Services That Do Not Require Precertification

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Services that do not require precertification

The following is a list of services that do not require preapproval/precertification from AmeriHealth.

Fine needle aspiration; without imaging guidance Colorectal cancer screening; colonoscopy on individual at high risk Colorectal cancer screening; colonoscopy on individual not meeting for a high risk H-reflex, amplitude and latency study; record gastrocnemius/soleus muscle H-reflex, amplitude and latency study; record muscle other than gastrocnemius/soleus muscle Monitoring for localization of cerebral seizure focus by computerized portable 16 or more channel EEG; electroencephalographic (EEG) recording and interpretation each 24 hours Needle electromyography studies (EMG) of anal or urethral sphincter, any technique Needle electromyography using single fiber electrode, with quantitative measurement of jitter, blocking, and/or fiber density, any/all sites of each muscle studied Needle electromyography, four extremities with or without related paraspinal areas Needle electromyography, one extremity with or without related paraspinal areas Needle electromyography, three extremities with or without related paraspinal areas Needle electromyography, two extremities with or without related paraspinal areas Needle electromyography; cranial nerve-supplied muscle(s), unilateral Needle electromyography; cranial nerve-supplied muscles, bilateral Needle electromyography; limited study of muscles in one extremity or non-limb (axial) muscles (unilateral or bilateral), other than thoracic paraspinal, cranial nerve-supplied muscles, or sphincters Needle electromyography; thoracic paraspinal muscles (excluding T1 or T12) Needle oculoelectromyography, one or more extraocular muscles, one or both eyes, with interpretation and report Nerve conduction, amplitude and latency/velocity study, each nerve; motor, with F-wave study Nerve conduction, amplitude and latency/velocity study, each nerve; motor, without F-wave study Nerve conduction, amplitude and latency/velocity study, each nerve; sensory Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any one method Amniocentesis Angiography sel., each add’l vessel studied after basic exam, rad. supervision and interpretation Angiography, adrenal, unlateral, selective, radiological supervision and interpretation Angiography, adrenal,bilateral, selective, radiological supervision and interpretation Angiography, internal mammary, radiological supervision and interpretation Angiography, pulmonary, by non-selective catheter or venous injection, radiological supervision Anorectal manometry Aspiration/injection of renal cyst or pelvis by needle, percutaneous

For more information regarding precertification requirements, please call Customer Service at 1-800-275-2583 or refer to the Care Management and Coordination section of the Provider Manual for Participating Professional Providers.

1 AmeriHealth HMO, Inc. • AmeriHealth Insurance Company of New Jersey • 11/09 QCC Insurance Company d/b/a AmeriHealth Insurance Company Services that do not require precertification

Biliary duct stone extraction, percutaneous via T tube tract/basket/snare Biliary endoscopy, percutaneous via T tube/other tract, w biopsy Biliary endoscopy, percutaneous via T tube/other tract, w dilation biliary duct stricture w stent Biliary endoscopy, percutaneous via T tube/other tract, w dilation biliary duct stricture w/o stent Biliary endoscopy, percutaneous via T tube/other tract, w removal of calculus Biliary endoscopy, percutaneous via T-tube or other tract; diagnostic, w or w/o collection of specimen by brushing and/or washing Biopsies, prostate, needle, transperineal, stereotactic template guided saturation sampling, including imaging guidance Biopsy of breast, perc, ndl core, auto vacuum-asst or rotating bx device, using imag guidance Biopsy of breast, perc, needle core, not using imaging guidance Biopsy of breast, perc, needle core, using imaging guidance Biopsy of intestine by capsule, tube, peroral Biopsy of liver, needle, percutaneous Biopsy of liver, needle, percutaneous, w other operation Biopsy of pancreas, percutaneous needle Biopsy of spinal cord, percutaneous needle Biopsy of stomach by capsule, tube peroral Biopsy, abdominal or retroperitoneal mass, percutaneous needle Biopsy, bone, trocar or needle, deep Biopsy, bone, trocar or needle, superficial Biopsy, lung or mediastinum, percutaneous needle Biopsy, muscle, percutaneous needle Biopsy, pleura, percutaneous needle Biopsy, prostate, needle or punch, single or multiple, any approach Biopsy, thyroid, percutaneous core needle Bone Marrow; Smear Interpretation Only, with or without Differential Cell Count Breast biopsy, open, incisional Breath hydrogen test(detection of lactase deficiency), fructose intolerance, bacterial overgrowth or oro-cecal gi transit) Cardiovascular stress test using treadmill or bicycle exercise, cont ECG monitoring Change of gastrostomy tube Change of percutuaneous biliary drainage catheter Chorionic villus sampling Cisternal or lateral cervical (C1-C2) puncture, w injection of drug/other substance

