Provider Manual Section 5.0 Utilization...

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Provider Manual

Section 5.0

Utilization Management

Table of Contents

5.1 Utilization Management 5.2 Review Criteria/Standards for Review

5.3 Authorization Requirements 5.4 Online Authorization 5.5 Inpatient Admissions and Observation 5.6 Outpatient Services 5.7 High Cost Medication

5.8 Prior Authorization for Members with Original Medicare 5.9 Retrospective Authorization 5.10 Denials

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5.0 Utilization Management 5.1 Utilization Management

Utilization Management (UM) is the process of influencing the continuum of care by evaluating the

necessity and efficiency of health care services and affecting patient care decisions through assessments

of the appropriateness of care. The UM department helps to assure prompt delivery of medically-

appropriate health care services to Passport Health Plan members and subsequently monitors the

quality of care. Medically Necessary or Medical Necessity means Covered Services which are medically

necessary as defined under 907 KAR 3:130 or other applicable Kentucky law or regulation, and

provided in accordance with 42 CFR §440.230, including children’s services pursuant to 42 U.S.C.

1396d(r).

All Passport Health Plan participating providers are required to obtain prior authorization from the

Plan’s UM department for inpatient services and specified outpatient services listed in Section 5.3,

―Authorization Requirements.‖

Failure to submit an authorization or failure to submit an authorization in a timely manner may result in

a denial of services. An authorization is not a guarantee of benefits. Member eligibility should be

verified for every request of service.

The UM department is available Monday through Friday from 8:00 a.m. to 5:30 p.m. EST, except

holidays. All requests for authorization of services may be received during these hours of operation by

calling or faxing:

Department Phone Number Fax Number General Number (800) 578-0636 (502) 585-7989

Concurrent Review (502) 585-2023 (502) 585-7989

Retrospective Review (502) 585-7972 (502) 585-8207

Home Health (502) 585-7320 (502) 585-8204

DME (502) 585-7310 (502) 585-7990

Therapies/Pain

Management

(502) 585-6055

(502) 585-8205

Cosmetics

(502) 585-7069

Request can be sent via confidential email to: PassportUMCosmetics @Passporthealthplan.com

Appeals (502) 585- 7307 (502) 585-8461

High Dollar Radiology

Administered by MedSolutions

1-877-791-4099 1-888-693-3210 or on-line authorization at

www.Medsolutionsonline.com

After business hours or on holidays, a provider can leave a message and a representative will return the

call the next business day.

Passport Health Plan provides the opportunity for the provider to discuss a decision with the Medical

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Director, to ask questions about a utilization management issue, or to seek information from the nurse

reviewer about the Utilization Management process and the authorization of care by calling Utilization

Management at (800) 578-0636.

Because of frequent changes in member eligibility for Medicaid coverage, providers should verify

continued eligibility via the Plan’s web site, www.passporthealthplan.com, or by calling the IVR or

Provider Services at (800) 578-0775.

5.2 Review Criteria/Standards for Review

Passport Health Plan’s Utilization Management (UM) department is charged with ensuring that the

Plan’s members use their benefits appropriately. Passport’s UM Department uses InterQual® Criteria

during the review process. In the event InterQual® Criteria is not available for a specific request, the

reviewer may use internal medical policies which are reviewed and approved by actively practicing

practitioners in the community.

The Partnership Council approves both the use of InterQual Criteria® and Medical Polices. Criteria are

only made available to participating and non-participating providers as allowed under copyright

limitations and trademark considerations.

At the request of the practitioner, the Passport UM Department, or the Chief Medical Officer, will

provide a copy of up to three (3) InterQual® Criteria guidelines. If the guidelines are not available for

distribution, or the number of guidelines exceeds the copyright limit, the practitioner has the option to

request the guideline be read over the telephone, or review the guideline at Passport Health Plan.

Internal Medical policies are communicated to providers via the Provider Newsletter or the Passport

Health Plan web site, www.passporthealthplan.com. Providers may request a copy of a policy at any

time from the Passport UM Department or the Chief Medical Officer.

Durable medical equipment is reviewed utilizing Medicaid and Medicare guidelines as well as any

applicable Passport Health Plan internal medical policies. Medicare and Medicaid criteria/guidelines are

shared with providers upon request. These requests may be made by contacting the UM Department or

the Chief Medical Officer. Criteria are distributed to providers who have Medicare/Medicaid

practitioner numbers issued by state and federal entities.

5.3 Authorization Requirements

The Passport UM department hours of operation are 8 a.m. to 5:30 p.m., Monday through Friday. The

general UM department phone number is: (800) 578-0636. The general UM department fax number is

(502) 585-7989.

The following table lists procedures and/or services that require authorization from Passport Health

Plan’s Utilization Management (UM) department.

Services Requiring Authorization

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All Inpatient Admissions /

Hospitalizations

Maternity

Code Range: 644.XX through 665.XX ---

•If stay is less than or equal to 3 days with the above codes, no

authorization is required

AUTHORIZATION IS REQUIRED FOR:

All Cesarean Sections

All Scheduled inductions

All Non-par providers, regardless of delivery type

Rehabilitation 23 Hour Observation greater than one (1) overnight stay

Pain Management (i.e. Epidural

Blocks – Trigger Point Injections)

Home Hospice

Stem Cell/Progenitor Cell Retrieval Investigational/Experimental Procedures

Cosmetic Procedures Ocular Photodynamic Therapy/with Verteporfin (Visudyne)

Neuropsychological Testing Diabetic Education

Therapy Services Chiropractic Services

No authorization for the first 12 visits in a calendar year

Services beyond 12 visits require authorization

Benefit limit = total of 26 chiropractic visits within a calendar

period

Specified Outpatient Surgical

Procedures:

Adenoidectomy - Cardiac

Catheterization - EGD

PET Scan / MRI / MRA / CT / CTA / Select Cardiac Imaging

– Authorization administered by MSI

DME > $500 – rental or purchase All DME with E1399 Codes

Enteral Products Select Orthotics / Prosthetics

Ostomy Supplies Home Health / Skilled Nursing / Private Duty Nursing

Home Infusion – IV Therapy (IVT)

Authorization for IVT will be administered

by PBM

High Cost Medication > $400

Synagis Injections – Synagis Injections

– Authorizations administered by PBM

Nonparticipating Provider Services

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Select EPSDT Special Services Family Planning – Terminations

To determine if a service or supply, such as cosmetic procedures, is considered benefit exclusion, please

contact the Passport Utilization Management (UM) department.

The assigned authorization number must be submitted on the claim form.

Policy for Newborns:

An infant born by Normal Vaginal Delivery (NVD) does not require authorization until day four (4). If

an infant born via NVD stays <= 3 days, authorization is not required.

An infant born by C-Section does not require authorization until day six (6). If an infant born via C-

Section stays <= 5 days, authorization is not required.

Benefit inclusions/exclusions must be considered in determining eligibility for coverage for individual

cases.

To determine if a service or supply, such as cosmetic procedures, is considered a benefit exclusion,

please contact the Passport Utilization Management (UM) department.

The assigned authorization number must be submitted on the claim form.

5.4 Online Authorization

Passport Health Plan’s Utilization Management Department utilizes an online authorization system via

NaviNet. The online authorization system is a web-based auto-review system for providers to obtain

authorization for services.

For questions regarding the online authorization, contact NaviNet or your Provider Network Account

Manager.

The online authorization system also allows you, the provider, to search for authorizations by member,

authorization number, date of service and/or physician. View the following information online for each

authorization:

• Member identification number, coverage dates, and PCP

• Authorization number • Service requested

• Primary diagnosis • Treatment dates

• Status of the authorization

The use of the online authorization system via NaviNet for select services is highly encouraged.

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5.5 Inpatient Admissions

UM reviews all requests for inpatient admissions utilizing InterQual® criteria and internal medical

policies. For those requests meeting the established medical necessity criteria, an inpatient will be

authorized.

Requests not meeting the established medical necessity criteria will be referred to Passport’s Medical

Director for further review and evaluation.

When requesting a review, at a minimum, documentation must include:

• The member’s name and Passport Health Plan ID number.

• The diagnosis for which the treatment or testing procedure is being sought.

• Other treatment or testing methods that have been tried, their duration, and any outcomes.

• Additional clinical information as applicable to the requested service.

• Applicable sections of the medical record.

Some authorization requests may require a physician’s letter of medical necessity or a copy of the

medical records. These should be directed to the Utilization Management nurse who is coordinating the

specific case.

To receive authorization for an admission, contact Passport Health Plan’s Utilization Management

department at (800) 578-0636 or fax request to (502) 585-7989, Monday through Friday, between the

hours of 8 a.m. and 5:30 p.m.

5.5.1 Inpatient Admissions and Observation Requirements

All inpatient admissions require an authorization.

If a member is discharged from an inpatient level of care and subsequently re-admitted to the same

hospital within 24 hours, the UM Department continues the member's inpatient stay under the same

case reference number.

Requests for prior authorization of elective inpatient services should be received prior to the date the

requested service will be performed. Passport Health Plan will accept the hospital’s or the attending

physician’s request for prior authorization of elective hospital admissions; however, neither party

should assume that the other has obtained prior authorization.

For an urgent or emergent admission, the facility must notify the plan within one business day of the

admission.

For weekend admissions to a hospital or for services delivered on the weekend or after normal

business hours, authorization must be obtained within one business day of the admission or service

being provided.

If the member’s condition or results of evaluation and testing meet inpatient criteria after the 23-hour

observation period, the stay will be converted to inpatient beginning with the observation stay

admission date. All claims for this type of stay should be submitted with the entire length of stay as an

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inpatient.

To receive authorization for an inpatient admission, contact Passport Health Plan’s Utilization

Management department at (800) 578-0636 or fax the request to (502) 585-7989, Monday through

Friday, between the hours of 8 a.m. and 5:30 p.m. EST.

To receive authorization for an inpatient admission, contact Passport Health Plan’s Utilization

Management department at (800) 578-0636 or fax request to (502) 585-7989, Monday through Friday,

between the hours of 8 a.m. and 5:30 p.m. EST.

Failure to obtain authorization of an admission will result in an administrative denial of the admission

(see Section 2.11).

Denied authorization requests may be appealed (see Section 2.11).

Inpatient Only Codes:

In accordance with the Centers for Medicare and Medicaid Services (CMS) billing requirements, select

surgical procedures must be performed in the inpatient setting.

A detailed list of codes may be obtained at the following CMS website:

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-

Payment/HospitalOutpatientPPS/downloads/cms-1427-p_addE.pdf

If a provider performs one of the listed procedures in an outpatient setting and the claim is denied,

they may submit supporting medical records documentation for review through the claims appeals

process.

5.5.2 Inpatient Admissions to Non-Participating Facilities

Requests for admission to non-participating facilities should be submitted to the Passport Health Plan

UM department for review.

