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HealthAm Adv prior auth list final

VIEWS: 6 PAGES: 3

									                 HEALTHAMERICA/HEALTHASSURANCE/ADVANTRA
                      2010-2011 PRIOR-AUTHORIZATION LIST
                               (EFFECTIVE 10/1/2010)


ALL HOSPITAL ADMISSIONS (INCLUDES ELECTIVE/EMERGENT, SKILLED NURSING FACILITY AND/ACUTE
REHABILITATION)
OBSERVATION STAYS/ADMISSIONS- FOR STAYS GREATER THAN 23 HOURS
CLINICAL TRIALS, EXPERIMENTAL & INVESTIGATIONAL PROCEDURES,PHARMACEUTICALS, THERAPIES
TRANSPLANT SERVICES INCLUDING PRE-TRANSPLANT EVALUATIONS (Except Corneal)
OUT-OF-NETWORK AND OUT-OF-AREA SERVICES, PROCEDURES, SURGERIES
UNLISTED, UNCLASSIFIED AND MISCELLANEOUS CPT AND/OR HCPC CODES
GASTRIC BYPASS, BARIATRIC SURGERIES INCLUDING LAPAROSCOPIC BANDING AND SERVICES
RELATED TO COMPLICATIONS OR FOLLOW-UP EVALUATIONS
PLASTIC AND RECONSTRUCTIVE SURGERIES & PROCEDURES
CT SCANS, MRIs, MRAs, SPECT, PET, PET/CT FUSION SCANS
CATEGORY THREE CODES-CPT Codes ENDING in “T”
THERAPIES/REHABILITATION SERVICES- PHYSICAL/OCCUPATIONAL/SPEECH/PULMONARY/CARDIAC
MUGA SCANS, NUCLEAR CARDIAC IMAGING, MYOCARDIAL INFUSION STUDIES, CARDIAC STRESS
ECHOCARDIOGRAPY

          Retrospective Requests for Services will not be accepted after 72 hours

 If you are not certain if a particular service requires prior-authorization, please contact Customer Service
for Eastern PA at 1-800-788-8445, Western PA at 1-800-735-4404 and Advantra at 1-800-290-0190 for
specific code requirements. Benefit coverage is subject to all plan provisions, limitations, and eligibility.

                         (THE BELOW LISTING IS NOT ALL INCLUSIVE)


 A                                                         C
 Ablation                                                  Capsule Endoscopy/ Camera Pill
 Adult Immunizations                                       Cellular Therapy
 Advanced Reproductive Technology                          Chelation Therapy
 Alcohol Sclerotherapy                                     Chemodenervation
 Ambulatory continuous glucose monitoring                  Chemoembolization /Embolization
 Anodyne Infrared Therapy                                  Chondrocyte Transplant, Autologous (ankle, hip, knee)
 Apheresis                                                 Chemotherapy
 Aorta Graft (David or Yacoub Procedure)                   Coil Embolization
                                                           Complex Diagnostic Testing (Includes MRI, MRA, CT
 B                                                         Excludes routine radiology and lab)
 Biofeedback                                               Computed Corneal Topography
 Bone Growth Stimulators                                   Cryoablation
 Botulinum Toxic Treatments                                Cryodenervation/ Cryosurgery
 Brachytherapy/ Liquid Brachytherapy                       Cytogenic Studies (Genetic Testing)
                                                           CT Angiography




