medical record requirements for pre-service reviews · medical record requirements for pre-service...

Proprietary Information of UnitedHealthcare. Copyright 2020 United HealthCare Services, Inc.

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Medical Record Requirements for Pre-Service Reviews This document lists medical record requirements for pre-service reviews. These requirements are developed using the clinical criteria in UnitedHealthcare medical policies in conjunction with the guidance provided by UnitedHealthcare physicians and pharmacists with experience in reviewing pre-service requests

for coverage. These medical record requirements were developed in an effort to decrease the need for repeated requests for additional information and to improve turnaround time for coverage decisions.

Please prepare the suggested materials in advance. We reserve the right to request more information, if necessary. Medical record requirements for case review(s) may vary among various UnitedHealthcare Commercial, UnitedHealthcare Community Plan and UnitedHealthcare Medicare Advantage benefit plans. Please review the requirements for notifications and prior authorization requests at UHCprovider.com/priorauth.

These medical record requirements are provided for reference purposes only and may not include all services or codes. Listing of a service or code in this document does not imply that it is a covered or non-covered health service or code. Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws.

This document is the property of UnitedHealthcare and unauthorized copying, use or distribution of this information is strictly prohibited. It is regularly reviewed, updated and subject to change.

Click a service category from the Table of Contents to jump to the applicable section of this document.

http://www.uhcprovider.com/priorauth

Table of Contents Click a service category below to jump to the applicable section of this document.


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Ablative Treatment for Spinal Pain .................... 6 Abortion ....................................................... 6 Accidental Dental Services .............................. 6 Actemra (tocilizumab) .................................... 6 Acupuncture ................................................. 7 Adagen® (pegademase bovine) ........................ 7 Adakveo® (crizanlizumab-tmca) ...................... 8 Akynzeo (netupitant) ...................................... 9 Aldurazyme (laronidase) ................................. 9 Alimta (pemetrexed) ..................................... 10 Ambulance Service ‒ Non-Emergency Air Transport .................................................... 10 Antineoplastic Agents .................................... 11 Apheresis .................................................... 11 Aqueous Shunt to Extraocular Reservoir ........... 11 Aralast NP (alpha1-proteinase inhibitor (Alpha1-PI)) ............................................................ 11 Aranesp (darbepoetin alfa) ............................. 12 Arcalyst (rilonacept) ...................................... 12 Arthroscopy - Knee ....................................... 13 Arthroscopy (Wrist, Shoulder, Knee, Hip or Ankle) .................................................................. 13 Attended Polysomnography (Sleep Study) for

Evaluation of Sleep Disorders ......................... 13 Autologous Chondrocyte Transplantation .......... 14 Automatic External Defibrillator ...................... 15 Avonex or Rebif (Interferon beta-1a) ............... 15 Balloon Sinus Ostial Dilation (Sinuplasty) ......... 16 Bariatric Surgery .......................................... 16 Behavioral Health Services ............................. 17 Benlysta® (belimumab) ................................. 17 Betaseron or Extavia (interferon beta-1b) ........ 18 Blepharoplasty, Blepharoptosis, and Brow Ptosis Repair ......................................................... 18 Bone Growth Stimulator - Ultrasonic ................ 18 Bone Growth Stimulator Electric - Electromagnetic .................................................................. 19 Bone or Soft Tissue Healing and Fusion Enhancement Products .................................. 19 Botulinum Toxins A and B .............................. 20 Botulinum Toxins A and B to Treat Achalasia ..... 20 Botulinum Toxins A and B to Treat Blepharospasm

.................................................................. 21 Botulinum Toxins A and B to Treat Cervical

Dystonia ...................................................... 21

Botulinum Toxins A and B to Treat Chronic Anal Fissure ........................................................ 22 Botulinum Toxins A and B to Treat Detrusor

Overactivity ................................................. 22 Botulinum Toxins A and B to Treat Migraine Headaches ................................................... 22 Botulinum Toxins A and B to Treat Overactive

Bladder ....................................................... 23 Breast Reconstruction Post Mastectomy ........... 23 Breast Reduction Surgery .............................. 23 Breast Repair/ Reconstruction Not Following Mastectomy ................................................. 24 Brineura (cerliponase alfa) ............................. 24 Bronchial Thermoplasty ................................. 25 Camptosar (irinotecan) for KS Community Plan members ..................................................... 25 Cardiac Catheterization With or Without

Angiography ................................................ 25 Cardiac Event Monitoring ............................... 25 Cerezyme (imiglucerase) ............................... 26 Certified Nursing Assistant (CAN) or Home Health Aide for Adults 21 and Older for Florida Community Plan ........................................... 26 Chiropractic Services ..................................... 26 Cinqair® (reslizumab) .................................... 27 Clinical Trials ............................................... 27 Cochlear Implants & Other Auditory Implants ... 27 Congenital Heart Disease - Diagnostic and Therapeutic Services ..................................... 28 Continuous Glucose Monitoring (CGM) ............. 28 Continuous Passive Motion (CPM) for Knee Surgery ....................................................... 28 Continuous Positive Airway Pressure (CPAP) ..... 28 Cosmetic & Reconstructive ............................. 29 Cough Stimulating Device .............................. 29 Crysvita® (burosumab-twza) ......................... 29 Custom Ankle-Foot Orthoses (AFO) and Knee-

Ankle-Foot Orthoses (KAFO) ........................... 31 Custom Knee Orthotic (KO) ............................ 31 Decompression Unspecified Nerves ................. 32 Deep Brain and Cortical Stimulation ................ 32 Denosumab (Prolia®) .................................... 32 Denosumab (Prolia®) for KS Community Plan ... 32 Denosumab (Xgeva®) ................................... 33 Elaprase (idursulfase) ................................... 33

Elaprase (idursulfase) for KS Community Plan Members ..................................................... 34 Electric Tumor Treatment Therapy (TIFT) ......... 34 Electrical Stimulation Device for Treatment of

Wounds ...................................................... 35 Electroencephalographic (EEG) Monitoring and Video Recording ........................................... 35 Elelyso (taliglucerase) ................................... 35 Empliciti (elotuzumab) for KS Community Plan Members ..................................................... 37 Enbrel (etanercept) ...................................... 37 Enteral Nutrition (Tube Feedings) ................... 37 Entyvio (vedolizumab) .................................. 38 Erbitux (cefuximab) ...................................... 39 Evenity (romosozumab-aqqg) ........................ 39 Exondys 51™ (eteplirsen) .............................. 40 External and Implantable Pump ...................... 41 External Insulin Pump ................................... 41 Extracorporeal Shock Wave Therapy ............... 42 Eylea (aflibercept) ........................................ 42 Fabrazyme (agalsidase beta).......................... 42 Factor IX ..................................................... 43 Factor IX - For Non-Medically Necessary Plans

Only ........................................................... 44 Factor –Products .......................................... 44 Factor –Products for KS Community Plan ......... 44 Factor VIII - For Non-Medically Necessary Plans

Only ........................................................... 44 Factor VIII – Non-Preferred Products ............... 44 Factor VIII – Preferred Products ..................... 45 Factor VIII (plasma-derived) / von Willebrand Factor Complex (plasma-derived) ................... 46 Factor X ...................................................... 46 Factor XIII .................................................. 46 Fasenra (benralizumab) ................................. 47 Femoroacetabular Impingement Syndrome (FAI) ................................................................. 47 Fibrinogen Concentrate (plasma-derived) ......... 47 Fibryga (fibrinogen) ...................................... 48 Firazyr (icatibant) ......................................... 48 Flolan (epoprostenol) or Veletri (epoprostenol powder) ...................................................... 48 Foot Surgery ............................................... 48 Foot Surgery – Bunion surgery ....................... 48 Functional Endoscopic Sinus Surgery (FESS) .... 48 Gamifant (emapalumab-lzsg) ......................... 49



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Gastrointestinal Motility Disorders, Diagnosis and

Treatment ................................................... 49 Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing For Infectious Diarrhea ............... 49 Gender Dysphoria ......................................... 50 Genetics and Molecular Pathology Testing (Including BRCA) .......................................... 50 Givlaari™ (givosiran) ..................................... 51 Glassia (alpha1 -proteinase inhibitor) .............. 52 Glatopa (glatiramer acetate) .......................... 53 Hearing Aids and Devices Including Wearable,

Bone-Anchored and Semi-Implantable ............. 53 Hemlibra (emicizumab-kxwh) ......................... 53 Hemophilia clotting factor, not otherwise classified .................................................................. 54 Herceptin (trastuzumab) ................................ 54 Herceptin (trastuzumab) for KS Community Plan .................................................................. 54 High Frequency Chest Wall Compression Devices .................................................................. 55 Home Health Care Services ............................ 55 Home Health Care Services for KS Community Plan ............................................................ 56 Hospital Beds ............................................... 56 HP Acthar (corticotropin) ............................... 57 Hyperbaric Oxygen Treatment ........................ 57 Hysterectomy ............................................... 58 Ilaris (canakinumab) ..................................... 59 Ilumya (tildrakizumab-Asmn) ......................... 60 Imfinzi (durvalumab) .................................... 61 Immune Globulin (IVIG) for Asthma ................ 61 Immune Globulin (IVIG) For Auto Immune Disease ....................................................... 62 Immune Globulin (IVIG) for Bone Marrow Transplant (BMT) .......................................... 63 Immune Globulin (IVIG) for Chronic Lymphocytic Leukemia (CLL) ............................................ 64 Immune Globulin (IVIG) for Demyelinating

Polyneuropathy ............................................ 64 Immune Globulin (IVIG) for Dermatomyositis or Polymyositis ................................................. 65 Immune Globulin (IVIG) for Diabetes Mellitus ... 66 Immune Globulin (IVIG) for Fetomaternal Alloimmune Thrombocytopenia ....................... 67 Immune Globulin (IVIG) for Guillain-Barré ........ 68 Immune Globulin (IVIG) for Immune Thrombocytopenic Purpura (ITP) ..................... 68

Immune Globulin (IVIG) for Kawasaki Disease .. 69 Immune Globulin (IVIG) for Lambert-Eaton Myasthenic Syndrome (LEMS) ........................ 70 Immune Globulin (IVIG) for Lennox Gastrate .... 71 Immune Globulin (IVIG) for Multifocal Motor

Neuropathy (MMN) ....................................... 71 Immune Globulin (IVIG) for Multiple Sclerosis ... 72 Immune Globulin (IVIG) for Myasthenia Gravis . 73 Immune Globulin (IVIG) for Neuromyelitis Optica ................................................................. 74 Immune Globulin (IVIG) for Pediatric HIV ......... 75 Immune Globulin (IVIG) for Post Transfusion Purpura ....................................................... 75 Immune Globulin (IVIG) for Primary Immunodeficiency ........................................ 76 Immune Globulin (IVIG) for Rasmussen Syndrome ................................................................. 77 Immune Globulin (IVIG) for Stiff Person

Syndrome ................................................... 78 Immune Globulin (IVIG) for Thrombocytopenia Secondary to HCV Infection............................ 78 Immune Globulin (IVIG) Initial & Continuation .. 79 Infertility ..................................................... 81 Inflectra (infliximab dyyb) .............................. 81 Injection Anesthetic Agent Greater Occipital Nerve

................................................................. 81 Intensity Modulated Radiation Therapy (IMRT) .. 82 Intravenous Iron Replacement Therapy ........... 82 Intron A (interferon alfa -2b) for KS Community Plan ............................................................ 83 Jaw Motion Rehabilitation System ................... 83 Jetrea (ocriplasmin) ...................................... 83 Joint Replacement – Ankle Arthroplasty ........... 83 Joint Replacement – Displaced Fracture of Femoral Neck, Hemi-Arthroplasty ................................ 84 Joint Replacement – Elbow Arthroplasty ........... 85 Joint Replacement – Hip Acetabuloplasty and Displaced Fracture of Femoral Neck, Hemi-

Arthroplasty ................................................. 86 Joint Replacement – Hip Arthroplasty .............. 88 Joint Replacement – Knee Arthroplasty or

Arthroplasty Revision .................................... 89 Joint Replacement – Shoulder Arthroplasty, Arthroplasty Revision .................................... 91 Joint Replacement – Shoulder Hemi-Arthroplasty

................................................................. 92 Kalbitor (ecallantide) ..................................... 93

Kanuma (sebelipase alfa) .............................. 93 Kanuma (sebelipase alfa) for KS Community Plan ................................................................. 94 Keytruda (pembrolizumab) for KS Community Plan ........................................................... 94 Krystexxa (pegloticase) ................................. 96 Kymriah (tisagenlecleucel) for All Plans Except KS Community Plan ........................................... 96 Kymriah (tisagenlecleucel) for KS Community Plan ................................................................. 96 Lemtrada (alemtuzumab) .............................. 97 Lower Extremity Angiography – Unilateral or Bilateral ...................................................... 98 Lucentis (ranibizumab) .................................. 98 Lumizyme or Myozyme (alglucosidase alfa) ...... 98 Lupron (leuprolide acetate) for KS Community Plan ........................................................... 99 Luxturna (voretigene neparvovec-rzyl) ............ 99 Magneto-encephalography ........................... 100 Makena (hydroxprogesterone caproate) for KS Community Plan ......................................... 100 Makena (hydroxyprogesterone caproate) ....... 100 Mastectomy for Gynecomastia ...................... 101 Mechanical Stretching Devices (Dynamic and

Static) ...................................................... 101 Member Lifts ............................................. 101 Meniscus Implant and Allograft ..................... 101 Mepsevii (vestronidase alfa-vjbk) .................. 101 Microfracture Repair ................................... 102 Milrinone (milrione lactate) .......................... 103 Miscellaneous DME ..................................... 103 Muscle Flap Procedures ............................... 104 Naglazyme (galsulfase) ............................... 104 Negative Pressure Wound Therapy (NPWT) - Wound VAC ............................................... 105 Neulasta (pegfilgrastim) .............................. 105 Neulasta (pegfilgrastim) for KS Community Plan ............................................................... 106 Neuromuscular Electrical Stimulation (NMES) . 106 Neuromuscular Stimulator for Scoliosis .......... 107 Neuromuscular Stimulators .......................... 107 Neurostimulator Electrode Array, Peripheral Nerve ............................................................... 107 Non Invasive Fractional Flow Reserve (FFR) ... 107 NovoSeven® RT [coagulation factor VIIa

(recombinant)] .......................................... 108 Nplate (romiplostim) ................................... 108



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Nucala (mepolizumab) ................................. 108 Obstructive Sleep Apnea (OSA) - Oral Appliances ................................................................ 109 Ocrevus (ocrelizumab) ................................. 109 Office Based Procedures Site of Service for

Commercial Plans ....................................... 110 Onivyde (irinotecan liposomal) for KS Community Plan .......................................................... 110 Onpattro (patisiran) .................................... 111 Opdivo (nivolumab) for KS Community Plan.... 112 Orencia (abatacept) .................................... 112 Orthognathic (Jaw) Surgery ......................... 113 Orthotics – Cranial ...................................... 114 Orthotics – Lower Body ................................ 114 Orthotics - Upper Body ................................ 114 Osteochondral Grafting (Autograft and Allograft) ................................................................ 115 Pacemaker (Replacement of Batteries, Generator)

................................................................ 120 Pacemaker (replacement of lead electrodes) ... 120 Pacemaker insertion (replacement) ............... 120 Panniculectomy and Body Contouring (Including Lipectomy and Abdominoplasty) ................... 121 Parsabiv (etelcalcetide) ................................ 121 Pectus Deformity Repair .............................. 122 Pediatric Day Care for Community Plan: ......... 122 Peg Intron (peginterferon alfa-2b) ................. 123 Pegsys (peginterferon alfa-2a) ...................... 123 Percussor Oscillatory Devices........................ 123 Percutaneous Lysis of Epidural Adhesions ....... 123 Percutaneous Patent Foramen Ovale (PFO)

Closure ..................................................... 124 Percutaneous Vertebroplasty and Kyphoplasty 124 Physical and Occupational Therapy (PT/ OT) ... 124 Physical and Occupational Therapy (PT/OT) – For

Community Plans ........................................ 124 Pneumatic Compression Devices ................... 125 Power Mobility Devices (Scooters, Wheelchairs)

................................................................ 126 Power Rim Assist for Manual Wheelchair ......... 127 Pressure Reducing Support Surface – Group 2 127 Pressure Reducing Support Surface – Group 3 128 Prialt (ziconotide intrathecal) ........................ 128 Private Duty Nursing (PDN) .......................... 128 Private Duty Nursing (PDN) for Community Plan:

................................................................ 129 Probuphine® (buprenorphine) ....................... 130

Procrit or Epogen (epoetin alfa) .................... 130 Prolastin (alpha 1-proteinase inhibitor – human) ............................................................... 131 Prosthetic - Breast ...................................... 132 Prosthetic - Eye and Face............................. 132 Prosthetic - Lower Limb ............................... 132 Prosthetic - Miscellaneous ............................ 133 Prosthetic - Upper Limb ............................... 133 Prothrombin Time (PT) International Normalized Ratio (INR) Monitor ..................................... 133 Proton Beam Therapy .................................. 134 Provenge (sipuleucel-T) ............................... 134 Radiation Therapy ...................................... 134 Radicava (edavarone) ................................. 134 Radiology Services - Breast Imaging for Screening

and Diagnosing Cancer ................................ 135 Radiology Services - Computed Tomographic (CT) Colonography ............................................. 136 Radiology Services - CT Abdomen/ Pelvis ....... 137 Radiology Services – CT Head ...................... 138 Radiology Services – MRI Breast ................... 138 Radiology Services – MRI Head ..................... 139 Radiology Services – MRI Joint Lower Extremity ............................................................... 140 Radiology Services - MRI Joint Upper Extremity

............................................................... 141 Radiology Services - MRI Spine..................... 142 Radiology Services - MRI Spine/ Pelvis........... 142 Radiology Services – MRI/ CT Scan – Site of Service ..................................................... 144 Radiology Services – Positron Emission

Tomography (PET) ...................................... 144 Radiology Services - Thyroid and Parathyroid . 145 Radiopharmaceuticals ................................. 145 Radium RA-223 Dichloride for KS Community Plan

............................................................... 145 Rebinyn (glycopegylated) ............................ 145 Remicade (infliximab) ................................. 145 Remicade (infliximab) for KS Community Plan. 147 Remicade (infliximab) for Washington (WA) Community Plan ......................................... 147 Renflexis (infliximab abda) ........................... 148 Respiratory Assistive Device – Bilevel Positive Airway Pressure (BIPAP) for Diagnosis of

Obstructive Sleep Apnea (OSA) and Other

Diagnoses ................................................. 148 Respiratory Interleukins .............................. 149

Retacrit (epoetin alfa –epbx) ........................ 150 Revcovi (elepegademase -lvlr) ..................... 150 Review at Launch for New to Market Medications -C&S ......................................................... 152 Review at Launch for New to Market Medications -

E&I .......................................................... 152 Rhinoplasty and Other Nasal Surgeries .......... 153 Rituxan (rituximab) For KS Community Plan ... 154 Rituximab ................................................. 154 Sandostatin (octreotide) .............................. 154 Seat Lifts .................................................. 155 Self-Administered Drugs .............................. 155 Simponi Aria (golimumab) ........................... 155 Site of Service – Outpatient for Community Plans: ............................................................... 156 Sleep Apnea Treatment and Surgeries ........... 157 Sodium Hyaluronate NON-Preferred Products C&S & E&I ....................................................... 158 Sodium Hyaluronate NON-Preferred Products for Medicare & Retirement (M&R) ...................... 159 Sodium Hyaluronate Preferred Products for

Community and State (C&S) & Commercial (E&I) Products ................................................... 159 Sodium Hyaluronate Preferred Products for

Medicare & Retirement (M&R) – Initial &

Continuation .............................................. 160 Soliris (eculizumab) Initial & Continuation ...... 160 Speech Therapy (ST) – For Community Plans . 162 Spinal Stimulator for Pain Management ......... 163 Spinal Surgery – Scoliosis ............................ 164 Spinal Ultrasonography ............................... 165 Spinraza (nusinersen) ................................. 165 Spravato (esketamine) ................................ 166 Stelara (ustekinumab) ................................ 166 Stress Echocardiogram ................................ 167 Sublocade (buprenophine) ........................... 167 Supprelin LA (histrelin) for KS Community Plan ............................................................... 167 Surgical Treatment for Spine Pain ................. 168 Taxel (onxal paclitaxel) ............................... 169 Temporomandibular Joint Disorders .............. 170 Therapeutic Embolization; Endometrial Ablation/Cryoablation .................................. 170 Therapeutic Procedures ............................... 170 Thorascopy – Sympathectomy for Treatment of

Hyperidrosis .............................................. 170 Total Artificial Disc Replacement ................... 170



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Total Artificial Heart .................................... 171 Transcatheter Heart Valve Procedures ............ 171 Transcutaneous Electrical Nerve Stimulation (TENS) ...................................................... 172 TransCyte - Skin and Soft Tissue Substitute ... 172 Transection or Avulsion of Greater Occipital Nerve ................................................................ 173 Transplant of Tissue or Organs ..................... 173 Trelstar (triptorelin) for KS Community Plan ... 173 Tremfya (guselkumab) ................................ 173 Triptodur (triptorelin) .................................. 173 Trogarzo™ (ibalizumab-uiyk) ........................ 174 Tysabri (natalizumab) ................................. 175 Ultomiris (ravulizumab) ............................... 175 Ultraviolet Cabinet ...................................... 177

Upper Gastrointestinal Endoscopy with Delivery of

Thermal Energy for Treatment of Gastroesophageal Reflux Disease .................. 177 Vagus and External Trigeminal Nerve Stimulation ............................................................... 177 Varubi (rolapitant) ...................................... 178 Velcade (bortezomib) .................................. 178 Ventavis (iloprost) ...................................... 178 Ventavis (iloprost) for KS Community Plan ..... 178 Ventilator .................................................. 179 Ventricular Assist Devices ............................ 179 Vimizim (elosulfase alfa) .............................. 179 Von Willebrand Factor (recombinant) ............. 180 VPRIV (Velaglucerase alfa) ........................... 180 WBC Stimulator for KS Community Plan ......... 181

WBC Stimulators ........................................ 181 Wheelchair – Manual ................................... 182 Xolair® (omalizumab) for Treating Asthma ..... 182 Xolair® (omalizumab) for Treating Uticaria ..... 183 Yervoy (ipilimumab) ................................... 184 Yescarta (axicabtagene ciloleucel) ................. 184 Yescarta (axicabtagene ciloleucel) for KS Community Plan ......................................... 184 Zemaira (alpha1-proteinase inhibitor (human)) ............................................................... 185 Zinplava (bezlotoxumab) ............................. 186 Zolgensma® (Onasemnogene Abeparvovec-Xioi) ............................................................... 186


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Service Category Applicable Codes Clinical Information Requested

Ablative Treatment for Spinal Pain

22899 64633 64635 Medical notes documenting all of the following:

1. Temperature of procedure 2. Duration of ablation 3. Functional Impairment due to facet pain

4. Specific identification of side and level of Medial Branch Blocks and ablation

5. Percentage of pain relief with Medial Branch Blocks or prior ablation if applicable

6. Duration of improvement from Medial Branch Blocks or prior ablation if applicable

Abortion 59830 59850 59851 59852 59855 59856 59857

Physician office notes:

1. Describing that the member suffers from a physical disorder, physical injury, or physical illness, including a life-endangering physical condition caused by or arising from the pregnancy itself, and

2. The life of the pregnant woman would be endangered if the fetus were carried to term, OR

3. That the pregnancy is the result of an act of rape or incest

Accidental Dental Services

All codes including CDT codes where applicable

1. Date of accident 2. Description of accident and identification of the tooth / teeth damaged

3. Date of initial contact with a Medical or Dental Professional 4. Detailed comprehensive treatment plan including submission of Pre and

Post imaging studies and clinical photos, if taken

5. Anticipated date of completion 6. Certification from the DDS that the tooth was sound and natural prior to

the accident

Actemra (tocilizumab) J3262 Please provide the following for an initial request: 1. Current prescription 2. Name and tax ID number of the servicing provider/ facility

3. Physician office notes that include: a. Member weight b. Member diagnosis

c. Documentation of treatments tried, failed, contraindicated. Include the dates and reason for discontinuation

d. Dose and frequency being requested e. List medications member will be taking to treat the condition

4. Location where the drug will be administered (e.g., infusion center, physician office, self-administered, home health nurse a. If the location is in a facility provide office notes for at least one of the

following: i. Medically unstable based upon submitted clinical history ii. Initial medication infusion of or re-initiation after more than 6

months following discontinuation of therapy iii. Previous experience of a severe adverse event following infusion.

Examples include but are not limited to anaphylaxis, seizure,

thromboembolism, myocardial infarction, renal failure

iv. Continuing experience of adverse events that cannot be mitigated by pre-medications or infusion rate adjustments


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v. Physically and/ or cognitively impaired and no home caregiver available

vi. Difficulty establishing and maintaining patent vascular access vii. Homecare or infusion provider has deemed that the member, home

caregiver, or home environment is not suitable for home infusion

therapy.

