WellFirst Employee Health Plan Master Service List

SSM Health Employee Plan UPDATED: March 1, 2022 Back to Table of Contents

Coverage of any medical or drug intervention discussed in this document is subject to the limitations and exclusions outlined in the member’s benefit certificate or policy and to applicable state and/or federal laws.

The complete medical policy library is available on SSM Health Employee Medical Plan .1

WellFirst SSM Health Employee Health Plan Master Service List (MSL)

Note: The pages with the purple sections give information on services that do not require prior authorization

https://wellfirstbenefits.com/Document-Library?SearchText=&SelectedAudienceOption=Provider&SelectedCategoryOption=Medical+Policies

https://wellfirstbenefits.com/employees




Table of Contents

NOTE: The codes listed on this document may not be an all-inclusive list of codes that require prior authorization and/or have coverage limitations. If you are unable to find the information you need, please contact the WellFirst SSM Health Employee Health Plan Customer Care Center at 877-274-4693.

Special Topic

Providers without Access to the WellFirst Health Provider Portal Magellan’s Musculoskeletal (MSK) Care Management Program

Medical Policy/Service Name Alternate Service Name(s) Medical Policy No.

Abortions (Surgical or Pharmacological) N/A MP9202 Acne N/A MP9023 Amino Acid- and Low Lipid-Based Formulas Elecare, Neocate, Nutramigen AA MP9355 Antihemophilia Factors and Clotting Factors N/A MB1802 Antihemophilic Factor VIII Products N/A MB2116 Antihemophilic Factor IX Products N/A MB2117 Auditory Brain Stem and Cochlear Implants N/A MP9016 Back or Spinal Orthosis: Lumbosacral (LSO) or Thoracolumbosacral (TLSO) LSO, TLSO MP9261 Bariatric Surgery N/A MP9319 Biofeedback N/A MP9163 Blepharoplasty or Blepharoptosis (Eyelid Surgery) Eyelid Surgery MP9214 Bone Anchored Hearing Aid BAHA MP9018 Bone Growth (Osteogenesis) Stimulators (BGS) BGS MP9076 Breast Pumps, Hospital Grade N/A MP9092 Breast Reconstruction Surgery Cancer-Related Breast Surgeries MP9476

Breast Surgeries Augmentation Mammoplasty, Non-Cancer-Related Breast Surgeries, Reduction Mammoplasty

MP9026

Cardioverter-Defibrillator, Wearable (Zoll LifeVest) AED, AED Vest for Individual Use, Automatic External Defibrillator (Garment Type), Zoll LifeVest

MP9522

Cardiac Monitoring Devices and Cardiac Procedures N/A MP9540 Cervical Spine Surgery, Inpatient and Outpatient C-Spine Surgery N/A Clinical Trials Non-Cancer-Related Clinical Trials MP9447 Continuous Glucose Monitoring N/A MP9091






Medical Policy/Service Name Alternate Service Name(s) Medical Policy No. Corneal Cross-Linking (CXL) CXL MP9470 Cranial Orthotic Devices for Plagiocephaly N/A MP9495

CT Scan CAT Scan, Computerized Tomography, Computerized Tomography Angiography, CTA

N/A

Deep Brain Stimulation (DBS) DBS MP9331 Dental Prosthesis and Oncology Services N/A MP9125

Dental Services and Treatment Required for Direct Treatment of a Medical Condition N/A MP9552 Diagnostic, Therapeutic, and Surveillance Colonoscopy N/A MP9510 Dynamic Splinting and Static Progressive Stretch Devices N/A MP9289 Echocardiogram and Stress Echocardiogram N/A MP9513 Electric Tumor Treatment Field (Optune) ETTF, Optune MP9474 Electroretinogram or Electroretinography (ERG) ERG MP9542 Endometrial Biopsy N/A MP9509 Engineered Products for Wound Healing N/A MP9287 Enteral Therapy Tube Feedings MP9069 Epidural Steroid Injection (ESI) ESI MP9362 Facet Joint Injections and Radiofrequency Ablation RFA MP9448 Gait Trainer, Pediatric N/A N/A Gastric Pacemaker and Gastric Electrical Stimulation N/A MP9463 General Anesthesia for GI Endoscopy N/A MP9519 Genetic Testing N/A MP9012 Glaucoma Surgery Devices N/A MP9467 Habilitation Services and Devices N/A MP9443 Health and Behavior Assessment Intervention for Stress Management and Relaxation Training N/A MP9375 Hearing Aids Non-Bone Anchored Hearing Aids MP9445 Hemodialysis and Peritoneal Dialysis HD, PD, dialysis N/A High Frequency Chest Compression (Vest System) N/A MP9235 Hip Surgery, Inpatient and Outpatient N/A N/A Home Health Care N/A N/A Home Infusion N/A N/A Hospice Services N/A MP9299






Medical Policy/Service Name Alternate Service Name(s) Medical Policy No.

Hospital Beds Manual Hospital Bed, Semi-Electric Hospital Bed

MP9292

Hyperbaric Oxygen Therapy (HBO) HBO, HBO Therapy MP9055 Hyperhidrosis Treatment N/A MP9224 Intermittent Pneumatic Compression Devices N/A MP9119 Interspinous Spacer System ISS VertiFlex MP9544 Intrathecal Pump Implantation N/A MP9278 Knee Surgery, Inpatient and Outpatient N/A N/A Laser Treatment for Psoriasis N/A MP9399 Limb Prosthesis N/A MP9103 LINX Reflux Management System N/A MP9471 Liver and Other Neoplasm – Chemoembolization (CE) and Intra-Hepatic Microspheres (TheraSphere)

N/A MP9462

Lumbar Discography Lumbar Paravertebral Injection MP9427 Lumbar Spine Surgery, Inpatient and Outpatient L-Spine Surgery N/A Lymphedema Compression Devices N/A MP9119 Mechanical Stretching Devices for Contracture and Joint Stiffness N/A MP9289 Micra Permanent Leadless Pacemaker N/A MP9518 Minimally Invasive Lumbar Decompression (MILD) (Vertos) Vertos MP9551

MRI/MRA Magnetic Resonance Angiography, Magnetic Resonance Imaging

N/A

Nasal Endoscopy N/A MP9514 Neuropsychological Testing N/A MP9493 Non-Covered Durable Medical Equipment/Supplies Non-Covered DME MP9347 Non-Covered Medical Procedures and Services N/A MP9415 Nuclear Stress Testing ETT, Exercise Tolerance Test N/A Occupational Therapy (OT) OT N/A Orthosis: Ankle (AFO), Knee Ankle Foot (KAFO), or Knee (KO) N/A MP9085 Oxygen (High Flow) for Cluster Headaches O2 Therapy N/A Partial Hospitalization Program (PHP) – Behavioral Health PHP MP9555 Pectus Excavatum and Pectus Carinatum Treatment N/A MP9206 Percutaneous Left Atrial Appendage (LAA) Closure Therapy LAA MP9499 Percutaneous Left Ventricular Assist Device (pVAD) pVAD MP9528






Medical Policy/Service Name Alternate Service Name(s) Medical Policy No. Percutaneous Mitral Valve Repair (MitraClip®) MitraClip® MP9500 Percutaneous Pulmonary Valve Implantation (Melody Valve) Melody Valve MP9440 PET Scan Positron Emission Tomography N/A Phototherapy for Skin Conditions, Including Home Ultraviolet Light (UVB) UVB MP9057 Physical Therapy (PT) PT N/A Plastic and Reconstructive Surgery N/A MP9022 Port Wine Stain Laser Treatment N/A MP9207 Pressure Reducing Support Surfaces N/A MP9494 Prostate Treatment N/A MP9361 Prothrombin Time (INR) Home Monitoring Device N/A MP9263 Refractive and Therapeutic Keratoplasty Corneal Surgery MP9461 Repairs/Replacement of Durable Medical Equipment/Supplies DME Repairs/Replacement MP9106 Residential Treatment – Behavioral Health N/A MP9554 Responsive Cortical Stimulation RNS MP9496 Risk Reducing (Prophylactic) Mastectomy N/A MP9449 Sacroiliac (SI) Joint Injections SI Joint Injections MP9466 Seat-Lift Mechanisms N/A MP9102 Services Related to Dental Care N/A MP9271 Sex Reassignment (Sex Transformation) Surgery N/A MP9465 Shingrix (RZV), Non-Routine Use Shingles vaccine MP9549 Shoes and Shoe Modifications (Custom Molded/Corrective/Therapeutic) N/A MP9061 Shoulder Surgery, Inpatient and Outpatient N/A N/A Skilled Nursing Facility Nursing Home, SNF MP9310 Sleep Studies: Attended Polysomnography and Portable Polysomnography Tests, Multiple Sleep Latency Testing and Maintenance of Wakefulness Testing

MSLT, MWT, Portable Sleep Studies, PSG MP9132

Sleep Studies: Home Sleep Studies Home Sleep Studies MP9132 Speech Generating Device (SGD) Alternative Communication Device, SGD MP9523

Speech Therapy (Rehabilitative/Habilitative) Acute Speech Therapy, Habilitative Speech Therapy, Rehabilitative Speech Therapy

MP9171

Spinal Cord or Dorsal Column Stimulation and Dorsal Root Ganglion (DRG) Stimulation DCS, DRG, SCS MP9430 Stereotactic Body Radiotherapy N/A MP9459 Stereotactic Cranial Radiosurgery N/A MP9345






Medical Policy/Service Name Alternate Service Name(s) Medical Policy No. Temporomandibular Disease (TMD) Services TMD, TMJ MP9272

Therapeutic Contact Lens Bandage Lens, Hydrophilic Lens, Rigid Gas Permeable (RGP) Lens

MP9201

Total Ankle Arthroplasty N/A MP9363 Total Knee Arthroplasty (TKA) and Total Hip Arthroplasty (THA) Ambulatory Level of Care TKA, THA MP9550 Traction for Cervical and Lumbar Pain N/A MP9302 Transcranial Magnetic Stimulation TMS MP9526

Transport of Members (Ambulance) Air Ambulance, Ambulance, Ground Ambulance, Stretcher Van

MP9137

Treatment of Obstructive Sleep Apnea (OSA) BiPAP, CPAP, OSA MP9239 Upper Endoscopy (EGD) Esophagogastroduodenoscopy EGD MP9517

Urine Drug Testing (UDT) Presumptive and Definitive UDT, Urine Drug Screening, Urine Drug Testing

MP9460

Vagus Nerve Stimulation (VNS) VNS MP9232 Vein Disease Treatment N/A MP9241 Vertebroplasty (Kyphoplasty) Kyphoplasty MP9429 Vesicoureteral Reflux Treatment in Children VUR, VUR Treatment in Children MP9475

Wheelchairs: Manual or Power Operated and Power Operated Vehicles (POV)/Scooters

High-Strength Lightweight Wheelchair, Lightweight Wheelchair, Manual Wheelchair, POV, Power Operated Vehicle, Power Wheelchair, PWC, Scooter, Standard Wheelchair, Ultra-Lightweight Manual Wheelchair

MP9111






Providers without Access to the WellFirst Health Provider Portal There are a small number of WellFirst Health contracted providers that do not have access to the WellFirst Health Provider Portal. For these providers only, a written Authorization Request form must be used. If you are a provider that does not have access to the WellFirst Health Provider Portal, please follow the guidelines below: • The various Authorization Request forms can be found on the Medical Management page of WellFirst Health.com; • Authorization request forms should be mailed or faxed on the date the request has been completed to ensure timely processing of the authorization request; • Please complete all fields on the top part of the form in their entirety, otherwise the WellFirst Health Utilization Management Department will return it to the referring physician

for completion; • Authorization requests must be signed by the ordering provider if they are indicated as pre-service medically urgent; and • When an authorization is requested to a non-contracted provider, please include as much information as possible regarding why the request is being submitted and the plan

provider(s) that the member has already seen. The WellFirst Health Utilization Management Department will review the authorization request to ensure that (1) medically necessary care has been requested and that (2) the service(s) requested are not available with plan providers.

