Medical/Surgical Prior Authorization List The following is a list of medical/surgical and injectable/infusion services which require prior authorization for contracted providers. PreferredOne has made every effort to ensure this list is comprehensive. The fact that a particular service is not included on the list does not mean that such service is otherwise covered. For details on Pharmacy prior authorization requirements, please contact Customer Service. Note: While it is expected that prior authorization is obtained before services are rendered, PreferredOne reserves the right to conduct medical necessity reviews at the time the claim is received if no authorization was previously requested. Additionally, it is recommended that prior authorization be obtained before services are rendered by non-contracted providers, and PreferredOne reserves the right to conduct a medical necessity review at the time a claim is received if no authorization was previously requested. Procedures that are normally done as an inpatient but are planned as outpatient and converted to inpatient post-operatively may also be subject to a medical necessity review. Benefits must be available for health care services. Health care services must be ordered by a provider. Health care services must be medically necessary, applicable conservative treatments must have been tried, and the most cost-effective alternative must be requested for coverage consideration. Please call the customer service number on the back of the member’s ID card to verify the specific requirements of the member’s plan. Revision Date: November 19, 2020
Transcript
Medical/Surgical Prior Authorization List The following is a list of medical/surgical and injectable/infusion services which require prior authorization for contracted providers. PreferredOne has made every effort to ensure this list is comprehensive. The fact that a particular service is not included on the list does not mean that such service is otherwise covered. For details on Pharmacy prior authorization requirements, please contact Customer Service. Note: While it is expected that prior authorization is obtained before services are rendered, PreferredOne reserves the right to conduct medical necessity reviews at the time the claim is received if no authorization was previously requested. Additionally, it is recommended that prior authorization be obtained before services are rendered by non-contracted providers, and PreferredOne reserves the right to conduct a medical necessity review at the time a claim is received if no authorization was previously requested. Procedures that are normally done as an inpatient but are planned as outpatient and converted to inpatient post-operatively may also be subject to a medical necessity review. Benefits must be available for health care services. Health care services must be ordered by a provider. Health care services must be medically necessary, applicable conservative treatments must have been tried, and the most cost-effective alternative must be requested for coverage consideration. Please call the customer service number on the back of the member’s ID card to verify the specific requirements of the member’s plan. Revision Date: November 19, 2020
Medical/Surgical Prior Authorization List CATEGORY
Bariatric Surgery including conversion, revision and reversal/takedown CPTs 43644, 43645, 43770, 43771,
• Septoplasty for sleep apnea, only [ICD-10 G47.30, G47.33 & G47.39] CPT 30520
•• Ultraviolet or laser light therapy for potentially cosmetic conditions, such as but not limited to, acne, dyssebacia, onychomycosis, pityriasis alba, rosacea, or seborrheic dermatitis
Dental, if requesting coverage for anesthesia and/or hospitalization under medical benefit
Durable Medical Equipment, Prosthetics, Orthotics, and Supplies USE THE DME LIST TO DETERMINE IF PA IS NEEDED Eye • Amniotic membrane implantation/injection, including ocular surface procedures CPTs 65778, 65779, 65780
• Blepharoplasty, blepharoptosis repair (see Cosmetic entry)
• Collagen-cross linking for keratoconus 0402T (Photrexa/riboflavin J2787)
Infusions/Injections… (continued) • Zulresso (brexanolone) C9055 *Subject to Site of Care review https://www.preferredone.com/shared/Phase1DrugList.pdf
• Non-invasive Pregnancy Testing (NIPT) - cell-free DNA CFDNA Harmony, MaterniT21, verifi - No PA for CFFDNA/NIPT for singleton pregnancy and mother is 35 years of age or older at time of delivery CPTs 0009M, 0168U, 81420, 81507
# PreferredOne contracted provider, ie, not a member’s narrow network OR a national network
Revision History: 11/19/20 Infusions/Injections… /Radiopharmaceutical for Oncology Use: added “brachytherapy source (microspheres) C2616” to the Yttrium-90 (y-90) entry; Lab Tests: deleted Drug antibody or metabolizer testing entry (what is required for PA for this type of testing is accounted for under the Pharmacogenetic/Pharmacogenomic entry) 11/15/20 Infusions/Injections: addition of Hyaluronic Acid derivatives and associated agents/HCPCS codes (note not all agents require PA), revised HCPCS code for Elaprase, deleted Boniva, pamidronate, Reclast and Zometa; Radiology; addition of CPT codes 61799, 77371, 77372, and 77373 to Stereotactic radiosurgery (SRS) and stereotactic body radiation therapy (SBRT) entry 09/22/20 Infusions/Injections: addition of Blenrep (belantamab mafodotin) and Tecartus (brexucaptagene autoleucel); Lab Tests - Pharmacogenetic/Pharmacogenomic: addition of CPT 86152 08/06/20 Infusions/Injections: Fensolvi added HCPCS code and notation that it requires PA when billed with specific