Please provide the following for a continuation request: 1. Current prescription 2. Name and tax ID number of the servicing provider/ facility

3. Physician office notes that include: a. Member weight b. Member diagnosis c. Documentation of treatments tried, failed, contraindicated. Include the

dates and reason for discontinuation d. Dose and frequency being requested e. List medications member will be taking to treat the condition

f. Documentation of positive response to the requested medication 4. Location where the drug will be administered (e.g., infusion center,

physician office, self-administered, home health nurse

a. If the location is in a facility provide office notes for at least one of the following: i. Medically unstable based upon submitted clinical history ii. Initial medication infusion of or re-initiation after more than 6

months following discontinuation of therapy

iii. Previous experience of a severe adverse event following infusion. Examples include but are not limited to anaphylaxis, seizure,

thromboembolism, myocardial infarction, renal failure iv. Continuing experience of adverse events that cannot be

mitigated by pre-medications or infusion rate adjustments


vi. Difficulty establishing and maintaining patent vascular access vii. Homecare or infusion provider has deemed that the member,

home caregiver, or home environment is not suitable for home infusion therapy

Acupuncture 97810 97811 97813 97814 1. Current prescription 2. Name and tax ID number of the servicing provider/ facility to facilitate

claim processing

3. Physician office notes that include: 4. Member diagnosis 5. Imaging reports 6. Previous treatments rendered, dates of treatments and response

7. Treatment plan

Adagen® (pegademase

bovine)

J2504 Please provide the following for an initial request:

1. Current prescription


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2. Name and tax ID number of the servicing provider/ facility to facilitate claim processing

3. Physician office notes that include: a. Member diagnosis

b. Laboratory results to support deficiency of adenosine deaminase

c. Documentation that member is not a candidate or failed hematopoietic cell transplantation (HCT)

d. Dose, frequency including the physician treatment plan 4. Location where the drug will be administered (e.g., infusion center,

physician office, self-administered, home health nurse)

a. If the location is in a facility, provide office notes for at least one of the following: i. Medically unstable based on submitted clinical history ii. Initial medication infusion of or re-initiation after more than 6

months following discontinuation of therapy iii. Previous experience of a severe adverse event following infusion


thromboembolism, myocardial infarction, renal failure iv. Continuing experience of adverse events that cannot be mitigated

by pre-medications or infusion rate adjustments

v. Physically and/ or cognitively impaired AND no home caregiver available


home caregiver, or home environment is not suitable for home

infusion therapy

Request to continue administration provide the following:

1. Current prescription 2. Name and tax ID number of the servicing provider/ facility to facilitate

claim processing 3. Physician office notes that include:

a. Documentation with member’s response to therapy b. Dose, frequency including the physician treatment plan

c. Laboratory results to support the positive response to therapy

Adakveo®

(crizanlizumab-tmca)

C9053 C9399 J3490 J3590 Please provide the following for an initial request:

1. Current prescription 2. Name and specialty of the prescribing and/ or consulting provider 3. Name and tax ID number of the servicing provider/ facility if different than

prescribing/ consulting provider 4. Physician office notes that include:

a. Member weight b. Member diagnosis

c. Member's history of vasoocclusive crisis episodes including

pretreatment baseline experience d. Documentation of treatments tried, failed, contraindicated. Include the

dates and reason for discontinuation


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e. Dose and frequency being requested In addition to the above, please also provide the following for continuation: 1. Documentation of positive response to the requested medication

Akynzeo (netupitant)

NOTE: Also applies to KS Community Plan

J1454 Please provide the following:

1. Current Prescription


3. Physician office notes that include the following:

a. Cancer diagnosis b. Chemotherapy regime

Aldurazyme (laronidase) J1931 Please provide the following for an initial request: 1. Current prescription 2. Name and tax ID number of the servicing provider/ facility to facilitate

claim processing

3. Physician office notes that include: a. Member diagnosis b. Documentation of signs and symptoms

c. Laboratory results to support deficiency or absence of fibroblast or leukocyte enzyme activity of alpha-L-iduronidase enzyme activity

d. Laboratory result to support Molecular genetic confirmation of

mutations in the alpha-L-iduronidase gene; Hurler variance e. Dose, frequency including the physician treatment plan

4. Location where the drug will be administered (e.g., infusion center, physician office, self-administered, home health nurse)

a. If the location is in a facility, provide office notes for at least one of the following: i. Medically unstable based on submitted clinical history

ii. Initial medication infusion of or re-initiation after more than 6 months following discontinuation of therapy

iii. Previous experience of a severe adverse event following infusion

Examples include but are not limited to anaphylaxis, seizure, thromboembolism, myocardial infarction, renal failure



vi. Difficulty establishing and maintaining patent vascular access

vii. Homecare or infusion provider has deemed that the member, home caregiver, or home environment is not suitable for home infusion therapy



2. Name and tax ID number of the servicing provider/ facility to facilitate



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a. Documentation with member’s response to therapy b. Dose, frequency including the physician treatment plan c. Laboratory results to support the positive response to therapy

Alimta (pemetrexed) J9305 Please provide the following for an initial request: Current prescription

Medication name

Name and specialty of the prescribing and/ or consulting provider Name and tax ID number of the servicing provider/ facility if different than

prescribing/ consulting provider

Physician office notes that include: a. Member weight b. Member diagnosis c. Documentation of treatments tried, failed, contraindicated. Include the


In addition to the above, please also provide the following for continuation:

Documentation of positive response to the requested medication

Date the therapy was started

Ambulance Service ‒

Non-Emergency Air Transport

A0430 A0431 A0435 A0436 S9960 S9961 Please include the following:

a. Date of Service b. Ordering physician’s name and phone# (if request is made to Air

Ambulance provider) c. Physician order and documentation by Physician explaining the reason

for Air Ambulance transport d. Any additional equipment or personnel needed for transport e. Member’s diagnosis and chief complaint

f. Physician notes evaluating members current condition / clinical summary) including:

g. Co-morbidities

h. Current functional limitations i. Description of members inpatient (IP) stay and progress if applicable j. Describe where member is traveling from (facility name & contact

name (phone number)

k. Describe where member is traveling to (facility name & contact name(phone number)

l. Mileage (one-way) for transport including air mileage and land mileage

for transport


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Antineoplastic Agents J0640 J0641 J9000 J9015 J9017 J9019 J9020 J9022 J9023 J9025 J9027 J9031 J9032 J9033 J9034 J9035 J9039 J9040 J9041 J9042 J9043 J9045 J9047 J9050 J9055 J9060 J9065 J9070 J9098 J9100

J9120 J9130 J9145 J9150 J9151 J9155 J9160 J9165 J9171 J9175 J9176 J9178 J9179 J9181 J9185 J9190 J9200 J9201


J9230 J9245 J9250 J9260 J9261 J9262 J9263 J9266 J9268 J9270 J9271 J9280 J9285 J9293 J9295 J9299 J9301 J9302 J9303 J9305 J9306 J9307 J9308 J9315


Q2017 Q2049Q2050

Request for an initial start: 1. Current Prescription 2. Physician office notes that include the following:

a. Drug dosage and frequency including the treatment plan

b. Associated orders for an infusion pump or a nebulizer needed to

administer the drug c. History of the medical condition requiring treatment including clinical

indications d. If dose and/or frequency are different from the FDA approved package

insert, provide literature support for the specific schedule chosen

e. If the patient is receiving this drug as part of a clinical trial, please provide information about the clinical trial, including the clinical trial identifier

3. Documentation of how the drug will be supplied and who will administer

the drug to the patient (e.g., supplied by office/facility, obtained by patient from either a pharmacy or OptumRx Specialty Pharmacy Program)

NOTE: For members with Medicare, If drug is obtain by the patient prior authorization may be required through the member’s Part D benefits.

Apheresis 36514 Medical notes documenting all of the following:

Medical history

a. Diagnosis b. Treatment plan

Aqueous Shunt to

Extraocular Reservoir

66180 Medical notes documenting all of the following:

1. Condition/ diagnosis requiring procedure

2. History and physical by the attending/ treating physician

3. History and duration of unsuccessful conservative therapy, when applicable

4. Previous related surgical procedures

5. Name of drainage device to be used

Aralast NP (alpha1-proteinase inhibitor (Alpha1-PI))

J0256 Please provide the following for an initial request: 1. Current prescription 2. Name and tax ID number of the servicing provider/ facility to facilitate

claim processing

3. Physician office notes that include: a. Member diagnosis b. Laboratory results of alpha1-antitrypsin (AAT) level and genetic

testing to confirm diagnosis c. Current Pulmonary function test results d. Documentation of signs and symptoms

e. List of medications being taken for this condition f. Documentation that member is a nonsmoker, g. Dose, frequency including the physician treatment plan

4. Location where the drug will be administered (e.g., infusion center,



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iii. Previous experience of a severe adverse event following infusion Examples include but are not limited to anaphylaxis, seizure,











Aranesp (darbepoetin

alfa)

J0881 1. Current prescription

2. Physician office notes that support documentation of: a. Drug dosage, route of administration and frequency including

physician’s treatment plan

b. History of the medical condition requiring treatment including clinical indications and the most recent hgb (hct, serum erythropoietin level and other pertinent labs such as iron studies

c. Previous treatment provided including the name of the drug, course of

treatment and response d. If the member is receiving this drug as part of a clinical trial, please

provide information about the clinical trial, including the clinical trial

identifier 3. Documentation of how the drug will be supplied and who will administer

the drug to the member (e.g., supplied by office/ facility, obtained by

member from either a pharmacy or OptumRx Specialty Pharmacy Program)

NOTE: If drug is obtain by the member prior authorization may be required through the member’s Part D benefits

Arcalyst (rilonacept)

J2793 1. Current Prescription 2. Name and tax ID number of the servicing provider/ facility to facilitate

claim processing


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3. Physician office notes that include the following: a. Diagnosis b. Results of tuberculosis screen c. List all medications being taken for condition with Arcalyst

4. Physicians treatment plan including the dose, frequency and duration

Arthroscopy - Knee 27488 29870 29873 29874 29875 29876 29877 29880 29881 29882 29883 29884

29885 29886 29887 29888 29889

1. Current physician office notes indicating:

2. Condition requiring procedure a. Severity of pain and details of functional disability(ies) interfering with

activities of daily living (preparing meals, dressing, driving, walking)

b. Co-morbid medical condition(s) c. Pertinent physical examination of the knee or relevant joint, with

history of present illness and joint pathology d. Physician’s treatment plan including pre-op discussion

e. Therapies tried and failed of the following, including dates: i. Orthotics ii. Medications/ injections

iii. Physical therapy iv. Surgery v. Other pain management procedures

vi. Conservative measures tried and failed vii. Laboratory results (such as ESR, Rheumatoid Factor, or other

pertinent labs) 3. Complete report(s) of diagnostic imaging (MRI, CT Scan, and X-rays)

Arthroscopy (Wrist,

Shoulder, Knee, Hip or

Ankle)

27437 27438 27440 27441 27442 27443

29805 29806 29807 29819 29820 29821 29822 29823 29824 29825 29826 29827

29828 29830 29834 29835 29836 29837 29838 29840 29843 29844 29845 29846 29847 29860 29861 29862 29863 29871

29891 29894 29895 29897 29898 29899

Please provide the following:

1. Complete report(s) of diagnostic imaging (MRI, CT Scan, X-rays and Bone

Scan) 2. Current physician office note indicating:

a. Condition requiring procedure

b. Severity of pain and details of functional disability(ies) interfering with activities of daily living (preparing meals, dressing, driving, walking)

c. Physician’s treatment plan including pre-op discussion

d. Pertinent physical examination of the relevant joint e. Co-morbid medical condition(s) f. Therapies tried and failed of the following including dates :

i. Orthotics

ii. Medications/ injections iii. Physical therapy iv. Surgical

v. Other pain management procedures 3. Date of failed previous surgery to the same joint, if applicable

Attended Polysomnography (Sleep Study) for Evaluation of Sleep

Disorders

95805 95807 95808 95810 95811 Medical notes documenting all of the following:

1. Physical exam that includes the member’s height, weight and BMI 2. Clinical signs and symptoms

3. Epworth Sleepiness Score

4. Co-morbid conditions a. Pulmonary: provide spirometry results


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b. Cardiac: provide the NYHA heart failure class and/or left ventricular ejection fraction

c. Neurologic health issue impacting sleep that may include seizure disorder

d. Obesity hypoventilation syndrome: provide PaCO2 results

5. Previous Sleep study reports, if applicable 6. Indicate whether the testing is for a Commercial Driving License (CDL)

7. If requesting 95811, indicate whether the request is for PAP titration or split night study

8. For a member already on PAP therapy, provide most recent print out for

compliance

9. For Multiple Sleep Latency Testing [(MSLT); (CPT 95805)], provide any evaluation/documentation showing that other causes of Excessive Daytime Sleepiness have been excluded

Autologous Chondrocyte Transplantation

27412 J7330 S2112 Medical notes documenting all of the following: 1. Complete report(s) of diagnostic imaging (MRI, CT Scan, X-rays and Bone

Scan)

Note: For pediatric age, indicate status of growth plates. 2. Indication for procedure 3. Pertinent physical examination of the relevant joint

4. Size and location of defect 5. Cause of defect e.g., acute or repetitive trauma 6. Co-morbid medical condition(s)

7. Therapies tried and failed for the following including dates:

a. Orthotics b. Medications c. Injections

d. Physical therapy e. Surgical f. Other pain management procedures

8. Physician’s treatment plan including pre-op discussion If the location is being requested as an inpatient stay, provide office notes to

support at least one of the following: 1. Surgery is bilateral 2. Member has significant co-morbidities. Include the list of comorbidities and

current treatment

3. Member does not have appropriate resources to support post-operative care after an outpatient procedure. Include the barriers to care as an outpatient

Implant material:

J7330

Note: Prior Authorization request must be received from the surgeon preforming the Autologous Chondrocyte Transplantation (27412, S2112)

before the implant authorization can be processed.

Refer to the documentation requirements for CPT code 27412 and HCPCS S2112 for specific information needed to authorize the implantation.


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The laboratory providing the implant material should provide the following information: Thank you for your prior authorization request for autologous cultured

chondrocytes, implant (J7330). In order for your request to be processed a

prior authorization request must also be received from the surgeon preforming the Autologous Chondrocyte Transplantation (27412, S2112). In an effort to

streamline the processing of your prior authorization request, please provide the following:

Surgeon Name: Surgeon/ Practice Address: Surgeon/ Practice Phone: Surgeon/ Practice Fax:

Surgeon/ Practice Email: We also ask you provide the following information (if available) related to the

Autologous Chondrocyte Transplantation (27412, S2112):

Diagnosis (ICD-10 code(s))

Location where procedure will take place Members Age, if patient is of pediatric age, indicate status of growth plates Cause of defect What is the size of the defect

Location of the defect

Treatments tried, failed, contraindicated (e.g., physical therapy, braces, and/or nonsteroidal anti-inflammatory drugs (NSAIDs), debridement,

microfracture, drilling/abrasion arthroplasty, or osteochondral allograft/autograft)

Automatic External Defibrillator

E0617 K0607 K0608 K0609 1. Current prescription from physician 2. Indicate whether this is an initial request, ongoing, replacement or

purchase a. If ongoing request, provide data (downloaded report) indicating that

member is wearing the equipment b. If replacement, provide reason

3. Clinical documentation that identifies risk for sudden death including but

not limited to: a. History of cardiac arrest b. Ventricular fibrillation or ventricular tachyarrhythmia

c. Familial or inherited conditions d. History of a prior implanted defibrillator e. History of myocardial infarction or dilated cardiomyopathy with a

measured ventricular ejection fraction

f. Coronary artery disease with a documented prior myocardial infarction

g. History of a prior implanted defibrillator

Avonex or Rebif (Interferon beta-1a)

J1826 Q3027 Q3028 Initial request provide the following: 1. Current Prescription


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3. Physician office notes that include the following: a. Diagnosis

b. Documentation that drug is being prescribed or in consultation with a

neurologist c. List of all medications being taken for this condition with this drug

4. Physicians treatment plan including the dose, frequency and duration Coninuation request provide the following:

1. Current Prescription 2. Name and tax ID number of the servicing provider/ facility to facilitate

claim processing 3. Physician office notes that include the following documentation of clinical

benefit

Balloon Sinus Ostial

Dilation (Sinuplasty)

31295 31296 31297 31298 Medical notes documenting all of the following:

1. History of illness including symptoms and duration 2. Recent physical exam 3. Diagnosis

4. Medication(s) and therapy(ies) tried and failed 5. CT scan images that show the abnormality for which surgery is being

requested. Consultation with requesting surgeon may be of benefit to select the optimal images

Note: CT images are required and must be labeled with: a. The date taken

b. Applicable case number obtained at time of notification, or member's

name and ID number on the image(s) c. Whether the image(s) was taken pre- or post-medical therapy CT images can be submitted via the external portal at

www.uhcprovider.com/paan or via email at [email protected]; faxes will not be accepted

6. CT scan report 7. Evidence that the sinusitis involves frontal, maxillary, or sphenoid sinuses

8. Planned procedure: a. Specify area of sinus(es) to be treated b. Include if the procedure will be part of a functional endoscopic sinus

surgery (FESS)

Bariatric Surgery Initial:

0312T 0313T 0314T 0315T 0316T 0317T 43644 43645 43647 43648 43659 43770 43771 43772 43773 43774 43775 43842

43843 43845 43846 43847 43848 43881 43882 43886 43887 43888 64590 64595,

Subsequent : 43860 43865

For initial bariatric surgery, provide medical notes documenting all of the following: 1. Height 2. Weight 3. Current and five year history of BMI (body mass index) 4. Diet history 5. Co-morbidities 6. Medical treatment tried and failed including diet and exercise

http://www.uhcprovider.com/paan


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7. Psychological evaluation by a licensed behavioral health professional 8. Nutritional consult 9. Name of the facility where the procedure will be performed For subsequent bariatric surgery, provide medical notes documenting all of the above in addition to the following:

Previous unsuccessful medical treatment Initial bariatric surgery performed and date and subsequent complications

that require further surgical intervention

Behavioral Health Services

All codes Provider should call the number on the member’s identification (ID) card when referring for any mental health or substance abuse/ substance use services

Benlysta® (belimumab) J0490 Please provide the following for an initial request: 1. Current prescription 2. Name and tax ID number of the servicing provider/ facility to facilitate

claim processing

3. Physician office notes that include: a. Member diagnosis b. Laboratory results or genetic testing to confirm diagnosis

c. Documentation of signs and symptoms d. Dose, frequency including the physician treatment plan


physician office, self-administered, home health nurse) a. If the location is in a facility, provide office notes for at least one of the

following: i. Medically unstable based on submitted clinical history


iii. Previous experience of a severe adverse event following infusion.


iv. Continuing experience of adverse events that cannot be

mitigated by pre-medications or infusion rate adjustments v. Physically and/ or cognitively impaired AND no home caregiver

available vi. Difficulty establishing and maintaining patent vascular access





3. Physician office notes that include:


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Betaseron or Extavia (interferon beta-1b)


J1830 Initial request provide the following: 1. Current Prescription


claim processing 3. Physician office notes that include the following:

a. Diagnosis

b. Documentation that drug is being prescribed or in consultation with a neurologist

c. List of all medications being taken with this medication 4. Physicians treatment plan including the dose, frequency and duration

Continuation request provide the following: 1. Current Prescription



a. Documentation of clinical benefit

Blepharoplasty,

Blepharoptosis, and Brow Ptosis Repair

15820 15821 15822 15823 21280 21282 67900 67901 67902 67903 67904 67906 67908 67909 67911 67914 67915 67916

67917 67921 67922 67923 67924 67950

67966

Medical Notes documenting the following:

Goldman, manual or automated technique visual fields, taped and untaped a. Marginal reflex distance (MRD-1) b. Physician office notes describing visual complaints, functional

impairments and ruling out other causes c. High-quality photograph(s). All photos must be full face, labeled with

the date taken and the applicable case number obtained at time of

notification, or member’s name and ID number on the photograph(s). Photos can’t be faxed. Please use the Prior Authorization and Notification app on Link to send photos

Bone Growth Stimulator - Ultrasonic

20979 E0760 1. Current physician prescription or order

2. Documentation to explain the reason the member will need a bone growth stimulator

3. Member with an acute fracture include the following:

4. Date and type of fracture a. Complete report of diagnostic imaging

5. Member with a non-union of the fracture include the following:

a. Date and site of fracture

b. All X-rays reports including: i. The initial X-ray ii. Follow-up X-ray(s) at least 90 days apart

6. Treatment of the fracture, including:

a. treatment already completed b. Treatment planned

7. Member with a tibial osteotomy include the treatment plan


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Bone Growth Stimulator Electric - Electromagnetic

20974 20975 E0747 E0748 E0749 1. Current physician prescription or order

2. Document the reason the member will need a bone growth stimulator

3. Member with other issues such as diabetes, obesity,

osteoporosis, or current tobacco use include supporting

clinical

4. Member has or will be having a spinal fusion include the following:

a. Date of surgery, either past or future and number of vertebral levels

fused; or

b. Documentation of failed spinal fusion and date of reoperation of same site

For E0747, E0748 and E0749 provide the following: 1. All X-rays reports including:

a. The initial X-ray b. Follow-up X-ray(s) at least 90 days apart

2. Treatment of the fracture, including:

a. Treatment already completed b. Treatment planned

Bone or Soft Tissue Healing and Fusion Enhancement Products

22558 22585 22899 Medical notes documenting the following: 1. Condition requiring procedure 2. History and co-morbid medical condition(s)

3. Symptoms, pain, location, and severity including functional impairment

that is interfering with activities of daily living (meals, walking, getting dressed, driving)

4. Physical exam, including neurologic exam

5. History and duration of previous therapy, when applicable including: a. Physical therapy b. Medications/ injections

c. Previous surgery, d. Other attempted treatments

6. Planned procedure and plan of care; include if the surgery will be performed with direct visualization

7. Complete report(s) of diagnostic studies, i.e., MRI, CT, etc. 8. Describe the surgical approach planned (e.g.: AxialLIF, XLIF, GOLIF, LALIF,

Image-guided minimally invasive lumbar Decompression (MILDR),

percutaneous endoscopic discectomy with or without laser, etc.) 9. Which of the following allograft products will you be using (Please indicate

all products and provide brand names, if applicable)?

a. Cadaver allograft b. Animal allograft (demineralized bone matrix (DBM) Allograft or

Synthetic DBM)

c. Amniotic tissue membrane

d. Bone morphogenetic protein-7 (BMP-7) e. Bone morphogenetic protein-2 (BMP-2)


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f. Please indicate which of the following: i. Infuse bone graft (LT-cage lumbar tapered fusion device) ii. Infuse bone graft (interfix threaded fusion device) iii. Infuse bone graft (interfix rp threaded fusion device)

g. Other cage type (for example PEEK or other);

h. Ceramic-Based Products ‒ please indicate which of the following: i. Beta tricalcium phosphate (b-TCP)

ii. Other; must provide the brand name i. Cell-based products ‒ please indicate which of the following:

i. Mesenchymal stem cells

ii. Infuse(Mastergraft Posterolateral Revision Device System iii. Optimesh iv. Platelet-rich plasma (PRP) v. Other

Botulinum Toxins A and B

• Botox

(onabotulinumtoxinA)

• Dysport (abobotulinumtoxinA)

• Myobloc (rimabotulinumtoxinB)

• Xeomin

(incobotulinumtoxinA)

J0585 J0586 J0587 J0588 Request for an initial therapy: 1. Current prescription



a. History and physical documenting severity of condition b. Related laboratory testing and imaging c. Dose and frequency being requested, including treatment plan d. List medications member has tried and failed, contraindications,

intolerance to

Request for continuation therapy

1. New prescription 2. Physician office notes that include:

a. Dose and frequency being requested

b. Member response to therapy with the requested medication c. Date the therapy was started

3. Physicians treatment plan

Botulinum Toxins A and B to Treat Achalasia

• Botox (onabotulinumtoxinA)

• Dysport

(abobotulinumtoxinA)

J0585 J0586 Request for an initial therapy: 1. Current prescription 2. Name and tax ID number of the servicing provider/ facility to facilitate


a. Diagnosis confirmed by esophageal manometry testing

b. List of medications tried and failed, contraindications, and intolerance c. Explanation why member is not a candidate for pneumatic dilation or

myotomy

d. Results of Upper GI endoscopy to rule out cause of dysphagia e. Dose and frequency being requested, treatment plan f. List medications member will be taking to treat the condition

Request for an continuation therapy: 1. New prescription


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2. Physician office notes that include: a. Dose and frequency being requested b. Member response to therapy with the requested medication c. Date the therapy was started


4. Name and tax ID number of the servicing provider/ facility if different from the initial request

Botulinum Toxins A and B to Treat

Blepharospasm

• Xeomin


J0588 Request for an initial therapy: 1. Current prescription


3. Physician office notes that include: a. History and physical documenting severity of condition

b. Related laboratory testing and imaging c. Dose and frequency being requested, treatment plan d. List medications member has tried and failed, contraindications,

intolerance to Request for continuation therapy:


a. Dose and frequency being requested b. Member response to therapy with the requested medication

c. Date the therapy was started 3. Physician’s treatment plan

Botulinum Toxins A and

B to Treat Cervical Dystonia


• Dysport

(abobotulinumtoxinA) • Myobloc

(rimabotulinumtoxinB • Xeomin


J0585 J0586 J0587 J0588 Request for an initial therapy:


claim processing

3. Physician office notes that include: a. Diagnosis confirmed as cervical dystonia b. Documentation of the relevant symptoms, please include the following

i. Sustained head tilt or abnormal posturing resulting in pain or functional impairment

ii. Recurrent involuntary contraction of one or more muscles of the neck

4. Dose and frequency being requested, treatment plan


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Botulinum Toxins A and B to Treat Chronic Anal Fissure


• Dysport


J0585 J0586 Request for an initial therapy: 1. Current prescription 2. Name and tax ID number of the servicing provider/ facility to facilitate

claim processing


a. Diagnosis confirmed as chronic anal fissures b. Medications tried and failed, contraindications, intolerance previously

c. Documentation of relevant symptoms experienced and length of time Please include information about pain and bleeding

d. Dose and frequency being requested, treatment plan

Request for a continuation therapy: 1. New prescription 2. Physician office notes that include:

a. Dose and frequency being requested b. Physicians treatment plan c. Member response to therapy with the requested medication

d. Date the therapy was started 3. Physicians treatment plan 4. Name and tax ID number of the servicing provider/ facility if different from

the initial request

Botulinum Toxins A and B to Treat Detrusor

Overactivity

• Botox

(onabotulinumtoxinA) • Dysport


• Myobloc (rimabotulinumtoxinB)

J0585 J0586 J0587 Request for an initial therapy: 1. Current prescription



a. Diagnosis confirmed as detrusor overactivity or detrusor-sphincter dyssynergia due to spinal cord injury or disease;

b. Medications tried and failed, contraindications, intolerance for this

diagnosis c. Dose and frequency being requested, including the treatment plan

Botulinum Toxins A and B to Treat Migraine Headaches


J0585 Request for an initial therapy: 1. Current prescription 2. Name and tax ID number of the servicing provider/ facility to facilitate

claim processing

3. Physician office notes that include: a. Diagnosis confirmed as chronic migraines. Provide the number of

occurrences per month and length of time for each headache.

b. Medications tried and failed, contraindications, intolerance to the following therapeutic classes, include the length of time tried with any of the classes:

i. Antidepressant ii. Antiepileptic iii. Beta blocker

c. Dose and frequency being requested, including the treatment plan


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Botulinum Toxins A and B to Treat Overactive Bladder

• Botox

(onabotulinumtoxinA)

J0585 Request for an initial start 1. Current prescription 2. Name and tax ID number of the servicing provider/ facility to facilitate

claim processing


a. Diagnosis confirmed as overactive bladder b. Symptoms including the length of time experienced

c. Medications tried and failed, contraindications, intolerance d. Dose and frequency being requested, including the treatment plan

Breast Reconstruction Post Mastectomy

19324 19325 19330 19340 19342 19350 19355 19357 19361 19364 19366 19367 19368 19369 19380 19396 L8600

Note: These documentation requirements only apply when a Pre-Determination is requested. Mastectomy after a diagnosis of breast cancer does not require Prior Authorization/Advance Notification.