All written Authorization Request forms must be either faxed or mailed to WellFirst Health using the following information:

Fax Number (314) 951-5483

Mailing Address

WellFirst Health ATTN: Utilization Management

P.O. Box 56099 Madison, WI 53705

NOTE: Any prior authorization submitted as ‘Medically Urgent’ that does not meet the definition of medically urgent and/or does not have a physician’s signature may be changed to ‘Administratively Urgent’. This determination is made only by medically licensed personnel, and includes a call to the requesting provider’s office advising of this change and determination. NOTE: Only services that are not provided within the WellFirst Health provider network are considered for approval with a non-contracted provider.



https://wellfirstbenefits.com/employees/ASO-medical-management




Musculoskeletal (MSK) Care Management Program

WellFirst Health works with Magellan Healthcare for review and authorization of our Musculoskeletal (MSK) Care Management Program. This includes prior authorization by the treating physician for non-emergent inpatient and outpatient musculoskeletal surgeries, specifically hip, knee, shoulder, and lumbar and cervical spine. This new program incorporates the following key components: • Applicable to the following WellFirst Health product lines:

o Commercial – WellFirst Health HMO, WellFirst Health POS and WellFirst Health PPO o Administrative Services Only (ASO)

• Magellan’s Musculoskeletal (MSK) Care Management Program manages the medical necessity review for non-emergent inpatient and outpatient musculoskeletal surgeries

through physician authorization, prior to performing the surgery. • Members who require the services of a provider who is not a WellFirst Health network provider may require two authorizations. The initial authorization will need to be obtained

for the use of the non-network provider via the WellFirst Health Utilization Management Department. • Authorization may be submitted using Magellan’s website www.RadMD.com or the Magellan toll-free phone number at 877.642.0622. • Musculoskeletal surgeries included in this program are non-emergent hip, knee, shoulder, and lumbar and cervical spine surgeries. Click to see a list of MSK-affected CPT codes.

Magellan Healthcare Customer Service You can contact Magellan's customer service representatives Monday through Friday, from 7:00 a.m. to 7:00 p.m. (CST), at 877.642.0622.



https://wellfirstbenefits.com/Providers/Medical-Management/Musculoskeletal-program

http://www.radmd.com/

https://staging.wellfirstbenefits.com/Document-Library/PDF/Providers/Musculoskeletal-Surgery-Utilization-Review-Matrix?uh=4de779d710167c8c40cf78a03fdab4f9507ffcd8d80f995a9d1b61ead7a7dda0




Abortions (Surgical or Pharmacological) (MP9202)

Medical Policy Abortions (Surgical or Pharmacological) (MP9202) Alternate Service Name(s) N/A Additional Information Elective abortions are not a covered service.

Patients with WellFirst Health Employee Health Plan Codes that Require Authorization 59840, 59841, 59850, 59851, 59852, 59855, 59856, 59857, 59866, S0190, S0191, S0199, S2260, S2265, S2266, S2267

Submission Responsibilities

• EHP EPO members – contracted WellFirst providers are responsible for submitting prior authorizations for WellFirst Health Employee Health Plan members.

• For all other providers, WellFirst EHP PPO members need to verify that their providers have submitted a prior authorization before the service is performed in order to avoid incurring additional financial liability.

Submission Method WellFirst Health contracted providers - WellFirst Health Provider Portal; All other providers – Prior Authorization Forms may be accessed by clicking here.

Note: For EHP plan members, prior authorization and plan coverage of any medical or drug intervention discussed in the EHP Master Service List (MSL) is subject to the requirements outlined in the member’s Summary Plan Document (SPD). You can access the member’s SPD through the Provider Portal or by calling Customer Service at 877-274-4693.



https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Abortions-surgical-or-pharmacological-9202

https://providerauth.wellfirstbenefits.com/SignIn?referredBy=https://provider.wellfirstbenefits.com/






Acne (MP9023)

Medical Policy Acne (MP9023) Alternate Service Name(s) N/A Additional Information N/A

Patients with WellFirst SSM Health Employee Health Plan

Codes that are considered non-covered. *This list of codes is provided for informational purposes only and may not be all inclusive. Benefit coverage for any service is determined by the member’s policy of health coverage with WellFirst Health Employee Health Plan.*

15780, 15781, 15782, 15783, 11950 11951, 11952, 11954, 15788, 15789, 15792, 15793, 17360

Codes that Require Authorization Prior authorization is not required when (1) the patient meets criteria for MP9023 and when (2) the service is provided by an in-network provider.








https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Acne







Amino Acid- and Low Lipid-Based Formulas (MP9355)

Medical Policy Amino Acid- and Low Lipid-Based Formulas (MP9355) Alternate Service Name(s) Elecare, Neocate, Nutramigen AA Additional Information N/A

Patients with WellFirst SSM Health Employee Health Plan Codes that are considered non-covered. *This list of codes is provided for informational purposes only and may not be all inclusive. Benefit coverage for any service is determined by the member’s policy of health coverage with WellFirst Health Employee Health Plan.*

T2101

Codes that Require Authorization B4158, B4159, B4160, B4161, B4162








https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Amino-acid-and-low-lipid-based-formulas-9355







Antihemophilia Factors and Clotting Factors (MB1802)

Medical Policy Antihemophilia Factors and Clotting Factors (MB1802) Alternate Service Name(s) N/A

Additional Information This service must be ordered by a hematology specialist. For factor VIII products please use MB2116. For factor IX products please use MB2117.

Patients with WellFirst Health Employee Health Plan

Codes that Require Authorization J7175, J7178, J7179, J7180, J7181, J7188, J7189, J7198, J7212








https://wellfirstbenefits.com/Document-Library/PDF/Drug-Policies/Antihemophilia-and-clotting-factors-1802

https://www.wellfirstbenefits.com/Document-Library/PDF/Drug-Policies/Antihemophilic-Factor-VIII-Products-2116

https://www.wellfirstbenefits.com/Document-Library/PDF/Drug-Policies/Antihemophilic-Factor-IX-Products-2117







Antihemophilic Factor VIII Products MB2116

Medical Policy Antihemophilic Factor VIII Products (MB2116) Alternate Service Name(s) N/A

Additional Information This service must be ordered by a hematology specialist. For factor IX products please use MB2117. For other factor products please use MB1802.


Codes that Require Authorization J7182, J7183, J7185, J7186, J7187, J7190, J7192, J7204, J7205, J7207, J7208, J7209, J7210, J7211










https://www.wellfirstbenefits.com/Document-Library/PDF/Drug-Policies/Antihemophilia-Factors-and-Clotting-Factors-1802







Antihemophilic Factor IX Products MB2117

Medical Policy Antihemophilic Factor IX Products (MB2117) Alternate Service Name(s) N/A

Additional Information This service must be ordered by a hematology specialist. For factor VIII products please use MB2116. For other factor products please use MB1802.


Codes that Require Authorization J7193, J7194, J7195, J7200, J7201, J7202, J7203










https://www.wellfirstbenefits.com/Document-Library/PDF/Drug-Policies/Antihemophilia-Factors-and-Clotting-Factors-1802







Auditory Brain Stem and Cochlear Implants (MP9016)

Medical Policy Auditory Brain Stem and Cochlear Implants (MP9016) Alternate Service Name(s) N/A Additional Information N/A










https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Auditory-brain-stem-and-chochlear-implants-9016







Back or Spinal Orthosis: Lumbosacral (LSO) or Thoracolumbosacral (TLSO) (MP9261)

Medical Policy Back or Spinal Orthosis: Lumbosacral (LSO) or Thoracolumbosacral (TLSO) (MP9261) Alternate Service Name(s) LSO, TLSO

Additional Information • Prefabricated or standard orthoses may be ordered by primary care providers (PCPs) or specialists; and • Custom-made orthoses must be ordered by in-network specialists, such as neurologists, neurosurgeons, occupational medicine providers, orthopedic surgeons, physical or sports medicine providers, or rheumatologists.

Patients with WellFirst SSM Health Employee Health Plan Codes that Require Authorization N/A








https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Back-or-spinal-orthosis-lumbosacral-(LSO)-or-thora







Bariatric Surgery (MP9319)

Medical Policy Bariatric Surgery (MP9319) Alternate Service Name(s) N/A

Additional Information Bariatric Surgery is a covered service when (1) the patient meets criteria for MP9319 and when (2) Bariatric Surgery is a covered benefit of the patient’s specific plan type.


43842, 0312T

Codes that Require Authorization 43644, 43645, 43648, 43659 only requires a prior authorization if related to bariatric surgery or when performed for weight management, 43770, 43771, 43772, 43773, 43775, 43843, 43845, 43846, 43847 , 43848, 43886, 43887 , 43888








https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Bariatric-surgery-9319







Biofeedback (MP9163)

Medical Policy Biofeedback (MP9143) Alternate Service Name(s) N/A

Additional Information • Biofeedback therapy is initially limited to eight (8) sessions and should include instructions for a home program; and • Requests for additional sessions require a letter of medical necessity detailing response to treatment, number of additional sessions requested, and expectation of improvement with longer therapy.



E0746, 90875, 90876

Codes that Require Authorization 90901, 90912, 90913








https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Biofeedback-9143







Blepharoplasty or Blepharoptosis (Eyelid Surgery) (MP9214)

Medical Policy Blepharoplasty or Blepharoptosis (Eyelid Surgery) (MP9214) Alternate Service Name(s) Eyelid Surgery Additional Information N/A


Codes that Require Authorization 15820, 15821, 15822, 15823, 64612, 67900, 67901, 67902, 67903, 67904, 67906, 67908, 67909








https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Blepharoplasty-or-blepharoptosis-(eyelid-surgery)







Bone Anchored Hearing Aid (MP9018)

Medical Policy Bone Anchored Hearing Aid (MP9018) Alternate Service Name(s) BAHA Additional Information N/A


69710

Codes that Require Authorization 69716, 69719, L8691








https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Hearing-aid-benefit-bone-anchored-hearing-aid







Bone Growth (Osteogenesis) Stimulators (BGS) (MP9076)

Medical Policy Bone Growth (Osteogenesis) Stimulators (BGS) (MP9076) Alternate Service Name(s) BGS Additional Information N/A

Patients with WellFirst SSM Health Employee Health Plan Codes that Require Authorization 20974, 20975, 20979, E0747, E0748, E0749, E0760








https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Bone-growth-(Osteogenesis)-stimulators-9076







Breast Pumps, Hospital Grade (MP9092)

Medical Policy Breast Pumps, Hospital Grade (MP9092) Alternate Service Name(s) N/A

Additional Information Coverage for hospital grade, heavy duty electric breast pumps (i.e., E0604) is discontinued when the infant is discharged from the hospital or is feeding normally.

