Mercy Health Plans



Prior Authorization Guide Effective January 1, 2015Medical Observation admits greater than 23 hours.Surgical Observation admits where the procedure requires Prior Authorization, or greater than 23 hoursAll Inpatient Hospital, Behavioral Health, Chemical Dependency, Skilled Nursing, Long-term Acute care and Rehabilitation admissions require Prior Referral/Authorization.Maternity admissions for Vaginal Delivery greater than 48 hours and for Cesarean Delivery greater than 96 hours.Mental health servicesNeuropsychological testingNutritional Support (enteral feeding)Home Health, except for Physical Therapy, Occupational Therapy and Speech Therapy.HospiceDurable Medical Equipment (DME) over $1000.00 single line item purchase price, or cumulative rental of a single item (does not include oxygen and oxygen equipment). In addition the following items, including but not limited to:CPAP units (not supplies)TENS units (not supplies)Bone growth or neuromuscular stimulatorsHospital bedsWheelchairsAll custom made itemsInsulin pumps (not supplies)Continuous Glucose MonitorsOrthotics over $1000, all foot orthotics or any custom orthoticNon emergent ambulance transfersAir ambulancesPhototherapyClinical trialsTransplantsProsthetic > $1000Accidental dental servicesAll CPT codes ending in “99”All CPT codes ending in “T”Genetic testing (except codes 83890-83912)All CPT codes in the below tablesIntegumentary SystemCPT/HCPCS CodeDescription11920-11921Tattooing, intradermal11960Insertion of tissue expander(s) for other than breast, including subsequent expansion11970Replacement of tissue expander with permanent prosthesis11971Removal of tissue expander(s) without insertion of prosthesis11976Removal, implantable contraceptive capsules11981-11982Insertion, removal, non-biodegradable drug delivery implant**15822-15823Blepharoplasty, upper eyelid15830, 15847Excision, excessive tissue skin and subcutaneous tissue15840-15845Graft for facial nerve paralysis; free muscle graft; free muscle flap; regional muscle transfer19300Mastectomy for gynecomastia19316Mastopexy19318Reduction mammaplasty19324-19325Mammaplasty, augmentation; with and without prosthetic implant19328Removal of intact mammary implant19330Removal of mammary implant material19340-19342Immediate/ delayed insertion of breast prosthesis following mastopexy, mastectomy, or in reconstruction19350Nipple reconstruction19357-19369Breast reconstruction19380-19396Revision of reconstructed breast; preparation of moulage for custom breast implantMusculoskeletal SystemCPT/HCPCS CodeDescription20974-20975Electrical stimulation to aid bone healing; noninvasive; invasive20979Low intensity ultrasound stimulation to aid bone healing21010Arthrotomy, temporomandibular joint21050-21060Condylectomy/ Menisectomy; temporomandibular joint21070Coronoidectomy21076-21088Impression and custom preparation; maxillofacial prosthesis21089Unlisted maxillofacial prosthetic procedure21100Application of halo type appliance for maxillofacial fixation, includes removal21110Interdental fixation for other than fracture21116Injection procedure for temporomandibular joint arthrography21120-21123Genioplasty21125-21127Augmentation, mandibular body or angle; prosthetic material, with bone graft, onlay,or interpositional21137-21139Reduction forehead21141-21160Reconstruction midface, LeFort I, II, III21172-21196Reconstruction of orbital rims, forehead, cranial bones, mandibular rami21198-21199Osteotomy, mandible, segmental; with genioglossus advancement21206-21208Osteoplasty, facial bones; augmentation21210-21235Graft bone; nasal, maxillary or malar areas; rib cartilage, autogenous, toface, chin, nose, or ear; ear cartilage, autogenous, to nose or ear21240-21243Arthroplasty, temporomandiular joint; autograft, allograft, prosthetic joint replacement21244-21249Reconstruction of mandible or maxilla21255Reconstruction of zygomatic arch and glenoid fossa21256-21268Reconstruction of orbit with osteotomies; periorbital osteotomies; orbital