Medical notes documenting all of the following:

1. History of the medical condition(s) requiring treatment or surgical intervention

2. Physical exam

3. Relevant medical history

4. Relevant surgical history, including dates

5. Whether the surgery is for removal, replacement (of an implant), or revision of a previous surgery

6. Specific diagnostic image(s) that show the abnormality for which surgery is being requested. Consultation with requesting surgeon may be of benefit

to select the optimal images

Note: Diagnostic images must be labeled with:

a. The date taken

b. Applicable case number obtained at time of notification, or member's name and ID number on the image(s)

Submission of diagnostic imaging is required via the external portal at www.uhcprovider.com/paan or via email at [email protected]; faxes will not

be accepted

7. Diagnostic image(s) report(s)

8. Physicians plan of care

Breast Reduction Surgery

19318 Medical notes documenting all of the following: 1. History of the medical condition(s) requiring treatment or surgical

intervention and all of the following:

a. Chief complaint, history of the complaint and physical exam b. Previous evaluations and diagnostic tests results used to rule out

orthopedic, neurologic, rheumatologic, endocrine or metabolic causes

c. Member’s bra size, height, weight 2. Macromastia is the primary etiology of the member’s functional

impairments and etiology Note: With a diagnosis of macromastia, include high quality color

image(s). All image(s) must be labeled with the: a. Date taken and



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Submission of color image(s) are required and can be submitted via the external portal at www.uhcprovider.com/paan or via email at

[email protected]; faxes will not be accepted

3. Description of physiologic functional impairments (e.g., back pain, grooving from bras straps, skin breakdown, etc.)

4. Previous conservative measures, response and duration 5. Amount of breast tissue to be removed per breast 6. Reduction mammoplasty documentation should include:

a. The evaluation and management note for the date of service b. The note for the day the decision to perform surgery was made

Breast Repair/

Reconstruction Not Following Mastectomy


1. History of the medical condition(s) requiring treatment or surgical intervention

2. Chief complaint, history of the complaint and physical exam 3. Relevant medical-surgical history including dates 4. Specific diagnostic image(s) that show the abnormality for which surgery is

being requested Note: Diagnostic images must be labeled with: a. The date taken and


Submission of diagnostic image(s) is required via the external portal at

www.uhcprovider.com/paan or via email at [email protected]; faxes will not be

accepted 5. Diagnostic image(s) report(s) 6. Complications which necessitate the need for removal of the prosthetic

Note: For Capsular contracture include Baker grade and functional impairment

Brineura (cerliponase alfa)

J0567 Please provide medical notes documenting the following for an initial request: 1. Current prescription 2. Name and tax ID number of the servicing provider/facility to facilitate

claim processing

3. Patient age is 3 years or older 4. Physician office notes should include:

a. Diagnosis

b. If the drug is being prescribed by or in consultation with a neurologist with expertise in the diagnosis CLN2

c. Results of the clinical scoring for LINCL

d. Method of administration e. Dose and frequency being requested, including the treatment plan

Note: Initial authorization will be for no more than 6 months

Please provide medical notes documenting the following for a continuation request:


mailto:[email protected]



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1. In addition to the above, documentation patient has a score of 1 or higher in the motor domain of the Clinical Scoring System for LINCL4

2. Continuation authorization will be for no more than 6 months

Bronchial Thermoplasty 31660 31661 Please provide the following information: 1. Provider office notes with the following:

a. Documentation that member has been treated with Alair System in the

same area b. Documentation that member has been free from an active respiratory

infection, no change in systemic corticosteroids over the last 14 days

c. Documentation that member has no known coagulopathy d. List all medications tried, failed, contraindicated e. List sensitivity to all medications that are to be used in the procedure

Camptosar (irinotecan) for KS Community Plan members

J9206 Initial treatment request provide the following: 1. Current Prescription 2. Name and tax ID number of the servicing provider/ facility to facilitate


a. Documentation that drug is being prescribed or in consultation with an

oncologist / hematologist b. Drug dosage and frequency including the treatment plan c. List of all medications taken for condition with this drug

d. Results of Pregnancy Test and breast feeding status, if applicable Renewal request provide the following information: 1. Current Prescription



a. Documentation of positive clinical response to medication 4. Physicians treatment plan

Cardiac Catheterization With or Without Angiography

93452 93453 93454 93455 93456 93457 93458 93459 93460 93461

Current prescription Physician office notes that include:

a. Diagnosis, including suspected diagnosis, the necessity to evaluate a condition and treatment planning

b. Relevant history & physical, including history of cardiac trauma c. Reports of all recent imaging studies and applicable diagnostics (i.e.

EKG/ ECG)

d. Documentation of signs and symptoms; including onset, duration, and frequency

Cardiac Event Monitoring

33285 E0616 Medical notes documenting all the following: 1. Physician Order 2. Diagnosis 3. The member is high risk for arrhythmias

4. Holter monitor or other non-invasive cardiac monitoring are

contraindicated or non-revealing 5. Episodes of syncope, including test results, cardiac etiology and/or

unexplained episodes


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Cerezyme (imiglucerase)

NOTE: Also applies to KS

Community Plan

J1786 Please provide the following for an initial request 1. Current prescription 2. Name and tax ID number of the servicing provider/ facility to facilitate

claim processing


a. Member weight b. Member diagnosis (type 1 or type 3 of Gaucher’s disease)

c. Documentation of severity of symptoms d. Documentation of treatments tried, failed, contraindicated or intolerant

to VPRIV

e. Dose and frequency being requested, including the treatment plan 4. Location where the drug will be administered (e.g., infusion center,


Please provide the clinical for a continuation request 1. New prescription 2. Physician office notes that include:-

a. Member weight b. Member diagnosis ( type 1 or type 3 of Gaucher’s disease) c. Documentation and severity of symptoms being experience

d. Dose and frequency being requested e. Member response to therapy with the requested medication f. Follow-up member assessments pertinent to this request

3. Date the therapy was started


claim processing

Certified Nursing Assistant (CAN) or Home Health Aide for

Adults 21 and Older for Florida Community Plan

T1021 Please note that T1021 is subject to a Coverage Determination Guideline, which can be found at UHCprovider.com/policies > Community Plan Policies > Medical & Drug Policies and Coverage Determination Guidelines for Community

Plan > Certified Nursing Assistant (CNA) or Home Health Aide for Adults Age 21 and Older (For Florida Only). A written order, a plan of care, as well as a fully documented Letter of Medical

Necessity, including attestation of physical examination or medical consultation, are necessary.

The Letter of Medical Necessity form can be found at: uhc.provider.com / Health Plans by State / Florida / UnitedHealthcare Community Plan of Florida Homepage / Prior Authorization and Notification.

Please refer to the above Coverage Determination Guideline for complete requirements.

Chiropractic Services 98940 98941 98942 98943 1. Current prescription 2. Name and tax ID number of the servicing provider/ facility to facilitate

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b. Imaging reports c. Previous treatments rendered, dates of treatments and response d. Treatment plan

Cinqair® (reslizumab) J2786 For an initial request: 1. Current prescription

2. Medication name

3. Name and specialty of the prescribing and/ or consulting provider 4. Name and tax ID number of the servicing provider/ facility if different than


5. Physician office notes that include: a. Member’s diagnosis b. Provide results of the Asthma Control Questionnaire (ACO) or Asthma

Control Test (ACT) if available

c. Provide blood eosinophil level and date drawn (within the last 6 weeks) d. Provide results of the Forced Expiratory Volume (FEV1) e. Asthma related emergency treatment describe the treatment provided

and number of occurrences over the last 6 months f. Documentation of treatments tried, failed, contraindicated. Include the


g. Dose and frequency being requested, including the treatment plan h. List other medications member will be taking to treat the condition


a. If the location is in a facility, provide documentation to support facility administration

In addition to the above, for a continuation request provide the following: 1. Physician office notes that include:

a. Member response to therapy with the requested medication

b. Current utilization of ancillary medications c. Date the therapy was started

Clinical Trials All codes Provider should call the number on the member’s ID card when referring for any clinical trial.

Cochlear Implants & Other Auditory Implants

69930 L8614 L8618 L8619 Medical notes documenting all of the following:

Degree and frequencies of sensorineural hearing impairment

a. Effectiveness of hearing or vibrotactile aids previously tried b. Documentation indicating:

i. Absence from middle ear infection

ii. An accessible cochlear lumen that is structurally suited to implantation

iii. Freedom from lesions in the auditory nerve and acoustic areas of

the central nervous system c. Member’s cognitive ability to use auditory clues and a willingness to

undergo an extended program of rehabilitation

d. Proposed procedure(s) if any. Indicate whether this request is part of a

staged procedure


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e. Indicate the type of cochlear implant or other auditory implant including the name of the device

For replacement of any components please indicate date of implant, model and reason for replacement

Congenital Heart

Disease - Diagnostic and

Therapeutic Services

All codes For any diagnostic/ therapeutic services related to congenital

heart disease, provider should call the number on the member’s ID card when referring

Continuous Glucose

Monitoring (CGM)

A4226 A9276 A9277 A9278 E0787 E1399 K0553 K0554


1. Provide the member’s current Type of Diabetes(i.e., Type I, Type II or Gestational)

2. Lab results from the three (3) months

3. Provide the Last 3 months of member’s office notes and 4. Treatment plan 5. Current signed physician order 6. Provide the type of Make and Model of the device requested

7. If the request is to replace a device; provide the reason(s) why does the current device need replacement

Continuous Passive Motion (CPM) for Knee Surgery

E0935 1. Current prescription from physician

2. Surgical date and procedure

a. Documentation that supports the service start date within two (2) days

following surgery

3. Proposed duration of use

Continuous Positive Airway Pressure (CPAP)

E0601 Please provide the following for an initial request:

1. Current (within the last year) prescription from physician

2. Physician office notes that include face-to-face clinical evaluation prior to

the sleep test to assess for obstructive sleep apnea

3. Sleep study that includes apneal hypopnea index (AHI) (using a 4% decline in oxygen saturation definition of hypopnea) and clinical symptoms noted during the study

4. Documentation that appropriate instructions were provided on the use of

the device

Please provide the following for an continuation request:

1. Face-to-face clinical re-evaluation by the treating physician with

documentation of the clinical response to PAP therapy treatment trial 2. Objective evidence of adherence to use of the PAP device, reviewed by the

treating physician

To requalify for CPAP due to failed CPAP trial:

Date of failed CPAP trial period

Face-to-face clinical re-evaluation by the treating physician to determine the etiology of the failure to respond to PAP therapy

For Medicare only: Repeat sleep test in a facility-based setting (Type 1 study).This may be a repeat diagnostic, titration or split-night study


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Replacement CPAP

1. Age of the current device 2. Reason as to why the device needs to be replaced rather than repaired

3. If the device is five years or older, a face-to-face evaluation by the treating physician that documents that the member continues to use and benefit

from the PAP device

Cosmetic & Reconstructive

11960 14000 14001 14040 14041 17999 19316 19324 19325 21137 21138 21139 21172 21175 21179 21180 21181 21182

21183 21184 21208 21209 21230 21235 21248 21249 21255 21256 21260 21261 21263 21267 21268 21275 21295 21296

21299 28344 30540 30545 30560 30620 36468 67912 L8600 Q2026

Medical notes documenting all of the following: 1. History of medical conditions requiring treatment or surgical invention

which includes all of the following:

a. To prove medical necessity, a well-defined physical/physiologic abnormality resulting in a medical condition that requires treatment

b. Recurrent or persistent functional impairment caused by the

abnormality 2. Clinical studies/tests addressing the physical/physiologic abnormality

confirming its presence and degree to which it causes impairment 3. High-quality color image(s) of the physical/physiologic abnormality:

Note: All image(s) must be labeled with the: a. Date taken and b. Applicable case number obtained at time of notification, or member’s

name and ID number on the image(s) Submission of color image(s) are required and can be submitted via the external portal at www.uhcprovider.com/paan or via email at

[email protected]; faxes will not be accepted 4. Physician plan of care with proposed procedures and whether this request is

part of a staged procedure; indicate how the procedure will improve and/or restore function

Cough Stimulating Device

E0482 1. Current prescription from physician

2. Diagnosis

3. Physician office notes with clinical documentation of history and the Member’s current respiratory treatment program including frequency and duration of use for the requested

items

Crysvita® (burosumab-twza)



a. Member diagnosis and age

b. Genetic testing or Laboratory results of serum fibroblast growth factor 23 (FGF23), and serum phosphorus

c. Documentation of signs and symptoms

d. Dose, frequency, duration, including the physician treatment plan 4. Location where the drug will be administered (e.g., infusion center,


following:




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i. Medically unstable based on submitted clinical history ii. Initial medication infusion of or re-initiation after more than 6





available



Please provide the following for an continuation request: 1. Current prescription



a. Member diagnosis b. Documentation with member’s response to therapy, including recent

fracture history or reduced bone pain c. Growth curve

d. Laboratory results including updated serum phosphorus

e. Documentation of signs and symptoms f. Dose, frequency, duration, including the physician treatment plan

4. Location where the drug will be administered (e.g., infusion center, physician office, self-administered, home health nurse) a. If the location is in a facility, provide office notes for at least one of the

following: i. Medically unstable based on submitted clinical history ii. Initial medication infusion of or re-initiation after more than 6


iii. Previous experience of a severe adverse event following infusion Examples include but are not limited to anaphylaxis, seizure, thromboembolism, myocardial infarction, renal failure


v. Physically and/ or cognitively impaired AND no home caregiver

available vi. Difficulty establishing and maintaining patent vascular access vii. Homecare or infusion provider has deemed that the member,


infusion therapy


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Custom Ankle-Foot Orthoses (AFO) and Knee-Ankle-Foot Orthoses (KAFO)

L1904 L1920 L1932 L1951 L1960 L2000 L2005 L2010 L2020 L2030 L2034 L2036 L2037 L2038 L2040 L2126 L2128 L2136 L2232 L4631


1. Current prescription from physician 2. Physician office notes with the following

a. The reason for the orthotic

i. Diagnosis including diabetes

b. Physical exam related to support the need of the orthotic. Include the neurological, circulatory, skin and musculoskeletal examination that

supports the request c. Duration the condition is expected to persist d. Physician documentation indicating weakness or instability of the knee,

ankle or foot requiring support in more than one plane e. Physician office notes indicating a neurological, circulatory or

orthopedic condition(s) that supports the need for a custom orthotic f. Detailed documented clinical from the physician to support a custom

orthoses versus a prefabricated device g. Functional impairment that is interfering with activities of daily living

(meals, walking, getting dressed, driving)

h. Date and type of injury/ surgery, if applicable 3. Orthotist notes to include the following:

a. Equipment quote with billing codes and cost

b. Reason for the orthotic If a replacement: Please provide age of current orthotic and reason for replacement

Custom Knee Orthotic (KO)

L1810 L1820 L1832 L1834 L1843 L1844 L2387 L2800


1. Current prescription from physician 2. Physician office notes with the following:

a. The reason for the orthotic

b. Diagnosis c. Physical exam related to support the need of the orthotic Include the

neurological, circulatory, skin and musculoskeletal examination that

supports the request d. Documentation of deformity of the leg or knee e. Size of thigh and calf f. Sufficiency of muscle mass

g. Documentation that pediatric orthotics for small limbs or straps with additional length for large limbs have been ruled out

h. Functional impairment that is interfering with activities of daily living

(meals, walking, getting dressed, driving) i. Date and type of injury/ surgery, if applicable

3. Orthotist notes to include the following:

a. Equipment quote with billing codes and cost b. Reason for the orthotic

If a replacement: Please provide age of current orthotic and reason for

replacement


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Decompression Unspecified Nerves

64722 1. Physician office notes including:


b. History and physical by the attending/ treating Physician

c. Symptoms and functional impairment

d. Pertinent imaging studies

e. History and duration of unsuccessful conservative therapy, when applicable

Deep Brain and Cortical Stimulation

61863 61864 61867 61868 61885 61886 L8680 L8682 L8685 L8686 L8687 L8688

For stimulation used for Idiopathic Parkinson’s Disease, Essential Tremor and Primary Dystonia medical notes documenting all of the following: 1. Specify specific procedure (e.g., thalamic VIM, STN or GPI deep brain

stimulation) 2. Symptoms 3. Co-morbidities 4. Previous movement disorder surgery within the affected basal ganglion

5. For Thalamic VIM include: Fahn-Tolosa-Marin Clinical Tremor Rating Scale or equivalent scale

6. For STN or GPI include:

a. Hoehn and Yahr stage or b. Unified Parkinson’s Disease Rating Scale part III motor subscale:

i. L-dopa responsiveness

ii. Persistent disabling Parkinson symptoms despite optimal medical therapy

Denosumab (Prolia®) J0897 Please provide the following for an initial request:

Current prescription

Medication name Name and specialty of the prescribing and/ or consulting provider

Name and tax ID number of the servicing provider/ facility if different than prescribing/ consulting provider

Physician office notes that include:

a. Member weight b. Member diagnosis c. Documentation of treatments tried, failed, contraindicated. Include the



In addition to the above, please also provide the following for continuation: Documentation of positive response to the requested medication Date the therapy was started

Denosumab (Prolia®) for KS Community Plan

J0897 For KS Community Plan for treatment of bone loss provide the all the following:


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3. Physician office notes documenting a high risk of fractures

4. Physician office notes with either of the diagnoses:


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a. Diagnosis of non-metastatic prostate cancer AND is receiving androgen-deprivation therapy

b. Diagnosis of breast cancer AND is receiving adjuvant aromatase inhibitor therapy

5. Physician treatment plan

For KS Community Plan for treatment of osteoporosis provide the all the

following: 1. Current Prescription

a. Name and tax ID number of the servicing provider/ facility to facilitate

claim processing) b. Physician Office notes with the following: c. Diagnosis d. History of osteoporotic fracture

e. Provide risk factors for fracture f. Tried and failed other osteoporosis therapy; include the drug name,

dose and duration used


Denosumab (Xgeva®) J0897 Request for an initial start:

1. Current prescription 2. Physician office notes that include the following:

a. Drug dosage and frequency including physician’s treatment plan b. Associated orders for an infusion pump or a nebulizer needed to

administer the drug c. History of the medical condition requiring treatment including clinical

indications

d. If dose and/ or frequency are different from the FDA approved package insert, provide literature support for the specific schedule chosen

e. If the member is receiving this drug as part of a clinical trial, please

provide information about the clinical trial, including the clinical trial identifier

3. Documentation of how the drug will be supplied and who will administer the drug to the member (e.g., supplied by office/ facility, obtained by

member from either a pharmacy or OptumRx Specialty Pharmacy Program) NOTE: If drug is obtain by the member prior authorization may be

required through the member’s Part D benefits.

Elaprase (idursulfase) J1743 Please provide the following for an initial request:

Current prescription Medication name Name and specialty of the prescribing and/ or consulting provider



a. Member weight

b. Member diagnosis


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In addition to the above, please also provide the following for continuation: Documentation of positive response to the requested medication


Elaprase (idursulfase)

for KS Community Plan Members

J1743 Initial request provide the following:



a. Drug dosage and frequency including physicians treatment plan b. Weight c. Result of the 6-minute walk test

Continuation request provide the following: 1. Current Prescription


3. Physician office notes that include the following: a. Weight

b. Results of current 6-minute walk test

Electric Tumor

Treatment Therapy (TIFT)

77299 E0766 Treatment of newly diagnosis glioblastoma

1. Physician Order 2. Diagnosis 3. Physician notes to include the following

a. Documenting prior treatment with Radiation Therapy b. Provide results of the Karnofsky Performance Status (KPS) c. Documentation that the member is willing to wear the device for 18

hours d. Documentation that the member or caregiver has been trained and is

willing and able to apply the device daily e. Documentation that member is taking Temozolomide

Treatment of a reoccurrence of glioblastoma 1. Physician Order

2. Diagnosis 3. Physician notes to include the following:

a. Provide results of the Karnofsky Performance Status (KPS)

b. Documentation that drug is being used as a monotherapy i.e. completed initial chemotherapy

c. Documentation that the member is willing to wear the device for 18

hours

d. Documentation that the member or caregiver has been trained and is willing and able to apply the device daily


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Request to continue therapy 1. Results of MRI imaging 2- 4 months prior to the request to continue

therapy

2. Provide results of the Karnofsky Performance Status (KPS)

3. Documentation that the member is willing to wear the device for 18 hours

Electrical Stimulation Device for Treatment of Wounds

E0761 E0769 1. Current prescription from physician

2. Diagnosis

3. Physician office notes with:

a. Wound stage and size

b. Prior treatment duration and response c. Plan of treatment

Electroencephalographic

(EEG) Monitoring and Video Recording

95700 95711 95712 95713 95714 95715 95716 95718 95720 95722 95724 95726



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3. Physician office notes that include a. Member diagnosis b. History ( Physical with the following:

i. Results of resting EEG c. Prior seizure treatments, neuro imaging, medications d. Hospitalizations e. Seizure frequency and intensity

f. All medications the member is taking

g. All medications tried, failed and contraindicated, including names of the medicines and dates tried

h. Dose, frequency, and the physician treatment plan 4. Location where the service will be administered

a. If the location is in a facility provide office notes for at least one of the

following: i. Medically unstable based upon submitted clinical history ii. Previous experience of a severe adverse event iii. Continuing experience of adverse events that cannot be

mitigated by pre-medications iv. Physically and/ or cognitively impaired and no home caregiver

available

v. Homecare provider has deemed that the member, home caregiver, or home environment is not suitable for monitoring

Elelyso (taliglucerase) J3060 Request for an initial therapy: 1. Current prescription 2. Name and tax ID number of the servicing provider(facility to facilitate


a. Diagnosis confirmed as Type 1 Gaucher disease

b. Describe clinical signs and symptoms

c. Medication treatment tried and failed, contraindications, intolerance to medication named VPRIV


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d. Dose and frequency being requested, including the treatment plan e. List medications member will be taking to treat the condition


a. If the location is in a facility, provide office notes for at least one of the









Request for a continuation:

1. New prescription



a. Member response to therapy with the requested medication b. Date the therapy was started c. Dose and frequency being requested, including the treatment plan


following:



iii. Previous experience of a severe adverse event following infusion. Examples include but are not limited to anaphylaxis, seizure, thromboembolism, myocardial infarction, renal failure




vii. Homecare or infusion provider has deemed that the member, home caregiver, or home environment is not suitable for home

infusion therapy


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Empliciti (elotuzumab) for KS Community Plan Members

J9176 Initial treatment request provide the following: 1. Current Prescription 2. Name and tax ID number of the servicing provider/ facility to facilitate

claim processing


a. Diagnosis b. Documentation that drug is being prescribed or in consultation with an

oncologist/ hematologist c. Drug dosage and frequency including the treatment plan d. List of all medications taken with this drug

e. List of previous treatments tried, failed and contraindicated f. Results of Pregnancy Test and breast feeding status, if applicable

Continuation request provide the following information:


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3. Physician office notes that include the following: a. Documentation of positive clinical response to medication b. Results of Pregnancy Test and breast feeding status, if applicable

4. Physician’s treatment plan

Enbrel (etanercept)


Community Plan

J1438 Please provide the following: 1. Current Prescription



a. Documentation that the medication is prescribed or in consultation with a Rheumatologist, Gastroenterologist, Dermatologist, or Ophthalmologist

b. List of all medications taken with this medication c. List of all medication tried, failed, contraindicated for the condition

including dates and duration d. Result of tuberculosis test

4. Physicians Treatment Plan

Enteral Nutrition (Tube

Feedings)

B4102 B4103 B4104 B4149 B4150 B4152 B4153 B4155 B4158 B4159 B4160 B4161

B9000 B9002 B9004 B9006 B9998

1. Current prescription from physician

2. Office notes and clinical documentation that includes: a. The name of the formula b. The diagnosis for which the formula is being prescribed

c. The member's current height and weight d. Copy of a nutritional evaluation e. Documentation of the member’s daily dietary/ calorie intake

f. Documentation whether the formula is the member’s sole source of nutrition

g. Documentation that a feeding tube is in place and in use

3. If a pump is ordered, include the following documentation:

a. Justification as to why gravity feed is not satisfactory b. Rate of infusion


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Entyvio (vedolizumab) J3380 Please provide the following for an initial request: 1. Current prescription 2. Name and tax ID number of the servicing provider /facility to facilitate

claim processing




d. Dose and frequency being requested including treatment plan

e. List medications member will be taking to treat the condition 4. Location where the drug will be administered (e.g., infusion center,

physician office, self-administered, home health nurse) a. If the location is in a facility provide office notes for at least one of the


months following discontinuation of therapy iii. Previous experience of a severe adverse event following infusion.



mitigated by pre-medications or infusion rate adjustments v. Physically and/ or cognitively impaired and no home caregiver

available



Please provide the clinical for a continuation request: 1. New prescription 2. Name and tax ID number of the servicing provider/ facility to facilitate

claim processing



d. Dose and frequency being requested including treatment plan

e. List medications member will be taking to treat the condition f. Date the therapy was started g. Member response to therapy with the requested medication h. Follow-up member assessments pertinent to this request



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iii. Previous experience of a severe adverse event following infusion. Examples include but are not limited to anaphylaxis, seizure,






Erbitux (cefuximab) J9055 Please provide the following for an initial request: Current prescription Medication name


prescribing/ consulting provider Physician office notes that include:


c. Documentation of treatments tried, failed, contraindicated. Include the



Documentation of positive response to the requested medication Date the therapy was started

Evenity (romosozumab-aqqg)

J3111 Provide the following: 1. Current prescription



a. Diagnosis b. Results of Bone Mineral Density (BMD T-score) test c. Documentation with the history of fractures to the hip, distal radius,

proximal humerus, pelvis or vertebrae d. Results of the Fracture Risk Assessment Tool (FRAX) for one of the

following:

e. 10 yr fracture probability major osteoporotic fracture

f. 10 yr fracture probability hip fracture


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g. List of bisphosphonate medications (oral or Intravenous) tried, failed, contraindicated or intolerant to

h. Documentation that the member is not receiving Evenity in combination with any of the following:

i. Parathyroid hormone analogs (e.g., Forteo, Tymlos)

ii. RANK ligand inhibitors (e.g., Prolia, Xgeva); i. Physician Treatment Plan

Exondys 51™ (eteplirsen)

J1428 Please provide the following for an initial request: 1. Current prescription


3. Physician office notes that include: a. The drug is being prescribed by or in consultation with a neurologist

with expertise in diagnosis of Duchenne Muscular Dystrophy (DMD) b. Documentation and severity of symptoms being experience c. Results of 6-Minute Walk Time (6MWT)

d. Provide results of genetic testing to confirm mutation of DMD gene that is amenable to exon 51 skipping

e. Dose and frequency being requested

4. Location where the drug will be administered (e.g., infusion center, physician office, self-administered, home health nurse) a. If the location is in a facility provide office notes for at least one of the

following:

i. Medically unstable based upon submitted clinical history ii. Initial medication infusion of or re-initiation after more than 6







infusion therapy Request for continuation therapy:

1. New prescription 2. Name and tax ID number of the servicing provider/ facility to facilitate


4. The drug is being prescribed by or in consultation with a neurologist with

expertise in diagnosis of Duchenne Muscular Dystrophy (DMD) 5. Results of 6-Minute Walk Time (6MWT)

6. Dose and frequency being requested


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7. Member response to therapy with the requested medication 8. Location where the drug will be administered (e.g., infusion center,


following:








External and Implantable Pump

E0779 E0780 E0781 E0782 E0783 E0785 E0786 E0791 K0455

1. Physician office notes indicating condition requiring treatment.

2. Prescription, which includes name of drug, dosage, duration and frequency of infusion

3. State if the infusion will be intermittent or continuous

a. If intermittent, state how many hours for infusion of each dose

4. Reason for replacement, if applicable

External Insulin Pump A9274 A9276 A9277 A9278 E0784 1. Current prescription from physician

2. Physician office notes with clinical documentation of:

a. History of compliance with diabetic regimen b. Labs including recent A1C levels, C-Peptide with fasting blood sugar

level (obtained at the same time) or beta cell autoantibody

c. Number of daily finger sticks d. Current Insulin management regimen (e.g., number of injections, type

of insulin) e. History of Emergency Room or hospitalization within the last six (6)

months f. History of wide fluctuations in pre-prandial BG levels, hypoglycemia

unawareness, nocturnal hypoglycemia, or dawn phenomenon

g. A history of suboptimal glycemic control h. Completed comprehensive diabetes education program and is

demonstration of ability to follow an aggressive self-testing regimen

Is this for a replacement device? If yes, include:

Indicate age and make and model of current device, reason for

replacement rather than repair and warranty status a. Make and model of the device being requested