diagnosis codes; Neurology – addition of Cranial nerve stimulation, include vagus/vagal and CPT code 06/30/20 Infusions/injections: asterisks have been added to Actimmune, Adakveo, Arcalyst, Avsola, Fensolvi, Givlaari, Phesgo, Reblozyl, Tepezza, Ultomiris, Uplizna, and Vyepti to note they are subject to Site of Care review; HCPCS replaced on Adakveo and Givlaari; HCPCS added to anti-hemophilia/blood clotting/coagulation factors entry, Avsola, Enhertu, immune globulin, Myozyme, Nulojix, Padcev, Reblozyl, Ruxience, Tepezza, Vyepti and Zolgensma entries; added Actimmune, Arcalyst, Fensolvi, Phesgo, Uplizna, and Zepzelca; deleted Gemzar (gemcitabine) and Taxotere (docetaxel) – PA is no longer required; Lab Tests: PLA code 0018U added to Gene Expression Profiling entry; Neurology: Peripheral nerve stimulation - CPT codes for cranial/vagus nerve and entries of pudendal, sacral stimulation have been removed: CPTs added to phrenic nerve stimulator – Remede entry; New Technology – Under Comments, removed “Includes most health care services billed with Category III “T” codes, eg, 0278T” – all T codes that require PA are noted on the List under the applicable category; Orthopedic surgery, Total disc arthroplasty – initial and revisions and the CPT code for revision added. Lab Tests: PLA code 0018U added to Gene Expression Profiling entry; Neurology: Peripheral nerve stimulation - CPT codes for cranial/vagus nerve and entries of pudendal, sacral stimulation have been removed: CPTs added to phrenic nerve stimulator – Remede entry; Orthopedic surgery, Total disc arthroplasty – initial and revisions and the CPT code for revision added. 05/28/20 Infusions/injections: removed Vyondys 53 (golodirsen) (this has been added to the Investigative List), Yescarta - added HCPCS; lab Test: NIPT – added HCPCS. 04/28/20 Cosmetic (potentially):- addition of Lipoma removal if requesting general anesthesia ; Infusions/injections: Adakveo, Givlaari, addition of HCPCS; Herceptin Hylecta HCPCS revised; Hormone pellet implantation for males (estradiol and/or testosterone pellets) deleted; addition of Depo-estradiol, Estradiol, Estrogen, Firmagon, Goserlin, Histrelin, Leuprolide, Testosterone, and Triptodur when billed with F64.0,F64.1,F64.2,F64.8,F64.9,Z87.890 (F64.0 transsexualism, F64.1 dual role transvestism, F64.2 gender identify disorder of childhood, F64.8 other gender identity disorders, F64.9 gender identify disorder, unspecified, Z87.890 personal history of sex reassignment status); deleted Supprelin LA - implant (histrelin) - initial placement only (J9226) (captured in new histrelin entry); Neurology, Hypoglossal nerve stimulation – added CAT III code 0467T; Other Procedures/Treatments Gender reassignment: added surgical procedures for reassigning biological gender for all ages and the CPTs and diagnosis codes associated with this entry; Percutaneous Left Atrial Appendage Occlusion Closure and associated CPT added 03/10/20 Cosmetic (potentially) - added mastopexy/mammaplasty w/ or w/o implant, added implant material to the breast implant removal entry, added breast periprosthetic capsulectomy and associated CPTs, added breast reconstruction and associated CPTs, added or lipectomy to Excision entry, added breast to the revision of reconstructive procedures entry; Infusions/Injections… added Site of Care review asterisk designation (and HCPCS where they were missing), with a 4/6 effective date, to the currently listed drugs: Actemra, Aldurazyme, Benlysta, Berinert, Cerezyme, Cinqair, Cinryze, Crysvita, Elaprase, Elelyso, Exondys 51, Fabrazyme, Fasenra, Gattex, Glassia, Ilaris, Immune globulins, Kanuma, Krystexxa, Lumizyme, Mepsevii, Naglazyme, Nucala, Orencia, Ruconest , Soliris, Strensiq, Vimizim, VPriv; Newly added drugs also with a Site of Care review asterisk designation and a 4/6 effective date: Aralast NP, Flolan, Nulojix, Prolastin C, Remodulin, Xolair, Zemaira; Newly added drugs without Site of Care designation/no HCPCS: Adakveo, Avsola, Cablivi, Enhertu, Givlaari, Padcev, Reblozyl, Scenesse, Tepezza, Vyepti, Vyondys 53; Lab tests – added Comparative Genomic Hybridization and CPTs, heart transplant rejection added CPT 81595, added CPTs to the Non-invasive Pregnancy Testing (NIPT) entry; Orthognathic surgery – added CPTs; Other Procedure/Treatments – added Left Atrial Appendage Closure and CPT, added intraosseous basivertebral nerve to the Radiofrequency entry, deleted remote monitoring of physiologic parameters, added Septoplasty and Tracheostomy for sleep apnea, only. 01/21/20 Infusions/Injections – Zulresso – added HCPCS; Outpatient Therapy Services – removed Early Intensive Behavioral and Developmental Interventions / Therapy (EIBDI/ EIBDT/ABA), Autism 12/31/19 Infusions/Injections - removed Mvasi and Zirabev – PA is no longer required for these medications; Lab Tests – Gene Expression Assays, Heart Transplant Rejection testing, Kidney Transplant Rejection testing, Pharmacogenetic/Pharmacogenomic Testing entries - CPTs/HCPCS added; Other Procedures/Treatments - Leadless Pacemaker Insertion and Left Atrial Appendage cardiac device deleted (these are on the Investigative List); Myocardial imaging, PET, with specific CPTs added; Radiofrequency ablation – addition of CPTs 64624 and 64625 (representative of procedures that were already on the list [RFA genicular and sacroiliac nerves] but did not have specific CPT codes) 11/11/19 Hospice and Home Palliative Care: removed (no longer requires PA); Infusion/Injection: revised HCPCS code for Lumoxiti; Other Procedures: Remote monitoring of physiologic parameters - added 99457 HCPCS code.
