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Services That Require Precertification Standard Precert Effective: 7/1/2021 This Applies to Elective, Nonemergency Services

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Services That Require Precertification Standard Precert Effective: 7/1/2021 This Applies to Elective, Nonemergency Services Services that require precertification Standard Precert Effective: 7/1/2021 This applies to elective, nonemergency services. Some services or supplies in this list may not be covered by your benefits plan. Please check your benefit plan documents. Inpatient services Reconstructive procedures and potentially • Acute rehabilitation admissions cosmetic procedures (continued) • Elective surgical and nonsurgical inpatient • Keloid removal admissions • Lipectomy, liposuction, or any other excess fat • Inpatient hospice admissions removal procedure (such as panniculectomy and • Long term acute care (LTAC) facility admissions abdominoplasty) • Skilled nursing facility admissions • Otoplasty • Rhinoplasty Procedures • Rhytidectomy • Bronchial thermoplasty • Scar revision • Carticel (ACI), osteochondral allograft, and • Skin closures including: autograft transplantations – Skin grafts • Cochlear implant surgery and associated supplies/ – Skin flaps bone-anchored (osseointegrated) hearing aids, – Tissue grafts implantable bone conduction hearing aids • Surgery for varicose veins, including perforators • Obesity surgery and sclerotherapy • Uvulopalatopharyngoplasty (UPPP), including laser-assisted Experimental or investigational Any procedure, device, or service that may be Reconstructive procedures and potentially considered experimental or investigational including: cosmetic procedures • New emerging technology/procedures, as well as • Blepharoplasty/blepharoptosis repair existing technology and procedures applied for new • Bone graft, genioplasty, and mentoplasty uses and treatments • Breast: reconstruction, reduction, augmentation, mammoplasty, mastopexy, insertion and removal of Elective (nonemergency) ground, air, and sea breast implants ambulance transportation • Canthopexy/canthoplasty Outpatient private-duty nursing • Cervicoplasty • Chemical peels Day rehabilitation programs • Dermabrasion • Excision of subcutaneous skin and/or subcutaneous Interventional pain management services tissue • Epidural injection procedures and diagnostic • Gender reassignment surgery selective nerve root blocks • Genetically and bioengineered skin substitutes for • Paravertebral facet injection/nerve block/neurolysis wound care • Regional sympathetic nerve block • Hair transplants • Sacroiliac joint injections • Injectable dermal fillers • Implanted spinal cord stimulators Radiology DME (continued) • Cardiac blood pool imaging or MUGA-resting or • Power operated vehicles (POV) exercise • Pressure reducing support surfaces including: • Computed tomography (CT), cardiac – Air fluidized bed • Computed tomography (CT), coronaries – Non-powered advanced pressure reducing • Computed tomography angiogram (CTA), mattress coronaries – Powered air flotation bed (low air loss therapy) • Magnetic resonance angiography (MRA), cardiac – Powered pressure reducing mattress • Magnetic resonance imaging (MRI), cardiac • Push rim activated power assist devices • Myocardial perfusion imaging • Repair or replacement of all DME items that • Positron emission tomography (PET) scan/positron require precertification emission transverse tomography (PETT) scan • Speech generating devices • Single photon emission computerized tomography (SPECT), technetium or thallium Medical foods Home-Care Services Hyperbaric oxygen therapy • Enternal feeding therapy (tube feeding) Proton beam therapy • Home health care Sleep studies (facility based) • Home infusion therapy • Hospice Transplants All transplant procedures, with the exception of corneal Prosthetics/orthoses transplants • Bone-anchored hearing aids • Custom ankle-foot orthoses Mental health/serious mental illness/substance abuse1 • Custom knee-ankle-foot orthoses • Mental health and serious mental illness treatment • Custom knee braces (inpatient/partial hospitalization programs/ • Custom limb prosthetics including accessories/ intensive outpatient programs) components • Substance abuse treatment (inpatient/partial • Repair of replacement of all prosthetics/orthoses hospitalization programs/intensive outpatient that require precertification programs) Durable medical equipment (DME) Autism spectrum disorders • Bone growth stimulators Applied behavioral analysis • Continuous positive airway pressure (CPAP) device and bi-level (Bi-PAP) devices Maternity services • Dynamic adjustable and static progressive Call as soon as the doctor confirms the pregnancy and stretching devices (excludes CPMs) after delivery. • Electric, power, and motorized wheelchairs Services that require notification only including custom accessories End stage renal disease/dialysis services • External