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b. Recent A1C levels

Extracorporeal Shock Wave Therapy

28890 Physician office notes describing: a. Length of time the member has been symptomatic b. Member response to conservative measures for at least the last two

months, including: i. Rest ii. Physical therapy

iii. Anti-inflammatory medications iv. Local corticosteroid injections v. Heel orthotics or forearm sleeve as applicable

c. Documentation that the member is not a candidate for surgical treatment

Eylea (aflibercept) J0178 Please include the following: 1. Current prescription 2. Physician office notes that include the following:

a. Physician’s orders with drug dosage and frequency

b. History of the medical condition requiring treatment, clinical indications including results of optical coherence tomography or fluorescein angiography where appropriate

c. If dose and/ or frequency are different from the FDA approved package insert, provide literature support for the specific schedule chosen


the drug to the member (e.g., supplied by office/ facility, obtained by member from either a pharmacy or OptumRx Specialty Pharmacy

Program)


Fabrazyme (agalsidase beta)



a. Member diagnosis b. Laboratory results or genetic testing to confirm diagnosis




following:






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infusion therapy



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3. Physician office notes that include: a. Documentation with member’s response to therapy b. Dose, frequency including the physician treatment plan


Factor IX

• AlphaNine® SD

[coagulation factor IX

(human)] • Bebulin® [factor IX

complex (human)]

• Mononine®

[coagulation factor IX (human)]

• Profilnine SD® [factor

IX complex human)] • BeneFIX® [coagulation

factor IX

(recombinant)] • Rixubis® [coagulation

factor IX (recombinant)]

• Alprolix® [coagulation factor IX (recombinant), Fc

fusion protein] • Idelvion® [coagulation

factor IX

(recombinant), albumin fusion protein]

J7193 J7194 J7200 J7201 J7202 1. Current Prescription


a. Members age,

b. Diagnosis of Hemophilia B

c. Method of administration (if the medicine is self-administered or administered by a caregiver)

d. Drug dosage and frequency being requested



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Factor IX - For Non-Medically Necessary Plans Only

• Ixinity® [coagulation

factor IX (recombinant)]

• Rebinyn® [coagulation factor IX (recombinant),

GlycoPEGylated]

J7195 J7203 1. Current Prescription


a. Members age, b. Diagnosis of Hemophilia B


d. Drug dosage and frequency being requested


Factor –Products J7175 J7178 J7179 J7180 J7181 J7182 J7183 J7185 J7186 J7187 J7188 J7189 J7190 J7191 J7192 J7193 J7194 J7195

J7198 J7199 J7200 J7201 J7202 J7205 J7207 J7210 J7211

1. Current Prescription 2. Physician office notes that include the following:

a. Physician’s orders with drug dosage and frequency b. History of the medical condition requiring treatment including clinical

indications

c. Physicians treatment plan

Factor –Products for KS

Community Plan

J7201 J7202 J7203 J7205 J7207 1. Current Prescription



a. Diagnosis b. Weight c. Physician’s orders with drug dosage and frequency

d. History of the medical condition requiring treatment including the

results of the pharmacokinetic assay test 4. Physicians treatment plan describing treatment for perioperative

treatment, on-demand treatment and/ or routine prophylaxis treatment

Factor VIII - For Non-Medically Necessary

Plans Only

• Adynovate®

[antihemophilic factor

(recombinant), PEGylated]

• Esperoct

(antihemophilic factor (recombinant), glycopegylated-exei)

• Helixate® FS [antihemophilic factor (recombinant)]

J7188 J7199 J7207 1. Current Prescription 2. Physician office notes that include the following:

a. Members age, b. Diagnosis of Hemophilia A c. Whether it is being used for routine prophylaxis, peri-operative

management of surgical bleed or treatment of bleeding episodes

d. Method of administration (if the medicine is self-administered or administered by a caregiver)

3. Drug dosage and frequency being requested


Factor VIII – Non-Preferred Products

J7170 J7185 J7186 J7188 J7199 J7205


a. Members age


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• Advate® [antihemophilic factor (recombinant)]

• Recombinate®


(recombinant)] • Xyntha®

[antihemophilic factor (recombinant)]

• Xyntha® Solofuse™

[antihemophilic factor (recombinant)]

• Afstyla® [antihemophilic factor

(recombinant)] • Eloctate®


(recombinant), Fc fusion protein]

• Jivi® [antihemophilic

factor (recombinant), PEGylated-aucl]

• Hemlibra® (emicizumab )

b. Diagnosis of Hemophilia A c. Whether it is being used for routine prophylaxis, peri-operative

management of surgical bleed or treatment of bleeding episodes d. History of failure, contraindication or intolerance to, or failure to meet

treatment goals on any of the preferred products (Kogenate® FS,

Kovaltry®, Novoeight®, Nuwiq®,) e. Method of administration (if the medicine is self-administered or

administered by a caregiver)

3. Drug dosage and frequency being requested 4. Physician’s treatment plan

Factor VIII – Preferred Products

• Hemofil M®


(human)] • Koāte®-DVI

[antihemophilic factor (human)]

• Monoclate-P® [antihemophilic factor (human)]

• Kogenate® FS [antihemophilic factor (recombinant)]

• Kovaltry® [antihemophilic factor (recombinant)]

• Novoeight®


(recombinant)]

J7182 J7188 J7190 J7192 J7207 1. Current Prescription 2. Physician office notes that include the following:

a. Members age b. Diagnosis of Hemophilia A c. Whether it is being used for routine prophylaxis, peri-operative

management of surgical bleed or treatment of bleeding episodes d. Method of administration (if the medicine is self-administered or

administered by a caregiver) 3. Drug dosage and frequency being requested



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• Nuwiq® [antihemophilic factor (recombinant)]

• Obizur®


(recombinant), porcine sequence]

Factor VIII (plasma-derived) / von

Willebrand Factor Complex (plasma-derived)

• Alphanate® [antihemophilic factor (human)]

• Humate-P® [antihemophilic factor (human)]

• Wilate® [antihemophilic factor (human)]


a. Members age, b. Diagnosis of severe or mild/moderate von Willebrand's disease c. For diagnosis of:

i. Severe von Willebrand's identify whether use is for peri-

operative management of surgical bleeds or for management of bleeding episodes

OR

ii. Mild to moderate von Willebrand's:

1) Confirm history of failure, contraindication or intolerance to treatment with Desmopressin

AND

2) Identify whether use is for peri-operative management of surgical bleeds or for management of bleeding episodes

Exception: If request is for Wilate failure, contraindication or

intolerance to treatment with Desmopressin not required




Factor X

• Coagadex®

[coagulation factor X (human)]

J7175 1. Current Prescription 2. Physician office notes that include the following:

a. Members age,

b. Method of administration (if the medicine is self-administered or administered by a caregiver)



Factor XIII

• Corifact® [factor XIII concentrate (human)]

• Tretten® [coagulation

factor XIII A-subunit (recombinant)]



a. Members age b. Diagnosis Factor XIII deficiency or Factor XIII A-subunit deficiency c. Whether it is being used for routine prophylaxis, perioperative

management of surgical bleed or treatment of bleeding episodes




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Fasenra (benralizumab) J0517 For an initial request: 1. Current prescription

2. Medication name


prescribing/ consulting provider 5. Physician office notes that include:

a. Member’s diagnosis b. Provide results of the Asthma Control Questionnaire (ACO) or Asthma

Control Test (ACT) if available c. Provide blood eosinophil level and date drawn (within the last 6 weeks) d. Provide results of the Forced Expiratory Volume (FEV1)

e. Asthma related emergency treatment describe the treatment provided and number of occurrences over the last 6 months

f. Documentation of treatments tried, failed, contraindicated. Include the

dates and reason for discontinuation g. Dose and frequency being requested, including the treatment plan h. List other medications member will be taking to treat the condition


physician office, self-administered, home health nurse) a. If the location is in a facility, provide documentation to support facility

administration


a. Member response to therapy with the requested medication b. Current utilization of ancillary medications c. Date the therapy was started

Femoroacetabular Impingement Syndrome (FAI)

29914 29915 29916 Medical notes documenting all of the following: 1. Proposed procedure 2. Condition requiring procedure

3. Associated co-morbidities 4. Medical/surgical therapies tried and failed 5. Member’s degree of pain and functional disability

6. Radiographic reports

Fibrinogen Concentrate (plasma-derived)

• RiaSTAP® [fibrinogen

concentrate (human)] • Fibryga® [fibrinogen

(human)]



a. Members age b. Diagnosis of congenital fibrin deficiency

c. Whether it is being used for routine prophylaxis, perioperative management of surgical bleed or treatment of bleeding episodes

d. Method of administration (if the medicine is self-administered or





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Fibryga (fibrinogen) J7177 Please provide the following for a request: 1. Current prescription 2. Name and tax ID number of the servicing provider/ facility to facilitate

claim processing


a. Diagnosis b. Reason for administration

c. Physician Plan of Care

Firazyr (icatibant)





a. Diagnosis b. Results of diagnostic testing


Flolan (epoprostenol) or

Veletri (epoprostenol powder)





a. Diagnosis b. Documentation that the medication is prescribed or in consultation with

a pulmonologist, cardiologist or specialized treatment center


Foot Surgery 28285 28289 28291 Provide physician office notes with the following: 1. Chief complaint 2. Description of the deformity

3. Physician Plan of Care

Foot Surgery – Bunion

surgery

28292 28296 28297 28298 28299 Provide physician office notes with the following:

Chief complaint and symptoms a. Description of the deformity b. Failed Non Operative therapy c. Physician Plan of Care

Functional Endoscopic Sinus Surgery (FESS)

31240 31253 31254 31255 31256 31257 31259 31267 31276 31287 31288

Medical notes documenting the following: 1. History of illness including symptoms and duration

2. Recent physical exam 3. Diagnosis 4. Medication(s) and therapy(ies) tried and failed

5. Recent CT scan images that show the abnormality for which surgery is being requested. Consultation with requesting surgeon may be of benefit to select the optimal images Note: CT images are required and must be labeled with:

a. The date taken


c. Whether the imaging was taken pre-or post-medical therapy


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CT images can be submitted via the external portal at www.uhcprovider.com/paan or via email at [email protected]; faxes will not be accepted

6. CT scan report

Gamifant (emapalumab-

lzsg)

J9210 For initial and continuation:


2. Name and tax ID number of the servicing provider/facility to facilitate claim processing

3. Submission of medical records (e.g., chart notes, laboratory values) confirming one the following:

a. Confirmation of a gene mutation known to cause primary HLH

b. Confirmation that five of the following clinical characteristics are present prior to treatment: i. Fever ≥ 101.3°F ii. Splenomegaly

iii. Two of the following cytopenias in the peripheral blood:

1) Hemoglobin <9 g/dL 2) Platelet count <100 x 109/L

3) Neutrophils <1 x 109/L

iv. One of the following:

1) Hypertriglyceridemia defined as fasting triglycerides ≥3

mmol/L or ≥265 mg/dL 2) Hypofibrinogenemia defined as fibrinogen ≤1.5 g/L

c. Hemophagocytosis in bone marrow or spleen or lymph nodes with no

evidence of malignancy

d. Low or absent natural killer cell activity (according to local laboratory reference)

e. Ferritin ≥ 500 mg/L

f. Soluble CD25 (i.e., soluble IL-2 receptor) ≥2,400 U/ml, and

4. Patient has refractory, recurrent or progressive disease or intolerance with conventional HLH therapy (i.e., etoposide + dexamethasone); and

5. Emapalumab will be administered with dexamethasone; and

6. Patient is a candidate for stem cell transplant; and

7. Approval is for no more than 6 months

Gastrointestinal Motility

Disorders, Diagnosis and Treatment

43647 43648 43881 43882 64590 64595 Medical notes documenting the following:

1. Diagnosis 2. Relevant history to include symptomatology 3. Physical findings

4. Results of diagnostic tests and imaging studies 5. Co-morbidities 6. Medical treatments tried, failed and contraindicated 7. Current physician treatment plan, if applicable

Gastrointestinal Pathogen Nucleic Acid

87505 87506 87507

Medical notes documenting all of the following: 1. Current diagnosis

2. History of illness and date of onset




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Detection Panel Testing For Infectious Diarrhea

3. Co-morbidities 4. Results of blood cultures and other lab tests 5. Number of pathogen targets being tested 6. Physician treatment plan based on the results of panel testing

Gender Dysphoria 11950 11951 11952 11954 11980 14000

14001 14020 14021 14041 14061 14302 15750 15757 15758 15775 15776 15777

15780 15781 15782 15783 15787 15788 15789 15792 15793 15819 15824 15825 15826 15828 15829 15832 15833 15834

15835 15836 15837 15838 15839 17380 19303 21083 21087 21120 21122 21172 21173 21270 21899 31599 31750 45399 45999 53410 53420 53425 53430 54125

54400 54401 54405 54408 54520 54660 54690 55175 55180 55866 55970 55980 56625 56800 56805 57106 57110 57291

57292 57295 57296 57335 57426 58260 58262 58290 58291 58661 58720 58940 58999 64856 64892 64896 69300 90285

92508 96372

1. Physician office notes describing:

a. The history of medical conditions requiring treatment or surgical intervention

b. A well-defined physical/ physiologic abnormality resulting in a medical

condition that requires treatment c. Recurrent or persistent functional deficit caused by the abnormality

2. Clinical studies/ tests addressing the physical/ physiologic abnormality confirming its presence and degree to which it causes impairment

3. Color photos, where applicable, of the physical and/ or physiological abnormality

4. Physician plan of care with proposed procedures and whether this request

is part of a staged procedure. Indicate how the procedure will improve and/ or restore function

For 58260, 58262, 58290 and 58291 codes provide the additional information:

1. Physician office notes describing: 2. The history of medical conditions requiring treatment or surgical

intervention 3. Physician plan of care with proposed procedures and whether this request

is part of a staged procedure 4. A written psychological assessment from at least two qualified behavioral

health providers experienced in treating gender dysphoria, who have

independently assessed the individual. The assessment should include all of the following: a. The member is capable to make a fully informed decision and to

consent for treatment b. The member must be at least 18 years of age (age of majority) c. If significant medical or mental health concerns are present, they must

be reasonably well controlled

d. The member has completed at least 12 months of successful continuous full-time real-life experience in the desired gender

e. The member has completed 12 months of continuous cross-sex

hormone therapy appropriate for the desired gender (unless medically contraindicated)

5. A treatment plan that includes ongoing follow-up and care by a qualified

behavioral health provider experienced in treating gender dysphoria

Genetics and Molecular Pathology Testing

(Including BRCA)

0004M 0006M 0007M 0001U 0012U 0013U 0014U 0016U 0017U 0018U 0022U 0023U 0026U 0027U 0028U 0030U 0031U 0032U

0033U 0034U 0068U 0070U 0071U 0072U 0073U 0074U 0075U 0076U 0084U 0087U 0088U 0097U 0101U 0102U 0103U 0111U

For all testing please include the name of the lab test being requested (e.g., BRCA 1 Targeted Analysis or Ovarian Tumor Profile)

For inherited conditions: Medical notes documenting all of the following:

1. Personal history of the condition, if applicable, including age at diagnosis


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0129U 0130U 0131U 0132U 0133U 0134U 0135U 0136U 0317U 0138U 0168U 0171U 81105 81106 81107 81108 81109 81110 81111 81120 81121 81161 81162 81163

81164 81165 81166 81167 81170 81171

81172 81173 81174 81175 81176 81177 81178 81179 81180 81181 81182 81183

81184 81185 81186 81187 81188 81189 81190 81200 81201 81202 81203 81204 81205 81206 81207 81208 81209 81210

81211 81212 81213 81214 81215 81216 81217 81218 81219 81220 81221 81222 81223 81224 81225 81226 81227 81228 81229 81230 81231 81232 81233 81234

81235 81236 81237 81238 81239 81240 81241 81242 81243 81244 81245 81246 81247 81248 81249 81250 81251 81252

81253 81254 81255 81256 81257 81258 81259 81260 81261 81262 81263 81264 81265 81266 81267 81268 81269 81270

81271 81272 81273 81274 81275 81276 81283 81284 81285 81286 81287 81288 81289 81290 81291 81292 81293 81294 81295 81296 81297 81298 81299 81300

81301 81302 81303 81304 81305 81306

81310 81311 81312 81313 81314 81315 81316 81317 81318 81319 81320 81321

81322 81323 81324 81325 81326 81327 81328 81329 81330 81331 81332 81333 81334 81335 81336 81340 81341 81342

81343 81344 81345 81346 81350 81355 81361 81362 81363 81364 81370 81371 81372 81373 81374 81375 81376 81377 81378 81379 81380 81381 81382 81383

81400 81401 81402 81403 81404 81405 81406 81407 81408 81410 81411 81412 81413 81414 81415 81416 81417 81420

81430 81431 81432 81433 81434 81435 81436 81437 81438 81439 81440 81442 81445 81448 81460 81465 81470 81471

81479 81507 81518 81519 81520 81521 81522 81545 81595 81599 87480 87481 87482 87510 87511 87512 87660 87661 87797 87798 87799 87800 87801

2. Complete family history (usually three-generation pedigree) relevant to condition being tested

3. Genetic testing results of family member, if applicable, and reason for testing

4. Ethnicity/ ancestry (e.g. Ashkenazi Jewish), if reason for testing

5. Any prior genetic testing results 6. How clinical management will be impacted based on results of genetic

testing 7. Genetic counseling (if available)

For Genitourinary Pathogen Acid Detection Panel Testing: Medical notes documenting all of the following: 1. Diagnosis 2. History of illness, including date of onset, and physical exam findings

3. Specific tests being ordered (e.g. test requisition form) To guide cancer treatment:

Medical notes documenting all of the following: 1. Cancer type and stage including, if applicable, tumor size and nodal status 2. Results of other biomarker testing (e.g. estrogen receptor, HER-2 neu), if

applicable 3. Proposed treatment based on results of genetic testing (if available) For Fetal Aneuploidy Testing:


1. Maternal age 2. History of prior pregnancy with a trisomy, if applicable

3. History of parental balanced Robertsonian translocation 4. Abnormal first- or second-trimester screening test result

For Pharmacogenetic Testing: Medical notes documenting all of the following: 1. Diagnosis 2. History of illness including treatments tried and failed

3. Number of genes being tested 4. Physician treatment plan based on the results of the genetic testing

Givlaari™ (givosiran) C9056 C9399 J3490 J3590 Please provide the following for an initial request: 1. Current prescription 2. Name and specialty of the prescribing and/ or consulting provider


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3. Name and tax ID number of the servicing provider/ facility if different than prescribing/ consulting provider

4. Physician office notes that include: a. Member weight

b. Member diagnosis

c. Member hemin administration requirement and/ or porphyria attack history including pretreatment baseline

d. Documentation of treatments tried, failed, contraindicated. Include the dates and reason for discontinuation

e. Dose and frequency being requested

In addition to the above, please also provide the following for continuation: 1. Documentation of positive response to the requested medication

Glassia (alpha1 -proteinase inhibitor)



a. Member diagnosis

b. Laboratory results of alpha1-antitrypsin (AAT) level and genetic testing to confirm diagnosis

c. Current Pulmonary function test results d. Documentation of signs and symptoms

e. List of medications being taken for this condition f. Documentation that member is a nonsmoker,

g. Dose, frequency including the physician treatment plan









infusion therapy




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3. Physician office notes that include: a. Documentation with member’s response to therapy

b. Dose, frequency including the physician treatment plan


Glatopa (glatiramer acetate)


J1595 Please provide the following: 1. Current Prescription 2. Name and tax ID number of the servicing provider/ facility to facilitate


a. Diagnosis b. Documentation that drug is being prescribed or in consultation with a

neurologist c. List of all medications being taken for this condition with this

medication

4. Physicians treatment plan including the dose, frequency and duration

Hearing Aids and

Devices Including Wearable, Bone-Anchored and Semi-

Implantable

69710 69714 69715 69717 69718 69799 L8690 L8691 L8692


1. What is being requested bone anchored, semi-implantable, implantable, etc.

2. Medical notes documenting all of the following:

3. Describe the type of hearing loss (sensorineural vs. conductive or mixed) 4. Severity and frequencies affected 5. Whether or not member is a candidate for an air-conduction hearing aid

For replacement of any components please indicate date of initial purchase and the reason for replacement

Hemlibra (emicizumab-kxwh)


a. Members age, diagnosis of Hemophilia A

b. Documentation related to the administration of the medicine. Include if the medicine is self-administered or provided by a responsible caregiver

c. Drug dosage and frequency being requested

d. History of the medical condition requiring treatment including clinical indications

e. Physicians treatment plan

f. If applicable, If being requested at a facility, validate that the facility is a registered Hemophilia clinic

g. Location where the drug will be administered (e.g., infusion center,

physician office, self-administered, home health nurse) 3. If the location is in a facility provide office notes for at least one of the

following: a. Medically unstable based upon submitted clinical history

i. Initial medication infusion of or re-initiation after more than 6 months following discontinuation of therapy


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ii. Previous experience of a severe adverse event following infusion Examples include but are not limited to anaphylaxis, seizure, thromboembolism, myocardial infarction, renal failure

iii. Continuing experience of adverse events that cannot be


iv. Physically and/ or cognitively impaired and no home caregiver available

v. Difficulty establishing and maintaining patent vascular access vi. Homecare or infusion provider has deemed that the member,


infusion therapy

Hemophilia clotting factor, not otherwise

classified


a. Members age b. Diagnosis c. Whether it is being used for routine prophylaxis, perioperative

management of surgical bleed or treatment of bleeding episodes d. Method of administration (if the medicine is self-administered or


e. Previous treatments tried or failed or intolerant

3. Drug dosage and frequency being requested 4. Physician’s treatment plan

Herceptin (trastuzumab) J9355 Please provide the following for an initial request: Current prescription

Medication name



Physician office notes that include: a. Member weight b. Member diagnosis






Herceptin (trastuzumab)

for KS Community Plan

J9355 For Community Plan Kansas members, please provide the following:



a. Documentation that drug is being prescribed or in consultation with an oncologist / hematologist

b. Results of HER-2 testing


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c. Result of ER/ PR test d. If ER/ PR result is negative then provide documentation of at least one

high risk features e. Drug dosage and frequency including the treatment plan

f. List of all medications for the condition taken with this drug

g. Results of Pregnancy Test and breast feeding status, if applicable

Continuation request: 1. Current Prescription 2. Name and tax ID number of the servicing provider/ facility to facilitate


a. Documentation of positive clinical response to medication b. Results of Pregnancy Test and breast feeding status, if applicable


High Frequency Chest

Wall Compression Devices

A7025 E0483 1. Current prescription from physician

2. Documentation of failed standard treatments to adequately mobilize retained secretions

3. Diagnosis

4. CT scan report confirming diagnosis of bronchiectasis if

applicable

5. Frequency of exacerbations requiring antibiotic therapy

6. Duration and frequency of productive cough

Home Health Care

Services

99503 G0151 G0152 G0153 G0154 G0155

G0156 G0157 G0158 G0159 G0163 G0164 G0299 G0300 G0493 G0494 G0495 G0496 S9122 S9123 S9124 S9127 S9128 S9129

S9131 S9474


Initial and subsequent requests:

1. Must include services requested (SN, PT/OT/ST, HHA, SW), number of

visits and weekly frequency, diagnosis codes, procedure codes, start date of care

2. Indicate the number of hours per visit for skilled nursing and home health

aide services

Initial Episode:

1. Physician order and completed 485 Plan of Care for period being requested

2. Current Skilled Nurse Assessment and or initial visit summary

Subsequent Episodes:

1. Current 485 (may be unsigned) or 485 draft

2. Signed 485 from the previous episode. This must be signed by physician

Note: The 485 is required if unable to provide at this time then submit the 60 day Skilled Nurse Summary to include the following:

a. Nursing summary needs to be current and related to ALL stated

diagnoses b. PT, OT, ST, SW evaluations and notes if applicable

c. Home Health Aide duties


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d. Vital Signs ranges, 02 Sats, glucose levels, PT/ INR levels, HCT/ HGB if receiving B12 injections

e. Medication changes, wound care with wound measurements, edema with description, weight gain/ weight loss

f. Member’s functional mobility

g. Caregiver must be identified i. Does caregiver participate in care of the member?

ii. Who lives with the member? Name and relationship iii. Who administers medications?

h. Recent inpatient or ER visits with dates and diagnosis

i. Discharge Plan

Home Health Care Services for KS

Community Plan

99600 99601 99602 G0156 G0299 G0300 S0315 S0316 S5181 S9128 S9129 S9131 S9460 T1002 T1003 T1004 T1021 T1023

T1030 T1031 T1502

A Face to Face evaluation is required. Please include the Members full name, Date of Birth and Member ID number on the Face to Face evaluation.

The document must include the Face to Face evaluation date and the ordering physician signature. Please provide a brief narrative describing the member’s clinical condition during the face to face visit to support that the member is

homebound and the need for skilled services within 90 days before the start of the service.

Hospital Beds Fixed Height:

E0250 E0251 E0270 E0290 E0291 E0328

Variable Height:

E0255 E0256 E0292 E0293

Semi Electric:

E0260 E0261 E0294 E0295 E0329

Total Electric:

E0265 E0266 E0296 E0297

Heavy Duty:

E0301 E0302 E0303 E0304

Pediatric:

E0300

Fixed Height /Heavy Duty /Pediatric:


2. Office notes with clinical documentation identifying:

a. The need for positioning of the body in ways not feasible with an ordinary bed; and/ or

b. The need for positioning of the body in ways not feasible with an

ordinary bed to alleviate pain; and/ or c. The need for the head of bed elevated more than 30 degrees and why;

and/ or d. The need for traction equipment e. Member Weight

Variable Height:



a. The need for positioning of the body in ways not feasible with an

ordinary bed; and/ or b. The need for positioning of the body in ways not feasible with an

ordinary bed to alleviate pain; and/ or

c. The need for the head of bed elevated more than 30 degrees and why; and/ or

d. The need for traction equipment

e. Member weight


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3. Explanation of requirement for height difference (to permit transfers to chair, wheelchair or standing position)

4. Current transfer and bed mobility skills

5. Current functional limitations with regards to activities of daily

living

Semi-Electric:



a. The need for positioning of the body in ways not feasible with an ordinary bed; and/ or

b. The need for positioning of the body in ways not feasible with an ordinary bed to alleviate pain; and/ or

c. The need for the head of bed elevated more than 30 degrees and why; and/ or

d. The need for traction equipment

e. Member weight

3. Rationale for requirement for frequent or immediate changes in body position

4. Susceptibility to ulcers, identify reasons

HP Acthar

(corticotropin)



claim processing


a. Member weight b. Member diagnosis and age c. Dose and frequency including taper plan being requested

d. List medications member will be taking to treat the condition 4. Physicians treatment plan 5. Location where the drug will be administered (e.g., infusion center,


Please provide the clinical for a continuation request: 1. New prescription

2. Physician office notes that include: a. Member weight b. Dose and frequency including taper plan being requested

c. Member response to therapy with the requested medication d. Date the therapy was started

3. List medications member will be taking to treat the condition


Hyperbaric Oxygen

Treatment

99183 C1300 1. An initial assessment and medical history detailing the condition requiring

Hyperbaric Oxygen Treatment (HBO) therapy and a physical exam.


