PRIOR AUTHORIZATION LIST Call Paramount's Provider Inquiry Department at 419-887-2564 or toll-free at 1-888-891-2564.

Electronic submission is preferred. Fax prior authorization request to the appropriate fax number or toll-free at 1-866-214-2024. Prior authorizations can be emailed to Paramount's Utilization Management staff at [email protected].

Imaging procedures can be submitted through the web-based prior authorization submission tool (McKesson's Clear Coverage), via MyParamount.org as of 2/1/18.

Note: All products/benefit packages may not require prior authorization.

Providers: Please call Provider Inquiry at 419-887-2564 or toll-free at 1-888-891-2564.

Members: Please call Member Services at 419-887-2525 or toll-free 1-800-462-3589. TTY service for the hearing impaired is available at 419-887-2526 or toll-free at 1-888-740-5670. Hours of operation are Monday through Friday (excluding holidays) are: Commercial products 8am to 5pm; Paramount Advantage 7am-7pm; Paramount Elite 8am to 8pm.

NOTE: Prior Authorizations are required for payment for primary, secondary, or tertiary coverage. Retro-authorization reviews/provider appeals for denied claims for failure to follow precertification requirements will be considered for review for the following exception: the member represented as a self-pay. As a registered user to the Paramount Portal, you may also verify Paramount eligibility on MyParamount.org. Non Participating Providers are required to obtain prior authorization for all nonemergent services before services are rendered. Paramount will not pay claims for services in which prior authorization is required, but not obtained by the provider. Services will be denied with NO PATIENT LIABILITY. Paramount provides an easy hassle free process to requires Prior Authorizations electronically. Please visit https://www.myparamount.org/ Call Paramount 's Utilization/ Case Management Department at 419-887-2520 or toll-free at 1-800-891-2520.

Updated 08/17/2021 PRIOR AUTHORIZATION REQUIRED = X

HMO/ Individual PPO/CDHP ELITE ADVANTAGE CODES MEDICAL POLICY SERVICE/PROCEDURE Marketplace

95803 Effective 4/1/2021 procedure 95803 is Non-Covered for ALL PG0198 Actigraphy and ACTIGRAPHY NON-COVERED NON-COVERED NON-COVERED NON-COVERED Product lines Accelerometry Sleep Diagnositics

Effective 01/21/2020 acupuncture services are covered with chronic low Effective 10/01/17. back pain. ICD-10 M54.5. 97810, 97811, 97813, Up to 12 visits in 90 days, 97814, require a prior no prior authorization is authorization if required. An additional 8 treatments beyond five visits will be covered for (5) visits without proven ACUPUNCTURE NON-COVERED NON-COVERED 97810, 97811, 97813, 97814 PG0382 Acupuncture those patients success or treatments demonstrating an beyond thirty (30) visits improvement, a prior per calendar year. authorization is required, Effective 04/01/2021 as of 5/1/2020. Total of 20 additional covered acupuncture treatments conditions. may be administered annually.

ALL OUT OF NETWORK SERVICES (EXCEPT ER) X X X X

Effective 5/1/2021, Effective 5/1/2021, Effective 5/1/2021, Effective 5/1/2021, Ambulatory EEG Ambulatory EEG Ambulatory EEG Ambulatory EEG monitoring, with or monitoring, with or monitoring, with or monitoring, with or without without video, requires without video, requires without video, requires 95708 x 4, 95709 x 4, 95710 x 4, 95714 x 4, 95715 x 4, 95716 x 4, AMBULATORY EEG MONITORING REQUIRES PRIOR AUTHORIZATION FOR > 84 hours video, requires prior PG0333 Ambulatory EEG Monitoring prior authorization for > prior authorization for > prior authorization for > 95719 x 4, 95720 x 4, 95725, 95726, authorization for > 84 84 hours. See 84 hours. See 84 hours. See hours. See highlighted highlighted coding highlighted coding highlighted coding coding scheme below. scheme below. scheme below. scheme below. PG0335 Children's Adaptive Behavior Services. 10/01/19: 2019 Adaptive Behavior Services Update. Changed Title 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 0362T, from Children’s Intensive Behavioral CHILDREN'S ADAPTIVE BEHAVIOR SERVICES X X NON-COVERED X 0373T Service/ Applied Behavioral Analysis (ABA) to Children’s Adaptive Behavior Service. This reflects the 2019 AMA CPT Code nomenclature.

ARTIFICIAL INTERVERTEBRAL DISC REPLACEMENT - CERVICAL ARTIFICIAL DISC PG0027 Artificial Intervertebral Disc X X X X 22858 REPLACEMENT AT MORE THAN ONE LEVEL Replacement ARTIFICIAL INTERVERTEBRAL DISC REPLACEMENT - LUMBAR ARTIFICIAL DISC PG0027 Artificial Intervertebral Disc X X X X 22857 REPLACEMENT AT ONE LEVEL Replacement AUTISM TREATMENT: Refer to Medical Policy PG0335 Children’s Adaptive Behavior PG0335 Children's Adaptive Behavior X X X X Services Services AVISE PG NON-COVERED NON-COVERED X NON-COVERED 84999 PG0194 Avise PG

NO Prior Authorization NO Prior Authorization Required. The hearing NO Prior Authorization Required. The hearing Covered binaural aid products, Required. The hearing aid aid products, dispensing hearing aids & related dispensing fees, and products, dispensing fees, fees, and repairs are supplies require prior repairs are covered and repairs are covered covered under the authorization for V5014, V5030, V5040, V5060, V5070, V5080, V5130, V5140, V5150, under the hearing aid under the hearing aid rider BINAURAL HEARING AIDS and SINGLE HEARING AIDS hearing aid rider benefit. Advantage. A single V5160, V5170, V5180, V5190, V5200, V5210, V5220, V5230, V5240, PG0141 Hearing Aids rider benefit. These are benefit. These are covered These are covered hearing aid for an V5252, V5253, V5260, V5261, V5264, V5266, V5267, V5298 covered based on the based on the member’s based on the member’s Advantage member does member’s benefit benefit coverage for a benefit coverage for a not require prior coverage for a specific specific product line or specific product line or authorization. product line or provider provider group. provider group. group.

43644, 43645, 43770, 43771, 43772, 43773, 43774, 43775, 43842, METABOLIC AND BARIATRIC SURGERY X X X X 43843, 43845, 43846, 43847, 43848, 43850, 43886, 43887, 43888, PG0163 Bariatric Services S2083

PG0007 Blepharoplasty, Reconstructive BLEPHAROPLASTY X X X NON-COVERED 15820, 15821, 15822 Eyelid Surgery, and Brow Lift

PG0007 Blepharoplasty, Reconstructive BLEPHAROPLASTY X X X X 15823 Eyelid Surgery, and Brow Lift

PG0007 Blepharoplasty, Reconstructive BROW PTOSIS, UPPER EYELID BLEPHAROPTOSIS REPAIR, LID RETRACTION X X X X 67900, 67901, 67902, 67903, 67904, 67906, 67908, 67909, 67911 Eyelid Surgery, and Brow Lift

BRONCHIAL THERMOPLASTY NON-COVERED NON-COVERED NON-COVERED X 31660, 31661 PG0316 Bronchial Thermoplasty

Effective 1/1/2020 no Effective 1/1/2020 no Effective 1/1/2020 no prior Effective 1/1/2020 no CANDELA LASER - PULSED DYE LASER (PDL) THERAPY FOR CUTANEOUS VASCULAR prior authorization prior authorization authorization required when prior authorization PG0308 Pulsed Dye Laser Therapy for 17106, 17107, 17108 LESIONS required when medical required when medical medical necessity is required when medical Cutaneous Vascular Lesions necessity is indicated necessity is indicated indicated necessity is indicated

78451, 78452, 78453, 78454 Effective 08/01/2021, an additional option for outpatient imaging prior Effective 9/1/2020 Effective 9/1/2020 Effective 9/1/2020 authorization requests from Paramount participating in-plan providers; procedures 78451, procedures 78451, No prior authorization procedures 78451, 78452, Paramount is recognizing the Protecting Access to Medicare Act PG0479 Cardiovascular Nuclear Stress CARDIOVASCULAR NUCLEAR STRESS TESTING-MYOCARDIAL PERFUSION IMAGING 78452, 78453 & 78454 78452, 78453 & 78454 required when medical 78453 & 78454 require a (PAMA) scores greater than or equal to a score of 8, for administrative Testing-Myocardial Perfusion Imaging require a prior require a prior necessity is indicated prior authorization approvals across all product lines. The request form can be located at: authorization authorization https://www.paramounthealthcare.com/assets/documents/provider/Fax- Request-Form-imaging.pdf

CARTICEL AUTOLOGOUS CHONDROCYTE TRANSPLANTATION (ACT)/AUTOLOGOUS PG0190 Focal Articular Cartilage of the X X X X 27412, J7330 CHONDROCYTE IMPLANTATION (ACI) Knee