To receive authorization for admission to a non-participating facility, contact Passport Health Plan’s

Utilization Management department at (800) 578-0636 or fax the request to (502) 585-7989, Monday

through Friday, between the hours of 8 a.m. and 5:30 p.m. EST.

5.5.3 Elective Participating-Hospital Transfer Policy

Elective participating facility transfers must be prior authorized by Passport Health Plan. Patient

clinical information will be required to complete the authorization process, approve the transfer, and

determine prospective length of stay.

Either the transferring or receiving facility may initiate the prior authorization; however, the

transferring facility will be able to provide the most accurate required clinical information. If a hospital

transfer request is made by another Passport Health Plan facility, the receiving facility may request that

the transferring facility obtain the authorization before the case will be accepted at the receiving facility.

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/downloads/cms-1427-p_addE.pdf

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The receiving facility should contact Passport Health Plan to confirm the authorization.

In cases deemed emergent, notification of the admission is required within one business day after the

transfer.

To assist with transfers, contact Passport Health Plan’s Utilization Management department at (800)

578-0636 or fax the request to (502) 585-7989, Monday through Friday, between the hours of 8 a.m.

and 5:30 p.m.

5.5.4 Inpatient Rehabilitation Admissions

If a member requires an inpatient rehabilitation admission, the rehabilitation hospital will contact the

on-site review nurse at the acute-care facility where the member is currently an inpatient. If there is not

an on-site review nurse at the acute-care facility, the rehab hospital can contact Passport Health Plan’s

Utilization Management via phone (800) 578-0636 or fax (502) 585-7989.

Inpatient rehabilitation includes Acute Inpatient Rehab, Inpatient Cardiac Rehab and Inpatient

Pulmonary Rehab.

If the member is to be directly admitted from home or any other sub-acute facility, contact Passport

Health Plan’s Case Management department at (800) 578-0636 ext. 2024.

5.5.5 Inpatient Skilled-Nursing Facility

Passport Health Plan is not responsible for, nor does it reimburse nursing facility costs, for members at

skilled-nursing facilities. Those services are covered by the Kentucky Medicaid Program. Passport

Health Plan is responsible for costs of professional services, such as physician or therapist services that

are not part of the routine facility service. After a member is in a nursing facility for 31 days, the

disenrollment process begins for that member. Passport Health Plan’s responsibility for those non-

facility services continues for any of its members while they are still enrolled with the Plan. After the

Kentucky Medicaid Program completes the managed care disenrollment process and reinstates the

member in the fee-for-service Medicaid program, the Plan no longer has financial responsibility for any

services for that Medicaid recipient. To obtain skilled-nursing facility authorization, please call the

DMS-contracted review entity.

5.6 Outpatient Services

For authorization of select outpatient services listed in Section 5.3, ―Authorization Requirements,‖ the

PCP/specialist notifies Passport Health Plan via the online authorization system, telephonically or by

fax. Prior authorization is mandatory for select outpatient procedures / diagnostics to qualify for

payment.

When requesting a review, at a minimum, documentation submitted must include:

• The member’s name and Passport Health Plan ID number.

• The diagnosis for which the treatment or testing procedure is being sought.

• Other treatment or testing methods that have been tried, their duration, and any outcomes.

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• Additional clinical information as applicable to the requested service.

• Applicable sections of the medical record.

Some authorization requests may require a physician’s letter of medical necessity or a copy of the

medical records. These should be directed to the Utilization Management nurse who is coordinating the

specific case.

Requests for prior authorization of elective services should be received prior to the date the requested

service will be performed.

Requests for authorization of urgent and emergent services must be submitted to UM within one

business day of the procedure being performed.

Passport Health Plan will accept the hospital’s or the attending physician’s request for prior

authorization of elective hospital admissions; however, neither party should assume that the other has

obtained prior authorization.

Failure to obtain prior authorization for an elective procedure / service or failure to request

authorization of an urgent or emergent procedure / service within one business day of the procedure/

service being performed or rendered will result in an administrative denial of the service (see Section

5.10.2). Denied requests may be appealed (see Section 2.11).

The assigned prior-authorization number must be on the claim form. If practitioners wish to confirm

authorization, they may verify online via the online authorization system.

5.6.1 Outpatient Procedures / Diagnostics / Services

Providers are required to obtain prior authorization for select outpatient procedures / diagnostics from

the Plan’s Utilization Management Department.

See Table in section 5.3 for outpatient list.

For authorization of select outpatient services listed in Section 5.3, ―Authorization Requirements,‖ the

provider notifies Passport Health Plan via the online authorization system, telephonically or by fax.

The general UM department phone number is: (800) 578-0636. The general UM department fax

number is (502) 585-7989.

For Outpatient Imaging Services requiring authorization, see section 5.6.2.

5.6.2 Outpatient Radiology Services

Providers are required to obtain authorization for select radiological services through the high dollar

radiology program for advanced diagnostic imaging services. This program is administered in

partnership with MedSolutions (MSI).

Authorizations are required for select diagnostic imaging services performed in an outpatient setting.

Advanced diagnostic imaging includes:

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• Computed Tomography (CT); Computed Tomographic Angiogram (CTA)

• Magnetic Resonance Imaging (MRI); Magnetic Resonance Angiogram (MRA)

• Positron Emissions Tomography (PET)

• Nuclear Cardiac Imaging (NCM)

Authorizations are performed at MSI using their own internal criteria and medical management system.

MSI performs initial review, retrospective review, denials and 1st level appeals. Authorization is

required for advanced diagnostic imaging services performed in any outpatient setting.

Authorization is NOT required if the imaging service is performed in:

• Emergency rooms

• Inpatient settings

• 23-hour observations – Service performed in observation do not require an authorization. There are three (3) ways to request an authorization:

1. Internet: www.medsolutionsonline.com - Available 24/7

2. Phone: (877) 791-4099 Available 8 a.m. - 9 p.m. EST, Monday through Friday Toll free

3. Fax: 1-888-693-3210 Forms available at www.medsolutionsonline.com or by calling MedSolutions Customer Service at (877) 791-4099 Only MedSolutions fax forms are accepted Available 24/7

See Appendix A for a list of codes that require an authorization.

5.6.3 Durable Medical Equipment

The Department for Medicaid Services (DMS) requires that an updated Certificate of Medical

Necessity (CMN) be signed by the provider for all supplies and equipment and kept on file by the

supplier for a period of five (5) years. The only exception is oxygen for which Passport Health Plan

follows Medicare guidelines.

DME PURCHASE

DME items with billable charges greater than $500 require an authorization. Requests for authorization

of purchase MUST be received PRIOR to the end of the rental period.

DME RENTAL

Authorization requirements of rentals are determined by the billable price of the item being rented.

Rental charges will be applied to purchase price.

If the billable price of the rental is $500 or less, no authorization is required. If the billable price of the

rental is greater than $500, authorization is required.

All items requiring customization or accessories require prior authorization.

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All mini-nebulizers will be a purchase only item and do not require prior authorization.

Authorization requirements for DME purchases are based on total monthly cost or monthly quantity

of items purchased. The following is a list of purchases with authorization requirements by quantity:

Item

m

Quantity Limitations

Name Brand Diapers Regardless of quantity, all requests for name

brand diapers require authorization

Generic Diapers 180 per month require authorization

Underpads (Chux) 180 per month require authorization

Ostomy Supplies 2 boxes per month require authorization

Bedside Drainage Bags 4 per month require authorization

Syringes 100 per month require authorization

G-Tube

Compression Stockings

1 per month requires authorization

6 pair per year require authorization

* Maintenance, repair, or replacement in excess of $500 must have prior authorization from the UM

department.*

Enteral Products

• Enteral products with allowable amounts greater than $500 for a month’s supply require an authorization.

These services should be billed according to the fee schedule in your Provider Contract (Allowable

Charges).

For authorization of DME, the provider notifies Passport Health Plan via the online authorization

system, telephonically or by fax. The DME phone number is: (502) 585-7310. The DME fax number

is: (502) 585-7990.

For a list of Orthotics and Prosthetics that require an Authorization, see Appendix A.

For a list of Ostomy supplies that require an Authorization, see Appendix B.

5.6.4 Home Health Services

When medically appropriate, home health, private duty nursing, or home infusion may be a good

alternative to hospitalization.

Prior authorization of all home health / private duty nursing / hospice / home infusion services is

required. If the member is an inpatient and the facility has a Passport Health Plan on-site nurse

reviewer, the request may be given directly to the on-site review nurse.

Private duty nursing is limited to 2,000 hours per calendar year. Additional hours for children may be

obtained under EPSDT Special Services.

A request for prior authorization must be received prior to the delivery of the service for a non-urgent

request and within one business day of the service being performed for an urgent or emergent service.

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For authorization of Home Health Services, including home health care, private duty nursing and home

hospice, the provider notifies Passport Health Plan through the online authorization system,

telephonically or by fax. The Home Health phone number is: (502) 585-7320. The Home Health fax

number is: (502) 585-8204.

For authorization of home infusion, the provider should submit the infusion therapy authorization

form to Magellan via fax at (800) 229-3928. The authorization form can be found at

http://www.passporthealthplan.com/pharmacy.

5.6.5 Therapy, Chiropractic Services and Outpatient Rehab Services

Providers are required to obtain prior authorization for physical, occupational, aquatic and speech

therapy for acute and chronic conditions and chiropractic services.

• Therapy

Authorization of outpatient therapy services (physical, occupational, aquatic and speech) is required.

If the member is an inpatient and the facility has a Passport Health Plan onsite nurse reviewer, the

request may be given directly to the onsite review nurse. Review is required for the initial therapy

visit and all subsequent visits.

Requests for continuation of a service that is ongoing should be sent to the therapy department

seven days prior to the end of the authorization period. Please fax request together with progress

notes and current plan of care to (502) 585-8204.

For authorization of therapy requests, providers must notify Passport Health Plan through the online

authorization system, telephonically or by fax. The therapy phone number is: (502) 585-6055. The

therapy fax number is (502) 585-8205.

• Chiropractic Services

Authorization requests for chiropractic services are required after the 12th visit. No authorization is

required for the first 12 visits in a calendar year. The benefit limit equals the total of 26 chiropractic

visits within a 12-month calendar period.

• Outpatient Rehab Services

Authorization requests for outpatient rehab services (cardiac rehab and pulmonary rehab) are

required. If the member is an inpatient and the facility has a Passport Health Plan onsite nurse

reviewer, the request may be given directly to the onsite review nurse. For authorization of

chiropractic or outpatient rehab services, providers must notify Passport Health Plan telephonically

at (502) 585-6055 or via fax at (502) 585-8205.

5.7 High-Cost Medications

Providers are required to obtain prior authorization for High-Cost Medications greater than $400

billable amount per dose from the Utilization Management Department.

This applies to high-cost medications billed to Passport Health Plan, excluding chemotherapy. This

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does not apply to the pharmacy benefit. See Section 14 for prior authorizations related to pharmacy.

Authorizations for Synagis must be requested from Passport’s Pharmacy Benefits Manager. See section

14 for prior authorizations related to pharmacy.