repositioning21270Malar augmentation, prosthetic material21275Secondary revision of orbitocraniofacial reconstruction21740-21743Reconstructive repair of pectus excavatum or carinatum22100-22116Partial excision vertebral component or vertebral body22206-22226Osteotomy spine22520-22525Percutaneous vertebroplasty, kyphoplasty22526-22527IDET (Intradiscal electrothermal therapy)22548-22812Arthrodesis, spine22818-22819Kyphectomy22830Exploration of spinal fusion22840-22855Spinal instrumentation22856-22865Total disc arthroplasty23473-23474Revision total shoulder24370-24371Revision total elbowRespiratory SystemCPT/HCPCS CodeDescription30400-30450Rhinoplasty, primary or secondary, including major septal repair30460-30462Rhinoplasty for nasal deformity secondary to congenital cleft lip and/or palate30465Repair of nasal vestibular stenosis30520-30630Septoplasty or submucous resection; repair choanal atresia; lysisintranasal synechia; repair fistula; dermatoplasty; repair nasal septal perforations31660-31662Bronchoscopy with bronchial thermoplastyCardiovascular System CPT/HCPCS CodeDescription32664Thoracoscopy with thoracic sympathectomy33361-33369Transcatheter aortic valve replacement (TAVH/TAVI)33990-33991Insertion of ventricular assist device33782-33783Nikaidoh procedure33975-33983Insertion/Replace VAD38243HPC Boost93228-93229External mobile cardiovascular telemetryG0166Enhanced External Counterpulsation (35 treatments over 9 weeks)Digestive SystemCPT/HCPCS CodeDescription41512Tongue suspension41530Tongue base volume reduction41800-41806Drainage of abscess, cyst, hematoma; removal of embedded foreign body from dentoalveolar structures41820-41874Gingivectomy; operculectomy; excision of tuberosities dentoalveolar structures; gingivoplasty41899Unlisted procedure, dentoalveolar structures42140Uvulectomy42145Palatopharyngoplasty42280Maxillary impression for palatal prosthesis42281Insertion of pin-retained palatal prosthesis43206Esophagoscopy with optical endomicroscopy43252Upper GI endoscopy with optical endomicroscopy43281-43282Laprascopic paraesophageal hernia repair43659Unlisted laproscopy procedure, stomach43647, 43881-43882Gastric neurostimulator electrodes, implanatation, revision, replacement, removal43644-43645,43770-43775,43842-4384843886-43888Bariatric surgeryS2083Allowed 6 in first 12 months following procedure, 3 in second 12 months following procedure without prior authorization All other visits for S2083 require prior authorization44705Preparation of fecal microbotia for instillation49411Placement of interstitial devices for radiation therapy guidanceMale/Female CPT/HCPCS CodeDescription52287Cystourethoscopy with injection(s) fro chemodenervation of the bladder53860Transurethral radiofrequency micro-remodeling of the female bladder neck and proximal urethra for stress incontinence54400-54417Penile prosthesis58150-58240Total abdominal hysterectomy, with or without removal of tube(s) and/or ovary(s)58951Resection of ovarian, tubal, or primary peritoneal malignancy with bilateral salpingo-oopherectomy and omentectomy; with total abdominal hysterectomy, pelvic and limited para-aortic lymphadenectomy59525Hysterectomy after cesarean deliveryNervous SystemCPT/HCPCS CodeDescription61793Stereotactic radiation61796-61800Stereotactic radiosurgery, cranial lesion61850-61888Insertion/removal/revision neurostimulator62263 - 62264Percutaneous lysis of epidural adhesions63620-63621Stereotactic radiosurgery, spinal lesion63650-63688Neurostimulators, spinal64550-64595Neurostimulator, peripheral64611-64615Chemodenervation of muscle(s); cervical spinal muscle(s)64633-64636Destruction by neurolytic agent, paravertebral facet joint nerves64910-64911Nerve repair with synthetic conduit or vein allograft64405Nerve block greater occiputal nerve (injection of anesthetic agent)64450Injection of other peripheral nerves or branch (usually billed with the above code)64640RFA - inject rx other peripheral nerve - destruction by neurolytic agent, chemodervervationEye