2016 and 2017 Prior Authorization List and Quick Reference ... · appliances (MORA), Trigger Point...

MDwise.org/providersMDwise Marketplace, Inc. is a Qualified Health Plan issuer in the Health Insurance Marketplace

2016 and 2017 Prior Authorization List and Quick Reference Guide

Certain services provided to MDwise Marketplace members require prior authorization. Requests for authorization should be submitted to the delivery system of the member. Authorization requests must be submitted on the MDwise Marketplace prior authorization form, which can be found online at MDwise.org/forms. Please make certain to send the prior authorization form to the appropriate member delivery system. The delivery system’s prior authorization fax number is located on the top of the prior authorization form. For additional delivery system contact information please see the MDwise Marketplace Quick Contact Guide at MDwise.org/quickcontact.Network providers will receive confirmation of authorization decisions via an authorization letter, which will be sent either by fax or mail. The authorization letter will include an authorization identification number, authorization decision, number of days/visits and the duration approved. Prior authorizations that result in a denial will be communication via a denial letter, which will be sent via fax or mail and includes the rationale for the denial, the criteria applied, the right to peer review and the process to initiate an internal appeal.Detailed response timelines for prior authorization can be found in the MDwise Marketplace Provider Manual at MDwise.org/providers.

MDwise Marketplace Services that Require PAThis reference document is to provide general information for services that require prior authorization for MDwise Marketplace and should not be considered all inclusive. Please see the MDwise Marketplace Reimbursement Manual at MDwise.org/providers for more information.Important: MDwise Marketplace requires prior authorization for any non-emergency service provided by a non-contracted provider or facility. Non-contracted providers must contact the member’s delivery system so that provider enrollment information can be obtained to complete enrollment for reimbursement for services authorized.

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Category Description Details

Non-participating Any service that will be provided by a non-participating practitioner or facility

Inpatient

All medical, surgical, inpatient admissions and observation stays, including acute hospital; non-routine OB inpatient admissions, inpatient and day rehab, and transitional, and skilled nursing facility.

Maternity admissions for normal vaginal delivery or cesarean section do not require priorauthorization

Rev. December, 2016

http://www.MDwise.org/providers

http://www.MDwise.org/forms

http://www.MDwise.org/quickcontact





Surgical

OP procedures and surgeries

Uvulopalatoplasty or any type of palatopharyngoplasty: 42145Tonsillectomy and adenoidecomty (T&A): 42820–42836Excision of benign lesions: 11400–11471*Prior authorization would NOT be required for 11400-11471 if the following diagnosis/symptom is the reason for the excision:• Carcinoma in situ 232–232.9• Personal history of malignant melanoma V10.82• Personal history of other malignant neoplasm of

skin V10.83• Cellulitis or abscess 682-682.9Hysterectomy: 51925, 58150–58294, 58541–58544, 58548–58554, 58570–58573, 58951–58956

Potentially cosmetic and reconstructive surgeries

11200–11201, 11920–11922, 11950–11954, 15775–15776,15780–15839, 15847, 15876–15879, 17106–17108, 19300, 19316–19396, 21740–21743, 30400–30462, 30520, 36468–36471, 37785, 40650–40761, 42200–42281, 54660, 67900–67975, 69300, or diagnosis 757.32 or 757.33

Transplants: All solid organ, bone marrow/stem cell transplants includes the evaluation, work-up and travel accommodations

Heart/lung: 33930–33945Liver: 47133–47147Pancreas: 48550–48556Intestine: 44132–44137, 44715–44721Bone Marrow: 38240–38242Heart valve tissue: 33933, 33944Stem cell: 38204–38215, 38230–38232 andTransplant related Lodging, meals and transportation: S9975

Outpatient ST/OT/PT

The initial evaluation does not require prior auth. Prior authorization is required for services exceeding the 12 visits per discipline within a calendar year

PT - Revenue codes - 420, 421, 422, 423, 429, and 97002 - 97546 97750 - 97762 OT - Revenue codes 430, 431, 432, 433, 439ST - Revenue codes 440, 441, 442, 443, 449, 92507, 92508, 92520, 92521, 92522, 92523, 92524, 92525, 92526

Pulmonary rehabilitation G0237-G0239, G0424 and revenue code 948






DME and Medical Supplies

DME - Durable Medical Equipment and Supplies over $500 billed charges per claim including insulin pumps, breast pumps and CPAP, whether rented or purchased, replacement, or repair unless otherwise indicated in this list.

All DME unless otherwise indicated below. Please also refer to the orthotics category of this document for other items that may be considered DME that require prior authorization.