For requests of high cost medications, providers may contact the UM Department at (800) 578-0636 or

fax the request to (502) 585-7989.

5.8 Prior Authorization for Members with Medicare

Prior authorization is not required for services listed on the prior authorization list when the member

has Medicare as the primary payer and benefits under Medicare have not been exhausted. This applies

to both inpatient and outpatient services. When benefits are exhausted, or if the service is not a benefit

covered under Medicare, and Passport Health Plan becomes the primary payer, prior authorization

requirements apply for both outpatient and inpatient services.

For those members who have exhausted their Medicare Part A inpatient lifetime reserve days, prior

authorization of inpatient services must be obtained. If a member’s lifetime reserve days are exhausted

during an inpatient hospitalization, notification to Passport Health Plan must be made within one

business day of the notification to the facility of the exhaustion of benefits by Medicare.

5.9 Retrospective Authorization

Retrospective review of inpatient services is performed when the patient was not a member of Passport

Health Plan prior to or at the time of the service. Outpatient services do not require retrospective

review by Utilization Management for members whose eligibility is determined retrospectively.

Providers have 60 days from the notification of eligibility on retrospectively enrolled members to submit

medical records for review and utilization management authorization request. If the practitioner does

not provide documentation, the card issue date, segment date, and claims history are used. A decision

and written notification is provided within ten (10) business days of receipt of the medical information

for the retrospective review request. An administrative denial is issued for retrospective requests when

the provider fails to request a utilization management review of the medical record within the timeframe

specified.

The provider is notified of all decisions regarding retrospective reviews. In cases of denial, a written

notification is provided.

Requests received beyond 60 days from the card issue date or from the provider’s documentation of the

date when they were aware of the member’s eligibility will be administratively denied.

Send requests for retrospective review to:

Utilization Management Retrospective Review

5100 Commerce Crossings Drive Louisville, KY 40229

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The phone number for retrospective review is: (502) 585-7972 or fax to: (502) 585-8207 (for large chart

review, please send records via mail).

5.10 Denials

An authorization request for a service may be denied for failure to meet guidelines, protocols, medical

policies, or failure to follow administrative procedures outlined in the Provider Contract or this Provider

Manual.

Members may not be billed by participating providers for deductibles, copays, and coinsurance except

those allowed by DMS. If pre-authorization criteria are not met resulting in a denied claim, members

must be held harmless for denied services.

To speak with the Medical Director or to the nurse reviewer regarding a denial, please contact

Utilization Management at (800) 578-0636.

5.10.1 Medical Necessity Denials

Utilization Management utilizes InterQual® Guidelines, medical policies and protocols to render

review decisions. Requests not meeting the guidelines, protocols, or policies are referred to a Medical

Director for clinical review.

A Passport Health Plan Medical Director renders all medical necessity denial decisions. Whenever a

denial is issued, Utilization Management provides the name, telephone number, title, and office hours

of the Medical Director who rendered the decision. The Passport Health Plan Medical Director is

available to discuss any decision rendered with the attending practitioner.

5.10.2 Administrative Denials

An administrative denial is issued for those services for which the provider has not followed the

requirements set forth in the Provider Contract or this Provider Manual. For example, an administrative

denial may be issued for failure to prior authorize an elective service, procedure, or admission. It may

also be issued for failure to notify Utilization Management within one business day of an emergency

service, procedure, or admission.

A provider may appeal an administrative denial by submitting the appeal request in writing to:

Clinical Appeals Department

5100 Commerce Crossings Drive

Louisville, KY 40229

Appendix A: Radiology Codes The codes on the list below require authorization through MedSolutions

CPT

® Category

CPT® Code

CPT® Description

MRI TMJ 70336 MRI Temporomandibular Joint (s)

CT 70450 CT Head without contrast

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CPT

® Category

CPT® Code

CPT® Description

CT 70460 CT Head with contrast

CT 70470 CT Head with & without contrast

CT 70480 CT Orbit, et al without contrast

CT 70481 CT Orbit, et al with contrast

CT 70482 CT Orbit, et al W & W/O

CT 70486 CT Maxillofacial area, (sinus) without contrast

CT 70487 CT Maxillofacial area, (sinus) with contrast

CT 70488 CT Maxillofacial area, (sinus) W & W/O

CT 70490 CT Soft-tissue Neck without contrast

CT 70491 CT Soft-tissue Neck with contrast

CT 70492 CT Soft-tissue Neck with & without contrast W & W/O

CT Angiography (CTA) 70496 CTA HEAD, with contrast, including noncontrast images, if performed, & image post-processing

CT Angiography (CTA) 70498 CTA NECK, with contrast, including noncontrast images, if performed, & image post-processing

MRI 70540 MRI Orbit, Face and/or Neck without contrast

MRI 70542 MRI Orbit, Face and/or Neck with contrast

MRI 70543 MRI Orbit, Face and/or Neck W & W/O

MRA 70544 MR Angiography (MRA) Head without contrast

MRA 70545 MR Angiography (MRA) Head with contrast

MRA 70546 MR Angiography (MRA) Head with and without contrast W & W/O

MRA 70547 MR Angiography (MRA) Neck without contrast

MRA 70548 MR Angiography (MRA) Neck with contrast

MRA 70549 MR Angiography (MRA) Neck with and without contrast W & W/O

MRI 70551 MRI Brain (Head) without contrast

MRI 70552 MRI Brain (Head) with contrast

MRI 70553 MRI Brain (Head) with and without contrast W & W/O

Functional MRI (fMRI) 70554 MRI Brain, functional MRI; including test selection and administration of repetitive body part movement and/or visual stimulation, not requiring physician or psychologist administration

Functional MRI (fMRI) 70555 MRI, Brain, functional MRI; requiring physician or psychologist administration of entire neurofunctional testing

CT 71250 CT Chest without contrast

CT 71260 CT Chest with contrast

CT 71270 CT Chest with and without contrast W & W/O

CT Angiography (CTA) 71275 CTA CHEST, (non-coronary), with contrast, including noncontrast images, if performed, & image post-processing

MRI 71550 MRI Chest without contrast

MRI 71551 MRI Chest with contrast

MRI 71552 MRI Chest with and without contrast W & W/O

MRA 71555 MR Angiography (MRA) Chest (excluding myocardium)- W or W/O

CT 72125 CT Cervical Spine without contrast

CT 72126 CT Cervical Spine with contrast

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CPT

® Category

CPT® Code

CPT® Description

CT 72127 CT Cervical Spine with and without contrast W & W/O

CT 72128 CT Thoracic Spine without contrast

CT 72129 CT Thoracic Spine with contrast

CT 72130 CT Thoracic Spine with and without contrast W & W/O

CT 72131 CT Lumbar Spine without contrast

CT 72132 CT Lumbar Spine with contrast

CT 72133 CT Lumbar Spine with and without out contrast W & W/O

MRI 72141 MRI Cervical Spine without contrast

MRI 72142 MRI Cervical Spine with contrast

MRI 72146 MRI Thoracic Spine without contrast

MRI 72147 MRI Thoracic Spine with contrast

MRI 72148 MRI Lumbar Spine without contrast

MRI 72149 MRI Lumbar Spine with contrast

MRI 72156 MRI Cervical Spine with and without contrast W & W/O

MRI 72157 MRI Thoracic Spine with and without contrast W & W/O

MRI 72158 MRI Lumbar Spine with and without contrast W & W/O

MRA 72159 MR Angiography (MRA) Spinal Canal and contents -with or w/o contrast

CT Angiography (CTA) 72191 CTA PELVIS, with contrast, including noncontrast images, if performed, & image post-processing

CT 72192 CT Pelvis without contrast

CT 72193 CT Pelvis with contrast

CT 72194 CT Pelvis with and without contrast W & W/O

MRI 72195 MRI Pelvis without contrast

MRI 72196 MRI Pelvis with contrast

MRI 72197 MRI Pelvis with and without contrast W & W/O

MRA 72198 MR Angiography (MRA) Pelvis -with or without contrast

CT 73200 CT Upper Extremity without contrast

CT 73201 CT Upper Extremity with contrast

CT 73202 CT Upper Extremity with and without contrast W & W/O

CT Angiography (CTA) 73206 CTA Upper Extremity, with contrast, including noncontrast images, if performed, & image postprocessing

MRI 73218 MRI Upper Extremity-other than joint-without contrast

MRI 73219 MRI Upper Extremity-other than joint-with contrast

MRI 73220 MRI Upper Extremity-other than joint-W & W/O

MRI 73221 MRI Any Joint of Upper Extremity--without contrast

MRI 73222 MRI Any Joint of Upper Extremity--with contrast

MRI 73223 MRI Any Joint of Upper Extremity—W & W/O

MRA 73225 MR Angiography (MRA) Upper Extremity -with or without contrast

CT 73700 CT Lower Extremity without contrast

CT 73701 CT Lower Extremity with contrast

CT 73702 CT Lower Extremity with and without contrast W & W/O

CT Angiography (CTA) 73706 CTA Lower Extremity, with contrast, including noncontrast images, if performed, & image postprocessing

MRI 73718 MRI Lower Extremity-other than joint-without contrast

MRI 73719 MRI Lower Extremity-other than joint-with contrast

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CPT

® Category

CPT® Code

CPT® Description

MRI 73720 MRI Lower Extremity-other than joint- W & W/O

MRI 73721 MRI Any Joint of Lower Extremity--without contrast

MRI 73722 MRI Any Joint of Lower Extremity--with contrast

MRI 73723 MRI Any Joint of Lower Extremity—W & W/O

MRA 73725 MR Angiography (MRA) Lower Extremity-with or without contrast

CT 74150 CT Abdomen without contrast

CT 74160 CT Abdomen with contrast

CT 74170 CT Abdomen with and without contrast W & W/O

CT Angiography (CTA) 74174 Computed tomographic angiography; abdomen and pelvis; with contrast material(s), including noncontrast images, if performed, and image postprocessing

CT Angiography (CTA) 74175 CTA ABDOMEN, with contrast, including noncontrast images, if performed, & image postprocessing

CT 74176 CT Abdomen & Pelvis, without contrast

CT 74177 CT Abdomen & Pelvis, with contrast

CT 74178 CT Abdomen & Pelvis, with and without contrast

MRI 74181 MRI Abdomen without contrast

MRI 74182 MRI Abdomen with contrast

MRI 74183 MRI Abdomen with and without contrast W & W/O

MRA 74185 MR Angiography (MRA) Abdomen-with or without contrast

Diagnostic CT Colonography (CTC)

74261 Computed tomographic (CT) colonography, diagnostic, including image postprocessing; without contrast material

Diagnostic CT Colonography (CTC)

74262 Computed tomographic (CT) colonography, diagnostic, including image postprocessing; with contrast material(s) including noncontrast images, if performed