2 AmeriHealth HMO, Inc. • AmeriHealth Insurance Company of New Jersey • 11/09 QCC Insurance Company d/b/a AmeriHealth Insurance Company Services that do not require precertification

Colonoscopy through stoma w removal of tumor/lesion/polyp, by snare Colonoscopy through stoma w transendoscopic stent placement Colonoscopy through stoma, diagnostic Colonoscopy through stoma, w ablation of tumor/polyp/lesion, not by forceps/cautery/snare Colonoscopy through stoma, w biopsy Colonoscopy through stoma, w control of bleeding any method Colonoscopy through stoma, w removal of foreign body Colonoscopy through stoma, w removal of tumor/polyp/lesion, by biopsy forceps/cautery Colonoscopy w ablation of tumor/polyp/lesion, not by forceps/cautery/snare Colonoscopy w biopsy single or multiple Colonoscopy w control of bleeding any method Colonoscopy w removal of foreign body Colonoscopy w removal of tumor/polyp/lesion, by forceps/cautery Colonoscopy w removal of tumor/polyp/lesion, by snare Colonoscopy w transendoscopic stent placement Colonoscopy through stoma, diagnostic Colonoscopy through stoma, w ablation of tumor/polyp/lesion, not by forceps/cautery/snare Colonoscopy through stoma, w biopsy Colonoscopy through stoma, w control of bleeding any method Colonoscopy through stoma, w removal of foreign body Colonoscopy through stoma, w removal of tumor/polyp/lesion, by biopsy forceps/cautery Colonoscopy w ablation of tumor/polyp/lesion, not by forceps/cautery/snare Colonoscopy w biopsy single or multiple Colonoscopy w control of bleeding any method Colonoscopy w removal of foreign body Colonoscopy w removal of tumor/polyp/lesion, by forceps/cautery Colonoscopy w removal of tumor/polyp/lesion, by snare Colonoscopy w transendoscopic stent placement Colonoscopy, flexible, proximal to splenic flexure Colonoscopy, flexible, proximal to splenic flexure; with dilation by balloon, 1 or more strictures Colonoscopy, flexible, proximal to splenic flexure; with directed submucosal injection(s), any substance Colonoscopy, flexible, proximal to splenic flexure; with endoscopic ultrasound examination

3 AmeriHealth HMO, Inc. • AmeriHealth Insurance Company of New Jersey • 11/09 QCC Insurance Company d/b/a AmeriHealth Insurance Company Services that do not require precertification