Diabetic Shoes with custom mold or compression mold or deluxe A5500-A5513

Enteral and Parenteral Nutruition B4034 -B9998Nutritional counseling after the first/initial visit 97802-97804, G0270-G0271

Prosthetics over $500 billed charges per claim L5500-L9900

Orthotics of $250 or more L0100-L4631

HOME

Home Health CareHome and OP Infusion Therapy, includes Tocolytics. ALL prior authorization requests for tocolytics must be referred to an MD to determine medical necessity.

99601-99602 and Tocolytics - S9349

Home Oxygen including supplies, home oxygen tent, and oxygen concentrators regardless of billed charges

A4615- A4616, A7046, E0424-E0455, E0460-E0461, E0463, E1352-E1392, E1405-E1406, K0738

Hospice Hospice Services (Inpatient or Outpatient) Revenue codes 651, 652, 655 and 656 with HCPCS codes Q5001-Q5010





Diagnostics

Genetic testing (all requests for genetic testing require MD review)

72090, 77072, 80502, 81228-81229, 81265-81266, 81331, 81400-81408, 88230, 88262, 88289, 88291, 88367

Clinical TrialsCT Scan- maxillofacial, cervical, thoracic and lumbar spine, thorax, abdomen, pelvis, 3D CT scans

70486, 70487, 70488, 72125-72133, 71250-71275, 74150-74178, 72191, 72192, 72193, 72194, 76376-76377

MRIs - head, brain, cervical, thoracic and lumbar spine, chest, abdomen, pelvis, lower extremity, 3D MRIs

Revenue codes: 611,612, 615, 616, 71250–71275, 71550–71552, 72125–72133, 72141–72158, 73718–73723, 72191–72194, 74150–74178 , 74181–74183, 72195–72197, C8900, C8901, C8902, C8909 – C8920, C8914, 77058–77059, 73700–73706, 70551–70559

MRA74185, 73225, 71555, 70544-70546, 73725, 70547-70549, 72198, 72159, 73725 (billed under MRI revenue codes)

PET Scans 340-349, 404, G0219-G0235, 78459, 78491-78492, 78608-78609, 78811-78816

The following radiation therapy requires prior auth: IMRT 77385 and 77386

Bone Density Study for members under 65 years of age G0130, 76977, 77078-77082, 78350-78351

Routine OB ultrasounds greater than 2 per pregnancy

76801-76817 – with the following diagnosis: O00.xx-O003.xx and O00.0-O03.9, O24.31, O24.311-O24.319

Ambulance

Ambulance - Facility to facility and/or non-emergent transfers A0426, A0428

Ambulance - Fixed Wing Air (a retrospecitve review of rotary wing air ambulance)

A0430, A0435





Pain Management

Pain Management services/procedures listed below, Office place of service onlyTENS unit including electrodes, batteries, etc. regardless of billed charges A4556-A4558, A4595, A4630, E0720, E0730-E0731

Facet Joint and/or Facet Joint Nerve Injection 64490-64495

Epidural Steroid Injection Anesthesia for Facet Joint and Epidural Injection

62310-62311, 64479-64484, 72275, 77003. Codes 72275 and 77003 require an auth only if billed with one of the codes listed here.

Neurostimulator 64550-64581, 61850-61888, 64561, 64581 E0744-E0749, E0762, E0766, L8679-L8695

Hyperbaric Oxygen Hyperbaric Oxygen A4575, C1300, G0277, 99183

Diabetic services and supplies

Diabetic education if more than 10 hours within the first calendar year of diagnosis or more than 2 hours for subsequent years

G0108-G0109 with diagnosis codes E10-E10.9 and E11.0-E11.9

Vision Vision Surgery as indicated are to be filed with the Vision Carrier S0800, S0810, S0812, 65767

Dental

Dental - Emergency procedures/services including general anesthesia to treat dental emergencies for children 6 years of age and younger

D0100-D0199

Podiatry Prior authorization is needed after 6 visits

Podiatry visits require prior authorization AFTER the 6th visit. All services rendered during the visit unless otherwise noted on this prior authorization list are included in the visit limit without authorization 99201-99215, 11055-11057, 11719-11721

Chiropractic Chiropractic Spinal Manipulation for members less than 5 years old 98940, 98941 and 98942




TMJ

TMJ Services - including Arthroplasty, Arthroscopy, Reconstruction, Discectomy (with or without disc replacement), Mandibular orthopedic repositioning appliances (MORA), Trigger Point Injections, Arthrocentesis. Treatment plan/services ordered for TMJ may also be a service that is included on the Prior Authorization list (e.g., physical therapy, DME or prosthetic greater than $500

21010, 21025-21026, 21050, 21060, 21070, 21073, 21116, 21193-21196, 21240-21249, 21255, 29800, 29804, S8262 and diagnosis M26.60-M22.69, S03.0, S03.4, M19.9-M19.93, M24.30, M24.40, T84.018, T84.019, T84.098-099, T84.029, T84.038-39, T84.89, T84.9

Behavioral Health Behavior Health/Mental Health/Substance abuse

Coding PA requirement as outlined below and on the following pages.