Patients with WellFirst SSM Health Employee Health Plan Codes that Require Authorization E0604








https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Breast-pumps,-hospital-grade-9092







Breast Reconstruction Surgery (MP9476)

Medical Policy Breast Reconstruction Surgery (MP9476) Alternate Service Name(s) Cancer-Related Breast Surgeries

Additional Information

• Mastectomy surgeries on a cancer-affected breast do not require prior authorization; • Information regarding prophylactic mastectomies can be found via the following link: Risk Reducing (Prophylactic) Mastectomy

(MP9449); and • Information regarding non-cancer-related breast surgeries can be found via the following link: Breast Surgeries (MP9026).


Codes that Require Authorization The following codes do not require a prior authorization when billed with a breast cancer diagnosis: 19316, 19318, 19325, 19328, 19330,19340, 19342, 19350, 19355, 19357, 19361, 19364, 19367, 19368, 19369, 19370, 19371, 19380, 19396, 19499








https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Breast-reconstruction-surgery-9476







Breast Surgeries (MP9026)

Medical Policy Breast Surgeries (MP9026) Alternate Service Name(s) Augmentation Mammoplasty, Non-Cancer-Related Breast Surgeries, Reduction Mammoplasty, Gynecomastia

Additional Information • Information regarding prophylactic mastectomies can be found via the following link: Risk Reducing (Prophylactic) Mastectomy

(MP9449); and • Information regarding cancer-related breast surgeries can be found via the following link: Breast Reconstruction Surgery (MP9476).


15877

Codes that Require Authorization 19318








https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Breast-surgeries-9026







Cardiac Monitoring Devices and Cardiac Procedures (MP9540)

Medical Policy Cardiac Monitoring Devices and Cardiac Procedures (MP9540) Alternate Service Name(s) N/A Additional Information None


0674T, 0676T, 0677T, 0678T, 0679T, 0680T, 0681T, 0682T, 0683T, 0684T, 0684T, 0685T









https://www.wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Cardiac-Monitoring-Devices-9540







Cardioverter-Defibrillator, Wearable (Zoll LifeVest) (MP9522)

Medical Policy Cardioverter-Defibrillator, Wearable (Zoll LifeVest) (MP9522) Alternate Service Name(s) AED, AED Vest for Individual Use, Automatic External Defibrillator (Garment Type), Zoll LifeVest Additional Information N/A

Patients with WellFirst SSM Health Employee Health Plan Codes that Require Authorization K0606, K0607, K0608, K0609








https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Cardioverter-Defibrillator,-Wearable-(Zoll-LifeVes







Cervical Spine Surgery, Inpatient and Outpatient

Medical Policy Magellan Clinical Guidelines for MSK Surgeries Alternate Service Name(s) C-Spine Surgery Additional Information Musculoskeletal Program information


Codes that Require Authorization 22548, 22551, 22552, 22554, 22585, 22590, 22595, 22600, 22614, 22856, 22858, 22861, 22864, 63001, 63015, 63020, 63035, 63040, 63043, 63045, 63048, 63050, 63051, 63075, 63076, 0095T, 0098T








https://www1.radmd.com/media/859657/_2019-2020-nia-msk-spine-surgery-clinical-guidelines-v2.pdf

https://staging.wellfirstbenefits.com/Providers/Medical-Management/Musculoskeletal-program







Clinical Trials (MP9447)

Medical Policy Clinical Trials (MP9447) Alternate Service Name(s) Non-Cancer-Related Clinical Trials

Additional Information • WellFirst Health will cover routine or standard patient care related to clinical trials for life-threatening diseases. A life-threatening illness is an illness or condition that more likely than not will end a person’s life within six (6) months.

Patients with WellFirst SSM Health Employee Health Plan Codes that Require Authorization Review MP9447 to determine which codes require prior authorization.








https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Clinical-trials-9447







Continuous Glucose Monitoring (MP9091)

Medical Policy Continuous Glucose Monitoring (MP9091) Alternate Service Name(s) N/A Additional Information This medical policy applies to members of all ages.

Patients with WellFirst SSM Health Employee Health Plan Codes that Require Authorization A9278, A9279, K0553, K0554


• Prior authorizations for continuous glucose monitoring are submitted to Navitus. • EHP EPO members – contracted WellFirst providers are responsible for submitting prior authorizations for WellFirst Health

Employee Health Plan members. • For all other providers, WellFirst EHP PPO members need to verify that their providers have submitted a prior authorization

before the service is performed in order to avoid incurring additional financial liability.





https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Continuous-glucose-monitoring-9091







Corneal Cross-Linking (CXL) (MP9470)

Medical Policy Corneal Cross-Linking (CXL) (MP9470) Alternate Service Name(s) CXL Additional Information N/A

Patients with WellFirst SSM Health Employee Health Plan Codes that Require Authorization Prior authorization not required.








https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Corneal-cross-linking-(CXL)-9470







Cranial Orthotic Devices for Plagiocephaly (MP9495)

Medical Policy Cranial Orthotic Devices for Plagiocephaly (MP9495) Alternate Service Name(s) N/A

Additional Information Cranial Orthotic Devices for Plagiocephaly is a covered service when (1) the patient meets criteria for MP9495 and when (2) Cranial Orthotic Devices for Plagiocephaly is a covered benefit of the patient’s specific plan type.

Patients with WellFirst SSM Health Employee Health Plan Codes that Require Authorization S1040








https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Cranial-Orthotic-Devices-for-Plagiocephaly-9495







CT Scan

Medical Policy N/A – Refer to the Radiology Prior Authorization page on WellFirst Health.com for additional information Alternate Service Name(s) CAT Scan, Computerized Tomography, Computerized Tomography Angiography, CTA Additional Information N/A


G0297

Codes that Require Authorization

70450, 70460, 70470, 70480, 70481, 70482, 70486, 70487, 70488, 70490, 70491, 70492, 70496, 70498, 71250, 71260, 71270, 71271, 71275, 72125, 72126, 72127, 72128, 72129, 72130, 72131, 72132, 72133, 72191, 72192, 72193, 72194, 73200, 73201, 73202, 73206, 73700, 73701, 73702, 73706, 74150, 74160, 74170, 74174, 74175, 74176, 74177, 74178, 74261, 74262, 74263, 75571, 75572, 75573, 75574, 75635, 76380, 77078, S8092 Alert: Effective for service dates on and after 9/1/2020, the health plan is reinstating the prior authorization requirement for Chest CT scans, which was temporarily waived in response to the COVID-19 public health emergency CHEST CT COVID-19.




Submission Method National Imaging Associates (NIA) Note: For EHP plan members, prior authorization and plan coverage of any medical or drug intervention discussed in the EHP Master Service List (MSL) is subject to the requirements outlined in the member’s Summary Plan Document (SPD). You can access the member’s SPD through the Provider Portal or by calling Customer Service at 877-274-4693.



https://wellfirstbenefits.com/Providers/Medical-Management/Radiology

https://wellfirstbenefits.com/Document-Library/PDF/Providers/COVID-19-Provider-Communication073020

https://wellfirstbenefits.com/Document-Library/PDF/Providers/COVID-19-Provider-Communication073020



https://www1.radmd.com/radmd-home.aspx





Deep Brain Stimulation (DBS) (MP9331)

Medical Policy Deep Brain Stimulation (DBS) (MP9331) Alternate Service Name(s) DBS Additional Information N/A

Patients with WellFirst SSM Health Employee Health Plan Codes that Require Authorization 61885, 61886








https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Deep-brain-stimulation-(DBS)-9331







Dental Prosthesis and Oncology Services (MP9125)

Medical Policy Dental Prosthesis and Oncology Services (MP9125) Alternate Service Name(s) N/A


All dental oncology services or prosthetics are subject to the following limitations: • If the member has a dental policy, the dental policy should be billed as primary. WellFirst Health will cover services as a secondary payer, or if denied by the dental policy; and • Dental appliances (e.g., bridges, dentures) are excluded from coverage, even when a covered treatment resulted in the need for the teeth to be replaced or repaired.


21088, 21082, 21083, 21084

Codes that Require Authorization Review MP9125 to determine which codes require prior authorization.








https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Dental-prosthesis-and-oncology-services-9125







Dental Services and Treatment Required for Direct Treatment of a Medical Condition (MP9552)

Medical Policy Dental Services and Treatment Required for Direct Treatment of a Medical Condition (MP9552) Alternate Service Name(s) N/A

Additional Information Services must be arranged and/or provided by Network Providers, including oral surgeons, dentist or TMD providers,unless otherwise stated.

Patients with WellFirst SSM Health Employee Health Plan Codes that Require Authorization Prior authorization is required. Please refer to MP9552 for additional information.








https://www.wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Dental-Services-and-Treatment-Required-for-Direct







Diagnostic, Therapeutic, and Surveillance Colonoscopy (MP9510)

Medical Policy Diagnostic, Therapeutic, and Surveillance Colonoscopy (MP9510) Alternate Service Name(s) Proctosigmoidoscopy, sigmoidoscopy


A Prior Authorization will NOT be processed for these requests and will be cancelled as not required if submitted. An appropriate diagnosis code must appear on the claim; claims will deny in the absence of an appropriate diagnosis code. If a claim is submitted without a diagnosis code considered Medically Necessary per MP9510, the claim will deny unless coverage is mandated by state/federal laws. If these services are provided by an out-of-network provider for an EPO or HMO, use of an out-of-network provider must be authorized prior to the service.

Patients with WellFirst Employee Health Plan

CPT codes applicable to this policy (NOTE: these codes do NOT require a prior authorization.)

45300, 45303, 45305, 45307, 45308, 45309, 45315, 45317, 45320, 45321, 45327, 45330, 45331, 45332, 45333, 45334, 45335, 45337, 45338, 45340, 45341, 45342, 45346, 45347, 45349, 45350, 45378, 45379, 45380, 45381, 45382, 45384, 45385, 45386, 45388, 45389, 45390, 45391, 45392, 45393, 45398, 44388, 44389, 44390, 44391, 44392, 44394, 44401, 44402, 44403, 44404, 44405, 44406, 44407, 44408

Provider Responsibilities to facilitate claims payment

• A prior authorization is NOT required when provided by an in-network provider under the member’s plan. • Prior authorization, if submitted, will be cancelled as not needed for the service. • If a claim is submitted without a diagnosis code considered Medically Necessary per MP9510 the claim will deny. • Denied claims will be addressed through the provider appeal process.

Submission Method Not Applicable-Prior authorization is not required for these services



https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Diagnostic,-Therapeutic-and-Surveillance-Colonosco




Dynamic Splinting and Static Progressive Stretch Devices (MP9289)

Medical Policy Dynamic Splinting and Static Progressive Stretch Devices (MP9289) Alternate Service Name(s) N/A Additional Information N/A

Patients with WellFirst SSM Health Employee Health Plan Codes that Require Authorization Prior authorization is not required.








https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Dynamic-splinting-and-static-progressive-stretch-d







Echocardiogram and Stress Echocardiogram (MP9513)

Medical Policy Echocardiogram and Stress Echocardiogram (MP9513) Alternate Service Name(s) ECHO, TTE, TEE, Fetal, stress


A Prior Authorization will NOT be processed for these requests and will be cancelled as not required if submitted. An appropriate diagnosis code must appear on the claim; claims will deny in the absence of an appropriate diagnosis code. If a claim is submitted without a diagnosis code considered Medically Necessary per MP9513, the claim will deny. If these services are provided by an out-of-network provider for an EPO or HMO, use of an out-of-network provider must be authorized prior to the service.



