06 by iasiatube


									Provider Manual
Section 6.0
Utilization Management
Table of Contents
6.1      Utilization Management ……………………………………………………………..2  
6.2      Review Criteria/Standards for Review …………………………………………3  
6.3     Authorization Requirements ……………………………………….…..………...4 
6.4     Online Authorization …………………………………………………….…………….6  
6.5      Inpatient Admissions and Observation ………………………………………..7  
6.6      Outpatient Services ……………………………………………………………………10   
6.7      High Cost Medication …………………………………………………………………15     
6.8      Prior Authorization for Members with Original Medicare ………….15 
6.9    Retrospective Authorization ………………………………………………………15  
6.10    Denials ………………………………………………………………………………………16  
6.11    Appeals ……………………………………………………………………………………..17  
6.12    Available forms ………………………………………………………………………….20  
Appendix A: Radiology Codes ………………………………………………………………21  
Appendix B: L codes …………………………………………………………………………….27   
Appendix C:  Ostomy Supplies ……………………………………………………………..41 

                             Section 6 • Page 1
6.0 Utilization Management
6.1 Utilization Management
Utilization Management (UM) is the process of influencing the continuum of care by evaluating the
necessity and efficiency of health care services and affecting patient care decisions through
assessments of the appropriateness of care. The UM department helps to assure prompt delivery of
medically-appropriate health care services to Passport Health Plan members and subsequently
monitors the quality of care.

All Passport Health Plan participating providers are required to obtain prior authorization from the
Plan’s UM department for inpatient services and specified outpatient services listed in Section 6.3,
“Authorization Requirements.”

Failure to submit an authorization or failure to submit an authorization timely may result in
  a denial of services. An Authorization is not a guarantee of benefits. Member eligibility
                        should be verified for every request of service.

The UM department is available Monday through Friday from 8:00 a.m. to 5:30 p.m., except
holidays. All requests for authorization of services may be received during these hours of operation
by calling or faxing:

        Department                   Phone Number                        Fax Number
General Number                   (800) 578-0636             (502) 585-7989
Concurrent Review                (502) 585-2023             (502) 585-7989
Retrospective Review             (502) 585-7972             (502) 585-8207
Home Health                      (502) 585-7320             (502) 585-8204
DME                              (502) 585-7310             (502) 585-7990
Management/Chiropractic          (502) 585-6055             (502) 585-8205
                                                            Request can be sent via confidential
                                                            email to: Passport
Cosmetics                        (502) 585-7069             UMCosmetics@Passporthealthplan.com
Appeals                          (502) 585- 7307            N/A

Radiology - Administered by MedSolutions
                                                                     Available 24 hours a day/7 days
                                                                     a week
                                                                     Online Authorization process;
MedSolutions Internet             www.medsolutionsonline.com         may obtain immediate approval
                                                                     Available 24 hours a day/7 days
                                                                     a week
                                                                     Providers must use MSI forms
                                                                     – Available online or by calling
                                                                     MedSolutions Customer

                                       Section 6 • Page 2
Fax                                1-888-693-3210                     Service at 1-877-791-4099
                                                                      Available 8 a.m. - 9 p.m. EST,
Phone                              1-877-791-4099                     Monday through Friday
                                                                      Available 8 a.m. - 9 p.m. EST,
                                                                      Monday through Friday

                                                                      If imaging services are required
                                                                      in less than 48 hours due to
                                                                      medically urgent conditions,
Emergent / Urgent Requests         1-877-791-4099                     providers are to call MSI
                                                                      8 a.m. to 9 p.m. EST Monday -
Appeals                            1-877-791-4099                     Friday, excluding holidays

After business hours or on holidays, a provider can leave a message and a representative will return
the call the next business day.

Passport Health Plan provides the opportunity for the provider to discuss a decision with the
Medical Director, to ask questions about a utilization management issue, or to seek information
from the nurse reviewer about the Utilization Management process and the authorization of care by
calling Utilization Management at (800) 578-0636.

Because of frequent changes in member eligibility for Medicaid coverage, providers should verify
continued eligibility via the Plan’s web site, www.passporthealthplan.com, or by calling the IVR or
Provider Services at (800) 578-0775.

6.2 Review Criteria/Standards for Review
Passport Health Plan’s Utilization Management (UM) department is charged with ensuring that the
Plan’s members use their benefits appropriately. Passport’s UM Department uses InterQual®
Criteria during the review process. In the event InterQual® Criteria is not available for a specific
request, the reviewer may use internal medical policies which are reviewed and approved by actively
practicing practitioners in the community.

The Partnership Council approves both the use of Interqual Criteria® and Medical Polices.
Criteria are only made available to participating and non-participating providers as allowed under
copyright limitations and trademark considerations.

At the request of the practitioner, the Passport UM Department, or the Chief Medical Officer, will
provide a copy of up to three (3) Interqual® Criteria guidelines. If the guidelines are not available
for distribution, or the number of guidelines exceeds the copyright limit, the practitioner has the
option to request the guideline be read over the telephone, or review the guideline at Passport
Health Plan.

Internal Medical policies are communicated to providers via the Provider Newsletter or the Passport
Health Plan web site, www.passporthealthplan.com. Providers may request a copy of a policy at any
time from the Passport UM Department or the Chief Medical Officer.

                                       Section 6 • Page 3
Durable medical equipment is reviewed utilizing Medicaid and Medicare guidelines as well as any
applicable Passport Health Plan internal medical policies. Medicare and Medicaid criteria/guidelines
are shared with providers upon request. These requests may be made by contacting the UM
Department or the Chief Medical Officer. Criteria are distributed to providers who have
Medicare/Medicaid practitioner numbers issued by state and federal entities.

Passport Health Plan is equally concerned with and monitors for over-and under-utilization of
health care services. Utilization Management decision making is based only on appropriateness of
care and service and existence of coverage. Passport Health Plan does not specifically reward
practitioners or other individuals conducting utilization review for issuing denials of coverage or
services. Financial incentives for UM decision makers do not encourage decisions that result in

6.3 Authorization Requirements
The Passport UM department hours of operation are 8 a.m. to 5:30 p.m., Monday through Friday.
The general UM department phone number is: (800) 578-0636. The general UM department fax
number is (502) 585-7989.

The following table lists procedures and/or services that require authorization from Passport Health
Plan’s Utilization Management (UM) department.

               Service                             Special Requirements, if applicable
Inpatient Admission /                   Includes Acute, Urgent, Scheduled, Medical, Surgical,
Hospitalization                         Rehabilitation Facility, Long Term Acute Care (LTAC)
                                        Code Range: 644.XX through 665.XX ---
                                             If stay is less than or equal to 3 days with the above
                                               codes, no authorization is required
                                             The Code identified in the range above should be
                                               billed as primary on the claim
                                             If length of stay is 4 days or greater, authorization
                                               is required for the entire stay.

                                        If authorization is not obtained, the entire claim will be
                                        denied. All stays greater than 4 days must have an
                                        authorization for the entire length of stay.

                                        AUTHORIZATION IS REQUIRED FOR:
                                        All Cesarean Sections
                                        All Scheduled inductions
Maternity Admissions                    All Non-par providers, regardless of delivery type
                                        1. Excludes OB Labor Check Observation
                                        2. When a 23-hour observation is converted to an inpatient
                                        admission, the 23-hour observation day is considered to be
23-Hour Observation                     the first inpatient day

                                       Section 6 • Page 4
Pulmonary Rehab                         Inpatient and Outpatient
Cardiac Rehab                           Inpatient and Outpatient
Pain Management                         1. Example: Epidural Blocks – Trigger Point Injections
Home Hospice
Stem Cell/Progenitor Cell Retrieval
Investigational/Experimental            1. Investigational/Experimental Procedures are normally
Procedures                              not a covered service
                                        1. Cosmetic procedures are normally not a covered benefit
                                        2. Coverage may be based on medical necessity
                                        Example: Reduction Mammoplasty
Cosmetic Procedures
Ocular Photodynamic Therapy/with
Verteporfin (Visudyne)
Neuropsychological Testing
Diabetic Education
Therapy Services
                                        1. No authorization for the first 12 visits in a rolling year
                                        2. Services beyond 12 visits require authorization
                                        3. Benefit limit = total of 26 chiropractic visits within a 12-
Chiropractic Services                   month rolling calendar period
Specified Outpatient Surgical           1. Adenoidectomy - Cardiac Catheterization - EGD
PET Scan / MRI / MRA / CT /
CTA / Select Cardiac Imaging            Performed by MedSolutions
DME > $500 – rental or purchase
Enteral Products
Orthotics / Prosthetics
Home Health / Skilled nursing
Home Infusion
                                        1. Applies to high-cost medications billed to Passport
                                        Health Plan, excluding chemotherapy
                                        2. Does not apply to the pharmacy benefit. See Section 14
High Cost Medication > $400             for prior authorizations related to pharmacy
Synagis Injections                      Performed by PerformRx
Nonparticipating Provider Services

Policy for Newborns:
An infant born by Normal Vaginal Delivery (NVD) does not require authorization until day four (4)
If an infant born via NVD stays <= 3 days, authorization is not required.

An infant born by C-Section does not require authorization until day six (6.).
If an infant born via C-Section stays <= 5 days, authorization is not required.

Abortion and sterilization services must be coordinated through AmeriHealth HMO, Inc. as
described in “Family Planning,” Section 17.

                                       Section 6 • Page 5
Allergy Injections/Serum Coverage is for members ages 21 and younger. A referral is required from
the PCP to the specialist. No prior authorization for the injection is required.

All services are subject to review for medical necessity with audits performed retrospectively. Benefit
inclusions/exclusions must be considered in determining eligibility for coverage for individual cases.
To determine if a service or supply, such as cosmetic procedures, is considered a benefit exclusion,
please contact the Passport Utilization Management (UM) department.

           The assigned authorization number must be submitted on the claim form.

6.4 Online Authorization
Passport Health Plan’s Utilization Management Department utilizes an online authorization system
via NaviNet. The online authorization system is a web-based auto-review system for providers to
obtain authorization for services, including but not limited to:

        Acute Therapies
        BiPAP
        Cesarean Section
        Cardiac Rehabilitation
        Hospital Bed
        Mediplanner
        Home Health Aid
        CPAP
        EGD
        Bili Lites
        Pulmonary Rehabilitation

For questions regarding the online authorization, contact Navinet or your Provider Network
Account Manager.

The online authorization system also allows you, the provider, to search for authorizations by
member, authorization number, date of service and/or physician. View the following information
online for each authorization:
 Member identification number, coverage dates, and PCP
 Authorization number
 Service requested
 Primary diagnosis
 Treatment dates
 Status of the authorization

       The use of the online authorization system via NaviNet for select services is highly

                                       Section 6 • Page 6
6.5 Inpatient Admissions and Observation
Some authorization requests may require a physician’s letter of medical necessity or a copy of the
medical records. These should be directed to the Utilization Management nurse who is coordinating
the specific case.

At a minimum, documentation must include:
• The member’s name and Passport Health Plan ID number.
• The diagnosis for which the treatment or testing procedure is being sought.
• Other treatment or testing methods that have been tried, their duration, and any outcomes.
• Additional clinical information as applicable to the requested service.
• Applicable sections of the medical record

To receive authorization for an admission / observation stay, contact Passport Health Plan’s
Utilization Management department at (800) 578-0636 or fax request to (502) 585-7989, Monday
through Friday, between the hours of 8 a.m. and 5:30 p.m.

6.5.1 Inpatient Status

UM reviews all requests for inpatient admissions utilizing InterQual® Criteria. For those requests
meeting the established medical necessity criteria, an inpatient stay will be authorized.

Requests not meeting the established medical necessity criteria will be referred to Passport’s Medical
Director for further review and evaluation.

If a member is discharged from an inpatient level of care and subsequently re-admitted to the same
hospital within 24 hours, the UM Department continues the member's inpatient stay under the same
case reference number.

To receive authorization for admission stays, contact Passport Health Plan’s Utilization Management
department at (800) 578-0636 or fax request to (502) 585-7989, Monday through Friday, between
the hours of 8 a.m. and 5:30 p.m.

6.5.2 Prior Authorization of Elective Inpatient Services

Providers are required to obtain prior authorization for all elective hospital admissions from the
Plan’s Utilization Management Department.

Prior authorization is mandatory for elective inpatient cases to qualify for payment.

Requests for prior authorization of elective services should be received by UM 14 days prior to the
date the requested service will be performed. Prior authorization of the service must be requested
prior to the procedure being performed.

Passport Health Plan will accept the hospital’s or the attending physician’s request for prior
authorization of elective hospital admissions; however, neither party should assume that the other
has obtained prior authorization.

                                       Section 6 • Page 7
Failure to obtain prior authorization of an elective admission will result in an administrative denial of
the admission (see Section 6.11).

Denied prior-authorization requests may be appealed (see Section 6.12).

To receive authorization for elective inpatient services, contact Passport Health Plan’s Utilization
Management department at (800) 578-0636 or fax the request to (502) 585-7989, Monday through
Friday, between the hours of 8 a.m. and 5:30 p.m.

6.5.3 Emergency Admissions

For an urgent or emergent admission / observation at an acute-care facility, the facility must notify
the plan within one business day of the admission.

For weekend admissions to a hospital or for services delivered on the weekend or after normal
business hours, authorization must be obtained within one business day of the admission or service
being provided.