Service Type PA requirements

Psychiatric Diagnostic Interview CPT code 90791 or 90792 (Interactive Inter-view)

1 Unit per member, per billing provider, per calendar year allowed with no PA. 2 units are allowed without PA when member is separately evaluated both by a physician, an advanced practice nurse or HSPP and another mid-level practitioner.

Psychotherapy Visits CPT code: 90832 Psytx Office 30 min90834 Psytx Office 45 min90837 Psytx off. 60 min90846 Family medical psychotherapy90847 Family Psytx conjoint90849 Multi-family group therapy90853 Group psychotherapy

Does not requires PA (contracted providers)

MDwise Marketplace Behavioral Health Services that Require PA





Rule prior to 10.1.14 - 19 Medication Management visit per billing provider PA rule 99201-99205, New patient, office99211-99215, Existing patient, office

Effective for claims processed on or after 10.1.14, PA is not required for CPT codes 99201-99203 and 99211-99215, (contracted providers only)

Prior to 10.1.14, after the initial diagnostic interview (90791 or 90792), PA is not required for the first 19 visits per billing provider for this group of codes. (Service provided by a psychiatrist or nurse practitioners/clinical nurse specialists who have prescription authority.) All other therapy visits for these codes beyond initial 19 require PA. See note below for authorization application guideline.After 10.1.14 processing dates, no PA is required.

Interactive Complexity (CPT code 90785) is an add-on code to this CPT group and does not require a separate authorization.

Therapy visits with E/M:90838 Interactive Psytx w/medical EM 60 min

Prior to 10.1.14 dates of service requires PA. With dates of service 10.1.14 and beyond, PA is not required.

Health and Behavioral Assessment Codes CPT 96151-96155 ( Applied Behavioral Analysis)

PA is required for persons with Autism Spectrum Disorder Diagnosis (299.0, 299.8). Authorizations are to be given in accordance with treatment plan which can only be required every six months.





Electroconvulsive Therapy ECT - 90870 Requires PA. Anesthesia (CPT code 00104) and outpatient facility (i.e., observation room) may also be provided. If ECT authorized, anesthesia/anesthesia provider and facility service to be authorized.

Screening & Brief Intervention Services (SBI) - Drug/Alcohol Abuse:G0396 Alcohol &/or SA structured SBI 15-30 minG0397 Alcohol &/or SA SBI greater than 30 min

PA not required for one G0396 or G0397 per member, per contracted billing provider. PA is required for non-contracted providers, except if provided as emergency service. SBI services are not typically billed by behavioral health clinics as screening and interventions are already included in behavioral health assessment/treatment CPT codes.

Acute Outpatient Services:Partial Hospitalization and Intensive Outpatient ServicesPartial Half Day: Rev Code 912, HCSPCS H0035Partial Full Day: Rev Code 913, HCSPCS H0035IOP, Psychiatric: Rev Code 905, HCSPCS S9480IOP, SA: Rev Code 906, HCSPCS H0015

Requires PAService is provided for individuals who require less than full-time hospitalization, but need more extensive or structured treatment than intermittent outpatient mental health services. The number of days per week required is determined by what is medically necessary and indicated in the member’s treatment plan.

Residential Services Requires PA




MDwise Marketplace Behavioral Health Professional Services During Medical/Surgical Stay

Service Type PA requirementsDiagnostic Interview CPT codes 90791 or 90792

PA is not required per inpatient episode of care.

Inpatient Services: With the exception of emergency admissions, prior authorization is required for any psychiatric admission stay, including admissions for substance abuse, and any observation stay or partial hospitalization. Residential Services requires prior authorization for Psychiatric and Substance Abuse stays.Please note: For services requiring authorization, authorizations provided for a higher level code may be applied to the claim submitted by that provider with a lower level code, rather than denying the lower level code for no authorization. For example, in the event an authorization is given for a more involved visit, i.e., 90837, but in turn, a claim is submitted with CPT code 90832 or 90834, the claim would be paid on the 90837 authorization rather than denied for no authorization. Individual and Family therapy sessions can be used interchangeably; therefore authorization applies to this group of codes. Non-contracted BH providers: Except for emergency services, all BH services provided by non-contracted behavioral health providers require PA.