10/22/19 Cosmetic: added Gynecomastia surgery; Infusions/Injections: added Kanjinti, Polivy, Ruxience, Truxima, Zirabev, Zolgensma; various CPTs HCPCS codes updated through-out. Transplants: added Comments reflecting Groups for which P1 does not perform transplant authorizations. 07/29/19 Cosmetic: Septoplasty - updated diagnosis codes; Home Health, Hospice, and Home Palliative Care Services: removed, “Open case after the initial evaluation has been completed and the HHC agency will be going out again” notation; Infusions/Injections – added more examples of immune globulins; Other Procedures/Treatments – added Hyoid Myotomy for sleep apnea with associated diagnosis and CPT codes; various CPT codes updated through-out. 07/05/19 Infusions/Injections: added Alpha -1 proteinase inhibitor and newly effective HCPCS to Anti-hemophilia /blood clotting/coagulation factors, Gamifant, Triferic; Infusions/Injections - Antineoplastic/Chemotherapy /Immunotherapy/Radiopharmaceutical for Oncology Use - added Belrapzo and Herceptin Hylecta and newly effective HCPCS to Elzonris, Libtayo, Lumoxiti, Ogivri, Ontruzant, Truxima; Lab Tests – added Kidney transplant rejection; Maternity - revised entry to, “If LOS exceeds 2 days post vaginal delivery or 4 days post c-section delivery for mom or newborn”; Corrected CPT for Autologous Chondrocyte implantation entry. 06/14/19 Removed CT scan (computed tomography) for lung cancer screening (requesting coverage at no cost sharing [preventive] benefit G0297 – this no longer requires prior authorization. 05/22/19 Bariatric Surgery: added takedown; Cosmetic: Breast augmentation/implant – added removal to this entry: Genioplasty/mentoplasty – deleted, as this is always considered cosmetic and not subject to a M/N review: Revision of reconstructive procedures – deleted such as but not limited to retattooing of nipple. This will no longer require PA; Infusions/Injection: Botulinum toxin removed chemodenervation bladder, extremity, facial, larynx, neck, or trunk muscles as the PA for these drugs is not limited to these conditions; Evenity, Ixifi, and Zulresso added; Neurology: Neurostimulators – added neve blocking to this entry, Gastric – deleted eg VBLOC and added Enterra; Orthopedic: Arthrodesis, sacroiliac joint, minimally invasive aand Open osteochondral autograft, talus added, Hip resurfacing deleted; Other Procedures/Treatments: Fetal in-utero surgery added,Tonsillectomy and/or adenoidectomy - age for PA changed from 16 years or older to 12 years or older to correspond with the description of some of the CPT codes that are flagged: Ventricular restoration added. # has been added to all Comments related to INN or OON: A corresponding definition has been added at the bottom of the grid. 04/01/19 Eye: added Photrexa/riboflavin to the Collagen-cross linking for keratoconus entry; Home Health Care – added the following “(per diem S codes do not require prior authorization)”; Infusions/Injections - added Spravato; Antineoplastic/ Chemotherapy/ Immunotherapy/Radiopharmaceutical for Oncology use – added Trazimera (trastuzumab-qyyp); Infusions/Injections – Antineoplastic/ Chemotherapy/ Immunotherapy/ Radiopharmaceutical for Oncology Use: added an asterisk to drugs impacted by the Site of Care process and a reference at the end of the column and a hyperlink to a list including more detail 03/22/19 Eye - Intravitreal/intraocular – removed Avastin; Infusions/Injections – Antineoplastic/ Chemotherapy/ Immunotherapy/Radiopharmaceutical for Oncology use – removed Avastin 02/19/19 Home Health – under Comments, removed Hennepin County from the “No PA until the 30th visit is completed visit” notation. 02/11/19 CPTs and HCPCS add/updated on various entries; Infusions/Injections: added Gamifant, Haegarda, Ultomiris ; Infusions/Injections - Antineoplastic/Chemotherapy/Immunotherapy/Radiopharmaceutical for Oncology Use: added Asparlas, Elzonris, Herzuma, Ogivri, Ontruzant and Truxima; Lab Tests: under Comments for no PA, added Spinal Muscular Atrophy(SMA/SMN) CPTs 81329, 81336, 81337; thalassemias/hemoglobinopathies CPTs 81361,81362, 81363, 81364; Neurology: added Phrenic nerve stimulator; Other Procedures/Treatments: revised Amniotic membrane implantation/injection to now include use in ocular procedures; added Leadless pacemaker insertion, transcatheter; Microwave ablation via bronchoscopy; Prostate thermotherapy by radiofrequency generated water vapor; Remote monitoring of physiologic parameters. 