Clinical information must be provided at the time of the notification.

Failure to provide timely notification or clinical data will result in an administrative denial of those
days prior to the notification regardless of medical necessity (see Section 6.11).

To receive authorization for emergency admissions, contact Passport Health Plan’s Utilization
Management department at (800) 578-0636 or fax the request to (502) 585-7989, Monday through
Friday, between the hours of 8 a.m. and 5:30 p.m.

6.5.4 Observation to Inpatient Status

Some requests for inpatient evaluation of members who present with conditions that may warrant
evaluation and monitoring, but do not meet the criteria for inpatient admission, are reviewed for an
observation stay (hospital stay of 23 hours or less).

Observation status is based on medical necessity determined by using or InterQual® Criteria and
internal medical policies.

If the member’s condition, or results of evaluation and testing meet inpatient criteria after the 23-
hour observation period, the stay will be converted to inpatient beginning with the observation stay
admission date. All claims for this type of stay should be submitted with the entire length of stay as
an inpatient.

To receive authorization for observation to inpatient, contact Passport Health Plan’s Utilization
Management department at (800) 578-0636 or fax the request to (502) 585-7989, Monday through
Friday, between the hours of 8 a.m. and 5:30 p.m.

                                         Section 6 • Page 8
6.5.5 Inpatient Admissions to Non-Participating Facilities

Requests for admission to non-participating facilities should be submitted to the Passport Health
Plan UM department for review.

To receive authorization for admission to a non-participating facility, contact Passport Health Plan’s
Utilization Management department at (800) 578-0636 or fax the request to (502) 585-7989, Monday
through Friday, between the hours of 8 a.m. and 5:30 p.m.

6.5.6 Elective Participating-Hospital Transfer Policy

Elective participating facility transfers must be prior authorized by Passport Health Plan. Patient
clinical information will be required to complete the authorization process, approve the transfer, and
determine prospective length of stay.

Either the transferring or receiving facility may initiate the prior authorization; however, the
transferring facility will be able to provide the most accurate required clinical information. If a
hospital transfer request is made by another Passport Health Plan facility, the receiving facility may
request that the transferring facility obtain the authorization before the case will be accepted at the
receiving facility.

The receiving facility should contact Passport Health Plan to confirm the authorization.

In cases deemed emergent, notification of the admission is required within one business day after
the transfer.

To assist with transfers, contact Passport Health Plan’s Utilization Management department at (800)
578-0636 or fax the request to (502) 585-7989, Monday through Friday, between the hours of 8 a.m.
and 5:30 p.m.

6.5.7 Inpatient Rehabilitation Admissions

If a member requires an inpatient rehabilitation admission, the rehabilitation hospital will contact the
on-site review nurse at the acute-care facility where the member is currently an inpatient. If there is
no on-site review nurse at the acute-care facility, the rehab hospital can contact Passport Health
Plan’s Utilization Management via phone (800) 578-0636 or fax (502) 585-7989

Inpatient rehabilitation includes Acute Inpatient Rehab, Inpatient Cardiac Rehab and Inpatient
Pulmonary Rehab.

If the member is to be directly admitted from home or any other sub-acute facility, contact Passport
Health Plan’s Case Management department at (800) 578-0636 ext. 2024.

                                        Section 6 • Page 9
6.5.8 Inpatient Skilled-Nursing Facility

Passport Health Plan is not responsible for, nor does it reimburse nursing facility costs for, members
at skilled-nursing facilities. Those services are covered by the Kentucky Medicaid Program. Passport
Health Plan is responsible for costs of professional services, such as physician or therapist services
that are not part of the routine facility service. After a member is in a nursing facility for 31 days, the
disenrollment process begins for that member. Passport Health Plan’s responsibility for those non-
facility services continues for any of its members while they are still enrolled with the Plan. After the
Kentucky Medicaid Program completes the managed care disenrollment process and reinstates the
member in the fee-for-service Medicaid program, the Plan no longer has financial responsibility for
any services for that Medicaid recipient. To obtain skilled-nursing facility authorization, please call
the DMS-contracted review entity, SHPS, at (502) 426-4888.

6.6 Outpatient Services
For authorization of select outpatient services listed in Section 6.3, “Authorization Requirements,”
the PCP/specialist notifies Passport Health Plan via the online authorization system, telephonically
or by fax. Prior authorization is mandatory for select outpatient procedures / diagnostics to qualify
for payment.

Some authorization requests may require a physician’s letter of medical necessity or a copy of the
medical records. These should be directed to the Utilization Management nurse who is coordinating
the specific case.

At a minimum, documentation must include:
• The member’s name and Passport Health Plan ID number.
• The diagnosis for which the treatment or testing procedure is being sought.
• Other treatment or testing methods that have been tried, their duration, and any outcomes.
• Additional clinical information as applicable to the requested service.
• Applicable sections of the medical record.

Requests for prior authorization of elective services should be received by UM 14 days prior to the
date the requested service will be performed. Prior authorization of the service must be requested
prior to the procedure being performed.

Requests for authorization of urgent and emergent services must be submitted to UM within one
business day of the procedure being performed.

Passport Health Plan will accept the hospital’s or the attending physician’s request for prior
authorization of elective hospital admissions; however, neither party should assume that the other
has obtained prior authorization.

Failure to obtain prior authorization for an elective procedure / service or failure to request
authorization of an urgent or emergent procedure / service within one business day of the
procedure/ service being performed or rendered will result in an administrative denial of the service
(see Section 6.11).

                                        Section 6 • Page 10
The assigned prior-authorization number must be on the claim form. If practitioners wish to
confirm authorization, they may verify online via the online authorization system.

6.6.1 Outpatient Procedures / Diagnostics / Services

Providers are required to obtain prior authorization for select outpatient procedures / diagnostics
from the Plan’s Utilization Management Department.

See Table in section 6.3 for outpatient list.

For Outpatient Imaging Services requiring authorization, see section 6.6.2.

For authorization of select outpatient services listed in Section 6.3, “Authorization Requirements,”
the provider notifies Passport Health Plan via the online authorization system, telephonically or by
fax. The general UM department phone number is: (800) 578-0636. The general UM department
fax number is (502) 585-7989.

The use of the online authorization system is highly recommended for the outpatient
services listed in section 6.4.

6.6.2 Outpatient Radiology Services

Providers are required to obtain authorization for select radiological services through the high dollar
radiology program for advanced diagnostic imaging services. This program is administered in
partnership with MedSolutions (MSI).

Authorizations are required for select diagnostic imaging services performed in an outpatient setting.
Advanced diagnostic imaging includes:

       Computed Tomography (CT); Computed Tomographic Angiogram (CTA)
       Magnetic Resonance Imaging (MRI); Magnetic Resonance Angiogram (MRA)
       Positron Emissions Tomography (PET)
       Nuclear Cardiac Imaging (NCM)

Authorizations are performed at MSI using their own internal criteria and medical management
system. MSI performs initial review, retrospective review, denials and 1st level appeals.

Authorization is required for advanced diagnostic imaging services performed in any outpatient

Authorization is NOT required if the imaging service is performed in:

       Emergency rooms
       Inpatient settings

                                        Section 6 • Page 11
       23-hour observations – Service performed in observation do not require an authorization.
        However, the observation stay will still require a review by Passport.

There are three (3) ways to request an authorization:

    1. Internet: www.medsolutionsonline.com - Available 24/7

    2. Phone: (877) 791-4099
       Available 8 a.m. - 9 p.m. EST, Monday through Friday
       Toll free

    3. Fax: 1-888-693-3210
       Forms available at www.medsolutionsonline.com or by calling MedSolutions Customer
       Service at (877) 791-4099
       Only MedSolutions fax forms are accepted
       Available 24/7

See Appendix A for a list of codes that require an authorization.

6.6.3 Durable Medical Equipment

The Department for Medicaid Services (DMS) requires that an updated Certificate of Medical
Necessity (CMN) be signed by the provider for all supplies and equipment and kept on file by the
supplier for a period of five years. The only exception is oxygen for which Passport Health Plan
follows Medicare guidelines.

DME items with billable charges greater than $500 require an authorization.
Requests for authorization of purchase MUST be received PRIOR to the end of the rental period.

Authorization requirements of rentals are determined by the billable price of the item being rented.
Rental charges will be applied to purchase price.

If the billable price of the rental is $500 or less, no authorization is required. If the billable price of
the rental is greater than $500, authorization is required.

All items requiring customization or accessories require prior authorization.

All mini-nebulizers will be a purchase only item and do not require prior authorization.

Authorization requirements for DME purchases are based on total monthly cost or monthly
quantity of items purchased. The following is a list of purchases with authorization requirements by

                                         Section 6 • Page 12
                      Item                                        Quantity Limitations
Name Brand Diapers                                     Regardless of quantity, all requests for name
                                                        brand diapers require authorization
Generic Diapers                                        180 per month require authorization
Underpads (Chux)                                       180 per month require authorization
Ostomy Supplies                                        2 boxes per month require authorization
Bedside Drainage Bags                                  4 per month require authorization
Syringes                                               100 per month require authorization
G-Tube                                                 1 per month requires authorization
Compression Stockings                                  6 pair per year require authorization

* Maintenance, repair, or replacement in excess of $500 must have prior authorization from the UM

Enteral Products
     • Enteral products with allowable amounts greater than $500 for a month’s supply require an

These services should be billed according to the fee schedule in your Provider Contract (Allowable

For authorization of DME, the provider notifies Passport Health Plan via the online authorization
system, telephonically or by fax. The DME phone number is: (502) 585-7310. The DME fax
number is: (502) 585-7990.

The use of the online authorization system is highly recommended for DME listed in section 6.4.

For a list of Orthotics and Prosthetics that require an Authorization, see Appendix A.

For a list of Ostomy supplies that require an Authorization, see Appendix B.

6.6.4 Home Health Services

When medically appropriate, home health / home hospice care and home infusion may be a good
alternative to hospitalization. Home health care, including both skilled and unskilled nursing and
hospice care and home infusion may be appropriate at other times as well.

Prior authorization of all home health / hospice / home infusion services is required. If the
member is an inpatient and the facility has a Passport Health Plan on-site nurse reviewer, the request
may be given directly to the on-site review nurse.

A request for prior authorization must be received prior to the delivery of the service for a non-
urgent request and within one business day of the service being performed for an urgent or
emergent service.

                                       Section 6 • Page 13
For authorization of Home Health Services, the provider notifies Passport Health Plan via the
online authorization system, telephonically or by fax. The Home Health phone number is: 585-
7320. The Home Health fax number is: (502) 585-8204.

The use of the online authorization system is highly recommended for home health services listed in
section 6.4.

Requests for continuation of a service that is ongoing should be sent to the Home Health
department seven days prior to the end of the authorization period. Please fax request together with
progress notes and current plan of care to (502) 585-8204.

6.6.5 Therapy, Chiropractic Services and Outpatient Rehab Services

Providers are required to obtain prior authorization for physical, occupational, aquatic and speech
therapy for acute and chronic conditions and chiropractic services.

   Therapy
    Authorization of outpatient therapy services (physical, occupational, aquatic and speech) is
    required. If the member is an inpatient and the facility has a Passport Health Plan onsite nurse
    reviewer, the request may be given directly to the onsite review nurse. Review is required for
    the initial therapy visit and all subsequent visits

    Requests for continuation of a service that is ongoing should be sent to the therapy department
    seven days prior to the end of the authorization period. Please fax request together with progress
    notes and current plan of care to (502) 585-8204.

    For authorization of therapy requests, providers must notify Passport Health Plan through the
    online authorization system, telephonically or by fax. The therapy phone number is: (502) 585-
    6055. The therapy fax number is (502) 585-8205.

    The use of the online authorization is highly recommended for the therapy services listed in
    section 6.4.

   Chiropractic Services
    Authorization requests for chiropractic services are required after the 12th visit.
    No authorization is required for the first 12 visits in a rolling year.
    The benefit limit equals the total of 26 chiropractic visits within a 12-month rolling calendar

   Outpatient Rehab Services
    Authorization requests for outpatient rehab services (cardiac rehab and pulmonary rehab) are
    required. If the member is an inpatient and the facility has a Passport Health Plan onsite nurse
    reviewer, the request may be given directly to the onsite review nurse.

    For authorization of chiropractic or outpatient rehab services, providers must notify Passport
    Health Plan telephonically at (502) 585-6055 or via fax at (502) 585-8205.

                                       Section 6 • Page 14
6.7 High Cost Medications
Providers are required to obtain prior authorization for High Cost Medications greater than $400
billable amount per dose from the Utilization Management Department.

Authorizations for Synagis must be requested from Passport’s Pharmacy Benefits Manager. See
section 14 for prior authorizations related to pharmacy.

This applies to high-cost medications billed to Passport Health Plan, excluding chemotherapy. This
does not apply to the pharmacy benefit. See Section 14 for prior authorizations related to pharmacy.

For requests of high cost medications, providers may contact the UM Department at (800) 578-0636
or fax the request to (502) 585-7989.

6.8 Prior Authorization for Members with Original Medicare
Prior authorization is not required for services listed on the prior authorization list when the
member has Original Medicare as the primary payer and benefits under Medicare have not been
exhausted. This applies to both inpatient and outpatient services. When benefits are exhausted or if
the service is not a benefit covered under Original Medicare, and Passport Health Plan becomes the
primary payer, prior authorization requirements apply for both outpatient and inpatient services.

