PRECERTIFICATION QUICK REFERENCE GUIDE - COLORADO & NEVADA
Verify Benefits and Eligibility With Customer Service For All Services. There may be differences in coverage at the member or group level. Services listed in this Guide may be governed by
Anthem Medical Policies or Clinical Guidelines and may impact coverage decisions even when they do not require precertification. To review Medical Policies and Clinical Guidelines refer to the
Provider Manual at www.anthem.com.
NOTE: This list applies to all local members
Colorado
Nevada
Call the Provider Precertification Line at 800-832-7850
For alpha prefixes: AGR, AKI, ARK, CBW, CLN, COG, CSS, CST, CUH, DQJ, DYY, EFM, EIL,
ENH, EOW, EXE, FFW, FIV, FOW, FQJ, GRL, GVC, GXS, HKE, HQA, HTQ, KOS, LGQ, MOO,
NIB, NMX, NOH, NQM, NRX, NWD, OAG, OHR, OLU, PEA, PQC, PQQ, RNF, ROW, ROZ, RXY,
SLE, TED, TGZ, TMC, TZX, UCD, UCL, UCF, UCV, UIT, ULA, ULX, UOW, UQC, UQJ, UZT,
VAE, WOZ, WPQ, WSR, WVY, WZT, XFA, XFB, XFC, XFD, XFE, XFF, XFH, XFI, XFJ, XFK,
XFL, XFM, XFN, XFP, XFS, XFT, XFW, XFX, XFY, SFV, XFZ, VAB, VAC, VAA, VAD
Call the Provider Precertification Line at 800-336-7767
For alpha prefixes: AAE, ADX, AYT, BJZ, FZR, GFH ,LQP, MGF, NWD, NXV, PTZ, PXM, RAR,
RUI, TNJ, TXJ, UKF, UMQ, UPW, UWJ, YFA, YFB, YFF, YFJ, YFK, YFL, YFN, YFP, YFT, YFU,
YFW, YFY, YFO, YFI, YFM, YFQ, YFC, YFH, YFD
For Radiology procedures authorization is performed by American Imaging Management (AIM). Visit their site at https://www.providerportal.com/, or call 877-291-0366, EXCEPT in the
following cases:
* Look on the member ID card for these group numbers.
* Providers are only required to contact Anthem UM for PET, SPECT,and ULTRAFAST CT scans
Colorado
AIMCO/AIMCO Park Towne Union
Carriage Healthcare
CF & I Retirees
City & County of Broomfield
CO School of Mines (Only ASO/ASC)
Colorado State University (CSU)
University of Colorado (CU)
Coleman Natural Foods
Compassion International
County Health Pool (includes several counties)
CROCS
Cummins Rocky Mountain
Einstein Noah Restaurant
Elizabeth CO School District
EMSC (Emergency Medical Services Corp.)*Exception
auth required for MRI’s (MRA, MRS) ,CT Scans, PET,
Nuclear
Fast Enterprises
GCC of America
Greenleaf Wholesale Florist
Harrison School District
Hawaii Job Corp Center
IMI American
La Plata County
Lynchberg VA Exempt Premier
Nevada
Newmont Mining
Outward Bound
Oxbow Carbon
Public Sector
Healthcare Group
Prime Marketing
Prowers County General
QEP Resources Inc.
Renewable Energy Systems
Rocla Concrete
Sanjel USA
SLE - Prefix, Several Groups
Source Gas LLC
StarTek
Sturm Financial
Sunflower Farmers Market
Ebara International
Florida Canyon Mining
GO Wireless
Jensen Precast
Jipango International
Pinnacle Entertainment (UM for MRI,
MRA, MRS, CT Scans, PET, Nuclear)
Sheet Metal Workers
Sunbelt Communications
SW Carpenters
Swift Communications
Teamster Gen Security Fund
Teamster Retires
Tagawa Greenhouse
Teller County
TGZ - MTC MGT Training Corp
Tolin Mechanical
Town of Estes Park
Town of Windsor
TZX - MTC MGT Training Corp
United Launch Alliance
Wet Oilfield Service
Page 1
Authorization List - Externalized_ Internalized CO NV 8 20 14.xls
Mortgage Solution
National Cinemedia
WZT - Several Groups
Xanterra Parks and Resorts
Grid Legend:
"Yes" or "Yes" with additional text, indicates service requires precertification.
"No" indicates no pre-certification is necessary. If service is inpatient precertification is required.
Procedure
STANDARD
EXCEPTION:
EXCEPTION:
CO TONIK
NV TONIK
PRIOR AUTH NOT PRIOR AUTH NOT
REQUIRED,
REQUIRED,
HOWEVER SOME HOWEVER SOME
SERVICES WILL
SERVICES WILL BE
BE REVIEWED
REVIEWED POST
POST SERVICE.
SERVICE. OFFER
OFFER A PRE-D
A PRE-D REVIEW IF
REVIEW IF A
A MRU/MJ CLAIM
MRU/MJ CLAIM
EDIT EXISTS.
EDIT EXISTS.
EXCEPTION:
Lumenos - CDHP
PRIOR AUTH NOT
REQUIRED,
HOWEVER SOME
SERVICES WILL BE
REVIEWED POST
SERVICE. OFFER
A PRE-D REVIEW IF
A MRU/MJ CLAIM
EDIT EXISTS.
COMMENTS
CODES LISTED BELOW ARE REFERENCED IN
PROVIDER COMMUNICATIONS AND ARE NOT
INCLUSIVE OF ALL CODES REQUIRING
PRECERTIFICATION.
A pre-determination is offered for codes with a
suspend/deny or MRU edit.
* Call Customer Service at the number on the Member's
Health Plan ID card to confirm benefits for any and all
services.
Ablative techniques (Barrett's Esophagus)
Ablative techniques (Liver malignancies)
Abortion – elective
Abraxane(Paclitaxel)
Actemra (Toclizumab)
Acupuncture
Adcetris (Brentuximab vedotin)
Adenoidectomy
Admission- ER, direct admit, elective, scheduled
ALL medical & surgical inpatient admissions - except
Maternity & Hospice require authorization
Yes
Yes
No
Yes
Yes
No
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
No
No
Yes
Yes
No
Yes
Yes
Yes
43229, 43270
47370, 47371, 47380, 47381, 47382
Aldurazyme (Laronidase)
Alimta (Pemetrexed)
Ambulance- Air or Water
Yes
Yes
Yes
No
No
No
No
No
No
Yes
Yes
No
J1931, SPMM - use profile SPMNOF
J9305, SPMM - use profile SPMNOF
Authorization required as of 7/30/10; no penalty for
failure to precert for emergent ambulance services
A0430, A0431, A0435, A0436, A0999
Amniocentesis
Anesthesia for Colonoscopy
Angiography
Angioplasty
Angioplasty with or without Stent Placement
No
No
No
No
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Ankle Replaceemnt
Appendectomy (lap & open)
Aralast (Alpha 1 proteinase inhibitor)
Aranesp (Darbepoetin alfa)
Aria (Simponi)
Yes
No
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Page 2
J9264, SPMM - use profile SPMNOF
J3262, SPMM - use profile SPMNOF
CO HMO members- refer to Landmark
J9042, SPMM - use profile SPMNOF
42830, 42831, 42835, 42836
0075T, 0076T, 35475, 37215, 37216, 61630, 61635,
61640, 61641, 61642
27702
J0256, SPMM - use profile SPMNOF
J0881 J0882, SPMM - use profile SPMNOF
J1602, SPMM - use profile SPMNOF
Authorization List - Externalized_ Internalized CO NV 8 20 14.xls
Procedure
STANDARD
EXCEPTION:
EXCEPTION:
CO TONIK
NV TONIK
PRIOR AUTH NOT PRIOR AUTH NOT
REQUIRED,
REQUIRED,
HOWEVER SOME HOWEVER SOME
SERVICES WILL
SERVICES WILL BE
BE REVIEWED
REVIEWED POST
POST SERVICE.
SERVICE. OFFER
OFFER A PRE-D
A PRE-D REVIEW IF
REVIEW IF A
A MRU/MJ CLAIM
MRU/MJ CLAIM
EDIT EXISTS.
EDIT EXISTS.
EXCEPTION:
Lumenos - CDHP
PRIOR AUTH NOT
REQUIRED,
HOWEVER SOME
SERVICES WILL BE
REVIEWED POST
SERVICE. OFFER
A PRE-D REVIEW IF
A MRU/MJ CLAIM
EDIT EXISTS.
COMMENTS
CODES LISTED BELOW ARE REFERENCED IN
PROVIDER COMMUNICATIONS AND ARE NOT
INCLUSIVE OF ALL CODES REQUIRING
PRECERTIFICATION.
A pre-determination is offered for codes with a
suspend/deny or MRU edit.
* Call Customer Service at the number on the Member's
Health Plan ID card to confirm benefits for any and all
services.
Arteriography
Arthroplasty - Ankle Replacement
Arthroplasty - Hip Replacement
No
Yes
Yes
No
No
No
No
No
No
No
Yes
Yes
Arthroplasty - Knee Replacement
Yes
No
No
Yes
Arthroscopy (knee)
Arthroscopy (non knee)
Artificial Disc
Artificial – In Vitro Fertilization
Artificial insemination
Artificial Intervertebral Discs
Aspiration or Decompression procedure
Auditory Brainstem Implants
No
No
Yes
No
No
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
No
Avastin (Bevacizumab)
Avonex (Interferon beta-1a)
Yes
Yes
No
No
No
No
No
No
C9257 J9035, SPMM - use profile SPMNOF
J1826, Q3027, Q3028 SPMM - use profile SPMNOF
Bariatric Services
Barium Swallow With or Without Speech Therapy
Benign Prostatic Hyperplasia (BPH)
Yes
No
Yes
Yes
No
No
Yes
No
No
Yes
No
No
See related codes under "Gastric Bypass"
Benlysta (Belimumab)
Berinert (C1 Esterase Inhibitor - human)
Betaseron (Interferon beta 1b)
Biophysical Profile for OB care
Biopsy (any)
Bivigam (Immune globulin-powder 500mg)
Blepharoplasty
Yes
Yes
Yes
No
No
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
No
No
Yes
No
J0490, SPMM - use profile SPMNOF
J0597, SPMM - use profile SPMNOF
J1830, SPMM - use profile SPMNOF
Bone Growth Stimulator
Yes
No
No
No
20974, 20975, 20979, E0747, E0748, E0749 , E0760,
Bone Scan (body part or whole body)
No
No
No
No
Page 3
27702
27130, 27132 **When OP, no authorization needed
27440, 27441, 27442, 27443, 27445, 27446, 27447
**When OP, no authorization needed
22856, 22857, 22865, 22862, 0163T
Confirm Benefit
Confirm Benefit
0092T, 0095T, 0098T, 22856
62287
Authorization required as of 7/30/10. S3854 Auth not
required for 92640
52450, 52647, 52648, 52649, 55873, 53850, 53852
J1556, SPMM - use profile SPMNOF
15820, 15821, 15822, 15823, 67900, 67901, 67902,
67903, 67904, 67906, 67908
Authorization List - Externalized_ Internalized CO NV 8 20 14.xls
Procedure
STANDARD
EXCEPTION:
EXCEPTION:
CO TONIK
NV TONIK
PRIOR AUTH NOT PRIOR AUTH NOT
REQUIRED,
REQUIRED,
HOWEVER SOME HOWEVER SOME
SERVICES WILL
SERVICES WILL BE
BE REVIEWED
REVIEWED POST
POST SERVICE.
