosis |
Repair of droopy eyelids |
|
Reduction of overcorrection of ptosis |
Repair of overcorrection of droopy eyelid |
|
Correction of lid retraction |
Repair of inability to close the eyelid |
|
Blepharoplasty, lower eyelid |
Removal of fat and excess skin and muscle from lower eyelid |
|
Reduction, forehead contouring and set back sinus wall |
Reshaping of forehead and sinuses |
|
Secondary revision of orbitocraniofacial reconstruction |
Repair of bones of eye socket, head and face |
|
Rhinoplasty |
Reshaping of nose |
|
Excision, inferior turbinate |
Removal of internal nose bones (intranasal) |
|
Nasal/sinus endoscopy, surgical |
Nasal and sinus surgery using a scope |
|
Septoplasty |
Surgery to straighten the bone and cartilage between nostrils of nose |
|
Osteoplasty facial bones, augmentation |
Repair of bones of face by adding bone or other material |
|
Osteoplasty, facial bones, reduction |
Repair of bones of face by removal of bone or other material |
|
Malar augmentation, prosthetic material |
Rebuilding of cheek bone with artificial material |
|
Palatopharyngoplasty |
Surgery to remove excess tissue on roof of mouth |
|
Removal of implanted tooth-bony |
Removal of tooth that is wedged in the jawbone |
Focus Outpatient Precertification Listing (Effective date 7/1/2007)
Heart and Blood Vessels
| Procedure |
Explanation |
|
Transcatheter placement of radiation delivery devices for subsequent coronary
brachytherapy |
Placement of a device used to deliver radiation to the coronary arteries |
|
Transcatheter placement of carotid artery stent |
Placement of a tiny tube into an artery (vessel) |
|
Vascular endoscopy, with ligation of perforator veins |
Location and tying of veins using a scope |
|
Transcatheter occlusion or embolization |
Closing off of abnormal vessels with various substances |
|
Ligation and division of saphenous veins |
Procedure to alter blood supply to varicose veins |
|
Ligation, division and stripping of saphenous veins |
Procedure to tie off blood supply to varicose veins |
|
Injection of sclerosing solution, veins of leg |
Special solution injected in a vein that causes the vein to collapse and fade
from view |
Endovenous ablation therapy of
incompetent veins |
A method using a laser or radio waves to treat (shrink) varicose veins |
|
Phlebectomy of varicose veins |
Surgical method of removing varicose veins on the surface of the leg |
Focus Outpatient Precertification Listing (Effective date 7/1/2007)
Spine and Spinal Cord
| Procedure |
Explanation |
|
Osteotomy of spine, including discectomy, cervical |
Removal of spinal disk in neck |
|
Percutaneous vertebroplasty, thoracic |
Injection of material into upper back to strengthen a broken spinal bone |
|
Osteotomy of spine, including discectomy, lumbar |
Removal of spinal disk in lower back |
|
Percutaneous vertebroplasty, lumbar |
Injection of material into lower back to strengthen a broken spinal bone |
|
Endolysis of epidural adhesions |
Breaking up of internal scar tissue around the spinal cord |
Focus Outpatient Precertification Listing (Effective date 7/1/2007)
Abdomen/Urogenital
| Procedure |
Explanation |
|
Laparoscopy, gastric bypass |
Procedure using a scope to reduce the size of the stomach |
Gastric restrictive procedure for
morbid obesity |
Surgery that reduces the size of the stomach and intestine to aid in weight
loss |
|
Revision of gastric restrictive procedure |
Reversal of gastric bypass surgery |
|
Gastrointestinal tract imaging, intraluminal |
Taking images of the inside of the digestive tract |
|
Panniculectomy with lipectomy |
Removal of fat and excess skin from lower abdomen |
|
Ablation, open, of one or more liver tumors |
Surgical treatment of a liver tumor |
|
Laparoscopy, ablation of liver tumors, radiofrequency |
Treatment, using a scope, of a liver tumor using sound waves |
|
Laparoscopy, ablation of liver tumors, cryosurgical |
Treatment, using a scope, of a liver tumor by freezing |
Transurethral balloon dilation of
prostatic urethra |
Prostate surgery through male urethra |
|
Cryosurgical ablation of the prostate |
Removal of prostate tumors by freezing |
Focus Outpatient Precertification Listing (Effective date 7/1/2007)
Lower Extremeties
| Procedure |
Explanation |
|
Autologous chondrocyte implantation, knee |
Injection of cartilage in knee |
|
Osteochondral allograft, knee |
Repair of knee with bone and cartilage |
|
Arthroscopy, knee, surgical; osteochondral autograft |
Repair of knee with bone and cartilage using a scope |
|
Osteochondral allograft, knee |
Transplanted bone and cartilage |
|
Meniscal transplantation |
Cartilage transplantation into the knee |
|
External Counterpulsation |
Applying pressure cuffs to legs to increase blood flow to the heart |
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