CARTICEL AUTOLOGOUS CHONDROCYTE TRANSPLANTATION (ACT)/AUTOLOGOUS PG0190 Focal Articular Cartilage of the X X NON-COVERED NON-COVERED S2112 CHONDROCYTE IMPLANTATION (ACI) Knee PG0287 Cell-Free DNA Tests For Fetal FETAL CHROMOSOMAL MICRODELETION NON-COVERED NON-COVERED NON-COVERED X 81422 Aneuploidy PG0287 Cell-Free DNA Tests For Fetal CELL-FREE DNA TESTING (e.g., MaterniT21™, Verifi™, Harmony™, Panorama™) X X X X 81420 Aneuploidy Coverage based on the Coverage per CMS criteria Coverage based on the member’s benefit of subluxation (98940- member’s benefit coverage for a specific 98942). Effective coverage for a specific Chiropractic services & product line or provider 1/1/2021 a Prior product line or provider spinal manipulation group. Chiropractic Authorization is required for CHIROPRACTIC SERVICES & SPINAL MANIPULATION FOR CHILDREN 0-3 YEARS OF group. Chiropractic (98940-98942) require PG0150 Chiropractic Services & Spinal services & spinal all chiropractic visits 98940, 98941, 98942, 98943 AGE services & spinal prior authorization for Manipulation manipulation (98940- exceeding 30 per year. manipulation (98940- children under 4 years 98943) require prior This policy includes all 98943) require prior of age authorization for combination of procedure authorization for children children under 4 years codes 98940, 98941 and under 4 years of age of age. 98942.

See details related to Clinical Trials Prior Authorization and CLINICAL TRIALS PRIOR AUTHORIZATION AND NOTIFICATIONS X X X X Notification , Out-Patient services, procedures at Medical Policy PG0446 Clinical Trials PG0466.

PG0281 Cochlear and Auditory COCHLEAR (TRADITONAL) & AUDITORY BRAINSTEM IMPLANTS X X X NON-COVERED L8625 Brainstem Implants PG0281 Cochlear and Auditory COCHLEAR (TRADITONAL) & AUDITORY BRAINSTEM IMPLANTS X X X X 69930, L8614, S2235 Brainstem Implants

Effective 11/1/2019 no Prior authorization is Prior authorization is Effective 11/1/2019 no prior authorization required for A9274, required for A9274, prior authorization required Coverage to PG0177 Continuous Blood Glucose CONTINUOUS BLOOD GLUCOSE MONITORING SYSTEMS – LONG TERM A9276, A9277, A9278, A9276, A9277, A9278, required Coverage to A9274, A9276, A9277, A9278, E0784, K0553 and K0554 follow Ohio Department Monitoring Services E0784, K0553 and E0784, K0553 and follow CMS coverage of Medicaid coverage K0554 K0554 guidelines. guidelines.

Effective 12/1/2020 The Effective 12/1/2020 The Effective 12/1/2020 The Effective 12/1/2020 The use of convalescent use of convalescent use of convalescent use of convalescent ICD-10 PCS Codes XW13325 AND XW14325 require a prior PG0481 COVID-19 Convalescent COVID-19 CONVALESCENT PLASMA plasma for COVID-19 is plasma for COVID-19 is plasma for COVID-19 is plasma for COVID-19 is authorization. Plasma covered with a facility covered with a facility covered with a facility prior covered with a facility prior authorization. prior authorization. authorization. prior authorization.

NON-COVERED Except Procedures 22526, procedure 0275T is 22527 and 62287 require 22526, 22527, 62287, 0274T, 0275T, 0627T, 0628T, 0628T, 0630T, DISCOGENIC PAIN TREATMENT NON-COVERED NON-COVERED covered when part of a a PA. the remaining PG0026 Discogenic Pain Treatment S2348 clinical trial, no prior listed procedure codes authorization required are NON-COVERED

Refer to PG0069 Urine Drug Testing for specifics: G0431, G0434, G0477, G0480, G0481, G0482, G0483, 80300, 80301, 80302, 80303, 80304, 80305, 80306, 80307, 80320, 80321, 80322, 80323, 80324, 80325, 80326, 80327, 80328, 80329, 80330, 80331, 80332, 80333, DRUG TESTING X X X X 80334, 80335, 80336, 80337, 80338, 80339, 80340, 80341, 80342, PG0069 Drug Testing 80343, 80344, 80345, 80346, 80347, 80348, 80349, 80350, 80351, 80352, 80353, 80354, 80355, 80356, 80357, 80358, 80359, 80360, 80361, 80362, 80363, 80364, 80365, 80366, 80367, 80368, 80369, 80370, 80371, 80372, 80373, 80374, 80375, 80376, 80377, 83992 Effective 07/01/2021 Effective 07/01/2021 Effective 07/01/2021 Effective 07/01/2021 prior ELECTIC TUMOR TREATMENT FIELDS prior authorization prior authorization prior authorization E0766 PG0371 Electric Tumor Treatment Fields authorization required required required required Effective August 1st, Effective August 1st, Effective August 1st, 2021 Effective August 1st, 2021 Procedures 2021 Procedures Procedures E0745, E0764, 2021 Procedure E0770 E0745, E0764, E0770. Note: Procedure E0744 - neuromuscular ELECTRICAL STIMULATION THERAPY (NMES, FES) E0745, E0764, E0770 E0745, E0764, E0770 PG0228 Electrical Stimulation Therapy E0770 require a prior require a prior stimulator for scoliosis - is non-covered for all product lines. require a prior require a prior authorization authorization authorization authorization

PG0485 Electroconvulsive Therapy ELECTROCONVULSIVE THERAPY (ECT) X X X X 00104, 90870 (ECT)

ELECTRONIC BRACHYTHERAPY NON-COVERED NON-COVERED X NON-COVERED 0182T, 0394T, 0395T PG0315 Electronic Brachytherapy

As of 1/1/2020 procedure ENDOMETRIAL ABLATION X X 58563 requires a prior X 58563 PG0388 Endometrial Ablation authorization. Effective 1/1/2020 no Effective 1/1/2020 no Effective 1/1/2020 no prior Effective 1/1/2020 no prior authorization prior authorization authorization required when prior authorization EXTERNAL COUNTERPULSATION THERAPY (ECP) G0166, 92971 PG0209 External Counterpulsation required when medical required when medical medical necessity is required when medical necessity is indicated necessity is indicated indicated necessity is indicated

PG0004 Extracorporeal Shock Wave EXTRACORPOREAL SHOCK WAVE FOR PLANTAR FASCIITIS X X X X 28890 Therapy (ESWT)

90832-90899 Psychotherapy, other psychotherapy, and other psychiatric services or procedures, when related to eye movement PG0464 Eye Movement Desensitization EYE MOVEMENT DESENSITIZATION and REPROCESSING (EMDR) X X X X desensitization and reprocessing (EMDR) therapy prior authorization is and Reprocessing (EMDR) required.

Only procedure 27412 requires a prior authorization prior to 1/1/2020. As of 1/1/2020 X excluding S2112 which PG0190 Focal Articular Cartilage of the FOCAL ARTICULAR CARTILAGE REPAIR OF THE KNEE X X 27412, 27415, 27416, 29866, 29867, 27599, S2112 procedures 27415, 27416, is noncovered Knee 29866, 29867, 27599 also require a prior authorization.

Effective 1/1/2020 no Effective 1/1/2020 no Effective 1/1/2020 no Effective 1/1/2020 no prior prior authorization prior authorization prior authorization authorization required, required, 41010, 41115, required,41010, 41115, required, 41010, 41115, FRENECTOMY OR FRENOTOMY OF THE LINGUAL FRENULUM FOR ANKYLOGLOSSIA 41010, 41115, 41520, 41520, when medical PG0407 Frenectomy or Frenotomy for 41520, when medical 41520, when medical 40806, 40819,41010, 41115, 41520 FOR MEMBERS ≥1 YEAR OF AGE when medical necessity is necessity is indicated. Ankyloglossia necessity is indicated. necessity is indicated. indicated. 40806, 40819 Procedures 40806 and 40806, 40819 are 40806, 40819 are are noncovered. 40819 require a prior noncovered. noncovered. authorization.

PG0235 Gastric Electrical Stimulation GASTRIC NEUROSTIMULATOR X X X X 43647, 43648, 43881, 43882 (GES)

55970, 55980, and all additional services when performed for gender GENDER REASSIGNMENT SURGERY X X X X PG0311 Gender Reassignment Surgery reassignment surgery.