SERVICE. OFFER
OFFER A PRE-D
A PRE-D REVIEW IF
REVIEW IF A
A MRU/MJ CLAIM
MRU/MJ CLAIM
EDIT EXISTS.
EDIT EXISTS.
EXCEPTION:
Lumenos - CDHP
PRIOR AUTH NOT
REQUIRED,
HOWEVER SOME
SERVICES WILL BE
REVIEWED POST
SERVICE. OFFER
A PRE-D REVIEW IF
A MRU/MJ CLAIM
EDIT EXISTS.
COMMENTS
CODES LISTED BELOW ARE REFERENCED IN
PROVIDER COMMUNICATIONS AND ARE NOT
INCLUSIVE OF ALL CODES REQUIRING
PRECERTIFICATION.
A pre-determination is offered for codes with a
suspend/deny or MRU edit.
* Call Customer Service at the number on the Member's
Health Plan ID card to confirm benefits for any and all
services.
Botulinum toxin (BOTOX)
Yes
No
No
Yes
If the request for J0585 includes 64633, 64634, 64635,
64636, 64650 – refer to SPMM and build with Profile
SPMNOF. If J0585 is NOT requested, build in WMDS
and refer to PSR.
Brachytherapy
Yes
No
No
No
Please refer callers to AIM 877-291-0366 for
preauthorization: 77761 [77762, 77763, 77776, 77777,
77778, 77785, 77786, 77787] (C-77326, 77327, 77328,
Q3001){A-43499, 47999, 55899, 67218, 19296,19297,
19298,20555, 41019, 55860, 55862, 55865, 55875,
76873, 55920, 31643, 57155, 57156, 58346}
Breast Prosthesis
Breast Reconstruction
Yes
Yes
No
No
No
No
No
No
C1789, L8600
19340, 19342, 19350, 19355, 19357, 19361, 19364,
19366, 19367, 19368, 19369, 19380, 19396, C1789,
L8600,S2066,S2067, S2068
Breast Reconstruction for Cancer Dx
Breast Reconstruction for Non-cancer Diagnosis
Breast Reduction
Yes
Yes
Yes
No
No
No
No
No
No
Yes if inpatient
No
Yes if inpatient
Bronchoscopy
Bunionectomy (Foot surgery)
CABG (Coronary Artery Bypass Graft)
Campath (Alemtuzumab)
Canaloplasty
Capsule Endoscopy
Cardiac Catheterization
Cardiac Rehabilitation
Cardiac Resyncronization Therapy
No
No
No
Yes
Yes
Yes
No
No
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
No
No
No
No
Cardioversion
Carimune (Immune globulin-powder)
Carpal Tunnel
Cataract Surgery
Chin Implants
Chiropractic
No
Yes
No
No
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
No
No
No
Page 4
Approve 2 day LOS if Inpatient
Not a benefit
Confirm benefit.
19318 Clinical review is not required if diagnosis is related
to breast cancer.
J9010, SPMM - use profile SPMNOF
66174, 66175
91110, 91111
33202, 33203, 33207, 33208, 33211, 33213, 33214,
33216, 33217, 33224, 33225, 33226, 33249
J1566, SPMM - use profile SPMNOF
21125
CO HMO members- refer to Landmark
Authorization List - Externalized_ Internalized CO NV 8 20 14.xls
Procedure
STANDARD
EXCEPTION:
EXCEPTION:
CO TONIK
NV TONIK
PRIOR AUTH NOT PRIOR AUTH NOT
REQUIRED,
REQUIRED,
HOWEVER SOME HOWEVER SOME
SERVICES WILL
SERVICES WILL BE
BE REVIEWED
REVIEWED POST
POST SERVICE.
SERVICE. OFFER
OFFER A PRE-D
A PRE-D REVIEW IF
REVIEW IF A
A MRU/MJ CLAIM
MRU/MJ CLAIM
EDIT EXISTS.
EDIT EXISTS.
EXCEPTION:
Lumenos - CDHP
PRIOR AUTH NOT
REQUIRED,
HOWEVER SOME
SERVICES WILL BE
REVIEWED POST
SERVICE. OFFER
A PRE-D REVIEW IF
A MRU/MJ CLAIM
EDIT EXISTS.
COMMENTS
CODES LISTED BELOW ARE REFERENCED IN
PROVIDER COMMUNICATIONS AND ARE NOT
INCLUSIVE OF ALL CODES REQUIRING
PRECERTIFICATION.
A pre-determination is offered for codes with a
suspend/deny or MRU edit.
* Call Customer Service at the number on the Member's
Health Plan ID card to confirm benefits for any and all
services.
Cholecystectomy (laparoscopy & open)
Chondrocyte Implantation
Cimzia (Certolizumab pegol)
Cinryze (C1 Esterase inhibitor - human)
Clostridial Collagenase Histolyticum Injection
Cochlear Implant
No
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
No
No
Colonoscopy – medical
Colonoscopy – routine
Colonoscopy – virtual
Colposcopy
Communication/Speech Generating Devices
Computer-assisted surgical navigational procedure
No
No
Yes
No
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Copaxone (Glatiramer acetate)
Corneal Topography
Cosmetic – Reconstructive
Yes
No
Yes
No
No
No
No
No
No
Yes
No
No
J1595, SPMM - use profile SPMNOF
Cryablation
Yes
No
No
No
64640
Cryopreservation
Yes
No
No
No
89344, 89354
Cryosurgical ablation
Yes
No
No
No
19105, 50250, 50542, 50593, 55873
Page 5
27412, S2112, J7330
J0717, SPMM - use profile SPMNOF
J0598, SPMM - use profile SPMNOF
20527, 26341, J0775
Procedure and external speech processor requires
authorization. Auth required: L8614, L8619, L8627,
L8628, S2235
Auth not required for 92603, L8615, L8616, L8617,
L8618
Call AIM to preauthorize 877-291-0366
E1902, E2351
0054T, 0055T, 20985
11920, 11921, 11922, 11950, 11951, 11952, 11954,
17106, 17107, 17108, 21740, 21742, 21743, 30120,
30400, 36469, 54440, 56800, 56805, 56810, 57291,
57292, 64716, 64732, 64734, 64736, 64738, 64740,
64742, 64864, 64865, 64866, 64868, 64870, 69090,
69300, 69955, D7995, D7996
Authorization List - Externalized_ Internalized CO NV 8 20 14.xls
Procedure
STANDARD
CT (Computerized tomography)
Yes
CTA (Computerized Tomography Angiography)
Yes
Custom knee braces
Cyber Knife
Cystoscopy
Deep Brain Stimulation
EXCEPTION:
EXCEPTION:
CO TONIK
NV TONIK
PRIOR AUTH NOT PRIOR AUTH NOT
REQUIRED,
REQUIRED,
HOWEVER SOME HOWEVER SOME
SERVICES WILL
SERVICES WILL BE
BE REVIEWED
REVIEWED POST
POST SERVICE.
SERVICE. OFFER
OFFER A PRE-D
A PRE-D REVIEW IF
REVIEW IF A
A MRU/MJ CLAIM
MRU/MJ CLAIM
EDIT EXISTS.
EDIT EXISTS.
Yes
EXCEPTION:
Lumenos - CDHP
PRIOR AUTH NOT
REQUIRED,
HOWEVER SOME
SERVICES WILL BE
REVIEWED POST
SERVICE. OFFER
A PRE-D REVIEW IF
A MRU/MJ CLAIM
EDIT EXISTS.
COMMENTS
CODES LISTED BELOW ARE REFERENCED IN
PROVIDER COMMUNICATIONS AND ARE NOT
INCLUSIVE OF ALL CODES REQUIRING
PRECERTIFICATION.
A pre-determination is offered for codes with a
suspend/deny or MRU edit.
* Call Customer Service at the number on the Member's
Health Plan ID card to confirm benefits for any and all
services.
Yes
Yes
Please refer callers to AIM 877-291-0366 for
preauthorization: 877-291-0366: 74150, 74160, 74170,
71250, 71260, 71270, 73200, 73201, 73202, 73700,
73701, 73702, 70450, 70460, 70470, 70480, 70481,
70482, 70486, 70487, 70488, 70490, 70491, 70492,
72192, 72193, 72194, 72125, 72126, 72127, 72128,
72129, 72130, 72131, 72132, 72133, 74176, 74177,
74178, 75574, 75572, 75573, 75571, 74263, 74261,
74262 (Add-on-Codes: 76376 & 76377)
No
No
Yes
Please refer callers to AIM 877-291-0366 for
preauthorization: 74175, 75635, 74174, 71275, 73206,
73706, 70496, 70498, 72191, 77078
No
Yes
No
Yes
No
No
No
No
No
No
No
No
No
No
No
No
Defibrillator (Implantable Cardioverter)
Yes
No
No
No
33202, 33203, 33216, 33217, 33249, C1721, C1722,
C1777, C1882, C1895, C1896, 0102T
Defibrillator (Wearable Cardioverter)
Delivery (cesarean)
Yes
No
No
No
No
No
No
No
K0606
Requires notification if member hospitalized longer
than 4 days
Delivery (vaginal)
No
No
No
No
Requires notification if member hospitalized longer
than 2 days
Dental caries-facility and anesthesia
Yes
No
No
Yes
For requests with DX521.00 and CPT codes 00170
and/or 41899, build WMDS case and pend to PSR.
Dental-related services
Destruction of lesion (benign or malignant)
Dexascan
Diabetic (dietitian) education
Dialysis
Dihydroergotamine Mesylate (DHE) (Treatment of
Migraine or Cluster Headaches in Adults)
Yes
No
No
No
No
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Dilation & Curettage (D&C)
No
No
No
No
Page 6
63620, 63621, G0173, G0251
61863, 61864, 61867, 61868, 61870, 61875, 61885,
61886, L8680
76977, 77080, 77082, 78350, 78351, G0130
J1110
Authorization List - Externalized_ Internalized CO NV 8 20 14.xls
Procedure
Discogram
Drainage Devices (Intraocular Anterior Segment)
STANDARD
No
Yes
EXCEPTION:
EXCEPTION:
CO TONIK
NV TONIK
PRIOR AUTH NOT PRIOR AUTH NOT
REQUIRED,
REQUIRED,
HOWEVER SOME HOWEVER SOME
SERVICES WILL
SERVICES WILL BE
BE REVIEWED
REVIEWED POST
POST SERVICE.