Colonoscopy, flexible, proximal to splenic flexure; with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s) Colonoscopy, rigid or flexible, transabdominal via colectomy, single or multiple Colorectal cancer screening; alternative to g0105, screening colonoscopy, barium enema Complex uroflowmetry Contrast injection for assessment of abscess or cyst via previously placed catheter Contrast injection(s) for radiological evaluation of existing gastrostomy, duodenostomy, jejunostomy, gastro-jejunostomy, or cecostomy (or other colonic) tube, from a percutaneous approach including image documentation and report Conversion of gastrostomy tube to gastro-jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report Dilation of esophagus w balloon (30 mm diameter or larger) for achalsia Dilation of esophagus, by balloon or dilator retrograde Dilation of esophagus, by unguided sound or bougie, single/multiple passes Dilation of esophagus, over guidewire ECG (Echocardiography) Echocardiography during cardiovascular stress test Echocardiography, transthoracic, real-time with image documentation (2d), includes M-mode recording, when performed during rest and cardiovascular stress test using treadmill, bicycle exercise and/or pharmacologically induced stress, with interpretation and report; including performance of continuous electrocardiographic monitoring, with physician supervision Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, complete, with spectral Doppler echocardiography, and with color flow Doppler echocardiography Electroencephalogram (EEG) extended monitoring; 41-60 min Electroencephalogram (EEG); including recording awake and asleep Endoscopic evaluation of small intestine pouch, diagnostic Endoscopic evaluation of small intestine pouch, w biopsy Esophageal function test Esophageal intubation and collection of washings for cytology Esophageal motility (manomometric study of the esophagus and/or gastroesophageal junction Esophageal motility (manomometric study of the esophagus and/or gastroesophageal junction w/ mecholyl of similar stimulant

Esophageal motility (manomometric study of the esophagus and/or gastroesophageal junction with acid perfusion studies Esophagoscopic injection sclerosis of esophageal varices Esophagoscopy w ablation of tumor,poylp,lesion,not amenable by forceps,cautery

4 AmeriHealth HMO, Inc. • AmeriHealth Insurance Company of New Jersey • 11/09 QCC Insurance Company d/b/a AmeriHealth Insurance Company Services that do not require precertification

Esophagoscopy w balloon dilation Esophagoscopy w control of bleeding, any method Esophagoscopy w endoscopic ultrasound examination Esophagoscopy w insertion of guide wire then dilation over wire Esophagoscopy w insertion of plastic tube or stent Esophagoscopy w removal of tumor,polyp, lesion by snare technique Esophagoscopy w removal of tumor,polyp,lesion,by hot bx forceps or bipolar caute Esophagoscopy w transendoscopic US-guided FNA or needle biopsy Esophagoscopy with band ligation of esophageal varices Esophagoscopy with biopsy Esophagoscopy with removal of foreign body Esophagoscopy, diagnostic Esophagoscopy, rigid or flexible; with directed submucosal injection(s), any substance Esophagus, acid perfusion (Bernstein) test for esophagitis Esophagus, gastroesophageal reflux test, with catheter pH electrodes placement, recording, analysis and interpretation Esophagus, gastroesophageal reflux test, with mucosal attached telemetry pH electrodes placement, recording, analysis and interpretation Evaluation of oral and pharyngeal swallowing function Evaluation of speech, language, voice, communication, auditory processing and /or rehabilitation status Fine needle aspiration, w or w/o smears, deep tissue Fine needle aspiration, w or w/o smears, superficial tissue Fine needle aspiration; with imaging guidance Flexible fiberoptic endoscopic evaluation of swallowing and laryngeal sensory testing by cine or video recording Flexible fiberoptic endoscopic evaluation of swallowing by cine or video recording Flexible fiberoptic endoscopic evaluation, laryngeal sensory testing by cine or video recording Free jejunum transfer w/microvascular anastomosis Gastric analysis test with injection of stimulant of gastric secretions Gastric intubation, and aspiration or lavage for treatment Gastric intubation, washings, and preparing slides for pathology Gastric motility (manometric studies) Ileoscopy through stoma, diagnostic Ileoscopy through stoma, w biopsy Ileoscopy through stoma, w transendoscopic stent placement

5 AmeriHealth HMO, Inc. • AmeriHealth Insurance Company of New Jersey • 11/09 QCC Insurance Company d/b/a AmeriHealth Insurance Company Services that do not require precertification