76825, 76826, 76827, 76828, 93303, 93304, 93306, 93307, 93308, 93312, 93313, 93314, 93315, 93316, 93317, 93318, 93320, 93321, 93325, 93350, 93351, 93355






https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Echocardiogram-9513




Electric Tumor Treatment Field (Optune) (MP9474)

Medical Policy Electric Tumor Treatment Field (Optune) (MP9474) Alternate Service Name(s) ETTF, Optune Additional Information This service must be ordered by an oncology specialist.









https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Electric-tumor-treatment-field-(Optune)







Electroretinogram or Electroretinography (ERG) MP9542

Medical Policy Electroretinogram or Electroretinography (ERG) MP9542 Alternate Service Name(s) N/A Additional Information The appropriate diagnosis codes must appear on the claim. Claims will deny in the absence of an appropriate diagnosis code.

Patients with WellFirst SSM Health Employee Health Plan Codes that Require Authorization No prior authorization is required.








https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Electroretinogram-or-Electroretinography-(ERG)-954







Endometrial Biopsy (MP9509)

Medical Policy Endometrial Biopsy (MP9509) Alternate Service Name(s) Hysteroscopy, polypectomy





58100, 58100, 58558






https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Endometrial-Biopsy-9509




Engineered Products for Wound Healing (MP9287)

Medical Policy Engineered Products for Wound Healing (MP9287) Alternate Service Name(s) N/A Additional Information N/A


A2001, A2002, A2003, A2004, A2005, A2006, A2007, A2008, A2009, A2010, A6025, Q4102, Q4103, Q4104, Q4105, Q4107, Q4108, Q4110, Q4111, Q4112, Q4113, Q4114, Q4115, Q4117, Q4118, Q4121, Q4122, Q4123, Q4124, Q4125, Q4126, Q4127, Q4128, Q4130, Q4134, Q4135, Q4136, Q4141, Q4146, Q4148, Q4160, Q4161, Q4162, Q4163, Q4164, Q4165, Q4166, Q4167, Q4168, Q4169, Q4170, Q4171, Q4173, Q4174, Q4175, Q4176, Q4177, Q4178, Q4179, Q4180, Q4181, Q4182, Q4183, Q4184, Q4185, Q4187, Q4188, Q4189, Q4190, Q4191, Q4192, Q4193, Q4194, Q4197, Q4198, Q4199, Q4251, Q4252, Q4253, C9354, C9355, C9356, C9358, C9360


15271, 15272, 15273, 15274, 15275, 15276, 15277, 15278, 15777, Q4101, Q4106, Q4116 (does not require a PA when billed as part of a breast reconstruction procedure), Q4100, Q4132, Q4133, Q4186. Q4195, Q4196 requires prior authorization when products are used for wound healing








https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Engineered-products-for-wound-healing-9287







Enteral Therapy (MP9069)

Medical Policy Enteral Therapy (MP9069) Alternate Service Name(s) Tube Feedings

Additional Information Further information for infants less than one (1) year of age can be found in the following medical policy: Amino Acid- and Low Lipid-Based Formulas (MP9355)

Patients with WellFirst SSM Health Employee Health Plan Codes that Require Authorization B4102, B4103, B4104, B4105, B4149, B4150, B4152, B4153, B4154, B4155, B4157, B4158, B4159, B4160, B4161, B4162








https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Enteral-therapy-9069







Epidural Steroid Injection (ESI) (MP9362)

Medical Policy Epidural Steroid Injection (ESI) (MP9362) Alternate Service Name(s) ESI Additional Information N/A

Patients with WellFirst SSM Health Employee Health Plan Codes that Require Authorization 62320, 62321, 62322, 62323, 64479, 64480, 64483, 64484








https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Epidural-steroid-injection-(ESI(-and-selective-ner







Facet Joint Injections and Radiofrequency Ablation (MP9448)

Medical Policy Facet Joint Injections and Radiofrequency Ablation (MP9448) Alternate Service Name(s) RFA Additional Information This service must be ordered by a pain management specialist or a provider trained in interventional pain management.


64625, 0440T, 0441T, 0442T

Codes that Require Authorization 64490, 64493, 64624, 64633, 64635, 0213T, 0216T








https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Facet-join-injections-and-radiofrequency-ablation







Gait Trainer, Pediatric

Medical Policy MCG (Milliman Care Guidelines) criteria is available from WellFirst Health Utilization Management (UM) upon request. Alternate Service Name(s) N/A Additional Information N/A

Patients with WellFirst SSM Health Employee Health Plan Codes that Require Authorization E8000, E8001, E8002














Gastric Pacemaker and Gastric Electrical Stimulation (MP9463)

Medical Policy Gastric Pacemaker and Gastric Electrical Stimulation (MP9463) Alternate Service Name(s) N/A Additional Information The coverage decision is based on the Food and Drug Administration’s (FDA) approval as a Humanitarian Device Exemption.


E0765

Codes that Require Authorization 43647, 43648, 43881, 43882








https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Gastric-pacemaker-and-gastric-electrical-stimulati







General Anesthesia for Dental Services (MP9271)

Medical Policy General Anesthesia for Dental Services (MP9271) Alternate Service Name(s) N/A

Additional Information General Anesthesia for Dental Services is a covered service when (1) the patient meets criteria for MP9271 and when (2) General Anesthesia for Dental Services is a covered benefit of the patient’s specific plan type.









https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/General-anesthesia-for-dental-services-9271







General Anesthesia for GI Endoscopy (MP9519)

Medical Policy General Anesthesia for GI Endoscopy (MP9519) Alternate Service Name(s) N/A Additional Information An appropriate diagnosis code must appear on the claim; claims will deny in the absence of an appropriate diagnosis code.










https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/General-Anesthesia-for-GI-Endoscopy-9519







Genetic Testing (MP9012)

Medical Policy Genetic Testing (MP9012) Alternate Service Name(s) N/A Additional Information N/A


Codes that Require Authorization Prior authorization is required for all genetic testing with the exception of the tests listed on the following document: Covered Genetic Testing that Does Not Require Prior Authorization








https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Genetic-testing-9012

https://wellfirstbenefits.com/Document-Library/PDF/Providers/Genetic-testing-no-prior-auth-required

https://wellfirstbenefits.com/Document-Library/PDF/Providers/Genetic-testing-no-prior-auth-required







Glaucoma Surgery Devices (MP9467)

Medical Policy Glaucoma Surgery Devices (MP9467) Alternate Service Name(s) N/A Additional Information N/A










https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Glaucoma-surgery-devices-9467







Habilitation Services and Devices (MP9443)

Medical Policy Habilitation Services and Devices (MP9443) Alternate Service Name(s) N/A

Additional Information • Habilitation Services and Devices is a covered service when (1) the patient meets criteria for MP9443 and when (2) Habilitation Services and Devices is a covered benefit of the patient’s specific plan type.









https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Habilitation-services-and-devices-9443







Health and Behavior Assessment Intervention for Stress Management and Relaxation Training (MP9375)

Medical Policy Health and Behavior Assessment Intervention for Stress Management and Relaxation Training (MP9375) Alternate Service Name(s) N/A Additional Information N/A










https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Health-and-behavior-assessment-intervention-for-st







Hearing Aids (MP9445)

Medical Policy Hearing Aids (MP9445) Alternate Service Name(s) Non-Bone Anchored Hearing Aids Additional Information The Hearing Aid prior authorization form is required for all adult patients.


V5266

Codes that Require Authorization V5030, V5040, V5050, V5060, V5070, V5080, V5100, V5120, V5130, V5140, V5150, V5171, V5172, V5181, V5190, V5211, V5212, V5213, V5214, V5215, V5221, V5230, V5242, V5243, V5244, V5245, V5246, V5247, V5248, V5249, V5250, V5251, V5252, V5253, V5254, V5255, V5256, V5257, V5258, V5259, V5260, V5261, V5262, V5263, V5298





Required Supplemental Document for In-Network Providers Only

• Adult Patients: Hearing Aid Prior Authorization Form (Complete the entire form and attach it to the prior authorization that is submitted via the Provider Portal)

• Patients under the age of 19 do not require prior authorization. Note: For EHP plan members, prior authorization and plan coverage of any medical or drug intervention discussed in the EHP Master Service List (MSL) is subject to the requirements outlined in the member’s Summary Plan Document (SPD). You can access the member’s SPD through the Provider Portal or by calling Customer Service at 877-274-4693.



https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Hearing-aids-9445



https://wellfirstbenefits.com/Document-Library/PDF/SSM-employee-health-plan/Hearing-aid-auth-form-SSM-empl-health-plan





Hemodialysis and Peritoneal Dialysis

Medical Policy Hemodialysis and Peritoneal Dialysis Alternate Service Name(s) HD, PD, dialysis


A Prior Authorization will NOT be processed for these requests and will be cancelled as not required if submitted. A prior authorization will be required when services are provided by a non-plan provider. If these services are provided by an out-of-network provider for an EPO or HMO, use of an out-of-network provider must be authorized prior to the service.


CPT codes applicable to this service (NOTE: these codes do NOT require a prior authorization.)

90935, 90937, 90940, 90945, 90947, 90963, 90964, 90965, 90966, 90967, 90968, 90969, 90970, 90989, 90993, 90999


• A prior authorization is NOT required when provided by an in-network provider under the member’s plan. • Prior authorization, if submitted, will be cancelled as not needed for the service. • If a claim is submitted without a diagnosis code considered Medically Necessary, the claim will deny. • Denied claims will be addressed through the provider appeal process.






High Frequency Chest Compression (Vest System) (MP9235)

Medical Policy High Frequency Chest Compression (Vest System) (MP9235) Alternate Service Name(s) N/A Additional Information This service must be ordered by a pulmonologist, transplant surgeon, or cystic fibrosis-treating provider.









https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/High-frequency-chest-compression-(vest-system)-923







Hip Surgery, Inpatient and Outpatient

Medical Policy Magellan Clinical Guidelines for MSK Surgeries Alternate Service Name(s) N/A

Additional Information Musculoskeletal Program information For more information on total hip arthroplasty (code 27130*), please see Total Knee Arthroplasty (TKA) and Total Hip Arthroplasty (THA) Ambulatory Level of Care (MP9550)

Patients with WellFirst SSM Health Employee Health Plan Codes that Require Authorization 27130* (*when performed as inpatient), 27132, 27134, 27137, 27138, 29860, 29861, 29862, 29863, 29914, 29915, 29916, S2118




Submission Method Magellan Healthcare or by phone at (866) 307-9729 Note: For EHP plan members, prior authorization and plan coverage of any medical or drug intervention discussed in the EHP Master Service List (MSL) is subject to the requirements outlined in the member’s Summary Plan Document (SPD). You can access the member’s SPD through the Provider Portal or by calling Customer Service at 877-274-4693.










Home Health Care

Medical Policy N/A Alternate Service Name(s) N/A Additional Information N/A

Patients with WellFirst SSM Health Employee Health Plan Codes that Require Authorization Home health services require prior authorization.