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2. Medical history should list prior treatments including antibiotic therapy and surgical interventions

3. Documentation of current adjunctive treatment should include type of treatment, and the effectiveness of same

4. Physician progress notes and any communication between Physicians

detailing past or future proposed treatments 5. Established goals and Plan of Care for HBO therapy

6. Condition specific information such as: a. Documentation that the member has Type I or Type II diabetes and

a lower extremity wound due to diabetes

i. Wagner grade classification ii. Failed response to an adequate course of standard therapy iii. Documentation showing there has been no measurable signs of

healing for at least 30 days of treatment with standard wound

therapy b. Definitive radiographic findings or positive bone culture with sensitivity

studies to confirm the diagnosis of osteomyelitis, and documentation

of failed antibiotic therapy and surgical management c. History of radiation therapy, including date and anatomical site of

radiation therapy, with documentation of fracture or resorption of

bone, and radiographic studies, if available, to confirm the diagnosis of osteoradionecrosis;

d. History of radiation therapy and clinical photographs of the necrotic site will help support the medical necessity of HBO services for soft

tissue radionecrosis;

e. Documentation of radiographic and laboratory tests (e.g., positive Gram-stain smear or culture) that confirm the diagnosis of gas

gangrene is required; f. Documentation supporting a threatened loss of function, limb, or life; g. Surgical and pathology reports for treatment of necrotizing fasciitis

Hysterectomy Abdominal Hysterectomy:

58150 58152 58180

Laparoscopic Assisted Vaginal

Hysterectomy:

58550 58552 58553 58554

Laparoscopic Hysterectomy:

58541 58542 58543 58544 58570 58571 58572 58573

Vaginal Hysterectomy:

58260 58262 58263 58267 58270 58275

58280 58290 58291 58292 58293 58294


1. Primary indication for the hysterectomy 2. Physician office notes which includes the following:

a. Complete history including OB/ GYN, surgical and co-morbid medical condition(s)

b. Symptoms attributable to pelvic disease i. Duration ii. Severity

iii. Relation to menstrual cycle c. Reports of all relevant diagnostic evaluations

i. Laboratory

ii. Pathology iii. Imaging includes Ultrasound, MRI, CT etc. iv. Prior procedure/ operative reports

d. Reports of all attempted treatments (offered, attempted or declined),

including dates and clinical response


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e. Investigational procedures (e.g. endometrial sampling, PAP, laboratory studies, hysteroscopy or D&C within ACOG guidelines)

Ilaris (canakinumab) J0638 Please provide the following for an initial request:


claim processing


c. Member consult with a rheumatologist or immunologist d. Dose and frequency being requested including the treatment plan e. List medications member will be taking to treat the condition



following:






available



infusion therapy




a. Member weight b. Member diagnosis c. Member consult with a rheumatologist or immunologist

d. Dose and frequency being requested including a treatment plan e. List medications member will be taking to treat the condition f. Date the therapy was started g. Member response to therapy with the requested medication

h. Follow-up member assessments pertinent to this request



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Ilumya (tildrakizumab-Asmn)



a. Diagnosis b. Attestation that member is unable to self-administer and that there is

no competent caregiver to administer the drug that includes explanation

c. List of other medications that this member is currently using for this

diagnosis d. For plaque psoriasis, percent of body surface involvement including

description of areas involved

e. List of other medications that this member has tried for this diagnosis. Include dates of therapy and outcome of treatment

f. Dose and frequency being requested including the physicians treatment plan







available


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Please provide the following for a continuation request: 1. Current prescription



a. Documentation of response to Ilumya therapy b. Attestation that member is unable to self-administer and that there is

no competent caregiver to administer the drug that includes explanation

c. List of other medications that this member is currently using to treat this diagnosis

Imfinzi (durvalumab)


Community Plan

J9173 Please provide the following for an initial request: 1. Current Prescription 2. Name and tax ID number of the servicing provider/ facility to facilitate


a. Documentation that drug is being prescribed or in consultation with an oncologist / hematologist

b. Drug dosage and frequency including the treatment plan c. List of all medications for the condition taken with this drug including

previous trials of other treatment

d. Results of Pregnancy Test and breast feeding status, if applicable Please provide the following for an continuation request:



a. Documentation of positive clinical response to medication 4. Physician’s treatment plan

Immune Globulin (IVIG) for Asthma

• Bivigam™ (IV) • Carimune® NF (IV) • Cuvitru™ (SC)

• Flebogamma® DIF (IV) • Gammagard® Liquid

(IV, SC)

• Gammagard® S(D (IV)

• Gammaked™ (IV, SC) • Gammaplex® (IV)

J1459 J1555 J1556 J1557 J1559 J1561 J1562 J1566 J1568 J1569 J1572 J1575 J1599

Please provide the following for an initial request: 1. Current prescription 2. Name and tax ID number of the servicing provider/ facility

3. Physician office notes that include: a. Patient weight b. Patient diagnosis

c. Lab results to define immunoglobulin A (IgA) deficiency with anti-IgA antibodies including IgG levels

d. Dose and frequency being requested and treatment plan including

titration plan

e. Documentation of treatments tried, failed, contraindicated. Include the date range the medication was used and reason for discontinuation


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• Gamunex®-C (IV, SC) • Hizentra® (SC) • HyQvia® (SC) • Octagam® (IV)

• Privigen® (IV)

f. List of medications patient will be taking to treat the condition 4. Location where the drug will be administered (e.g., infusion center,

physician office, self-administered, home health nurse) a. If the drug will be administered in a facility include physician office

notes with the following:

i. Documentation that the service is an initial infusion of immune globulin, or re-initiation of therapy after more than 6 months off

of immune globulin ii. The service is a change of immune globulin products and the

patient is clinically unstable

iii. Documentation that the patient has a history of severe adverse events to immune globulin (including but not limited to anaphylaxis, seizure, thromboembolism, myocardial infarction, renal failure)

iv. Documentation that the patient has episodes of moderate to severe adverse events that have not been responsive to acetaminophen, steroids, diphenhydramine, fluids, infusion rate

reductions, or other therapy pre-medications, thereby increasing risk to the patient when administration is in the home or office setting

v. Outpatient treatment in the home or office setting presents a health risk due to a clinically significant physical or cognitive impairment

Immune Globulin (IVIG)

For Auto Immune Disease

• Bivigam™ (IV) • Carimune® NF (IV)

• Cuvitru™ (SC) • Flebogamma® DIF (IV) • Gammagard® Liquid

(IV, SC)

• Gammagard® S(D (IV) • Gammaked™ (IV, SC) • Gammaplex® (IV)

• Gamunex®-C (IV, SC) • Hizentra® (SC) • HyQvia® (SC)

• Octagam® (IV) • Privigen® (IV)

J1459 J1555 J1556 J1557 J1559 J1561

J1562 J1566 J1568 J1569 J1572 J1575 J1599

Please provide the following for an initial request: 1. Current prescription

2. Name and tax ID number of the servicing provider/ facility



d. Documentation of treatments tried, failed, contraindicated. Include the date range the medication was used and reason for discontinuation

e. Dose and frequency being requested and treatment plan f. List of medications patient will be taking to treat the condition




i. Documentation that the service is an initial infusion of immune globulin, or re-initiation of therapy after more than 6 months off of immune globulin

ii. The service is a change of immune globulin products and the


iii. Documentation that the patient has a history of severe adverse events to immune globulin (including but not limited to


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anaphylaxis, seizure, thromboembolism, myocardial infarction, renal failure)

iv. Documentation that the patient has episodes of moderate to severe adverse events that have not been responsive to

acetaminophen, steroids, diphenhydramine, fluids, infusion rate

reductions, or other therapy pre-medications, thereby increasing risk to the patient when administration is in the home or office

setting v. Outpatient treatment in the home or office setting presents a

health risk due to a clinically significant physical or cognitive

impairment

Immune Globulin (IVIG) for Bone Marrow

Transplant (BMT)

• Bivigam™ (IV)

• Carimune® NF (IV) • Cuvitru™ (SC) • Flebogamma® DIF (IV)

• Gammagard® Liquid (IV, SC)

• Gammagard® S(D (IV) • Gammaked™ (IV, SC)

• Gammaplex® (IV)

• Gamunex®-C (IV, SC) • Hizentra® (SC)

• HyQvia® (SC) • Octagam® (IV) • Privigen® (IV)

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2. Name and tax ID number of the servicing provider/ facility 3. Physician office notes that include:

a. Patient weight

b. Patient diagnosis c. Lab results to define immunoglobulin A (IgA) deficiency with anti-IgA

antibodies including IgG levels

d. Provide date of the Allogeneic Bone Marrow transplant e. Dose and frequency being requested and treatment plan f. List of medications patient will be taking to treat the condition





ii. The service is a change of immune globulin products and the patient is clinically unstable



iv. Documentation that the patient has episodes of moderate to

severe adverse events that have not been responsive to acetaminophen, steroids, diphenhydramine, fluids, infusion rate reductions, or other therapy pre-medications, thereby increasing

risk to the patient when administration is in the home or office setting

v. Outpatient treatment in the home or office setting presents a health risk due to a clinically significant physical or cognitive

impairment


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Immune Globulin (IVIG) for Chronic Lymphocytic Leukemia (CLL)



(IV, SC)

• Gammagard® S(D (IV) • Gammaked™ (IV, SC) • Gammaplex® (IV) • Gamunex®-C (IV, SC)

• Hizentra® (SC) • HyQvia® (SC) • Octagam® (IV)

• Privigen® (IV)

J1459 J1555 J1556 J1557 J1559 J1561 J1562 J1566 J1568 J1569 J1572 J1575 J1599

Please provide the following for an initial request: 1. Current prescription 2. Name and tax ID number of the servicing provider/ facility 3. Physician office notes that include:

a. Patient weight


antibodies including IgG levels d. Provide history of bacterial infections associated with B-cell CLL e. Documentation of medication treatments tried, failed, contraindicated.

Include the trial of systemic corticosteroids with the date range the medication was used and reason for discontinuation

f. Dose and frequency being requested and treatment plan g. List of medications patient will be taking to treat the condition

4. Location where the drug will be administered (e.g., infusion center, physician office, self-administered, home health nurse) a. If the drug will be administered in a facility include physician office

notes with the following: i. Documentation that the service is an initial infusion of immune

globulin, or re-initiation of therapy after more than 6 months off


patient is clinically unstable iii. Documentation that the patient has a history of severe adverse

events to immune globulin (including but not limited to




v. Outpatient treatment in the home or office setting presents a

health risk due to a clinically significant physical or cognitive impairment

Immune Globulin (IVIG) for Demyelinating Polyneuropathy


• Flebogamma® DIF (IV)



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3. Physician office notes that include: a. Patient weight b. Patient diagnosis c. Lab results to define immunoglobulin A (IgA) deficiency with anti-IgA


d. Provide results of Electrophysiologic testing; include the number of motor nerves impacted


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• Gammaked™ (IV, SC) • Gammaplex® (IV) • Gamunex®-C (IV, SC) • Hizentra® (SC)

• HyQvia® (SC)


e. Documentation describing severity of symptoms being experience and duration

f. Documentation of medication treatments tried, failed, contraindicated. Include the trial of systemic corticosteroids with the date range the

medication was used and reason for discontinuation

g. Dose and frequency being requested and treatment plan h. List of medications patient will be taking to treat the condition



globulin, or re-initiation of therapy after more than 6 months off of immune globulin


iii. Documentation that the patient has a history of severe adverse

events to immune globulin (including but not limited to anaphylaxis, seizure, thromboembolism, myocardial infarction, renal failure)

iv. Documentation that the patient has episodes of moderate to severe adverse events that have not been responsive to acetaminophen, steroids, diphenhydramine, fluids, infusion rate reductions, or other therapy pre-medications, thereby increasing

risk to the patient when administration is in the home or office



Immune Globulin (IVIG) for Dermatomyositis or Polymyositis



(IV, SC)

• Gammagard® S(D (IV) • Gammaked™ (IV, SC) • Gammaplex® (IV) • Gamunex®-C (IV, SC)

• Hizentra® (SC)

• HyQvia® (SC) • Octagam® (IV)

• Privigen® (IV)

J1459 J1555 J1556 J1557 J1559 J1561 J1562 J1566 J1568 J1569 J1572 J1575 J1599


a. Patient weight b. Patient diagnosis c. Lab results to define immunoglobulin A (IgA) deficiency with anti-IgA

antibodies including IgG levels d. Documentation of treatments tried, failed, contraindicated or

intolerance to. Include the date range the medication was used and

reason for discontinuation e. Dose and frequency being requested and treatment plan that includes

the titration plan f. List of medications patient will be taking to treat the condition





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severe adverse events that have not been responsive to acetaminophen, steroids, diphenhydramine, fluids, infusion rate reductions, or other therapy pre-medications, thereby increasing risk to the patient when administration is in the home or office



impairment


for Diabetes Mellitus


• Cuvitru™ (SC)


(IV, SC) • Gammagard® S(D (IV) • Gammaked™ (IV, SC)

• Gammaplex® (IV) • Gamunex®-C (IV, SC) • Hizentra® (SC) • HyQvia® (SC)


J1459 J1555 J1556 J1557 J1559 J1561 J1562 J1566 J1568 J1569 J1572 J1575

J1599

Please provide the following for an initial request:

1. Current prescription 2. Name and tax ID number of the servicing provider/ facility 3. Physician office notes that include:

a. Patient weight



d. Provide the date patient diagnosed as IDDM and documentation that the patient is not a candidate or refractory to insulin therapy

e. Documentation of medication treatments tried, failed, contraindicated

Include the date range the medication was used and reason for discontinuation










of 186



risk to the patient when administration is in the home or office



Immune Globulin (IVIG) for Fetomaternal Alloimmune Thrombocytopenia



(IV, SC) • Gammagard® S(D (IV) • Gammaked™ (IV, SC) • Gammaplex® (IV)

• Gamunex®-C (IV, SC)

• Hizentra® (SC) • HyQvia® (SC)


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a. Patient weight b. Patient diagnosis including a previous affected pregnancy, family

history and /or platelet alloantibodies found on screening

c. If the service is for a newborn include documentation that the patient has received a platelet transfusion

d. Lab results to define immunoglobulin A (IgA) deficiency with anti-IgA

antibodies including IgG levels e. Documentation of treatments tried, failed, contraindicated. Include the

date range the medication was used and reason for discontinuation f. Dose and frequency being requested and treatment plan

g. List of medications patient will be taking to treat the condition 4. Location where the drug will be administered (e.g., infusion center,


a. If the drug will be administered in a facility include physician office notes with the following: i. Documentation that the service is an initial infusion of immune



iii. Documentation that the patient has a history of severe adverse events to immune globulin (including but not limited to anaphylaxis, seizure, thromboembolism, myocardial infarction,

renal failure) iv. Documentation that the patient has episodes of moderate to

severe adverse events that have not been responsive to

acetaminophen, steroids, diphenhydramine, fluids, infusion rate reductions, or other therapy pre-medications, thereby increasing risk to the patient when administration is in the home or office setting




of 186


Immune Globulin (IVIG) for Guillain-Barré

• Bivigam™ (IV)






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a. Patient weight

b. Patient diagnosis c. Documentation describing the date of the onset of neuropathic

symptoms and functional limitations d. Lab results to define immunoglobulin A (IgA) deficiency with anti-IgA



f. Dose and frequency being requested and treatment plan including the taper plan

g. List of medications patient will be taking to treat the condition 4. Location where the drug will be administered (e.g., infusion center,






events to immune globulin (including but not limited to anaphylaxis, seizure, thromboembolism, myocardial infarction,





Immune Globulin (IVIG) for Immune

Thrombocytopenic Purpura (ITP)

• Bivigam™ (IV)

• Carimune® NF (IV)

• Cuvitru™ (SC) • Flebogamma® DIF (IV)

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a. Patient weight b. Patient diagnosis

c. Lab results to define immunoglobulin A (IgA) deficiency with anti-IgA



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d. Documentation of medication or surgical treatments tried, failed, contraindicated. Include the trial of systemic corticosteroids with the date range the medication was used and reason for discontinuation

e. Dose and frequency being requested and treatment plan

f. List of medications patient will be taking to treat the condition











Immune Globulin (IVIG) for Kawasaki Disease



(IV, SC)



• Privigen® (IV)

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d. Documentation of medication treatments tried, failed, contraindicated







of immune globulin


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anaphylaxis, seizure, thromboembolism, myocardial infarction,





impairment


for Lambert-Eaton Myasthenic Syndrome (LEMS)






• Privigen® (IV)

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J1599





d. Documentation of medication treatments tried, failed, contraindicated Include the date range the medication was used and reason for

discontinuation

e. Dose and frequency being requested and treatment plan include the taper plan










acetaminophen, steroids, diphenhydramine, fluids, infusion rate reductions, or other therapy pre-medications, thereby increasing


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impairment


for Lennox Gastrate

• Bivigam™ (IV)

• Carimune® NF (IV) • Cuvitru™ (SC) • Flebogamma® DIF (IV) • Gammagard® Liquid

(IV, SC) • Gammagard® S(D (IV) • Gammaked™ (IV, SC)

• Gammaplex® (IV) • Gamunex®-C (IV, SC) • Hizentra® (SC)


J1459 J1555 J1556 J1557 J1559 J1561 J1562 J1566 J1568 J1569 J1572 J1575

J1599





d. Documentation of treatments tried, failed, contraindicated include trials with seizure medicine. Include the date range the medication was used and reason for discontinuation

e. Dose and frequency being requested and treatment plan including the taper plan





of immune globulin









Immune Globulin (IVIG) for Multifocal Motor Neuropathy (MMN)


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(IV, SC)





c. Documentation describing severity of symptoms being experience and duration. Include asymmetric involvement and the number of nerves impacted

d. Lab results to define immunoglobulin A (IgA) deficiency with anti-IgA



f. Dose and frequency being requested and treatment and taper plan g. List of medications patient will be taking to treat the condition














impairment

Immune Globulin (IVIG) for Multiple Sclerosis






• Octagam® (IV)

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a. Patient weight

b. Patient diagnosis c. Documentation describing the symptoms and progression of the

member’s clinical status

d. Lab results to define immunoglobulin A (IgA) deficiency with anti-IgA antibodies including IgG levels

e. Documentation of at least two or more disease modifying medication treatments tried, failed, contraindicated. Include the date range the

medication was used and reason for discontinuation



of 186


• Privigen® (IV)



i. Documentation that the service is an initial infusion of immune











for Myasthenia Gravis

• Bivigam™ (IV)




• Gammaplex® (IV) • Gamunex®-C (IV, SC) • Hizentra® (SC)


J1459 J1555 J1556 J1557 J1559 J1561 J1562 J1566 J1568 J1569 J1572 J1575

J1599


1. Current prescription 2. Name and tax ID number of the servicing provider/ facility


a. Patient weight b. Patient diagnosis c. Documentation describing severity of symptoms experienced,

progression and duration d. Lab results to define immunoglobulin A (IgA) deficiency with anti-IgA

antibodies including IgG levels e. Documentation of treatments tried, failed, contraindicated. Include the

date range the medication was used and reason for discontinuation f. Dose and frequency being requested and treatment plan g. List of medications patient will be taking to treat the condition








of 186








impairment

Immune Globulin (IVIG) for Neuromyelitis Optica







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a. Patient weight



d. Documentation of two disease modifying medication treatments tried, failed, contraindicated. Include the date range the medication was used and reason for discontinuation














of 186


Immune Globulin (IVIG) for Pediatric HIV

• Bivigam™ (IV)







J1459 J1555 J1556 J1557 J1559 J1561 J1562 J1566 J1568 J1569 J1572 J1575 J1599


a. Patient weight and age


antibodies including IgG levels d. Lab results to support the functional antibody deficit with specific

antibody titers or recurrent bacterial infections














Immune Globulin (IVIG) for Post Transfusion Purpura





J1459 J1555 J1556 J1557 J1559 J1561 J1562 J1566 J1568 J1569 J1572 J1575 J1599

Please provide the following for all request: 1. Current prescription 2. Name and tax ID number of the servicing provider/ facility

3. Physician office notes that include: a. Patient weight b. Patient diagnosis c. Lab results to define immunoglobulin A (IgA) deficiency with anti-IgA


d. Documentation of treatments tried, failed, contraindicated. Include the date range the medication was used and reason for discontinuation



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• HyQvia® (SC)













for Primary Immunodeficiency



(IV, SC)




J1459 J1555 J1556 J1557 J1559 J1561

J1562 J1566 J1568 J1569 J1572 J1575 J1599



3. Physician office notes that include: a. Patient weight b. Patient diagnosis including history of recurrent infections

c. Documentation describing the failure to produce antibodies to specific antigens

d. Lab results to define immunoglobulin A (IgA) deficiency with anti-IgA antibodies including IgG levels


f. Dose and frequency being requested and treatment plan including the

titration plan g. List of medications patient will be taking to treat the condition








of 186




severe adverse events that have not been responsive to acetaminophen, steroids, diphenhydramine, fluids, infusion rate



Immune Globulin (IVIG) for Rasmussen Syndrome



(IV, SC)





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Please provide the following for all requests: 1. Current prescription 2. Name and tax ID number of the servicing provider/ facility




discontinuation e. Describe why IVIG therapy is the choice of treatment versus surgical

intervention













setting


of 186



Immune Globulin (IVIG) for Stiff Person

Syndrome



(IV, SC)




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J1599






discontinuation e. Dose and frequency being requested and treatment plan including the

taper plan











Immune Globulin (IVIG) for Thrombocytopenia Secondary to HCV

Infection

• Bivigam™ (IV)



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3. Physician office notes that include: a. Patient weight b. Patient diagnosis include if the patient is receiving concurrent antiviral

therapy



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d. Platelet count results drawn in the last 30 days e. Documentation of medication treatments tried, failed, contraindicated


f. Dose and frequency being requested and treatment plan











Immune Globulin (IVIG) Initial & Continuation



(IV, SC)



• Privigen® (IV)

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J1599





d. Dose and frequency being requested

e. List of medications member will be taking to treat the condition 4. Location where the drug will be administered (e.g., infusion center,




of immune globulin

ii. The service is a change of immune globulin products and the member is clinically unstable


of 186


iii. Documentation that the member has a history of severe adverse events to immune globulin (including but not limited to anaphylaxis, seizure, thromboembolism, myocardial infarction, renal failure)

iv. Documentation that the member has episodes of moderate to

severe adverse events that have not been responsive to acetaminophen, steroids, diphenhydramine, fluids, infusion rate

reductions, or other therapy pre-medications, thereby increasing risk to the member when administration is in the home or office setting

v. Treatment in the home or office setting presents a health risk due to a clinically significant physical or cognitive impairment

Please provide the following for a continuation request:

1. New prescription 2. Name and tax ID number of the servicing provider/ facility 3. Physician office notes that include:

a. Member weight b. Member diagnosis c. Lab results to define immunoglobulin A (IgA) deficiency with anti-IgA

antibodies including IgG levels d. Dose and frequency being requested e. Member response to therapy with the requested medication f. Date the therapy was started



notes with the following: i. Documentation that the service is a continuation of infusion of

immune globulin, or re-initiation of therapy after more than 6

months off of immune globulin ii. The service is a change of immune globulin products and the

member is clinically unstable iii. Documentation that the member has a history of severe adverse


iv. Documentation that the member has episodes of moderate to severe adverse events that have not been responsive to acetaminophen, steroids, diphenhydramine, fluids, infusion rate

reductions, or other therapy pre-medications, thereby increasing risk to the member when administration is in the home or office setting

v. Treatment in the home or office setting presents a health risk

due to a clinically significant physical or cognitive impairment


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Infertility 0058T 58321 58322 58323 58752 58760 58970 58974 58976 79648 89250 89251 89253 89254 89255 89257 89258 89259 89260 89261 89264 89268 89272 89280 89281 89290 89291 89335 89337 89342

89343 89344 89346 89352 89353 89354 89356 S4011 S4013 S4014 S4015 S4016 S4022 S4023 S4025 S4026 S4028 S4030

S4031 S4035 S4037

Physician office notes with the following:

1. Initial history and physical 2. All clinical notes including rationale for proposed treatment plan

3. All ovarian stimulation sheets for timed intercourse, IUI and/or IVF cycles 4. All embryology reports

5. All operative reports

6. Laboratory report FSH, AMH, estradiol and any other pertinent information 7. Ultrasound report antral follicle count and any other pertinent information 8. HSG report

9. Semen analysis

Inflectra (infliximab dyyb)

Q5103 Please provide the following for an initial request: 1. Current prescription 2. Name and tax ID number of the servicing provider/facility


c. Medication treatments tried, failed, contraindicated. Include the dates and reason for discontinuation

d. Dose and frequency being requested and treatment plan



following:








Please provide the clinical for a continuation request: 1. Documentation of positive response to the requested medication

Injection Anesthetic Agent Greater Occipital Nerve

64405 1. Physician office notes including:

a. History and physical findings b. Identification of the problem including diagnosis, precipitating events

c. Frequency, duration and intensity of pain d. Previous response to therapies e. Laboratory and other tests relevant to the service request


of 186


Intensity Modulated Radiation Therapy (IMRT)

77385 77386 G6015 G6016 Medical notes documenting all of the following: 1. Specific condition and target volume requiring IMRT 2. Specific history of prior radiation therapy. Information to include sites of

delivery, total dose and dose per fraction

3. A statement documenting the special need for performing IMRT vs

Conventional or 3-Dimensional radiation treatment. If failure of dose constraints, please cite the specific constraint, including protocol number, if

applicable. Please note, only Quantec or RTOG dose constraints are applicable

4. For hypofractionated radiation therapy provide the prescribed total dose

and dose per fraction 5. For delivery of a prescribed radiation therapy course with standard

fractionation, submit the dose prescription along with documentation in the form of a clearly labeled, color comparative 3D and IMRT dose volume

histogram and dose table, in absolute doses. When citing an RTOG dose constraint, provide the RTOG protocol number

6. An immediately adjacent area has been previously irradiated or will be

irradiated, and abutting portals must be established with high precision For IMRT used for breast cancer provide all of the above and answers to the

following: 1. Will the left-sided internal mammary nodes be treated? 2. Will the patient be receiving partial breast irradiation (when dose is at least

3Gy/fraction)?

3. What is the mid-tangential treatment separation measurement in

centimeters?

For IMRT used for uterine/ endometrial cancer, provide all of the above and answers to the following:

1. Has the member had total hysterectomy?

For IMRT used for rectal cancer, provide all of the above and answers to the following: 1. What is the measurement, in centimeters, from the distal aspect of the

rectal tumor to the anal verge?