                                                      1
D
Deep Brain Stimulators                                     Molecular Studies (Genetic Testing)
Dental Anesthesia (Outpatient Hospital Surgeries)          MRCP
Dermatological Laser Phototherapy                          MUGA Scans
Donor Lymphocyte Infusion                                  Myocardial Infusion Studies
Durable Medical Equipment (includes orthotics and
prosthetics)- if billed charges are above $250.00          N
                                                           Neuropsych Testing
E                                                          Novalis Shaped Beam Surgical System
Echosclerotherapy                                          Nuclear Cardiac Imaging
EECP- Enhanced External Counterpulsation
Electron Beam Computed Tomography                          O
Emobilization Therapy                                      Ocular Photo Screening
Extracorporeal Shock Wave Therapy (Except Kidney)          Oral Surgery
                                                           Outpatient Surgeries (hospital or freestanding surgical
F                                                          centers/See exclusion list below)
Fabric Wrapping Abdominal Aneurysm                         Osteochondral autograft
Fetal Intrauterine Procedures/Surgeries
Fibrin Glue Sealant (i.e.; Anal fistual, ventral hernia,   P
vesicovaginal repairs)                                     Pain Management Programs (structured inpatient or outpatient
                                                           comprehensive programs) excludes individual episodic
G                                                          treatments such as trigger point injections or epidurals
Galvanic Stimulator- High Voltage                          Pelvic Floor Therapy
Gamma Knife AND/OR Stereotactic Radio Surgeries            Percutaneous Neuromodulation Therapy
Gastric Bypass, Bariatric Surgeries                        PET Scans
Gastric Neuro Stimulator/ Gastric Pacer                    Photophoresis, Extracorporeal
Genetic Studies                                            Plasmapheresis
Graft Jacket Regenerative Tissue Matrix                    Prolotherapy
                                                           Proton Beam Therapy
H                                                          Pulmonary Vein Isolation
Hepatitis A Vaccination- Adult                             Pulsed Magnetic Neuromodulation
Hepatitis B Vaccination- Adult
Home Computerized telemetry                                R
Home Health/Hospice Care                                   Radiofrequency Denervation
Hyperbaric Oxygen Therapy                                  Radiofrequency Thermal Ablation
                                                           Reconstructive AND/OR Plastic Surgeries AND Procedures
I                                                          (Cosmetic Procedures are excluded from coverage)
Implantable Intra Arterial Infusion                        Robotic assisted surgeries/procedures
Implantable Neuromuscular Electrical Stimulation
IMRT- Intensity Modulated Radiation Therapy                S
Injectable Medication Requests (excludes medications       Seventeen Alpha-Hydroxyprogesterone Caproate (17-P)
administered from office stock, i.e. immunizations,        Sir-Spheres
Insulin)                                                   Sleep Studies
Interferential Stimulator                                  Stress Echocardiography
Intradiscal Electrothermal Therapy (IDET)
Intragrastic Hypothermia                                   T
Intrathecal Pumps                                          Temporomandibular Joint Disorder Treatment/Therapies
Intravitreal Injections                                    (Includes Arthroscopy)
Iontophoresis                                              Thermally induced arthroscopy w/or w/o capsulorrhaphy
                                                           (ankle, hip, shoulder, finger)
K                                                          Thermogram cephalic/peripheral
Kyphoplasty                                                TOPAZ Procedure
                                                           Transthoracic Echocardiography (TEE)
L                                                          Transurethral microwave thermotherapy (TUMT)
Laser Light Therapy (High and Low Level)                   Transcranial Magnetic Stimulation Treatment

M
Mammosite Radiation Therapy
Meniscal Transplantation (medial or lateral)
Microvolt T-wave alternans
                                                            2
U                                                           W
Unlisted, Unclassified, and Miscellaneous CPT AND/OR        Wound Vacuum
HCPC Code related services
Uterine Artery Embolization OR Cryoblation OR               X
Endometrial Ablation/Thermal                                XTRAC –Excimer Laser Phototherapy

V
Vein Bypass Graft/ Brachial-Ulnar, Radial
Vein Sclerosing Agents/Injection/Ligation/Stripping
Visudyne Therapy
Vertebroplasty




    Original Medicare (Part A and B) As Primary Insurance and HealthAmerica
    As Secondary



                              Prior Authorization Requirements
                                   LTAC (LONG TERM ACUTE CARE)
                                      LIFE-TIME RESERVE DAYS
                     TRANSPLANTS (Medicare approved transplant service and approved facility)
                                           CLINICAL TRIALS
                                 SELF-ADMINISTERED INJECTABLES
                        (SEE SELF-ADMINISTERED INJECTABLE/THERAPEUTIC LIST)
                                              INFUSIONS
                            NON-EMERGENT AMBULANCE TRANSPORTATION




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