Home Infusion

Medical Policy N/A Alternate Service Name(s) N/A Additional Information N/A

Patients with WellFirst SSM Health Employee Health Plan Codes that Require Authorization S9500, 99601, 99602, G0068, G0069, G0070














Hospice Services (MP9299)

Medical Policy Hospice Services (MP9299) Alternate Service Name(s) N/A Additional Information N/A


Codes that Require Authorization G0151, G0152, G0157, G0158, G0299, G0300, G0337, Q5001, Q5002, Q5003, Q5004, Q5005, Q5006, Q5007, Q5008, Q5009, Q5010, S0271, S9126








https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Hospice-services-9299







Hospital Beds (MP9292)

Medical Policy Hospital Beds (MP9292) Alternate Service Name(s) Manual Hospital Bed, Semi-Electric Hospital Bed Additional Information N/A


Codes that Require Authorization E0250, E0251, E0255, E0256, E0260, E0261, E0265, E0266, E0270, E0290, E0291, E0292, E0293, E0294, E0295, E0296, E0297, E0300, E0301, E0302, E0303, E0304, E0328, E0329








https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Hospital-beds-9292







Hyperbaric Oxygen Therapy (HBO) (MP9055)

Medical Policy Hyperbaric Oxygen Therapy (HBO) (MP9055) Alternate Service Name(s) HBO, HBO Therapy Additional Information N/A



A4575, E0446

Codes that Require Authorization Self-funded plans (ASO) may require prior authorization. Please refer to the member’s Summary Plan Document (SPD) or call the Customer Service number found on the member’s card for specific prior authorization requirements.








https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Hyperbaric-oxygen-therapy-9055







Hyperhidrosis Treatment (MP9224)

Medical Policy Hyperhidrosis Treatment (MP9224) Alternate Service Name(s) N/A


• Hyperhidrosis Treatment is a covered service when (1) the patient meets criteria for MP9224 and when (2) Hyperhidrosis Treatment is a covered benefit of the patient’s specific plan type.

• Botulinum Toxin (BOTOX) A or B for uses other than hyperhidrosis treatment is prior authorized through Navitus. See drug policy MB9020 Botulinum Toxin.

Patients with WellFirst SSM Health Employee Health Plan Codes that Require Authorization 32664, 97033








https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Hyperhidrosis-treatment-9224

https://wellfirstbenefits.com/Document-Library/PDF/Drug-Policies/Botulinum-toxin-9020







Intermittent Pneumatic Compression Devices (MP9119)

Medical Policy Intermittent Pneumatic Compression Devices (MP9119) Alternate Service Name(s) N/A Additional Information N/A

Patients with WellFirst SSM Health Employee Health Plan Codes that Require Authorization E0650, E0651, E0652, E0655, E0656, E0657, E0660, E0665, E0666, E0667, E0668, E0669, E0670, E0671, E0672, E0673, E0675, E0676








https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Lymphedema-compression-devices-9119







Interspinous Spacer System ISS (VertiFlex) MP9544

Medical Policy Interspinous Spacer System ISS (VertiFlex) MP9544 Alternate Service Name(s) VertiFlex Additional Information N/A

Patients with WellFirst SSM Health Employee Health Plan Codes that Require Authorization 22867, 22869, 22868, 22870, C1821








https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Percutaneous-Interspinous-Spacer-(VertiFlex)-9544







Intrathecal Pump Implantation (MP9278)

Medical Policy Intrathecal Pump Implantation (MP9278) Alternate Service Name(s) N/A Additional Information N/A

Patients with WellFirst SSM Health Employee Health Plan Codes that Require Authorization Permanent placement or trials do not require prior authorization.








https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Intrathecal-pump-implantation







Knee Surgery, Inpatient and Outpatient

Medical Policy Magellan Clinical Guidelines for MSK Surgeries Alternate Service Name(s) N/A

Additional Information Musculoskeletal Program information For more information on total knee arthroplasty (code 27447*), please see Total Knee Arthroplasty (TKA) and Total Hip Arthroplasty (THA) Ambulatory Level of Care (MP9550)


Codes that Require Authorization 27332, 27333, 27403, 27405, 27407, 27409, 27412, 27415, 27416, 27418, 27420, 27422, 27424, 27425, 27427, 27428, 27429, 27438, 27446, 27447* (*when performed as inpatient), 27486, 27487, 27570, 29866, 29867, 29868, 29870, 29873, 29874, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29888, 29889, G0289







https://staging.wellfirstbenefits.com/Document-Library/PDF/Providers/Musculoskeletal-Surgery-Utilization-Review-Matrix?uh=4de779d710167c8c40cf78a03fdab4f9507ffcd8d80f995a9d1b61ead7a7dda0







Laser Treatment for Psoriasis (MP9399)

Medical Policy Laser Treatment for Psoriasis (MP9399) Alternate Service Name(s) N/A Additional Information N/A

Patients with WellFirst SSM Health Employee Health Plan Codes that Require Authorization 96920, 96921, 96922








https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Laser-treatment-for-psoriasis







Limb Prosthesis (MP9103)

Medical Policy Limb Prosthesis (MP9103) Alternate Service Name(s) N/A

Additional Information • Replacement of a prosthesis or prosthetic component due to loss is not a covered benefit. • A functional level description can be found on MP9103.



L5000, L5010, L5020, L5050, L5060, L5100, L5105, L5150, L5160, L5200, L5210, L5220, L5230, L5250, L5270, L5280, L5301, L5312, L5321, L5331, L5341, L5500, L5505, L5510, L5520, L5530, L5535, L5540, L5560, L5570, L5580, L5585, L5590, L5595, L5600, L5610, L5611, L5613, L5614, L5616, L5617, L5618, L5620, L5622, L5624, L5626, L5628, L5629, L5630, L5631, L5632, L5634, L5636, L5637, L5638, L5639, L5640, L5642, L5643, L5644, L5645, L5646, L5647, L5648, L5649, L5650, L5651, L5652, L5653, L5654, L5655, L5656, L5658, L5661, L5665, L5671, L5673, L5676, L5677, L5679, L5681, L5682, L5683, L5700, L5701, L5702, L5703, L5704, L5705, L5706, L5707, L5711, L5716, L5718, L5722, L5724, L5726, L5728, L5780, L5781, L5782, L5785, L5790, L5795, L5810, L5811, L5812, L5814, L5816, L5818, L5822, L5824, L5826, L5828, L5830, L5840, L5845, L5848, L5856, L5857, L5858, L5859, L5910, L5920, L5930, L5940, L5950, L5960, L5961, L5962, L5964, L5966, L5968, L5970, L5971, L5972, L5973, L5974, L5976, L5978, L5979, L5980, L5981, L5982, L5984, L5985, L5986, L5987, L5988, L5999, L6000, L6010, L6020, L6026, L6050, L6055, L6100, L6110, L6120, L6130, L6200, L6205, L6250, L6300, L6310, L6320, L6350, L6360, L6370, L6400, L6450, L6500, L6550, L6570, L6580, L6582, L6584, L6586, L6588, L6590, L6611, L6621, L6623, L6624, L6625, L6628, L6629, L6638, L6646, L6647, L6648, L6680, L6682, L6686, L6687, L6688, L6689, L6690, L6692, L6693, L6694, L6695, L6696, L6697, L6698, L6703, L6706, L6707, L6708, L6709, L6711, L6712, L6713, L6714, L6715, L6721, L6722, L6880, L6881, L6882, L6883, L6884, L6885, L6895, L6900, L6905, L6910, L6915, L6920, L6925, L6930, L6935, L6940, L6945, L6950, L6955, L6960, L6965, L6970, L6975, L7007, L7008, L7009, L7040, L7045, L7170, L7180, L7181, L7185, L7186, L7190, L7191, L7400, L7402, L7403, L7404, L7405, L7499, L7510, L7520, L8701, L8702








https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Limb-prosthesis-9103

https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Limb-prosthesis-9103







LINX Reflux Management System (MP9471)

Medical Policy LINX Reflux Management System (MP9471) Alternate Service Name(s) N/A Additional Information N/A

Patients with WellFirst SSM Health Employee Health Plan Codes that Require Authorization 43284








https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/LINX-reflux-management-system-9471







Liver and Other Neoplasm – Chemoembolization (CE) and Intra-Hepatic Microspheres (TheraSphere) (MP9462)

Medical Policy Liver and Other Neoplasm – Chemoembolization (CE) and Intra-Hepatic Microspheres (TheraSphere) (MP9462) Alternate Service Name(s) N/A Additional Information N/A

Patients with WellFirst SSM Health Employee Health Plan Codes that Require Authorization Prior authorization is required.








https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Liver-Neoplasm-Chemoembolization-IntraHepatic-Micr







Lumbar Discography (MP9427)

Medical Policy Lumbar Discography (MP9427) Alternate Service Name(s) Lumbar Paravertebral Injection Additional Information This service is restricted to neurosurgery and orthopedic surgery providers.


62291, 72285

Codes that Require Authorization 62290








https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Lumbar-discography-9427







Lumbar Spine Surgery, Inpatient and Outpatient

Medical Policy Magellan Clinical Guidelines for MSK Surgeries Alternate Service Name(s) L-Spine Surgery Additional Information Musculoskeletal Program information


Codes that Require Authorization 22533, 22534, 22558, 22585, 22612, 22614, 22630, 22632, 22633, 22634, 62380, 63005, 63012, 63017, 63030, 63035, 63042, 63044, 63047, 63048, 63052, 63053, 63056, 63057














Micra Permanent Leadless Pacemaker (MP9518)

Medical Policy Micra Permanent Leadless Pacemaker (MP9518) Alternate Service Name(s) N/A Additional Information N/A









https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Micra-Permanent-Leadless-Pacemaker-9518







Minimally Invasive Lumbar Decompression (MILD) (Vertos) MP9551

Medical Policy Minimally Invasive Lumbar Decompression (MILD) (Vertos) MP9551 Alternate Service Name(s) Vertos Additional Information N/A

Patients with WellFirst SSM Health Employee Health Plan Codes that Require Authorization 0275T








https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Vertos-Minimally-Invasive-Lumbar-Decompression-(MI







MRI/MRA

Medical Policy N/A – Refer to the Radiology Prior Authorization page on WellFirst Health.com for additional information Alternate Service Name(s) Magnetic Resonance Angiography, Magnetic Resonance Imaging Additional Information N/A



70336, 70540, 70542, 70543, 70544, 70545, 70546, 70547, 70548, 70549, 70551, 70552, 70553, 70554, 70555, 71550, 71551, 71552, 71555, 72141, 72142, 72146, 72147, 72148, 72149, 72156, 72157, 72158, 72159, 72195, 72196, 72197, 72198, 73218, 73219, 73220, 73221, 73222, 73223, 73225, 73718, 73719, 73720, 73721, 73722, 73723, 73725, 74181, 74182, 74183, 74185, 75557, 75559, 75561, 75563, 75565, 76390, 77046, 77047, 77048, 77049, 77084, S8037













Nasal Endoscopy (MP9514)

Medical Policy Nasal Endoscopy (MP9514) Alternate Service Name(s) N/A





31231, 31233, 31235, 31237, 31239, 31240, 31253, 31254, 31255, 31256, 31257, 31259, 31267, 31276. 31287, 31288, 31295, 31296, 31297, 31298






https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Nasal-Endoscopy-9514




Neuropsychological Testing (MP9493)

Medical Policy Neuropsychological Testing (MP9493) Alternate Service Name(s) N/A Additional Information This service must be performed by a licensed physician, psychologist, or mental health professional.