and Ocular Adnexa CPT/HCPCS CodeDescription65760Keratomileusis65771Radial keratotomy67221-67225Photodynamic therapy67345Chemodenervation of extraocular muscle67909Reduction of ptosis67911Correction of lid retraction67912Ocular surface reconstruction67914-67924Repair of ectropian69714-69717Osseointegrated implant, implantation, removal, replacement69930Cochlear device implantation, with or without mastoidectomyJ3396VisudyneRadiologyCPT/HCPCS CodeDescription70332Temporomandibular joint arthrography70554-70555Functional MRI brain72291-72292Radiological supervision, vertebroplasty74261-74263CT colonography74742Xray fallopian tubes75557-75565Cardiac MRI75571-75574CT Heart76390Magnetic resonance spectroscopy76498Unlisted MRI76977, 78350Bone density testing when performed on a woman < 65 yrs age or a77078-77083man <70 yrs age, or when more than once every 2 years.61793, 77371-77373, G0339-G0340Stereotactic radiation77058-77059Breast MRI77338Multi-leaf collimator device for IMRT78459Myocardial imaging, positron emission tomography (PET), metabolic evaluation78491-78492Myocardial imaging, positron emission tomography (PET), single or multiple studies78608-78609Brain imaging, positron emission tomography (PET); metabolic evaluation, perfusion evaluation78811 -78816Tumor imaging, positron emission tomography (PET), metabolic evaluationG0219, G0235,G0252PET imagingMedicine CPT/HCPCS CodeDescription90378RSV IG intramuscular90875-90876Individual psychophysiological therapy90901-90911Biofeedback91110-91112GI tract imaging, intraluminal e.g. capsule endoscopy93228-93229External mobile cardiovascular telemetry96020Neurofunctional testing96118-96120Neuropsychological testing battery96900Actinotherapy (ultraviolet light)96902Microscopic examination of hairs plucked or clipped by the examiner 96910-96913Photochemotherapy (Goeckerman and/or PUVA)97532Development of cognitive skills97533Sensory integrative techniques97537Community/work reintegratin97545-97546Work hardening97605-97606Negative pressure wound therapy99183Physician attendance and supervision of hyperbaric oxygen therapy, per sessionJ0585-J0588BotoxJ1745RemicadeCosmetic: Not CoveredCPT/HCPCS CodeDescription11950-11954Subcutaneous injection of filling material (e.g. collagen)15775-15776Punch graft for hair transplant15780-15811Dermabrasion, abrasion, chemical peel, and salabrasion15819Cervicoplasty15820-15821Blepharoplasty, lower eyelid15824-15829Rhytidectomy15830-15839Excision, excessive skin and subcutaneous tissue (including lipectomy); abdomen (abdominoplasty)15876-15879Suction assisted lipectomy17380Electrolysis epilation19316Mastopexy19355Correction of inverted nipples21209Osteoplasty, facial bones; reduction21280-21282Medial canthopexy; lateral canthopexy21295-21296Reduction of masseter muscle and bone; extraoral , intraoral approach30120Excision or surgical planing of skin of nose for rhinophyma36468-36471Single or multiple injections of sclerosing solutions (spider veins); limb, trunk, face, legs67715Canthotomy67900-67911Repair of brow ptosis; repair of blepharoptosis; repair of overcorrection of ptosis; correction of lid retraction67950Canthoplasty69090Ear piercing69300Otoplasty, protruding ear, with or without size reductionInfertility: Not Covered CPT/HCPCS CodeDescription55400Vasovasostomy VasovasorrhaphyDental: Not Covered CPT/HCPCS CodeDescription40840Vestibuloplasty; Anterior40842Vestibuloplasty; Post Unilateral40843Vestibuloplasty; Post Bilateral40844Vestibuloplasty; Entire Arch40845Vestibuloplasty; COMPLXUnlisted not ending in “99” CPT/HCPCS CodeDescription88749Unlisted In vivo lab service89398Unlisted reproductive medicine lab procedureThis list excludes xxxxT (Category III Codes). If a Category III code is available for a given service or procedure, use the Category III code instead of a Category I Unlisted code. If billing with a temporary code, include supporting documentation with the claim. ................
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