Therapeutic Category Brand Name Generic Name Applicable Code (s)

Botulinum toxins

Botox onabotulinumtoxin A J0585Dysport abobtulinumtoxin A J0586Myobloc rimabotulinumtoxin B J0587Xeomin incobotulinumtoxin A J0588

Endocrine AgentsH.P. Acthar corticotropin J0800Makena hydroxyprogesterone caproate None

Enzyme Replacement Rherapy

Cerezyme imiglucerase J1786Elelyso taliglucerase J3060Lumizyme alglucosidase alfa J0221Myozyme alglucosidase alfa J0220Vimizim elosulfase alfa J1322VPRIV velaglucerase J3385

Hormonal modifiers

Eligard, Lupron leuprolide J9217, J9218, J1950Sandostatin octreotide J2354Sandostatin LAR octreotide J2353Trelstar LA triptorelin J3315Zoladex goserelin J9202

Immune Globulins

Bivigam immune globulin, human J1556Carimune immune globulin, human J1566Flebogamma / Flebogamma DIF immune globulin, human J1572

GamaSTAN S/D immune globulin, human J1460, J1560Gammagard S/D immune globulin, human J1566Gammaplex immune globulin, human J1557Privigen immune globulin, human J1459Gammagard Liquid immune globulin, human J1569Hizentra immune globulin, human J1559Gamunex-C immune globulin, human J1561Gammaked immune globulin, human J1561Octagam immune globulin, human J1568

Hyqviaimmune globulin, human with recombinant hyaluronidase, human

J1575

Medical Benefit Drugs That Require PA



Therapeutic Category Brand Name Generic Name Applicable Code (s)

Immunomodulators for Inflammatory Conditions

Actemra tocilizumab J3262Benylsta belimumab J0490Entyvio vedolizumab J3380Orencia abatacept J0129Remicade infliximab J1745Rituxan rituximab J9310Simponi Aria golimumab J1602

Miscellaneous Immunomodulators

Ilaris canakinumab J0638Soliris eculizumab J1300Sylvant siltuximab J2860

Immuno-modulators for multiple sclerosis Tysabri natalizumab J2323

Metabolic bone disease

Aredia pamidronate J2430Boniva ibandronate J1740Reclast zoledronic acid J3489Prolia, Xgeva denosumab J0897Zometa zoledronic acid J3489

Osteoarthritis

Euflexxa sodium hyaluronate J7323Gel-One sodium hyaluronate J7326Hyalgan, Supartz sodium hyaluronate J7321Monovisc sodium hyaluronate J7327Orthovisc sodium hyaluronate J7324Synvisc/Synvisc-One sodium hyaluronate J7325

Pulmonary Arterial Hypertension (PAH) Agents

Flolan epoprostenol J1325Veletri epoprostenol J1325

Respiratory agents

Aralast NP proteinase inhibitor J0256Glassia proteinase inhibitor J0257Prolastin proteinase inhibitor J0256Zemaira proteinase inhibitor J0257Xolair omilzumab J2357




Authorization AppealsMembers and providers have the right to request an internal appeal of an adverse authorization determination. Internal appeals must be filed with MDwise within 180 calendar days of the adverse determination. Standard or non-expedited appeals can be requested in writing and mailed to MDwise Marketplace Medical Management at MDwise Marketplace, P.O. Box 441099, Indianapolis, IN 46244-1099.Non-expedited appeals will be resolved within 30 calendar days for pre-service authorization decisions and within 45 calendar days for post-service decisions (where the member has already received services).An expedited internal appeal can be requested by calling MDwise Marketplace Medical Management at 1-855-417-5615. Expedited appeals will be resolved within 48 hours or less.If the original decision is upheld, the provider and member have the right to request an external review by an Independent Review Organization (IRO) within 120 calendar days of the decision. A non-expedited external review will be resolved no later than 15 business days after receiving the request. Expedited external reviews will be resolved within 72 hours.

More information on appeals can be found in the MDwise Marketplace Provider Manual at MDwise.org/providers. Members can be directed to MDwise Marketplace customer service at 1-855-417-5615 for additional directions and assistance regarding their appeal rights.



2016 and 2017 Prior Authorization List and Quick Reference ... · appliances (MORA), Trigger Point...

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