Patients with WellFirst SSM Health Employee Health Plan Codes that Require Authorization 96116, 96121, 96132, 96133








https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Neuropsychological-Testing-9493







Non-Covered Durable Medical Equipment/Supplies (MP9347)

Medical Policy Non-Covered Durable Medical Equipment/Supplies (MP9347) Alternate Service Name(s) Non-Covered DME Additional Information N/A


T2039, E0240, E0247, E0248, E0625, E0190, E0218, E0935, E0936, E0118, S9433, S9434, A4660, E0244, A9281, A4520, T4521, T4522, T4523, T4524, T4529, T4530, T4538, T4525, T4526, T4527, T4528, T4529, T4531, T4532, T4533, T4534, T4535, T4536, T4537, T4539, T4540, T4541, T4543, T4544, E0210, E0215, E1300, K1003, E0189, A9281, E0700, A8001, A8002, A8003, A8004, S0516, E0203, A4634, S9090, E0625, E0605, E0710, E1310

Codes that Require Authorization NOTE: Review MP9347 to determine whether the DME/supply you are intending to request has been identified as ‘Non-Covered’.








https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Non-covered-durable-medical-equipment-supplies-934







Non-Covered Medical Procedures and Services (MP9415)

Medical Policy Non-Covered Medical Procedures and Services (MP9415) Alternate Service Name(s) N/A Additional Information N/A

CPT Codes Related to this Policy

Summary

This policy indicates services which are considered either Experimental/Investigational (E/I) or Not Medically Necessary. Some MAY be considered for coverage in specific situations. Review of the actual policy is needed to determine whether the procedure/service you are intending to request has been identified as E/I or NMN. *The list of codes is provided for informational purposes only and may not be all inclusive. Benefit coverage for any service is determined by the member’s policy of health coverage with SSM Health Employee Plan.*

Procedure codes addressed in MP 9415-Non-covered Medical Procedures and Services. This is NOT an all inclusive list. Please verify the name of the service/procedure within the policy

CPT/HCPCS Code 69705, 69706, 0232T, 0481T, 82172, 0616T, 0617T, 0618T, 0633T, 0634T, 0635T, 0636T, 0637T, 0638T, S1034, 0623T, 0624T, 0625T, 0626T, 88240, 0623T, 0624T, 0625T, 0626T, C9771, G0281, G0282, G0295, G0329, 0615T, 0602T, 0603T, E0770, 81291, 22526, 22527, 22526, 22527, C9772, C9773, C9774, C9775, C1062, 0600T, 0601T, E2120, 0378T, 0379T, 0071T, 0072T, 0707T, E0764, C1825, C1839, A6000, E0231, E0232, G2170, G2171, 0627T, 0628T, 0629T, 0630T, 22526, 22527, 0232T, M0076, 33289, C2624, 64625, 0106T, 0107T, 0108T, 0109T, 0110T, 62263, 62264, 0200T, 0201T, 93278, 0335T, 0639T, 33745, 33746, 0631T, 93025, 0596T, 0597T, G2171, 93895, S1035, S1036, S1037, S2140, S2142, 76981, 76391, 91200, C9777, K1018, K1015, S8130, S8131, A9274, C1062, 0398T, 0219T, 0220T, 0221T, 0222T, A9500, S8080, 30468, 0266T, 0267T, 0268T, 0269T, 0270T, 0271T ,0272T, 0273T, 0247U, S1091, 0510T, 0511T, S2117, 67999, 0278T, K1016, K1023, 0441T, 0658T, C9777, 0651T, 0648T, 0649T, 0655T; 0656T, 0659T, 0664T, 0665T, 0666T, 0667T, 0668T, 0669T, 0670T, 0692T, 0693T, 0695T, 0696T, 0697T, 0698T, 93602, 95905, 38308, 83529, 61736, 61737


Continued on next page



https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Non-covered-medical-procedures-and-services-9415







Codes that Require Authorization NOTE: Review MP9415 to determine whether the procedure/service you are intending to request has been identified as ‘Non-Covered’.




Submission Method

WellFirst Health contracted providers - WellFirst Health Provider Portal; All other providers – Prior Authorization Forms may be accessed by clicking here.










Nuclear Stress Testing

Medical Policy N/A – Refer to the Radiology Prior Authorization page on WellFirst Health.com for additional information Alternate Service Name(s) ETT, Exercise Tolerance Test Additional Information N/A

Patients with WellFirst SSM Health Employee Health Plan Codes that Require Authorization 78451, 78452, 78453, 78454, 78481, 78483













Occupational Therapy (OT)

Medical Policy N/A – Refer to the Physical Therapy/Occupational Therapy Prior Authorization page on WellFirst Health.com for additional information Alternate Service Name(s) OT Additional Information N/A


Codes that Require Authorization 97010, 97012, 97014, 97016, 97018, 97022, 97024, 97028, 97032, 97033, 97034, 97035, 97036, 97039, 97110, 97112, 97113, 97116, 97124, 97139, 97140, 97168, 97530, 97533, 97535, 97755, 97760, 97761







https://wellfirstbenefits.com/Providers/Medical-Management/Physical-Medicine






Orthosis: Ankle (AFO), Knee Ankle Foot (KAFO), or Knee (KO) (MP9085)

Medical Policy Orthosis: Ankle (AFO), Knee Ankle Foot (KAFO), or Knee (KO) (MP9085) Alternate Service Name(s) N/A


• All initial custom-made orthotics must be ordered by a specialist in neurology, neurosurgery, occupational medicine, orthopedic surgery, physical or sports medicine, podiatry, or rheumatology.

• WellFirst Health Health Plan does not cover repair or replacement if the item becomes unusable or non-functioning because of individual misuse, abuse, neglect, or loss.


L2006

Codes that Require Authorization L1834, L1840, L1843, L1844, L1845, L1846, L1860, L1900, L1904, L1907, L1920, L1940, L1945, L1950, L1960, L1970, L1980, L1990, L2000, L2005, L2010, L2020, L2030, L2034, L2036, L2037, L2038, L2128, L4396, L4631








https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Orthosis-Ankle-(AFO),-knee-ankle-foot-(KAFO),-or-k







Oxygen (High Flow) for Cluster Headaches

Medical Policy MCG (Milliman Care Guidelines) criteria is available from WellFirst Health Utilization Management (UM) upon request. Alternate Service Name(s) O2 Therapy Additional Information N/A


Codes that Require Authorization Prior authorization is required for E0424, E0425, E0430, E0431, E0433, E0434, E0435, E0439, E0441, E0442, E0443, E0444, E1390, and E1391 only when billed with one of the following cluster headache diagnosis codes: G44.001, G44.009, G44.011, G44.019, G44.021, or G44.029














Partial Hospitalization Program (PHP) – Behavioral Health (MP9555)

Medical Policy Partial Hospitalization Program (PHP) – Behavioral Health (MP9555) Alternate Service Name(s) PHP


A facility that provides Partial Hospitalization programs may be a stand-alone mental health facility or a physically and programmatically-distinct unit within a facility licensed for this specific purpose, or a department within a general medical healthcare system. Boarding is not covered as this level of care is an ambulatory service. Multidisciplinary treatment program should occur 5 days a week and provide at least 20 hours of weekly clinical services intended to comprehensively address the needs identified in the member’s treatment plan. Activities that are primarily recreational or diversionary or that do not addres the serious presenting symptoms or problems do not count towards the total hours of treatment delivered.

Patients with WellFirst SSM Health Employee Health Plan Codes that Require Authorization Prior authorization is required for the partial hospitalization program. See medical policy for criteria.








https://www.wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Partial-Hospitalization-Behavioral-Health-9555







Pectus Excavatum and Pectus Carinatum Treatment (MP9206)

Medical Policy Pectus Excavatum and Pectus Carinatum Treatment (MP9206) Alternate Service Name(s) N/A Additional Information N/A









https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Pectus-excavatum-and-pectus-carinatum-treatment-92







Percutaneous Left Atrial Appendage (LAA) Closure Therapy (MP9499)

Medical Policy Percutaneous Left Atrial Appendage (LAA) Closure Therapy (MP9499) Alternate Service Name(s) LAA Additional Information N/A









https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Percutaneous-Left-Atrial-Appendage-(LAA)-Closure-D







Percutaneous Left Ventricular Assist Device (pVAD) (MP9528)

Medical Policy Percutaneous Left Ventricular Assist Device (pVAD) (MP9528) Alternate Service Name(s) pVAD Additional Information N/A










https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Percutaneous-Left-Ventricular-Assist-Device-(pVAD)







Percutaneous Mitral Valve Repair (MitraClip®) (MP9500)

Medical Policy Percutaneous Mitral Valve Repair (MitraClip®) (MP9500) Alternate Service Name(s) MitraClip® Additional Information N/A









https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Percutaneous-Mitral-Valve-Repair-(MitraClip)-9500







Percutaneous Pulmonary Valve Implantation (Melody Valve) (MP9440)

Medical Policy Percutaneous Pulmonary Valve Implantation (Melody Valve) (MP9440) Alternate Service Name(s) Melody Valve Additional Information N/A









https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Transcatheter-pulmonary-valve-implantation-(Melody







PET Scan

Medical Policy N/A – Refer to the Radiology Prior Authorization page on WellFirst Health.com for additional information Alternate Service Name(s) Positron Emission Tomography Additional Information N/A

Patients with WellFirst SSM Health Employee Health Plan Codes that Require Authorization 78429, 78430, 78431, 78432, 78433, 78434, 78459, 78491, 78492, 78608, 78609, 78811, 78812, 78813, 78814, 78815, 78816, G0235













Phototherapy for Skin Conditions, Including Home Ultraviolet Light (UVB) (MP9057)

Medical Policy Phototherapy for Skin Conditions, Including Home Ultraviolet Light (UVB) (MP9057) Alternate Service Name(s) N/A

Additional Information WellFirst Health Health Plan covers the purchase of one (1) system per enrollee per lifetime. The enrollee is responsible for the cost of repairs or replacement lights.

Patients with WellFirst SSM Health Employee Health Plan Codes that Require Authorization E0691, E0692, E0693, E0694








https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Phototherapy-for-skin-conditions-9057







Physical Therapy (PT)

Medical Policy N/A – Refer to the Physical Therapy/Occupational Therapy Prior Authorization page on WellFirst Health.com for additional information Alternate Service Name(s) PT Additional Information N/A


Codes that Require Authorization 97010, 97012, 97014, 97016, 97018, 97022, 97024, 97028, 97032, 97033, 97034, 97035, 97036, 97039, 97110, 97112, 97113, 97116, 97124, 97139, 97140, 97164, 97530, 97533, 97535, 97755, 97760, 97761, 97763







https://wellfirstbenefits.com/Providers/Medical-Management/Physical-Medicine






Plastic and Reconstructive Surgery (MP9022)

Medical Policy Plastic and Reconstructive Surgery (MP9022) Alternate Service Name(s) N/A


American Medical Association (AMA) approved definitions: • Cosmetic Surgery: Cosmetic Surgery is performed to reshape normal structure of the body in order to improve the patient’s

appearance and self-esteem; and • Reconstructive Surgery: Reconstructive Surgery is performed on abnormal structures of the body, caused by congenital defect,

developmental abnormalities, trauma, infection, tumors or disease. It is generally performed to improve function.