12/20/18 HCPCS added/updated on various entries; Infusions/Injections: Crysvita added; Makena – added note that “hydroxyprogesterone caproate HCPCS J1729 does not require PA”; Libtayo added; Revcovi added; Lab Tests: added heart transplant rejection monitoring. Other Procedures/Treatments: removed Eustachian tube balloon dilation (procedure is on the Investigative List); Added “ie, not for sterilization” to the Prophylactic organ removal entry; removed Sinus implant with Propel. 11/01/18 Bariatric Surgery added including conversion, revision and reversal; Cosmetic added specific procedures that require prior authorization, as noted in the Cosmetic policy; Infusions/Injections added Makena, Onpattro, Palenziq, Poteligeo and Sublocade; HCPCS added/updated for Antihemophilia, Luxturna, Zilretta entries; Antineoplastic/Chemotherapy for Oncology Use added Radiopharmaceutical to this entry and moved Xofigo and Yttrium here; added Azedra and Lumoxiti: HCPCS added to Aliqopa and Lutathera; Other procedures removed Propel (this is investigative); Outpatient Therapy Services removed vision therapy 06/04/18 Infusions/Injections added Alglucosidase alfa, NOS, Besponsa, Ilumya (tildrakizumab-asmn), Immune globulin – added Cuvitru, Ilumya (tildrakizumab-asmn), Ruconest, Simulect, Vyxeos; Antineoplastic/Chemotherapy for
Oncology Use added Treanda; Orthopedic Surgery Total Disc arthroplasty (artificial intervertebral disc) added lumbar
as now requiring prior authorization; Other Procedures/treatments – removed intraoperative Somatosensory evoked potentials (SSEP) monitoring and/or motor evoked potentials (MEPs) during spinal surgeries; Radiology-removed Space OARS 04/20/18 Cosmetic/Reconstructive added Blepharoplasty, blepharoptosis repair, brow lift; Eye added Blepharoplasty, blepharoptosis repair – Under Comments added No PA for ectropion or entropion repair 04/12/18 Infusions/Injections Botulinum toxin Comments added any spasticity, added Zilretta (triamcinolone acetonide); Antineoplastic/Chemotherapy for Oncology Use added Lutathera (lutetium LU 177 dotate): added HCPCS Q2041 to Yescarta; Inhaled/Inhalation added Pulmozyme; Other Procedures/Treatments added Ablation of
kidney/renal tumors, Intraoperative Somatosensory evoked potentials (SSEP) monitoring and/or motor evoked potentials (MEPs) during spinal surgeries CPTs 95940, 95941, G0453, CPT 33340 added to Left Atrial Appendage cardiac device/occlusion procedure, initial placement and revision/replacement added to Ventricular Assist Device Implantation (LVAD or RVAD) 01/22/18 Eye: added Luxturna (voretigene neparvovec-rzyl); Infusions/Injections; added Fasenra, Gene Therapy, Immune globulin – added Cuvtro, Mepsevii (vestronidase alfa-vjbk); added HealthEast to the Comments for all behavioral health services managed by BHP; Other Procedures, removed Transcatheter arterial chemoembolization (TACE) CPT 37243; Radiology/Radiation Therapy: added SpaceOAR System CPT 55874 12/2017 Infusions/Injections: removed drugs that self-administered, ie, coverage and PA requirements by the PBMs, under the pharmacy benefit. Drugs removed include Avonex, Betaseron, Cimzia, Copaxone, Dupixent, Enbrel, Extavia, Firazyr, Forteo, Growth Hormone, Humira, Increlex, Kineret, Pegasys, Peg-Intron, Plegridy, Rebif, Signifor, Simoni and Stelara SQ. 11/21/17 Infusions/Injections: added Simponi Aria; Antineoplastic/Chemotherapy for Oncology Use added Parsabiv 11/08/17 Infusions/Injections: added Brineura, Mvasi, and Renflexis; Antineoplastic/Chemotherapy for Oncology Use added Aliqopa, Besponsa, Mvasi, Mylotarg, Vyxeos and Yescarta. Under Transcatheter arterial chemoembolization (TACE) added CPT 37243. 08/31/17 Infusions/Injections: removed Pegasys (pegylated-interferon), Peg-Intron (pegylated-interferon), and Plegridy (pegylated-interferon); Antineoplastic/Chemotherapy for Oncology Use: added Immunotherapy to this header and added Kymriah (tisagenlecleucel) CAR T 07/11/17 Infusions/Injections – removed HP Acthar Gel (non-covered under Cost Benefit Program); Infusions/Injections Chemotherapy for Oncology Use- added Rituxan Hycela; Other Procedures/Treatments – added HIFU and Eustachian tube balloon dilation – removed Implantable wireless pulmonary artery pressure monitoring (CardioMEMS) – this is on the Investigative List; Radiology/Radiation Therapy - HCPCS S8032 removed from CT for lung cancer screening entry. This is no longer a valid code. Transplants – added Fecal/ stool microbiota bacteriotherapy. 