Coventry Healthcare of DE Pre-Authorization Quick Reference Guide Commercial 2009
Service Inpatient Back Surgery Transplant Services Ambulance Transport Pulmonary Rehab Cardiac Diagnostic & Imaging Studies
Pre-Auth Fax Request Form Fax # 866-889-7573 Telephonic 800-727-9951
Guidelines/Corresponding CPT/HCPCS Codes* All elective/emergent/observation (Location 21)/Hospice/Skilled Nursing Facility and Rehab admits and services. 22505, 22520-21, 22526, 22532-33, 22554-58, 22600-614, 22630, 22632, 22350-51, 2280019, 22851, 63001-295, S2348-51 All services related to organ transplants Non-urgent transport Possible benefit limitations 78460-61, 78464-65, 78472-73, 78478, 78480, 78483 Off label/Non- FDA approved drugs/and the following medications for non-neoplasm diagnoses/indications: Avastin, Abraxane, Erbitux, Gemzar, Herceptin, Ixempra, Leucovorin, Rituxan, Torisel, Trelstar, Vantas, Zevalin & Zoladex. All Phases 69930 No authorization is required for the removal of boney impacted wisdom teeth. All other requests for coverage of dental services under the patient's medical benefit are subject to review. All equipment billed purchase amount greater than $200. 30801, 30802, 0088T, 30520, 69300, 69310 91110-11 43644-65, 43770-74, 43842-43, 43846-48, 43886-88 83900-14, 88230, 88233, 88235, 88237, 88245, 88248-49, 88261-64, 88267, 88269, 8827275, 88280,88283, 88285, 88289, 88291, 88299, S3818-20, S3822-23, S3828-31, S3833-34, S3840, S3843-44, S3852-55, S3855 All services provided in the home, i.e.: Skilled Nursing, Social Services, Dietician, Home Infusion, Hospice and Therapies- Physical/Occupational/Speech 61850-88, 63650-88, 64553-81 Possible benefit limitations 17A Hydroxyprogesterone, Acthar Gel, Advate, Aldurazyme, Alferon, Amevive, Aralast, Aredia, BayRho, Bexxar, Boniva, Cerezyme, Cimzia, Clolar, Dacogen, Delatestryl, Elaprase, Euflexxa, Fabrazyme, Flolan, Foscavir Inj., Geref, Hyalgan, Kepivance, Lucentis, Lupron, Macugen, Metastron, MyoBloc, Myozyme, Naglazyme, Neumega, Orencia, Orthovisc, Profasi, Prolastin, Proleukin, Quadramet, Reclast, Refludan, Remicade, Remodulin, Respigam, RhoGAM, Saizen, Sandostatin LAR, Soliris, Somatuline Depot, Supartz, Supprelin LA, Synagis, Synvisc, Tev Tropin, Thyrogen, Tysabri, Vectibix, Ventavis, Viadur,Vidaza, Visudyne, Vivitrol, Win Rho, Xolair, Zemaira, Zenapax and Zometa. Auth required for all insulin pumps Possible benefit limitations Auth required if NOT done at LabCorp Precerted by MedSolutions- call 800-727-9951, Option 7 Fax PRA forms to 866-889-7573 Possible benefit limitations No authorization required for diabetic nutritional counseling HMO Member or Member with NO OON benefit and/or a service that requires prior authorization. 21120-21249 Possible benefit limitations All rentals.
Chemotherapy Clinical Trials Cochlear Implants
Dental Services DME ENT Procedures/Services Endoscopy- Camera Gastric Bypass
Genetic Testing/Counseling
Home Health Implanted Nerve Stimulators Infertility (Eval, Testing, Drugs)
Injectables Medications Insulin Pumps Investigational/Experimental Laboratory CT, PET, MRA, MRI Prenatal Risk Assessment Form Medical Foods Nutritional Counseling Non Par Provider/Facility Orthognathic Surgery Orthotics/Prosthetics
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Coventry Healthcare of DE Pre-Authorization Quick Reference Guide Commercial 2009
Selected Outpatient Surgery Pain Management/ Pain Pumps/ Neuro Ablation Plastic/Cosmetic Procedures Abdominoplasty/Panniculectomy/Lipectomy Blepharoplasty/Blepharoptosis Breast Augmentation Reduction Mammoplasty Rhinoplasty Skin Ligation/Stripping/Varicose/Sclerotherapy IMRT (ISRT,IGRT)& Brachytherapy Temporomandibular Joint (TMJ) Services Procedures Outpatient Therapy Hyperbaric Oxygen
Pre-Auth Fax Request Form Fax # 866-889-7573 Telephonic 800-727-9951
To determine authorization requirements for a particular procedure, please visit www.chcde.com or call Customer Service 800-833-7423 62281-82, 62310-11, 62318-19, 62350-68, 64470, 64472, 64475-76, 64479-80, 64483-84, 64600-81 (See below) 15830-39, 15847,15876-79 15820-29, 67900-09, 67911-12, 67916-24 19324-25 19316, 19318 30120, 30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462, 30465 Keloid revisions 36468-79, 37700-85 77326-28, 0182T, 77301 21010, 21050-60, 21240-43, 21255, 21295-96, 21480-90, 29804 Physical/Occupational/Speech/Rehab 99183
*CPT/HCPCS codes are not all inclusive. If you are not certain if a particular service requires preauthorization, please call Customer Service at 800-833-7423. Inclusion of an item on this list does not imply coverage under all benefit plans. Pre-authorization is for medical necessity review and does not guarantee benefits, coverage or elgibility. Pre-authorization request may be faxed to the Pre-Authorization department at 866-889-7573, using the Preauthorization Physician Request form which is located on www.chcde.com
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