For those members who have exhausted their Original Medicare Part A inpatient lifetime reserve
days, prior authorization of inpatient services must be obtained. If a member’s lifetime reserve days
are exhausted during an inpatient hospitalization, notification to Passport Health Plan must be made
within one business day of the notification to the facility of the exhaustion of benefits by Medicare.

6.9 Retrospective Authorization
Retrospective review of inpatient services is performed only when the patient was not a member of
Passport Health Plan prior to or at the time of the service. Outpatient services do not require
retrospective review by Utilization Management for members whose eligibility is determined

Providers have 60 days from the notification of eligibility on retrospectively enrolled members to
submit medical records for review and utilization management authorization request. If the
practitioner does not provide documentation, the card issue date, segment date, and claims history
are used. A decision and written notification is provided within ten (10) business days of receipt of
the medical information for the retrospective review request. An administrative denial is issued for
retrospective requests when the provider fails to request a utilization management review of the
medical record within the timeframe specified.

The provider is notified of all decisions regarding retrospective reviews. In cases of denial, a written
notification is provided.

                                       Section 6 • Page 15
Requests received beyond 60 days from the card issue date or from the provider’s documentation of
the date when they were aware of the member’s eligibility will be administratively denied.

Send requests for retrospective review to:
Utilization Management
Retrospective Review
5100 Commerce Crossings Drive
Louisville, KY 40229

The phone number for retrospective review is: (502) 585-7972 or fax to: (502) 585-8207 (for large
chart review, please send records via mail).

6.10 Denials
An authorization request for a service may be denied for failure to meet guidelines, protocols,
medical policies, or failure to follow administrative procedures outlined in the Provider Contract or
this Provider Manual.

Members may not be billed by participating providers for deductibles, copays, and coinsurance
except those allowed by DMS. If pre-authorization criteria are not met resulting in a denied claim,
members must be held harmless for denied services.

To speak with the Medical Director or to the nurse reviewer regarding a denial, please contact
Utilization Management at (800) 578-0636.

6.10.1 Medical Necessity Denials

Utilization Management utilizes medical policies, protocols, and industry standard guidelines to
render review decisions. Requests not meeting the guidelines, protocols, or policies are referred to a
Medical Director for clinical review.

A Passport Health Plan Medical Director renders all denial decisions. Whenever a denial is issued,
Utilization Management provides the name, telephone number, title, and office hours of the Medical
Director who rendered the decision. The Passport Health Plan Medical Director is available to
discuss any decision rendered with the attending practitioner.

6.10.2    Administrative Denials

An administrative denial is issued for those services for which the provider has not followed the
requirements set forth in the Provider Contract or this Provider Manual. For example, an
administrative denial may be issued for failure to prior authorize an elective service, procedure, or
admission. It may also be issued for failure to notify Utilization Management within one business
day of an emergency service, procedure, or admission.

                                       Section 6 • Page 16
Administrative denials will only apply to those days between the admission/service date and the date
the health plan was notified of the admission/service.

6.11 Appeals
An appeal is a request for review of a Passport Health Plan action related to covered services or
services provided. An action is defined as the denial or limited authorization of a requested service,
including the type or level of service; reduction, suspension, or termination of a previously
authorized service; denial, in whole or in part, of payment for a service; failure to provide services in
a timely manner; failure to act within specified timeframes; denial of a request to obtain services
outside the network for specific reasons. All appeals must be received in writing.

There are three types of appeals that may be directed to the Passport Health Plan appeals

1. A pre-service medical-necessity denial appeal;
2. A post-service medical-necessity denial appeal; and,
3. An administrative denial appeal.

Please address all medical-necessity and administrative appeals to:
Passport Health Plan
Attn: Appeals Coordinator
5100 Commerce Crossings Drive
Louisville, KY 40229

To speak with the Appeals Coordinator regarding an appeal, please call (502) 585-7307

6.11.1 Pre-service Medical-Necessity Appeals

A pre-service appeal is a request for review of an action by Passport Health Plan related to covered
services not yet received by the member.

The member, an authorized representative of the member, or a provider acting on behalf of the
member may file pre-service appeals. Appeals filed by the provider on the member’s behalf require
the member’s written consent. If the member’s written consent is not received within 30 days of the
action, then no appeal will be initiated.

The appeal must be filed in writing, and the Plan must receive it within 30 calendar days from the
date of a notice of an action by the Plan. When an appeal request is submitted, it must be
accompanied by all supporting documentation. Within three business days of receipt of the written
appeal, the Plan will send the member a letter acknowledging receipt of the appeal and advising of
the date the appeal will be heard. A board-certified physician with clinical expertise in treating the
member’s condition or disease, and who was not involved in the initial denial, will review all
member pre-service medical appeals.

                                        Section 6 • Page 17
The Plan will communicate to the member and to the provider an appeal decision within 30 calendar
days from the Plan’s receipt of the appeal.

6.11.2 Expedited Appeals

An expedited review process is available when the Plan determines, or the provider indicates, that
taking the time for a standard resolution could seriously jeopardize the member’s life, health, or
ability to attain, maintain, or regain maximum function.

Expedited appeals are available for prospective and concurrent services. An expedited appeal is not
available for those requests which are made retrospectively. For all expedited appeals, a physician
other than the physician rendering the original denial decision will review the appeal request.

A decision will be communicated to the appeal requestor within 72 hours from the Plan’s receipt of
the appeal.

6.11.3    Provider Post-Service Medical-Necessity Appeals

A post-service appeal is a request for review of an action by Passport Health Plan related to covered
services received by the member but for which the provider has not been paid because of a
Utilization Management medical-necessity denial.

Post-service appeals must be received within 60 calendar days from the date of the Plan’s notice of
an action or 60 calendar days from the date of discharge from an inpatient setting. The appeal must
be filed in writing and must be accompanied by all supporting documentation. Within three business
days of receipt of the written appeal, the Plan will send to the provider a letter acknowledging
receipt of the appeal. A board-certified physician who was not involved in the initial denial, will
review all post-service provider appeals.

The provider may also request that the reviewing physician be of like or similar specialty. The
provider will be notified in writing of the appeal decision within 30 calendar days from the Plan’s
receipt of the appeal.

The appeal decision is final, and at this point, the provider has exhausted all appeal options with
Passport Health Plan.

6.11.4    Provider Administrative Appeals

An administrative appeal is a request for review of an action by the Plan to administratively deny a
service based upon the provider’s contract and this Provider Manual. The provider is notified by a
formal denial letter that specifies the reason for the administrative denial.

The Plan must receive an appeal of a Utilization Management administrative denial within 60
calendar days from the date of the Plan’s denial letter. The appeal must be filed in writing and must

                                       Section 6 • Page 18
be accompanied by all supporting documentation. Within three business days of receipt of the
written appeal, the Plan will send the provider a letter acknowledging receipt of the appeal.

Passport Health Plan’s Administrative Appeals Committee reviews all Utilization Management
administrative denial appeals. The Plan will notify the provider in writing of the appeal decision
within 30 calendar days from the Plan’s receipt of the appeal.

The appeal decision is final, and at this point, the provider has exhausted all appeal options with
Passport Health Plan.

6.11.5 Radiology Appeals

MedSolutions, Passport Health Plan’s Radiology Partner, will conduct First Level appeals for
radiology services not authorized.

First Level Appeals include:

       Pre-Service Medical Necessity Denial Appeal
       Provider Post Service Medical Necessity Denial Appeal
       Administrative Denial Appeal

See Sections 6.12.1 through 6.12.4 in the Provider Manual for a description of appeal types.

All appeals must be submitted in writing. Please submit all Appeal Requests to:


Appeals Department

730 Cool Springs Blvd., Suite 800

Franklin, TN 37067

Expedited Radiology Appeals

An expedited review process is available when Passport’s radiology benefits manager determines, or
the provider indicates, that taking time for a standard resolution could seriously jeopardize the
member’s life, health or ability to attain, maintain or regain maximum function. Expedited appeals
are available for prospective services only. (See section 6.12.2 in the Provider Manual for further
description an Expedited Appeal.)

You may contact MedSolutions at 888-693-3211, extension 2262, Monday through Friday excluding
holidays from 9 a.m. –to 6 p.m. EST for an expedited appeal request.

                                       Section 6 • Page 19
6.12 Available Forms
Authorization forms can be found in section 19 of the provider manual. Available forms include:

      Home Health Authorization Form
      DME Authorization Form
      Home Infusion Authorization Form
      Pain Management Medical Necessity Review Check List
      Cosmetic Prior Authorization Form
      Initial Therapy Authorization Form
      Continued Therapy Authorization Form
      Chiropractic Prior Authorization Request

                                     Section 6 • Page 20
Appendix A: Radiology Codes
The codes on the list below require authorization through MedSolutions

         CPT®              CPT®                                    CPT® 
       Category            Code                                Description 
MRI TMJ                  70336     MRI Temporomandibular Joint (s) 
CT                       70450     CT Head without contrast 
CT                       70460     CT Head with contrast 
CT                       70470     CT Head with & without contrast 
CT                       70480     CT Orbit, et al without contrast 
CT                       70481     CT Orbit, et al with contrast 
CT                       70482     CT Orbit, et al W & W/O 
CT                       70486     CT Maxillofacial area, (sinus) without contrast 
CT                       70487     CT Maxillofacial area, (sinus) with contrast 
CT                       70488     CT Maxillofacial area, (sinus) W & W/O 
CT                       70490     CT Soft‐tissue Neck without contrast 
CT                       70491     CT Soft‐tissue Neck with contrast 
CT                       70492     CT Soft‐tissue Neck with & without contrast W & W/O 
CT Angiography (CTA)     70496     CTA HEAD, with contrast, including noncontrast images, if 
                                   performed, & image post‐processing 
CT Angiography (CTA)     70498     CTA NECK, with contrast, including noncontrast images, if 
                                   performed, & image post‐processing 
MRI                      70540     MRI Orbit, Face and/or Neck without contrast 
MRI                      70542     MRI Orbit, Face and/or Neck with contrast 
MRI                      70543     MRI Orbit, Face and/or Neck W & W/O 
MRA                      70544     MR Angiography (MRA) Head without contrast 
MRA                      70545     MR Angiography (MRA) Head with contrast 
MRA                      70546     MR Angiography (MRA) Head with and without contrast W & 
MRA                      70547     MR Angiography (MRA) Neck without contrast 
MRA                      70548     MR Angiography (MRA) Neck with contrast 
MRA                      70549     MR Angiography (MRA) Neck with and without contrast W & 
MRI                      70551     MRI Brain (Head) without contrast 
MRI                      70552     MRI Brain (Head) with contrast 
MRI                      70553     MRI Brain (Head) with and without contrast W & W/O 
Functional MRI (fMRI)    70554     MRI Brain, functional MRI; including test selection and 
                                   administration of repetitive body part movement and/or visual 
                                   stimulation, not requiring physician or psychologist 
Functional MRI (fMRI)    70555     MRI, Brain, functional MRI; requiring physician or psychologist 
                                   administration of entire neurofunctional testing 
CT                       71250     CT Chest without contrast 
CT                       71260     CT Chest with contrast 
CT                       71270     CT Chest with and without contrast W & W/O 

                                   Section 6 • Page 21
CT Angiography (CTA)    71275    CTA CHEST, (non‐coronary), with contrast, including noncontrast 
                                 images, if performed, & image post‐processing 
MRI                     71550    MRI Chest without contrast 
MRI                     71551    MRI Chest with contrast 
MRI                     71552    MRI Chest with and without contrast W & W/O 
MRA                     71555    MR Angiography (MRA) Chest (excluding myocardium)‐ W or 
CT                      72125    CT Cervical Spine without contrast 
CT                      72126    CT Cervical Spine with contrast 
CT                      72127    CT Cervical Spine with and without contrast W & W/O 
CT                      72128    CT Thoracic Spine without contrast 
CT                      72129    CT Thoracic Spine with contrast 
CT                      72130    CT Thoracic Spine with and without contrast W & W/O 
CT                      72131    CT Lumbar Spine without contrast 
CT                      72132    CT Lumbar Spine with contrast 
CT                      72133    CT Lumbar Spine with and without out contrast W & W/O 
MRI                     72141    MRI Cervical Spine without contrast 
MRI                     72142    MRI Cervical Spine with contrast 
MRI                     72146    MRI Thoracic Spine without contrast 
MRI                     72147    MRI Thoracic Spine with contrast 
MRI                     72148    MRI Lumbar Spine without contrast 
MRI                     72149    MRI Lumbar Spine with contrast 
MRI                     72156    MRI Cervical Spine with and without contrast W & W/O 
MRI                     72157    MRI Thoracic Spine with and without contrast W & W/O 
MRI                     72158    MRI Lumbar Spine with and without contrast W & W/O 
MRA                     72159    MR Angiography (MRA) Spinal Canal and contents ‐with or w/o 
CT Angiography (CTA)    72191    CTA PELVIS, with contrast, including noncontrast images, if 
                                 performed, & image post‐processing 
CT                      72192    CT Pelvis without contrast 
CT                      72193    CT Pelvis with contrast 
CT                      72194    CT Pelvis with and without contrast W & W/O 
MRI                     72195    MRI Pelvis without contrast 
MRI                     72196    MRI Pelvis with contrast 
MRI                     72197    MRI Pelvis with and without contrast W & W/O 
MRA                     72198    MR Angiography (MRA) Pelvis ‐with or without contrast 
CT                      73200    CT Upper Extremity without contrast 
CT                      73201    CT Upper Extremity with contrast 
CT                      73202    CT Upper Extremity with and without contrast W & W/O 
CT Angiography (CTA)    73206    CTA Upper Extremity, with contrast, including noncontrast 
                                 images, if performed, & image postprocessing 
MRI                     73218    MRI Upper Extremity‐other than joint‐without contrast 
MRI                     73219    MRI Upper Extremity‐other than joint‐with contrast 
MRI                     73220    MRI Upper Extremity‐other than joint‐W & W/O 
MRI                     73221    MRI Any Joint of Upper Extremity‐‐without contrast 
MRI                     73222    MRI Any Joint of Upper Extremity‐‐with contrast 