CT Colonography (CTC) for Screening

74263 Computed tomographic (CT) colonography, screening, including image postprocessing

Cardiac MRI 75557 Cardiac MRI for morphology and function without contrast

Cardiac MRI 75559 Cardiac MRI for morphology and function without contrast material; with stress imaging

Cardiac MRI 75561 Cardiac MRI for morphology and function without contrast, followed by contrast W & W/O

Cardiac MRI 75563 Cardiac MRI for morphology and function without contrast, followed by contrast; with stress imaging

Cardiac MRI 75565 Cardiac magnetic resonance imaging for velocity flow mapping

(List separately in addition to code for primary procedure)

Cardiac CT Calcium Scoring

75571 CT, heart, without contrast with quantitative

Cardiac CT 75572 CT, heart, with contrast material, for evaluation of cardiac structure and morphology (including 3D image post processing, assessment of cardiac function, and evaluation of venous structures, if performed)

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CPT

® Category

CPT® Code

CPT® Description

Cardiac CT 75573 CT, heart, with contrast material, for evaluation of cardiac structure and morphology in the setting of congenital heart disease (including 3D image post processing, assessment of cardiac LV function, RV structure and function and evaluation of venous structures, if performed)

CT Coronary Angiography (CTCA)

75574 CT, heart, coronary arteries and bypass grafts (when present), with contrast material, including 3D image post processing (including evaluation of cardiac structure and morphology, assessment of cardiac function, and evaluation of venous structures, if performed)

CT Angiography (CTA) 75635 CTA ABDOMINAL AORTA and bilateral iliofemoral lower extremity runoff, with contrast, including noncontrast images, if performed, and image post-processing

3D Rendering 76376 3D Rendering with interpretation and reporting of CT,

3D Rendering 76377 3D Rendering with interpretation and reporting of CT,

CT 76380 CT Limited or Localized follow-up

MR Spectroscopy (MRS) 76390 MR Spectroscopy (MRS)

Unlisted CT 76497 Unlisted CT procedure (eg, diagnostic, interventional)

Unlisted MR 76498 Unlisted MR procedure (eg, diagnostic, interventional)

CT guidance 77011 CT guidance stereotactic localization

CT guidance 77012 CT guidance needle placement (eg, biopsy, aspiration, injection, localization device)

CT guidance 77013 CT Guidance for, and monitoring of, parenchymal tissue

MR Guidance 77021 MR guidance for needle placement (eg, for biopsy,

MR Guidance 77022 MR guidance for, and monitoring of, parenchymal tissue

Breast MRI 77058 MRI BREAST, without and/or with contrast UNILATERAL

Breast MRI 77059 MRI BREAST, without and/or with contrast BILATERAL

CT Bone Density 77078 CT BONE MINERAL DENSITY study, 1 or more sites, axial

skeleton MRI Bone Marrow 77084 MRI Bone Marrow blood supply

Nuclear Cardiac Imaging 78451 Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study, at rest or stress (exercise or pharmacologic)

Nuclear Cardiac Imaging 78452 Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection

Nuclear Cardiac Imaging 78453 Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study, at rest or stress (exercise or pharmacologic)

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CPT

® Category

CPT® Code

CPT® Description

Nuclear Cardiac Imaging 78454 Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection

Cardiac PET 78459 PET Cardiac (myocardial imaging) – metabolic evaluation

Nuclear Cardiac Imaging 78466 Myocardial Imaging, infarct avid, planar; qualitative or quantitative

Nuclear Cardiac Imaging 78468 Myocardial Imaging, infarct avid, planar; w/ EF by first pass technique

Nuclear Cardiac Imaging 78469 Myocardial Imaging, infarct avid, planar; tomographic SPECT

Nuclear Cardiac Imaging 78472 Cardiac Blood Pool imaging, gated equilibrium; planar, single study at rest or stress

Nuclear Cardiac Imaging 78473 Cardiac Blood Pool imaging, gated equilibrium; multiple studies, wall motion plus ejection fraction, at rest and stress

Nuclear Cardiac Imaging 78481 Cardiac Blood Pool imaging, (planar), first pass technique; single study, at rest or with stress, wall motion study plus ejection fraction

Nuclear Cardiac Imaging 78483 Cardiac Blood Pool imaging, (planar), first pass technique; multiple studies at rest and with stress, wall motion study plus ejection fraction

Cardiac PET 78491 PET Cardiac (myocardial imaging), perfusion single study at rest or stress

Cardiac PET 78492 PET Cardiac (myocardial imaging), perfusion multiple studies rest/stress

Nuclear Cardiac Imaging 78494 Cardiac Blood Pool imaging, gated equilibrium, SPECT

Nuclear Cardiac Imaging 78496 Cardiac Blood Pool imaging, gated equilibrium, RV EF by first pass

Unlisted Nuclear Cardiology

78499 Unlisted Nuclear Cardiology diagnostic nuclear

Non-Cardiac PET 78608 PET Brain – metabolic evaluation

Non-Cardiac PET 78609 PET Brain – perfusion evaluation

Non-Cardiac PET 78811 PET imaging; limited area (eg, chest, head/neck)

Non-Cardiac PET 78812 PET imaging; skull base to mid-thigh

Non-Cardiac PET 78813 PET imaging; whole body

Non-Cardiac PET 78814 PET imaging with concurrently acquired CT for attenuation correction and anatomical localization; limited area (eg, chest, head/neck)

Non-Cardiac PET 78815 PET imaging with concurrently acquired CT for attenuation correction and anatomical localization; skull base to mid-thigh

Non-Cardiac PET 78816 PET imaging with concurrently acquired CT for attenuation correction and anatomical localization; whole body

Ceberal Perfusion 0042T Ceberal Perfusion Analysis using CT with contrast

Analysis

CAD for Breast MRI 0159T CAD, including computer algorithm analysis, BREAST

Magnetic Source Imaging

S8035 Magnetic Source Imaging

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CPT

® Category

CPT® Code

CPT® Description

MRCP S8037 MRCP (Magnetic ResonancE)

MRI Low field S8042 MRI Low field

Cardiac CT Calcium Scoring

S8092 CT ELECTRON BEAM (Ultrafast CT) for calcium scoring

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Appendix B – Orthotics and Prosthetics (L codes)

AUTHORIZATION REQUIRED HCPCS Description HCPC

S

Description

L0113 Cranial cervical orthosis, torticollis type, w/wo joint, w/o soft interface, prefab. Incl. fitting & adj.

L5460 Postop app non-wgt bear dsg

L0130 Flex thermoplastic collar molded to patient

L5500 Init bk ptb plaster direct

L0170 Cervical collar molded to pt L5505 Init ak ischal plstr direct

L0220 Thor rib belt custom fabrica L5510 Prep BK ptb plaster molded

L0430 Spinal orthosis, Dewall posture protector

L5520 Perp BK ptb thermopls direct

L0452 TLSO flexible, provides trunk support, upper thoracic region, customized

L5530 Prep BK ptb thermopls molded

L0456 TLSO, flexible thoracic region, prefab L5535 Prep BK ptb open end socket

L0460 TLSO, triplanar control prefab L5540 Prep BK ptb laminated socket

L0462 TLSO, triplanar control, prefab L5560 Prep AK ischial plast molded

L0464 TLSO, triplanar control 4 piece rigid plastic with interface, prefab

L5570 Prep AK ischial direct form

L0480 TLSO, triplanar control, one piece rigid plastic shell

L5580 Prep AK ischial thermo mold

L0482 TLSO, triplanor, custom fabricated, one piece rigid plastic shell, each

L5585 Prep AK ischial open end

L0484 TLSO, triplanor control, two piece L5590 Prep AK ischial laminated

L0486 TLSO, triplanor control 2 piece rigid plastic with interface, custom

L5595 Hip disartic sach thermopls

L0488 TLSO triplanor, one piece, prefab L5600 Hip disart sach laminat mold

L0491 TLSO 2 rigid plastic shells, pre fab L5610 Above knee hydracadence

L0622 Sacroiliac orthosis, flexible, custom L5611 Ak 4 bar link w/fric swing

L0623 Sacroiliac orthosis, rigid or semi-rigid, pre fab

L5613 Ak 4 bar ling w/hydraul swig

L0624 Sacroiliac orthosis, rigid or semi-rigid, custom

L5614 4-bar link above knee w/swng

L0629 Lumbar-sacral orthosis, flexible, custom L5616 Ak univ multiplex sys frict

L0631 Lumbar-sacral orthosis, sagittal control, pre fab

L5639 Below knee wood socket

L0632 Lumbar-sacral orthosis, sag. Control, rigid ant./post. Custom

L5643 Hip flex inner socket ext fr

L0634 Lumbar-sacral orthosis, sag. Control, rigid post., custom

L5645 Ak flexibl inner socket ext

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L0635 Lumbar-sacral orthosis, sag-coronal control, prefab

L5647 Below knee suction socket

L0636 Lumbar-sacral orthosis, sag-coronal control, custom

L5648 Above knee air cushion socket

L0637 Lumbar-sacral orthosis, sag-coronal control, rigid ant/post., prefab

L5649 Isch containmt/narrow m-l so

L0638 Lumbar-sacral orth, sag-coronal control, rigid ant./post., custom

L5651 Ak flex inner socket ext fra

L0639 Lumbar-sacral orthosis, sag.-coronal control, rigid post. Prefab

L5670 Bk molded supracondylar susp

L0640 Lumbar-sacral orthosis, sag-coronal control, rigid post., custom

L5673 below knee/above knee socket insert, silicone gel or elastomeric w/locking mech, custom

L0700 Ctlso a-p-l control molded L5679 below knee/above knee socket insert, silicone gel or elastomeric no locking mech, custom

L0710 Ctlso a-p-l control w/ inter L5681 below knee/above knee, custom fab. Socket inset initial only for cong. Or atypical

L0810 Halo cervical into jckt vest L5682 Bk thigh lacer glut/ischia molded

L0820 Halo cervical into body jack L5683 below knee/above knee, custom fab, socket inset, initial only not cong.or atypical

L0830 Halo cerv into milwaukee typ L5700 Replace socket below knee

L0999 Addition to spinal orthosis, NOS L5701 Replace socket above knee

L1000 Ctlso milwauke initial model L5702 Replace socket hip

L1001 Cervical TLSO, infant, prefab L5704 Custom shape covr below knee

L1200 Furnsh initial orthosis only L5705 Custom shape cover above knee

L1300 Body jacket mold to patient L5706 Custom shape cvr knee disart

L1310 Post-operative body jacket L5707 Custom shape cover hip disart

L1499 Spinal orthosis NOS L5716 Knee-shin exo mech stance ph

L1500 Thkao mobility frame L5718 Knee-shin exo frct swg & sta

L1510 Thkao standing frame L5722 Knee-shin pneum swg frct exo

L1520 Thkao swivel walker L5724 Knee-shin exo fluid swing ph

L1680 Pelvic & hip control thigh c L5726 Knee-shin ext jnts fld swg e

L1685 Post-op hip abduct custom fa L5728 Knee-shin fluid swg & stance

L1686 HO post-op hip abduction L5780 Knee-shin pneum/hydra pneum

L1690 Combination bilateral LS/hip/femur L5781 Addt. to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system

L1700 Legg perthes orth toronto typ L5782 Addt. To lower leg prosth. Vacuum

L1710 Legg perthes orth newington L5790 Exoskeletal ak ultra-light m

L1720 Legg perthes orthosis trilat L5795 Exoskel hip ultra-light mate

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L1730 Legg perthes orth scottish L5811 Endo knee-shin mnl lck ultra

L1755 Legg perthes patten bottom L5814 Endo knee-shin hydral swg ph

L1832 KO adj jnt pos rigid support L5816 Endo knee-shin polyc mch sta

L1834 KO w/0 joint rigid molded to L5818 Endo knee-shin frct swg & st

L1840 KO derot ant cruciate custom L5822 Endo knee-shin pneum swg frc

L1843 KO single upright thigh & calf- prefabricated, each

L5824 Endo knee-shin fluid swing p

L1844 KO w/adj jt rot cntrl molded L5826 Miniature knee joint

L1845 KO w/ adj flex/ext rotat cus L5828 Endo knee-shin fluid swg/sta

L1846 KO w adj flex/ext rotat mold L5830 Endo knee-shin pneum/swg pha

L1860 KO supracondylar socket mold L5840 Multi-axial knee/shin system

L1904 AFO molded ankle gauntlet L5845 Knee-shin sys stance flexion

L1907 supramalleolar w/straps w/wo interface/pads, custom fabricated

L5848 Knee-shin system dampening feature

L1932 AFO, rigid anterior tibial section,pre fab, incl. Fitting & adj.