06/01/17 Infusions/Injections - added Radicava; Infusions/Injections Chemotherapy for Oncology Use – added Imfinzi 05/01/17 Chiro –Comments added ISD 270 Hopkins- OON No PA for routine maintenance care; Acupuncture -Comments added ISD 270 Hopkins-No PA for INN and OON 04/27/17 Home Health, Hospice and Home Palliative Care Services – Comments added No PA for OT/PT/ST for PKA20006 If no Skilled Nursing is Involved; Outpatient Therapy Services - Comments related to the “No PA for FV group PKA20006, OT/PT/ST- regardless of age”, added no matter the setting 04/25/17 Infusions/Injections – Firazyr -changed M to P 04/11/17 Infusions/Injections - added Dupixent, Ocrevus; Infusions/Injections Chemotherapy for Oncology Use - added Bavencio 03/29/17 Infusions/Injections - added Spinraza; Other Procedures/Treatments – Comments related to Varicose Veins Surgery– added Varicose Vein procedures on Investigative List: Endomechanical or mechanicochemical ablation (MOCA), eg, ClariVein; Medical adhesive treatments, eg, VenaSeal; Micronized purified flavonoid fraction (MPFF); VeinGogh Ohmic Thermolysis. 03/07/17 Infusions/Injections - added Inflectra, Off-label Drug use, Probuphine, Infusions/Injections Chemotherapy for Oncology Use - added Yondelis. Other Procedures/ Treatments - added CardioMEMS 12/09/16 Infusions/Injections Chemotherapy for Oncology Use – added Lartruvo; Other Procedures/ Treatments, under Comments added, Fallopian tube removal for sterilization (salpingectomy) is not considered prophylactic organ removal and does not require PA 11/10/16 References to BHP handling behavioral health reviews for PreferredHealth removed from the Comments under Inpatient Confinements, Other Procedures/Treatments, and Outpatient Therapy Services 09/28/16 Infusions/Injections – added Cinqair and Exondys 51; Other Procedures/Treatment, under Injection, enzyme (eg, Xiaflex [collagenase]), palmar fascial cord (ie, Dupuytren's contracture) added Peyronie’s; Radiology/Radiation Therapy, under CT Scan for Lung Cancer Screening – removed CPT 71250 (no longer covered for screening) 09/08/16 Eye – added Collagen-cross linking for keratoconus 08/23/16 Orthopedics – removed multiple level only (not required for single level) from the artificial intervertebral disc entry; under Comments added Total disc arthroplasty, lumbar, on Investigative List. Removed all references to Prairie Island - this group termed in 2015. 08/19/16 Cosmetic/Reconstructive – added Revision of reconstructive procedures (including for breast cancer) as requiring prior authorization; under Comments, revised statement to reflect no PA for biopsies or initial reconstructive procedures for breast cancer. Infusions/Injections - added Synagis (palivizumab) 07/01/16 Moved all Behavioral Health services and associated comments, to the corresponding medical surgical entries – Autism EIBDT and Eating Disorders are under Therapies, now require PA for in network and out of network Eating Disorder treatment; Infusions/Injections – deleted Novantrone – this no longer requires PA, added HCPCS for Bendeka and Gazyva 06/22/16 Biofeedback- under Comments, added example of Urostym; Infusion/injections – Chemotherapy for Oncology Use - added Tecetriq; Lab Tests - added drug antibody testing; Outpatient Therapy Services - Under Comments, added No PA for Fairview Range PKA20003 when PT/OT/ST is provided at Fairview Range facility - regardless of age; Transplants – added Donor lymphocyte infusions 04/20/16 Infusions/Injections added Pamidronate; CT scan for lung cancer screening, added “requesting coverage under preventive benefit” and HCPCS G0297 (moved to Radiology area) 03/17/16 Infusions/Injections and Other Procedures - added Hormone pellet implantation for males (estradiol and/or testosterone pellets)
03/15/16 Chiropractic – under Notes, added Magellan to the Non-HSM entry; Infusions/Injections - added Nucala, Strensiq; Neurology – under Neurostimulators, added Gastric and Hypoglossal; Other Procedures - removed bronchial thermoplasty, added orthodontic treatment, under Medical benefit 01/21/16 Eye, added Implantable miniature telescope (IMT); Infusions/Injections – added Duopa, HyQvia added Kanuma, Triferic, chemotherapy, added Bendeka, Empliciti; added CPTs to transcatheter heart valve replacement and SIRT 12/04/15 Chiropractic-under Comments, added no PA for Hennepin County; Infusions/injections – chemotherapy, added Portrazza (necitumumab) 11/18/15 Chemotherapy for Oncology use, added Darzalex, Onivyde, Unituxin, Radiofrequency ablation; added genicular and occipital. Next to New technology, added anything potentially investigative. 09/09/15 Lab Tests removed Panorama from the examples of NIPTs. Orthopedic Surgery – arthroplasty entry - removed “with implants”. 08/05/15 Biofeedback – under Comments, added PEIP groups 05/15/15 Infusions/injections - added Cosentyx, Plegridy, and Xeljanz Growth Hormone – revised Comments that first line meds are on Intake Notification List; Neurology, added Transcranial Magnetic Stimulation 04/21/15 Eye, added Iluvien and Retisert; Home Health Care, under Comments, added No PA for lactation consultant in the home; Injections/ Infusions, added Campath, Iluvien and Retisert; Orthopedic, added Autologous Chondrocyte Implantation; Radiology – added (yttrium-90) to Therasphere entry