Patients with WellFirst SSM Health Employee Health Plan Codes that are considered non-covered. *This list of codes is provided for informational purposes only and may not be all inclusive. Benefit coverage for any service is determined by the member’s policy of health coverage with SSM Health Employee Health Plan.*

11950, 11951, 11952, 11954, 15775, 15776, 15780, 15781, 15782, 15783, 15786, 15787, 15788, 15789, 15792, 15793, 15824, 15825, 15826, 15828, 15829, 15876, 15877, 15878, 15879, 17360, 17380, 21082, 21083, 21084, 21086, 21087, 21088, 21193, 21194, 21195, 21198, 21206, 21208, 21209, 36468, 69090


00802, 11960, 15819, 15830, 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, 15847, 19316, 19370, 19371, 21100, 21120, 21121, 21122, 21123, 21125, 21127, 21137, 21138, 21139, 21196, 21199, 21270, 30400, 30410, 30420, 30430, 30435, 30450, 64612, 69300, 0479T, 0480T, J0585 Codes 11920, 11921, 11922 require prior authorization unless related to services outlined in MP9476 Breast Reconstruction Surgery








https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Plastic-and-reconstructive-surgery







Port Wine Stain Laser Treatment (MP9207)

Medical Policy Port Wine Stain Laser Treatment (MP9207) Alternate Service Name(s) N/A Additional Information N/A

Patients with WellFirst SSM Health Employee Health Plan Codes that Require Authorization 17106, 17107, 17108 when billed with D18.00 through D18.02 or Q82.0 through Q82.9 diagnosis codes.








https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Port-wine-stain-laser-treatment-9207







Pressure Reducing Support Surfaces (MP9494)

Medical Policy Pressure Reducing Support Surfaces (MP9494) Alternate Service Name(s) N/A Additional Information N/A

Patients with WellFirst SSM Health Employee Health Plan Codes that Require Authorization (In-Network Provider)

E0193, E0194, E0277, E0371, E0372, E0373 NOTE: These codes require prior authorization when provided by an In-Network Provider.

Codes that Require Authorization (Out-of-Network Provider)

A4640, E0184, E0185, E0186, E0187, E0193, E0194, E0196, E0197, E0198, E0199, E0277, E0371, E0372, E0373 NOTE: These codes require prior authorization when provided by an Out-of-Network Provider








https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Pressure-Reducing-Support-Surfaces-9494







Prostate Treatment (MP9361)

Medical Policy Prostate Treatment (MP9361) Alternate Service Name(s) N/A Additional Information N/A


53854, 0421T, 55880, 0619T

Codes that Require Authorization N/A








https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Prostate-treatment-9361







Prothrombin Time (INR) Home Monitoring Device (MP9263)

Medical Policy Prothrombin Time (INR) Home Monitoring Device (MP9263) Alternate Service Name(s) N/A Additional Information Prothrombin time (INR) home monitoring devices do not require prior authorization.









https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Prothrombin-time-(INR)-home-monitoring-device







Refractive and Therapeutic Keratoplasty (MP9461)

Medical Policy Refractive and Therapeutic Keratoplasty (MP9461) Alternate Service Name(s) Corneal Surgery Additional Information N/A


S0800, 65765

Codes that Require Authorization Effective 12/01/2021, does not require prior authorization.








https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Refractive-and-therapeutic-keratoplasty-9461







Repairs/Replacement of Durable Medical Equipment/Supplies (MP9106)

Medical Policy Repairs/Replacement of Durable Medical Equipment/Supplies (MP9106) Alternate Service Name(s) DME Repairs/Replacement Additional Information Replacement of equipment/supplies due to loss is not a covered benefit.


A4233, A4234, A4235, A4236, A1366, A4634, A4638, A4639, A8004 L7367, L7368, L7902, V5336

Codes that Require Authorization E2368, E2369, E2370, E2374, E2376, K0672, L4000, L4010, L4020, L4030, L4130, L8514, L8681, L8684, L8689, L8691








https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Repairs-replacememt-of-durable-medical-equipment-s







Residential Treatment – Behavioral Health (MP9554)

Medical Policy Residential Treatment – Behavioral Health (MP9554) Alternate Service Name(s) N/A

Additional Information A facility that provides Residential Treatment is either a stand-alone mental health facility or a physically and programmatically-distinct unit within a facility licensed for this specific purpose and that includes 7 days per week, 24 hour supervision and monitoring.

Patients with WellFirst SSM Health Employee Health Plan Codes that Require Authorization Prior authorization is required for residential treatment. See medical policy for criteria.








https://www.wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Residential-Treatment-%E2%80%93-Behavioral-Health-9554







Responsive Cortical Stimulation (MP9496)

Medical Policy Responsive Cortical Stimulation (MP9496) Alternate Service Name(s) RNS Additional Information N/A









https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Responsive-Cortical-Stimulation-9496







Risk Reducing (Prophylactic) Mastectomy (MP9449)

Medical Policy Risk Reducing (Prophylactic) Mastectomy (MP9449) Alternate Service Name(s) N/A Additional Information N/A


Codes that Require Authorization Prior authorization is required for 19300, 19303, 19304, 19305, 19306, and 19307 only when billed with one of the following diagnosis code: Z40.01








https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Risk-reducing-(prophylactic)-mastectomy-9449







Sacroiliac (SI) Joint Injections (MP9466)

Medical Policy Sacroiliac (SI) Joint Injections (MP9466) Alternate Service Name(s) SI Joint Injections

Additional Information • Therapeutic sacroiliac joint injections are limited to a maximum of four (4) times per 12 month period; and • Diagnostic sacroiliac joint injections are limited to a maximum of two (2) times per year.

Patients with WellFirst SSM Health Employee Health Plan Codes that Require Authorization 27096, 64451, G0260








https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Sacroiliac-(SI)-joint-injections-9466







Seat-Lift Mechanisms and Standing Devices (MP9102)

Medical Policy Seat-Lift Mechanisms and Standing Devices (MP9102) Alternate Service Name(s) N/A


All seat-lift mechanisms are subject to the following: • Coverage is limited only to those types that operate smoothly, can be controlled by the patient, and effectively assist a patient

in standing up and sitting down without other assistance; and • Coverage is limited to the seat-lift mechanism only, even if it is incorporated into a chair.


E0172, E0625

Codes that Require Authorization E0627, E0629, E0630, E0635, E0636, E0637, E0638, E0639, E0640, E0641, E0642, E0135, E0136








https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Seat-lift-mechanisms-and-standing-devices-9102







Services Related to Dental Care (MP9271)

Medical Policy Services Related to Dental Care (MP9271) Alternate Service Name(s) N/A

Additional Information Services Related to Dental Care are a covered service when (1) the patient meets criteria for MP9271 and when (2) Services Related to Dental Care are a covered benefit of the patient’s specific plan type.









https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/General-anesthesia-for-dental-services-9271







Sex Reassignment (Sex Transformation) (MP9465)

Medical Policy Sex Reassignment (Sex Transformation) Surgery (MP9465) Alternate Service Name(s) N/A


• Sex Reassignment Surgery is a covered service when the member meets criteria for MP9465. • Authorization may only be granted if the member is an active participant in a recognized gender identity treatment program. • Services described in this policy are not restricted to those Certificates which contain the Sex Transformation Surgery Rider, and

are not excluded from those Certificates which have a Sex Transformation Surgery exclusion. • Sex Reassignment Surgery is defined as a surgery performed for the treatment of a confirmed gender dysphoria diagnosis.


Codes that Require Authorization The following codes require prior authorization for a diagnosis of gender dysphoria: 17380, 19301, 19303, 19304, 19325, 19350, 51575, 53430, 54125, 54520, 54690, 56625, 56800, 56805, 56810, 57106, 57107, 57110, 57111, 57291, 57292, 57335, 58150, 58180, 58260, 58262, 58275, 58280, 58285, 58290, 58291, 58570, 58571, 58572, 58573








https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Sex-reassignment-(sex-transformation)-surgery-9465







Shingrix (RZV), Non-Routine Use MP9549

Medical Policy Shingrix (RZV), Non-Routine Use (MP9549) Alternate Service Name(s) Shingles vaccine


This policy applies to non-routine use of Shingrix vaccine in adult members under the age of 50 which are under the care of a specialist and meet specific criteria as outlined below. Requests for Shingrix under both the Medical and Pharmacy benefit for members <50 years old are submitted to Navitus. Shingrix for immunocompetent adults age 50 years and older is a covered Preventive Service and this policy does not apply..

Patients with WellFirst Health Commercial Insurance

Codes that Require Authorization 90750 for members less than 50 years of age








https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Shingrix-(RZV)-Non-Routine-Use-9549







Shoes and Shoe Modifications (Custom Molded/Corrective/Therapeutic) (MP9061)

Medical Policy Shoes and Shoe Modifications (Custom Molded/Corrective/Therapeutic) (MP9061) Alternate Service Name(s) N/A Additional Information Shoes and shoe modifications are limited to one (1) pair per 12 months.









https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Shoes-and-shoe-modifications-(custom-molded-correc







Shoulder Surgery, Inpatient and Outpatient

Medical Policy Magellan Clinical Guidelines for MSK Surgeries Alternate Service Name(s) N/A Additional Information Musculoskeletal Program information


Codes that Require Authorization 23120, 23125, 23130, 23405, 23410, 23412, 23415, 23420, 23430, 23450, 23455, 23460, 23462, 23465, 23466, 23470, 23472, 23473, 23474, 23700, 29805, 29806, 29807, 29819, 29820, 29821, 29822, 29823, 29824, 29825, 29826, 29827, 29828














Skilled Nursing Facility (MP9310)

Medical Policy Skilled Nursing Facility (MP9310) Alternate Service Name(s) Nursing Home, SNF, Swing Bed Additional Information N/A









https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Skilled-nursing-facility-9310







Sleep Studies: Attended Polysomnography and Portable Polysomnography Tests, Multiple Sleep Latency Testing and Maintenance of Wakefulness Testing (MP9132)

Medical Policy Sleep Studies: Attended Polysomnography and Portable Polysomnography Tests, Multiple Sleep Latency Testing and Maintenance of Wakefulness Testing (MP9132)

Alternate Service Name(s) Home Sleep Studies, MSLT, MWT, Portable Sleep Studies, PSG Additional Information This applies to in-lab sleep studies only. In-lab studies require prior authorization, see entry for in-home studies for information.

Patients with WellFirst SSM Health Employee Health Plan Codes that Require Authorization 95783, 95782, 95805, 95807, 95808, 95810, 95811








https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Sleep-studies-9132








Sleep Studies: Home Sleep Study (MP9132)

Medical Policy Sleep Studies: Attended Polysomnography and Portable Polysomnography Tests, Multiple Sleep Latency Testing and Maintenance of Wakefulness Testing MP9132

Alternate Service Name(s) HST


A Prior Authorization will NOT be processed for these requests and will be cancelled as not required if submitted. If a claim is submitted that does not meet the medical necessity indicated in MP9132, the claim will be denied. If these services are provided by an out-of-network provider for an EPO or HMO, use of an out-of-network provider must be authorized prior to the service. This applies to home sleep studies only. In-lab studies require prior authorization, see entry for in-lab sleep studies for information.



95800, 95801, 95806, G0398, G0399, G0400













Speech Generating Device (SGD) (MP9523)

Medical Policy Speech Generating Device (SGD) (MP9523) Alternate Service Name(s) Alternative Communication Device, SGD Additional Information N/A


E2500, E2502, E2504

Codes that Require Authorization 92618, E2506, E2508, E2510, E2511, E2512, E2599








https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Speech-Generating-Device-(SGD)-9523







Speech Therapy (Rehabilitative/Habilitative) (MP9171)

Medical Policy Speech Therapy (Rehabilitative/Habilitative) (MP9171) Alternate Service Name(s) ST


A Prior Authorization will NOT be processed for these requests and will be cancelled as not required if submitted. If a claim is submitted that doesn’t meet the medical necessity indicated in MP9171, the claim will be denied. If these services are provided by an out-of-network provider for an EPO or HMO, use of an out-of-network provider must be authorized prior to the service. Note: For ASO plan members, prior authorization and plan coverage of any medical or drug intervention discussed in the Dean Health Plan Master Service List (MSL) is subject to the requirements outlined in the member’s Summary Plan Document (SPD).