SERVICE. OFFER
OFFER A PRE-D
A PRE-D REVIEW IF
REVIEW IF A
A MRU/MJ CLAIM
MRU/MJ CLAIM
EDIT EXISTS.
EDIT EXISTS.
EXCEPTION:
Lumenos - CDHP
PRIOR AUTH NOT
REQUIRED,
HOWEVER SOME
SERVICES WILL BE
REVIEWED POST
SERVICE. OFFER
A PRE-D REVIEW IF
A MRU/MJ CLAIM
EDIT EXISTS.
COMMENTS
CODES LISTED BELOW ARE REFERENCED IN
PROVIDER COMMUNICATIONS AND ARE NOT
INCLUSIVE OF ALL CODES REQUIRING
PRECERTIFICATION.
A pre-determination is offered for codes with a
suspend/deny or MRU edit.
* Call Customer Service at the number on the Member's
Health Plan ID card to confirm benefits for any and all
services.
No
No
No
No
No
No
DME (Durable Medical Equipment) other than as listed No
as "yes" on this list
No
No
No
Duplex Scan
Dysport (Abobotulinum toxin A)
Echocardiogram
No
Yes
Yes
No
No
No
No
No
No
No
Yes
Yes
Ectropion Repair
Education Classes
EEG (Electroencephalogram)
EGD (Esophagogastroduodenoscopy)
EKG (electrocardiogram)
Egrifta (Tesamorelin)
Yes
No
No
No
No
Yes
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
No
No
No
No
67917
Confirm benefit
Electrothermal shrinkage
Yes
Electronic analysis of implanted neurostimulator pulse Yes
generator system
No
No
No
No
No
Yes
S2300, 29999
See "Vagus Nerve Stimulation Therapy"
Elelyso (Taliglucerase alfa)
Embolization - Ovarian, Iliac, Uterine Artery
Emergency Room Visit
EMG (Electromyography) Nerve Conduction Test
Enbrel (Etanercept)
Endoscopic Fundoplication
Enteral Feedings
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
No
No
Yes
No
No
J3060, SPMM - use profile SPMNOF
37241
Yes
Yes
No
No
Yes
Yes
Yes
Page 7
0253T, 0191T, 66183
J0586, SPMM - use profile SPMNOF
Please refer callers to AIM 877-291-0366 for
preauthorization: 877-291-0366: 93350, 93351, 93303,
93304, 93306, 93307, 93308, 93312, 93313, 93314,
93315, 93316, 93317 (Add-on-Codes 93320, 93321,
93325, 93352)
Use J3490 if they specifically ask for Egrifta and use
OPPX as the WMDS profile. This is an SPMM drug.
J1438, SPMM - use profile SPMNOF
43257
B4034, B4035, B4036, B4081, B4082, B4083, B4087,
B4088, B4100, B4102 B4103, B4104, B4149, B4150,
B4152, B4153, B4154, B4155, B4157, B4158, B4159,
B4160, B4161, B4162, B9000, B9002 S9340, S9341,
S9342, S9343, S9433, S9434, S9435
Authorization List - Externalized_ Internalized CO NV 8 20 14.xls
Procedure
STANDARD
EXCEPTION:
EXCEPTION:
CO TONIK
NV TONIK
PRIOR AUTH NOT PRIOR AUTH NOT
REQUIRED,
REQUIRED,
HOWEVER SOME HOWEVER SOME
SERVICES WILL
SERVICES WILL BE
BE REVIEWED
REVIEWED POST
POST SERVICE.
SERVICE. OFFER
OFFER A PRE-D
A PRE-D REVIEW IF
REVIEW IF A
A MRU/MJ CLAIM
MRU/MJ CLAIM
EDIT EXISTS.
EDIT EXISTS.
EXCEPTION:
Lumenos - CDHP
PRIOR AUTH NOT
REQUIRED,
HOWEVER SOME
SERVICES WILL BE
REVIEWED POST
SERVICE. OFFER
A PRE-D REVIEW IF
A MRU/MJ CLAIM
EDIT EXISTS.
COMMENTS
CODES LISTED BELOW ARE REFERENCED IN
PROVIDER COMMUNICATIONS AND ARE NOT
INCLUSIVE OF ALL CODES REQUIRING
PRECERTIFICATION.
A pre-determination is offered for codes with a
suspend/deny or MRU edit.
* Call Customer Service at the number on the Member's
Health Plan ID card to confirm benefits for any and all
services.
Epogen (Epoetin alfa)
Yes
No
No
Yes
J0885 Q4081 J0886, SPMM - use profile SPMNOF
Erbitux (Cetuximab)
ERCP (Endoscopic retrograde
cholangiopancreatography)
Yes
No
No
No
No
No
Yes
No
J9055, SPMM - use profile SPMNOF
ESI (Epidural Steroid Injections)
Ethmoidectomy
Euflexxa (Hyaluronic Acid)
No
Yes
Yes
No
No
No
No
No
No
No
No
Yes
Event Monitor
Excision of Benign Lesion
Excision Inferior Turbinate, Partial or Complete, any
method
No
No
Yes
No
No
Yes
No
No
No
No
No
No
Excision of Malignant Lesion
Excision (Nasal Polyps)
Extavia (Interferon beta 1b)
External infusion pumps, including insulin
Extracorporeal shock wave therapy (ESWT)
Eye lid Reconstruction
Eylea (Afibercept)
Fabrazyme (Agalsidase Beta)
Fasciotomy
Fixed wing air mileage, per statue mile
Flatfoot Treatments (Extraosseous Subtalar Joint
Implantation and Subtalar Arthoereisis)
No
Yes
Yes
Yes
Yes
No
Yes
Yes
No
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
No
No
Yes
Yes
No
No
No
Flebogamma (Immune globulin-liquid
Flolan (Epoprostenol)
Foot surgery
Forehead Reduction
Functional Electrical Stimulators (FES)
Functional Endoscopic Sinus Surgery (FESS)
Yes
Yes
No
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
No
No
Yes
No
Page 8
31200, 31201, 31205
J7323, SPMM - use profile SPMNOF. Authorizations
not required for injections in the knee only -- DX
codes 715.16- 716.96 Osteoarthrosis, lower leg (all
codes in this range ending with fifth digit 6). All
other requests require pre-authorization.
30130
30115, 30110
J1830, SPMM - use profile SPMNOF
E0784, A9274
0019T, 0101T, 0102T, 28890
67973
J0178, SPMM - use profile SPMNOF
J0180, SPMM - use profile SPMNOF
A0435
S2117, 0335T, 28899
J1572, SPMM - use profile SPMNOF
J1325, SPMM - use profile SPMNOF
21137, 21138, 21139
E0764, E0770
Authorization required as of 7/30/10. 31237, 31254,
31255, 31256, 31267, 31276, 31287, 31288
Authorization List - Externalized_ Internalized CO NV 8 20 14.xls
Procedure
STANDARD
EXCEPTION:
EXCEPTION:
CO TONIK
NV TONIK
PRIOR AUTH NOT PRIOR AUTH NOT
REQUIRED,
REQUIRED,
HOWEVER SOME HOWEVER SOME
SERVICES WILL
SERVICES WILL BE
BE REVIEWED
REVIEWED POST
POST SERVICE.
SERVICE. OFFER
OFFER A PRE-D
A PRE-D REVIEW IF
REVIEW IF A
A MRU/MJ CLAIM
MRU/MJ CLAIM
EDIT EXISTS.
EDIT EXISTS.
EXCEPTION:
Lumenos - CDHP
PRIOR AUTH NOT
REQUIRED,
HOWEVER SOME
SERVICES WILL BE
REVIEWED POST
SERVICE. OFFER
A PRE-D REVIEW IF
A MRU/MJ CLAIM
EDIT EXISTS.
COMMENTS
CODES LISTED BELOW ARE REFERENCED IN
PROVIDER COMMUNICATIONS AND ARE NOT
INCLUSIVE OF ALL CODES REQUIRING
PRECERTIFICATION.
A pre-determination is offered for codes with a
suspend/deny or MRU edit.
* Call Customer Service at the number on the Member's
Health Plan ID card to confirm benefits for any and all
services.
Fundoplication, Endoscopic
Gamma Knife – Stereotactic radiosurgery
Gamma globulin, IM
Gammagard (Immune globulin-liquid)
Gammaplex (Immune globulin, IV)
Gamunex (Immune globulin-liquid
Gastrectomy
Gastric Bypass, Laparoscopic; Surgery for Morbid
Obesity
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
Yes
No
No
No
No
No
No
No
Yes
No
No
Yes
Yes
Yes
Yes
No
Yes
43257
Call AIM to preauthorize: 877-291-0366
J1560, J1460, SPMM - use profile SPMNOF
J1569, SPMM - use profile SPMNOF
J1557, SPMM - use profile SPMNOF
J1561, SPMM - use profile SPMNOF
43632
43644, 43645, 43659, 43770, 43774, 43842, 43843,
43845, 43846, 43847, 43848, 43886, 43887, 43888,
43771, 43772, 43773
Gastric Pacemaker
Gel-One (Hyaluronic acid)
Yes
Yes
Yes
No
Yes
No
Yes
Yes
43647, 43648, 43881, 43882, 64595
J7326 USE OPPX. Authorizations not required for
injections in the knee only -- DX codes 715.16- 716.96
Osteoarthrosis, lower leg (all codes in this range
ending with fifth digit 6). All other requests require
pre-authorization.
Gender Reassignment Surgery
Yes
No
No
No
54125, 54520, 54690, 55180, 55970, 56625, 55980,
56800, 56805, 57110, 57291, 57292, 57295, 57296,
54660
Genetic Testing
Yes
No
No
No
81321, 81322, 81323, 81324, 81325, 81326, 81402,
81403, 81404, 81405, 81406, 81479, 81599,
Genetic Testing for Cancer Susceptibility (BRCA,
HNPCC, and FAP testing)
Yes
No
No
No
81211, 81212, 81213, 81214, 81215, 81216, 81217,
81292, 81293, 81294, 81295, 81296, 81297, 81298,
81299, 81300, 81301, 81317, 81318, 81319, S3840
Genioplasty
Generator, neurostimulator (implantable)
Genotropin (Somatropin (rDNA origin))
Glassia (Alpha 1 proteinase inhibitor)
Glaucoma Treatment (Drainage Devices)
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
No
21120, 21121, 21122, 21123
C1767
J2941, SPMM - use profile SPMNOF
J0257, SPMM - use profile SPMNOF
See "Drainage Devices (Intraocular Anterior
Segment)"
Glossectomy
Gonadotropin Releasing Hormone (GnRH) Analogs
Yes
Yes
No
No
No
No
No
No
41599
J9202, J9217, J9218
Graft, bone (reconstructive surgery)
Yes
No
No
No
21235, 21230
Page 9
Authorization List - Externalized_ Internalized CO NV 8 20 14.xls
Procedure
STANDARD
EXCEPTION:
EXCEPTION:
CO TONIK
NV TONIK
PRIOR AUTH NOT PRIOR AUTH NOT
REQUIRED,
REQUIRED,
HOWEVER SOME HOWEVER SOME
SERVICES WILL
SERVICES WILL BE
BE REVIEWED
REVIEWED POST
POST SERVICE.