03/17/15 Infusions/injections – chemotherapy, added Blincyto; Other Procedures, added Left Atrial Appendage, cardiac devices/occlusion procedures; under Comments for Varicose Vein Surgery, added VenaSeal procedure – send to nurse for PA, Therapies, under Comments added, regardless of age to the No PA for Cuyuna Regional Medical Center entry. 02/19/15 Neurology, Neurostimulator, under Comments, revised to reflect that replacement/revision require prior authorization. Other Procedures, added Amniotic membrane implantation/injection, except for ocular procedures. Therapies, under Comments, added “No PA for Fond du Lac PKA20381 PT/OT/ST, INN & OON, regardless of age (eff 1/1/13)” 01/12/15 Orthopedics – added Total disc arthroplasty (artificial intervertebral disc) cervical, multiple levels and associated CPT codes. HCPCS: S8032 added to the CT scan (computed tomography) for lung cancer screening entry 01/05/15 Infusions/Injections, added Lemtrada (alemtuzumab), Sylatron (pegylated-interferon), Sylvant (siltuximab) Chemotherapy, added Beleodaq (belinostat), Cyramza (ramucirumab), Keytruda (pembrolizumab), Opdivo (nivolumab). Other Procedures, added CT scan for lung cancer screening, removed Cardioverter-defibrillator, subcutaneous CPTs 0139T or 0321T (PA is no longer required for this procedure), added bone to Cryoablation/ Cryosurgery entry. 12/17/14 Genetic Testing – No PA for Cystic Fibrosis (CF) carrier or newborn testing - CPT 81220 only. Other non-standard CF testing would require PA. 10/31/14 Lab Testing; Under Comments, added No PA for the following: F2 or F5 (Leiden) coagulation factor genetic testing - CPTs 81240, 81241 10/14/14 Therapies; Under Comments, changed information regarding Fairview to No PA for FV group PKA20006, regardless of age. 09/18/14 Infusions/Injections: under Comments, a new note has been added, “New FDA approved drugs, under the medical or pharmacy benefit, are typically considered non-covered until a full internal review has occurred. Per P1’s policy, this may take up to 180 days. See PP/R001.” Removed New Drugs or New FDA Indications. 09/03/14 Behavioral Health, under Comments removed the “No PA for St. Croix Chippewa tribal members for any kind of MH/CD treatment” statement; we are now doing PA for these members. Under Dental, under Comments, removed reference to Notification List – all requests for Facets groups, members age five and older, go to a nurse for PA. 08/20/14 Cosmetic, ultraviolet and laser treatments: added rosacea to the listing of diagnoses that require PA. Neurology – Neurostimulators: under Comments, added note that revision does not require PA. 08/08/14 Infusions/Injections, added Entyvio, Orthopedic, removed Artificial disc placement, intervertebral; cervical (arthroplasty) – PA is no longer required for this procedure 06/02/14 Cosmetic: Under Comments, added ICD-9 diagnosis code for port wine stain. Removed all references to precertification. 05/13/14 Home Health: Under Comments, revised to now state, No PA for Synagis or the Nursing visits when administering Synagis in a home setting. Outpatient Therapy Services: Under Comments, revised to now state, Fairview age 12 and under no PA for children 12 and under. (Non MNA plans). 04/25/14 Home Health Care -removed Comment regarding Synagis and not requiring PA, even if given in the home. Infusions/Injections – revised Supprelin entry to read initial placement only, Lab Tests - added under NIPT entry itself “No PA for NIPT for singleton pregnancy and mother is 35 years of age or older at time of delivery.” Other Procedures – added prophylactic organ removal. 03/25/14 Other Procedures, removed “implantable” and added CPTs to cardioverter-defibrillator, subcutaneous to differentiate this from the implanted device that is done via thoracotomy approach, which does not require PA. 03/14/14 Cosmetic, added ultraviolet or laser light therapy for potentially cosmetic conditions, such as but not limited to, acne, dyssebacia, onychomycosis, pityriasis alba, or seborrheic dermatitis as treatments/diagnoses that require PA. Under Comments, added in-office treatment by laser or ultraviolet light treatment for dermatitis, eczema, lichenification, mycosis fungoides, psoriasis, or vitiligo as treatments/diagnoses that do not require PA.