L5856 Addt. To lower ext. prosthesis, knee shin sys.,microprocessor, incl. Sensor, any type

L1940 AFO, plastic or other material custom L5857 Addt. To lower ext. prosth., swing phase only knee shin sys.,micro, incl. Sensor , any type

L1945 AFO molded plas rig ant tib L5858 Addt. To lower ext. prosth, knee shin sys.,micro, incl. Sens , stance phase

L1950 AFO spiral molded to pt plas L5930 High activity knee frame

L1951 spiral, IRM type, plastic or other material prefab, incl. Fitting and adj.

L5950 Endo ak ultra-light material

L1960 AFO pos solid ank plastic mo; custom L5960 Endo hip ultra-light materia

L1970 AFO plastic molded w/ankle j L5964 addt. Endoskeleton above knee, flexible protective outer surface

L1980 AFO sing solid stirrup calf custom L5966 Hip flexible cover system

L1990 AFO doub solid stirrup calf; custom L5968 Multiaxial ankle w dorsiflex

L2000 KAFO using fre stirr thi/calf; custom L5973 Endoskeletal ankle foot system, microprocessor, incl. power source

L2005 KAFO any material, single or dbl. Upright includes ankle joint custom fabricated

L5976 Energy storing foot

L2010 KAFO single upright, free ankle, solid stirrup

L5979 Multi-axial ankle/ft prosth

L2020 KAFO dbl solid stirrup band/ L5980 Flex foot system

L2030 KAFO dbl solid stirrup w/o j L5981 Flex-walk sys low ext prosth

L2034 KAFO full plastic, single upright, w/wo free motion knee,custom fabricated

L5987 Shank ft w vert load pylon

L2036 KAFO plas doub free knee mol L5988 Vertical shock reducing pylo

L2037 KAFO plas sing free knee mol L5990 addt. To lower ext. user adj. ht

L2038 KAFO w/o joint multi-axis an L5999 Lower extremity prosthesis, NOC

L2050 Hkafo torsion cable hip pelv; custom L6000 Par hand robin-aids thum rem

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L2060 Hkafo torsion ball bearing j; custom L6010 Hand robin-aids little/ring

L2070 Hkafo torsion unilat rot str; custom L6020 Part hand robin-aids no fing

L2080 Hkafo unilat torsion cable, custom L6050 Wrst MLd sck flx hng tri pad

L2090 Hkafo unilat torsion ball br, custom L6055 Wrst mold sock w/exp interfa

L2106 AFO tib fx cast plaster mold, custom L6100 Elb mold sock flex hinge pad

L2108 AFO tib fx cast molded to pt L6110 Elbow mold sock suspension t

L2116 Afo tibial fracture rigid L6120 Elbow mold doub splt soc ste

L2126 Kafo fem fx cast thermoplas L6130 Elbow stump activated lock h

L2128 Kafo fem fx cast molded to p L6200 Elbow mold outsid lock hinge

L2132 Kafo femoral fx cast soft L6205 Elbow molded w/ expand inter

L2134 Kafo fem fx cast semi-rigid L6250 Elbow inter loc elbow forarm

L2136 Kafo femoral fx cast rigid L6300 Shlder disart int lock elbow

L2232 Addt. To lower extremity orthosis, rocker bottom, custom fabricated only

L6310 Shoulder passive restor comp

L2280 Molded inner boot L6320 Shoulder passive restor cap

L2330 Lacer molded to patient, custom L6350 Thoracic intern lock elbow

L2340 Pre-tibial shell molded to p L6360 Thoracic passive restor comp

L2350 Prosthetic type socket molded L6370 Thoracic passive restor cap

L2510 Th/wght bear quad-lat brim m L6380 Postop dsg cast chg wrst/elb

L2520 Th/wght bear quad-lat brim custom L6382 Postop dsg cast chg elb dis/

L2525 Th/wght bear m-l brim mo L6384 Postop dsg cast chg shlder/t

L2526 Th/wght bear m-l brim cu L6400 Below elbow prosth tiss shap

L2540 Thigh/wght bear lacer molded L6450 Elb disart prosth tiss shap

L2627 Plastic mold recipro hip & c L6500 Above elbow prosth tiss shap

L2628 Metal frame recipro hip & ca L6550 Shldr disar prosth tiss shap

L2768 Orthotic side bar, Disconnect device, each

L6570 Scap thorac prosth tiss shap

L2861 addt. to lower ext-joint, knee or ankle, custom only, each

L6580 Wrist/elbow bowden cable mol

L2999 Lower extremity orthosis NOS L6582 Wrist/elbow bowden cbl dir f

L3060 Foot arch support, removable, premolded, longitudinal & horizontal, each

L6584 Elbow fair lead cable molded

L3201 Oxford w supinator/pronator inf each L6586 Elbow fair lead cable dir fo

L3202 Oxford w supinator/pronator child each L6588 Shdr fair lead cable molded

L3203 Oxford w supinator/pronator jun each L6590 Shdr fair lead cable direct

L3204 Hightop w supp/pronator infant each L6611 Addt. To upper ext. prosthesis, ext. pwr switch addt.

L3206 Hightop w supp/pronator child each L6623 Spring-asst. rot wrst w/ latch

L3207 Hightop w supp/pronator junior each L6624 Upper ext. addt. Flex. Ext rotation wrist

L3208 Surgical boot, each infant L6638 upper ext addt. To prosth. Electric locking only for use with manually powered elbow

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L3209 Surgical boot, each child L6686 Suction socket

L3211 Surgical boot, each junior L6689 Frame typ socket shoulder di

L3212 Benesch boot pair infant L6690 Frame typ sock interscap-tho

L3213 Benesch boot pair child L6693 Locking elbow forearm cntrbal

L3214 Benesch boot pair junior L6694 Add. To upper ext. pros.,for use with locking mechanism

L3215 Orthopedic ftwear ladies oxf each L6695 Add. To upper ext. pros., not for use with locking mechanism, custom

L3216 Orthopedic ftwear ladies depth each L6696 Add. To upper ext. pros., congenital or atypical traumatic amputees, initial only

L3217 Ladies shoes hightop depth each L6697 Add. To upper ext. pros., other than congenital or traumatic amputees, initial only

L3219 Orthopedic mens shoes oxford each L6707 term dev hook, mech vol closing, any material, any size, lined or unlined

L3221 Orthopedic mens shoes dpth each L6708 term dev, hand, mech vol opening, any material, any size

L3222 Mens shoes hightop depth inl each L6709 term dev hand, mech vol. closing, any material, any size

L3224 Woman's shoe oxford brace each L6712 Terminal device, hook,mechanical vol. closing, any material, any size, lined or unlined, Pediatric, each

L3225 Man's shoe oxford brace each L6713 Terminal device, hand, mechanical, vol. opening, any material, any size,lined or unlined, Pediatric, each

L3230 Custom shoes depth inlay each L6714 Terminal device, mechanical, vol. closing, any material, any size, Pediatric, each

L3250 Custom mold shoe remov prost each L6721 terminal device, hook or hand, hvy, dty., mechanical, vol.opening, any material, any size, lined or unlined, each

L3251 Shoe molded to pt silicone s each L6722 Terminal device, hook or hand, heavy duty, mechanical, vol. closing, any material, any size, lined or unlined, each

L3252 Shoe molded plastazote cust each L6881 Automatic grasp, addt. To upper limb elect. Prosth. Terminal device

L3253 Shoe molded plastazote cust each L6882 Microprocessor control feature, addt. To upper limb prosth. Terminal device

L3254 Orth foot non-std size/w L6895 Custom glove

L3255 Orth foot non-std size/w L6900 Hand restorat thumb/1 finger

L3257 Orth foot add charge split L6905 Hand restoration multiple fi

L3330 Lift elevation, metal extension, (skate) each

L6910 Hand restoration no fingers

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L3649 orthopedic shoe modification NOS L6915 Hand restoration replacmnt g

L3671 Shoulder othosis, cap design w/o joints L6920 Wrist disarticul switch ctrl

L3702 elbow orthosis w/o joints, may include soft interface, straps, custom fabricated incl. fitting & adj.

L6925 Wrist disart myoelectronic c

L3720 Forearm/arm cuffs free motio L6930 Below elbow switch control

L3730 Forearm/arm cuffs ext/flex a L6935 Below elbow myoelectronic ct

L3740 Cuffs adj lock w/ active con L6940 Elbow disarticulation switch

L3763 elbow wrist hand orthosis rigid w/o joints custom fab incl. fitting & adj.