SERVICE. OFFER
OFFER A PRE-D
A PRE-D REVIEW IF
REVIEW IF A
A MRU/MJ CLAIM
MRU/MJ CLAIM
EDIT EXISTS.
EDIT EXISTS.
EXCEPTION:
Lumenos - CDHP
PRIOR AUTH NOT
REQUIRED,
HOWEVER SOME
SERVICES WILL BE
REVIEWED POST
SERVICE. OFFER
A PRE-D REVIEW IF
A MRU/MJ CLAIM
EDIT EXISTS.
COMMENTS
CODES LISTED BELOW ARE REFERENCED IN
PROVIDER COMMUNICATIONS AND ARE NOT
INCLUSIVE OF ALL CODES REQUIRING
PRECERTIFICATION.
A pre-determination is offered for codes with a
suspend/deny or MRU edit.
* Call Customer Service at the number on the Member's
Health Plan ID card to confirm benefits for any and all
services.
Growth Hormone Therapy (Somatropin)
(GENOTROPIN, HUMATROPE, SEROSTIM)
Yes
No
No
Yes
J2941
Gynecomastia repair
Hair transplant
Halavan (Eribulin)
HALT procedure
Hammertoe Repair
Hearing Aids
Yes
Yes
Yes
Yes
No
Yes
No
No
No
No
No
Yes
No
No
No
No
No
Yes
No
No
Yes
No
No
Yes
19300
15775, 15776
J9179, SPMM - use profile SPMNOF
58578
Hearing Aids (Bone Anchored)
Yes
No
No
No
69710, 69714, 69715, 69717, 69718 , L8690, L8691,
L8692
Heart Monitors/Real-Time Remote Heart Monitors
[external mobile cardiovascular telemetry]
Yes
No
No
No
93228, 93229
Hemorrhoidectomy
Hepatectomy
Herceptin (Trastuzumab)
Hernia Repair
High Frequency Chest Wall Oscillation
No
Yes
Yes
No
Yes
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
No
Hizentra (Immune globulin)
Holter Monitor
Home Health Care
Home IV Therapy - all others
Home IV Therapy - antibiotics & Solumedrol
Home Uterine Monitoring
Hospice - Inpatient or Outpatient
Yes
No
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
No
No
No
No
Yes -only for
respite care
Hospital beds
HP Acthar gel (Corticotrophin Injection)
Humatrope (Somatropin (rDNA origin))
Humira (Adalimumab)
No
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Page 10
Minor children under 18 years of age
S2230, 69714
47120
J9355, SPMM - use profile SPMNOF
See "Oscillatory Devices for Airway Clearance"
J1559, SPMM - use profile SPMNOF
Check SPMM list
Check SPMM list
J0800, SPMM - use profile SPMNOF
J2941, SPMM - use profile SPMNOF
J0135, SPMM - use profile SPMNOF
Authorization List - Externalized_ Internalized CO NV 8 20 14.xls
Procedure
STANDARD
EXCEPTION:
EXCEPTION:
CO TONIK
NV TONIK
PRIOR AUTH NOT PRIOR AUTH NOT
REQUIRED,
REQUIRED,
HOWEVER SOME HOWEVER SOME
SERVICES WILL
SERVICES WILL BE
BE REVIEWED
REVIEWED POST
POST SERVICE.
SERVICE. OFFER
OFFER A PRE-D
A PRE-D REVIEW IF
REVIEW IF A
A MRU/MJ CLAIM
MRU/MJ CLAIM
EDIT EXISTS.
EDIT EXISTS.
EXCEPTION:
Lumenos - CDHP
PRIOR AUTH NOT
REQUIRED,
HOWEVER SOME
SERVICES WILL BE
REVIEWED POST
SERVICE. OFFER
A PRE-D REVIEW IF
A MRU/MJ CLAIM
EDIT EXISTS.
COMMENTS
CODES LISTED BELOW ARE REFERENCED IN
PROVIDER COMMUNICATIONS AND ARE NOT
INCLUSIVE OF ALL CODES REQUIRING
PRECERTIFICATION.
A pre-determination is offered for codes with a
suspend/deny or MRU edit.
* Call Customer Service at the number on the Member's
Health Plan ID card to confirm benefits for any and all
services.
Hyalgan (Hyaluronic acid)
Yes
No
No
Yes
J7321, SPMM - use profile SPMNOF. Authorizations
not required for injections in the knee only -- DX
codes 715.16- 716.96 Osteoarthrosis, lower leg (all
codes in this range ending with fifth digit 6). All
other requests require pre-authorization.
Hycamtin (Topotecan)
Hyperbaric Oxygen Therapy
Hyperhidrosis
Hysterectomy
Yes
Yes
Yes
Yes
No
No
No
Yes
No
No
No
Yes
Yes
No
No
Yes
J9351, SPMM - use profile SPMNOF
99183, C1300 (effective 10/1/14)
32664
Prior authorization required for inpatient and
outpatient hysterectomy, eff 050114. 58150, 58152,
58180, 58200, 58210, 58240, 58260, 58262, 58263,
58267, 58270, 58275, 58280, 58285, 58290, 58291,
58292, 58293, 58294, 58541, 58542, 58543, 58544,
58548, 58550, 58552, 58553, 58554, 58570, 58571,
58572, 58573, 58953, 58954, 58956, 59525
Hysteroscopy
No
Ilaris (Canakinumab)
Yes
Immune Globin (Caramune J1566, Flebogamma J1572, Yes
Gamma Globulin J1460, J1560, Gammagard J1569,
Gamunex J1561, Hizentra J1559, Privigen J1459, SCIg
90284)
No
Yes
No
No
Yes
No
No
Yes
Yes
Implanted (Epidural and Subcutaneous) Spinal Cord
Stimulators (SCS)
Yes
No
No
No
See "Implanted (Epidural and Subcutaneous) Spinal
Cord Stimulators (SCS)"
IMRT- Intermodulated radiation therapy
Yes
No
No
No
Please refer callers to AIM 877-291-0366 for
preauthorization: 77418[0073T](C-77301, 77338)
Implantable Infusion Pumps
Implantable Devices for Spinal Stenosis
In Vitro Fertilization
Incontinence Therapy
Infertility
Insulin Pump
Intrapulmonary percussive ventilation system (IPV)
Yes
Yes
No
No
No
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
36260, 36563, 61215
0202T
Confirm Benefits
Page 11
J0638, SPMM - use profile SPMNOF
90281, J1599, SPMM - use profile SPMNOF
Confirm benefit
E0784 Insulin Pump requires review
See "Oscillatory Devices for Airway Clearance"
Authorization List - Externalized_ Internalized CO NV 8 20 14.xls
Procedure
STANDARD
EXCEPTION:
EXCEPTION:
CO TONIK
NV TONIK
PRIOR AUTH NOT PRIOR AUTH NOT
REQUIRED,
REQUIRED,
HOWEVER SOME HOWEVER SOME
SERVICES WILL
SERVICES WILL BE
BE REVIEWED
REVIEWED POST
POST SERVICE.
SERVICE. OFFER
OFFER A PRE-D
A PRE-D REVIEW IF
REVIEW IF A
A MRU/MJ CLAIM
MRU/MJ CLAIM
EDIT EXISTS.
EDIT EXISTS.
EXCEPTION:
Lumenos - CDHP
PRIOR AUTH NOT
REQUIRED,
HOWEVER SOME
SERVICES WILL BE
REVIEWED POST
SERVICE. OFFER
A PRE-D REVIEW IF
A MRU/MJ CLAIM
EDIT EXISTS.
COMMENTS
CODES LISTED BELOW ARE REFERENCED IN
PROVIDER COMMUNICATIONS AND ARE NOT
INCLUSIVE OF ALL CODES REQUIRING
PRECERTIFICATION.
A pre-determination is offered for codes with a
suspend/deny or MRU edit.
* Call Customer Service at the number on the Member's
Health Plan ID card to confirm benefits for any and all
services.
Intravenous Pyelogram
IV Therapy – antibiotics & Solumedrol
IVIG (generic) (Immune globulin-powder)
JAS or DYNA Splint
Jevtana (Cabozotaxel)
Kineret (Anakinra)
No
Yes
Yes
No
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Kyphoplasty
Yes
No
No
Yes
Laminectomy - any level
Yes
No
No
Yes
Laparoscopy
Laparotomy
Laryngoscopy
Laser Assisted Uvulopalatoplasty (LAUP)
LEEP procedure
Leukine (Sargramostim)
Lipectomy
No
No
No
Yes
No
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
S2080
Liposuction
Lithotripsy
Lucentis (Ranibizumab)
Lumbar Discography
Lumizyme (Alglucosidase alfa)
Lung Reduction
Macugen (Pegaptanib)
Malar (cheek) implants
Mammography (routine & non routine)
Mammoplasty (Augmentation of breast)
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
No
No
No
J2778, SPMM - use profile SPMNOF
62290, 72295
J0221, SPMM - use profile SPMNOF
32491
J2503, SPMM - use profile SPMNOF
15828
Page 12
Must check drug code for MRU edit
90283, J1566, SPMM - use profile SPMNOF
J9043, SPMM - use profile SPMNOF
Use J3490 if they specifically ask for Kineret and use
OPPX as the WMDS profile. This is an SPMM drug.
22520, 22521, 22522, 22523, 22524, 22525, 72291,
72292, 22999
63005, 63011, 63012, 63017, 63030, 63035, 63042,
63044, 63047, 63048, 63190, 63200, 63252, 63267,
63272, 63277, 63282, 63287, 63290, 63655, 22632,
63185, 22630, 22633, 22634
J2820, SPMM - use profile SPMNOF
15833, 15834, 15835, 15836, 15837, 15838, 15839,
15876, 15877, 15878, 15879, 15832
19324, 19325
Authorization List - Externalized_ Internalized CO NV 8 20 14.xls
Procedure
STANDARD
EXCEPTION:
EXCEPTION:
CO TONIK
NV TONIK
PRIOR AUTH NOT PRIOR AUTH NOT
REQUIRED,
REQUIRED,
HOWEVER SOME HOWEVER SOME
SERVICES WILL
SERVICES WILL BE
BE REVIEWED
REVIEWED POST
POST SERVICE.