Infusions/Injections, added Vimizim, Chemotherapy for Oncology use added Gazyva, Lab Tests: added HLA typing CPTs 81370-81383 as tests that do not require PA, Neurology Under Comments – added PA not required for Urgent PC percutaneous posterior tibial neuromodulation (CPT 64566), Other Procedures: Chemodenervation entry – added larynx, extremities, and trunk; Cryoablation/cryosurgery entry - added pulmonary; Ventricular Assist Devices entry – added RVAD. 01/16/14 Lab Tests: added AlloMap Molecular Expression Testing, Orthodontic treatment deleted, Other Procedures: added Transcatheter Arterial Chemoembolization (TACE), Therapies: revised the Comments regarding PA requirements for Fairview 12/31/13 Behavioral Health: added Autism Spectrum Disorders in Children: Early Intensive Behavioral and Developmental Therapy, revised entry to reflect that PA is now only required for all Out of Network (IP and OP) and all IP treatment settings, Orthodontic Treatment added, Under Therapies, added Comment No PA for OT, PT, and ST for all Fairview. 12/16/13 Lab Tests: Under Genetic Testing, added “for carrier or newborn testing” to the “not required for Cystic Fibrosis” entry, Under Comments, added “Molecular Pathology CPTs 81265-81268 do NOT require PA”, under Non-invasive Pregnancy Testing (NIPT): removed Counsyl - as this is not a form of NIPT 11/12/13 Acupuncture – Under Comments changed PA from after initial evaluation to after the 15th visit. 10/30/13 Under Home Health Comments, added No PA for one well child/mother visit when discharged early Under Lab Tests, removed Counsyl from the NIPT entry, under Comments, added Cytogenetic Studies for Chromosome analysis/ Karyotyping do NOT require PA along with specific CPT codes 10/10/13 Under Comments for Behavioral Health, added No PA for St. Croix Chippewa tribal members any kind of CD/MH treatment, under Comments for Lab Tests, removed LOMN as a requirement for genetic testing, added no PA for NIPT for singleton pregnancy and mother is 35 years of age or older at time of delivery. Under Radiology/Radiation Therapy added Radium Therapy with Xofigo. 09/13/13 Under Comments for Other Procedures, Acupuncture, revised information regarding Fairview and PA requirements for the different plan types. 08/08/13 Under Comments for Home Health added that Synagis does not require PA, even if given in the home, under Infusions/Injections added Bivigam, Gammaked, Gamunex-C to Immune Globulin, and Gattex, Kynamro, Signifor. 07/24/13 Under Infusions/Injections Chemotherapy for Oncology use, added Elspar, Erwinaze, Kidrolase, and Oncaspar 07/12/13 Under Infusions/Injections added Jetrea, under Chemotherapy for Oncology use, added Xofigo. Under Genetic Testing, added notation that PA is not required for Cystic Fibrosis.
06/05/13 Pain Management Programs removed; PA is no longer required 05/01/13 Other procedures, Acupuncture - under Comments added Fairview as another group for whom we do not require prior authorization for this healthcare service 04/12/13 Behavioral Health, under Comments, added PREFERREDHEALTH & UCARE as additional groups that are handled at BHP. Under Botox Comments, added spasticity related to contractures as another diagnosis that is allowable without opening a case, Under Infusions/Injections, added Ilaris and Soliris; Chemotherapy for Oncology use, added Kadcyla, and added HCPCS to Zaltrap. Removed Investigational Services and reference to the List under Comments, Other procedures, added Penile Implant. 03/21/13 Under Behavioral, removed the following: Treatment of Autism/Pervasive Developmental Disorders (Autism spectrum) for age 12 and under. Under Infusions/Injections, removed Hyaluronic Acid (Euflexxa, Gel-One, Hyalgan, Hyaluranon, Sodium Hyaluronate, Orthovisc, Supartz, Synvisc, Synvisc-One) and Vivitrol (naltrexone) 01/30/13 Injectable/infusible Meds, added Synribo (omacetaxine), Nutritional/Dietitian Counseling removed – PA is not required, Other Procedures, added Devices with HDE FDA approval 01/01/13 Injectable/infusible Meds, added Elelyso (taliglucerase alfa) and Omontys (peginesatide), Lab Tests, added Prenatal blood testing: Counsyl, Harmony, MaterniT21, Verifi, Other Procedures, added Arthroplasty (joint replacement) with implant – ankle, elbow, and wrist, Chemodenervation bladder, Chemodenervation facial and neck muscles, Implantable cardioverter-defibrillator, subcutaneous (AICD), Sinus implant with Propel (mometasone furoate), Transcatheter heart valve replacement 10/10/12 Lab Testing, added Drug Metabolizer Testing 08/31/12 Injectable/infusible Meds Chemotherapy for Oncology Use added Marqibo and Zaltrap. Radiology/Radiation Therapy, outpatient setting, added TheraSphere 08/17/12 Botulinum toxin Comments, removed hyperhidrosis as a diagnosis that does not need PA 08/07/12 Injectable/infusible Meds Chemotherapy for Oncology Use removed Zelboraf (it is not an injectable), Other Procedures, added Bronchial Thermoplasty, removed Intraperitoneal from Hyperthermic Intraperitoneal Chemotherapy (all hyperthermic chemotherapy requires PA) 07/24/12 Injectable/infusible Meds Chemotherapy for Oncology Use Kyprolis (carfilzomib) 6/28/12 Injectable/infusible Meds Chemotherapy for Oncology Use added Perjeta 06/25/12 Neurology – removed Percutaneous/Posterior Tibial Nerve stimulation (PTNS) 06/12/12 Other procedures - added Cryoablation/Cryosurgery for Hepatic, Prostate, and Renal Oncology Indications and Injection, enzyme (e.g., collagenase), palmar fascial cord (i.e., Dupuytren's contracture) CPT 20527 05/24/12 Eye - added Eylea, Injectable/infusible Meds - added Antibiotics, intravenous, for Lyme Disease, Elaprase, Eylea, and Firazyr. Injectable/infusible Meds Chemotherapy for Oncology Use - removed Taxol. 05/01/12 Injectable/infusible Meds Chemotherapy for Oncology Use added Alimta, Eloxatin, Gemzar, Herceptin, Rituxan, Taxol, and Taxotere. Under Lab added Pharmacogenetic Testing. Under Other Procedures added Hyperthermic Intraperitoneal Chemotherapy. Under Radiation Therapy added Neutron Beam