                                 Section 6 • Page 22
MRI                      73223    MRI Any Joint of Upper Extremity—W & W/O 
MRA                      73225    MR Angiography (MRA) Upper Extremity ‐with or without 
CT                       73700    CT Lower Extremity without contrast 
CT                       73701    CT Lower Extremity with contrast 
CT                       73702    CT Lower Extremity with and without contrast W & W/O 
CT Angiography (CTA)     73706    CTA Lower Extremity, with contrast, including noncontrast 
                                  images, if performed, & image postprocessing 
MRI                      73718    MRI Lower Extremity‐other than joint‐without contrast 
MRI                      73719    MRI Lower Extremity‐other than joint‐with contrast 
MRI                      73720    MRI Lower Extremity‐other than joint‐ W & W/O 
MRI                      73721    MRI Any Joint of Lower Extremity‐‐without contrast 
MRI                      73722    MRI Any Joint of Lower Extremity‐‐with contrast 
MRI                      73723    MRI Any Joint of Lower Extremity—W & W/O 
MRA                      73725    MR Angiography (MRA) Lower Extremity‐with or without 
CT                       74150    CT Abdomen without contrast 
CT                       74160    CT Abdomen with contrast 
CT                       74170    CT Abdomen with and without contrast W & W/O 
CT Angiography (CTA)     74174    Computed tomographic angiography; abdomen and pelvis; with 
                                  contrast material(s), including non contrast images, if 
                                  performed, and image postprocessing 
CT Angiography (CTA)     74175    CTA ABDOMEN, with contrast, including noncontrast images, if 
                                  performed, & image postprocessing 
CT                       74176    CT Abdomen & Pelvis, without contrast 
CT                       74177    CT Abdomen & Pelvis, with contrast 
CT                       74178    CT Abdomen & Pelvis, with and without contrast 
MRI                      74181    MRI Abdomen without contrast 
MRI                      74182    MRI Abdomen with contrast 
MRI                      74183    MRI Abdomen with and without contrast W & W/O 
MRA                      74185    MR Angiography (MRA) Abdomen‐with or without contrast 
Diagnostic CT            74261    Computed tomographic (CT) colonography, diagnostic, including 
Colonography (CTC)                image postprocessing; without contrast material 
Diagnostic CT            74262    Computed tomographic (CT) colonography, diagnostic, including 
Colonography (CTC)                image postprocessing; with contrast material(s) including non‐
                                  contrast images, if performed 
CT Colonography (CTC)    74263    Computed tomographic (CT) colonography, screening, including 
for Screening                     image postprocessing 
Cardiac MRI              75557    Cardiac MRI for morphology and function without contrast 
Cardiac MRI              75559    Cardiac MRI for morphology and function without contrast 
                                  material; with stress imaging 
Cardiac MRI              75561    Cardiac MRI for morphology and function without contrast, 
                                  followed by contrast W & W/O 
Cardiac MRI              75563    Cardiac MRI for morphology and function without contrast, 
                                  followed by contrast; with stress imaging 
Cardiac MRI              75565    Cardiac magnetic resonance imaging for velocity flow mapping 

                                  Section 6 • Page 23
                                    (List separately in addition to code for primary procedure) 
Cardiac CT Calcium         75571    CT, heart, without contrast with quantitative   
Cardiac CT                 75572    CT, heart, with contrast material, for evaluation of cardiac 
                                    structure and morphology (including 3D image post processing, 
                                    assessment of cardiac function, and evaluation of venous 
                                    structures, if performed) 
Cardiac CT                 75573    CT, heart, with contrast material, for evaluation of cardiac 
                                    structure and morphology in the setting of congenital heart 
                                    disease (including 3D image post processing, assessment of 
                                    cardiac LV function, RV structure and function and evaluation of 
                                    venous structures, if performed) 
CT Coronary                75574    CT, heart, coronary arteries and bypass grafts (when present), 
Angiography (CTCA)                  with contrast material, including 3D image post processing 
                                    (including evaluation of cardiac structure and morphology, 
                                    assessment of cardiac function, and evaluation of venous 
                                    structures, if performed) 
CT Angiography (CTA)       75635    CTA ABDOMINAL AORTA and bilateral iliofemoral lower 
                                    extremity runoff, with contrast, including noncontrast images, if 
                                    performed, and image post‐processing 
3D Rendering               76376    3D Rendering with interpretation and reporting of CT, 
3D Rendering               76377    3D Rendering with interpretation and reporting of CT, 
CT                         76380    CT Limited or Localized follow‐up 
MR Spectroscopy (MRS)      76390    MR Spectroscopy (MRS) 
Unlisted CT                76497    Unlisted CT procedure (eg, diagnostic, interventional) 
Unlisted MR                76498    Unlisted MR procedure (eg, diagnostic, interventional) 
CT guidance                77011    CT guidance stereotactic localization 
CT guidance                77012    CT guidance needle placement (eg,biopsy, aspiration, injection, 
                                    localization device)  
CT guidance                77013    CT Guidance for, and monitoring of, parenchymal tissue 
MR Guidance                77021    MR guidance for needle placement (eg, for biopsy, 
MR Guidance                77022    MR guidance for, and monitoring of, parenchymal tissue 
Breast MRI                 77058    MRI BREAST, without and/or with contrast UNILATERAL 
Breast MRI                 77059    MRI BREAST, without and/or with contrast BILATERAL 
CT Bone Density            77078    CT BONE MINERAL DENSITY study, 1 or more sites, axial skeleton 
MRI Bone Marrow            77084    MRI Bone Marrow blood supply 
Nuclear Cardiac Imaging    78451    Myocardial perfusion imaging, tomographic (SPECT) (including 
                                    attenuation correction, qualitative or quantitative wall motion, 
                                    ejection fraction by first pass or gated technique, additional 
                                    quantification, when performed); single study, at rest or stress 
                                    (exercise or pharmacologic) 
Nuclear Cardiac Imaging    78452    Myocardial perfusion imaging, tomographic (SPECT) (including 
                                    attenuation correction, qualitative or quantitative wall motion, 
                                    ejection fraction by first pass or gated technique, additional 
                                    quantification, when performed); multiple studies, at rest and/or 
                                    stress (exercise or pharmacologic) and/or redistribution and/or 
                                    rest reinjection 

                                    Section 6 • Page 24
Nuclear Cardiac Imaging    78453    Myocardial perfusion imaging, planar (including qualitative or 
                                    quantitative wall motion, ejection fraction by first pass or gated 
                                    technique, additional quantification, when performed); single 
                                    study, at rest or stress (exercise or pharmacologic) 
Nuclear Cardiac Imaging    78454    Myocardial perfusion imaging, planar (including qualitative or 
                                    quantitative wall motion, ejection fraction by first pass or gated 
                                    technique, additional quantification, when performed); multiple 
                                    studies, at rest and/or stress (exercise or pharmacologic) and/or 
                                    redistribution and/or rest reinjection 
Cardiac PET                78459    PET Cardiac (myocardial imaging) – metabolic evaluation 
Nuclear Cardiac Imaging    78466    Myocardial Imaging, infarct avid, planar; qualitative or 
Nuclear Cardiac Imaging    78468    Myocardial Imaging, infarct avid, planar; w/ EF by first pass 
Nuclear Cardiac Imaging    78469    Myocardial Imaging, infarct avid, planar; tomographic SPECT 
Nuclear Cardiac Imaging    78472    Cardiac Blood Pool imaging, gated equilibrium; planar, single 
                                    study at rest or stress 
Nuclear Cardiac Imaging    78473    Cardiac Blood Pool imaging, gated equilibrium; multiple studies, 
                                    wall motion plus ejection fraction, at rest and stress 
Nuclear Cardiac Imaging    78481    Cardiac Blood Pool imaging, (planar), first pass technique; single 
                                    study, at rest or with stress, wall motion study plus ejection 
Nuclear Cardiac Imaging    78483    Cardiac Blood Pool imaging, (planar), first pass technique; 
                                    multiple studies at rest and with stress, wall motion study plus 
                                    ejection fraction 
Cardiac PET                78491    PET Cardiac (myocardial imaging), perfusion single study at rest 
                                    or stress 
Cardiac PET                78492    PET Cardiac (myocardial imaging), perfusion multiple studies 
Nuclear Cardiac Imaging    78494    Cardiac Blood Pool imaging, gated equilibrium, SPECT 
Nuclear Cardiac Imaging    78496    Cardiac Blood Pool imaging, gated equilibrium, RV EF by first 
Unlisted Nuclear           78499    Unlisted Nuclear Cardiology diagnostic nuclear  
Non‐Cardiac PET            78608    PET Brain – metabolic evaluation 
Non‐Cardiac PET            78609    PET Brain – perfusion evaluation 
Non‐Cardiac PET            78811    PET imaging; limited area (eg, chest, head/neck) 
Non‐Cardiac PET            78812    PET imaging; skull base to mid‐thigh 
Non‐Cardiac PET            78813    PET imaging; whole body 
Non‐Cardiac PET            78814    PET imaging with concurrently acquired CT for attenuation 
                                    correction and anatomical localization; limited area (eg, chest, 
Non‐Cardiac PET            78815    PET imaging with concurrently acquired CT for attenuation 
                                    correction and anatomical localization; skull base to mid‐thigh 
Non‐Cardiac PET            78816    PET imaging with concurrently acquired CT for attenuation 
                                    correction and anatomical localization; whole body 
Ceberal Perfusion          0042T    Ceberal Perfusion Analysis using CT with contrast 

                                    Section 6 • Page 25
CAD for Breast MRI    0159T    CAD, including computer algorithm analysis, BREAST 
Magnetic Source       S8035    Magnetic Source Imaging 
MRCP                  S8037    MRCP (Magnetic ResonancE)  
MRI Low field         S8042    MRI Low field 
Cardiac CT Calcium    S8092    CT ELECTRON BEAM (Ultrafast CT) for calcium scoring  

                               Section 6 • Page 26
Appendix B – Orthotics and Prosthetics (L codes)

                                    AUTHORIZATION REQUIRED
HCPCS  Description                                                   HCPCS Description 
L0113  Cranial cervical orthosis, torticollis type,                  L5460  Postop app non‐wgt bear dsg 
       w/wo joint, w/o soft interface, prefab.  
       Incl. fitting & adj. 
L0130  Flex thermoplastic collar molded to                           L5500    Init bk ptb plaster direct 
L0170  Cervical collar molded to pt                                  L5505    Init ak ischal plstr direct 
L0220  Thor rib belt custom fabrica                                  L5510    Prep BK ptb plaster molded 
L0430  Spinal orthosis, Dewall posture                               L5520    Perp BK ptb thermopls direct 
L0452    TLSO flexible, provides trunk support,                      L5530    Prep BK ptb thermopls molded 
         upper thoracic region, customized 
L0456    TLSO, flexible thoracic region, prefab                      L5535    Prep BK ptb open end socket 

L0460   TLSO, triplanar control prefab                               L5540    Prep BK ptb laminated socket 
L0462  TLSO, triplanar control, prefab                               L5560    Prep AK ischial plast molded 
L0464  TLSO, triplanar control 4 piece rigid                         L5570    Prep AK ischial direct form 
        plastic with interface, prefab 
L0480  TLSO, triplanar control, one piece rigid                      L5580    Prep AK ischial thermo mold 
        plastic shell  
L0482  TLSO, triplanor, custom fabricated, one                       L5585    Prep AK ischial open end 
        piece rigid plastic shell, each 
L0484  TLSO, triplanor control, two piece                            L5590    Prep AK ischial laminated 
L0486    TLSO, triplanor control 2 piece rigid                       L5595    Hip disartic sach thermopls 
         plastic with interface, custom 
L0488    TLSO triplanor, one piece, prefab                           L5600    Hip disart sach laminat mold 
L0491    TLSO 2 rigid plastic shells, pre fab                        L5610    Above knee hydracadence 
L0622    Sacroiliac orthosis, flexible, custom                       L5611    Ak 4 bar link w/fric swing 
L0623    Sacroiliac orthosis, rigid or semi‐rigid,                   L5613    Ak 4 bar ling w/hydraul swig 
         pre fab 
L0624    Sacroiliac orthosis, rigid or semi‐rigid,                   L5614    4‐bar link above knee w/swng 
L0629    Lumbar‐sacral orthosis, flexible, custom                    L5616    Ak univ multiplex sys frict 
L0631    Lumbar‐sacral orthosis, sagittal control,                   L5639    Below knee wood socket 
         pre fab     
L0632    Lumbar‐sacral orthosis, sag. Control,                       L5643    Hip flex inner socket ext fr 
         rigid ant./post. Custom 
L0634    Lumbar‐sacral orthosis,  sag. Control,                      L5645    Ak flexibl inner socket ext 
         rigid post., custom 

