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Services That Do Not Require Precertification

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Services That Do Not Require Precertification 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 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. 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 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. 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
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