92507, 92508, 92521, 92522, 92523, 92523, 92524, 92526, 92550, 92551, 92552, 92553, 92554, 92555, 92556, 92557, 92558, 92559, 92560, 92561, 92562, 92563, 92564, 92565, 92566, 92567, 92568, 92569, 92570, 92571, 92572, 92573, 92574, 92575, 92576, 92577, 92578, 92579, 92580, 92581, 92582, 92583, 92584, 92585, 92586, 92587, 92588, 92589, 92590, 92591, 92592, 92593, 92594, 92595, 92596, 92597, 92610, 92611, 92612, 92613, 92614, 92615, 92616, 92617, 92618






https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Speech-therapy-(rehabilitative-habilitative-9171




Spinal Cord or Dorsal Column Stimulation and Dorsal Root Ganglion (DRG) Stimulation (MP9430)

Medical Policy Spinal Cord or Dorsal Column Stimulation and Dorsal Root Ganglion (DRG) Stimulation (MP9430) Alternate Service Name(s) DCS, DRG, SCS


• Prior authorization is required for the permanent placement of Spinal Cord or Dorsal Column Stimulation and Dorsal Root Ganglion (DRG) Stimulation.

• Prior authorization is not required for a trial placement of Spinal Cord or Dorsal Column Stimulation and Dorsal Root Ganglion (DRG) Stimulation.

• Following the trial, there must be documentation of improvement in pain.

Patients with WellFirst SSM Health Employee Health Plan Codes that Require Authorization 63655, 63685 (when billing for the permanent insertion of the stimulator), L8689








https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Spinal-cord-or-dorsal-column-stimulation-and-dorsa







Stereotactic Body Radiotherapy (MP9459)

Medical Policy Stereotactic Body Radiotherapy (MP9459) Alternate Service Name(s) N/A Additional Information N/A










https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Stereotactic-body-radiotherapy-9459







Stereotactic Cranial Radiosurgery (MP9345)

Medical Policy Stereotactic Cranial Radiosurgery (MP9345) Alternate Service Name(s) N/A Additional Information N/A










https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Stereotactic-cranial-radiosurgery-9345







Temporomandibular Disease (TMD) Services (MP9272)

Medical Policy Temporomandibular Disease (TMD) Services (MP9272) Alternate Service Name(s) TMD, TMJ Additional Information Coverage does not include reimbursement for cosmetic or elective orthodontic care, periodontal care, or general dental care.


21247, 21195, 21198, 21206, 21193, 21194

Codes that Require Authorization 20150, 21010, 21060, 21070, 21073, 21110, 21240, 21242, 21243, 21490, 29800, 29804, D7810, D7820, D7830, D7840, D7850, D7852, D7854, D7856, D7858, D7860, D7865, D7870, D7871, D7872, D7873, D7874, D7875, D7876, D7877








https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Temporomandibular-disease-(TMD)-services-9272







Therapeutic Contact Lens (MP9201)

Medical Policy Therapeutic Contact Lens (MP9201) Alternate Service Name(s) Bandage Lens, Hydrophilic Lens, Rigid Gas Permeable (RGP) Lens

Additional Information Documentation must be present in the medical record supporting the medical necessity of therapeutic contact lenses for each eye requested.










https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Therapeutic-contact-lens-9201







Total Ankle Arthroplasty (MP9363)

Medical Policy Total Ankle Arthroplasty (MP9363) Alternate Service Name(s) N/A Additional Information This service is restricted to orthopedic surgeons.









https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Total-ankle-arthroplasty







Total Knee Arthroplasty (TKA) and Total Hip Arthroplasty (THA) Ambulatory Level of Care (MP9550)

Medical Policy Total Knee Arthroplasty (TKA) and Total Hip Arthroplasty (THA) Ambulatory Level of Care (MP9550) Alternate Service Name(s) THA, TKA

Additional Information When performed in an inpatient setting, Total Knee Arthroplasty and Total Hip Arthroplasty require prior authorization by Magellan Health Musculoskeletal (MSK) Care Management Program.



Knee • Effective July 1, 2021, if a Total Knee Arthroplasty (CPT Code 27447) is done in an Outpatient Hospital or Ambulatory Surgery Setting

a prior authorization is NOT required. • All other Outpatient Hospital or Ambulatory Setting knee procedures require a prior authorization. • If the Total Knee Arthroplasty (CPT Code 27447) is done as an Inpatient a prior authorization is required. Hip • Effective July 1, 2021, if a Total Hip Arthroplasty (CPT Code 27130) is done in an Outpatient Hospital or Ambulatory Surgery Setting

a prior authorization is NOT required. • All other Outpatient Hospital or Ambulatory Setting hip procedures require a prior authorization. • If the Total Hip Arthroplasty (CPT Code 27130) is done as an Inpatient a prior authorization is required.




Submission Method Magellan Healthcare or by phone at (866) 307-9729. Note: For EHP plan members, prior authorization and plan coverage of any medical or drug intervention discussed in the EHP Master Service List (MSL) is subject to the requirements outlined in the member’s Summary Plan Document (SPD). You can access the member’s SPD through the Provider Portal or by calling Customer Service at 877-274-4693.



https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/TKA-and-THA-Site-of-Care-9550-Effective-07-01-2021








Traction for Cervical and Pain (MP9302)

Medical Policy Traction for Cervical and Pain (MP9302) Alternate Service Name(s) N/A Additional Information N/A


E0840, E0856

Codes that Require Authorization E0830, E0849, E0850, E0855








https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Traction-for-cervical-and-lumbar-pain-9302







Transcranial Magnetic Stimulation (MP9526)

Medical Policy Transcranial Magnetic Stimulation (MP9526) Alternate Service Name(s) TMS Additional Information N/A









https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Transcranial-Magnetic-Stimulation-9526







Transport of Members (Ambulance) (MP9137)

Medical Policy Transport of Members (Ambulance) (MP9137) Alternate Service Name(s) Air or water Ambulance, Ambulance, Ground Ambulance, Stretcher Van


• Any ground, air or water ambulance transportation for member convenience or for non-clinical (e.g., social) reasons is not a covered benefit; and

• As a general rule, ambulance transportation is only a covered benefit when the member is taken to the nearest facility (e.g., hospital, skilled nursing facility) which could be expected to have appropriate facilities for treatment of the illness or injury involved.










https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Ambulance-transport-of-members-9137







Treatment of Obstructive Sleep Apnea (OSA) (MP9239)

Medical Policy Treatment of Obstructive Sleep Apnea (OSA) (MP9239) Alternate Service Name(s) BiPAP, CPAP, OSA Additional Information N/A


0424T, 0425T, 0426T, 0437T, K1027, 64582, 64583, 64584

Codes that Require Authorization 21120, 21121, 21122, 21123, 21199, 42145, E0470, E0471, E0472, E0485, E0486, E0601, S2080








https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Obstructive-Sleep-Apnea-9239







Upper Endoscopy (EGD) Esophagogastroduodenoscopy (MP9517)

Medical Policy Upper Endoscopy (EGD) Esophagogastroduodenoscopy (MP9517) Alternate Service Name(s) EGD





43180, 43191, 43192, 43193, 43194, 43195, 43196, 43197, 43198, 43200, 43201, 43202, 43204, 43205, 43206, 43210, 43211, 43212, 43213, 43214, 43215, 43216, 43217, 43220, 43226, 43227, 43229, 43231, 43232, 43235, 43236, 43237, 43238, 43239, 43240, 43241, 43242, 43243, 43244, 43245, 43246, 43247, 43248, 43249, 43250, 43251, 43252, 43253, 43254, 43255, 43257, 43259, 43266, 43270






https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Upper-Endoscopy-(EGD)-Esophagogastroduodenoscopy-9




Urine Drug Testing (UDT) Presumptive and Definitive (MP9460)

Medical Policy Urine Drug Testing (UDT) Presumptive and Definitive (MP9460)

Alternate Service Name(s) UDT, Urine Drug Screening, Urine Drug Testing Additional Information N/A










https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Urine-drug-testing-(UDT)-presumptive-and-definitiv







Vagus Nerve Stimulation (VNS) (MP9232)

Medical Policy Vagus Nerve Stimulation (VNS) (MP9232) Alternate Service Name(s) VNS Additional Information Revision or replacement does not require prior authorization.









https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Vagus-nerve-stimulation-9232







Vein Disease Treatment (MP9241)

Medical Policy Vein Disease Treatment (MP9241) Alternate Service Name(s) N/A Additional Information N/A


36468

Codes that Require Authorization 36465, 36466, 36470, 36471, 36473, 36474, 36475, 36476, 36478, 36479, 36482, 36483, 37500, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37785, 0524T








https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Vein-disease-treatment-9241







Vertebroplasty (Kyphoplasty) (MP9429)

Medical Policy Vertebroplasty (Kyphoplasty) (MP9429) Alternate Service Name(s) Kyphoplasty Additional Information N/A










https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Vertebroplasty-(Kyphoplasty)-9429







Vesicoureteral Reflux Treatment in Children (MP9475)

Medical Policy Vesicoureteral Reflux Treatment in Children (MP9475) Alternate Service Name(s) VUR, VUR Treatment in Children Additional Information N/A









https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Vesicoureteral-reflux-treatment-in-children-9475







Wheelchairs: Manual or Power Operated and Power Operated Vehicles (POV)/Scooters (MP9111)

Medical Policy Wheelchairs: Manual or Power Operated and Power Operated Vehicles (POV)/Scooters (MP9111)

Alternate Service Name(s) High-Strength Lightweight Wheelchair, Lightweight Wheelchair, Manual Wheelchair, POV, Power Operated Vehicle, Power Wheelchair, PWC, Scooter, Standard Wheelchair, Ultra-Lightweight Manual Wheelchair

Additional Information N/A


E1037, E1038, E1039, E2367, E2351


E0986, E1002, E1003, E1004, E1005, E1006, E1007, E1008, E1083, E1084, E1085, E1086, E1087, E1088, E1089, E1090, E1092, E1093, E1100, E1110, E1130, E1161, E1170, E1171, E1172, E1180, E1190, E1195, E1200, E1220, E1221, E1222, E1223, E1224, E1227, E1228, E1230, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, E1240, E1250, E1260, E1270, E1280, E1285, E1290, E1295, E2300, E2301, E2310, E2311, E2330, E2331, E2373, E2398, E2609, E2610, E2617, E2626, E2627, E2628, E2629, E2630, K0001, K0002, K0003, K0004, K0005, K0006, K0007, K0008, K0013,K0800, K0801, K0802, K0806, K0807, K0808, K0812, K0813, K0814, K0815, K0816, K0820, K0821, K0822, K0823, K0824, K0825, K0826, K0827, K0828, K0829, K0830, K0831, K0835, K0836, K0837, K0838, K0839, K0840, K0841, K0842, K0843, K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855, K0856, K0857, K0858, K0859, K0860, K0861, K0862, K0863, K0864, K0868, K0869, K0870, K0871, K0877, K0878, K0879, K0880, K0884, K0885, K0886, K0890, K0891, K0898








https://wellfirstbenefits.com/Document-Library/PDF/Medical-Policies/Wheelchairs-Manual-or-power-operated-and-power-ope




WellFirst Employee Health Plan Master Service List

Documents

Transcript of WellFirst Employee Health Plan Master Service List