                                              Section 6 • Page 27
L0635    Lumbar‐sacral orthosis, sag‐coronal          L5647    Below knee suction socket 
         control, prefab   
L0636    Lumbar‐sacral orthosis, sag‐coronal          L5648    Above knee air cushion socket 
         control, custom 
L0637    Lumbar‐sacral orthosis, sag‐coronal          L5649    Isch containmt/narrow m‐l so 
         control, rigid ant/post.,  prefab   
L0638    Lumbar‐sacral orth,  sag‐coronal control,    L5651    Ak flex inner socket ext fra 
         rigid ant./post., custom   
L0639    Lumbar‐sacral orthosis, sag.‐coronal         L5670    Bk molded supracondylar susp 
         control, rigid post. Prefab 
L0640    Lumbar‐sacral orthosis, sag‐coronal          L5673    below knee/above knee socket insert, 
         control, rigid post.,  custom                         silicone gel or elastomeric w/locking 
                                                               mech, custom 
L0700    Ctlso a‐p‐l control molded                   L5679    below knee/above knee socket insert, 
                                                               silicone gel or elastomeric no locking 
                                                               mech, custom 
L0710    Ctlso a‐p‐l control w/ inter                 L5681    below knee/above knee, custom fab. 
                                                               Socket inset initial only for cong. Or 
L0810    Halo cervical into jckt vest                 L5682    Bk thigh lacer glut/ischia molded 
L0820    Halo cervical into body jack                 L5683    below knee/above knee, custom fab, 
                                                               socket inset, initial only not cong.or 
L0830    Halo cerv into milwaukee typ                 L5700    Replace socket below knee 
L0999    Addition to spinal orthosis,  NOS            L5701    Replace socket above knee 
L1000    Ctlso milwauke initial model                 L5702    Replace socket hip 
L1001    Cervical TLSO, infant, prefab                L5704    Custom shape covr below knee 
L1200    Furnsh initial orthosis only                 L5705    Custom shape cover above knee 
L1300    Body jacket mold to patient                  L5706    Custom shape cvr knee disart 
L1310    Post‐operative body jacket                   L5707    Custom shape cover hip disart 
L1499    Spinal orthosis NOS                          L5716    Knee‐shin exo mech stance ph 
L1500    Thkao mobility frame                         L5718    Knee‐shin exo frct swg & sta 
L1510    Thkao standing frame                         L5722    Knee‐shin pneum swg frct exo 
L1520    Thkao swivel walker                          L5724    Knee‐shin exo fluid swing ph 
L1680    Pelvic & hip control thigh c                 L5726    Knee‐shin ext jnts fld swg e 
L1685    Post‐op hip abduct custom fa                 L5728    Knee‐shin fluid swg & stance 
L1686    HO post‐op hip abduction                     L5780    Knee‐shin pneum/hydra pneum 
L1690    Combination bilateral LS/hip/femur           L5781    Addt. to lower limb prosthesis, vacuum 
                                                               pump, residual limb volume 
                                                               management and moisture evacuation 
L1700    Legg perthes orth toronto typ                L5782    Addt. To lower leg prosth. Vacuum 
L1710    Legg perthes orth newington                  L5790    Exoskeletal ak ultra‐light m 
L1720    Legg perthes orthosis trilat                 L5795    Exoskel hip ultra‐light mate 

                                          Section 6 • Page 28
L1730    Legg perthes orth scottish r                   L5811    Endo knee‐shin mnl lck ultra 
L1755    Legg perthes patten bottom t                   L5814    Endo knee‐shin hydral swg ph 
L1832    KO adj jnt pos rigid support                   L5816    Endo knee‐shin polyc mch sta 
L1834    KO w/0 joint rigid molded to                   L5818    Endo knee‐shin frct swg & st 
L1840    KO derot ant cruciate custom                   L5822    Endo knee‐shin pneum swg frc 
L1843    KO single upright thigh & calf‐                L5824    Endo knee‐shin fluid swing p 
         prefabricated, each 
L1844    KO w/adj jt rot cntrl molded                   L5826    Miniature knee joint 
L1845    KO w/ adj flex/ext rotat cus                   L5828    Endo knee‐shin fluid swg/sta 
L1846    KO w adj flex/ext rotat mold                   L5830    Endo knee‐shin pneum/swg pha 
L1860    KO supracondylar socket mold                   L5840    Multi‐axial knee/shin system 
L1904    AFO molded ankle gauntlet                      L5845    Knee‐shin sys stance flexion 
L1907    supramalleolar w/straps w/wo                   L5848    Knee‐shin system   dampening feature 
         interface/pads, custom fabricated 
L1932    AFO, rigid anterior tibial section,pre fab,    L5856    Addt. To lower ext. prosthesis, knee 
         incl. Fitting & adj.                                    shin sys.,microprocessor, incl. Sensor , 
                                                                 any type 
L1940    AFO, plastic or other material custom          L5857    Addt. To lower ext. prosth., swing 
                                                                 phase only knee shin sys.,micro, incl. 
                                                                 Sensor , any type 
L1945    AFO molded plas rig ant tib                    L5858    Addt. To lower ext. prosth, knee shin 
                                                                 sys.,micro, incl. Sens , stance phase  
L1950    AFO spiral molded to pt plas                   L5930    High activity knee frame 
L1951    spiral, IRM type, plastic or other             L5950    Endo ak ultra‐light material 
         material prefab, incl. Fitting and adj. 
L1960    AFO pos solid ank plastic mo; custom           L5960    Endo hip ultra‐light materia 
L1970    AFO plastic molded w/ankle j                   L5964    addt. Endoskeleton above knee, 
                                                                 flexible protective outer surface 
L1980    AFO sing solid stirrup calf custom             L5966    Hip flexible cover system 
L1990    AFO doub solid stirrup calf; custom            L5968    Multiaxial ankle w dorsiflex 
L2000    KAFO using fre stirr thi/calf; custom          L5973    Endoskeletal ankle foot system, 
                                                                 microprocessor, incl. power source 
L2005    KAFO any material, single or dbl. Upright      L5976    Energy storing foot 
         includes ankle joint custom fabricated 
L2010    KAFO single upright, free ankle, solid         L5979    Multi‐axial ankle/ft prosth 
L2020    KAFO dbl solid stirrup band/                   L5980    Flex foot system 
L2030    KAFO dbl solid stirrup w/o j                   L5981    Flex‐walk sys low ext prosth 
L2034    KAFO full plastic, single upright, w/wo        L5987    Shank ft w vert load pylon 
         free motion knee,custom fabricated 
L2036    KAFO plas doub free knee mol                   L5988    Vertical shock reducing pylo 
L2037    KAFO plas sing free knee mol                   L5990    addt. To lower ext. user adj. ht 
L2038    KAFO w/o joint multi‐axis an                   L5999    Lower extremity prosthesis, NOC 
L2050    Hkafo torsion cable hip pelv; custom           L6000    Par hand robin‐aids thum rem 

                                          Section 6 • Page 29
L2060    Hkafo torsion ball bearing j; custom        L6010    Hand robin‐aids little/ring 
L2070    Hkafo torsion unilat rot str; custom        L6020    Part hand robin‐aids no fing 
L2080    Hkafo unilat torsion cable, custom          L6050    Wrst MLd sck flx hng tri pad 
L2090    Hkafo unilat torsion ball br, custom        L6055    Wrst mold sock w/exp interfa 
L2106    AFO tib fx cast plaster mold, custom        L6100    Elb mold sock flex hinge pad 
L2108    AFO tib fx cast molded to pt                L6110    Elbow mold sock suspension t 
L2116    Afo tibial fracture rigid                   L6120    Elbow mold doub splt soc ste 
L2126    Kafo fem fx cast thermoplas                 L6130    Elbow stump activated lock h 
L2128    Kafo fem fx cast molded to p                L6200    Elbow mold outsid lock hinge 
L2132    Kafo femoral fx cast soft                   L6205    Elbow molded w/ expand inter 
L2134    Kafo fem fx cast semi‐rigid                 L6250    Elbow inter loc elbow forarm 
L2136    Kafo femoral fx cast rigid                  L6300    Shlder disart int lock elbow 
L2232    Addt. To lower extremity orthosis,          L6310    Shoulder passive restor comp 
         rocker bottom, custom fabricated only 
L2280    Molded inner boot                           L6320    Shoulder passive restor cap 
L2330    Lacer molded to patient, custom             L6350    Thoracic intern lock elbow 
L2340    Pre‐tibial shell molded to p                L6360    Thoracic passive restor comp 
L2350    Prosthetic type socket molded               L6370    Thoracic passive restor cap 
L2510    Th/wght bear quad‐lat brim m                L6380    Postop dsg cast chg wrst/elb 
L2520    Th/wght bear quad‐lat brim custom           L6382    Postop dsg cast chg elb dis/ 
L2525    Th/wght bear  m‐l brim mo                   L6384    Postop dsg cast chg shlder/t 
L2526    Th/wght bear  m‐l brim cu                   L6400    Below elbow prosth tiss shap 
L2540    Thigh/wght bear lacer molded                L6450    Elb disart prosth tiss shap 
L2627    Plastic mold recipro hip & c                L6500    Above elbow prosth tiss shap 
L2628    Metal frame recipro hip & ca                L6550    Shldr disar prosth tiss shap 
L2768    Orthotic side bar, Disconnect device,       L6570    Scap thorac prosth tiss shap 
L2861    addt. to lower ext‐joint, knee or ankle,    L6580    Wrist/elbow bowden cable mol 
         custom only, each 
L2999    Lower extremity orthosis NOS                L6582    Wrist/elbow bowden cbl dir f 
L3060    Foot arch support, removable,               L6584    Elbow fair lead cable molded 
         premolded, longitudinal & horizontal, 
L3201    Oxford w supinator/pronator inf each        L6586    Elbow fair lead cable dir fo 
L3202    Oxford w supinator/pronator child each      L6588    Shdr fair lead cable molded 
L3203    Oxford w supinator/pronator jun each        L6590    Shdr fair lead cable direct 
L3204    Hightop w supp/pronator infant each         L6611    Addt. To upper ext. prosthesis, ext. pwr 
                                                              switch addt. 
L3206    Hightop w supp/pronator child each          L6623    Spring‐asst.  rot wrst w/ latch 
L3207    Hightop w supp/pronator junior each         L6624    Upper ext. addt. Flex. Ext rotation wrist 
L3208    Surgical boot, each infant                  L6638    upper ext addt. To prosth. Electric 
                                                              locking only for use with manually 
                                                              powered elbow 

                                        Section 6 • Page 30
L3209    Surgical boot, each child                   L6686    Suction socket 
L3211    Surgical boot, each junior                  L6689    Frame typ socket shoulder di 
L3212    Benesch boot pair infant                    L6690    Frame typ sock interscap‐tho 
L3213    Benesch boot pair child                     L6693    Locking elbow forearm cntrbal 
L3214    Benesch boot pair junior                    L6694    Add. To upper ext. pros.,for use with 
                                                              locking mechanism 
L3215    Orthopedic ftwear ladies oxf each           L6695    Add. To upper ext. pros., not for use 
                                                              with locking mechanism, custom 
L3216    Orthopedic ftwear ladies depth each         L6696    Add. To upper ext. pros., congenital or 
                                                              atypical traumatic amputees, initial 
L3217    Ladies shoes hightop depth each             L6697    Add. To upper ext. pros., other than 
                                                              congenital or traumatic amputees, 
                                                              initial only 
L3219    Orthopedic mens shoes oxford each           L6707    term dev hook, mech vol closing, any 
                                                              material, any size, lined or unlined 
L3221    Orthopedic mens shoes dpth each             L6708    term dev, hand, mech vol opening, any 
                                                              material, any size 
L3222    Mens shoes hightop depth inl each           L6709    term dev hand, mech vol. closing, any 
                                                              material, any size 
L3224    Woman's shoe oxford brace  each             L6712    Terminal device, hook,mechanical  vol. 
                                                              closing, any material, any size, lined or 
                                                              unlined, Pediatric, each 
L3225    Man's shoe oxford brace  each               L6713    Terminal device, hand, mechanical, vol. 
                                                              opening, any material, any size,lined or 
                                                              unlined, Pediatric, each 
L3230    Custom shoes depth inlay each               L6714    Terminal device, mechanical, vol. 
                                                              closing, any material, any size, 
                                                              Pediatric, each 
L3250    Custom mold shoe remov prost  each          L6721    terminal device, hook or hand, hvy, 
                                                              dty., mechanical, vol.opening, any 
                                                              material, any size, lined or unlined, 
L3251    Shoe molded to pt silicone s each           L6722    Terminal device, hook or hand, heavy 
                                                              duty, mechanical, vol. closing, any 
                                                              material, any size, lined or unlined, 
L3252    Shoe molded plastazote cust each            L6881    Automatic grasp, addt. To upper limb 
                                                              elect. Prosth. Terminal device 
L3253    Shoe molded plastazote cust each            L6882    Microprocessor control feature, addt. 
                                                              To upper limb prosth. Terminal device 
L3254    Orth foot non‐std size/w                    L6895    Custom glove 
L3255    Orth foot non‐std size/w                    L6900    Hand restorat thumb/1 finger 
L3257    Orth foot add charge split                  L6905    Hand restoration multiple fi 
L3330    Lift elevation, metal extension, (skate)    L6910    Hand restoration no fingers 