Image guided placement metallic localization clip, perc, during breast biopsy Injection and placement of chain for contrast and/or chain urethrocystogrpahy Injection for cystography or voiding urethrocystography Injection for retrograde urethrocystography Injection of air or contrast into peritoneal cavity Injection of contrast medium for dacryocystography Injection of sinus tract, diagnostic Injection procedure (e.g., thrombin) for percutaneous treatment of extremity pseudoaneurysm Injection procedure for ankle arthrotomy Injection procedure for cholangiography through existing catheter Injection procedure for contrast venography Injection procedure for corpora cavernosography Injection procedure for elbow arthrography Injection procedure for evaluation of previously placed peritoneal-venous shunt Injection procedure for hip arthrography w anesthesia Injection procedure for hip arthrography w/o anesthesia Injection procedure for hysterosalpingography Injection procedure for knee arthrography Injection procedure for lymphangiography Injection procedure for mammary ductogram or galactogram Injection procedure for myelography and/or CAT, spinal (except C1-C2) Injection procedure for percutaneous transhepatic cholangiography Injection procedure for pyelography through ostomy tube Injection procedure for shoulder arthrography Injection procedure for sialography Injection procedure for splenoportography Injection procedure for temporomandibular joint arthrography Injection procedure for ureterography via ostomy or catheter Injection procedure for visualization of ileal conduit and/or ureteropyelography Injection procedure for wrist arthrography Insertion of a Miller-Abbott tube Insertion of cecostomy or other clonic tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report

6 AmeriHealth HMO, Inc. • AmeriHealth Insurance Company of New Jersey • 11/09 QCC Insurance Company d/b/a AmeriHealth Insurance Company Services that do not require precertification

Insertion of duodenostomy or jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s) image documentation and report

Insertion of gastrostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report Insertion of non-indwelling bladder catheter Insertion of temporary indwelling bladder catheter, complicated Insertion of temporary indwelling bladder catheter, simple Intestinal bleeding tube, passage, positioning, and monitoring Introduction of catheter, superior or inferior vena cava Introduction percutaneous transhepatic catheter for biliary drainage Introduction percutaneous transhepatic stent for internal/external drainage Laser treatment for inflammatory skin disease (psoriasis); total area less than 250 sq cm Measurement of post-voiding residual urine and/or bladder capacity by ultrasound, non-imaging Mechanical removal of obstructive material from gastrostomy, dudenostomy, jejunostomy, gastro-jejunostomy, or cecostomy (or other clonic) tube, any method, under fluoroscopic guidance including contrast injection(s), if performed, image documentation and report Motion fluoroscopic evaluation of swallowing function by cine or video recording Naso or oro-gastric tube placement Percutaneous aspiration, spinal cord cyst or syrinx Percutaneous placement of gastrostomy tube Peritoneocentesis, abdominal paracentesis or peritoneal lavage, subsequent Peritoneocentesis,abdominal paracentesis or perineal lavage, initial Preoperative placement of needle localization wire, breast Preoperative placement of needle localization wire, breast, each addl lesion Proctosigmoidoscopy, rigid, w ablation of tumor/polyp/lesion, not by forceps/cautery/snare Proctosigmoidoscopy, rigid, w biopsy, single or multiple Proctosigmoidoscopy, rigid, w decompression of volvulus Proctosigmoidoscopy, rigid, w removal multiple tumor/polyp/lesion by forceps/cautery/snare Proctosigmoidoscopy, rigid, w removal of foreign body Proctosigmoidoscopy, rigid, w removal of single lesion/tumor/polyp by snare Proctosigmoidoscopy, rigid, w removal of single tumor/polyp/lesion by forceps/cautery Proctosigmoidoscopy, rigid, w transendoscopic stent placement Proctosigmoidoscopy, rigid; diagnostic, with or without collection of specimen(s) by brushing or washing Proctosigmoidoscopy, rigid; diagnostic, with or without collection of specimen(s) by brushing or washing, with dilation

7 AmeriHealth HMO, Inc. • AmeriHealth Insurance Company of New Jersey • 11/09 QCC Insurance Company d/b/a AmeriHealth Insurance Company Services that do not require precertification