Effective 6/1/2020 prior Effective 6/1/2020 prior Effective 6/1/2020 prior Effective 6/1/2020 prior PG0471 Genicular Nerve Blocks and GENICULAR NERVE BLOCKS AND ABLATION FOR CHRONIC KNEE PAIN 64454, 64624 authorization required authorization required authorization required authorization required Ablation for Chronic Knee Pain

ProMedica Employee Health Plans No Prior Authorization No Prior Authorization No Prior Authorization PG0454 Hip Replacement and HIP REPLACEMENT AND RESURFACING SURGERY (ARTHROPLASTY) Administered by 27125, 27130, 27132, 27134, 27137, 27138, S2118 required required required Resurfacing Surgery (Arthroplasty) Paramount do require a prior authorization

HOME HEALTH CARE X X X X

Prior authorization is Prior authorization is Prior authorization is Prior authorization is required for ages under required for ages under required for ages under required for ages under 30 30 and over the age of 30 and over the age of 30 and over the age of and over the age of 65. PG0369 Human Papillomavirus (HPV) HUMAN PAPILLOMAVIRUS (HPV) SCREENING 65. Refer to Medical 65. Refer to Medical 65. Refer to Medical 87623, 87624, 87625, G0476 Refer to Medical Policy Screening Policy PG0369 for Policy PG0369 for Policy PG0369 for PG0369 for Exception r/t Exception r/t screening Exception r/t screening Exception r/t screening screening results. results. results. results.

Coverage ages 9-45 do Coverage ages 9-45 do Coverage ages 9-45 do not require a prior not require a prior not require a prior authorization. Prior authorization. Prior authorization. Prior PG0092 HPV Vaccine Gardasil and HUMAN PAPILLOMAVIRUS (HPV) VACCINES NON-COVERED 90649, 90650, 90651 authorization required authorization required authorization required for Cervarix for age under 9 and for age under 9 and over age under 9 and over over age 45. age 45. age 45. Endoscopic transthoracic sympathectomy (ETS), procedure 32664, requires a prior authorization for the treatment of hyperhidrosis, PG0466 Hyperhidrosis Treatment HYPERHIDROSIS TREATMENT (EXCLUDING BOTOX) X X X X diagnosis codes L74.510-L74.519, L74.52, R61. Procedure 97033 is (excluding Botox) noncovered with diagnosis codes L74.510-L74.519, L74.52, R61. INJECTABLE BULKING AGENTS (SOLESTA) FOR TREATMENT OF FECAL PG0260 Injectable Bulking Agents for NON-COVERED NON-COVERED X NON-COVERED L8605, 0377T INCONTINENCE Fecal Incontinence

PG0039 Ambulatory External and IMPLANTABLE SUBCUTANEOUS CARDIAC RHYTHM MONITOR X X X X Effective 06/01/2021 procedure 33285 requires a prior authorization Implantable Electrocardiographic Monitoring

PG0351 The Implantable Miniature IMPLANTABLE MINIATURE TELESCOPE (IMT) X X X NON-COVERED 0308T Telescope (IMT)

PG0225 Implantable Testosterone IMPLANTABLE TESTOSTERONE PELLETS (TESTOPEL) X X X X S0189, 11980 Pellets

INPATIENT HOSPITAL ADMISSIONS X X X X

Effective 11/1/2019 no Effective 11/1/2019 no PG0177 Continuous Glucose Monitoring INSULIN DELIVERY SYSTEM, EXTERNAL X X prior authorization A9274, A9276, A9277, A9278, E0784, K0553 and K0554 prior authorization required Systems and Insulin Pumps required

Effective 7/1/2021 Effective 7/1/2021 Effective 7/1/2021 Effective 7/1/2021 Intensive Outpatient Intensive Outpatient Intensive Outpatient Intensive Outpatient INTENSIVE OUTPATIENT ADMISSIONS Admissions do not Admissions do not Admissions do not Admissions do not require require a prior require a prior require a prior a prior authorization authorization authorization authorization

PG0213 Interspinous and Interlaminar INTERSPINOUS and INTERLAMINAR STABILIZATION/DISTRACTION DEVICES Effective 4/1/2021 prior Effective 4/1/2021 prior Effective 4/1/2021 prior Effective 4/1/2021 prior Stabilization/Distraction 22867, 22868, 22869, 22870, C1821 (SPACERS) authorization required authorization required authorization required authorization required Devices (Spacers)

When more than one When more than one Effective 01/01/2020 when When more than one spine level/site is spine level/site is more than one spine spine level/site is injected on the same injected on the same level/site is injected on the injected on the same Procedure codes 62320, 62321, 62322, 62323, 64480, 64484, 64491, date-of-service, date-of-service, same date-of-service, date-of-service, 64492, 64494, 64495 only require a prior authorization when more than PG0354 Interventional Pain Management INTERVENTIONAL PAIN MANAGEMENT INJECTIONS: SACROILIAC, EPIDURAL outpatient services outpatient services only, outpatient services only, outpatient services only, one spine level/site is injected on the same date-of-service. All the Injections: Sacroiliac, Epidural Steroid, STEROID, FACET AND TRIGGER POINT only, requires a prior requires a prior requires a prior requires a prior procedure codes addressed within the medical policy = 20552, 20553, Facet and Trigger Point authorization. 62320, authorization. 62320, authorization. 62320, authorization. 62320, 27096, 62320, 62321, 62322, 62323, 64451, 64479, 64480, 64483, 62321, 62322, 62323, 62321, 62322, 62323, 62321, 62322, 62323, 62321, 62322, 62323, 64484, 64490, 64491, 64492, 64493, 64494, 64495, G0260 64480, 64484, 64491, 64480, 64484, 64491, 64480, 64484, 64491, 64480, 64484, 64491, 64492, 64494, 64495 64492, 64494, 64495 64492, 64494, 64495 64492, 64494, 64495

PG0174 Intrastromal Corneal Ring INTRASTROMAL CORNEAL RING SEGMENTS (INTACS) X X X X 0099T, 65785 Segments (INTACS)

Prior authorization required 29870, 29871, 29873, 29874, 29875, 29876, 29877, 29879, 29880, KNEE ARTHROSCOPY X X X PG0458 Knee Arthroscopy as of 1/1/2020. 29881, 29882, 29883, 29884, 29885, 29886, 29887

ProMedica Employee Health Plans No Prior Authorization No Prior Authorization No Prior Authorization PG0452 Knee Replacement Surgery KNEE REPLACEMENT SURGERY (ARTHROPLASTY) TOTAL AND PARTIAL Administered by 27445, 27446, 27447, 27486, 27487 required required required (Arthroplasty) Paramount do require a prior authorization Medical Policy PG0430 Kymriah™(tisagenlecleucel) has been Retired from the Medical Policy Benefit coverage and relocated to the Pharmacy Benefits coverage. Please refer to Prescription Drug PG0460 Adoptive Immunotherapy CAR- KYMRIAH™ (TISAGENLECLEUCEL) Q2040 Benefits/Prior Authorizations. https://www.paramounthealthcare.com/services/providers/prescription-drug- T Cell Therapy benefits/ Procedure 0387T, 0388T have been deleted 1/1/2019. To report, use No Prior Authorization LEADLESS CARDIAC PACEMAKERS NON-COVERED NON-COVERED X 33274, 33275. Procedure 0389T, 0390T, 0391T have been deleted PG0395 Leadless Cardiac Pacemakers required 1/1/2019. To report, use 33274, 33275, 93286, 93288, 93294, 93296

PG0104 Cosmetic and Reconstructive LIPECTOMY NON-COVERED NON-COVERED NON-COVERED X 15876, 15878, 15879 Surgery

PG0299 Abdominoplasty, LIPOSUCTION/ABDOMINAL SUCTION-ASSISTED LIPECTOMY NON-COVERED NON-COVERED NON-COVERED X 15877 Panniculectomy and Liposuction PG0186 Magnetoencephalography (MEG) MAGNETIC SOURCE IMAGING (MSI) X X NON-COVERED NON-COVERED S8035 and Magnetic Source Imaging (MSI) PG0186 Magnetoencephalography (MEG) MAGNETOENCEPHALOGRAPHY (MEG) X X X X 95965, 95966, 95967 and Magnetic Source Imaging (MSI)

MAMMOPLASTY, REDUCTION X X X X 19318 PG0054 Reduction Mammoplasty

MANDIBULAR MAXILLARY OSTEOTOMY AND ADVANCEMENT AND/OR GENIGLOSSUS PG0056 Surgical Treatments for X X X X 21141, 21145, 21196, 21199, 21685 ADVANCEMENT WITH OR WITHOUT HYOID SUSPENSION Obstructive Sleep Apnea (OSA)

MASTECTOMY FOR GYNECOMASTIA X X X X 19300 PG0221 Mastectomy for Gynecomastia

NEW TECHNOLOGY (MEDICAL & BEHAVIORAL HEALTH PROCEDURES, DIAGNOSTICS, X X X X DURABLE MEDICAL EQUIPMENT)

A0140, A0420, A0424, A0430, A0431,A0435, A0436, A0888, A0999, A0140, A0430, A0431, A0140, A0430, A0431, A0140, A0430, A0431, A0140, A0430, A0461, PG0455 Non-Emergent Ambulance Air NON-EMERGENT AMBULANCE AIR AND WATER TRANSPORTATION S9960, S9961, T2007- Review medical policy for A0435, A0436 A0435, A0436, A0435, A0436 A0435, A0436, and Water Transportation coverage/noncoverage details.