                                         Section 6 • Page 31
L3649    orthopedic shoe modification NOS               L6915    Hand restoration replacmnt g 
L3671    Shoulder othosis, cap design w/o joints        L6920    Wrist disarticul switch ctrl 
L3702    elbow orthosis w/o joints, may include         L6925    Wrist disart myoelectronic c 
         soft interface, straps, custom fabricated 
         incl. fitting & adj. 
L3720    Forearm/arm cuffs free motio                   L6930    Below elbow switch control 
L3730    Forearm/arm cuffs ext/flex a                   L6935    Below elbow myoelectronic ct 
L3740    Cuffs adj lock w/ active con                   L6940    Elbow disarticulation switch 
L3763    elbow wrist hand orthosis rigid w/o            L6945    Elbow disart myoelectronic c 
         joints custom fab incl. fitting & adj. 
L3806    WHFO, incl. 1 or more nontorsion joints.       L6950    Above elbow switch control 
L3808    WHFO, rigid w/o joints, custom,                L6955    Above elbow myoelectronic ct 
L3891    Addt. to upper ext. joint, wrist, or           L6960    Shldr disartic switch contro 
         elbow, custom fabricated only, each 
L3900    Hinge extension/flex wrist/f                   L6965    Shldr disartic myoelectronic 
L3901    Hinge ext/flex wrist finger                    L6970    Interscapular‐thor switch ct 
L3904    Whfo electric custom fitted                    L6975    Interscap‐thor myoelectronic 
L3905    wrist/hand orthosis custom                     L7007    elect. Hand, myoelectric or switch, 
L3906    Wrist hand orthosis, w/o joints, custom        L7008    elect. Hand, myoelectric or switch, ped 
L3907    Whfo wrist gauntlt thmb spica                  L7009    elect hook, switch or myoelect, adult 
L3913    Hand finger orthosis, w/o joints, may          L7040    Prehensile actuator  switch controlled 
         include soft interface, straps, custom 
         fabricated, incl fitting & adjustment, 
L3927    Finger orthosis, PIP/DIP, non‐torsion          L7045    Electric hook, switch or myoelectric 
         w/o joint/spring, ext./flex., pre‐fab, incl             controlled, pediatric 
         fitting & adj., each 
L3933    Finger orthosis, w/o joints, may include       L7170    Electronic elbow hosmer swit 
         soft interface, custom fabricated, incl. 
         fitting & adjustment, each 
L3956    addt. Of joint to upper ext orth. any          L7180    Electronic elbow utah myoele 
         material, per joint 
L3960    Sewho airplan desig abdu pos                   L7181    electronic elbow, sim. Control of elbow 
                                                                 and terminal device 
L3962    Sewho erbs palsey design abd                   L7185    electronic elbow, sim. Variety Village or 
                                                                 equal switch control 
L3964    Seo mobile arm sup att to wc                   L7186    Electron elbow child switch 
L3965    Arm supp att to wc rancho ty                   L7190    Elbow adolescent myoelectron 
L3966    Mobile arm supports reclinin                   L7191    Elbow child myoelectronic ct 
L3968    Friction dampening arm supp                    L7260    Electron wrist rotator otto 
L3969    Monosuspension arm/hand supp                   L7261    Electron wrist rotator utah 
L3971    SEHWO, shoulder cap design, custom             L7266    Servo control steeper or equ 

                                          Section 6 • Page 32
L3999    Upper limb orthosis, not otherwise           L7272    Analogue control unb or equa 
L4000    Repl girdle milwaukee orth                   L7274    Proportional ctl 12 volt uta 
L4002    Replacement strap, any orthosis,             L7499    Upper extremity prosthesis NOS 
         includes all components, any lgth., any 
L4010    Replace trilateral socket brim               L7500    Prosthetic dvc repair hourly 
L4020    Replace quadlat socket brim                  L7510    Repair of prosthetic device, minor parts 
L4030    Replace socket brim cust fit                 L7520    Repair prosthetic device, labor 
                                                               component, per 15 min 
L4040    Replace molded thigh lacer                   L7600    Prosthetic donning sleeve, any material 
L4050    Replace molded calf lacer                    L7900    Vacuum erection system 
L4205    Repair orthotic device per 15 min labor      L8000    Mastectomy bra ‐ 5 per year  
L4210    repair or replace minor parts                L8001    Breast prosthesis , masectomy bra with 
                                                               integrated breast prothesis form, 
                                                               unilateral ‐ 5 per year  
L5000    Sho insert w arch toe filler                 L8002    Breast prosthesis, masectomy bra with 
                                                               integrated breast prothesis form, 
                                                               bilateral ‐ 5 per year  
L5010    Mold socket ank hgt w/ toe f                 L8020    Mastectomy form ‐ 2 per year  
L5020    Tibial tubercle hgt w/ toe f                 L8030    Breast prosthesis silicone/e ‐ 2 per year 
L5050    Ank symes mold sckt sach ft                  L8031    Breast prosthesis, silicone or equal, 
                                                               with intergral adhesive, each 
L5060    Symes met fr leath socket ar                 L8035    Custom breast prosthesis 
L5100    Molded socket shin sach foot                 L8039    Breast prosthesis, NOS 
L5105    Plast socket jts/thgh lacer                  L8040    Nasal prothesis, provided by a non‐
L5150    Mold sckt ext knee shin sach                 L8041    Midfacial prothesis, provided by a non‐
L5160    Mold socket bent knee shin s                 L8042    Orbital prothesis, provided by a non‐
L5200    Knee sing axis fric shin sach                L8043    Upper facial prosthesis, provided by a 
L5210    No knee/ankle joints w/ ft b                 L8044    Hemi‐facial prosthesis, provided by a 
L5220    No knee joint with artic ali                 L8045    Prosthetic External Ear provided by a 
L5230    Fem focal defic constant fri                 L8046    Partial facial prosthesis, provided by a 
L5250    Hip canadian  sing axi cons fric             L8047    Nasal septal prosthesis, provided by a 
L5270    Tilt table locking hip sing                  L8048    Unspecified Maxillofacial Prosthesis, by 
                                                               a non‐physician 
L5280    Hemipelvect canadian sing axis               L8049    Repair or modification of maxillofacial 
                                                               prosthesis, by a non‐physician 

                                          Section 6 • Page 33
L5301    Below Knee molded socket, shin each               L8499    Unlisted Misc prosthetic service 
         foot, endosketal system 
L5311    Knee disarticulation , molded socket,             L8500    artifical  larynx 
         external knee joints, shin,sach foot endo 
L5321    Above Knee, molded socket, open end,              L8501    Tracheostomy speaking valve  
         sach foot, endoskelttal system, single 
         axis knee 
L5331    Hip disarticulation, Canadian type,               L8505    Artificial larynx replacement 
         molded socket endoskeletal system, hip                     battery/accessory, any type, each 
         joint, single 
L5341    Hemipelvectomy, Canadian type,                    L8619    cochlear implant external speech 
         molded socket, endoskeletal hip joint                      processor replacement 
         single axis knee  
L5400    Postop dress & 1 cast chg bk                      L8627    Cochlear implant, external speech 
                                                                    processor, component, replacement 
L5410    Postop dsg bk ea add cast ch                      L8628    Cochlear implant, external controller 
                                                                    component, replacement 
L5420    Postop dsg & 1 cast chg ak/d                      L8629    Transmitting coil  and cable, integrated 
                                                                    for use with cochlear implant device, 
L5430    Postop dsg ak ea add cast ch                      L8691    auditory osseointegrated dev, ext. 
                                                                    sound replacer, repl only 
L5450    Postop app non‐wgt bear dsg                                  

                            AUTHORIZATION NOT REQUIRED
HCPCS    Description                                       HCPCS    Description 
L0120    Cerv flexible non‐adjustable                      L3670    Acromio/clavicular canvas&we 
L0140    Cervical semi‐rigid adjustab                      L3675    Canvas vest SO 
L0150    Cerv semi‐rig adj molded chn                      L3710    Elbow elastic with metal joi 
L0160    Cerv semi‐rig wire occ/mand                       L3760    Elbow orthosis, adj position locking 
                                                                    joints, prefab, inc fitting and adj 
L0172    Cerv col thermplas foam 2 piece                   L3762    Elbow orthosis rigid, w/o joints, prefab, 
                                                                    soft interface, incl. Fitting/adj. 
L0174    Cerv col foam 2 piece w thor                      L3807    WHFO w/o joints, prefab includes 
                                                                    fitting and adjustments any type 
L0180    Cer post col occ/man sup adj                      L3908    Wrist cock‐up non‐molded 
L0190    Cerv collar supp adj cerv ba ‐ 1 Per Year         L3912    Flex glove w/elastic finger 
L0200    Cerv col supp adj bar & thor ‐ 1 per              L3915    WHFO, rigid with 1 or more joints, 

                                         Section 6 • Page 34
         year *                                                       prefab, 
L0450    TLSO flexible, provides trunk support,              L3917    hand orthosis, metacarpal fracture 
         uper thoracic region, prefab                                 orthosis, prefab, incl fitting and adj. 
L0454    TLSO, Flexible, provides trunk support,             L3923    Hand finger orthosis, without joint, 
         sacrococcygeal juntion to T‐9, prefab                        prefab, inc fitting and adj 
L0466    TLSO Sagittal control, prefab                       L3925    Finger orthosis, PIP/DIP, non‐torsion 
                                                                      joint/spring, ext./flex., pre‐fab, incl 
                                                                      fitting & adj., each 
L0468    TLSO sagittal‐coronol control, rigid                L3929    Hand finger orthosis, incl. 1 or more 
         posterior frame ‐ 1 per year *                               nontorsion joints, turnbuckles, elastic  
                                                                      bands/spring, straps, pre‐fab, incl. 
                                                                      fitting & adj., each 
L0470    TLSO  triplanar control ‐ 1 per year *              L3931    Wrist, hand, finger orthosis, incl. 1 or 
                                                                      more nontorsion joints,turnbuckles, 
                                                                      elastic bands/springs, straps, pre‐fab, 
                                                                      incl. fitting & adj., each 
L0472    TLSO, triplanar control, hyperextension             L3970    Elevat proximal arm support 
         prefab ‐ 1 per year * 
L0490    TLSO sagittal coronal control one piece             L3972    Offset/lat rocker arm w/ ela 
L0492    TLSO 3 rigid plastic shells, pre fab ‐ 1            L3974    Mobile arm support supinator 
         per year *                               
L0621    Sacroiliac orthosis, flexible, pre fab              L3980    Upp ext fx orthosis humeral 
L0625    Lumbar orthosis, flexible, pre fab                  L3982    Upper ext fx orthosis rad/ul 
L0626    Lumbar orthosis, sagittal control, pre              L3984    Upper ext fx orthosis wrist 
L0627    Lumbar orthosis,  sagittal control with             L3995    Add. To upper ext. sock, fracture, or 
         rigid ant./post. Panels, pre fab                             equal, each 
L0628    Lumbar‐sacral orthosis, flexible, pre fab           L4045    Replace non‐molded thigh lac 
L0630    Lumbar‐sacral orthosis, sag. Control,               L4055    Replace non‐molded calf lace 
         pre fab        
L0633    Lumbar‐sacral orthosis,  sag. Control,              L4060    Replace high roll cuff 
         rigid post., pre fab    
L0970    Tlso corset front                                   L4070    Replace prox & dist upright 
L0972    Lso corset front                                    L4080    Repl met band kafo‐afo prox 
L0974    Tlso full corset                                    L4090    Repl met band kafo‐afo calf/ 
L0976    Lso full corset                                     L4100    Repl leath cuff kafo prox th 
L0978    Axillary crutch extension                           L4110    Repl leath cuff kafo‐afo cal 
L0980    Peroneal straps pair                                L4130    Replace pretibial shell 
L0982    Stocking supp grips set of 4                        L4350    Pneumatic ankle cntrl splint 
L0984    Protective body sock each                           L4360    Pneumatic walking splint 
L1010    Ctlso axilla sling                                  L4370    Pneumatic full leg splint 
L1020    Kyphosis pad                                        L4380    Pneumatic knee splint 
L1025    Kyphosis pad floating                               L4386    Non‐pneumatic walking boot 
L1030    Lumbar bolster pad                                  L4394    Replacement Foot Drop Splint 