L6945 Elbow disart myoelectronic c

L3806 WHFO, incl. 1 or more nontorsion joints. Custom

L6950 Above elbow switch control

L3808 WHFO, rigid w/o joints, custom, L6955 Above elbow myoelectronic ct

L3891 Addt. to upper ext. joint, wrist, or elbow, custom fabricated only, each

L6960 Shldr disartic switch contro

L3900 Hinge extension/flex wrist/f L6965 Shldr disartic myoelectronic

L3901 Hinge ext/flex wrist finger L6970 Interscapular-thor switch ct

L3904 Whfo electric custom fitted L6975 Interscap-thor myoelectronic

L3905 wrist/hand orthosis custom L7007 elect. Hand, myoelectric or switch, adult

L3906 Wrist hand orthosis, w/o joints, custom L7008 elect. Hand, myoelectric or switch, ped

L3907 Whfo wrist gauntlt thmb spica L7009 elect hook, switch or myoelect, adult

L3913 Hand finger orthosis, w/o joints, may include soft interface, straps, custom fabricated, incl fitting & adjustment, each

L7040 Prehensile actuator switch controlled

L3927 Finger orthosis, PIP/DIP, non-torsion w/o joint/spring, ext./flex., pre-fab, incl fitting & adj., each

L7045 Electric hook, switch or myoelectric controlled, pediatric

L3933 Finger orthosis, w/o joints, may include soft interface, custom fabricated, incl. fitting & adjustment, each

L7170 Electronic elbow hosmer swit

L3956 addt. Of joint to upper ext orth. any material, per joint

L7180 Electronic elbow utah myoele

L3960 Sewho airplan desig abdu pos L7181 electronic elbow, sim. Control of elbow and terminal device

L3962 Sewho erbs palsey design abd L7185 electronic elbow, sim. Variety Village or equal switch control

L3964 Seo mobile arm sup att to wc L7186 Electron elbow child switch

L3965 Arm supp att to wc rancho ty L7190 Elbow adolescent myoelectron

L3966 Mobile arm supports reclinin L7191 Elbow child myoelectronic ct

L3968 Friction dampening arm supp L7260 Electron wrist rotator otto

L3969 Monosuspension arm/hand supp L7261 Electron wrist rotator utah

L3971 SEHWO, shoulder cap design, custom fabricated

L7266 Servo control steeper or equ

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L3999 Upper limb orthosis, not otherwise specified

L7272 Analogue control unb or equa

L4000 Repl girdle milwaukee orth L7274 Proportional ctl 12 volt uta

L4002 Replacement strap, any orthosis, includes all components, any lgth., any type

L7499 Upper extremity prosthesis NOS

L4010 Replace trilateral socket brim L7500 Prosthetic dvc repair hourly

L4020 Replace quadlat socket brim L7510 Repair of prosthetic device, minor parts

L4030 Replace socket brim cust fit L7520 Repair prosthetic device, labor component, per 15 min

L4040 Replace molded thigh lacer L7600 Prosthetic donning sleeve, any material

L4050 Replace molded calf lacer L7900 Vacuum erection system

L4205 Repair orthotic device per 15 min labor L8000 Mastectomy bra - 5 per year

L4210 repair or replace minor parts L8001 Breast prosthesis , masectomy bra with integrated breast prothesis form, unilateral - 5 per year

L5000 Sho insert w arch toe filler L8002 Breast prosthesis, masectomy bra with integrated breast prothesis form, bilateral - 5 per year

L5010 Mold socket ank hgt w/ toe f L8020 Mastectomy form - 2 per year

L5020 Tibial tubercle hgt w/ toe f L8030 Breast prosthesis silicone/e - 2 per year

L5050 Ank symes mold sckt sach ft L8031 Breast prosthesis, silicone or equal, with intergral adhesive, each

L5060 Symes met fr leath socket ar L8035 Custom breast prosthesis

L5100 Molded socket shin sach foot L8039 Breast prosthesis, NOS

L5105 Plast socket jts/thgh lacer L8040 Nasal prothesis, provided by a non- physician

L5150 Mold sckt ext knee shin sach L8041 Midfacial prothesis, provided by a non- physician

L5160 Mold socket bent knee shin s L8042 Orbital prothesis, provided by a non- physician

L5200 Knee sing axis fric shin sach L8043 Upper facial prosthesis, provided by a non-physician

L5210 No knee/ankle joints w/ ft b L8044 Hemi-facial prosthesis, provided by a non-physician

L5220 No knee joint with artic ali L8045 Prosthetic External Ear provided by a non-physician

L5230 Fem focal defic constant fri L8046 Partial facial prosthesis, provided by a non-physician

L5250 Hip canadian sing axi cons fric L8047 Nasal septal prosthesis, provided by a non-physician

L5270 Tilt table locking hip sing L8048 Unspecified Maxillofacial Prosthesis, by a non-physician

L5280 Hemipelvect canadian sing axis L8049 Repair or modification of maxillofacial prosthesis, by a non-physician

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L5301 Below Knee molded socket, shin each foot, endosketal system

L8499 Unlisted Misc prosthetic service

L5311 Knee disarticulation , molded socket, external knee joints, shin,sach foot endo

L8500 artifical larynx

L5321 Above Knee, molded socket, open end, sach foot, endoskelttal system, single axis knee

L8501 Tracheostomy speaking valve

L5331 Hip disarticulation, Canadian type, molded socket endoskeletal system, hip joint, single

L8505 Artificial larynx replacement battery/accessory, any type, each

L5341 Hemipelvectomy, Canadian type, molded socket, endoskeletal hip joint single axis knee

L8619 cochlear implant external speech processor replacement

L5400 Postop dress & 1 cast chg bk L8627 Cochlear implant, external speech processor, component, replacement

L5410 Postop dsg bk ea add cast ch L8628 Cochlear implant, external controller component, replacement

L5420 Postop dsg & 1 cast chg ak/d L8629 Transmitting coil and cable, integrated for use with cochlear implant device, replacement

L5430 Postop dsg ak ea add cast ch L8691 auditory osseointegrated dev, ext. sound replacer, repl only

L5450 Postop app non-wgt bear dsg

AUTHORIZATION NOT REQUIRED HCPCS Description HCPC

S

Description

L0120 Cerv flexible non-adjustable L3670 Acromio/clavicular canvas&we

L0140 Cervical semi-rigid adjustab L3675 Canvas vest SO

L0150 Cerv semi-rig adj molded chn L3710 Elbow elastic with metal joi

L0160 Cerv semi-rig wire occ/mand L3760 Elbow orthosis, adj position locking joints, prefab, inc fitting and adj

L0172 Cerv col thermplas foam 2 piece L3762 Elbow orthosis rigid, w/o joints, prefab, soft interface, incl. Fitting/adj.

L0174 Cerv col foam 2 piece w thor L3807 WHFO w/o joints, prefab includes fitting and adjustments any type

L0180 Cer post col occ/man sup adj L3908 Wrist cock-up non-molded

L0190 Cerv collar supp adj cerv ba - 1 Per Year

*

L3912 Flex glove w/elastic finger

L0200 Cerv col supp adj bar & thor - 1 per L3915 WHFO, rigid with 1 or more joints,

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year * prefab,

L0450 TLSO flexible, provides trunk support, uper thoracic region, prefab

L3917 hand orthosis, metacarpal fracture orthosis, prefab, incl fitting and adj.

L0454 TLSO, Flexible, provides trunk support, sacrococcygeal juntion to T-9, prefab

L3923 Hand finger orthosis, without joint, prefab, inc fitting and adj

L0466 TLSO Sagittal control, prefab L3925 Finger orthosis, PIP/DIP, non-torsion joint/spring, ext./flex., pre-fab, incl fitting & adj., each

L0468 TLSO sagittal-coronol control, rigid posterior frame - 1 per year *

L3929 Hand finger orthosis, incl. 1 or more nontorsion joints, turnbuckles, elastic bands/spring, straps, pre-fab, incl. fitting & adj., each

L0470 TLSO triplanar control - 1 per year * L3931 Wrist, hand, finger orthosis, incl. 1 or more nontorsion joints,turnbuckles, elastic bands/springs, straps, pre-fab, incl. fitting & adj., each

L0472 TLSO, triplanar control, hyperextension prefab - 1 per year *

L3970 Elevat proximal arm support

L0490 TLSO sagittal coronal control one piece prefab

L3972 Offset/lat rocker arm w/ ela

L0492 TLSO 3 rigid plastic shells, pre fab - 1 per year *

L3974 Mobile arm support supinator

L0621 Sacroiliac orthosis, flexible, pre fab L3980 Upp ext fx orthosis humeral

L0625 Lumbar orthosis, flexible, pre fab L3982 Upper ext fx orthosis rad/ul

L0626 Lumbar orthosis, sagittal control, pre fab

L3984 Upper ext fx orthosis wrist

L0627 Lumbar orthosis, sagittal control with rigid ant./post. Panels, pre fab

L3995 Add. To upper ext. sock, fracture, or equal, each

L0628 Lumbar-sacral orthosis, flexible, pre fab L4045 Replace non-molded thigh lac

L0630 Lumbar-sacral orthosis, sag. Control, pre fab

L4055 Replace non-molded calf lace

L0633 Lumbar-sacral orthosis, sag. Control, rigid post., pre fab

L4060 Replace high roll cuff

L0970 Tlso corset front L4070 Replace prox & dist upright

L0972 Lso corset front L4080 Repl met band kafo-afo prox

L0974 Tlso full corset L4090 Repl met band kafo-afo calf/

L0976 Lso full corset L4100 Repl leath cuff kafo prox th

L0978 Axillary crutch extension L4110 Repl leath cuff kafo-afo cal

L0980 Peroneal straps pair L4130 Replace pretibial shell

L0982 Stocking supp grips set of 4 L4350 Pneumatic ankle cntrl splint

L0984 Protective body sock each L4360 Pneumatic walking splint

L1010 Ctlso axilla sling L4370 Pneumatic full leg splint

L1020 Kyphosis pad L4380 Pneumatic knee splint

L1025 Kyphosis pad floating L4386 Non-pneumatic walking boot

L1030 Lumbar bolster pad L4394 Replacement Foot Drop Splint

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L1040 Lumbar or lumbar rib pad L4396 Static AFO

L1050 Sternal pad L4398 Foot drop splint recumbent

L1060 Thoracic pad L5617 AK/BK self-aligning unit ea

L1070 Trapezius sling L5618 Test socket symes

L1080 Outrigger L5620 Test socket below knee

L1085 Outrigger bil w/ vert extens L5622 Test socket knee disarticula

L1090 Lumbar sling L5624 Test socket above knee

L1100 Ring flange plastic/leather L5626 Test socket hip disarticulat

L1110 Ring flange plas/leather molded to patient

L5628 Test socket hemipelvectomy

L1120 Covers for upright each L5629 Below knee acrylic socket

L1210 Lateral thoracic extension L5630 Syme typ expandabl wall sckt

L1220 Anterior thoracic extension L5631 Ak/knee disartic acrylic soc

L1230 Milwaukee type superstructur L5632 Symes type ptb brim design s

L1240 Lumbar derotation pad L5634 Symes type poster opening so

L1250 Anterior asis pad L5636 Symes type medial opening so

L1260 Anterior thoracic derotation pad L5637 Below knee total contact

L1270 Abdominal pad L5638 Below knee leather socket

L1280 Rib gusset (elastic) each L5640 Knee disarticulat leather so

L1290 Lateral trochanteric pad L5642 Above knee leather socket

L1600 Abduct hip flex frejka w cvr L5644 Above knee wood socket

L1610 Abduct hip flex frejka covr L5646 Below knee air cushion socket

L1620 Abduct hip flex pavlik harne L5650 Tot contact ak/knee disart s

L1630 Abduct control hip semi-flex L5652 Suction susp ak/knee disart

L1640 Pelv band/spread bar thigh c L5653 Knee disart expand wall sock

L1650 HO abduction hip adjustable L5654 Socket insert symes

L1660 HO abduction static plastic L5655 Socket insert below knee

L1810 KO elastic with joints L5656 Socket insert knee articulat

L1820 KO elas w/ condyle pads & jo L5658 Socket insert above knee

L1830 KO immobilizer canvas longit L5661 Multi-durometer symes

L1831 KO locking knee joint pre fab incl. Fitting and adj.