PG0457 Nursing Facility (NF) - NURSING FACILITY INTERMEDIATE LEVEL OF CARE (ILOC) X Revenue Code 0191 Intermediate Level of Care (ILOC)

PG0389 Occipital Nerve Block Therapy 64405 - Prior authorization is required for seven (7) injections or more OCCIPITAL NERVE BLOCK THERAPY X X X X for the Treatment of Headache and per calendar year Occipital Neuralgia ORAL APPLIANCES FOR OBSTRUCTIVE SLEEP APNEA – CUSTOM X X X X E0486 PG0131 Custom Oral Appliance for OSA 21120, 21121, 21122, 21123, 21125, 21127, 21141, 21142, 21143, 21145, 21146, 21147, 21150, 21151, 21154, 21155, 21159, 21160, PG0226 Orthognathic Surgery and 21181, 21182, 21183, 21184, 21188, 21193, 21194, 21195, 21196, ORTHOGNATHIC/MAXILLOFACIAL SURGERY X X X X PG0056 Surgical Treatments for 21198, 21199, 21206, 21208, 21209, 21210, 21215, 21230, 21240, Obstructive Sleep Apnea (OSA) 21244, 21245, 21246, 21247, 21248, 21249, 21255, 21270, 21275, 21295, 21296 OTOPLASTY X X X X 69300 PG0376 Otoplasty PG0415 Pancreatic Islet Cell PANCREATIC ISLET CELL TRANSPLANTATION X X X X 48160 Transplantation

PG0415 Pancreatic Islet Cell PANCREATIC ISLET CELL TRANSPLANTATION NON-COVERED NON-COVERED X NON-COVERED S2102 Transplantation

PG0299 Abdominoplasty, PANNICULECTOMY (15830) AND ABDOMINOPLASTY (15847) X X X X 15830, 15847 Panniculectomy and Liposuction PARTIAL HOSPITALIZATION X X X A Dental Provider prior authorization for medical services utilized under PEDIATRIC DENTAL CARE REQUIRING GENERAL ANESTHESIA IN AN OUTPATIENT anesthesia in the outpatient setting, is X X X X 41899 SETTING (OVER AGE 6) required. The CPT code requiring the Prior Authorization is the unlisted procedure 41899. Effective 7/1/2021 Effective 7/1/2021 Effective 7/1/2021, Effective 7/1/2021, PERCUTANEOUS OR MINIMALLY INVASIVE SACROILIAC JOINT STABILIZATION FOR procedure 27279 procedure 27279 procedure 27279, no Effective 7/1/2021 allow procedure 27279 to be covered for ALL procedure 27279, no prior PG0310 Sacroiliac Joint Fusion SACROILIAC JOINT FUSION covered and no prior covered and no prior prior authorization product lines without a prior authorization. authorization required authorization required authorization required required

PG0414 Peripheral Artery Disease (PAD) PERIPHERAL ARTERY DISEASE (PAD) NON-COVERED NON-COVERED X NON-COVERED 93668 Rehabilitation

POTENTIALLY COSMETIC SURGERY X X X X Obstructive Sleep Apnea

Procedure codes 19301, 19302, 19303, 19304, 19305, 19306, 19307 PROPHYLACTIC MASTECTOMY- RISK REDUCTION THERAPY (NO CANCER) X X X X when performed for diagnosis V50.41-Encouter for Prophylactic PG0251 Prophylactic Mastectomy Removal of Breast.

Procedure 33289 is non-covered for HMO,PPO, Individual PG0377 Pulmonary Artery Pressure PULMONARY ARTERY PRESSURE MONITORING (CardioMEMS) NON-COVERED NON-COVERED X X Marketplace, CDHP. Procedure 33289 is covered with a prior Monitoring (CardioMEMS) authorization for Advantage and Elite. PG0166 Endoscopic Therapies for TRANSORAL INCISIONLESS FUNDOPLICATION (TIF) (e.g., ESOPHYX) NON-COVERED NON-COVERED X X 43210 Gastroesophageal Reflux Disease (GERD) Bone Morphogenetic Bone Morphogenetic Bone Morphogenetic When unlisted procedure-musculoskeletal (20999), unlisted procedure Protein-2 (rhBMP-2) Protein-2 (rhBMP-2) Bone Morphogenetic Protein-2 (rhBMP-2) –spine (22899), unlisted procedure-humerus or elbow (24999), unlisted requires a prior requires a prior Protein-2 (rhBMP-2), No requires a prior procedure-forearm or wrist (25999), unlisted procedure-hands or authorization for HMO, authorization for HMO, Prior Authorization required authorization for HMO, PG0456 Recombinant Human Bone RECOMBINANT HUMAN BONE MORPHOGENETIC PROTEIN fingers (26989), unlisted procedure-femur or knee (27599), or unlisted PPO, Individual PPO, Individual through 12/31/2019. Prior PPO, Individual Morphogenetic Protein procedure-leg or ankle (27899) and 20930, Allograft, is determined to Marketplace, and Marketplace, and Authorization required as of Marketplace, and be recombinant human bone morphogenetic protein-2 and protein-7, Advantage, as of Advantage, as of 1/1/2020. Advantage, as of the above determinations will be followed. 10/1/2019. 10/1/2019. 10/1/2019. PG0166 Endoscopic Therapies for RADIOFREQUENCY THERAPY FOR GERD (STRETTA SYSTEM) & OTHER ENDOSCOPIC NON-COVERED NON-COVERED NON-COVERED X 43201, 43236, 43257, 43284, 43285 Gastroesophageal Reflux Disease THERAPIES FOR THE TREATMENT OF GERD (GERD) RADIOREQUENCY VOLUMETRIC TISSUE REDUCTION (RFVTR) OF THE SOFT PALATE, PG0056 Surgical Treatments for NON-COVERED NON-COVERED NON-COVERED X 41530 UVULA, OR TONGUE BASE (e.g., Coblation®, Somnoplasty®) Obstructive Sleep Apnea (OSA)

REHABILITATION ADMISSIONS X X X X

RESPITE BEHAVIORAL HEALTH NON-COVERED NON-COVERED NON-COVERED X <21 YO S5150, S5151 PER MEDICAID REQUIREMENTS

RESPITE MEDICAL CARE NON-COVERED NON-COVERED NON-COVERED X <21 YO S5150, S5151 PER MEDICAID REQUIREMENTS 5160-26-03 PG0012 Breast Implant Removal and Reimplantation Exception: breast implant removal and reimplantation (19328, 19330, 19340, 19342, 19370, and 19371) BREAST IMPLANT REMOVAL AND REIMPLANTATION X X X X 19328, 19330, 19340, 19342, 19370, 19371 will be reimbursed WITHOUT PRIOR AUTHORIZATION, when there is a predetermined cancer diagnosis, as listed in the medical policy. RHINOPLASTY X X X X 30400, 30410, 30420, 30430, 30435, 30450 PG0009 Rhinoplasty and Septoplasty

PG0045 Rhinomanometry and Acoustic - RHINOMANOMETRY AND ACOUSTIC/OPTICAL RHINOMETRY NON-COVERED NON-COVERED NON-COVERED X 92512 Optical Rhinometry

SKILLED NURSING FACILITY ADMISSIONS X X X X

Procedures 63650, 63655 & 63685 require a prior authorization. Additionally SPINAL CORD STIMULATION X X as of 01/01/2020 X 63650, 63655, 63663, 63664, 63685 PG0253 Spinal Cord Stimulation procedures 63663 & 63664 also require a prior authorization. Cervical Fusion: 22548, 22551, 22552, 22554, 22585, 22590, 22595, 22600, 22614. Thoracic Fusion: 22532, 22534, 22556, 22585, 22610, SPINAL FUSIONS X X X X PG0463 Spinal Fusion 22614. Lumbar Fusion: 22533, 22534, 22558, 22612, 22614, 22630, 22630, 22632, 22634 SUBTALAR ARTHROERESIS X X X X S2117, 0335T, 0511T PG0321 Subtalar Arthroeresis 69710, 69711, 69714, 69715, 69717, 69718, L8690, L8691, L8692, PG0218 Implantable Bone Conduction TEMPORAL BONE OSSEOINTEGRATED IMPLANTS (BAHA) X X X X L8693 and Bone-Anchored Hearing Aids THERAPEUTIC CONTACT LENSES X X X X V2520, V2521, V2522, V2523, V2530 PG0403 Therapeutic Contact Lenses THERAPEUTIC CONTACT LENSES X X NON-COVERED NON-COVERED S0515 PG0403 Therapeutic Contact Lenses

THERAPEUTIC CONTACT LENSES X X X NON-COVERED V2531 PG0403 Therapeutic Contact Lenses

TOTAL ANKLE REPLACEMENT X X X X 27702, 27703 PG0151 Total Ankle Replacement

PG0056 Surgical Treatments for TONGUE BASE SUSPENSION NON-COVERED NON-COVERED X X 41512 Obstructive Sleep Apnea (OSA)

PG0294 Transcranial Magnetic TRANSCRANIAL MAGNETIC STIMULATION (TMS) X X X NON-COVERED 90867, 90868, 90869 Stimulation (TMS) Transplant procedures include: heart transplants, liver transplants, kidney transplants, corneal transplants, lung or double lung transplants, simultaneous pancreas and kidney transplants, intestine transplants (includes small bowel transplants and multi-visceral transplants), bone PG0461 Transplant Prior Authorization TRANSPLANT PRIOR AUTHORIZATION AND NOTIFICATOIN X X X X marrow/stem cell transplants, and donor-leukocyte transplants. and Notification Including any additional multiple organ combination transplants See details related to Transplant: Evaluation-Prior Authorization and Notification, Out-Patient services, procedures at Medical Policy PG0461.