                                            Section 6 • Page 35
L1040    Lumbar or lumbar rib pad                   L4396    Static AFO 
L1050    Sternal pad                                L4398    Foot drop splint recumbent 
L1060    Thoracic pad                               L5617    AK/BK self‐aligning unit ea 
L1070    Trapezius sling                            L5618    Test socket symes 
L1080    Outrigger                                  L5620    Test socket below knee 
L1085    Outrigger bil w/ vert extens               L5622    Test socket knee disarticula 
L1090    Lumbar sling                               L5624    Test socket above knee 
L1100    Ring flange plastic/leather                L5626    Test socket hip disarticulat 
L1110    Ring flange plas/leather molded to         L5628    Test socket hemipelvectomy 
L1120    Covers for upright each                    L5629    Below knee acrylic socket 
L1210    Lateral thoracic extension                 L5630    Syme typ expandabl wall sckt 
L1220    Anterior thoracic extension                L5631    Ak/knee disartic acrylic soc 
L1230    Milwaukee type superstructur               L5632    Symes type ptb brim design s 
L1240    Lumbar derotation pad                      L5634    Symes type poster opening so 
L1250    Anterior asis pad                          L5636    Symes type medial opening so 
L1260    Anterior thoracic derotation pad           L5637    Below knee total contact 
L1270    Abdominal pad                              L5638    Below knee leather socket 
L1280    Rib gusset (elastic) each                  L5640    Knee disarticulat leather so 
L1290    Lateral trochanteric pad                   L5642    Above knee leather socket 
L1600    Abduct hip flex frejka w cvr               L5644    Above knee wood socket 
L1610    Abduct hip flex frejka covr                L5646    Below knee air cushion socket 
L1620    Abduct hip flex pavlik harne               L5650    Tot contact ak/knee disart s 
L1630    Abduct control hip semi‐flex               L5652    Suction susp ak/knee disart 
L1640    Pelv band/spread bar thigh c               L5653    Knee disart expand wall sock 
L1650    HO abduction hip adjustable                L5654    Socket insert symes 
L1660    HO abduction static plastic                L5655    Socket insert below knee 
L1810    KO elastic with joints                     L5656    Socket insert knee articulat 
L1820    KO elas w/ condyle pads & jo               L5658    Socket insert above knee 
L1830    KO  immobilizer canvas longit              L5661    Multi‐durometer symes 
L1831    KO locking knee joint pre fab incl.        L5665    Multi‐durometer below knee 
         Fitting and adj. 
L1847    KO adjustable w air chambers               L5666    Below knee cuff suspension 
L1850    KO swedish type                            L5668    Socket insert w/o lock lower 
L1900    AFO sprng wir drsflx calf bd               L5671    Addition to lower extremity, below 
                                                             knee/above knee suspension locking 
L1902    AFO ankle gauntlet                         L5672    Bk removable medial brim sus 
L1906    AFO multiligamentus ankle su               L5676    Bk knee joints single axis pair 
L1910    AFO sing bar clasp attach sh               L5677    Bk knee joints polycentric pair 
L1920    AFO sing upright w/ adjust s               L5678    Bk joint covers pair 
L1930    AFO plastic or other material, includes    L5680    Bk thigh lacer non‐molded 

                                       Section 6 • Page 36
         fitting & adjustment 
L1971    plastic or other material w/ankle joint,    L5684     Bk fork strap 
         prefab, incl. Fitting and adj. 
L2035    KAFO plastic pediatric size                 L5685     Addt. To lower ext. orthosis, below 
                                                               knee, susp./sealing sleeve, any mat. 
L2040    Hkafo torsion bil rot straps                L5686     below knee back check extension 
L2112    AFO tibial fracture soft, pre‐fab           L5688     Bk waist belt webbing 
L2114    AFO tib fx semi‐rigid, pre‐fab              L5690     Bk waist belt padded and lin 
L2180    Plas shoe insert w ank joint                L5692     Ak pelvic control belt light 
L2182    Drop lock knee                              L5694     Ak pelvic control belt pad/l 
L2184    Limited motion knee joint                   L5695     Ak sleeve susp neoprene/equa 
L2186    Adj motion knee jnt lerman t                L5696     Ak/knee disartic pelvic join 
L2188    Quadrilateral brim                          L5697     Ak/knee disartic pelvic band 
L2190    Waist belt                                  L5698     Ak/knee disartic silesian ba 
L2192    Pelvic band & belt thigh fla                L5699     Shoulder harness 
L2200    Limited ankle motion ea jnt                 L5710     Kne‐shin exo sng axi mnl loc 
L2210    Dorsiflexion assist each joi                L5711     Knee‐shin exo mnl lock ultra 
L2220    Dorsi & plantar flex ass/res                L5712     Knee‐shin exo frict swg & st 
L2230    Split flat caliper stirr & p                L5714     Knee‐shin exo variable frict 
L2240    Addt. To lower extremity orthosis,          L5785     Exoskeletal bk ultralt mater 
         round caliper & plate attachment 
L2250    Foot plate molded stirrup at                L5810     Endoskel knee‐shin mnl lock 
L2260    Reinforced solid stirrup                    L5812     Endo knee‐shin frct swg & st 
L2265    Long tongue stirrup                         L5850     Endo ak/hip knee extens assi 
L2270    Varus/valgus strap padded/li                L5855     Mech hip extension assist 
L2275    Plastic mod low ext pad/line                L5910     Addt. Endoskeleton, below knee, 
                                                               alignable system 
L2300    Abduction bar jointed adjust                L5920     Endo ak/hip alignable system 
L2310    Abduction bar‐straight                      L5925     Above knee manual lock 
L2320    Non‐molded lacer                            L5940     Endo bk ultra‐light material 
L2335    Anterior swing band                         L5962     Below knee flex cover system 
L2360    Extended steel shank                        L5970     Foot external keel sach foot 
L2370    Patten bottom                               L5971     All lower extremity prosthesis, SACH 
                                                               foot, replacement only 
L2375    Torsion ank & half solid sti                L5972     Flexible keel foot 
L2380    Torsion straight knee joint;                L5974     Foot single axis ankle/foot 
L2385    Straight knee joint heavy du                L5975     Combo ankle/foot prosthesis 
L2387    Addt. to lower extremity, polycentric       L5978     Ft prosth multiaxial ankl/ft 
         knee joint, for custom fabricated KAFO, 
         each joint 
L2390    Offset knee joint each                      L5982     Exoskeletal axial rotation   

                                         Section 6 • Page 37
L2395    Offset knee joint heavy duty                L5984     Endoskeletal axial rotation, w/wo 
L2397    Suspension sleeve lower ext                 L5985     Lwr ext dynamic prosth pylon 
L2405    Knee joint drop lock ea jnt                 L5986     Multi‐axial rotation unit 
L2415    Knee joint cam lock each joi                L6386     Postop ea cast chg & realign 
L2425    Knee disc/dial lock/adj flex                L6388     Postop applicat rigid dsg on 
L2430    Knee jnt ratchet lock ea jnt                L6600     Polycentric hinge pair 
L2492    Knee lift loop drop lock rin                L6605     Single pivot hinge pair 
L2500    Thi/glut/ischia wgt bearing                 L6610     Flexible metal hinge pair 
L2530    Thigh/wght bear lacer non‐mo                L6615     Disconnect locking wrist uni 
L2550    Thigh/wght bear high roll cu                L6616     Disconnect insert locking wr 
L2570    Hip clevis type 2 posit jnt                 L6620     Flexion‐friction wrist unit 
L2580    Pelvic control pelvic sling                 L6625     Rotation wrst w/ cable lock 
L2600    Hip clevis/thrust bearing fr                L6628     Quick disconn hook adapter o 
L2610    Hip clevis/thrust bearing lo                L6629     Lamination collar w/ couplin 
L2620    Pelvic control hip heavy dut                L6630     Stainless steel any wrist 
L2622    Hip joint adjustable flexion                L6632     Latex suspension sleeve each 
L2624    Hip adj flex ext abduct cont                L6635     Lift assist for elbow 
L2630    Pelvic control band & belt u                L6637     Nudge control elbow lock 
L2640    Pelvic control band & belt b                L6640     Shoulder abduction joint pai 
L2650    Pelv & thor control gluteal                 L6641     Excursion amplifier pulley t 
L2660    Thoracic control thoracic ba                L6642     Excursion amplifier lever ty 
L2670    Thorac cont paraspinal uprig                L6645     Shoulder flexion‐abduction joint, each 
L2680    Thorac cont lat support upri                L6650     Shoulder universal joint, each 
L2750    Plating chrome/nickel pr bar                L6655     Standard control cable extra 
L2755    Addt. Lower ext.,high strength, custom      L6660     Heavy duty control cable 
         fab. Only 
L2760    Extension per extension per                 L6665     Teflon or equal cable lining 
L2780    Non‐corrosive finish per bar                L6670     Hook to hand cable adapter 
L2785    Drop lock retainer each                     L6672     Harness chest/shlder saddle 
L2795    Knee control full kneecap                   L6675     Harness figure of 8 sing con 
L2800    Knee cap medial or lateral p                L6676     Harness figure of 8 dual con 
L2810    Knee control condylar pad                   L6680     Test sock wrist disart/bel e 
L2820    Soft interface below knee se                L6682     Test sock elbw disart/above 
L2830    Soft interface above knee se                L6684     Test socket shldr disart/tho 
L2840    Tibial length sock fx or equ                L6687     Frame typ socket bel ow elbow or wrist 
L2850    Femoral lgth sock fx or equa                L6688     Frame typ sock above elbow or elbow 
L3000    foot insert Berkeley shell, each            L6691     Removable insert each 
L3001    foot insert Spenco,  each                   L6692     Silicone gel insert or equal 
L3002    foot insert, Plastazote , each              L6698     Add. To upper ext. pros., lock 
                                                               mechanism, excludes socket insert 

                                         Section 6 • Page 38
L3003    foot insert, Silicone gel , each              L6703    term. Device, passive hand mitt, any 
                                                                material, any size 
L3010    Longitudinal Arch support each                L6704    term. Device, sport/rec/work, any 
                                                                material, any size 
L3020    Foot longitud/metatarsal supp                 L6706    term dev hook, mech vol opening, any 
                                                                material, any size 
L3030    Foot arch support remov prem                  L6711    Terminal device, hook, mechanical, vol. 
                                                                opening, any material, any size, lined 
                                                                or unlined, Pediatric, each 
L3040    Foot arch support remov premolded             L6805    Modifier wrist flexion unit   addt to 
         longitudinal, each                                     terminal device 
L3100    Hallus‐valgus night dynamic splint            L6810    Addt to terminal device, precision 
                                                                pinch device 
L3140    Abduction rotation bar shoe                   L6890    Production glove 
L3150    Abduction rotation bar w/o shoe               L7360    Six volt battery, each  
L3160    Shoe styled postioning device                 L7362    Battery charger, six volt, each 
L3170    Foot plastic heel stablizer                   L7364    Twelve volt battery , each ‐ 2 per year 
L3260    Ambulatory surgical boot each                 L7366    Battery charger 12 volt each ‐ 1 per 4 
                                                                years * 
L3265    Plastazole sandal each                        L7367    lithium ion battery replacement 
L3300    Lift, Elevation Heel, Tapered to Metata       L7368    Lithium battery charger ‐ 1 per 4 years 
L3310    Shoe lift elev heel/sole neo                  L7400    Addt. To upper ext. prosth. Ultralight 
L3320    shoe lift elev heel/sole cor                  L7401    Addt. To upper ext. prosthesis above 
                                                                elbow disart. Ultralight material 
L3332    Shoe lift inside tapered up to 1/2 inch       L7403    Addt. To upper ext. prosth. acrylic 
L3334    Shoe, lift elevation, heel, per inch, each    L7404    addt. To upper ext prosth. Above 
                                                                elbow disart. Acrylic 
L3340    shoe wedge sach                               L8010    Mastectomy sleeve 
L3350    shoe sole wedge                               L8015    Ext breast prosthesis garment 
L3360    shoe sole wedge outside sole                  L8300    Truss single w/ standard pad 
L3370    shoe sole wedge between sole                  L8310    Truss double w/ standard pad 
L3380    shoe clubfoot wedge                           L8320    Truss addition to std pad wa 
L3390    shoe outflare wedge                           L8330    Truss add to std pad scrotal 
L3400    shoe metarsal bar wedge                       L8400    Sheath below knee 
L3410    shoe metarsal bar between                     L8410    Sheath above knee 
L3420    full sole/heel wedge btween                   L8415    Sheath upper limb 
L3430    shoe heel count plast reinforc                L8417    Prosthetic sheath/sock, incl. gel 
                                                                cushion layer, below knee or above 
                                                                knee, each 
L3440    heel leather reinforced                       L8420    Prosthetic sock multi ply BK 
L3450    shoe heel sach cushion type                   L8430    Prosthetic sock multi ply AK 

                                          Section 6 • Page 39
L3455    shoe heel new leather standard              L8435     Pros sock multi ply upper lm 
L3460    shoe heel new rubber standard               L8440     Shrinker below knee 
L3465    shoe heel thomas with wedge                 L8460     Shrinker above knee 
L3470    shoe heel thomas extend to B                L8465     Shrinker upper limb 
L3480    shoe heel pad &depress for                  L8470     Pros sock single ply BK 
L3485    shoe heel pad removeable for                L8480     Pros sock single ply AK 
L3500    ortho shoe add leather insol                L8485     Pros sock single ply upper l 
L3510    orthopedic shoe add rub insl                L8507     Tracheo‐esophageal voice prosthesis, 
                                                               patient inserted, any type  
L3520    ortho shoe add felt w leather insol         L8509     Tracheo‐esophageal voice prosthesis, 
                                                               inst. by lic. Health care provider, any 
L3530    ortho shoe add half sole                    L8510     Voice Amplifier  
L3540    ortho shoe add full sole                    L8511     Insert for Indwelling T/E prosthesis 
                                                               with or W/O valve replacement each  
L3550    ortho shoe add standard toe tap             L8512     Gelatin capsules or equ.  use with T/E 
                                                               prosthesis replacement only per 10  
L3560    ortho shoe add horseshoe toe tap            L8513     Cleaning device used with T/E 
                                                               prosthesis replacement only each  
L3570    ortho  shoe add instep extension            L8514     T/E puncture dilator replacement only 
L3580    ortho shoe add instep velcro clos           L8515     gelatin capsule application device for 
                                                               use with TE voice prosthesis, each 
L3590    ortho shoe convert firm to soft count       L8615     Headset/Headpiece for use with 
                                                               cochlear implant device, replacement 
L3595    ortho shoe add march bar                    L8616     microphone for use with cochlear 
                                                               implant device, replacement 
L3600    Trans shoe calip plate exist                L8617     transmitting coil for use with cochlear 
                                                               implant device, replacement 
L3610    Trans shoe caliper plate new                L8618     transmitter cable for use with cochlear 
                                                               implant device, replacement 
L3620    Trans shoe solid stirrup existing           L8621     Zinc air battery for use with cochlear 
                                                               implant device, each 
L3630    Trans shoe solid stirrup new                L8622     Alkaline batt. For use with coch. Imp. 
                                                               Device, any size,each 
L3640    Shoe Dennis Browne splint both              L8623     Lithium ion battery   coch.  imp. Device 
                                                               speech proc.other than Ear level,  ea 
L3650    Shlder fig 8 abduct restrain                L8624     Lithium ion battery  for coch.  imp. 
                                                               Device speech proc. Ear level,  each 
L3660    Abduct restrainer canvas&web                L8695     ext recharging sys for battery(ext) for 
                                                               use with implantable neurostimulator 

                                         Section 6 • Page 40
Appendix C – Ostomy Supplies
Any request that exceeded $500.00 will require prior authorization.