SERVICE. OFFER
OFFER A PRE-D
A PRE-D REVIEW IF
REVIEW IF A
A MRU/MJ CLAIM
MRU/MJ CLAIM
EDIT EXISTS.
EDIT EXISTS.
EXCEPTION:
Lumenos - CDHP
PRIOR AUTH NOT
REQUIRED,
HOWEVER SOME
SERVICES WILL BE
REVIEWED POST
SERVICE. OFFER
A PRE-D REVIEW IF
A MRU/MJ CLAIM
EDIT EXISTS.
COMMENTS
CODES LISTED BELOW ARE REFERENCED IN
PROVIDER COMMUNICATIONS AND ARE NOT
INCLUSIVE OF ALL CODES REQUIRING
PRECERTIFICATION.
A pre-determination is offered for codes with a
suspend/deny or MRU edit.
* Call Customer Service at the number on the Member's
Health Plan ID card to confirm benefits for any and all
services.
Mandibular/Maxillary Osteotomies, (Orthognathic)
Surgery
Yes
No
No
No
Mastectomy - Contralateral or Prophylactic
Mastectomy for Breast Cancer
Mastectomy for Gynecomastia
Mastopexy
Maxillo-facial surgery (surgery on bones of face, jaw,
cheeks)
No
No
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
No
Maze Procedure
Yes
No
No
No
33254, 33255, 33256, 33257, 33258, 33259, 33265,
33266
Meniscal Transplantation
Migraine Headaches- surgical treatment
Yes
Yes
No
No
No
No
No
No
Misc/Unlisted DME code
Yes
No
No
No
29868
15824, 15826, 30130, 30140, 30520, 31200, 31201,
31205, 31254, 31255, 64732, 67900, 93580, 64640,
64722, 64744
-99
E1399
Mozobil (Plerixafor)
MRA (Magnetic Resonance Angiography)
Yes
Yes
No
No
Yes
Yes
Yes
Yes
Page 13
21120, 21121, 21122, 21123, 21125, 21127, 21141,
21142, 21143, 21244, 21145, 21146, 21147, 21150,
21151, 21154, 21155, 21159, 21160, 21172, 21175,
21179, 21180, 21188, 21193, 21194, 21195 , 21196,
21198, 21199, 21206, 21215, 21245, 21246, 21247,
21248, 21249, 21256, 21208, 21209, 21210, D7940,
D7941, D7943, D7944, D7945, D7946, D7947,
D7948 D7949, D7950, D7995, D7996
19300
19316
21193, 21199, 41512, 41530, 42145, C9727, 21685,
S2080, 21142, 21147, 21196
J2562, SPMM - use profile SPMNOF
Please refer callers to AIM 877-291-0366 for
preauthorization: 74185, 71555, 73225, 73725, 70544,
70545, 70546, 70547, 70548, 70549, 72198, 72159
Authorization List - Externalized_ Internalized CO NV 8 20 14.xls
Procedure
STANDARD
EXCEPTION:
EXCEPTION:
CO TONIK
NV TONIK
PRIOR AUTH NOT PRIOR AUTH NOT
REQUIRED,
REQUIRED,
HOWEVER SOME HOWEVER SOME
SERVICES WILL
SERVICES WILL BE
BE REVIEWED
REVIEWED POST
POST SERVICE.
SERVICE. OFFER
OFFER A PRE-D
A PRE-D REVIEW IF
REVIEW IF A
A MRU/MJ CLAIM
MRU/MJ CLAIM
EDIT EXISTS.
EDIT EXISTS.
EXCEPTION:
Lumenos - CDHP
PRIOR AUTH NOT
REQUIRED,
HOWEVER SOME
SERVICES WILL BE
REVIEWED POST
SERVICE. OFFER
A PRE-D REVIEW IF
A MRU/MJ CLAIM
EDIT EXISTS.
COMMENTS
CODES LISTED BELOW ARE REFERENCED IN
PROVIDER COMMUNICATIONS AND ARE NOT
INCLUSIVE OF ALL CODES REQUIRING
PRECERTIFICATION.
A pre-determination is offered for codes with a
suspend/deny or MRU edit.
* Call Customer Service at the number on the Member's
Health Plan ID card to confirm benefits for any and all
services.
MRI (Magnetic Resonance Imaging)
Yes
Yes
Yes
Yes
Call AIM to preauthorize 877-291-0366: 74181, 74182,
74183, 77084, 77058, 77059, 71550, 71551, 71552;
75557, 75559, 75561, 75563 (75565); 73218, 73219,
73220, 73221, 73222, 73223, 73718, 73719, 73720,
73721, 73722, 73723, 70336, 70540, 70542, 70543,
70551, 70552, 70553, 72195, 72196, 72197, 72141,
72142, 72156, 72146, 72147, 72157, 72148, 72149,
72158, 70554, 70555 (Add-on-Codes: 76376 & 76377)
MRS (Magnetic Resonance Spectroscopy)
Yes
Yes
Yes
Yes
Please refer callers to AIM 877-291-0366 for
preauthorization: 76390
MRI Guided Ultrasound Ablation (Fibroids)
Multiple Sleep Latency Test (MSLT)
Myelogram
Myobloc (Botulinum toxin Type B)
Myozyme (Alglucosidase alfa)
Myringotomy
Naglazyme (Galsulfase)
Nplate (Romiplostin)
Nasal (Dorsal-external) implants; Functional
Endoscopic Sinus Surgery (FESS)
Yes
Yes
No
Yes
Yes
No
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
No
Yes
Yes
Yes
0071T, 0072T
95805
62284
J0587, SPMM - use profile SPMNOF
J0220, SPMM - use profile SPMNOF
Nasal Endoscopy
Yes
No
No
No
S2342, 31237, 31254, 31255, 31256, 31267, 31276,
31287, 31288, S2342
31231-31235 no auth required
Nasal/ Sinus Endoscopy (EG, balloon dilation)
Yes
No
No
Yes
31295, 31296, 31297
Nasal Surgery for treatment of sleep apnea
Yes
No
No
No
Authorization required as of 7/30/10.
30110, 30115, 30130, 30140, 30465 30801, 30802, and
31237
Natalizumab (Tysabri)
Negative pressure wound therapy
Neulasta (Pegfilgrastim)
No
Yes
Yes
No
No
No
No
No
No
No
No
Yes
Page 14
J1458, SPMM - use profile SPMNOF
J2796, SPMM - use profile SPMNOF
21083
97605, 97606
J2505, SPMM - use profile SPMNOF
Authorization List - Externalized_ Internalized CO NV 8 20 14.xls
Procedure
STANDARD
EXCEPTION:
EXCEPTION:
CO TONIK
NV TONIK
PRIOR AUTH NOT PRIOR AUTH NOT
REQUIRED,
REQUIRED,
HOWEVER SOME HOWEVER SOME
SERVICES WILL
SERVICES WILL BE
BE REVIEWED
REVIEWED POST
POST SERVICE.
SERVICE. OFFER
OFFER A PRE-D
A PRE-D REVIEW IF
REVIEW IF A
A MRU/MJ CLAIM
MRU/MJ CLAIM
EDIT EXISTS.
EDIT EXISTS.
EXCEPTION:
Lumenos - CDHP
PRIOR AUTH NOT
REQUIRED,
HOWEVER SOME
SERVICES WILL BE
REVIEWED POST
SERVICE. OFFER
A PRE-D REVIEW IF
A MRU/MJ CLAIM
EDIT EXISTS.
COMMENTS
CODES LISTED BELOW ARE REFERENCED IN
PROVIDER COMMUNICATIONS AND ARE NOT
INCLUSIVE OF ALL CODES REQUIRING
PRECERTIFICATION.
A pre-determination is offered for codes with a
suspend/deny or MRU edit.
* Call Customer Service at the number on the Member's
Health Plan ID card to confirm benefits for any and all
services.
Neupogen (Filgrastim)
Yes
No
No
Yes
J1442, SPMM - use profile SPMNOF
Neuromuscular Stimulator
Neuropsych Testing
Neurostimulator Implantation
Yes
No
Yes
No
No
No
No
No
No
No
No
Yes
E0745
Norditropin (Somatropin (rDNA origin))
Norditropin Nordiflex (Somatropin (rDNA origin))
Yes
Yes
No
No
No
No
Yes
Yes
J2941, SPMM - use profile SPMNOF
J2941, SPMM - use profile SPMNOF
Nuclear Cardiography (Myocardial Perfusion)
Yes
Yes
Yes
Please refer callers to AIM 877-291-0366 for
preauthorization: 877-291-0366: 78451, 78452, 78453,
78454, 78466, 78468, 78469; 78472, 78473, 78481,
78483, 78494 (Add-on-Code: 78496)
Nulojix (Betacept)
Nutropin/Nutropin AQ/Nutropin Depot (Somatropin
(rDNA origin))
Yes
Yes
No
No
No
No
Yes
Yes
J0485, SPMM - use profile SPMNOF
J2941, SPMM - use profile SPMNOF
OB Care
Occipital Nerve Stimulation
Occupational therapy
Octagam (Immune globulin-liquid)
Omnitrope (Somatropin (rDNA origin))
OMT (Osteopathic Manipulation Therapy)
Oncotype DX test
Orencia (Abatacept)
Organ transplant
ORIF (Open Reduction-Internal Fixation)
No
Yes
No
Yes
Yes
No
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
Yes
No
No
No
No
No
No
No
No
No
Yes
No
No
No
No
Yes
Yes
No
Yes
Yes
Yes
No
Yes
Page 15
L8682, L8683, L8685, L8686, L8687, L8688, 63685,
63650, 63655, L8680, L8682, L8684
64555, 64575, 64590
J1568, SPMM - use profile SPMNOF
J2941, SPMM - use profile SPMNOF
81599
J0129, SPMM - use profile SPMNOF
Call to preauthorize: 888-574-7215
Authorization List - Externalized_ Internalized CO NV 8 20 14.xls
Procedure
STANDARD
EXCEPTION:
EXCEPTION:
CO TONIK
NV TONIK
PRIOR AUTH NOT PRIOR AUTH NOT
REQUIRED,
REQUIRED,
HOWEVER SOME HOWEVER SOME
SERVICES WILL
SERVICES WILL BE
BE REVIEWED
REVIEWED POST
POST SERVICE.
SERVICE. OFFER
OFFER A PRE-D
A PRE-D REVIEW IF
REVIEW IF A
A MRU/MJ CLAIM
MRU/MJ CLAIM
EDIT EXISTS.