PG0149 Transpupillary Thermotherapy TRANSPUPILLARY THERMOTHERAPY X X X X 67299 (TTT)

PG0497 Urinary Incontinence/ Voiding TRANSURETHRAL RADIOFREQUENCY NON-COVERED NON-COVERED NON-COVERED X 53860 Dysfunction Treatments and Devices

Effective 12/1/20 Effective 12/1/20 Effective 12/1/20 Effective 12/1/20 procedures 92548 and procedures 92548 and procedures 92548 and procedures 92548 and VESTIBULAR FUNCTION TESTING 92548, 92549 PG0323 Vestibular Function Testing 92549 coverage with a 92549 coverage with a 92549 coverage with a 92549 coverage with a Prior Authorization Prior Authorization Prior Authorization Prior Authorization

VISION THERAPY X X X X 92065 PG0318 Vision Therapy

WIRELESS CAPSULE ENDOSCOPY (PILL CAM) X X X X 91110, 91111 PG0028 Wireless Capsule Endoscopy

PG0394 Wireless Gastrointestinal Motility WIRELESS GASTROINTESTINAL MOTILITY MONITORING SYSTEM (SMARTPILL) X X X X 91112 Monitoring System

Medical Policy PG0431 Yescarta™(axicabtagene ciloleucel) has been Retired from the Medical Policy Benefit coverage and relocated to the Pharmacy Benefits coverage. Please refer to Prescription Drug PG0460 Adoptive Immunotherapy CAR- YESCARTA™ (AXICABTAGENE CILOLEUCEL) Q2041 Benefits/Prior Authorizations. https://www.paramounthealthcare.com/services/providers/prescription-drug- T Cell Therapy benefits/

GENETIC TESTING: Prior authorization is required for genetic testing unless otherwise noted in one of our policies.

Genetic Counseling (96040) provided by a trained genetic counselor does not require a prior authorization.

PG0067 Genetic Testing for Hereditary GENETIC TESTING FOR HEREDITARY BREAST AND OVARIAN CANCER SYDROM 81162, 81163, 81164, 81165, 81166, 81167, 81211, 81212, 81213, X X X X Breast and Ovarian Cancer Syndrome (HBOC) 81214, 81215, 81216, 81217, 81432, 81433 (HBOC)

PG0280 Genetic Testing for Cardiac CARDIAC CONDITIONS GENETIC TESTING X X X X 81413, 81414, 81439, S3865, S3866 Conditions 81228 & 81229 PG0296 Comparative Genomic COMPARATIVE GENOMIC HYBRIDIZATION (CGH)/CHROMOSOMAL MICROARRAY X X NON-COVERED REQUIRES PA/ S3870 81228, 81229, S3870 Hybridization (CGH)/Chromosomal ANALYSIS (CMA) is NON-COVERED Microarray Analysis (CMA)

CORUS® CAD GENETIC TESTING NON-COVERED NON-COVERED X NON-COVERED 81493 PG0363 CORUS® CAD

PG0436 CYP2C19 & CYP2D6 CYP2C19 & CYP2D6 GENETIC TESTING X X X X 81225, 81226 Pharmacogenetic Testing

PG0411 Genetic Testing for GENETIC TESTING FOR DYSTROPHINOPATHIES (DUCHENNE AND BECKER X X NON-COVERED X 81161, 81408 Dystrophinopathies (Duchenne and MUSCULAR DYSTROPHY Becker Muscular Dystrophy 81201, 81202, 81203, 81288, 81292, 81293, 81294, 81295, 81296, PG0302 Genetic Testing for Lynch GENETIC TESTING FOR LYNCH SYNDROME AND POLYPOSIS SYNDROMES X X X X 81297, 81298, 81299, 81300, 81301, 81317, 81318, 81403, 81401, Syndrome and Polyposis Syndromes 81406, 81435, 81436 PG0438 Next Generation Sequencing FOUNDATIONONE CDx™ (F1CDx) NON-COVERED NON-COVERED X NON-COVERED 0037U (NGS)Tests for Advanced Cancer

PG0360 Genetic Testing for Fragile X- GENETIC TESTING FOR FRAGILE X-RELATED DISORDERS X X NON-COVERED X 81243, 81244 Related Disorders

GENE EXPRESSION ANALYSIS FOR PROSTATE CANCER GENETIC TESTING - ONCOTYPE DX PROSTATE (0047U) - PG0367 Gene Expression Analysis for PROLARIS (81541) - NON-COVERED NON-COVERED X NON-COVERED 0047U, 81479, 81541, 81551 Prostate Cancer DECIPHER (81479) - CONFIRMMDX (81551)

GENE EXPRESSION ANALYSIS FOR PROSTATE CANCER GENETIC TESTING PG0367 Gene Expression Analysis for X X X X 81313 - PROGENSA PCA3 ASSAY (81313) Prostate Cancer GENE EXPRESSION ANALYSIS FOR PROSTATE CANCER GENETIC TESTING PG0367 Gene Expression Analysis for NON-COVERED NON-COVERED NON-COVERED X 81539 - 4KSCORE TEST Prostate Cancer

PG0368 GeneSight® Assay for GENESIGHT® ASSAY FOR REFRACTORY DEPRESSION GENETIC TESTING NON-COVERED NON-COVERED X NON-COVERED 81479 Refractory Depression

GENETIC EXPRESSION ASSAYS FOR BREAST CANCER PROGNOSIS: - ONCOTYPE DX BREAST CANCER ASSAY (81519) X - MAMMAPRINT (81521) PG0301 Genetic Expression Assays for X X (S3854 IS NON- X 81479, 81519, 81520, 81521, 0008M, S3854 - PROSIGNA BREAST CANCER ASSAY (81520, 0008M) Breast Cancer Prognosis - BREAST CENCER INDEX (81479) COVERED) - ENDOPREDICT (81479, S3854)

GENETIC EXPRESSION ASSAYS FOR BREAST CANCER PROGNOSIS: - PG0301 Genetic Expression Assays for NON-COVERED NON-COVERED X NON-COVERED 81479 HERMARK ASSAY (81479) Breast Cancer Prognosis

