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Services Needing Approval

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Effective 11/1/2011

Preauthorization/Precertification can be requested by members’ First Priority Health participating providers.

The following services require Preauthorization/Precertification:

  • All Inpatient Hospital admissions
  • Long Term Acute Care admissions
  • Skilled Nursing Facility admissions
  • Inpatient admission to a Rehabilitation Facility
  • Observation care in the acute care setting
  • Certain Outpatient Surgical Procedures
  • Home Health Visits
  • Certain Outpatient Diagnostic Radiology Procedures, for example: CAT Scans, MRI’s, MRA’s, Pet Scans, Behavioral Health Care services
  • All services from a non-participating provider (except in medical emergency)

For Some Plans if benefit is available:
Private Duty Nursing

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.

PET (Positron Emission Tomography) A computerized scan that uses radioactive substance to look for disease in the body. It shows how organs and tissues are working.

Radiology Precertification Guidelines

The following tests will require precertification thru National Imaging Associates (NIA) for fully insured groups.
Please refer to Advanced Imaging Guidelines.
CT/CTA/CCTA
MRI/MRA
Pet Scan
Nuclear Cardiology / Stress Echo

Radiologic tests that require precertification For Self Funded Members

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
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)
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
MRA of the head with dye
MRA of the head with and without dye
PET Scan ( see definition )

Outpatient Procedures that may require precertification:

Head / 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
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
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
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
Removal of implanted tooth-bony Removal of tooth that is wedged in the jawbone

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
Injection of sclerosing solution, veins of leg Special solution injected in a vein that causes the vein to collapse and fade from view

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/thoracic Injection of material into upper or lower back to strengthen a broken spinal bone

Abdomen/Urogenital

Procedure Explanation
Laparoscopy, gastric bypass Procedure using a scope to reduce the size of the stomach
Gastric restrictive procedure for morbid obesity

Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric band
  • Revision of adjustable band
  • Removal of adjustable band
  • Removal and replacement of adjustable
  • band
Gastric restrictive procedure with partial gastrectomy, duodenoileostomy and ileoileostomy

Laparoscopy, surgical, gastric restrictive procedure, longitudinal gastrectomy (IE, Sleeve Gastrectomy)
Surgery that reduces the size of the stomach and intestine to aid in weight loss

Placement of an adjustable band around the upper part of the stomach using a scope to reduce the functional capacity of the stomach

Surgery on the intestines and partial removal of the stomach for purposes of weight loss

Restrictive surgical weight loss procedure that limits the amount of food you can eat, a thin vertical sleeve is created and the rest of the stomach is removed.
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
Cryosurgical ablation of the prostate Removal of prostate tumors by freezing

Lower Extremities

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