EDIT EXISTS.
EXCEPTION:
Lumenos - CDHP
PRIOR AUTH NOT
REQUIRED,
HOWEVER SOME
SERVICES WILL BE
REVIEWED POST
SERVICE. OFFER
A PRE-D REVIEW IF
A MRU/MJ CLAIM
EDIT EXISTS.
COMMENTS
D7995, D7996
CODES LISTED BELOW ARE REFERENCED IN
PROVIDER COMMUNICATIONS AND ARE NOT
INCLUSIVE OF ALL CODES REQUIRING
PRECERTIFICATION.
A pre-determination is offered for codes with a
suspend/deny or MRU edit.
* Call Customer Service at the number on the Member's
Health Plan ID card to confirm benefits for any and all
services.
Orthognathic surgery (upper and lower jaw
augmentation)
Yes
No
No
No
Orthotics
Orthotripsy
Orthovisc (Hyaluronic acid)
No
Yes
Yes
No
No
No
No
No
No
No
No
Yes
Oscillatory Devices for Airway Clearance including
High Frequency Chest Compression and
Intrapulmonary Percussive Ventilation (IPV)
Yes
No
No
No
A7025, E0481, E0483
Osteochondral Defects (Treatment)
Yes
No
No
No
27412. 27415, 27416, 28446, 29866, 29867, 29892,
S2112
Osteoplasty, facial bones
Pacemaker Implant
Penile Prosthesis Implantation
Yes
No
Yes
No
No
No
No
No
No
No
No
No
21208, 21209
Percutaneous lumbar discectomy
Percutaneous lysis
Percutaneous radiofrequency neurolysis (RF)
Periodontal Mucosal Grafting
Pessary device
PET (Positron Emission Tomography Scan)
Yes
Yes
Yes
Yes
No
Yes
No
No
No
No
No
No
No
No
No
No
Yes
Yes
No
No
No
No
Yes
62287, S2348
62263, 62264
64640, 64633, 64634, 64635, 64636, 64999
41870
PFT (Pulmonary function Test)
Pharmacy
No
Yes
No
No
No
No
No
No
Photocoagulation laser treatment
Yes
*
*
Yes
Yes
Page 16
28899
J7324, SPMM - use profile SPMNOF. Authorizations
not required for injections in the knee only -- DX
codes 715.16- 716.96 Osteoarthrosis, lower leg (all
codes in this range ending with fifth digit 6). All
other requests require pre-authorization.
Confirm benefit
54400, 54401, 54405, 54410, 54411, 54416, 54417,
C1813, C2622, L8699
Please refer callers to AIM 877-291-0366 for
preauthorization: 78608, 78609, 78459, 78491, 78492;
78811, 78812, 78813, 78814, 78815, 78816
Medical Benefit Medications not included under
Pharmacy Benefit Rider or Pharmacy Benefit Plan
call:
800-832-7850 or 303-831-4115
* For questions related to benefits under the
Pharmacy Benefit Plan: APM - 800-338-6180
67220
Authorization List - Externalized_ Internalized CO NV 8 20 14.xls
Procedure
STANDARD
EXCEPTION:
EXCEPTION:
CO TONIK
NV TONIK
PRIOR AUTH NOT PRIOR AUTH NOT
REQUIRED,
REQUIRED,
HOWEVER SOME HOWEVER SOME
SERVICES WILL
SERVICES WILL BE
BE REVIEWED
REVIEWED POST
POST SERVICE.
SERVICE. OFFER
OFFER A PRE-D
A PRE-D REVIEW IF
REVIEW IF A
A MRU/MJ CLAIM
MRU/MJ CLAIM
EDIT EXISTS.
EDIT EXISTS.
EXCEPTION:
Lumenos - CDHP
PRIOR AUTH NOT
REQUIRED,
HOWEVER SOME
SERVICES WILL BE
REVIEWED POST
SERVICE. OFFER
A PRE-D REVIEW IF
A MRU/MJ CLAIM
EDIT EXISTS.
COMMENTS
CODES LISTED BELOW ARE REFERENCED IN
PROVIDER COMMUNICATIONS AND ARE NOT
INCLUSIVE OF ALL CODES REQUIRING
PRECERTIFICATION.
A pre-determination is offered for codes with a
suspend/deny or MRU edit.
* Call Customer Service at the number on the Member's
Health Plan ID card to confirm benefits for any and all
services.
Photodynamic therapy
Physical Therapy
Pneumatic Compression Devices for Lymphedema
No
No
Yes
No
No
No
No
No
No
No
No
No
E0652, E0656, E0657, E0670, E0671, E0672, E0673
Prialt (Ziconotide)
Privigen (Immune globulin-liguid)
Procrit (Epoetin alfa)
Yes
Yes
Yes
No
No
No
No
No
No
Yes
Yes
Yes
J2278, SPMM - use profile SPMNOF
J1459, SPMM - use profile SPMNOF
J0885 Q4081 J0886 , SPMM - use profile SPMNOF
Prokine (Sargramostim)
Prolastin (Alpha 1 proteinase inhibitor)
Proleukin (Ablesleukin)
Prolia, Xgeva (Denosumab)
Prolotherapy
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
No
J2820, SPMM - use profile SPMNOF
J0256, SPMM - use profile SPMNOF
J9015, SPMM - use profile SPMNOF
J0897, SPMM - use profile SPMNOF
Investigational - M0076
Prostate Radioactive Seed Implant
Prostatectomy
Prosthetics (Eye)
Prosthetics
No
No
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
Proton Beam (PBRT)
Yes
No
No
Yes
Please refer callers to AIM 877-291-0366 for
preauthorization: 77520[77522, 77523, 77525] (C61796-61797, 61798, 61799, 63620-63621, 61800,
77432, 77435, S8020)
Provenge (Sipuleucel-T)
Psych (Behavioral Health) Inpatient
Yes
BH
No
BH
No
BH
Yes
BH
Q2043, SPMM - use profile SPMNOF
Call Anthem Behavioral Health (ABH) to
preauthorize: 800-424-4014
Psych (Behavioral Health) Outpatient
BH
BH
BH
BH
Call Anthem Behavioral Health (ABH) to
preauthorize: 800-424-4014
Pulmonary Rehabilitation
Yes
No
No
No
G0237, G0238, G0239, G0302, G0303, G0304, G0305,
G0424, S9473
Page 17
0100T, C1841
(new or replacement) prosthetic
L6925, L6935, L6945, L6955, L6965, L6975, L6611,
L6677, L6880, L6881, L6882, L7007, L7008, L7009,
L7045, L7180, L7181, L7190, L7191, L6715
Authorization List - Externalized_ Internalized CO NV 8 20 14.xls
Procedure
STANDARD
EXCEPTION:
EXCEPTION:
CO TONIK
NV TONIK
PRIOR AUTH NOT PRIOR AUTH NOT
REQUIRED,
REQUIRED,
HOWEVER SOME HOWEVER SOME
SERVICES WILL
SERVICES WILL BE
BE REVIEWED
REVIEWED POST
POST SERVICE.
SERVICE. OFFER
OFFER A PRE-D
A PRE-D REVIEW IF
REVIEW IF A
A MRU/MJ CLAIM
MRU/MJ CLAIM
EDIT EXISTS.
EDIT EXISTS.
EXCEPTION:
Lumenos - CDHP
PRIOR AUTH NOT
REQUIRED,
HOWEVER SOME
SERVICES WILL BE
REVIEWED POST
SERVICE. OFFER
A PRE-D REVIEW IF
A MRU/MJ CLAIM
EDIT EXISTS.
COMMENTS
CODES LISTED BELOW ARE REFERENCED IN
PROVIDER COMMUNICATIONS AND ARE NOT
INCLUSIVE OF ALL CODES REQUIRING
PRECERTIFICATION.
A pre-determination is offered for codes with a
suspend/deny or MRU edit.
* Call Customer Service at the number on the Member's
Health Plan ID card to confirm benefits for any and all
services.
Radiation Therapy
Yes
No
No
No
Please refer callers to AIM 877-291-0366 for
preauthorization:
77761, 77326, Q3001, 43499, 47999, 55899, 67218,
19296, 20555, 41019, 55860, 55920, 31643, 57155,
77418, 77301, 77338, 77520, 61796, 63620, 61800,
77432, 77435, S8030, 77371, 61796, 61800, 77432,
77373, 63620, 77435
RadioFrequency Ablation
Yes
No
No
No
32998, 32982, 50542, 50592, 64633, 64634, 64635,
64636
Radiofrequency Ablation (Varicose Veins)
RadioSurgery/RadioTherapy
Real- time remote heart monitor
Rebif (Interferon beta-1a)
Yes
Yes
No
Yes
No
No
No
No
No
No
No
No
No
No
No
No
36475, 36476, 36478, 36479
Please refer callers to AIM 877-291-0366
93228, 93229
J1826, Q3027, Q3028 SPMM - use profile SPMNOF
Reconstructive-Cosmetic
Reduction mammoplasty
Yes
Yes
No
No
No
No
No
Yes if inpatient
Remicade (Infliximab)
Remodulin (Treprostinil)
Removal of Breast Implant
Removal of excess skin
Repair of distasis recti
Rhinoplasty
Rhytidectomy
Rituxin (Rituximab)
Rocephin (Ceftriaxone sodium)
Rotary wing air mileage, per statute mile
Routine Lab
Routine X ray
Sacral Nerve Stimulation
Saizen (Somatropin (rDNA origin))
Scar revisions
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
No
No
No
No
Yes
Yes
No
No
No
No
No
Yes
Yes
J1745 SPMM - use profile SPMNOF
J3285 SPMM - use profile SPMNOF
19328, 19330
22999
22999
30400, 30410, 30420, 30430, 30435, 30450
15824, 15826
J9310, SPMM - use profile SPMNOF
J0696 For treatment of Lyme Disease. Use HHINFU
as
the WMDS profile
A0436
SCIg (Immune Globulin)
Yes
No
No
Yes
90284, SPMM - use profile SPMNOF
Page 18
19318 - Clinical review not required when diagnosis
is related to mastectomy or breast cancer.
64561, 64581, 64590
J2941, SPMM - use profile SPMNOF
15781, 15782, 15783, 15787, 15786, 15788, 15789,
15792, 15793
Authorization List - Externalized_ Internalized CO NV 8 20 14.xls
Procedure
STANDARD
EXCEPTION:
EXCEPTION:
CO TONIK
NV TONIK
PRIOR AUTH NOT PRIOR AUTH NOT
REQUIRED,
REQUIRED,
HOWEVER SOME HOWEVER SOME
SERVICES WILL
SERVICES WILL BE
BE REVIEWED
REVIEWED POST
POST SERVICE.