81105, 81106, 81107, 81108, 81109, 81110, 81111, 81112, 81120, 81121, 81161, 81162, 81163, 81164, 81165, 81166, 81167, 81170, 81175, 81176, 81200, 81201, 81202, 81203, 81205, 81206, 81207, Prior authorization is Prior authorization is Prior authorization is 81208, 81209, 81212, 81215, 81216, 81217, 81218, 81219, 81220, Prior authorization is required for genetic required for genetic required for genetic 81221, 81222, 81223, 81224, 81225, 81226, 81227, 81228, 81229, required for genetic testing testing unless testing unless otherwise testing unless otherwise 81230, 81231, 81232, 81235, 81238, 81240, 81241, 81242, 81243, unless otherwise noted in otherwise noted in one noted in one of our noted in one of our 81244, 81245, 81246, 81247, 81248, 81249, 81250, 81251, 81252, one of our policies. Refer of our policies. Refer to policies. Refer to policies. Refer to Medical 81253, 81254, 81255, 81256, 81257, 81258, 81259, 81260, 81261, to Medical Policy PG0041 Medical Policy PG0041 Medical Policy PG0041 Policy PG0041 Genetic 81262, 81263, 81264, 81265, 81266, 81267, 81268, 81269, 81270, GENETIC TESTING Genetic Testing table for PG0041 Genetic Testing Genetic Testing table Genetic Testing table for Testing table for specific 81272, 81273, 81275, 81276, 81280, 81281, 81282, 81283, 81287, specific Coverage, Non- for specific Coverage, specific Coverage, Non- Coverage, Non- 81288, 81290, 81291, 81292, 81293, 81294, 81295, 81296, 81297, coverage, Medical Policy Non-coverage, Medical coverage, Medical coverage, Medical Policy 81298, 81299, 81300, 81301, 81302, 81303, 81304, 81310, 81311, specifics, and Prior Policy specifics, and Policy specifics, and specifics, and Prior 81313, 81314, 81315, 81316, 81317, 81318, 81319, 81321, 81322, Authorization Prior Authorization Prior Authorization Authorization 81323, 81324, 81325, 81326, 81327, 81328, 81329, 81330, 81331, Requirements. Requirements. Requirements. Requirements. 81332, 81334, 81335, 81336, 81337, 81340, 81341, 81342, 81346, 81350, 81355, 81361, 81362, 81363, 81364, 81370, 81371, 81372, 81373, 81374, 81375, 81376, 81377, 81378, 81379, 81380, 81381, 81382 81105, 81106, 81107, 81108, 81109, 81110, 81111, 81112, 81120, 81121, 81161, 81162, 81163, 81164, 81165, 81166, 81167, 81168, 81170, 81171, 81172, 81173, 81174, 81175, 81176, 81177, 81178, 81179, 81180 , 81181, 81182, 81183, 81184, 81185, 81186, 81187, 81188, 81189, 81190, 81191, 81192, 81193, 81194, 81200, 81201, 81202, 81203, 81204, 81205, 81206, 81207, 81208, 81209, 81212, Prior authorization is Prior authorization is Prior authorization is 81215, 81216, 81217, 81218, 81219, 81220, 81221, 81222, 81223, Prior authorization is required for genetic required for genetic required for genetic 81224, 81225, 81226, 81227, 81228, 81229, 81230, 81231, 81232, required for genetic testing testing unless testing unless otherwise testing unless otherwise 81233, 81234, 81235, 81236, 81237, 81238, 81239, 81240, 81241, unless otherwise noted in otherwise noted in one noted in one of our noted in one of our 81242, 81243, 81244, 81245, 81246, 81247, 81248, 81249, 81250, one of our policies. Refer of our policies. Refer to policies. Refer to policies. Refer to Medical 81251, 81252, 81253, 81254, 81255, 81256, 81257, 81258, 81259, to Medical Policy PG0041 Medical Policy PG0041 Medical Policy PG0041 Policy PG0041 Genetic 81260, 81261, 81262, 81263, 81264, 81265, 81266, 81267, 81268, GENETIC TESTING Genetic Testing table for PG0041 Genetic Testing Genetic Testing table Genetic Testing table for Testing table for specific 81269, 81270, 81271, 81272, 81273, 81274, 81275, 81276, 81277, specific Coverage, Non- for specific Coverage, specific Coverage, Non- Coverage, Non- 81278, 81279, 81283, 81284, 81285, 81286, 81287, 81288, 81289, coverage, Medical Policy Non-coverage, Medical coverage, Medical coverage, Medical Policy 81290, 81291, 81292, 81293, 81294, 81295, 81296, 81297, 81298, specifics, and Prior Policy specifics, and Policy specifics, and specifics, and Prior 81299, 81300, 81301, 81302, 81303, 81304, 81305, 81306, 81307, Authorization Prior Authorization Prior Authorization Authorization 81308, 81309, 81310, 81311, 81312, 81313, 81314, 81315, 81316, Requirements. Requirements. Requirements. Requirements. 81317, 81318, 81319, 81320, 81321, 81322, 81323, 81324, 81325, 81326, 81327, 81328, 81329, 81330, 81331, 81332, 81333, 81334, 81335, 81336, 81337, 81338, 81339, 81340, 81341, 81342, 81343, 81344, 81345, 81346, 81347, 81348, 81350, 81351, 81352, 81353, 81355, 81357, 81360, 81361, 81362, 81363, 81364, 81370, 81371, 81372, 81373, 81374, 81375, 81376, 81377, 81378, 81379, 81380, 81381, 81383 81400, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81479, 81410, 81411, 81412, 81413, 81414, 81415, 81416, 81417, 81419, 81420, 81422, 81425, 81426, 81427, 81430, 81431, 81432, 81433, 81434, 81435, 81436, 81437, 81438, 81439, 81440, 81442, 81443, 81445, 81448, 81450, 81455, 81460, 81465, 81470, 81471, 81479, 81490, 81493, 81500, 81503, 81504, 81506, 81507, 81508, 81509, 81510, 81511, 81512, 81518, 81519, 81520, 81521, 81522, 81525, 81528, 81529, 81535, 81536, 81538, 81539, 81540, 81541, 81542, 81545, 81546, 81551, 81552, 81554, 81595, 81596, 81599, Prior authorization is Prior authorization is Prior authorization is 88230, 88233, 88235, 88237, 88239, 88240, 88241, 88245, 88248, Prior authorization is required for genetic required for genetic required for genetic 88249, 88261, 88262, 88263, 88264, 88267, 88269, 88271, 88272, required for genetic testing testing unless testing unless otherwise testing unless otherwise 88273, 88274, 88275, 888280, 88283, 88285, 88289, 88291, 88299, unless otherwise noted in otherwise noted in one noted in one of our noted in one of our 0006M, 0007M, 0011M, 0012M, 0013M, 0001U, 0005U, 0009U, one of our policies. Refer of our policies. Refer to policies. Refer to policies. Refer to Medical 0012U, 0013U. 0014U, 0016U, 0017U, 0018U, 0019U, 0022U, 0023U, to Medical Policy PG0041 Medical Policy PG0041 Medical Policy PG0041 Policy PG0041 Genetic 0026U, 0027U, 0029U, 0030U, 0031U, 0032U, 0033U, 0034U, 0036U, GENETIC TESTING (CONTINUED) Genetic Testing table for Genetic Testing table Genetic Testing table for Testing table for specific 0037U. 0040U, 0045U, 0046U, 0047U, 0048U, 0049U, 0050U, 0053U, specific Coverage, Non- for specific Coverage, specific Coverage, Non- Coverage, Non- 0055U, 0056U, 0060U, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, coverage, Medical Policy Non-coverage, Medical coverage, Medical coverage, Medical Policy 0076U, 0078U, 0079U, 0084U, 0087U, 0088U, 0089U, 0090U, 0094U, specifics, and Prior Policy specifics, and Policy specifics, and specifics, and Prior 0101U, 0102U, 0103U, 0111U, 0118U, 0120U, 0129U, 0130U, 0131U, Authorization Prior Authorization Prior Authorization Authorization 0132U, 0133U, 0134U, 0135U, 0136U, 0137U, 0138U, 0153U, 0154U, Requirements. Requirements. Requirements. Requirements. 0155U, 0156U, 0157U, 0158U, 0159U, 0160U, 0161U, 0162U, 0168U, 0169U, 0170U, 0171U, 0172U, 0173U, 0174U, 0175U, 0177U, 0179U, 0180U, 0181U, 0182U, 0183U, 0184U, 0185U, 0186U, 0187U, 0188U, 0189U, 0190U, 0191U, 0192U, 0193U, 0194U, 0195U, 0196U, 0197U, 0198U, 0199U, 0200U, 0201U, 0203U, 0204U, 0205U, 0208U, 0209U, 0211U, 0212U, 0213U, 0214U, 0215U, 0216U, 0217U, 0218U, 0220U, 0221U, 0222U, 0229U, 0230U, 0231U, 0232U, 0233U, 0234U, 0235U, 0236U, 0237U, 0238U, 0239U, G0452, H9143, S3800, S3840, S3841, S3842, S3844, S3845, S3846, S3849, S3850, S3852, S3853, S3854,S3861,S3865,S3866,S3870

PG0355 Genetic Testing for Hereditary HEREDITARY THROMBOPHILIA X X X X 81240, 81241 Thrombophilia

PG0355 Genetic Testing for Hereditary HEREDITARY THROMBOPHILIA NON-COVERED NON-COVERED NON-COVERED X 81291 Thrombophilia

PG0437 HLA-B1502 & HLA-B5701 HLA-B1502 & HLA-B5701 PHARMACOGENETIC TESTING X X X X 81381 Pharmacogenetic Testing

PG0438 Next Generation Sequencing ONCOMINE DX TARGET TEST NON-COVERED NON-COVERED X NON-COVERED 0022U, 81455 (NGS)Tests for Advanced Cancer

PTEN GENETIC TESTING X X X X 81321, 81322, 81323 PG0336 PTEN Genetic Testing

PG0398 Genetic Testing for Spinal GENETIC TESTING FOR SPINAL MUSCULAR ATROPHY X X X X 81329, 81336, 81337 Muscular Atrophy

81410, 81411, 81412, 81413, 81414, 81415, 81416, 81417, 81419, 81420, 81422, 81425, 81426, 81427, 81430, 81431, 81432, 81433, PG0453 Germline Multi-Gene Panel GERMLINE MULTI-GENE PANEL TESTING X X X X 81434, 81435, 81436, 81437, 81438, 81439, 81440, 81442, 81443, Testing 81445, 81448, 81450, 81455, 81460, 81465, 81470, 81471