                               AUTHORIZATION REQUIRED
A4421     Ostomy supply, miscellaneous                                        Authorization is required  
A4465     Non elastic binder for extremity                                    Authorization is required  
A4466     Garment, belt, sleeve or other covering, elastic or similar         Authorization is required  
          stretchable material, any type, each 
A4483     Moisture exchanger, disposable, for use with invasive mechanical    Authorization is required  
          ventilation, each 
A4600     sleeve for intmt. Limb compression device, replac. only             Authorization is required  
A4601     Lithium ion battery for non‐prosthetic use, repl. Only              Authorization is required  
A4649     Surgical Supply, Miscellaneous                                      Authorization is required  
A4366     Ostomy vent, any type, each                                         Authorization required > 
                                                                              1 per calendar month 
A4367     Ostomy belt                                                         Authorization required > 
                                                                              1 per calendar month 
A4400     Ostomy irrigation set                                               Authorization required > 
                                                                              1 per calendar month 
A4404     Ostomy ring each                                                    Authorization required > 
                                                                              10 per calendar month 
A4362     Solid skin barrier                                                  Authorization required > 
                                                                              20 per calander month  
A4398     Ostomy irrigation bag                                               Authorization required > 
                                                                              4  per year 
A4399     Ostomy irrig cone/cath w brs                                        Authorizationrequired > 4  
                                                                              per year 
A4402     Lubricant   price is per oz. 1 oz.=1 unit                           Authorization required > 
                                                                              4 oz per calendar month 
A4397     Irrigation supply sleeve                                            Authorization required > 
                                                                              4 per calendar month 
A4361     Ostomy face plate                                                   Authorization required > 
                                                                              6 per year  
A4416     Ostomy pouch, closed, w/barrier att. W/filter 1 pc. Each            Authorization required > 
                                                                              60 per calendar month 
A4417     Ostomy pouch,closed, w/barrier att.,w/built‐in convexity, w/filter  Authorization required > 
          1 pc, each                                                          60 per calendar month 
A4418     Ostomy pouch,closed, w/o barrier att. W/filter 1 pc. Each           Authorization required > 
                                                                              60 per calendar month 
A4419     Ostomy pouch, closed, use on barrier w/non‐lock flange,w/filter     Authorization required > 
          2pc, each                                                           60 per calendar month 
A4420     Ostomy pouch, closed, use on barrier with lock flange 2 pc, each  Authorization required > 
                                                                              60 per calendar month 

                                         Section 6 • Page 41
A4423    Ostomy pouch closed, 2 pc. Locking flange, each                   Authorization required > 
                                                                           60 per calendar month 
A4424    Ostomy pouch, drainable,w/barrier 1 pc, each                      Authorization required > 
                                                                           60 per calendar month 
A4425    Ostomy pouch drainable, non‐locking flange 2 pc each              Authorization required > 
                                                                           60 per calendar month 
A4426    Ostomy pouch, drainable, with locking flange, 2 pc. Each          Authorization required > 
                                                                           60 per calendar month 
A4427    Ostomy pouch, drainable , use on barrier w/locking flange,        Authorization required > 
         w/filter 2 pc, each                                               60 per calendar month 
A4428    Electrodes, apnea monitor, per pair                               Authorization required > 
                                                                           60 per calendar month 
A4429    Ostomy pouch, urinary w/convexity, faucet type tap, each          Authorization required > 
                                                                           60 per calendar month 
A4430    ostomy pouch urinary, ext. wear, convexity, faucet tap, each      Authorization required > 
                                                                           60 per calendar month 
A4431    ostomy pouch, urinary, w/barrier, faucet type tap, w/valve ea.    Authorization required > 
                                                                           60 per calendar month 
A4432    ostomy pouch, urinary, non‐locking flange, faucet type, ea.       Authorization required > 
                                                                           60 per calendar month 
A4433    ostomy pouch, urinary, w/locking flange, ea.                      Authorization required > 
                                                                           60 per calendar month 
A4434    ostomy pouch, urinary, w/locking flange, w/faucet type tap ea.    Authorizationrequired > 
                                                                           60 per calendar month 
A4624    Tracheal suction tube                                             Authorization required > 
                                                                           91 per calendar month 
A4625    Trach care kit for new trach                                      Authorization required if 
                                                                           > 1 per calendar month 
A5082    Continent stoma catheter                                          Authorization required if 
                                                                           > 1 per calendar month 
A5093    Ostomy accessory convex inse                                      Authorization required if 
                                                                           > 10 per calendar month 
A4626    Tracheostomy cleaning brush                                       Authorization required if 
                                                                           > 2 per calendar month 
A5061    Pouch drainable w barrier at                                      Authorization required if 
                                                                           > 20 per calendar month 
A5062    Drnble ostomy pouch w/o barr                                      Authorization required if 
                                                                           > 20 per calendar month 
A5063    Drain ostomy pouch w/flange                                       Authorization required if 
                                                                           > 20 per calendar month 
A5071    Urinary pouch w/barrier                                           Authorization required if 
                                                                           > 20 per calendar month 
A5072    Urinary pouch w/o barrier                                         Authorization required if 
                                                                           > 20 per calendar month 
A5073    Urinary pouch on barr w/flng                                      Authorizationrequired if > 
                                                                           20 per calendar month 

                                         Section 6 • Page 42
A4623    Tracheostomy inner cannula                                    Authorization required if 
                                                                       > 31 per calendar month 
A5055    Stoma cap                                                     Authorization required if 
                                                                       > 31 per calendar month 
A5081    Continent stoma plug                                          Authorization required if 
                                                                       > 31 per calendar month 
A4455    Adhesive remover per ounce                                    Authorization required if 
                                                                       > 32 ounces  
A5051    Pouch clsd w barr attached                                    Authorization required if 
                                                                       > 60 per calendar month 
A5052    Clsd ostomy pouch w/o barr                                    Authorization required if 
                                                                       > 60 per calendar month 
A5053    Clsd ostomy pouch faceplate                                   Authorization required if 
                                                                       > 60 per calendar month 
A5054    Clsd ostomy pouch w/flange                                    Authorization required if 
                                                                       > 60 per calendar month 
                          AUTHORIZATION NOT REQUIRED
A4392    Urinary pouch w st wear barr                                  No authorization required  
A4363    Ostomy clamp, any type , each                                 No authorization required  
A4364    Adhesive, liquid or equal, any type, per ounce                No authorization required  
A4365    Ostomy adhesive remover wipe                                  No authorization required  
A4368    Ostomy filter                                                 No authorization required  
A4369    Skin barrier liquid per oz                                    No authorization required  
A4371    Skin barrier powder per oz                                    No authorization required  
A4372    Ostomy Skin barrier solid 4x4 equiv                           No authorization required  
A4373    Skin barrier with flange                                      No authorization required  
A4375    Drainable plastic pch w fcpl                                  No authorization required  
A4376    Drainable rubber pch w fcplt                                  No authorization required  
A4377    Drainable plstic pch w/o fp                                   No authorization required  
A4378    Drainable rubber pch w/o fp                                   No authorization required  
A4379    Urinary plastic pouch w fcpl                                  No authorization required  
A4380    Urinary plastic pouch w/o fp                                  No authorization required  
A4381    Ostomy pouch, urinary, for use on faceplate, plastic, each    No authorization required  
A4382    Urinary hvy plstc pch w/o fp                                  No authorization required  
A4383    Urinary rubber pouch w/o fp                                   No authorization required  
A4384    Ostomy faceplt/silicone ring                                  No authorization required  
A4385    Ost skn barrier sld ext wear                                  No authorization required  
A4387    Ost clsd pouch w att st barr                                  No authorization required  
A4388    Drainable pch w ex wear barr                                  No authorization required  
A4389    Drainable pch w st wear barr                                  No authorization required  
A4390    Drainable pch ex wear convex                                  No authorization required  
A4391    Urinary pouch w ex wear barr                                  No authorization required  
A4393    Urine pch w ex wear bar conv                                  No authorization required  
A4394    Ostomy pouch liq deodorant w/wo lubricant                     No authorization required  
A4395    Ostomy pouch solid deodorant                                  No authorization required  
A4396    Ostomy belt with peristomal hernia support                    No authorization required  

                                        Section 6 • Page 43
A4405    Ostomy skin barrier, non‐pectin based, paste, per oz                    No authorization required  
A4406    Ostomy skin barrier, pectin based, per oz                               No authorization required  
A4407    Ostomy skin barrier, with fl, extend wear, built in convexity, 4x4      No authorization required  
         or < 
A4408    Ostomy skin barrier, with fl, extend wear, built in convexity, 4x4      No authorization required  
         or > 
A4409    Ostomy skin barrier with flange                                         No authorization required  
A4410    Ostomy skin barrier, with fl, ex wear, without built in convexity,      No authorization required  
         >4x4 ea 
A4411    Ostomy skin barrier, solid 4x4 or eq. ext. wear, built in convexity,    No authorization required  
A4412    Ostomy pouch, drainable, high otpt, use on barrier w/ o   filter        No authorization required  
A4413    Ostomy pouch, drainable, high otpt, use on barrier w/ fl with           No authorization required  
         filter ea 
A4414    Ostomy skin barrier, with fl, w/o built in convexity 4x4 or <           No authorization required  
A4415    Ostomy skin barrier, with fl, w/o built in convexity 4x4 or >           No authorization required  
A4450    Tape, non‐water proof, 18 sq inches                                     No authorization required  
A4452    Tape, water proof , 18 sq inches                                        No authorization required  
A4456    Adhesive remover, wipes, any type, each                                 No authorization required  
A4481    Tracheostoma filter                                                     No authorization required  
A4556    Electrodes, apnea monitor, per pair                                     No authorization required  
A4557    Lead wires, apnea monitor per pair                                      No authorization required  
A4558    Conductive paste or gel for use with electrical device E.G. tens        No authorization required  
A4561    Pessary, rubber, any type                                               No authorization required  
A4562    Pessary, nonrubber, any type                                            No authorization required  
A4565    Slings                                                                  No authorization required  
A4566    Canvas vest SO                                                          No authorization required  
A4595    TENS suppl 2 lead per month                                             No authorization required  
A4604    tubing with integrated heat use with pos. airway pressure device        No authorization required  
A4605    Tracheal suction catheter, closed system, each                          No authorization required  
A4606    Oximeter probe  replacement                                             No authorization required  
A4608    Transtracheal oxygen catheter, each                                     No authorization required  
A4611    Heavy duty battery, Ventilator, replacement for patient owned           No authorization required  
A4612    Battery cables                                                          No authorization required  
A4613    Battery charger                                                         No authorization required  
A4614    Hand‐held PEFR meter                                                    No authorization required  
A4618    Breathing circuits                                                      No authorization required  
A4619    Face tent                                                               No authorization required  
A4627    Spacer, bag or reservoir for inhaler                                    No authorization required  
A4628    Oropharyngeal suction cath                                              No authorization required  
A4629    Tracheostomy care kit                                                   No authorization required  
A4630    Repl bat t.e.n.s. own by pt                                             No authorization required  
A4635    Underarm crutch pad                                                     No authorization required  
A4636    Handgrip for cane etc                                                   No authorization required  
A4637    Repl tip cane/crutch/walker                                             No authorization required  

                                        Section 6 • Page 44
A4640    Alternating pressure pad                                          No authorization required  
A5083    Continent device, stoma absorptive cover for continent device,    No authorization required  

                                      Section 6 • Page 45

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