defibrillator and associated accessories • Insulin pumps • Manual wheelchairs unless they are rented • Negative pressure wound therapy • Neuromuscular stimulators Genetic and genomic tests requiring precertification The following list is a guide to the types of genetic and genomic tests that require precertification. Due to the volume of tests, it is not possible to list each test separately. Hereditary cancer syndromes Pharmacogenomic tests • BRCA gene testing (breast and ovarian cancer • Cytochrome P450 metabolism gene testing syndrome) (CYP2D6, CYP2C9, CYP2C19) • Lynch syndrome gene testing • Specialized drug response gene panels (such • Familial adenomatous polyposis gene testing as Assurex GeneSight®, GeneTrait, Genecept®, • PTEN gene testing (Cowden syndrome) Millennium PGTSM) • General cancer type panels (such as colon, breast, • Warfarin response testing or neuroendocrine cancers) • MGMT methylation analysis for glioblastoma Hereditary heart diseases Other specialty tests • Long QT syndrome gene testing • Coronary artery disease risk testing (such as ® ® • Aortic dilation or aneurysm syndrome testing CorusCAD , CardioIQ , APOE, ACE, KIF6) (includes Marfan syndrome) • Heart disease risk testing (such as CorusCAD®, CardioIQ®, APOE, ACE, KIF6, MTHFR) Other full gene analysis testing • Cystic fibrosis full gene sequencing and deletion/ Genome-wide tests duplication analysis • Microarray studies • PMP22 full gene sequencing and deletion/ • Whole exome testing duplication analysis (Charcot-Marie-Tooth, • Whole genome testing hereditary neuropathy) • Mitochondrial genome or nuclear testing Tests for many genetic disorders ANY genetic test for more than one gene or simultaneously condition (often includes words like “panel” or • Expanded carrier screening panels (such as Carrier “comprehensive” in the name) Status DNA Insight®, Counsyl Family Prep Screen, Pan-Ethnic Carrier Screening) ANY genetic test that will be billed with a non- • Hearing loss panels specific procedure code • Intellectual disability panels • Billed with CPT® codes 81400–81408 (CPT Copyright 2016 American Medical Association. All rights • Noonan spectrum disorders panels reserved. CPT® is a registered trademark of the American Medical Association.) Specialty oncology tests • Billed with an unlisted code: 81479, 81599, 84999 • Cancer gene expression or protein signature tests (such as OncotypeDX®, MammaPrint®, Afirma®, Prosigna®, HeproDX™) • Tumor molecular profiling (such as FoundationOne®, neoTYPE™, OncoPlexDx®, and many others) • Tissue of origin testing (for cancer of unknown primary) • PCA3 testing for prostate cancer Specialty drugs that require precertification All listed brands and their generic equivalents or biosimilars require precertification. This list is subject to change. Antineoplastic agents/Chemotherapy Anti-PD-1/ PD-L1 human Enzyme replacement agents** • Abraxane® (paclitaxel protein-bound monoclonal antibodies*/Chemotherapy (continued) particles) • Vimizim™ (elosulfase alfa) ® (continued) • Adcetris (brentuximab vedotin) retifanlimab* VPRIV® (velaglucerase alfa) ® • • • Alimta (Pemetrexed Disodium) • Tecentriq™ (atezolizumab) • Avastin®‡ (bevacizumab) (except for eye Gene Therapy** conditions) Bone-modifying agents • Luxturna™ (voretigene neparvovec-rzyl) ® • Azedra (iobenguane I- 131) • Evenity® • Roctavian* (valoctocogene roxaparvovec) • Blenrep™ (belantamab mafodotin) • Prolia® (denosumab) • Zolgensma® (onasemnogene abeparvovec- ® • Blincyto (blinatumomab) • Xgeva® (denosumab) xioi) • Cyramza® (ramucirumab) • Zynteglo* • Darzalex® (daratumumab) Botulinum toxin agents • Darzalex Faspro™ (daratumumab/ • Botox® (onabotulinumtoxinA) Hemophilia/Coagulation factors** hyaluronidase-fihj) • Dysport® (abobotulinumtoxinA) • Elzonris™ (tagraxofusp) • Myobloc® (rimabotulinumtoxinB) Hyaluronate acid products ® • Cingal* (triamcinolone and Monovisc) • Enhertu (fam-trastuzumab-deruxtecan- • Xeomin® (incobotulinumtoxinA) nxki) • Durolane® ® • Erbitux (cetuximab) Chemotherapy-induced nausea and • Euflexxa™ • Erwinaze® (asparaginase Erwinia • Gel-One® chrysanthemi) vomiting (CINV) agents Sustol® (Granisetron Extended- release for • Gelsyn-3™ Herceptin®‡ (trastuzumab) • • Injection) • GenVisc 850® • Herceptin Hylecta™ • Hyalgan® ® • Herzuma (trastuzumab-pkrb) Chimeric antigen receptor (CAR-T) • Hymovis® ® • Instiladrin * (nadofaragene firadenovec) therapies/Chemotherapy** • Supartz® ® • Kadcyla (ado-trastuzumab emtansinel) • Abecma (idecabtagene vicleucel) • Synojoynt™ • Kanjinti™ (trastuzumab-anns) • Breyanzi (lisocabtagene maraleucel) • Triluron™ ® • Kyprolis (carfilzomib) • ciltacabtagene autoleucel* • TriVisc™ • Lumoxiti™ (moxetumomab pasudotox-tdfk) • Kymriah™ (tisagenlecleucel) • VISCO-3® • Margenza (margetuximab) • Tecartus™ (brexucabtagene autoleucel) • Mvasi™ (bevacizumab- awwb) (except for • Yescarta™ (axicabtagene ciloleucel) Immunological agents eye conditions) • Actemra®
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