PG0287 Non-Invasive Prenatal 81420 Requires a PA. 81420 Requires a PA. 81420 Requires a PA. NON-INVASIVE PRENATAL SCREENING (NIPS)/CELL-FREE DNA SCREENING FOR 81420, 81422, 81507 Screening (NIPS)/Cell-Free DNA 81422 and 81507 are 81422 and 81507 are 81422 and 81507 are 81420, 81422, 81507 FETAL ANEUPLOIDY GENETIC TESTING Requires a PA. Screening for Fetal Aneuploidy Genetic noncovered. noncovered. noncovered. Testing

PG0412 Genetic Testing Age-Related GENETIC TESTING AGE-RELATED MACULAR DEGENERATION NON-COVERED NON-COVERED NON-COVERED NON-COVERED 81401, 81405, 81408 Macular Degeneration

88230, 88233, 88235, 88237, 88239, 88240, 88241, 88245, 88248, MOLECULAR CYTOGENETIC TESTING X X X X 88249, 88261, 88262, 88263, 88264, 88267, 88269, 88271, 88272, PG0375 Molecular Cytogenetic Testing 88273, 88274, 88275, 88280, 88283, 88285, 88289, 88291, 88299 Requires a PA = 81200, Requires a PA = 81200, Requires a PA = 81220 Requires a PA = 81200, 81205, 81209, 81220, 81205, 81209, 81220, 81400, 81401, 81403, 81205, 81209, 81220, 81242, 81250, 81251, 81242, 81250, 81251, 81404, 81406, 81479. Non- 81242, 81250, 81251, 81252, 81253, 81254, 81252, 81253, 81254, Covered = 81200, 81205, 81252, 81253, 81254, 81255, 81257, 81258, 81255, 81257, 81258, 81209, 81242, 81250, 81255, 81257, 81258, 81200, 81205, 81209, 81220, 81242, 81250, 81251, 81252, 81253, 81259, 81260, 81269, 81259, 81260, 81269, 81251, 81252, 81253, 81259, 81260, 81269, 81254, 81255, 81257, 81258, 81259, 81260, 81265, 81266, 81269, 81290, 81330, 81361, 81290, 81330, 81361, 81254, 81255, 81257, 81290, 81330, 81361, PG0442 Carrier Screening for Genetic CARRIER SCREENING FOR GENETIC DISEASES 81290, 81330, 81361, 81362, 81363, 81364, 81400, 81401, 81403, 81362, 81363, 81364, 81362, 81363, 81364, 81258, 81259, 81260, 81362, 81363, 81364, Diseases 81404, 81406, 81412, 81443, 81479, S3844, S3845, S3846, S3849, 81400, 81401, 81403, 81400, 81401, 81403, 81269, 81290, 81330, 81400, 81401, 81403, S3850, S3852, S3853 81404, 81406, 81412, 81404, 81406, 81412, 81361, 81362, 81363, 81404, 81406, 81412, 81443, 81479. Non- 81443, 81479. Non- 81364, 81412, 81443, 81443, 81479. Non- Covered = S3844, Covered = S3844, S3844, S3845, S3846, Covered = S3844, S3845, S3846, S3849, S3845, S3846, S3849, S3849, S3850, S3852, S3845, S3846, S3849, S3850, S3852, S3853. S3850, S3852, S3853. S3853. S3850, S3852, S3853.

PG0387 Genetic Testing for Cystic GENETIC TESTING FOR CYSTIC FIBROSIS X X X X 81220, 81221, 81222, 81223, 81224 Fibrosis

PG0119 Gene Expression Profiling of GENE EXPRESSION PROFILING OF MELANOMAS X X X X 0089U, 0090U, 81401, 81529, 81552, 81479, 81599 Melanomas

81188, 81189, 81190, 81401, 81403, 81404, 81405, 41406, 81407, GENETIC TESTING FOR EPILEPSY X X X X PG0467 Genetic Testing for Epilepsy 81419, 81479

81415, 81416, 81417 81415, 81416, 81417 81415, 81416, 81417 is 81415, 81416, 81417, requires a prior requires a prior PG0468 Whole Exome Sequencing non-covered. 81425, 81425, 81426, 81427 WHOLE EXOME SEQUENCING (WES) AND WHOLE GENOME SEQUENCING (WGS) authorization. 81425, authorization. 81425, 81415, 81416, 81417, 81425, 81426, 81427 (WES) and Whole Genome Sequencing 81426, 81427 is non- requires a prior 81426, 81427 is non- 81426, 81427 is non- (WGS) covered. authorization. covered. covered.

VERISTRAT GENETIC TESTING X X X NON-COVERED 81538 PG0111 VeriStrat® Testing BDX-XL2 requires prior authorization. 0080U. All other Plasma-based proteomic testing in PG0476 Proteomic Testing in the PROTEOMIC TESTING in the MANAGEMENT OF PULMONARY NODULES NON-COVERED NON-COVERED patients with undiagnosed 0080U, 0092U Management of Pulmonary Nodules pulmonary nodules detected by computed tomography is noncovered. 0092U

PG0298 Molecular Markers in Fine MOLECULAR MARKERS IN FINE NEEDLE ASPIRATES OF THYROID NODULES X X X X 81445, 81479, 81545, 81546, 81599, 0018U, 0026U, 0208U Needle Aspirates of Thyroid Nodules

IMAGING PROCEDURES:

PRIOR AUTHORIZATION IS REQUIRED FOR IMAGING PROCEDURES PERFORMED IN AN ELECTIVE OUTPATIENT SETTING.

PRIOR AUTHORIZATION IS NOT REQUIRED FOR IMAGING PROCEDURES PERFORMED IN THESE SETTINGS: • EMERGENCY DEPARTMENT • FACILITY OBSERVATION SETTING • INPATIENT SETTING 70336, 70540, 70542, 70543, 70544, 70545, 70546, 70547, 70548, 70549, 70551, 70552, 70553, 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, PG0487 Magnetic Resonance Imaging MAGNETIC RESONANCE IMAGING (MRI) and MAGNETIC RESONANCE ANGIOGRAPHY S8037, S8042. Effective 08/01/2021, an additional option for outpatient X X X X (MRI) and Magnetic Resonance (MRA) imaging prior authorization requests from Paramount participating in- Angiography (MRA). plan providers; Paramount is recognizing the Protecting Access to Medicare Act (PAMA) scores greater than or equal to a score of 8, for administrative approvals across all product lines. The request form can be located at: https://www.paramounthealthcare.com/assets/documents/provider/Fax- Request-Form-imaging.pdf

70450, 70460, 70470, 70480, 70481, 70482, 70486, 70487, 70488, 70490, 70491, 70492, 70496, 70498, 71250, 71260, 71270, 71275, 72125, 72126, 72127, 72128, 72129, 72130, 72131, 72132, 72133, 72192, 72193, 72194, 73200, 73201, 73202, 73206, 73700, 73701, 73702, 73706, 74150, 74160, 74170, 74174, 74175, 74176, 74177, PG0482 Computed Tomography (CT) 74178, 75571, 75572, 75573, 75574, 76380. Effective 08/01/2021, an COMPUTED TOMOGRAPHY (CT) SCANS and COMPUTED TOMOGRAPHYS and Computed Tomography X X X X additional option for outpatient imaging prior authorization requests ANGIOGRAPHY (CTA) SCANS Angiography (CTA) Scans from Paramount participating in-plan providers; Paramount is recognizing the Protecting Access to Medicare Act (PAMA) scores greater than or equal to a score of 8, for administrative approvals across all product lines. The request form can be located at: https://www.paramounthealthcare.com/assets/documents/provider/Fax- Request-Form-imaging.pdf

CT VIRTUAL COLONSCOPY X X X X 74261-74263 PG0182 Virtual Colonoscopy

78608, 78609, 78811, 78812, 78813, 78814, 78815, 78816, G0235, G0252 Effective 08/01/2021, an additional option for outpatient imaging prior authorization requests from Paramount participating in-plan providers; PG0450 Positron Emission Tomography POSITRON EMMISSION TOMOGRAPHY (PET) ONCOLOGY AND MISCELLANEOUS X - Effective 12/1/2020 X - Effective 12/1/2020 X - Effective 12/1/2020 X - Effective 12/1/2020 Paramount is recognizing the Protecting Access to Medicare Act (PET) Oncology and Miscellaneous APPLICATIONS (PAMA) scores greater than or equal to a score of 8, for administrative Applications approvals across all product lines. The request form can be located at: https://www.paramounthealthcare.com/assets/documents/provider/Fax- Request-Form-imaging.pdf

DURABLE MEDICAL EQUIPMENT: ALL DME THAT EXCEEDS BENEFIT LIMITS X X X X AIRWAY CLEARANCE DEVICES X X X X A7025, A7026, E0483, A7020, E0482, E1399, E0480, E0484 PG0227 Airway Clearance Devices