04/10/12 Increased threshold of visits for Chiro reviews from 10 to 15 02/20/12 Injectable/infusible Meds added Glassia, added additional brand names of Hyaluronic Acid, added Krystexxa, under Chemotherapy for Oncology Use added Adcetris, Azerra, and Zelboraf, revised Neurostimulator entry for clarity 01/12/12 Acupuncture, added comment for Hennepin county Chiro, changed prior auth from after the 20th visit to after 10th visit. Cosmetic, clarified that no review required for in-office laser or ultraviolet light treatment for psoriasis and referred to DME list for UVA/UVB in the home. Dental, added if requesting coverage for anesthesia and/or hospitalization under medical benefit. Lab Tests category added – moved genetic testing and tumor markers under that category. 12/12/11 Behavioral Health – added age qualifier for Autism/ PDD treatments 11/18/11 Removed Pelvic Floor Electrical Stimulation and ESWT for musculoskeletal conditions 10/25/11 Injectable/infusible Meds: added Supprelin LA 10/06/11 Neurology: revised neurostimulator entries 09/30/11 Removal of Hearing Devices (BAHA, cochlear implant, MEI, and ABI), under Other Procedures added Cleft Lip/Palate repair if patient is aged 19 and older 08/16/11 Addition of INTACS (intrastromal corneal ring segments), deletion of Strabismus repair 06/28/11 Removed Chemodenervation of eccrine glands for hyperhidrosis 06/27/11 Genetic Testing: added Genotyping, Gene Expression Assays; Other Procedures, added Tumor Markers 06/17/11 Injectable/infusible Meds added Acthar Gel 06/07/11 Removed PA requirements for X-Stop 05/24/11 Neurology added Chemodenervation of eccrine glands for hyperhidrosis; Other Procedures added hyperhidrosis surgery 05/19/11 Injectable/infusible Meds added Benlysta, Jevtana, and Yervoy. Added New Drugs or New FDA Indications. 05/03/11 Addition of Ventricular Assist Device implantation and Lung volume reduction surgery 03/25/11 Injectable/infusible Meds added Pegasys, Peg-Intron, and Xgeva 01/12/11 Added No review for OP behavioral settings (effective 1/1); Under Injectable/infusible Meds added additional meds (some may be requested under the Pharmacy benefit): Actemra, Aldurazyme, Avonex, Berinert, Betaseron, Boniva, Ceredase, Cerezyme, Cimzia, Cinryze, Copaxone, Dysport, Enbrel, Fabrazyme, fertility drugs, Fabrazyme, Forteo, Humira, Increlex, Kalbitor, Kineret, Lumizyme, Lucentis, Macugen, Myobloc, Myozyme, Naglazyme, Orencia, Hyaluronic Acid, Prolia, Reclast, Simponi, Stelara, VPriv, Xeomin, Xiaflex; Under Neurology, added Deep Brain stimulator, Pelvic Floor stimulator, Sacral Nerve stimulator, Spinal Cord/Column stimulators, Vagus Nerve stimulator; Under Other Procedures, added gender reassignment surgery, removed Keratoplasty, Laser correction of cornea (refractive procedures are benefit exclusions and therefore non-covered), removed Phototherapeutic Keratotomy (not a refractive procedure but does not require PA) 12/01/10 Added intramuscular to Immune globulin listing 11/03/10 Genetic Testing: A is not required for maternal serum alpha-fetoprotein, triple screen, or quad screen 10/28/10 Removed Comment regarding ESWT; plantar fasciitis and renal/kidney stones 08/16/10 PA no longer required for Laser Therapy for Psoriasis
PreferredOne Community Health Plan (“PCHP”) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. PCHP does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.
PCHP:Provides free aids and services to people with disabilities to communicate effectively with us, such as:
• Qualified sign language interpreters• Written information in other formats (large print, audio, accessible electronic formats, other formats)
Provides free language services to people whose primary language is not English, such as:• Qualified interpreters• Information written in other languages
If you need these services, contact a Grievance Specialist.
If you believe that PCHP has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with:
Grievance SpecialistPreferredOne Community Health PlanPO Box 59052Minneapolis, MN 55459-0052Phone: 1.800.940.5049 (TTY: 763.847.4013)Fax: [email protected]
You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, a Grievance Specialist is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services200 Independence Avenue, SWRoom 509F, HHH BuildingWashington, D.C. 202011-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
PreferredOne Community Health Plan Nondiscrimination Notice
Language Assistance Services
NDR PCHP LV (10/16)
PreferredOne Insurance Company (“PIC”) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. PIC does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.
PIC:Provides free aids and services to people with disabilities to communicate effectively with us, such as:
• Qualified sign language interpreters• Written information in other formats (large print, audio, accessible electronic formats, other formats)
Provides free language services to people whose primary language is not English, such as:• Qualified interpreters• Information written in other languages
If you need these services, contact a Grievance Specialist.
If you believe that PIC has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with:
You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, a Grievance Specialist is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services200 Independence Avenue, SWRoom 509F, HHH BuildingWashington, D.C. 202011-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
PreferredOne Insurance Company Nondiscrimination Notice
