Services Requiring Preauthorization for the CoventryCares of West Virginia Program 2016 CoventryCares of West Virginia must preauthorize certain services and supplies for Medicaid members. Automatic Internal Cardiac Defibrillator (AICD) Bi-ventricular Pacemaker Biofeedback Therapy Clinical Trials CT Scans Dental Treatment for Dental Accidents Durable Medical Equipment (DME): all rentals of DME and repairs, purchase of DME costing over $500 (except ostomy supplies) Elective Cardiac Catheterizations Genetic Testing Hospice and Home Health Care (nursing, infusion, respiratory, etc.) Hospital Observation Stays Hyperbaric Oxygen All Places of Service Injectable and Self-Administered Injectable Drugs, if covered under the medical and surgical Benefit instead of prescription drug benefit Inpatient Hospital Care- includes inpatient hospice admissions Insulin Pump and Supplies Joint Replacements- whether received inpatient or outpatient Magnetic Resonance Imaging (MRI)/Magnetic Resonance Angiogram (MRA)/Positive Emission Tomography (PET Scan) Molecular Diagnostic Testing Non-Emergent Ambulance Transportation Non-implanted Prosthetic Devices Nuclear Radiology Nutritional Formulas and Supplements OB Ultrasounds (Beginning with 3rd Ultrasound) Oral Surgery Orthotics Outpatient Polysomnograms (Sleep Apnea Studies) Outpatient Surgery (Hospital or Freestanding Surgical Center) Pain Management Services/Programs, including Epidural Steroid Injections Page 1 of 5
Psychological or Neuropsychological Testing Radiation Oncology Services Rehabilitative Services: Physical, Occupational, or Speech Therapy whether received Inpatient or Outpatient Services from a non-participating provider except emergency services and family planning Stress Echocardiograms Transplant Consultations, Evaluations and Testing/Transplant Procedures In addition, the following specific services require preauthorization regardless of the place of service: CPT or HCPCS Code Description J0894, J9010, J9027, J9041, J9055, J9202, J9207, J9213, J9214, J9217, J9218, J9225, J9226, J9264, J9303, J9305, J9310, J9328, J9330 23470, 23472, 23473, 23474, 24360,24361, 24362, 24363, 24365, 24366, 24370, 24371, 27125, 27130, 27132, 27134, 27137, 27138, 27437, 27438, 27440, 27441, 27442, 27443, 27445, 27446, 27447, 27486, 27487, 27130, 27132, 27134, 27137, 27138, 27700, 27702, 27703 Chemotherapeutic Drugs Total Joint Replacements- Clinical is required for medical necessity review 50592, 50593, 32998 Radiofrequency Ablation 72285 Discography 76873, 76950, 76965, 77011, 77014, 77261, 77262, 77263, 77280, 77285, 77290, 77295, 77299, 77300, 77301, Stereotactic Radiosurgery and Radiation Oncology Services Page 2 of 5
77305, 77310, 77315, 77321, 77331, 77332, 77333, 77334, 77336, 77338, 77370, 77399, 77401, 77402, 77403, 77404, 77406, 77407, 77408, 77409, 77411, 77412, 77413, 77414, 77416, 77417, 77418, 77421, 77422, 77423, 77424, 77425, 77427, 77431, 77469, 77470, 77499, 77600, 77605, 77610, 77615, 77620, 77750, 77789, 77790, 77799, 0182T, G0251, G0339, G0340 77371, 77372, 77373, 77432, 77435, G0173 77600 Hyperthermia Treatment 77520, 77522, 77523, 77525 Proton Treatment Delivery 41019,77761-77779, 77326- Brachytherapy 77328, 77785-77787, C1716-C1719, C2616, C2634-C2699, Q3001 91035 Esophageal Reflux Tests 91111 Gastrointestinal tract imaging, intraluminal 93228, 93229 Real Time EKG 93350, 93351 Echocardiography 95951 Electroencephalography 96000-96004 Motion Analysis Studies 93025 Microvolt T-wave alternans for assessment of ventricular arrhythmias 93760, 93762 Thermogram; cephalic and peripheral 95250, 95251 Ambulatory continuous glucose monitoring of interstitial tissue fluid via a subcutaneous sensor for up to 72 hours; sensor placement, hook-up, calibration of monitor, patient training, removal of sensor, and printout of recording and physician Page 3 of 5
interpretation and report 96920-96922 Laser treatment for inflammatory skin disease (psoriasis) 95981, 95982 Electronic analysis of neruostimuilatorneurostimulator, with or without reprogramming 96570 Photodynamic Therapy Category Three Codes (CPT Temporary codes for emerging technology codes ending in T ) A4264 Permanent implantable contraceptive device A4575 A9277, A9278, A9279, S1031 Topical Hyperbaric Oxygen Transmitter, Receiver, Monitoring features for Continuous Blood Glucose Monitor to include non-invasive continuous glucose monitoring E1700, E1810 Rehabilitative, Orthopedic Devices G0166 External Counterpulsation, per treatment session G0237, G0238, G0239 Therapeutic procedures to improve respiratory function G0251,G0339,G0340 Stereotactic Radiosurgery G0302 G0305 Preoperative pulmonary surgery services for the preparation for LVRS, complete course of services M0075 M0076 M0100 M0300 M0301 Q3031 Q4107 S0345 S0347 S2107 S3650 S3652 Cellular Therapy Prolotherapy Intragastric hypothermia using gastric freezing IV Chelation therapy (chemical endarterectomy) Fabric wrapping of abdominal aneurysm Collagen skin test Graft Jacket Electrocardiographic monitoring utilizing a home computerized telemetry station with automatic activation and real-time notification of monitoring station, 24-hour attended monitoring, including physician review and interpretation Adoptive immunotherapy, i.e., development of specific antitumor reactivity (e.g. tumor-infiltrating lymphocyte therapy) per course of treatment Saliva test, hormone level; during menopause Saliva test, hormone level; to assess preterm labor risk Page 4 of 5
S3708 S3900 S3902 S3904 S3905 S9015 S9025 S9090 U256 Gastrointestinal fat absorption study Surface electromyography (EMG) Ballistocardiogram Master s two step Noninvasive electrodiagnostic testing with automatic computerized hand-held device to stimulate and measure neuromuscular signals in diagnosing and evaluating systematic entrapment neuropathies Automated EEG monitoring Omnicardiogram/ cardiointegram Vertebral axial decompression, per session Experimental Drugs Please Note: Not all of the above are covered benefits. Confirmation of benefits and eligibility is required at the time services are rendered, not only when they are preauthorized. Page 5 of 5