Intravenous Iron

Replacement Therapy

• Feraheme®

(ferumoxytol) • INJECTAFER® (ferric

carboxymaltose injection)

J1439

Q0138

1. Current prescription, including dose and frequency being requested

2. Name and specialty of the prescribing and/or consulting provider 3. Name and tax ID number of the servicing provider/ facility if different

than prescribing/consulting provider

4. Medical notes that include: a. Member's weight b. Member's diagnosis c. Results of diagnostic test (s)laboratory values

d. Documentation of treatments tried, failed, contraindicated. Include the

dates and reason for discontinuation e. Physician attestation that in their clinical opinion, this treatment is

expected to have a more favorable clinical response the clinical


of 186


response would be expected to be superior, than prior failed treatments experienced with the other products

Intron A (interferon alfa

-2b) for KS Community Plan

J9214 1. Current Prescription



a. Diagnosis b. Documentation that drug is being prescribed or in consultation with an

oncologist


Jaw Motion

Rehabilitation System

E1700 E1701 E1702 Physician office notes containing:

a. Member history b. Previous treatments tried and results

Jetrea (ocriplasmin)



Current Prescription Name and tax ID number of the servicing provider/ facility to facilitate

claim processing

Physician office notes that include the following: a. Documentation that drug is being prescribed or in consultation with an

ophthalmologist

b. Documentation of symptoms of vitreomacular adhesion (VMA) c. Documentation of prior treatment in the same eye

Physicians Treatment Plan including if treatment is for bilateral VMA

Joint Replacement –

Ankle Arthroplasty

27700 27702 27703 1. Complete report(s) of diagnostic imaging (MRI, CT Scan, X-rays and Bone

Scan) 2. Current physician office notes indicating:

a. Condition requiring procedure b. Severity of pain and details of functional disability(ies) interfering with

activities of daily living (preparing meals, dressing, driving, walking)

c. Co-morbid medical condition(s) d. Pertinent physical examination of the relevant joint e. Physician’s treatment plan including pre-op discussion f. Therapies tried and failed of the following including dates:

i. Orthotics ii. Medications/ injections iii. Physical therapy

iv. Surgery v. Other pain management procedures

Additional Clinical Information Note: Device information is not utilized in prior authorization determinations.

Provide the following details on the device you intend to use during the procedure:

1. Specify which implant brand or manufacturer to be used:

a. Arthrex b. BioMet

c. Conformis


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d. Consensus e. DePuy Synthes f. DJO Surgical g. MicroPort

h. Smith & Nephew

i. Stryker j. Zimmer

k. Other (include name and reason for this selection) 2. Provide the fixation type from the following:

a. Cemented

b. Cemented with antibiotic impregnated c. Non-cemented d. Other (if another fixation type, then explain) e. Cannot identify fixation prior to procedure

Joint Replacement – Displaced Fracture of

Femoral Neck, Hemi-Arthroplasty


1. Specific diagnostic image(s) that show the abnormality for which surgery is being requested, which may include MRI, CT scan, X-ray, and/or bone scan; consultation with requesting surgeon may be of benefit to select the

optimal images Note: Diagnostic images must be labeled with: a. The date taken and

b. Applicable case number obtained at time of notification, or member's name and ID number on the image(s) Submission of diagnostic imaging is required via the external portal at

www.uhcprovider.com/paan or via email at [email protected]; faxes will

not be accepted 2. Diagnostic imaging report(s) 3. Condition requiring procedure

4. Severity of pain and details of functional disability(ies) interfering with activities of daily living (preparing meals, dressing, driving, walking) using a standard scale, such as the Western Ontario and McMaster Universities

Arthritis Index (WOMAC) or the Hip Dysfunction and Osteoarthritis Outcome Score (HOOS)

5. Physician’s treatment plan, including pre-op discussion 6. Pertinent physical examination of the relevant joint

7. Co-morbid medical conditions (cardiovascular diseases, hypertension, diabetes, cancer, pulmonary diseases, neurodegenerative diseases)

8. Therapies tried and failed of the following including dates:

a. Orthotics b. Medications/injections c. Physical therapy

d. Surgical e. Other pain management procedures

9. Documentation that more conservative measures have been considered

(e.g., osteotomy, hemiarthroplasty) or that the member has failed or is not

a candidate for more conservative measure (e.g., osteotomy, hemiarthroplasty)




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10. Date of failed previous hip fracture fixation, if applicable 11. If the location is being requested as an inpatient stay, provide medical

notes to support at least one of the following: a. Surgery is bilateral

b. Member has significant co-morbidities; include the list of comorbidities

and current treatment c. Member does not have appropriate resources to support post-operative

care after an outpatient procedure; include the barriers to care as an outpatient

For revision surgery, include documentation of the complication and complete (staged) surgical plan

Additional Clinical Information

Note: Device information is not utilized in prior authorization determinations


1. Specify which implant brand or manufacturer to be used a. Arthrex

b. BioMet c. Conformis d. Consensus e. DePuy Synthes

f. DJO Surgical g. MicroPort h. Smith & Nephew

i. Stryker j. Zimmer k. Other (include name and reason for this selection)

2. Provide the fixation type from the following: a. Cemented b. Cemented with antibiotic impregnated c. Non-cemented

d. Other (if another fixation type, then explain) e. Cannot identify fixation prior to procedure

Joint Replacement – Elbow Arthroplasty

24360 24361 24362 24363 24370 24371 Medical notes documenting all of the following: 1. Specific diagnostic image(s) that show the abnormality for which surgery is

being requested, which may include MRI, CT scan, X-ray and/or bone scan Consultation with requesting surgeon may be of benefit to select the

optimal images Note: Diagnostic images must be labeled with: a. The date taken b. Applicable case number obtained at time of notification, or member's

name and ID number on the image(s)


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Submission of diagnostic imaging is required via the external portal at www.uhcprovider.com/paan or via email at [email protected]; faxes will not be accepted

2. Diagnostic imaging report(s)

3. Condition requiring procedure (i.e., rheumatoid arthritis, osteoarthritis,

degenerative joint disease, post-traumatic arthritis, severe fractures) 4. Pertinent physical examination of the relevant joint

5. Pain severity, location of pain, and details of functional disability(ies) interfering with activities of daily living (preparing meals, dressing, driving)

6. Therapies tried and failed of the following, including dates:

a. Orthotics b. Medications/injections c. Physical therapy d. Surgery

e. Other pain management procedures f. Physician’s treatment plan, including pre-op discussion

For revision surgery, also include: Details of complication Complete (staged) surgical plan



Provide the following details on the device you intend to use during the

procedure:

1. Specify which implant brand or manufacturer to be used: a. Arthrex

b. BioMet c. Conformis d. Consensus

e. DePuy Synthes f. DJO Surgical g. MicroPort h. Smith & Nephew


2. Provide the fixation type from the following: a. Cemented b. Cemented with antibiotic impregnated

c. Non-cemented d. Other (if another fixation type, then explain) e. Cannot identify fixation prior to procedure

Joint Replacement – Hip

Acetabuloplasty and Displaced Fracture of


1. Specific diagnostic image(s) that show the abnormality for which surgery is

being requested, which may include MRI, CT scan, X-ray and/or bone scan



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Femoral Neck, Hemi-Arthroplasty

Consultation with requesting surgeon may be of benefit to select the optimal images Note: Diagnostic images must be labeled with: a. The date taken and

b. Applicable case number obtained at time of notification, or member's

name and ID number on the image(s) Submission of diagnostic imaging is required via the external portal at



3. Condition requiring procedure 4. Severity of pain and details of functional disability(ies) interfering with

activities of daily living (preparing meals, dressing, driving, walking) using a standard scale, such as the Western Ontario and McMaster Universities

Arthritis Index (WOMAC) or the Hip Dysfunction and Osteoarthritis Outcome Score (HOOS)

5. Physician’s treatment plan including pre-op discussion

6. Pertinent physical examination of the relevant joint 7. Co-morbid medical conditions 8. Therapies tried and failed of the following, including dates:

a. Orthotics b. Medications/injections c. Physical therapy d. Surgery

e. Other pain management procedures

9. If the location is being requested as an inpatient stay, provide medical notes to support at least one of the following:

a. Surgery is bilateral b. Member has significant co-morbidities; include the list of comorbidities

and current treatment

c. Member does not have appropriate resources to support post-operative care after an outpatient procedure; include the barriers to care as an outpatient




10. Specify which implant brand or manufacturer to be used

a. Arthrex b. BioMet c. Conformis d. Consensus

e. DePuy Synthes

f. DJO Surgical g. MicroPort

h. Smith & Nephew



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11. Provide the fixation type from the following:

a. Cemented

b. Cemented with antibiotic impregnated c. Non-cemented


Joint Replacement – Hip Arthroplasty



being requested, which may include MRI, CT scan, X-ray, and/or bone scan; consultation with requesting surgeon may be of benefit to select the optimal images Note: Diagnostic images must be labeled with:

a. The date taken and b. Applicable case number obtained at time of notification, or member's



2. Diagnostic imaging report(s) 3. Condition requiring procedure 4. Severity of pain and details of functional disability(ies) interfering with

activities of daily living (preparing meals, dressing, driving, walking) using

a standard scale, such as the Western Ontario and McMaster Universities Arthritis Index (WOMAC) or the Hip Dysfunction and Osteoarthritis Outcome Score (HOOS)

5. Physician’s treatment plan, including pre-op discussion 6. Pertinent physical examination of the relevant joint 7. Co-morbid medical conditions (cardiovascular diseases, hypertension,

diabetes, cancer, pulmonary diseases, neurodegenerative diseases) 8. Therapies tried and failed of the following including dates:

a. Orthotics b. Medications/injections

c. Physical therapy d. Surgical e. Other pain management procedures

9. Documentation that more conservative measures have been considered (e.g., osteotomy, hemiarthroplasty) or that the member has failed or is not a candidate for more conservative measure (e.g., osteotomy,

hemiarthroplasty) 10. Date of failed previous hip fracture fixation, if applicable 11. If the location is being requested as an inpatient stay, provide medical

notes to support at least one of the following:

a. Surgery is bilateral




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b. Member has significant co-morbidities; include the list of comorbidities and current treatment

c. Member does not have appropriate resources to support post-operative care after an outpatient procedure; include the barriers to care as an

outpatient

For revision surgery, include documentation of the complication and complete

(staged) surgical plan Additional Clinical Information

Note: Device information is not utilized in prior authorization determinations.


procedure:

1. Specify which implant brand or manufacturer to be used a. Arthrex b. BioMet

c. Conformis d. Consensus e. DePuy Synthes

f. DJO Surgical g. MicroPort h. Smith & Nephew i. Stryker

j. Zimmer k. Other (include name and reason for this selection)


a. Cemented b. Cemented with antibiotic impregnated c. Non-cemented



Knee Arthroplasty or Arthroplasty Revision


1. Specific diagnostic image(s) that show the abnormality for which surgery is being requested, which may include MRI, CT scan, X-ray and/or bone scan.

Consultation with requesting surgeon may be of benefit to select the optimal images Note: Diagnostic image(s) must be labeled with:

a. The date taken b. Applicable case number obtained at time of notification, or member's


Submission of diagnostic image(s) is required via the external portal at www.uhcprovider.com/paan or via email at [email protected]; faxes will not be accepted


3. Condition requiring procedure



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4. Severity of pain and details of functional disability(ies) interfering with activities of daily living (preparing meals, dressing, driving, walking) according to one of the following standard scales a. The Western Ontario and McMaster Universities Arthritis Index

(WOMAC)[citation: PMID: 3068365] OR

b. The Knee injury and Osteoarthritis Outcome Score (KOOS)[citation: PMID: 9699158]

5. Physician’s treatment plan including pre-op discussion 6. Pertinent physical examination of the relevant joint 7. Co-morbid medical condition(s)

8. Therapies tried and failed of the following including dates: a. Orthotics b. Medications/injections c. Physical therapy

d. Surgical e. Other pain management procedures

9. Date of failed previous surgery to the same joint (proximal tibial or distal

femoral osteotomy, if applicable) 10. For revision surgery, include documentation of the complication and the

complete (staged) surgical plan

11. For CPT codes 27446 and 27447; if the location is being requested as an inpatient stay, provide medical notes to support at least one of the following: a. Surgery is bilateral

b. Member has significant co-morbidities; include the list of comorbidities

and current treatment c. Member does not have appropriate resources to support post-

operative care after an outpatient procedure; include the barriers to care as an outpatient




procedure:

12. Specify which implant brand or manufacturer to be used: a. Arthrex b. BioMet

c. Conformis d. Consensus e. DePuy Synthes

f. DJO Surgical g. MicroPort h. Smith & Nephew i. Stryker

j. Zimmer k. Other (include name and reason for this selection)



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a. Cemented b. Cemented with antibiotic impregnated c. Non-cemented d. Other (if another fixation type, then explain)

e. Cannot identify fixation prior to procedure


Shoulder Arthroplasty, Arthroplasty Revision


1. Specific diagnostic image(s) that show the abnormality for which surgery is being requested, which may include MRI, CT scan, X-ray and/or bone scan. Consultation with requesting surgeon may be of benefit to select the

optimal images Note: Diagnostic images must be labeled with: a. The date taken b. Applicable case number obtained at time of notification, or member's

name and ID number on the image(s) Submission of diagnostic imaging is required via the external portal at www.uhcprovider.com/paan or via email at [email protected]; faxes will not

be accepted 2. Diagnostic imaging report(s) 3. Condition requiring procedure

4. Severity of pain and details of functional disability(ies) interfering with activities of daily living (preparing meals, dressing, driving, walking)

5. Physician’s treatment plan including pre-op discussion 6. Pertinent physical examination of the relevant joint

7. Co-morbid medical condition(s) 8. Therapies tried and failed for the following including dates:

a. Orthotics

b. Medications/injections c. Physical therapy d. Surgical

e. Other pain management procedures 9. If the location is being requested as an inpatient stay, provide medical

notes to support at least one of the following: a. Surgery is bilateral


c. Member does not have appropriate resources to support post-operative

care after an outpatient procedure; include the barriers to care as an outpatient

For revision surgery, include documentation of the complication and complete (staged) surgical plan



1. Provide the following details on the device you intend to use during the procedure:




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e. DePuy Synthes

f. DJO Surgical g. MicroPort

h. Smith & Nephew i. Stryker j. Zimmer


a. Cemented b. Cemented with antibiotic impregnated


Joint Replacement – Shoulder Hemi-

Arthroplasty


1. Specific diagnostic image(s) that show the abnormality for which surgery is being requested, which may include MRI, CT scan, X-ray and/or bone scan. Consultation with requesting surgeon may be of benefit to select the

optimal images a. Diagnostic images must be labeled with:

i. The date taken

ii. Applicable case number obtained at time of notification, or

member's name and ID number on the image(s) Note: Submission of diagnostic imaging is required via the external portal at www.uhcprovider.com/paan or via email at [email protected];

faxes will not be accepted 2. Diagnostic imaging report(s) 3. Condition requiring procedure

4. Co-morbid medical condition(s) 5. Severity of pain and details of functional disability(ies) interfering with

activities of daily living (preparing meals, dressing, driving, walking) 6. Physician’s treatment plan, including pre-op discussion

7. Pertinent physical examination of the relevant joint 8. Therapies tried and failed for the following including dates:

a. Orthotics

b. Medications/injections c. Physical therapy d. Surgery

e. Other pain management procedures 9. Document the member has the ability to participate in post-surgical rehab 10. If the location is being requested as an inpatient stay, provide office notes

to support at least one of the following:

a. Surgery is bilateral



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c. Member does not have appropriate resources to support post-operative care after an outpatient procedure; include the barriers to care as an

outpatient



1. Provide the following details on the device you intend to use during the procedure:



e. DePuy Synthes f. DJO Surgical g. MicroPort

h. Smith & Nephew i. Stryker j. Zimmer


a. Cemented b. Cemented with antibiotic impregnated


Kalbitor (ecallantide)


J1290 Please provide the following: 1. Current Prescription



b. Results of diagnostic testing 4. Physicians Treatment Plan including who will be administering the

medication

Kanuma (sebelipase alfa)




b. Laboratory results or genetic testing to confirm diagnosis



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following:

i. Medically unstable based on submitted clinical history







infusion therapy





Kanuma (sebelipase alfa) for KS Community

Plan

J2840 For Kansas Community Plan members, provide the following: 1. Current Prescription



b. Documentation that drug is being prescribed by a neonatologist, geneticist, gastroenterologist, endocrinologist, lipidologist, or hepatologist

4. Physicians Treatment Plan including who will be administering the medication

Keytruda (pembrolizumab) for KS Community Plan

J9271 For Community Plan Kansas members, please provide the following: 1. Current Prescription 2. Name and tax ID number of the servicing provider/ facility to facilitate


a. Documentation that drug is being prescribed or in consultation with an

oncologist/ hematologist

b. Drug dosage and frequency including the treatment plan


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c. List of all medications for the condition taken with this drug include prior treatment tried, failed and contraindicated

d. Results of Pregnancy Test and breast feeding status, if applicable 4. Provide documentation that Keytruda to be administered for one of the

following:

a. Unresectable or metastatic melanoma b. Metastatic non-small cell lung cancer (NSCLC), include results of PD-L1

testing c. Metastatic non-small cell lung cancer (NSCLC), provide the following:

i. Results of PD-L1 testing

ii. Documentation that platinum containing chemotherapy has been given include dates

iii. Evidence of disease progression d. Metastatic non-squamous (NSCLC), include documentation member is

being given pemetrexed and carboplatinum e. Recurrent or metastatic head and neck squamous cell cancer, include

documentation member is being treated with platinum containing

chemotherapy and has disease progression f. Refractory classical Hodgkin’s Lymphoma or relapse after having

received 3 lines of therapy

g. Refractory primary mediastinal large B-cell lymphoma or relapse after having received 2 lines of therapy

h. Locally advanced or metastatic urothelial carcinoma, include results of PD-L1 testing and documentation member is not eligible for cisplatin

containing chemotherapy

i. Locally advanced or metastatic urothelial carcinoma, include documentation on disease progression while on platinum containing

chemotherapy or within 12 months of neoadjuvant / adjuvant treatment with platinum containing chemotherapy

j. Unresectable or metastatic, microsatellite instability-high or mismatch

repair deficient solid tumors that have progressed following prior treatment with no satisfactory alternative treatment options OR colorectal cancer that has progressed following treatment with a fluoropyrimidine, oxaliplatin and irinotecan

k. Recurrent locally advanced or metastatic gastric or gastroesophageal junction adenocarcinoma, include results of PD-L1 testing and documentation of disease progression after two lines of therapy

including fluoropyrimidine- and platinum-containing chemotherapy and if appropriate, HER2/ neu-targeted therapy

l. Recurrent or metastatic cervical cancer, include results of PD-L1

testing and documentation of disease progression on or after chemotherapy

m. Unresectable or metastatic, microsatellite instability-high or mismatch repair deficient solid tumors that have progressed following prior

treatment with no satisfactory alternative treatment options OR colorectal cancer that has progressed following treatment with a fluoropyrimidine, oxaliplatin and irinotecan


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n. Recurrent locally advanced or metastatic gastric or gastroesophageal junction adenocarcinoma, include results of PD-L1 testing and documentation of disease progression after two lines of therapy including fluoropyrimidine- and platinum-containing chemotherapy and

if appropriate, HER2/ neu-targeted therapy

o. Recurrent or metastatic cervical cancer, include results of PD-L1 testing and documentation of disease progression on or after

chemotherapy

Krystexxa (pegloticase)





a. Documentation of signs and symptoms b. List of all medications tried, failed or contraindicated to normalize

serum uric acid

c. Documentation of any prior adverse reactions 4. Physicians Treatment Plan

Kymriah (tisagenlecleucel) for All Plans Except KS

Community Plan

Q2040 Q2042 For all other Plans: Coverage reviews for CAR-T therapy are managed by Optum Transplant Resource Services through the same process as the transplant of tissue or

organs. Care providers will be required to contract with Optum Transplant Resource Services in order to receive prior authorization and bill for CAR-T therapy. Care Providers can contact Optum Transplant Resource Services at 1-888-936-7246.

Kymriah (tisagenlecleucel) for KS

Community Plan

Q2040 Q2042 For KS Community Plan please provide the following:


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For treatment of Acute Lymphoblastic Leukemia (ALL) provide Physician office notes that include:

1. Member diagnosis 2. Treatment is being prescribed by or in consultation with a hematologist or

oncologist

3. Results of CD19 testing 4. Medication treatments tried, failed, contraindicated. Include the dates and

reason for discontinuation

5. Dose and frequency being requested and treatment plan 6. List medications patient will be taking to treat the condition including of

member has received CAR-T therapy

For treatment of Relapsed or Refractory Diffuse Large B-Cell Lymphoma (DLBCL) provide Physician Office notes that include:

1. Member diagnosis

2. Treatment is being prescribed by or in consultation with a hematologist or oncologist


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3. Results of CD19 testing 4. Medication treatments tried, failed, contraindicated. Include the dates and

reason for discontinuation 5. Dose and frequency being requested and treatment plan

6. List medications patient will be taking to treat the condition including of

member has received CAR-T therapy 7. Location where the drug will be administered (e.g., infusion center,


Lemtrada

(alemtuzumab)




a. Member weight b. Member diagnosis c. Documentation and severity of symptoms being experience

d. Documentation of treatments tried, failed, contraindicated Include the date range the medication was used and reason for discontinuation

e. Documentation of past treatments with the drug being requested

f. Dose and frequency being requested include if the member will be receiving the drug in combination with another disease modifying agent



following:






available



infusion therapy

Please provide the clinical information for a continuation request: 1. New prescription




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c. Dose and frequency being requested, include if the member will be receiving the drug in combination with another disease modifying agent

d. Date the therapy was started


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Lower Extremity Angiography – Unilateral or Bilateral

75710 75716 Medical notes documenting the following: 1. Signs and symptoms of arterial disease 2. Results of Ankle Brachial Index (ABI)

3. Results of all imaging (CT, MRA, Doppler Ultrasound) 4. Functional Impairment(s) including a list of Activities of Daily Living (ADLs)

that are impaired 5. Any previous vascular history (i.e., treatments, diagnosis, surgery

(including the location) 6. Physician treatment plan

Lucentis (ranibizumab) J2778 Please include the following: 1. Current prescription 2. Physician office notes that include the following:

a. Drug dosage and frequency including physician’s treatment plan b. History of the medical condition requiring treatment, clinical indications

including results of optical coherence tomography or fluorescein

angiography where appropriate c. If dose and/or frequency are different from the FDA approved package

insert, provide literature support for the specific schedule chosen 3. Documentation of how the drug will be supplied and who will administer

the drug to the member (e.g., supplied by office/ facility, obtained by member from either a pharmacy or OptumRx Specialty Pharmacy Program)


Lumizyme or Myozyme (alglucosidase alfa)

J0221 Please include the following: 1. Current prescription 2. Physician office notes that include the following:

a. Drug dosage and frequency including physician’s treatment plan

b. Associated orders for an infusion pump or a nebulizer needed to administer the drug

c. History of the medical condition requiring treatment including clinical

indications d. If dose and/ or frequency are different from the FDA approved package

insert, provide literature support for the specific schedule chosen

e. If the member is receiving this drug as part of a clinical trial, please provide information about the clinical trial, including the clinical trial identifier


the drug to the member (e.g., supplied by office/ facility, obtained by member from either a pharmacy or OptumRx Specialty Pharmacy Program)


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Lupron (leuprolide acetate) for KS

Community Plan

J9218 For Kansas Community Plan members, provide the following: For treatment of Central Precocious puberty provide the following:




a. Diagnosis that includes the results of hormone evaluation and bone age advanced one year beyond chronological age

b. Documentation that drug is being prescribed or in consultation with an oncologist / hematologist

c. Drug dosage and frequency including the treatment plan d. List of all medications taken for condition with this drug e. Results of Pregnancy Test and breast feeding status, if applicable

For treatment of endometriosis provide the following: 1. Current Prescription



For palliative treatment of advanced prostate cancer provide the

following:


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For continuation request provide the following information:

Current Prescription a. Name and tax ID number of the servicing provider/ facility to facilitate

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b. Physician office notes that include the following: c. Documentation of positive clinical response to medication d. Physicians treatment plan

Luxturna (voretigene neparvovec-rzyl)

J3398 Medical notes documenting all of the following: 1. Medication name and regimen

2. Treatment of Inherited Retinal Dystrophies (IRD) including the following information: a. The member has not previously been treated with RPE65 gene therapy

in the intended eye

b. The member has sufficient retinal cells determined by the optical coherence tomography (OCT)


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c. The treatment will be administered by an ophthalmologist or retinal surgeon experienced in providing sub-retinal injections

d. Current age of the patient e. Genetic testing results confirming biallelic mutation of RPE65 gene

Magneto-

encephalography

95965 Physician office notes including:


2. History and physical by the attending/ treating physician

3. Symptoms and functional impairment

4. History and duration of unsuccessful conservative therapy, when applicable

Makena

(hydroxprogesterone caproate) for KS Community Plan

J1726 J1729 For KS Community Plan member, provide the following:



a. Documentation with history of singleton spontaneous preterm birth 4. Physicians Treatment Plan

Makena (hydroxyprogesterone caproate)

J1726 J1729 J2675 1. Current prescription 2. Name and tax ID number of the servicing provider/ facility to facilitate

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3. Physician office notes that include: a. Member diagnosis b. Relevant obstetrical member history, including current singleton

pregnancy

c. Documentation of signs and symptoms d. Current gestational age e. Dose, frequency, duration, including the physician treatment plan









infusion therapy


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Mastectomy for Gynecomastia

19300 1. Physician office notes with the history of the medical condition

2. Frontal and lateral colored photos of the torso

3. Treatment Plan for proposed surgery including expected outcome

4. Clinical studies that address the physical and/ or physiological

abnormality

5. Functional deficits and associated conditions and complications

6. Pertinent medication history and laboratory results

Mechanical Stretching

Devices (Dynamic and Static)

E1800 E1801 E1802 E1805 E1806 E1810 E1811 E1812 E1815 E1816 E1818 E1820

E1821 E1825 E1830 E1840

Medical notes documenting all the following:


2. Physician office notes that indicate all of the following:

a. The affected joint b. The date of injury/ surgery c. Previous treatments attempted

d. Treatment plan, including proposed duration of use

Member Lifts E0621 E0625 E0630 E0635 E0636 E0639 E0640 E1035 E1036


2. Office notes with clinical information including:

a. Diagnosis b. That addresses the inability to safely make transfers between bed and

a chair, wheelchair, or commode without the use of a lift c. That addresses a requirement for supine positioning for transfers and

rationale

Meniscus Implant and Allograft

29868 Medical notes documenting all of the following: 1. Complete report(s) of diagnostic imaging (MRI, CT scan, x-rays and bone

scan)

Note: For pediatric age, indicate status of growth plates 2. Condition requiring procedure 3. Severity of pain and details of functional disability(ies) interfering with

activities of daily living (preparing meals, dressing, driving, walking) 4. Physician’s treatment plan including pre-op discussion 5. Pertinent physical examination of the relevant joint 6. Co-morbid medical condition(s)

7. Therapies tried and failed If the location is being requested as an inpatient stay, provide office notes to

support at least one of the following: 1. Surgery is bilateral 2. Member has significant co-morbidities. Include the list of comorbidities and

current treatment 3. Member does not have appropriate resources to support post-operative

care after an outpatient procedure. Include the barriers to care as an outpatient

Mepsevii (vestronidase alfa-vjbk)



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b. Laboratory results or genetic testing to confirm diagnosis











infusion therapy






Microfracture Repair 29879 Medical notes documenting all of the following:

1. Complete report(s) of diagnostic imaging (MRI, CT Scan, X-rays and Bone Scan)

2. Indication for procedure including physical exam of pertinent joint


a. Orthotics

b. Medications c. Injections d. Physical therapy

e. Surgical

f. Other pain management procedures 5. Findings for the relevant joint


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a. Presence or absence of focal full-thickness articular cartilage defect b. Size of focal cartilage defect c. Outerbridge grade


If the location is being requested as an inpatient stay, provide office notes to support at least one of the following:

1. Surgery is bilateral 2. Member has significant co-morbidities. Include the list of comorbidities and

current treatment


Milrinone (milrione lactate)

J2260 Please provide the following for an initial request: Current prescription Medication name




dates and reason for discontinuation d. Dose and frequency being requested

e. List medications member will be taking to treat the condition




Miscellaneous DME A9900 E1399 1. Current prescription from physician

2. Equipment price quote with full description of item

3. Relevant physician office notes

4. Letter of Medical Necessity


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Muscle Flap Procedures 15734 15738 Medical notes documenting all of the following:

1. History of medical conditions requiring treatment or surgical intervention which includes all of the following:

a. A well-defined physical/physiologic abnormality resulting

in a medical condition that requires treatment

b. Recurrent or persistent functional deficit caused by the abnormality

2. Clinical Studies/tests addressing the physical/physiologic abnormality confirming its presence and degree to which it

causes impairment

3. High-quality color image(s) of the physical and/or physiological abnormality:

Note: All image(s) must be labeled with the:

a. Date taken and

b. Applicable case number obtained at time of notification, or member’s name and ID number on the image(s)

Submission of color image(s) are required and can be submitted via the external portal at


4. Physician plan of care with proposed procedures including expected outcome

Naglazyme (galsulfase) J1458 Please provide the following for an initial request:


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3. Physician office notes that include: a. Member diagnosis b. Laboratory results or genetic testing to confirm diagnosis



a. If the location is in a facility, provide office notes for at least one of the following: i. Medically unstable based on submitted clinical history








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1. Current prescription 2. Name and tax ID number of the servicing provider(facility to facilitate


a. Documentation with member’s response to therapy

b. Dose, frequency including the physician treatment plan c. Laboratory results to support the positive response to therapy

Negative Pressure

Wound Therapy (NPWT) - Wound VAC

E2402 Medical notes documenting all of the following:


2. Wound size/location/measurements

3. Wound type (post-surgical, venous stasis, decubitus ulcer, diabetic neuropathic ulcer)

4. Date(s) of surgery including debridement

5. The date the NPWT (wound vacuum assisted closure (VAC)) was started

6. Favorable wound environment has been maintained with:

a. Appropriate dressing/ dressing changes

b. Adequate nutritional status

c. Management of incontinence, if applicable

d. Wound is free of the following:

i. Necrotic tissue,

ii. Malignancy present in wound,

iii. Open fistula to an organ or body cavity within the vicinity of the wound

iv. Uncontrolled soft tissue infection or osteomyelitis within vicinity of wound

7. If member is diabetic, the member is maintained on a diabetic management program

8. Member is turned and repositioned with the presence of a Stage III or IV pressure ulcer

9. If applicable, NPWT (wound VAC) has been used previously on the same type of wound with a favorable clinical response. Please explain

Neulasta (pegfilgrastim) J2505 Please provide the following for an initial request: Current prescription

Medication name Name and specialty of the prescribing and/ or consulting provider Name and tax ID number of the servicing provider/ facility if different than




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Neulasta (pegfilgrastim)


J2505 For KS Community Plan provide the following:


a. Diagnosis b. List of all medications taken for condition with this drug

Neuromuscular Electrical Stimulation

(NMES)

E0762 1. Indicate if the request is for the trial or permanent use of the stimulator


3. Documentation that the item is approved by FDA

4. Physician office notes indicating the reason for the unit as opposed to conventional delivery

For Muscle Atrophy:

1. Diagnosis/ condition causing the muscle atrophy 2. Documentation of intact nerve supply to the affected muscle

For Spinal Cord Injury:

Physician office notes indicating:

a. Co-morbidities b. Intact lower motor units (L1 and below) (both muscle and peripheral

nerve)

c. Muscle and joint stability for weight bearing at upper and lower extremities that can demonstrate balance and control to maintain an upright support posture independently

d. Brisk muscle contraction to NMES and have sensory perception

electrical stimulation sufficient for muscle contraction e. Member possesses high motivation, commitment and cognitive ability

to use such devices for walking;

f. Member can transfer independently and can demonstrate independent standing tolerance for at least 3 minutes

g. Member has hand and finger function to manipulate controls

h. Date of spinal cord injury and restorative surgery i. Absence of hip and knee degenerative disease and no history of long

bone fracture secondary to osteoporosis j. Member demonstrates willingness to use the device long-term

k. Goal for use of the stimulator


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For Post-trial:

1. Documentation of the success of trial treatment period 2. Documentation of completion of training program including length of

program and number of physical therapy sessions

3. Description of the treatment for which the unit will be used

Neuromuscular Stimulator for Scoliosis

E0744 E0745 This procedure is considered unproven. To request a review please submit:


2. Physician office notes that relate to treatment of the condition

Neuromuscular Stimulators

E0745 E0764 E0770 1. Current prescription from physician

2. Diagnoses for the condition(s) needing treatment

3. Physician office notes with clinical documentation that indicate:

a. The device is being used to treat the diagnosis of disuse atrophy where

nerve supply to the muscle is intact, including brain, spinal cord and peripheral nerves, and other non-neurological reasons for disuse atrophy

b. Intact lower motor units both muscle and peripheral nerve c. Muscle and joint stability for weight bearing and the ability to support

upright posture independently

d. Muscle contractions and sensory perception response to electrical stimulation

e. Transfer ability and independent standing tolerance f. Hand and finger dexterity

g. Date of spinal cord injury and restorative surgery h. Pertinent medical/ surgical history i. If spinal cord injury present, documentation of completion of a training

program which consists of at least 32 physical therapy sessions with the device over a period of three months and is directly performed by the physical therapist as part of a one-on-one training program

Neurostimulator Electrode Array, Peripheral Nerve

64555 Physician office notes describing:

1. Frequency, duration and intensity of pain

2. Previous response to therapies

3. Documentation of pain relief from temporarily implanted

electrode

Non Invasive Fractional Flow Reserve (FFR)

0051T 0052T 0053T 0054T 1. Current prescription 2. Name and tax ID number of the servicing provider/ facility to facilitate


a. Member diagnosis related to the FFR service being requested

b. Reports of all recent imaging studies and applicable diagnostics (i.e. EKG)

c. Documentation of signs and symptoms; with onset, duration, and

frequency

d. Relevant medication(s) taken


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NovoSeven® RT [coagulation factor VIIa (recombinant)]

J7189 Medical notes documenting all of the following: 1. Current Prescription 2. Members age, 3. Diagnosis of factor VII deficiency or Glanzmann Thrombasthenia

4. Whether it is being used for:

a. VII deficiency: routine prophylaxis, peri-operative management of surgical bleed or treatment of bleeding episodes

OR b. Glanzmann Thrombasthenia: refractory to platelet transfusions or

peri-operative management of surgical bleed or treatment of bleeding

episodes c. Method of administration (if the medicine is self-administered or

administered by a caregiver) 5. Drug dosage and frequency being requested


Nplate (romiplostim)




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3. Physician office notes that include: a. Member diagnosis b. List of corticosteroids and immunoglobulins tried, failed or

contraindicated, include dates and duration

c. Splenectomy with insufficient response d. List of all medications being taken for condition with the medication

Nucala (mepolizumab) J2182 For an initial request: 1. Current prescription 2. Medication name



5. Physician office notes that include: a. Member’s diagnosis b. Provide results of the Asthma Control Questionnaire (ACO) or Asthma


c. Provide blood eosinophil level and date drawn (within the last 6 weeks) d. Provide results of the Forced Expiratory Volume (FEV1) e. Asthma related emergency treatment describe the treatment provided

and number of occurrences over the last 6 months f. Documentation of treatments tried, failed, contraindicated. Include the





a. If the location is in a facility, provide documentation to support facility administration


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b. Current utilization of ancillary medications

c. Date the therapy was started

Obstructive Sleep Apnea (OSA) - Oral Appliances

E0485 E0486 Physician office notes including:

1. Face-to-face clinical evaluation by the treating Physician prior

to the sleep test to assess need for obstructive sleep apnea testing

2. Prescription or referral from the treating physician for oral appliance therapy

3. Sleep study with clinical documentation of severity of the OSA with AHI/ RDI values and the compliance and effectiveness of

CPAP or BIPAP therapy

4. Does the member have an AHI higher than 5? a. If yes, include required Sleep Study b. If no, please explain why appliance is needed

Ocrevus (ocrelizumab) J2350 Please provide the following for an initial request: 1. Current prescription

2. Name and tax ID number of the servicing provider/ facility to assist with claim processing


b. Member diagnosis which includes the relapsing form of MS c. Documentation and severity of symptoms being experience d. Documentation of treatments tried, failed, contraindicated. Include the

date range the medication was used and reason for discontinuation e. Documentation of past treatments with the drug being requested f. Dose and frequency being requested. Include if the member will be

receiving the drug in combination with: i. Another disease modifying agent ii. B Cell Targeted Therapy iii. Lymphocyte trafficking blockers

g. Include if the member will be receiving the drug in combination with any other drug



following:





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infusion therapy Please provide the clinical for a continuation request:



c. Dose and frequency being requested. Include if the member will be receiving the drug in combination with any other medication

d. Member response to therapy with the requested medication

e. Date the therapy was started 3. Name and tax ID number of the servicing provider/ facility to facilitate

claim processing


following:

i. Medically unstable based upon submitted clinical history







infusion therapy

Office Based Procedures

Site of Service for Commercial Plans

11402 11403 11406 11422 11426 11442 19000 27096 31579 57460 62270 62321

64479 64490 64493 64633 64635

If the location being requested is anything other than the office, provide

medical notes documenting all of the following: 1. History 2. Physical examination including patient weight and co-morbidities 3. Surgical plan

4. American Society of Anesthesiologists (ASA) score, as applicable

Onivyde (irinotecan

liposomal) for KS Community Plan




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3. Physician office notes that include the following: a. Documentation that drug is being prescribed or in consultation with an

oncologist/ hematologist

b. Drug dosage and frequency including the treatment plan c. List of all medications taken for condition with this drug

d. Results of Pregnancy Test and breast feeding status, if applicable Renewal request provide the following information:



a. Documentation of positive clinical response to medication 4. Physicians treatment plan

Onpattro (patisiran) J0222 1. Current prescription 2. Name and tax ID number of the servicing provider/ facility to facilitate

claim processing

3. Physician office notes that include: a. Member diagnosis of hereditary transthyretin amyloidosis (hATTR)

amyloidosis with polyneuropathy b. Laboratory results for transthyretin (TTR) mutation

c. Results of polyneuropathy disability (PND) score d. Results of familial amyloid polyneuropathy (FAP) stage 1 or 2

e. Documentation of signs and symptoms

f. List of all medications currently being used for this disease g. Dose, frequency, duration, including the physician treatment plan










vii. Homecare or infusion provider has deemed that the member,



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Opdivo (nivolumab) for KS Community Plan

J9299 Provide the following: 1. Current Prescription 2. Name and tax ID number of the servicing provider/ facility to facilitate

claim processing


a. Documentation that drug is being prescribed or in consultation with an oncologist/ hematologist

b. Drug dosage and frequency including the treatment plan c. List of all medications taken for condition with this drug d. Results of Pregnancy Test and breast feeding status, if applicable

e. Provide documentation that Opdivo to be administered for one of the following: i. BRAF V600 wild type unresectable or metastatic melanoma as a

single agent

ii. BRAF V600 mutation positive unresectable or metastatic melanoma as a single agent

iii. Unresectable or metastatic melanoma in combination with

ipilimumab iv. Melanoma with lymph node involvement or metastatic disease

with complete resection

v. Metastatic non-small cell lung cancer with progression after platinum based chemotherapy

vi. Advanced renal cell carcinoma after received antiangiogenic therapy

vii. Intermediate or poor risk, previously untreated advanced renal

cell carcinoma, in combination with ipilimumab viii. Hodgkin lymphoma that has relapsed or progressed after

autologous hematopoietic stem cell transplantation (HSCT) and brentuximab vedotin OR 3 or more lines of systemic therapy that includes autologous HSCT

ix. Recurrent or metastatic squamous cell carcinoma of the head and neck with disease progression after a platinum-based therapy

x. Locally advanced or metastatic urothelial carcinoma who have disease progression during or following platinum-containing

chemotherapy OR have disease progression within 12 month of neoadjuvant or adjuvant treatment with platinum-containing chemotherapy

xi. Microsatellite instability-high (MSI-H) or mismatch repair deficient (dMMR) metastatic colorectal cancer that has progressed following treatment with a fluoropyrimidine,

oxaliplatin, and irinotecan, as a single agent or in combination with ipilimumab

xii. Hepatocellular carcinoma who have been previously treated with sorafenib

xiii. Metastatic small cell lung cancer with progression after platinum-based chemotherapy

Orencia (abatacept) J0129 Please provide the following for an initial request:


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a. Member weight

b. Member diagnosis c. Documentation of treatments tried, failed, contraindicated. Include the

date range the medication was used and reason for discontinuation d. Dose and frequency being requested including treatment plan e. List medications member will be taking to treat the condition


following:








infusion therapy

Orthognathic (Jaw)

Surgery

21121 21123 21125 21127 21141 21142 21143 21145 21146 21147 21150 21151

21154 21155 21159 21160 21188 21193 21194 21195 21196 21198 21199 21206 21210 21215 21244 21245 21246 21247


1. Comprehensive history of the medical condition(s) requiring treatment or surgical intervention; including all of the following: a. A well-defined physical and/or physiological abnormality (e.g.,

congenital abnormality, functional or skeletal impairments) resulting in

a medical condition that has required or requires treatment; and b. The physical and/or physiological abnormality has resulted in a

functional deficit; and

c. The functional deficit is recurrent or persistent in nature 2. Appropriate clinical studies/tests including cephalometric tracings and

analysis addressing the physical and/or physiological abnormality that

confirm its presence and the degree to which it is causing impairment, with appropriate measurements, when applicable Radiologic film interpretations including lateral cephalometric radiograph, AP radiograph and panoramic radiograph

3. Clinical photographs of the member’s occlusion

4. Treating physician’s plan of care including surgical treatment objectives, which must include the expected outcome for the improvement of the

functional deficit


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5. Diagnostic Polysomnography (sleep study) for obstructive sleep apnea surgery

6. History of previous non-surgical and surgical treatment (e.g., obstructive sleep apnea)

Orthotics – Cranial L0112 S1040 Please provide the following:


2. Reason for the orthotic 3. Diagnosis 4. Physical exam related to support the need of the orthotic. Include the

neurological, circulatory, skin and musculoskeletal examination that supports the request

5. Orthotist notes to include the following: a. Equipment quote with billing codes and cost

b. Reason for the orthotic c. Cephalic index d. Anthropometric Measurements

6. High-quality color photograph(s); all photos must be labeled with the date taken and the applicable case number obtained at time of notification number, or member’s name and ID number on the photograph(s) Note:

Submission of color photos are required and can be submitted via the external portal at www.uhcprovider.com/paan or via email at [email protected]; faxes of color photos will not be accepted

7. Date and type of injury/ surgery, if applicable

Replacement request provide medical notes documenting:

1. Age of current orthotic

2. Reason for replacement

Orthotics – Lower Body L1630 L1640 L1680 L1685 L1700 L1710

L1720 L1730 L1755 L2280 L2320 L2520 L2525 L2526 L2627 L2628 L2861 L2999 L3000 L3010 L3020 L3160 L3201 L3202

L3203 L3204 L3206 L3207 L3208 L3209 L3211 L3212 L3213 L3214 L3215 L3216 L3221 L3250 L3251 L3252 L3253 L3254 L3255 L3257 L3265 L3320 L3485 L3649

L3960 L4050 L4055 L5611 L5647 L5649 L5673 L5683 L5845 L5962


1. Current prescription from physician 2. Provide the reason for the orthotic

3. Physician office notes documenting the following: a. Diagnosis including diabetes b. Physical exam related to support the need of the orthotic. Include the


supports the request c. Functional impairment that is interfering with activities of daily living

(meals, walking, getting dressed, driving)

d. Date and type of injury/ surgery, if applicable 4. Orthotist notes to include the following:


b. Reason for the orthotic

If a replacement: Please provide age of current orthotic and

reason for replacement

Orthotics - Upper Body L0140 L0150 L0170 L0200 L0220 L0452 L0468 L0480 L0482 L0484 L0486 L0622

L0623 L0624 L0629 L0631 L0632 L0634


1. Current prescription from physician 2. Provide the reason for the orthotic



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L3901 L3904 L3921 L3956 L3961 L3967

L3971 L3973 L3975 L3976 L3977 L3978 L4000 L4030 L4040 L4045

3. Physician office notes documenting the following: a. Diagnosis b. Physical exam related to support the need of the orthotic. Include the


supports the request

c. Functional impairment that is interfering with activities of daily living (meals, walking, getting dressed, driving)

d. Date and type of injury/ surgery, if applicable 4. Orthotist notes to include the following:


b. Reason for the orthotic If a replacement: Please provide age of current orthotic and reason for replacement

Osteochondral Grafting (Autograft and

Allograft)

27415 27416 28446 29866 29867 Medical notes documenting all of the following: 1. Complete report(s) of diagnostic imaging (MRI, CT Scan, X-rays and Bone

Scan) 2. Indications for procedure 3. Symptoms

4. Severity of pain and details of functional disability(ies) interfering with activities of daily living (preparing meals, dressing, driving, walking)


a. Orthotics b. Medications

c. Injections

d. Physical therapy e. Surgical f. Other pain management procedures

7. Pertinent physical examination of the relevant joint a. Presence or absence of focal full-thickness articular cartilage defect b. Size of focal cartilage defect


If the location is being requested as an inpatient stay, provide office notes to support at least one of the following:

1. Surgery is bilateral 2. Member has significant co-morbidities. Include the list of comorbidities and

current treatment


Outpatient Surgical

Procedures – Site of

Service for Commercial

Plans

10121 10180 11000 11010 11012 11440

11441 11443 11444 11446 11450 11451

11462 11463 11470 11471 11601 11602

11603 11604 11620 11621 11622 11623

If the location being requested is an outpatient hospital provide medical notes

documenting all of the following:

1. History 2. Physical examination including patient weight and co-morbidities

3. Surgical plan


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11624 11626 11640 11641 11642 11643

11644 11646 11750 11755 11760 11770

11772 12031 12032 12034 12035 12037

12041 12042 12051 12052 13100 13101

13120 13121 13131 13132 13151 13152

14040 14060 14301 15100 15120 15220

15240 15260 15576 15760 15770 15850

17000 17004 17110 17111 17311 17313

19101 19110 19112 19120 19125 20200

20205 20220 20225 20240 20245 20520

20525 20526 20551 20552 20553 20600

20604 20605 20606 20610 20611 20612

20680 20693 20694 20912 21010 21011

21012 21013 21014 21030 21031 21040

21046 21048 21315 21320 21325 21330

21335 21336 21337 21356 21365 21385

21390 21407 21550 21552 21554 21555

21556 21557 21920 21930 21931 21932

21933 22900 22901 22902 22903 23071

23075 23076 23140 23150 23405 23415

23430 23480 23615 23630 23700 24000

24006 24065 24066 24071 24073 24075

24076 24101 24102 24105 24110 24120

24130 24147 24200 24201 24300 24310

24340 24357 24358 24366 24515 24516

24586 24615 24665 24666 25000 25071

25073 25075 25076 25085 25105 25107

25109 25110 25111 25112 25118 25120

25130 25151 25210 25215 25230 25240

25260 25270 25275 25280 25290 25295

25350 25445 25545 25605 25606 25607

25608 25609 25624 25628 25645 25652

25810 25825 26011 26020 26045 26055

26070 26075 26080 26105 26110 26111

26113 26115 26116 26121 26123 26160

26180 26200 26210 26215 26236 26320

26356 26357 26392 26410 26418 26420

26426 26432 26433 26437 26440 26442

26445 26455 26480 26500 26502 26516

26520 26525 26530 26535 26540 26541

26542 26567 26608 26615 26650 26665

4. Physician privileging information related to the need for the use of the hospital outpatient department



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26676 26715 26727 26735 26742 26746

26756 26765 26841 26842 26850 26860

26862 26910 26951 26952 27006 27043

27045 27047 27048 27062 27093 27095

27310 27323 27324 27327 27328 27329

27331 27332 27334 27335 27337 27339

27340 27345 27347 27372 27403 27407

27418 27570 27613 27614 27618 27619

27620 27626 27632 27634 27638 27640

27658 27665 27685 27705 27720 27756

27788 28005 28010 28011 28020 28022

28035 28039 28041 28043 28045 28047

28055 28060 28080 28086 28088 28090

28092 28100 28103 28104 28108 28110

28111 28112 28113 28118 28119 28120

28124 28126 28153 28160 28190 28192

28193 28208 28225 28234 28250 28272

28280 28286 28288 28295 28306 28310

28312 28313 28315 28475 28476 28496

28515 28525 28645 28666 28675 28755

28760 28825 29800 29804 29906 30000

30020 30100 30110 30115 30117 30118

30130 30140 30220 30310 30520 30580

30630 30801 30802 30930 31020 31030

31032 31200 31205 31525 31526 31528

31529 31530 31535 31536 31540 31541

31545 31570 31571 31574 31575 31576

31578 31591 31611 31622 31623 31624

31625 31628 31652 32405 32555 32557

33215 33216 33241 35045 36000 36010

36012 36215 36246 36471 36556 36569

36571 36581 36582 36589 36590 36821

36901 36902 37242 37248 37607 37609

37761 37765 37766 37785 38221 38222

38500 38505 38510 38520 38525 38740

38760 40520 40525 40530 40810 40812

40814 40816 41105 41110 41112 41113

41116 41520 41825 42100 42104 42106

42107 42140 42330 42335 42405 42408

42410 42415 42420 42425 42440 42450

42500 42650 42800 42804 42808 42810


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42820 42821 42825 42826 42830 42831

42870 43191 43195 43197 43200 43202

43214 43220 43226 43229 43233 43235

43236 43237 43238 43239 43240 43241

43242 43245 43246 43247 43248 43249

43250 43251 43253 43254 43255 43259

43260 43261 43265 43270 43274 43275

43276 43450 43453 44340 44360 44361

44364 44369 44376 44377 44380 44381

44382 44385 44386 44388 44389 44392

44394 44705 45100 45171 45172 45190

45305 45334 45335 45340 45341 45342

45346 45349 45350 45378 45379 45380

45381 45384 45385 45386 45389 45390

45398 45505 45541 45560 45905 45910

45915 45990 46020 46030 46040 46045

46050 46060 46080 46083 46200 46220

46221 46230 46250 46255 46257 46258

46261 46262 46270 46275 46280 46285

46288 46320 46505 46606 46607 46610

46612 46615 46706 46707 46750 46910

46917 46924 46930 46940 46945 46946

46947 46948 47000 49082 49083 49180

49250 49422 49505 49521 49525 49550

49553 49570 49572 49585 49587 49650

49651 49652 49653 49654 49655 49656

49900 50430 50435 50575 50590 50688

51102 51702 51710 51715 51720 51726

51728 51729 52000 52001 52005 52007

52204 52214 52224 52234 52235 52260

52265 52275 52276 52281 52282 52283

52285 52287 52300 52310 52315 52320

52325 52327 52330 52332 52341 52344

52351 52352 52353 52354 52356 52450

52500 52630 52640 53020 53230 53260

53265 53270 53440 53445 53450 53500

53605 53665 54001 54055 54057 54060

54100 54110 54150 54161 54162 54163

54164 54300 54360 54450 54512 54530

54600 54620 54640 54700 54830 54840

54860 55040 55041 55060 55100 55110


of 186


55120 55500 55520 55540 55700 56405

56420 56440 56441 56442 56501 56515

56605 56620 56700 56740 56810 56821

57000 57061 57065 57100 57105 57106

57130 57135 57240 57250 57260 57268

57282 57283 57287 57288 57295 57300

57410 57415 57420 57421 57425 57452

57454 57456 57461 57500 57505 57510

57511 57513 57520 57522 57530 57700

57720 57800 58100 58120 58263 58353

58558 58560 58561 58562 58563 58565

58700 58925 59150 59151 62281 64561

64585 64600 64610 64642 64644 64646

64647 64702 64718 64719 64721 64774

64776 64782 64784 64788 64795 64831

64835 65275 65400 65420 65426 65435

65436 65710 65730 65750 65755 65756

65772 65778 65779 65780 65800 65815

65820 65850 65855 65865 65875 65920

66172 66185 66250 66682 66710 66711

66761 66821 66825 66840 66850 66852

66982 66983 66984 66985 66986 66987

66988 67005 67015 67025 67028 67036

67039 67040 67041 67042 67043 67101

67105 67107 67108 67110 67113 67120

67121 67145 67210 67218 67220 67221

67228 67311 67312 67314 67316 67318

67345 67400 67412 67414 67420 67445

67550 67560 67700 67800 67801 67805

67808 67840 67875 67880 67935 67938

67971 67973 67975 68100 68110 68115

68135 68320 68440 68700 68720 68750

68811 68815 69100 69110 69140 69145

69222 69310 69320 69421 69424 69433

69436 69440 69450 69505 69550 69602

69610 69620 69631 69632 69633 69635

69636 69641 69642 69643 69644 69645

69646 69650 69660 69661 69662 69666

69801 69805 69806 G0289

Outpatient Surgical

Procedures – Site of

For applicable coding refer please visit our

Health Plans by State section of


1. History

https://www.uhcprovider.com/en/health-plans-by-state.html?rfid=UHCCP


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Service for Community

Plans

• Arizona (AZ)

• Florida (FL)

• Maryland (MD)

• Michigan (MI)

• Missouri (MO)

• New Jersey (NJ)

• New York (NY)

• Ohio (OH)

• Pennsylvania (PA)

• Rhode Island (RI)

• Tennessee (TN)

• Washington (WA)

UHCprovider.com and select the

appropriate state, then Community Plan to

view codes included in the Site of Service

program.

2. Physical examination including patient weight and co-morbidities

3. Surgical plan


Please answer the following questions and return this completed form. Is the

request for outpatient hospital site of care for ANY of the following?

1. There is no geographically accessible free standing ambulatory surgery

center that has the necessary equipment for the procedure

2. There is no geographically accessible free standing ambulatory surgery

center available at which the individual's physician has privileges

3. The Ambulatory Surgical Center's specific guideline regarding the

individual's weight or health conditions prevents the use of the ASC

4. None of the above

Pacemaker (Replacement of Batteries, Generator)

33212 33213 33221 33227 33228 33229 33230 33231 33240 33262 33263 33264

1. Current prescription 2. Physician office notes that include:

a. Documented non-reversible symptomatic bradycardia due to sinus node dysfunction

b. Documented non-reversible symptomatic bradycardia due to second degree and/ or third degree atrioventricular block

c. Relevant history & physical

d. Relevant medication(s) taken e. Reports of all recent imaging studies and applicable diagnostics (i.e.