L5665 Multi-durometer below knee

L1847 KO adjustable w air chambers L5666 Below knee cuff suspension

L1850 KO swedish type L5668 Socket insert w/o lock lower

L1900 AFO sprng wir drsflx calf bd L5671 Addition to lower extremity, below knee/above knee suspension locking mechanism

L1902 AFO ankle gauntlet L5672 Bk removable medial brim sus

L1906 AFO multiligamentus ankle su L5676 Bk knee joints single axis pair

L1910 AFO sing bar clasp attach sh L5677 Bk knee joints polycentric pair

L1920 AFO sing upright w/ adjust s L5678 Bk joint covers pair

L1930 AFO plastic or other material, includes L5680 Bk thigh lacer non-molded

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fitting & adjustment

L1971 plastic or other material w/ankle joint, prefab, incl. Fitting and adj.

L5684 Bk fork strap

L2035 KAFO plastic pediatric size L5685 Addt. To lower ext. orthosis, below knee, susp./sealing sleeve, any mat. Each

L2040 Hkafo torsion bil rot straps L5686 below knee back check extension control

L2112 AFO tibial fracture soft, pre-fab L5688 Bk waist belt webbing

L2114 AFO tib fx semi-rigid, pre-fab L5690 Bk waist belt padded and lin

L2180 Plas shoe insert w ank joint L5692 Ak pelvic control belt light

L2182 Drop lock knee L5694 Ak pelvic control belt pad/l

L2184 Limited motion knee joint L5695 Ak sleeve susp neoprene/equa

L2186 Adj motion knee jnt lerman t L5696 Ak/knee disartic pelvic join

L2188 Quadrilateral brim L5697 Ak/knee disartic pelvic band

L2190 Waist belt L5698 Ak/knee disartic silesian ba

L2192 Pelvic band & belt thigh fla L5699 Shoulder harness

L2200 Limited ankle motion ea jnt L5710 Kne-shin exo sng axi mnl loc

L2210 Dorsiflexion assist each joi L5711 Knee-shin exo mnl lock ultra

L2220 Dorsi & plantar flex ass/res L5712 Knee-shin exo frict swg & st

L2230 Split flat caliper stirr & p L5714 Knee-shin exo variable frict

L2240 Addt. To lower extremity orthosis, round caliper & plate attachment

L5785 Exoskeletal bk ultralt mater

L2250 Foot plate molded stirrup at L5810 Endoskel knee-shin mnl lock

L2260 Reinforced solid stirrup L5812 Endo knee-shin frct swg & st

L2265 Long tongue stirrup L5850 Endo ak/hip knee extens assi

L2270 Varus/valgus strap padded/li L5855 Mech hip extension assist

L2275 Plastic mod low ext pad/line L5910 Addt. Endoskeleton, below knee, alignable system

L2300 Abduction bar jointed adjust L5920 Endo ak/hip alignable system

L2310 Abduction bar-straight L5925 Above knee manual lock

L2320 Non-molded lacer L5940 Endo bk ultra-light material

L2335 Anterior swing band L5962 Below knee flex cover system

L2360 Extended steel shank L5970 Foot external keel sach foot

L2370 Patten bottom L5971 All lower extremity prosthesis, SACH foot, replacement only

L2375 Torsion ank & half solid sti L5972 Flexible keel foot

L2380 Torsion straight knee joint; L5974 Foot single axis ankle/foot

L2385 Straight knee joint heavy du L5975 Combo ankle/foot prosthesis

L2387 Addt. to lower extremity, polycentric knee joint, for custom fabricated KAFO, each joint

L5978 Ft prosth multiaxial ankl/ft

L2390 Offset knee joint each L5982 Exoskeletal axial rotation

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L2395 Offset knee joint heavy duty L5984 Endoskeletal axial rotation, w/wo adjustability

L2397 Suspension sleeve lower ext L5985 Lwr ext dynamic prosth pylon

L2405 Knee joint drop lock ea jnt L5986 Multi-axial rotation unit

L2415 Knee joint cam lock each joi L6386 Postop ea cast chg & realign

L2425 Knee disc/dial lock/adj flex L6388 Postop applicat rigid dsg on

L2430 Knee jnt ratchet lock ea jnt L6600 Polycentric hinge pair

L2492 Knee lift loop drop lock rin L6605 Single pivot hinge pair

L2500 Thi/glut/ischia wgt bearing L6610 Flexible metal hinge pair

L2530 Thigh/wght bear lacer non-mo L6615 Disconnect locking wrist uni

L2550 Thigh/wght bear high roll cu L6616 Disconnect insert locking wr

L2570 Hip clevis type 2 posit jnt L6620 Flexion-friction wrist unit

L2580 Pelvic control pelvic sling L6625 Rotation wrst w/ cable lock

L2600 Hip clevis/thrust bearing fr L6628 Quick disconn hook adapter o

L2610 Hip clevis/thrust bearing lo L6629 Lamination collar w/ couplin

L2620 Pelvic control hip heavy dut L6630 Stainless steel any wrist

L2622 Hip joint adjustable flexion L6632 Latex suspension sleeve each

L2624 Hip adj flex ext abduct cont L6635 Lift assist for elbow

L2630 Pelvic control band & belt u L6637 Nudge control elbow lock

L2640 Pelvic control band & belt b L6640 Shoulder abduction joint pai

L2650 Pelv & thor control gluteal L6641 Excursion amplifier pulley t

L2660 Thoracic control thoracic ba L6642 Excursion amplifier lever ty

L2670 Thorac cont paraspinal uprig L6645 Shoulder flexion-abduction joint, each

L2680 Thorac cont lat support upri L6650 Shoulder universal joint, each

L2750 Plating chrome/nickel pr bar L6655 Standard control cable extra

L2755 Addt. Lower ext.,high strength, custom fab. Only

L6660 Heavy duty control cable

L2760 Extension per extension per L6665 Teflon or equal cable lining

L2780 Non-corrosive finish per bar L6670 Hook to hand cable adapter

L2785 Drop lock retainer each L6672 Harness chest/shlder saddle

L2795 Knee control full kneecap L6675 Harness figure of 8 sing con

L2800 Knee cap medial or lateral p L6676 Harness figure of 8 dual con

L2810 Knee control condylar pad L6680 Test sock wrist disart/bel e

L2820 Soft interface below knee se L6682 Test sock elbw disart/above

L2830 Soft interface above knee se L6684 Test socket shldr disart/tho

L2840 Tibial length sock fx or equ L6687 Frame typ socket bel ow elbow or wrist

L2850 Femoral lgth sock fx or equa L6688 Frame typ sock above elbow or elbow disarticulation

L3000 foot insert Berkeley shell, each L6691 Removable insert each

L3001 foot insert Spenco, each L6692 Silicone gel insert or equal

L3002 foot insert, Plastazote , each L6698 Add. To upper ext. pros., lock mechanism, excludes socket insert

of 39

L3003 foot insert, Silicone gel , each L6703 term. Device, passive hand mitt, any material, any size

L3010 Longitudinal Arch support each L6704 term. Device, sport/rec/work, any material, any size

L3020 Foot longitud/metatarsal supp L6706 term dev hook, mech vol opening, any material, any size

L3030 Foot arch support remov prem L6711 Terminal device, hook, mechanical, vol. opening, any material, any size, lined or unlined, Pediatric, each

L3040 Foot arch support remov premolded longitudinal, each

L6805 Modifier wrist flexion unit addt to terminal device

L3100 Hallus-valgus night dynamic splint L6810 Addt to terminal device, precision pinch device

L3140 Abduction rotation bar shoe L6890 Production glove

L3150 Abduction rotation bar w/o shoe L7360 Six volt battery, each

L3160 Shoe styled postioning device L7362 Battery charger, six volt, each

L3170 Foot plastic heel stablizer L7364 Twelve volt battery , each - 2 per year *

L3260 Ambulatory surgical boot each L7366 Battery charger 12 volt each - 1 per 4 years *

L3265 Plastazole sandal each L7367 lithium ion battery replacement

L3300 Lift, Elevation Heel, Tapered to Metata L7368 Lithium battery charger - 1 per 4 years *

L3310 Shoe lift elev heel/sole neo L7400 Addt. To upper ext. prosth. Ultralight material

L3320 shoe lift elev heel/sole cor L7401 Addt. To upper ext. prosthesis above elbow disart. Ultralight material

L3332 Shoe lift inside tapered up to 1/2 inch L7403 Addt. To upper ext. prosth. acrylic material

L3334 Shoe, lift elevation, heel, per inch, each L7404 addt. To upper ext prosth. Above elbow disart. Acrylic

L3340 shoe wedge sach L8010 Mastectomy sleeve

L3350 shoe sole wedge L8015 Ext breast prosthesis garment

L3360 shoe sole wedge outside sole L8300 Truss single w/ standard pad

L3370 shoe sole wedge between sole L8310 Truss double w/ standard pad

L3380 shoe clubfoot wedge L8320 Truss addition to std pad wa

L3390 shoe outflare wedge L8330 Truss add to std pad scrotal

L3400 shoe metarsal bar wedge L8400 Sheath below knee

L3410 shoe metarsal bar between L8410 Sheath above knee

L3420 full sole/heel wedge btween L8415 Sheath upper limb

L3430 shoe heel count plast reinforc L8417 Prosthetic sheath/sock, incl. gel cushion layer, below knee or above knee, each

L3440 heel leather reinforced L8420 Prosthetic sock multi ply BK

L3450 shoe heel sach cushion type L8430 Prosthetic sock multi ply AK

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L3455 shoe heel new leather standard L8435 Pros sock multi ply upper lm

L3460 shoe heel new rubber standard L8440 Shrinker below knee

L3465 shoe heel thomas with wedge L8460 Shrinker above knee

L3470 shoe heel thomas extend to B L8465 Shrinker upper limb

L3480 shoe heel pad &depress for L8470 Pros sock single ply BK

L3485 shoe heel pad removeable for L8480 Pros sock single ply AK

L3500 ortho shoe add leather insol L8485 Pros sock single ply upper l

L3510 orthopedic shoe add rub insl L8507 Tracheo-esophageal voice prosthesis, patient inserted, any type

L3520 ortho shoe add felt w leather insol L8509 Tracheo-esophageal voice prosthesis, inst. by lic. Health care provider, any type

L3530 ortho shoe add half sole L8510 Voice Amplifier

L3540 ortho shoe add full sole L8511 Insert for Indwelling T/E prosthesis with or W/O valve replacement each

L3550 ortho shoe add standard toe tap L8512 Gelatin capsules or equ. use with T/E prosthesis replacement only per 10

L3560 ortho shoe add horseshoe toe tap L8513 Cleaning device used with T/E prosthesis replacement only each

L3570 ortho shoe add instep extension L8514 T/E puncture dilator replacement only each

L3580 ortho shoe add instep velcro clos L8515 gelatin capsule application device for use with TE voice prosthesis, each

L3590 ortho shoe convert firm to soft count L8615 Headset/Headpiece for use with cochlear implant device, replacement

L3595 ortho shoe add march bar L8616 microphone for use with cochlear implant device, replacement

L3600 Trans shoe calip plate exist L8617 transmitting coil for use with cochlear implant device, replacement

L3610 Trans shoe caliper plate new L8618 transmitter cable for use with cochlear implant device, replacement

L3620 Trans shoe solid stirrup existing L8621 Zinc air battery for use with cochlear implant device, each

L3630 Trans shoe solid stirrup new L8622 Alkaline batt. For use with coch. Imp. Device, any size,each

L3640 Shoe Dennis Browne splint both L8623 Lithium ion battery coch. imp. Device speech proc.other than Ear level, ea

L3650 Shlder fig 8 abduct restrain L8624 Lithium ion battery for coch. imp. Device speech proc. Ear level, each

L3660 Abduct restrainer canvas&web L8695 ext recharging sys for battery(ext) for use with implantable neurostimulator

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Appendix C – Ostomy Supplies Any request that exceeded $500.00 will require prior authorization.