AIR FLUIDIZED BEDS X X X X E0194 PG0352 Air Fluidized Bed

Effective June 1, 2021 procedure Q4100 requires a prior authorizatio PG0203 Bioengineered Skin and Tissue BIOENGINEERED SKIN AND TISSUE SUBSTITUTES X X X X for all product lines Substitutes

PG0232 Bone Growth Stimulating BONE GROWTH STIMULATORS X X X X E0747, E0748, E0749, E0760 Services-Devices (Osteogenic Stimulators)

CRANIAL ORTHOTIC REMOLDING DEVICE X X X NON-COVERED L0112, L0113 PG0120 Cranial Orthotic Devices

CRANIAL ORTHOTIC REMOLDING DEVICE X X NON-COVERED X S1040 PG0120 Cranial Orthotic Devices B4102, B4103, B4104, B4105, B4149, B4150, B4152, B4153, B4154, B4155, B4158, B4159, B4160, B4161. B4157 & B4162 - Prior ENTERAL NUTRITION X X X X PG0114 Enteral and Parenteral Nutrition authorization required if NOT diagnosed with inborn errors of metabolism

A4252, A4253, A4255, A4256, A4257, A4258, A4259, E0607, E2100, GLUCOSE TESTING SUPPLIES REQUIRE PRIOR AUTHORIZATION FOR COVERED E2101 S5560, S5561, S5565, S5566, S5570, S5571, S8490 - Prior X X X X PG0155 Glucose Testing Supplies CODES IF EXCEEDS BENEFIT LIMITS authorization required for glucose testing supplies if benefit limits are exceeded

PG0383 Home Phototherapy for HOME UVB PHOTOTHERAPY TREATMENT DEVICES X X X X E0691, E0692, E0693, E0694 Dermatologic Conditions Effective 11/1/2020 Effective 11/1/2020 Effective 11/1/2020 Effective 11/1/2020 procedures E0277, procedures E0277, procedures E0277, procedures E0277, E0300, E0300, E0328 and E0300, E0328 and E0300, E0328 and E0328 and E0329 require a E0329 require a prior E0329 require a prior E0329 require a prior prior authorization. HOSPITAL BEDS AND ACCESSORIES authorization. Effective authorization. Effective authorization. Effective E0277, E0300, E0328, E0329 PG0245 Hospital Beds and Accessories Effective Prior Prior Authorization Prior Authorization Prior Authorization Authorization requirement requirement date requirement date requirement date date moved/extended to be moved/extended to be moved/extended to be moved/extended to be in in effect 11/1/2020. in effect 11/1/2020. in effect 11/1/2020. effect 11/1/2020. PG0201 Breast Pump HOSPITAL GRADE BREAST PUMP X X X X E0604 - Prior authorization required if utilized for more that 6 months Equipment/Supplies and Counseling

Effective 11/1/2020 - Effective 11/1/2020 - Effective 11/1/2020 - Prior Authorization will Prior Authorization will Effective 11/1/2020 - Prior Prior Authorization will be required for Knee be required for Knee Authorization will be be required for Knee Orthosis with a charged Orthosis with a charged required for Knee Orthosis Orthosis with a charged amount greater than amount greater than with a charged amount amount greater than $500. Procedure codes: $500. Procedure codes: greater than $500. $500. Procedure codes: L1810, L1812, L1820, L1810, L1812, L1820, Procedure codes: L1810, L1810, L1820, L1830, L1830, L1831, L1832, L1830, L1831, L1832, L1812, L1820, L1830, L1832, L1834, L1840, L1833, L1834, L1836, L1833, L1834, L1836, L1831, L1832, L1833, L1843, L1844, L1845, L1810, L1812, L1820, L1830, L1831, L1832, L1833, L1834, L1836, KNEE ORTHOSIS L1840, L1843, L1844, L1840, L1843, L1844, L1834, L1836, L1840, L1846, L1847, L1850, L1840, L1843, L1844, L1845, L1846, L1850, L1851, L1852, L1860, PG0480 Knee Orthosis L1845, L1846, L1850, L1845, L1846, L1850, L1843, L1844, L1845, L1851, L1852, L1860. L1847, L1848 L1851, L1852, L1860. L1851, L1852, L1860. L1846, L1850, L1851, HCPCS codes L1812, HCPCS L1847 and HCPCS L1847 and L1852, L1860. HCPCS L1831, L1833, L1836, L1848 are noncovered. L1848 are noncovered. L1847 and L1848 are L1848 are noncovered. Effective Prior Effective Prior noncovered. Effective Prior Effective Prior Authorization Authorization Authorization requirement Authorization requirement date requirement date date moved/extended to be requirement date moved/extended to be moved/extended to be in effect 11/1/2020. moved/extended to be in in effect 11/1/2020. in effect 11/1/2020. effect 11/1/2020.

Effective April 1st, Effective April 1st, 2021, Effective April 1st, 2021, Effective April 1st, 2021, 2021, Prior L5301, L5321, L5647, L5649, L5651, L5673, L5700, L5950, L5980, LOWER LIMB PROSTHESES Prior Authorization is Prior Authorization is Prior Authorization is PG0489 Lower Limb Prostheses Authorization is L5981, L5986, and L5987 required required required required

E1392 - Portable Oxygen Concentrators require a Prior Authorization. OXYGEN, PORTABLE OXYGEN CONCENTRATORS X X X X Effective October 1st, 2021 Prior Authorization for HCPCS procedure PG0234 Home Oxygen Therapy E1392 will require prior authorization for all product lines

PG0215 Pneumatic Compression PHEUMATIC COMPRESSION DEVICES AND SUPPLIES X X X NON-COVERED E0652 Devices and Supplies Effective 9/1/2020 Effective 9/1/2020 procedures E0601, Effective 9/1/2020 procedures E0601, Effective 9/1/2020 E0470, E0471, and procedures E0601, E0470, E0471, and procedures E0601, E0470, E0472 require a prior E0470, E0471, and E0472 require a prior E0471, and E0472 require authorization. Effective E0472 require a prior authorization. Effective a prior authorization. 12/1/2020 a prior authorization. Effective 12/1/2020 a prior Effective 12/1/2020 a prior authorization is 12/1/2020 a prior authorization is required authorization is required for required for authorization is required PG0247 Positive Airway Pressure (PAP) POSITIVE AIRWAY PRESSURE (PAP) DEVICES FOR THE TREATMENT OF for replacement Positive replacement Positive replacement Positive for replacement Positive E0601, E0470, E0471, and E0472 Devices for the Treatment of Obstructive OBSTRUCTIVE SLEEP APNEA Airway Pressure (PAP) Airway Pressure (PAP) Airway Pressure (PAP) Airway Pressure (PAP) Sleep Apnea Devices for the Devices for the Treatment Devices for the Devices for the Treatment of of Treatment of Treatment of Obstructive Sleep Obstructive Sleep Apnea Obstructive Sleep Obstructive Sleep Apnea Apnea devices. devices. Exception: Prior Apnea devices. devices. Exception: Prior Exception: Prior Notification see medical Exception: Prior Notification see medical Notification see medical policy details. Notification see medical policy details. policy details. policy details.

E1230, K0800, K0801, K0802, K0806, K0807, K0808, K0812, E0985, E1239, K0010, K0011, K0012, K0013, K0014, 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, MANUAL, POWERED, AND MOTORIZED WHEELED MOBILITY DEVICES AND K0853, K0854, K0855, K0856, K0857, K0858, K0859, K0860, K0861, PG0284 Manual, Powered, and Motorized X X X X ACCESSORIES K0862, K0863, K0864, K0868, K0869, K0870, K0871, K0877, K0878, Wheeled Mobility Devices K0879, K0880, K0884, K0885, K0886, K0890, K0891, K0898, K0899 AND E0985, E0986, E1002, E1007, E1008, E1010, E1030, E2310, E2311, E2325, K0108. Additionally, Effective 10/1/2020 procedure E2373 requires prior authorization.

SPEECH GENERATING DEVICES X X X X E2500, E2502, E2504, E2506, E2508, E2510, E2511, E2512, E2599 PG0135 Speech Generating Devices WEARABLE CARDIOVERTER DEFIBRILLATORS X X X X K0606 PG0224 Cardioverter Defibrillators

PROSTHETICS: ALL ORTHOTICS / PROSTHETICS THAT EXCEEDS BENEFIT LIMITS INITIAL PURCHASE X ONLY L6026, L6611, L6646, L6648, L6715, L6880, L6881, L6882, L6920, X X X X L6925, L6930, L6935, L6940, L6945, L6950, L6955, L6960, L6965, PG0428 Myoelectric Upper Extremity MYOELECTRIC UPPER EXTREMITY PROSTHETIC DEVICES Effective 10/1/2021 Effective 10/1/2021 Effective 10/1/2021 Effective 10/1/2021 L6970, L6975, L7007, L7008, L7009, L7040, L7045, L7170, L7180, Prosthetic Devices L7181, L7185, L7186, L7190, L7191, L7259, L7400, L7401, L7402, L7403, L7404, L7405, L7499, L8701, and L8702.