SERVICE. OFFER
OFFER A PRE-D
A PRE-D REVIEW IF
REVIEW IF A
A MRU/MJ CLAIM
MRU/MJ CLAIM
EDIT EXISTS.
EDIT EXISTS.
EXCEPTION:
Lumenos - CDHP
PRIOR AUTH NOT
REQUIRED,
HOWEVER SOME
SERVICES WILL BE
REVIEWED POST
SERVICE. OFFER
A PRE-D REVIEW IF
A MRU/MJ CLAIM
EDIT EXISTS.
COMMENTS
CODES LISTED BELOW ARE REFERENCED IN
PROVIDER COMMUNICATIONS AND ARE NOT
INCLUSIVE OF ALL CODES REQUIRING
PRECERTIFICATION.
A pre-determination is offered for codes with a
suspend/deny or MRU edit.
* Call Customer Service at the number on the Member's
Health Plan ID card to confirm benefits for any and all
services.
Sclerotherapy
Septoplasty
Yes
Yes
No
No
No
No
No
No
36468, 36469, 36470, 36471, S2202
Authorization required as of 7/30/10
30520, 30620
Septoplasty with rhinoplasty
Serostim (Somatropin (rDNA origin))
Sigmoidoscopy
Simponi (Golimumab)
Yes
Yes
No
Yes
No
No
No
No
No
No
No
No
No
Yes
No
Yes
30420
J2941, SPMM - use profile SPMNOF
Single photon emission computed tomography
(SPECT) scan for specific body part
Yes
Yes
Yes
78071, 78320, 78710, 78807, 78607, 78803, 78647,
78699, S8080, 78205, 78206
Sinuplasty
Sleep Apnea (Obstructive)
Sleep Study (Home Study, In-Lab, CPAP/BPAP,
Supplies)
Yes
Yes
Yes
No
No
No
No
No
No
No
No
Yes
31295, 31296, 31297
21685, 41512, 41530, HCPCS Codes C9727
Please refer callers to AIM 877-291-0366 for
preauthorization: Home Sleep Study: G0399 [95800,
95801, 95806, G0398, G0399, G0400]; In-Lab:
95810[95807, 95808, 95811]; Titration: 95811; Oral
Appliances: E0485[E0486]; APAP/CPAP: E0601;
BPAP: E0470,E0471; Humidifier: E0561 [E0562];
Supplies for PAP: A4604 (A7046, A7027, A7030,
A7031, A7034, A7035, A7036, A7037, A7039, A7044,
A7045, A7028, A7029, A7032, A7033, A7038)
Soliris (Eculizumab)
Somatrem (Somatropin (rDNA origin))
Somatropin (Somatropin (rDNA origin))
Somnoplasty for snoring
Speech generating device
Speech Therapy
Yes
Yes
Yes
Yes
Yes
See Comment
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
No
No
No
J1300, SPMM - use profile SPMNOF
J2940, SPMM - use profile SPMNOF
J2941, SPMM - use profile SPMNOF
42299
E1902, E2351
Authorization is not required for Fully Insured/NonNational Account members as of 6/18/2012.
Spine/Joint Manipulation (Requiring Anesthesia)
Yes
No
No
No
22505
Yes
Page 19
Use J3590 if they specifically ask for Simponi and
use OPPX as the WMDS profile. This is an SPMM
drug.
Authorization List - Externalized_ Internalized CO NV 8 20 14.xls
Procedure
STANDARD
EXCEPTION:
EXCEPTION:
CO TONIK
NV TONIK
PRIOR AUTH NOT PRIOR AUTH NOT
REQUIRED,
REQUIRED,
HOWEVER SOME HOWEVER SOME
SERVICES WILL
SERVICES WILL BE
BE REVIEWED
REVIEWED POST
POST SERVICE.
SERVICE. OFFER
OFFER A PRE-D
A PRE-D REVIEW IF
REVIEW IF A
A MRU/MJ CLAIM
MRU/MJ CLAIM
EDIT EXISTS.
EDIT EXISTS.
EXCEPTION:
Lumenos - CDHP
PRIOR AUTH NOT
REQUIRED,
HOWEVER SOME
SERVICES WILL BE
REVIEWED POST
SERVICE. OFFER
A PRE-D REVIEW IF
A MRU/MJ CLAIM
EDIT EXISTS.
COMMENTS
CODES LISTED BELOW ARE REFERENCED IN
PROVIDER COMMUNICATIONS AND ARE NOT
INCLUSIVE OF ALL CODES REQUIRING
PRECERTIFICATION.
A pre-determination is offered for codes with a
suspend/deny or MRU edit.
* Call Customer Service at the number on the Member's
Health Plan ID card to confirm benefits for any and all
services.
Spine Procedures (Percutaneous)
Yes
No
No
No
22520, 22521, 22522, 22523, 22524, 22525, S2360,
S2361
Spinal Fusion
Yes
No
No
Yes
0195T, 0196T, 0309T, 22533, 22534, 22558, 22585,
22586, 22612, 22614, 22630, 22632, 22633, 22634,
22830 , 22857, 22862, 0163T, 0164T and 0165T
Spinal surgery - Allograft
Yes
No
No
Yes
20930, 20931
Note:
A clinical review is required for this secondary
procedure code only when requested with a lumbar
spinal surgery. Clinical review is not required for
cervical or thoracic spinal surgeries related to this
procedure code.
Spinal surgery - Autograft
Yes
No
No
Yes
20936, 20937, 20938
Note: A clinical review is required for this secondary
procedure code only when requested with a lumbar
spinal surgery. Clinical review is not required for
cervical or thoracic spinal surgeries related to this
procedure code.
Spinal Surgery
Yes
No
No
Yes
0219T, 0221T, 0222T, 63056, 63057, 63090, 63091 ,
22214, 22216 , 22841, 22842, 22843, 22844, 22845,
22846, 22847, 22849, 22851, 22852, 22855, S2350,
S2351 (current pre-auth)
********************************************************
(22224, 22840 - prior authorization required effective
12/1/14)
Spinal stimulators
Yes
No
No
No
See "Implanted (Epidural and Subcutaneous) Spinal
Cord Stimulators (SCS)"
Stab Phlebectomy of Varicose Veins, One Extremity
No
No
No
No
37765
Standing Frames
Stelara (Ustekinumab)
Stereotactic Body Radiotherapy (SBRT)
Yes
Yes
Yes
No
No
No
No
No
No
No
Yes
No
E0638, E0641, E0642, E0637, E2230
J3357, SPMM - use profile SPMNOF
Please refer callers to AIM 877-291-0366 for
preauthorization: 77373[G0173, G0251, G0339,
G0340](C-63620-63621, 77435)
Page 20
Authorization List - Externalized_ Internalized CO NV 8 20 14.xls
Procedure
Sterootactic Radiotherapy (SRS)
STANDARD
EXCEPTION:
EXCEPTION:
CO TONIK
NV TONIK
PRIOR AUTH NOT PRIOR AUTH NOT
REQUIRED,
REQUIRED,
HOWEVER SOME HOWEVER SOME
SERVICES WILL
SERVICES WILL BE
BE REVIEWED
REVIEWED POST
POST SERVICE.
SERVICE. OFFER
OFFER A PRE-D
A PRE-D REVIEW IF
REVIEW IF A
A MRU/MJ CLAIM
MRU/MJ CLAIM
EDIT EXISTS.
EDIT EXISTS.
EXCEPTION:
Lumenos - CDHP
PRIOR AUTH NOT
REQUIRED,
HOWEVER SOME
SERVICES WILL BE
REVIEWED POST
SERVICE. OFFER
A PRE-D REVIEW IF
A MRU/MJ CLAIM
EDIT EXISTS.
COMMENTS
CODES LISTED BELOW ARE REFERENCED IN
PROVIDER COMMUNICATIONS AND ARE NOT
INCLUSIVE OF ALL CODES REQUIRING
PRECERTIFICATION.
A pre-determination is offered for codes with a
suspend/deny or MRU edit.
* Call Customer Service at the number on the Member's
Health Plan ID card to confirm benefits for any and all
services.
Yes
No
No
No
Sterilization
No
Steroid Injection - see ESI
No
Stretta or Endocinch procedure, Endoscopic treatment Yes
for Gerd
No
No
No
No
No
No
No
No
No
43499
Strabismus
Submucous Resection Inferior Turbinate, Partial or
Complete
No
Yes
No
Yes
No
No
No
No
30140
Supartz (Hyaluronic acid)
Yes
No
No
Yes
J7321, SPMM - use profile SPMNOF. Authorizations
not required for injections in the knee only -- DX
codes 715.16- 716.96 Osteoarthrosis, lower leg (all
codes in this range ending with fifth digit 6). All
other requests require pre-authorization.
Suprachoroidal injection
Synagis (Palivizumab)
Synvisc/Synvisc-One (Hyaluronic acid)
Yes
Yes
Yes
No
No
No
No
No
No
No
Yes
Yes
67299
90378, SPMM - use profile SPMNOF
J7325, SPMM - use profile SPMNOF Authorizations
not required for injections in the knee only -- DX
codes 715.16- 716.96 Osteoarthrosis, lower leg (all
codes in this range ending with fifth digit 6). All
other requests require pre-authorization.
Tev-Tropin (Somatropin (rDNA origin))
Thyroidectomy
Tilt Table
Tinnitus Treatment (Transcranial Magnetic
Stimulation)
Yes
No
No
Yes
No
No
No
No
No
No
No
No
Yes
No
No
No
J2941, SPMM - use profile SPMNOF
Page 21
Please refer callers to AIM 877-291-0366 for
preauthorization: 77371 [77372, G01733, G0251,
G0339, G0340] (C-61796-61797, 61798, 61799, 61800,
77432)
90867, 90868, 90869
Authorization List - Externalized_ Internalized CO NV 8 20 14.xls
Procedure
STANDARD
EXCEPTION:
EXCEPTION:
CO TONIK
NV TONIK
PRIOR AUTH NOT PRIOR AUTH NOT
REQUIRED,
REQUIRED,
HOWEVER SOME HOWEVER SOME
SERVICES WILL
SERVICES WILL BE
BE REVIEWED
REVIEWED POST
POST SERVICE.
SERVICE. OFFER
OFFER A PRE-D
A PRE-D REVIEW IF
REVIEW IF A
A MRU/MJ CLAIM
MRU/MJ CLAIM
EDIT EXISTS.
EDIT EXISTS.
EXCEPTION:
Lumenos - CDHP
PRIOR AUTH NOT
REQUIRED,
HOWEVER SOME
SERVICES WILL BE
REVIEWED POST
SERVICE. OFFER
A PRE-D REVIEW IF
A MRU/MJ CLAIM
EDIT EXISTS.