AUTHORIZATION REQUIRED A4421 Ostomy supply, miscellaneous Authorization is required

A4465 Non elastic binder for extremity Authorization is required

A4466 Garment, belt, sleeve or other covering, elastic or similar stretchable material, any type, each

Authorization is required

A4483 Moisture exchanger, disposable, for use with invasive mechanical ventilation, each

Authorization is required

A4600 sleeve for intmt. Limb compression device, replac. only Authorization is required

A4601 Lithium ion battery for non-prosthetic use, repl. Only Authorization is required

A4649 Surgical Supply, Miscellaneous Authorization is required

AUTHORIZATION REQUIRED IF QUANTITY LIMIT IS

EXCEEDED A4366 Ostomy vent, any type, each Authorization required > 1 per calendar month

A4367 Ostomy belt Authorization required > 1 per calendar month

A4400 Ostomy irrigation set Authorization required > 1 per calendar month

A4404 Ostomy ring each Authorization required > 10 per calendar month

A4362 Solid skin barrier Authorization required > 20 per calander month

A4398 Ostomy irrigation bag Authorization required > 4 per year

A4399 Ostomy irrig cone/cath w brs Authorization required > 4 per year

A4402 Lubricant price is per oz. 1 oz.=1 unit Authorization required > 4 oz per calendar month

A4397 Irrigation supply sleeve Authorization required > 4 per calendar month

A4361 Ostomy face plate Authorization required > 6 per year

A4416 Ostomy pouch, closed, w/barrier att. W/filter 1 pc. Each Authorization required > 60 per calendar month

A4417 Ostomy pouch,closed, w/barrier att.,w/built-in convexity, w/filter 1 pc, each

Authorization required > 60 per calendar month

A4418 Ostomy pouch,closed, w/o barrier att. W/filter 1 pc. Each Authorization required > 60 per calendar month

A4419 Ostomy pouch, closed, use on barrier w/non-lock flange,w/filter 2pc, each


A4420 Ostomy pouch, closed, use on barrier with lock flange 2 pc, each Authorization required > 60 per calendar month

of 39

A4423 Ostomy pouch closed, 2 pc. Locking flange, each Authorization required > 60 per calendar month

A4424 Ostomy pouch, drainable,w/barrier 1 pc, each Authorization required > 60 per calendar month

A4425 Ostomy pouch drainable, non-locking flange 2 pc each Authorization required > 60 per calendar month

A4426 Ostomy pouch, drainable, with locking flange, 2 pc. Each Authorization required > 60 per calendar month

A4427 Ostomy pouch, drainable , use on barrier w/locking flange, w/filter 2 pc, each


A4428 Electrodes, apnea monitor, per pair Authorization required > 60 per calendar month

A4429 Ostomy pouch, urinary w/convexity, faucet type tap, each Authorization required > 60 per calendar month

A4430 ostomy pouch urinary, ext. wear, convexity, faucet tap, each Authorization required > 60 per calendar month

A4431 ostomy pouch, urinary, w/barrier, faucet type tap, w/valve ea. Authorization required > 60 per calendar month

A4432 ostomy pouch, urinary, non-locking flange, faucet type, ea. Authorization required > 60 per calendar month

A4433 ostomy pouch, urinary, w/locking flange, ea. Authorization required > 60 per calendar month

A4434 ostomy pouch, urinary, w/locking flange, w/faucet type tap ea. Authorization required > 60 per calendar month

A4624 Tracheal suction tube Authorization required > 91 per calendar month

A4625 Trach care kit for new trach Authorization required if > 1 per calendar month

A5082 Continent stoma catheter Authorization required if > 1 per calendar month

A5093 Ostomy accessory convex inse Authorization required if

> 10 per calendar month

A4626 Tracheostomy cleaning brush Authorization required if


A5061 Pouch drainable w barrier at Authorization required if


A5062 Drnble ostomy pouch w/o barr Authorization required if > 20 per calendar month

A5063 Drain ostomy pouch w/flange Authorization required if > 20 per calendar month

A5071 Urinary pouch w/barrier Authorization required if > 20 per calendar month

A5072 Urinary pouch w/o barrier Authorization required if > 20 per calendar month

A5073 Urinary pouch on barr w/flng Authorization required if > 20 per calendar month

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A4623 Tracheostomy inner cannula Authorization required if > 31 per calendar month

A5055 Stoma cap Authorization required if > 31 per calendar month

A5081 Continent stoma plug Authorization required if > 31 per calendar month

A4455 Adhesive remover per ounce Authorization required if > 32 ounces

A5051 Pouch clsd w barr attached Authorization required if > 60 per calendar month

A5052 Clsd ostomy pouch w/o barr Authorization required if > 60 per calendar month

A5053 Clsd ostomy pouch faceplate Authorization required if > 60 per calendar month

A5054 Clsd ostomy pouch w/flange Authorization required if > 60 per calendar month

AUTHORIZATION NOT REQUIRED A4392 Urinary pouch w st wear barr No authorization required

A4363 Ostomy clamp, any type , each No authorization required

A4364 Adhesive, liquid or equal, any type, per ounce No authorization required

A4365 Ostomy adhesive remover wipe No authorization required

A4368 Ostomy filter No authorization required

A4369 Skin barrier liquid per oz No authorization required

A4371 Skin barrier powder per oz No authorization required

A4372 Ostomy Skin barrier solid 4x4 equiv No authorization required

A4373 Skin barrier with flange No authorization required

A4375 Drainable plastic pch w fcpl No authorization required

A4376 Drainable rubber pch w fcplt No authorization required

A4377 Drainable plstic pch w/o fp No authorization required

A4378 Drainable rubber pch w/o fp No authorization required

A4379 Urinary plastic pouch w fcpl No authorization required

A4380 Urinary plastic pouch w/o fp No authorization required

A4381 Ostomy pouch, urinary, for use on faceplate, plastic, each No authorization required

A4382 Urinary hvy plstc pch w/o fp No authorization required

A4383 Urinary rubber pouch w/o fp No authorization required

A4384 Ostomy faceplt/silicone ring No authorization required

A4385 Ost skn barrier sld ext wear No authorization required

A4387 Ost clsd pouch w att st barr No authorization required

A4388 Drainable pch w ex wear barr No authorization required

A4389 Drainable pch w st wear barr No authorization required

A4390 Drainable pch ex wear convex No authorization required

A4391 Urinary pouch w ex wear barr No authorization required

A4393 Urine pch w ex wear bar conv No authorization required

A4394 Ostomy pouch liq deodorant w/wo lubricant No authorization required

A4395 Ostomy pouch solid deodorant No authorization required

A4396 Ostomy belt with peristomal hernia support No authorization required

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A4405 Ostomy skin barrier, non-pectin based, paste, per oz No authorization required

A4406 Ostomy skin barrier, pectin based, per oz No authorization required

A4407 Ostomy skin barrier, with fl, extend wear, built in convexity, 4x4 or <

No authorization required

A4408 Ostomy skin barrier, with fl, extend wear, built in convexity, 4x4 or >


A4409 Ostomy skin barrier with flange No authorization required

A4410 Ostomy skin barrier, with fl, ex wear, without built in convexity, >4x4 ea


A4411 Ostomy skin barrier, solid 4x4 or eq. ext. wear, built in convexity, each


A4412 Ostomy pouch, drainable, high otpt, use on barrier w/ o filter each


A4413 Ostomy pouch, drainable, high otpt, use on barrier w/ fl with filter ea


A4414 Ostomy skin barrier, with fl, w/o built in convexity 4x4 or < No authorization required

A4415 Ostomy skin barrier, with fl, w/o built in convexity 4x4 or > No authorization required

A4450 Tape, non-water proof, 18 sq inches No authorization required

A4452 Tape, water proof , 18 sq inches No authorization required

A4456 Adhesive remover, wipes, any type, each No authorization required

A4481 Tracheostoma filter No authorization required

A4556 Electrodes, apnea monitor, per pair No authorization required

A4557 Lead wires, apnea monitor per pair No authorization required

A4558 Conductive paste or gel for use with electrical device E.G. tens No authorization required

A4561 Pessary, rubber, any type No authorization required

A4562 Pessary, nonrubber, any type No authorization required

A4565 Slings No authorization required

A4566 Canvas vest SO No authorization required

A4595 TENS suppl 2 lead per month No authorization required

A4604 tubing with integrated heat use with pos. airway pressure device No authorization required

A4605 Tracheal suction catheter, closed system, each No authorization required

A4606 Oximeter probe replacement No authorization required

A4608 Transtracheal oxygen catheter, each No authorization required

A4611 Heavy duty battery, Ventilator, replacement for patient owned No authorization required

A4612 Battery cables No authorization required

A4613 Battery charger No authorization required

A4614 Hand-held PEFR meter No authorization required

A4618 Breathing circuits No authorization required

A4619 Face tent No authorization required

A4627 Spacer, bag or reservoir for inhaler No authorization required

A4628 Oropharyngeal suction cath No authorization required

A4629 Tracheostomy care kit No authorization required

A4630 Repl bat t.e.n.s. own by pt No authorization required

A4635 Underarm crutch pad No authorization required

A4636 Handgrip for cane etc No authorization required

A4637 Repl tip cane/crutch/walker No authorization required

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A4640 Alternating pressure pad No authorization required

A5083 Continent device, stoma absorptive cover for continent device, each


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