REFERRALS CPT CODES COMMENTS
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1 Gundersen Health Plan (GHP) Procedures & Services Requiring Prior Authorization Benefits and eligibility must be verified with the Health Plan Customer Service. Self-funded and Fully Insured Employer Group Plans: or Senior Preferred: or BadgerCare Plus: or GundersenOne: or This grid applies to all GHP members; it is intended to be a guide and does not guarantee coverage. Medical benefit plan language supersedes the general information provided on this grid. The presence or absence of an item on this list does not define whether or not coverage or benefits exist for the service or procedure and/or CPT code. Failure to prior authorize procedures or services on this grid may result in denial of coverage; as a result financial responsibility may be yours. Senior Preferred members may see Evidence of Coverage for complete benefit information. REFERRALS CPT CODES COMMENTS Any referral to a non-participating provider/facility for non-emergent services A signed written referral from the Health Plan is required prior to receiving services from a non participating provider/facility Initial Low Back Pain Consults with Orthopedic or Neurosurgery departments (follow up visits do not require prior authorization) For State of Wisconsin ETF members. Submit supporting medical documentation. Effective 1/01/2013 EXPERIMENTAL Experimental/Investigational Considered provider responsibility when the member would not be reasonably expected to know that the service is experimental. The Health Plan utilizes Hayes Medical Technology Directory to determine if services are experimental/ investigational. In addition to Hayes, other sources may be reviewed which include but are not limited to the evidence based medical literature, specialty Medical Advisory Panel, and other technology review resources.
2 MEDICAL SERVICES CPT CODES COMMENTS Autism Spectrum Disorders Continuous Passive Motion (CPM) E0935 (Coverage limited to knee only) Prior authorization required for CPM usage beyond 21 days post op. Submit supporting medical documentation Cranial Remolding Orthotic S1040 Durable Medical Equipment (DME) Senior Preferred All DME purchases, rentals and repairs (no dollar threshold) Senior Preferred Call Customer Service to verify eligibility of member Review Medicare criteria: - If item is statutorily excluded by Medicare, notify member item is not covered by Senior Preferred; if member wants to purchase item, obtain signature on NDMC (available on website) - If item meets Medicare criteria, dispense and bill Health Plan - If item does not meet Medicare medical necessity criteria, submit PA to Health Plan for organizational determination Commercial/BadgerCare Plus/ GundersenOne DME purchases exceeding dollar threshold (varies by group) and all rentals and repairs Commercial/BadgerCare Plus/GundersenOne Call Customer Service to verify eligibility of member and prior authorization requirements (please provide HCPCS code) Enteral Therapy B4034-B9999 Genetic Testing Home Health Member must be homebound and meet criteria for home health. Home Prothrombin Time Monitoring G0249, G0248 Home Sleep Studies (under C-PAP policy) Prior authorization required from a sleep disorder physician specialist or provider practicing under the supervision of a sleep disorder specialist. Submit supporting medical documentation Hyperbaric Oxygen Therapy (HBOT) Prior authorization is required. Submit supporting medical documentation.
3 Insulin pumps /Continuous glucose monitors/receivers and supplies IV Drugs outpatient hospital and clinic (except EPO) IV Infusions Mental Health, Alcohol and other drug addictions (M.H./A.O.D.A), Transitional Treatment (includes Partial Hospitalization services), Day Treatment BadgerCare Therapies E0784/S1030, S1031, A9276-A9278, E0607, E2100, E2101 Home IV Therapy requires prior authorization. Request to be received from supplier. Prior authorizations required after 35 visits per therapy discipline; however, some services always require prior authorization per ForwardHealth Guidelines. Please refer to the ForwardHealth portal. Providers must use the PA forms available via the portal. Senior Preferred Part B Therapies. All Part B therapies require prior authorization. Refer the Health Plan website for detailed instructions. Skilled Nursing Facility Prior authorization required from facility. Swing Bed Prior authorization required prior to admission. TheraSphere/Sir-Spheres Treatment CPT: 77790, 36245, 75726, 77778, HCPCS: C2616, Q3001, S2095 Submit supporting medical documentation and appropriate codes. PROCEDURES\SURGICAL CPT CODES COMMENTS TREATMENTS Abortions Only if medically necessary as determined by the Health Plan. Artificial Intervertebral Disc Replacement for Cervical and Lumbar Degenerative Disc Disease 0092T, 0095T, 0098T, 0163T, 0164T, 0165T, Member must be 18 or over. Medicare does not provide coverage for patients over age 60. Coverage will be limited to the cost of the procedure and the cost of one artificial intervertebral disc. Bone Anchored Hearing Aide (BAHA) Bariatric surgical treatment for Severe Obesity , , , S2083, 43886,43888 Blepharoplasty Upper and lower lid blepharoplasty will be subject to prior authorization. Photos and visual fields will be required.
4 CardioMems C97412, C2624 Chorionic Villus Sampling (CVS) Cochlear Implants 69930, Required for members age 18 and over LINX Reflux Management System Submit supporting medical documentation PROCEDURES/SURGICAL CPT CODES TREATMENTS CONTINUED Deep Brain Stimulation , L8680-L8689 High Tech Radiology Tests CT & CTA: 70450,70460,70470, , , , 70496, 70498, 71250, 71260, 71270, 71275, , , , 73206,73700, 73702, , 74150, 74160, 74170, , , , 75635, 76380, 77078,77079,S8092 COMMENTS For State of Wisconsin ETF members. Submit supporting medical documentation. Effective 1/01/2013. MRI & MRA: 70336, 70540, , ,71555, 72141, 72142, , , , ,73225, ,73725, , 74185, 75557, 75559, 75561, 75563, 75565, 77058, 77059, 77084, S8037, PET: 78608, 78609, , G0235, 0159T, S8037, , Nuclear Stress Test: , 78481, 78483, 78499, Hyperhidrosis, Surgical Treatment Reduction Mammoplasty Refractive Surgery 65765, S0800, S0810, S0812 Rhinoplasty or Rhino portion of Septorhinoplasty Surgical Removal of Redundant Skin , Surgical Treatment of Obstructive Sleep Apnea(OSA) Pillar Implants are not covered for Commercial or GundersenOne members.
5 Surgical Treatment of Pectus Excavatum and Carinatum Syndrome Transmyocardial Revascularization (TMR) Transplants (excluding corneal A referral request is required for all members. transplants) Surgical/Laser Treatment of Scars Vagus Nerve Stimulation , Varicose Vein Treatment (excludes vein stripping) 36468, 36469, , 37766
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Medicare Drug Coverage Under Part A, Part B, and Part D Medicare Part A and Part B generally do not cover outpatient prescription drugs, most of which are now covered under Part D. This document and the
please refer to our internet site, www.harvardpilgrim.org, or contact the Member Services
Schedule of s HPHC Insurance Company, Inc. THE HPHC INSURANCE COMPANY PPO PLAN MAINE ID: MD0000000750_F2 X This Schedule of s summarizes your benefits under The HPHC Insurance Company PPO Plan (the Plan)