Proctsigmoidoscopy, rigid, w control of bleeding, any method Puncture aspiration of cyst of breast Puncture aspiration of cyst of breast, each add’l cyst Puncture of shunt tubing or reservoir for aspiration or injection procedure Replacement of duodenostomy or jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report

Replacement of gastro-jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report

Replacement of gastrostomy or cecostomy (or other colonic) tube, percutaneous, under fluoroscopic guidance including contrast injection(s), image documentation and report Repositioning of the gastric feeding tube, any method, through the duodenum for enteric nutrition Revision/reinsertion of transhepatic tube Selective catheter placement, venous system, 1st order branch Selective catheter placement, venous system, 2nd order, more selective branch Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, including ileum; diagnostic, with or without collection of specimen(s) by brushing or washing

Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, including ileum; w/biopsy, single or multiple

Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, including ileum; w/control of bleeding, any method

Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, including ileum; w/transendoscopic stent placement (includes predilation) Small intestine endo/enteroscopy w ablation of tumor/polyps/lesions, other methods Small intestine endo/enteroscopy w control of bleeding any method Small intestine endo/enteroscopy w conversion of gastrotomy tube to jejunosotmy tube Small intestine endo/enteroscopy w placement of percutaneous jejunostomy tube Small intestine endo/enteroscopy w removal of foreign body Small intestine endo/enteroscopy w removal tumor/polyp/lesion by snare Small intestine endo/enteroscopy w removal tumor/polyp/lesion, by forceps/cautery Small intestine endo/enteroscopy, beyond 2nd part of duodenum, diagnostic Small intestine endo/enteroscopy, not incldg ileum, w transendoscopic stent placement Small intestine endo/enteroscopy, w biopsy Small intestine imaging; intraluminnal, from ligament of treitz to the ileiocecal valve, includes physician interpretation Sperm evaluation; hamster penetration test Swallowing function with video/cineradiography

8 AmeriHealth HMO, Inc. • AmeriHealth Insurance Company of New Jersey • 11/09 QCC Insurance Company d/b/a AmeriHealth Insurance Company Services that do not require precertification

TEE: Echocardiography, transesophageal, real time with image documentation (2d) (with or without M-mode recording); Tee:echocardiography, transesophageal, real time with image documentation (2d) (with or without m-mode recording); placement of transesophageal probe only Transfusion blood or blood products UGI endoscopy w ablation of tumor/polyp/lesion, not by hot forceps/cautery/snare UGI endoscopy w balloon dilation of esophagus UGI endoscopy w band ligation of esopagheal/gastric varices UGI endoscopy w biopsy UGI endoscopy w control of bleeding UGI endoscopy w dilation of gastric outlet for obstruction, any method UGI endoscopy w directed placement of percutaneous gastrostomy tube UGI endoscopy w endoscopic ultrasound exam UGI endoscopy w injection sclerosis of esophageal/gastric varices UGI endoscopy w insertion of guide wire then dilation of esophagus over wire UGI endoscopy w removal of foreign body UGI endoscopy w removal of tumor/polyp/lesion, by hot biopsy forceps or cautery UGI endoscopy w removal of tumor/polyp/lesion, by snare technique UGI endoscopy w transendoscopic intraluminal tube or catheter placement UGI endoscopy w transendoscopic stent placement UGI endoscopy w transendoscopic US-guided FNA or needle biopsy UGI endoscopy w transmural drainage of pseudocyst UGI endoscopy, diagnostic Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with directed submucosal injection(s), any substance

Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with endoscopic ultrasound examination limited to the esophagus Upper gastrointestinal endoscopy, simple primary exam Use of echocardiographic contrast agent during stress echocardiography Vestibular Rehabilitation program, non-physician provider.

9 AmeriHealth HMO, Inc. • AmeriHealth Insurance Company of New Jersey • 11/09 QCC Insurance Company d/b/a AmeriHealth Insurance Company