COMMENTS
CODES LISTED BELOW ARE REFERENCED IN
PROVIDER COMMUNICATIONS AND ARE NOT
INCLUSIVE OF ALL CODES REQUIRING
PRECERTIFICATION.
A pre-determination is offered for codes with a
suspend/deny or MRU edit.
* Call Customer Service at the number on the Member's
Health Plan ID card to confirm benefits for any and all
services.
TMD/TMJ (Temporomandibular disorders)
Yes
No
No
No
TMD/TMJ - Thermography (when requested for the
diagnosis of Temporomandibular disorders)
Yes
No
No
No
Tonsillectomy
Yes
No
No
No
42820, 42821, 42825, 42826. Applies to members
under the age of 18.
Total Hip or knee replacement
Yes
No
No
Yes
Refer to "Arthroplasty" for knee and hip sections
Total Parenteal Nutrition
Yes
No
No
Yes
See Benefit Language
B4185, S9364, S9365, S9366, S9367, S9368
Tracheotomy
Transcatheter Closure
Transcatheter Uterine Artery Embolization
No
Yes
Yes
No
No
No
No
No
No
No
No
No
Transplants
Treadmill
Trigger Point Injections
Tropism Testing for HIV Management
Tubal ligation
Tympanic treatment
Tympanoplasty
Tympanostomy
Tysabri (Natlizumab)
Tyvaso (Treprostinil, inhalation)
UGI (Upper GI)
Ultrafast computed tomography (CT), including use
for evaluation of the heart
Yes
No
No
Yes
No
Yes
No
No
No
Yes
No
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
Yes
No
No
No
No
No
No
No
No
No
No
No
Yes
No
No
No
No
No
No
No
No
Yes
No
Yes
Call to preauthorize: 888-574-7215
Ultrasound – 3D & 4D
Ultrasound – non OB
Yes
No
No
No
No
No
No
No
76376, 76377
Page 22
21010, 21050, 21060, 21073, 21116, 21210, 21240,
21242, 21243, 29800, 29804, D7810, D7820, D7830,
D7840, D7850, D7852, D7854, D7856, D7858, D7860,
D7865, D7870, D7881, D7873, D7874, D7875, D7876,
D7877; For code 20605, precert is only required
when the diagnosis is related to TMJ/TMD.
93580
37243, 37244
81400
E2120
J7686, SPMM - use profile SPMNOF
Call AIM to preauthorize: 877-291-0366
Authorization List - Externalized_ Internalized CO NV 8 20 14.xls
Procedure
STANDARD
EXCEPTION:
EXCEPTION:
CO TONIK
NV TONIK
PRIOR AUTH NOT PRIOR AUTH NOT
REQUIRED,
REQUIRED,
HOWEVER SOME HOWEVER SOME
SERVICES WILL
SERVICES WILL BE
BE REVIEWED
REVIEWED POST
POST SERVICE.
SERVICE. OFFER
OFFER A PRE-D
A PRE-D REVIEW IF
REVIEW IF A
A MRU/MJ CLAIM
MRU/MJ CLAIM
EDIT EXISTS.
EDIT EXISTS.
EXCEPTION:
Lumenos - CDHP
PRIOR AUTH NOT
REQUIRED,
HOWEVER SOME
SERVICES WILL BE
REVIEWED POST
SERVICE. OFFER
A PRE-D REVIEW IF
A MRU/MJ CLAIM
EDIT EXISTS.
COMMENTS
CODES LISTED BELOW ARE REFERENCED IN
PROVIDER COMMUNICATIONS AND ARE NOT
INCLUSIVE OF ALL CODES REQUIRING
PRECERTIFICATION.
A pre-determination is offered for codes with a
suspend/deny or MRU edit.
* Call Customer Service at the number on the Member's
Health Plan ID card to confirm benefits for any and all
services.
Ultrasound – OB
Unlisted codes
No
Yes
No
No
No
No
No
No
unlisted CPT codes - ending in 99 (sometimes 59, 89)
UPPP (Uvulopalato-pharyngoplasty)
Yes
No
No
No
42145
Page 23
Authorization List - Externalized_ Internalized CO NV 8 20 14.xls
Procedure
STANDARD
EXCEPTION:
EXCEPTION:
CO TONIK
NV TONIK
PRIOR AUTH NOT PRIOR AUTH NOT
REQUIRED,
REQUIRED,
HOWEVER SOME HOWEVER SOME
SERVICES WILL
SERVICES WILL BE
BE REVIEWED
REVIEWED POST
POST SERVICE.
SERVICE. OFFER
OFFER A PRE-D
A PRE-D REVIEW IF
REVIEW IF A
A MRU/MJ CLAIM
MRU/MJ CLAIM
EDIT EXISTS.
EDIT EXISTS.
EXCEPTION:
Lumenos - CDHP
PRIOR AUTH NOT
REQUIRED,
HOWEVER SOME
SERVICES WILL BE
REVIEWED POST
SERVICE. OFFER
A PRE-D REVIEW IF
A MRU/MJ CLAIM
EDIT EXISTS.
COMMENTS
CODES LISTED BELOW ARE REFERENCED IN
PROVIDER COMMUNICATIONS AND ARE NOT
INCLUSIVE OF ALL CODES REQUIRING
PRECERTIFICATION.
A pre-determination is offered for codes with a
suspend/deny or MRU edit.
* Call Customer Service at the number on the Member's
Health Plan ID card to confirm benefits for any and all
services.
Urgent Care
No
No
No
No
Vagus nerve stimulation therapy
Yes
No
No
No
64553, 61885, L8680, L8685, L8686, 95974, 95975
Varicose vein stripping and ligation, VNUS EVLT or
ELAS, ablation (laser)
Yes
No
No
No
36475, 36476, 36478, 36479, 36470, 36471, S2202,
36468
Vasectomy
VCUG (voiding cystourethrogram)
Vectibix (Panibumumab)
Veletri (Epoprostenol)
Ventavis (lloprost Inhalation)
Ventricular Assistive device (VAD)
No
No
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
No
Virtual Colonoscopy
Vision Therapy
VPRIV (Velaglucerase Alfa)
Wheelchair supplies (excluding power wheelchair
supplies)
Yes
No
Yes
No
No
No
No
No
No
No
No
No
No
No
Yes
No
Wheelchair, power operated vehicle/wheelchair and
supplies
Yes
No
No
No
E1009, E1010, E1230, E1239, E1002, E1003,E1004, E1005, E1006,
E1007, E1008, E0637, E2300, E2301, K0800, K0801, K0802, K0806,
K0807, K0808, K0812, K0813, K0814, K0815, K0816, K0820,
K0821, K0822, K0823, K0824, K0825, K0826, K0827, K0828,
K0829, K0830, K0831, K0835, K0836, K0837, K0838, K0839,
K0840, K0841, K0842, K0843, K0848, K0849, K0850, K0851,
K0852, K0853, K0854, K0855, K0856, K0857, K0858, K0859,
K0860, K0861, K0862, K0863, K0864, K0868, K0869, K0870,
K0871, K0877, K0878, K0879, K0880, K0884, K0885, K0886,
K0890, K0891, K0898, K0010, K0011, K0012, K0013, K0014
Wheelchair, Ultra lightweight manual
Wheelchair, unlisted procedure
Wound vac
Xeomin (Botulinum toxin Type A)
Xolair (Omalizumab)
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
K0005
K0899
E2402
J0588, SPMM - use profile SPMNOF
J2357, SPMM - use profile SPMNOF
Page 24
J9303, SPMM - use profile SPMNOF
J1325, SPMM - use profile SPMNOF
Q4074, SPMM - use profile SPMNOF
33975, 33976, 33979, 33981, 33982, 33983, 0051T,
0052T, 0053T
Call AIM to preauthorize: 877-291-0366
J3385, SPMM - use profile SPMNOF
No authorization required as of 7/30/10
Authorization List - Externalized_ Internalized CO NV 8 20 14.xls
Procedure
Yag Laser - after cataract
Yervoy (Ipilimumab)
Zemaira (Alpha 1 proteinase inhibitor)
Zorbtive (Somatropin (rDNA origin))
END
STANDARD
No
Yes
Yes
Yes
EXCEPTION:
EXCEPTION:
CO TONIK
NV TONIK
PRIOR AUTH NOT PRIOR AUTH NOT
REQUIRED,
REQUIRED,
HOWEVER SOME HOWEVER SOME
SERVICES WILL
SERVICES WILL BE
BE REVIEWED
REVIEWED POST
POST SERVICE.
SERVICE. OFFER
OFFER A PRE-D
A PRE-D REVIEW IF
REVIEW IF A
A MRU/MJ CLAIM
MRU/MJ CLAIM
EDIT EXISTS.
EDIT EXISTS.
No
No
No
No
No
No
No
No
EXCEPTION:
Lumenos - CDHP
PRIOR AUTH NOT
REQUIRED,
HOWEVER SOME
SERVICES WILL BE
REVIEWED POST
SERVICE. OFFER
A PRE-D REVIEW IF
A MRU/MJ CLAIM
EDIT EXISTS.
No
Yes
Yes
Yes
COMMENTS
CODES LISTED BELOW ARE REFERENCED IN
PROVIDER COMMUNICATIONS AND ARE NOT
INCLUSIVE OF ALL CODES REQUIRING
PRECERTIFICATION.
A pre-determination is offered for codes with a
suspend/deny or MRU edit.
* Call Customer Service at the number on the Member's
Health Plan ID card to confirm benefits for any and all
services.
J9228, SPMM - use profile SPMNOF
J0256, SPMM - use profile SPMNOF
J2941, SPMM - use profile SPMNOF
01/01/11 - Added Sturm Financial to AIM Exclusion List
1/5/2011 - Removed anesthesia
1/27/2011 - Added Prowers County General and Newmont Mining to AIM
Exclusion list
3/14/2012 Updated list with BABW Phase 2 and Phase 3 codes under
Comments section
7/16/2012 Added tonsillectomy to the standard list requiring prior auth.
Updated Prefix lists.
11/1/2012. Removed SPMM drugs, added BABW Phase 4, and AIM
Radiation Therapy/Sleep Therapy codes
12/1/2012. Updated language for Synvisc/Supartz/Hyalgen; Kineret, Egrifta,
Simponi; Tonsillectomy codes. Added codes: 62284 and 67973 as no auth
required. Removed 77295. Removed lined for Bone density studies as
there is already a line for DEXA.
1/4/2013 Correct Xeomin code from J0558 to J0588; added language to
Euflexxa, Orthovisc, and Gel-One; removed codes indicated for PostService review
5/1/2013 Updated coding/spelling errors, added codes from CGs, updated
AIM codes
6/17/2013. Updated list with new SPMM drugs,
Page 25
Authorization List - Externalized_ Internalized CO NV 8 20 14.xls
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