Oregon CPT Preapproval Grid

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1 * The following grid only identifies items that require preapproval from. Breast Pumps Notes: No preapproval required for 1st month rental; beyond one month rental requires preapproval Genetic Testing & Analysis Notes: Genetic Testing & Analysis requires PA whether code listed or not Home Health Stays - For all Initial Certification and Recertification periods Notes: Initial Certification review required effective 1/1/12. Inpatient Hospital Care Notes: Preapproval is required, except in an emergency. Mental Health, Behavioral Health or Substance Use Disorder Services Notes: A preapproval is NOT needed for a member to access, or a provider to refer to, the local community mental health/behavioral program for services. Outpatient Hospital Services/ASC Services Notes: We cover medically-necessary services you get in the outpatient department of a hospital for diagnosis or treatment of an illness or injury. Please refer to the preapproval grid to verify if the requested procedure or service requires preapproval as not all outpatient services require preapproval. Skilled Nursing Facility/Swing Bed Stays 0001T T Category III Temporary Codes For Emerging Technology, Services and Procedures Page 1 of 8 Effective: 01/01/2015

2 * The following grid only identifies items that require preapproval from Excision benign lesion Blepharoplasty Notes: If Opthamologist requesting, preapproval is not required Breast repair or reconstruction Mammaplasty, augmentation with or without prosthetic implant Notes: If breast cancer diagnosis, preapproval is not required Breast repair or reconstruction Spinal procedures Spinal procedures Spinal procedures Arthrodesis Lung transplant procedures Notes: Being certified as a Medicare approved facility is required for performing these procedures Heart/lung transplant Notes: Being certified as a Medicare approved facility is required for performing these procedures Endovenous Ablation Therapy Page 2 of 8 Effective: 01/01/2015

3 * The following grid only identifies items that require preapproval from Treatment of varicose veins Laparoscopic Gastric Bypass with Small Bowel Resection Other Laparoscopic Gastric Procedures Laparoscopic Bariatric Procedures Open Bariatric, Gastric Procedures Intestine transplant procedures Liver transplant Pancreas Transplant Kidney Transplant Circumcision procedures, frenulotomy of penis Plastic surgery on penis; insertion and repair of prosthesis Plastic repair of introitus, clitoroplasty, perineoplasty Hysterectomy, abdominal and vaginal enterocele repair Vaginal hysterectomy Vaginal hysterectomy with laparoscopy Unlisted laparoscopy procedures, uterus Stereotactic Radiosurgery (SRS): Brain Page 3 of 8 Effective: 01/01/2015

4 * The following grid only identifies items that require preapproval from Neurolysis & Injection/Aspiration of Spine, Diagnostic/Therapeutic Injection/Infusion Diagnostic/Therapeutic Material Procedures Related to Epidural and Interthecal Catheters Posterior Midline Laminectomy/Laminotomy/Decompression & Cervical Laminoplassty Procedures Spinal cord procedures Stereotactic Radiosurgery (SRS): Spine Spinal Neurostimulation Transforaminal Injection Injection(s), diagnostic or therapeutic agent, Paravertebral Facet Joint Nerve; Lumbar Or Sacral Peripheral nerve neurostimulators Peripheral nerve neurostimulators Peripheral nerve neurostimulators Peripheral nerve neurostimulators Destruction By Neurolytic Agent, Paravertebral Facet Joint Nerve; Lumbar Or Sacral Corneal transplant Corneal procedures Repair of Brow Ptosis, Blepharoptosis Page 4 of 8 Effective: 01/01/2015

5 * The following grid only identifies items that require preapproval from Implantation of hearing device Unlisted procedure, middle ear Cochlear implant & unlisted Magnetic Resonance Imaging (MRI) Temporomandibular Joint Magnetic Resonance Imaging (MRI) Orbit, Face, or Neck Magnetic Resonance Angiography (MRA) Head and Neck Magnetic Resonance Imaging (MRI) Brain Magnetic Resonance Imaging (MRI) Chest Magnetic Resonance Angiography (MRA) Thorax Magnetic Resonance Imaging/Magnetic Resonance Angiography (MRI/MRA) spinal canal Magnetic Resonance Imaging (MRI) Pelvis Magnetic Resonance Angiography (MRA) Pelvis Magnetic Resonance Imaging (MRI) Upper Extremity Magnetic Resonance Angiography (MRA) Shoulder, Arm, Hand Magnetic Resonance Imaging (MRI) Lower Extremity Magnetic Resonance Angiography (MRA) Leg, Ankle, Foot Magnetic Resonance Imaging (MRI) Abdomen - General Page 5 of 8 Effective: 01/01/2015

6 * The following grid only identifies items that require preapproval from Magnetic Resonance Angiography (MRA) Abdomen-General Magnetic Resonance Imaging (MRI) Heart Structure and Physiology Magnetic Resonance Spectroscopy Unlisted Ultrasound Procedure Magnetic Resonance Imaging (MRI) breast Magnetic Resonance Imaging (MRI) Bone Marrow Blood Supply Myocardial perfusion imaging, SPECT and planar Heart Positron Emission Tomography (PET), imaging, SPECT Brain Positron Emission Tomography (PET) Tumor Positron Emission Tomography (PET) Gene Analysis Notes: Genetic Testing & Analysis requires PA whether code listed or not Genetic Testing Notes: Genetic Testing & Analysis requires PA whether code listed or not Genetic Testing Notes: Genetic Testing & Analysis requires PA whether code listed or not Psychiatric Diagnostic Evaluation Page 6 of 8 Effective: 01/01/2015

7 * The following grid only identifies items that require preapproval from Family Psychotherapy Biofeedback related to Behavioral Health Biofeedback related to Physical Health Gastrointestinal tract imaging, eg capsule endoscopy Outpatient Rehabilitation Services - Treatment of Speech/Hearing Disorders Notes: All therapies require preapproval. Outpatient Rehabilitation Services - Treatment of swallowing and/or oral dysfunction for feeding Notes: All therapies require preapproval Cardiovascular Telemetry Unlisted neurological or neuromuscular diagnostic procedure Psychological Testing Neuropsychological Testing Health and Behavior Assessment and Intervention Notes: Preapproval required for units > 18 per member per year Outpatient Rehabilitation Services - Physical/Occupational Therapies Notes: All therapies require preapproval. Page 7 of 8 Effective: 01/01/2015

8 * The following grid only identifies items that require preapproval from Outpatient Rehabilitation Services - Development of cognitive skills to improve attention, memory, problem solving Notes: All therapies require preaproval. Medical Nutrition Therapy Notes: If diabetes and/or renal diagnosis, preapproval is not required Chiropractic manipulation Hyperbaric Page 8 of 8 Effective: 01/01/2015

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