EKG)

f. Documentation of signs and symptoms; with onset, duration, and frequency

Pacemaker

(replacement of lead electrodes)

33224 3225 1. Physician office notes that include:

a. Relevant history & physical, including history of initial pacemaker placement

b. Relevant medication(s) taken

c. Reports of all recent imaging studies and applicable diagnostics (i.e. EKG)

d. Documentation of signs and symptoms; with onset, duration, and

frequency

Pacemaker insertion

(replacement)

33206 33207 33208 33249 33270 1. Current prescription

2. Indicate whether this is an initial request, or replacement 3. Physician office notes that include:

a. Documented non-reversible symptomatic bradycardia due to sinus node dysfunction

b. Documented non-reversible symptomatic bradycardia due to second degree and/ or third degree atrioventricular block

c. Relevant history & physical

d. Relevant medication(s) taken


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e. Reports of all recent imaging studies and applicable diagnostics (i.e. EKG)

f. Documentation of signs and symptoms; with onset, duration, and frequency

Panniculectomy and

Body Contouring

(Including Lipectomy and Abdominoplasty)

15830 15847 Physician office notes describing:

1. Primary complaint, history of complaint and physical exam

2. Intertriginous rashes or other skin problems with documentation of treatment and response

3. Documentation of functional limitations due to pannus

4. High-quality color photographs of a full frontal view of the hanging pannus, a full frontal view of pannus elevated that allows any skin damage can be evaluated, and a full lateral view of the hanging pannus. All photos must be labeled with the date taken and the applicable case number obtained at

time of notification, or member’s name and ID number on the photograph(s)

Parsabiv (etelcalcetide) J0606 Please provide the following for an initial request: 1. Current prescription 2. Name and tax ID number of the servicing provider/ facility to facilitate

claim processing a. Physician office notes that include: b. Diagnosis

c. Documentation that member is currently on dialysis d. List of medications that were tried prior to Parsibiv e. List of other medications that the member is currently using to treat

this diagnosis

f. Documentation that this is being prescribed by or in consultation with and endocrinologist or nephrologist

g. Dose and frequency being requested including the physicians

treatment plan 3. Location where the drug will be administered (e.g., infusion center,












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Please provide the following for a continuation request: 1. Current prescription 2. Name and tax ID number of the servicing provider/ facility to facilitate

claim processing

3. Physician office notes that include: a. List of medications that the member is currently taking for this

diagnosis b. Documentation that this is being prescribed by or in consultation with

and endocrinologist or nephrologist

c. Documentation of a reduction in serum calcium from baseline

Pectus Deformity Repair 21740 21742 21743 For Pectus Excavatum repair provide the following: 1. Clinical notes documenting all of the following:

2. Results of imaging studies (CT scan confirming Haller Index greater than 3.25);

3. Documentation of functional limitation/ impairment

4. Results of Pulmonary function test (confirming restrictive lung capacity) the total lung capacity is documented as <80% of the predicted value; or

5. Provide results of one of the following:

a. Results of an echocardiogram (Ejection Fraction) confirming decreased cardiac output

b. Results of stress test demonstrating cardiopulmonary function that is below the predicted values

6. Physician Treatment Plan

For Pectus Carinatum repair provide the following:

1. Clinical notes documenting all of the following: a. Documentation of functional limitation/ impairment b. Physician Treatment Plan

Pediatric Day Care for Community Plan:

• Louisiana(LA) • Mississippi (MS) • Texas (TX)

T1025 T1026 T2002 Please provide the following information: 1. Current Physician order that is within 30 days of personally examining the

member 2. Physician office notes that include:

a. Member diagnosis, age, and letter of medical necessity b. Documentation of ongoing need for skilled nursing care and

supervision, therapeutic interventions, or skillful observations c. Status as medically dependent or technologically dependent d. Documentation of member stability for outpatient services and risk

status towards other persons e. Address whether delayed skilled intervention is expected to result in

the following:

i. Deterioration of a chronic condition; ii. Loss of function; iii. Imminent risk to health status due to medical fragility

iv. Risk of death

f. Documentation of current residence, including whether living with responsible adult or in any 24-hour care setting


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g. Relevant member history h. Treatment plan, including visit frequency and duration

Peg Intron

(peginterferon alfa-2b)


Community Plan

S0148 Please provide the following:


claim processing

3. Physician office notes that include the following: a. Diagnosis b. Results of HCV RNA test

c. Results of ALT test d. Results of liver biopsy e. Documentation that medication has been prescribed by or in

consultation with a gastroenterologist, hepatologist or infectious

disease specialist f. List of all medications taken for the condition. Include dates and

duration

g. List medications tried, failed/ unresponsive or contraindicated for the condition


Pegsys (peginterferon alfa-2a)


S0145 Please provide the following: 1. Current Prescription



b. Results of HBsAG test, include date c. Results of HBV DNA test d. Results of ALT test

e. Results of liver biopsy f. Documentation that medication has been prescribed by or in

consultation with a gastroenterologist, hepatologist or infectious

disease specialist g. List of all medications taken for the condition. Include dates and

duration 4. Physician treatment plan

Percussor Oscillatory Devices

E0480 E0484 1. Current prescription from physician 2. Physician office notes that indicate respiratory condition and clinical

documentation supporting inability to mobilize secretions 3. Documentation indicating that the member/ caregiver or therapist has

received appropriate training to use the device

Percutaneous Lysis of Epidural Adhesions

62263 62264 Physician office notes describing:

1. The nature of the cervical, lumbar or thoracic pain including the location, intensity and duration

2. Prior conservative treatment regimens tried and response (e.g.,

medications, injections, traction)

3. If procedure previously performed, provide dates


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Percutaneous Patent Foramen Ovale (PFO) Closure

93580 Medical notes documenting all of the following: 1. History and co-morbid medical condition(s) 2. Documentation of member’s symptoms 3. Complete report(s) of diagnostic imaging (MRI, CT Scan, X-rays)

4. Results of diagnostic testing performed to rule out other causes including,

but not limited to, carotid disease, hypercoagulable states or atrial fibrillation; and

5. Documentation of an evaluation by a cardiologist and a neurologist and both are in agreement that the stroke is likely embolic in nature

Percutaneous Vertebroplasty and Kyphoplasty

22510 25111 22512 22513 22514 22515 Medical notes documenting all of the following:

1. Onset of the condition, length and duration

2. Documentation of member’s symptoms, pain, location, and severity including functional impairment that is interfering with activities of daily living (meals, walking, getting dressed, driving)

3. History and co-morbid medical condition(s)

4. No evidence of spinal cord compression 5. Treatments tried and failed 6. Complete report(s) of diagnostic imaging (MRI, CT Scan, X-rays and/ or

bone scan)

Physical and Occupational Therapy

(PT/ OT)

97161 97162 97163 97164 97165 97166 97167 97168 97799

1. Current prescription by Physician 2. Indicate whether this is an initial request, or extended/ continued therapy

3. Specific diagnosis/ condition, with description of the Physical or Occupational therapy needed

4. Goals of therapy

5. Therapy plan of care by an occupational or physical therapist

6. Physician office notes that include: a. History & physical, including history of condition and limitations b. Medical and surgical history, including any planned procedures or

treatment c. Reports from any applicable imaging studies or diagnostic testing

7. For extended/continued therapy, please also provide the following:

a. Functional progress during initial therapy b. Generalization and carryover of targeted skills into natural

environment c. Goals of therapy are not yet met

d. Member is actively participating in treatment

Physical and

Occupational Therapy (PT/OT) – For Community Plans

Applicable to Community Plans that have a prior authorization requirement

• Florida (FL) • Nebraska (NE)

For applicable coding refer please visit our Health Plans by State section of

UHCprovider.com and select the appropriate state, then Community Plan to view codes included in the Outpatient

Therapy program.

For Community Plan members for a service request for therapy (PT, OT) must

be generated by an in-network physician. Please provide required documentation indicated in the UHC Community Plan Coverage Determination Guidelines for physical and occupational therapy

Request for the initial therapy evaluation/ initial therapy visit request should include the following: 1. Physician referral dated within 30 days of the request

2. Name and tax ID number of the servicing provider/facility 3. Medical notes documenting all of the following:

a. Diagnosis and ICD-10 code(s)



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• New York (NY) – HARP only

• Ohio (OH) • Tennessee (TN)

b. History & physical, including history of condition and limitations include the date of onset of illness and or injury

c. Describe the functional impairment that impact health, safety and independence

d. Provide a comparison of the prior level of function to the current level

of function e. Provide current durable medical equipment being utilized and future

durable medical needs identified f. Medical and surgical history, including any planned procedures or

treatment

g. Reports from any applicable imaging studies or diagnostic testing h. Short and long-term therapeutic goals and objectives: i. Treatment frequency, duration, and anticipated length of treatment

session(s) if applicable

Requests for continuation of therapy visits should include medical notes documenting:

1. Clinically significant and measurable improvement of the member’s condition

2. Start of care date

3. Time period covered by the report 4. Changes in prognosis, plan of care and/ or goals, with reason for change Request for re-evaluation should include medical notes documenting:

1. Date of last therapy evaluation/ revaluation

2. Update in prognosis, plan of care goals and clearly established discharge criteria with reasons for update

3. Updated plan of care must not be older than 90 days AND 4. Goals must be measurable, functional and time based

If the Site of Service requested is an Outpatient Hospital clinic in addition to the above, provide medical notes documenting the following: 1. Clinical documentation to indicate why an in network freestanding clinic is

not an option

2. Indicate if therapy is part of an annual or semi-annual Comprehensive Care Management assessment clinic visit for any of the following: paraplegia, quadriplegia, or traumatic brain injury

3. Indicate if therapy is due to a complication of the following: major multiple trauma, recent amputation, post-acute stroke, or severe burn injury

Pneumatic Compression Devices

E0650 E0651 E0652 E0655 E0656 E0657 E0660 E0666 E0665 E0667 E0668 E0669 E0670 E0671 E0672 E0673 E0675 E0676

1. Current prescription from physician 2. Physician office notes that address:

a. Member symptoms b. Clinical documentation that supports the diagnoses of Lymphedema or

Chronic Venous Insufficiency with Venous Stasis Ulcers

c. Previous conservative treatments attempted d. Evidence of regular Physician visits for the treatment of venous stasis

ulcer during the past six (6) months


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e. Date of trial and clinical response including objective effectiveness of treatment, pre- and post-treatment measurements and member compliance

For E0652 the following additional information is required:

1. Treatment plan including the pressure in each chamber, frequency and duration of each treatment

2. Documentation as to whether a segmented compressor without calibrated gradient pressure, (E0651, or a non-segmented compressor, E0650, with a segmented appliance, E0671-E0673) had been tried and the results

3. Why the features of the device are needed 4. Name, model number and manufacturer of the device

Power Mobility Devices

(Scooters, Wheelchairs)

E0983 E0984 E0986 E1002 E1003 E1004 E1005 E1006 E1007 E1008 E1009 E1010


K0005 K0008 K0010 K0011 K0012 K0013 K0014 K0108 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 K0899

Initial request for device:

1. Seven Element Order

2. Current Documentation that supports medical need for a power mobility device instead of alternate equipment for

home mobility (e.g., manual wheelchair, walker, cane, scooter)

3. Specific Health Care Common Procedure Coding System (HCPCS) codes for each accessories requested including

make, model and price quotation

4. For Power Operated Vehicles (POVs) include the following:

a. The ability to transfer safely to and from the POV device

b. The ability to operate the tiller steering system \

c. The ability to maintain postural stability and positon while operating the POV

5. Physician’s face-to-face evaluation record, which must be from office notes. A check off or pre-prepared form cannot be accepted. The information must include the following:

a. Current ambulation status including current mobility equipment being used and why it is no longer effective

b. Limitation of physical mobility that impacts mobility-related activities of daily living (MRADLs)

c. Estimated duration of use d. Measurement of:

i. Strength ii. Ability to move and distance moved with assistive equipment iii. Coordination deficits

iv. Pain level e. Documentation of missing or disabled legs or arms f. History of falls


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6. Primary setting of power mobility device use (e.g., home, community)

7. Documentation of ability/ inability to operate a manual

wheelchair

8. Documentation of ability/ inability to safely operate a power

wheelchair or POV

9. Documentation of Specialty Evaluation of power wheelchairs with special features that was performed by a licensed/

certified medical professional, such as a physical therapist (PT) or occupational therapist (OT), or Physician who has specific training and experience in rehabilitation wheelchair

evaluations and that documents the medical necessity for the wheelchair and its special features. The PT, OT or Physician may have no financial relationship with the supplier

10. For member transitioning from other insurance, please submit the information included with the original/ initial evaluation including the date

the member received the Power Mobility Device

For Replacement – same Power Mobility group

1. Current prescription from physician 2. Date acquired the chair and model 3. Detailed equipment repair quote 4. If stolen, include police report

For Replacement – different Power Mobility group

1. Date the current chair was acquired,

2. Make and model of current chair 3. All requirements listed for initial request

For Repair:

1. Date acquired the chair 2. Detailed equipment repair quote including complete description, serial

number, repair estimate and reason for repair

Power Rim Assist for Manual Wheelchair

E0986 Provide the following: 1. Current prescription



a. That a member has been self-propelling for at least a year b. Member has had a specialty evaluation by a licensed professional (OT,

PT or WC specialist) including that the device will be used in the home

c. Provide documentation that the wheelchair is provided by a RESNA certified Assistive Technology (ATP) professional

Pressure Reducing

Support Surface – Group 2

E0193 E0277 E0373 Provide the following:

1. Prescription from physician tied to current plan of care 2. Clinical documentation supporting:


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a. Decubitus ulcers with measurements, staging, measurements, location and description

b. Prior ulcer treatment program, duration and response to treatment c. Current plan of care including wound program, nutritional status and

expected length of need

d. Frequency of wound assessment by healthcare professional e. Prior use of a Group 1 support surface

3. For recent flap or skin graft include date of surgery and flap location

Pressure Reducing

Support Surface – Group 3

E0194 Provide the following:

1. Prescription from physician tied to current plan of care 2. Clinical documentations supporting:

a. Mobility limitations b. Wound ulcers with measurements, staging, measurements, location

and description c. Prior ulcer treatment program, duration and response to treatment,

including type of support surface currently used

d. Physician supervised current plan of care including wound program, nutritional status and expected length of need

e. Home assessment of structural support of floor and electrical system

Prialt (ziconotide intrathecal)


J2278 Provide the following: 1. Current Prescription


3. Physician office notes that include the following: 4. Diagnosis

a. Documentation that the prescriber is experienced with intrathecal administration

b. Documentation that the member does not have any of the following:

c. Pre-existing history of psychosis d. Intrathecal analgesia is contraindicated due to spinal cord obstruction,

bleeding diathesis or infection at the microinfusion site

e. Medical condition or treatment would render the intrathecal administration hazardous

f. Hypersensitivity to ziconotide g. Documentation that member is intolerant or refractory to one of the

following: i. Systemic analgesics ii. Adjunctive therapies

iii. Intrathecal morphine 5. Physician treatment plan

Private Duty Nursing (PDN)

S9122 S9123 S9124 T1000 T1002 T1003 Initial request:

1. Signed order and/ or Letter of Medical Necessity 2. Recent hospitalization documentation, if applicable

3. Recent clinical documentation from Primary Care Physician and/ or

specialist, if applicable 4. Recent home health agency notes if currently receiving services

5. Summary of Case Manager assessment and/ or notes


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Recertification of Services:

1. Current 485 (must be signed) 2. Current Letter of Medical Necessity and/ or order (must renew annually)

3. Note last time member was seen by Primary Care Physician (must see

Primary Care Physician annually) 4. 60 Day Skilled Nurse Summary including:

a. Nursing Summary needs to be current and related to ALL stated diagnosis

b. Vital Signs ranges, O2 Sats, glucose levels, PT/ INR levels, HCT/ HGB

if receiving B12 injections c. Medication changes, wound care with wound measurements, edema

with description, weight gain/ weight loss d. Member’s functional mobility

Caregiver must be identified. Does caregiver participate in care of the member? Who lives with the member? Who administers medications?

Recent inpatient or ER visits with dates and diagnosis Summary of most current Case Management notes

Private Duty Nursing (PDN) for Community Plan:

• Hawaii (HI)

• Maryland (MD) • Mississippi (MS)

• Missouri (MO) • Nebraska (NE) • Ohio (OH)

• Rhode Island (RI) • Wisconsin (WI)

For applicable coding refer please visit our Health Plans by State section of UHCprovider.com and select the appropriate state, then Community Plan to

view codes included in the program.

For initial request provide the following clinical information:

1. Home health certification and plan of care (CMS-485) signed by a physician

(MD or DO) 2. Signed order and/or Letter of Medical Necessity, if applicable 3. Recent hospitalization documentation, include the discharge summary or

recent progress note, if PDN requested upon discharge

4. Recent Consultation notes (actual clinic notes not after care summary) if the member is receiving services from subspecialist

5. Recent Nurses’ notes, logs and daily care flow sheets ; currently receiving

services if transitioning from another payer 6. Documentation of skilled care need and Medication Administration Record 7. Provide the days and hours of private duty nursing being requested.

Example: 8 hours a day x 5 days a week (9 am – 5 pm) 8. Documentation of the available support system must include but not

limited to the following: a. Provide the availability of the member’s primary caregiver such as

hours in the home as applicable b. Ability of the member’s primary caregiver to provide care as applicable c. School attendance and availability of coverage for services by school

district, if applicable; Include the time of school arrival and departure, number of hours private duty is provided in school

d. Primary caregiver’s work schedules, as applicable. Include days, hours

worked per day.

Note: Additional documentation clarifying clinical status (such as well child check and/or specialist visit notes) may be requested if clinical

documentation provided does not clearly support the hours being requested.



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For recertification of services provide the following information:

1. Current CMS-485 (must be signed and reviewed every 60 days) 2. Current Letter of Medical Necessity and/or order, if applicable 3. Nurses’ notes, logs and daily care flow sheets for 2 weeks prior to the

request as applicable.

4. Provide Primary caregiver’s work schedules, as applicable. Include days, hours worked per day.

Note: Additional documentation clarifying clinical status (such as well child check and/or specialist visit notes) may be requested if clinical

documentation provided does not clearly support the hours being requested.

Probuphine®

(buprenorphine)

J0570 For an initial request provide medical notes documenting the following:


2. Name and tax ID number of the servicing provider/facility

3. Weight

4. Diagnosis

5. Provide the date and dosage the member started oral, sublingual, or transmucosal buprenorphine

6. Patient has been on a stable oral, sublingual, or transmucosal buprenorphine dose for six months or longer without any need for

supplemental dosing or adjustments

7. Provider's unique dentification number specific to the prescription of medication assisted therapy (DEA-X)

8. Provider has completed a live training program for Probuphine insertion

9. Dose and frequency being requested including the treatment plan

10. Patient has not had an opioid-positive urine drug screen within 90 days of insertion

Request for continuation should include the elements required for an initial request above as well as medical notes documenting all of the following:

1. Patient has only had one Probuphine implant and has a viable, unused site

in the contralateral arm

2. There is no evidence of tampering and or attempted removal of previous

Probuphine implant

Procrit or Epogen (epoetin alfa)

J0885 Please provide the following: 1. Current prescription

2. Physician office notes that support documentation of: a. Drug dosage, route of administration and frequency including

physician’s treatment plan. Include documentation if the member is

receiving the drug as part of dialysis b. History of the medical condition requiring treatment including clinical

indications and the most recent hgb / hct, serum erythropoietin level and other pertinent labs such as iron studies

c. Previous treatment provided including the name of the drug, course of treatment including dates and response

d. Medications tried, failed or unable to tolerate


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e. If the member is receiving this drug as part of a clinical trial, please provide information about the clinical trial, including the clinical trial identifier

f. Documentation of how the drug will be supplied and who will

administer the drug to the member (e.g., supplied by office/ facility,

obtained by member from either a pharmacy or OptumRx Specialty Pharmacy Program)


Prolastin (alpha 1-proteinase inhibitor – human)

J0256 Please provide the following for an initial request: 1. Current prescription 2. Name and tax ID number of the servicing provider/ facility 3. Physician office notes that include:

a. Member diagnosis b. Laboratory results of alpha1-antitrypsin (AAT) level and genetic

testing to confirm diagnosis

c. Current Pulmonary function test results d. Documentation of signs and symptoms e. List of medications being taken for this condition

f. Documentation that member is a nonsmoker, g. Dose, frequency including the physician treatment plan


a. If the location is in a facility, provide office notes for at least one of the following:











claim processing

3. Physician office notes that include: a. Documentation with member’s response to therapy

b. Dose, frequency including the physician treatment plan


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Prosthetic - Breast A4280 L8000 L8001 L8002 L8010 L8015 L8020 L8030 L8031 L8032 L8035 L8039

S8460

Medical notes documenting the following: 1. Current prescription from physician 2. Diagnosis 3. Previous breast surgery (ies), reason and date(s)

4. Indicate if initial or replacement

a. Reason for replacement, if applicable b. Date received initial prosthetic, if applicable

Prosthetic - Eye and Face

Eye:

L8043 L8044 L8049

Face:

L8043 L8044 L8049

Medical notes documenting the following: 1. Current prescription from physician

2. Diagnosis 3. Type of prosthetic and anatomical location 4. Physician office notes with clinical information documenting:

a. Medical history related to the prosthetic including cause of facial defect

b. Current and previous surgery (ies)

Prosthetic - Lower Limb L5000 L5010 L5020 L5050 L5060 L5100 L5105 L5150 L5160 L5200 L5210 L5220



L5636 L5639 L5640 L5642 L5643 L5644

L5645 L5646 L5647 L5648 L5649 L5650 L5651 L5652 L5653 L5654 L5655 L5656





L5972 L5973 L5975 L5976 L5978 L5979 L5980 L5981 L5984 L5985 L5986 L5987 L5988 L5990 L5999 L8420

For Prosthetics provide the following items:

1. Vendor Coversheet with the narrative describing the request 2. Vendor invoice listing the HCPCS codes, make model description, indicate

if the item is right or left

3. As applicable include other healthcare professional supporting documentation

Provide the following clinical information: 1. Current prescription from physician 2. Physician office notes with clinical information documenting:

a. Medical history related to the prosthetic request

b. Members weight and height c. Examination findings to include ROM at the hip and knee d. Comorbidities

e. Specify absent limb. Indicate the date and level of amputation, if applicable. Document the current functional ability (include specific examples) and expected rehab potential as appropriate

f. Describe limitations to Activities of Daily Living (ADLs) include assistive devices to facilitate ambulation within and outside the home. Surfaces normally traversed include distance and environment

g. Condition of contralateral limb

h. Prosthetist notes i. Specify if the prosthetic is new for the member OR if it is a

replacement? Please indicate if this is a preparatory or permanent

device

If it is a replacement prosthesis, include the following additional documentation:

1. Indicate the components on the current prosthesis to include the following: Socket, Knee, Foot, Ankle, sock ply and liner thickness

2. Provide the age of the current prosthesis. Include the reason for

replacement


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3. Describe changes in limb including but not limited to comparative residual limb measurements

4. If request is for a socket replacement, describe what adjustments have been tried and failed

Prosthetic -

Miscellaneous

L5637 L5638 L6680 L6682 L7362 L7364

L7366 L7367 L8310 L8320 L8330 L8410 L8415 L8435 L8465 L8480 L8485 L8499


L8658 L8659 L8670 L8684 L8695 L8699

Note: Refer to anatomic site for detailed instructions (e.g.,

breast, eye, face, upper/ lower limb). For any prosthetic that does not fit into breast, eye, face, upper/lower limb categories

please submit the following:

1. Current prescription from physician 2. Physician office notes with clinical information documenting:

a. Reason for prosthetic device b. Medical history

c. Surgical history 3. Name of what is being requested, to include:

a. Brand name

b. Make and model c. Equipment quote

Prosthetic - Upper Limb L6000 L6010 L6020 L6025 L6050 L6055 L6100 L6110 L6120 L6130 L6200 L6205 L6250 L6300 L6310 L6320 L6350 L6360 L6370 L6380 L6382 L6384 L6386 L6388 L6400 L6450 L6500 L6550 L6570 L6580

L6582 L6584 L6586 L6588 L6590 L6600

L6605 L6610 L6611 L6615 L6616 L6620 L6621 L6623 L6624 L6625 L6628 L6629





L7181 L7185 L7186 L7190 L7191 L7400 L7401 L7402 L7403 L7404 L7405 L7499 L7500 L7600 L7260 L7261 L7266 L7272 L7274

For Prosthetics provide the following items: 1. Vendor Coversheet with a narrative describing the request 2. Vendor invoice listing the HCPCS codes, make/ model description, indicate

if the item is right or left. Include pricing for unlisted codes. 3. As applicable include other healthcare professional supporting

documentation

Provide the following clinical information:


2. Physician office notes with clinical information documenting: a. Member’s medical history related to the prosthetic request b. Members height and weight

c. Comorbidities d. Specify absent limb. Indicate the date and level of amputation, if

applicable e. Describe limitations to Activities of Daily Living (ADLs) with and

without the prosthetic f. Specify whether the prosthetic is an initial, replacement or a request to

upgrade. Describe the current prosthesis

3. Prosthetist notes 4. Condition of residual and contralateral limb 5. Motivation to use device

6. If powered, indicate why a body powered device is not sufficient 7. If myoelectric, include: 8. Microvolt threshold and outcome of test 9. Environment in which the device will be used

Prothrombin Time (PT) International

G0248 G0249 1. Current prescription from physician 2. Equipment quote

3. Physician office notes with:


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Normalized Ratio (INR) Monitor

a. Clinical documentation of diagnosis b. The most recent PT/ INR results c. Face to face educational program d. Length of time the member has been on anticoagulation

e. Frequency of self-testing

Proton Beam Therapy 77520 77522 77523 77525 Medical notes documenting all of the following:

1. History of medical condition requiring treatment 2. Documentation that sparing of the surrounding normal tissue cannot be

achieved with standard radiation therapy techniques

3. Evaluation includes a comparison of treatment plans for PBT, IMRT, and stereotactic body radiation therapy (SBRT)

4. For Hypofractionated radiation provide the prescribed total dose and dose per fraction

5. For delivery of radiation therapy course with standard fractionation, provide the dose prescription along with,

6. Documentation in the form of a clearly labeled, color comparative Proton,

and IMRT Dose Volume Histogram and dose table, in absolute doses noting that sparing of the surrounding normal tissue cannot be achieved with IMRT techniques

Submission of color comparative Proton and IMRT Dose Volume Histogram and dose table can be submitted via the external portal at www.uhcprovider.com/paan or via email at [email protected]; faxes will not be accepted

Note: If citing an RTOG dose constraint, please provide the RTOG protocol number

Provenge (sipuleucel-T)


Community Plan

Q2043 Please provide the following for an initial request: Current prescription Medication name








Radiation Therapy 77371 77372 77373 77385 77386 G0173 G0251 G0339 G0340 G6015 G6016

Physician office notes with include the following:

1. History of medical condition requiring treatment


Radicava (edavarone) J1301 Please provide the following:





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2. Physician office notes should include: a. If the drug is being prescribed by or in consultation with a neurologist b. Radicava dosing for ALS is in accordance with the U.S. Food and Drug

Administration (FDA)-approved labeling

c. EL Escorial and Airlie House diagnostic criteria results that indicate a

diagnosis of a definite or probable Amyotrophic Lateral Sclerosis (AML) d. ALS Functional Rating Scale-Revised (ALSFRS-R) results prior to

treatment e. Forced Vital Capacity (FVC) % at the start of treatment f. Physicians treatment plan


following:








infusion therapy

Radiology Services -

Breast Imaging for Screening and Diagnosing Cancer

76376 76377 76498 77046 77047 77048 77049

Provider should call the number on the member’s ID card when referring for

radiology services 1. Medical notes documenting all of the following: 2. Recent history & physical 3. Documentation to support medical necessity (i.e., family history, prior

treatment, genetic testing results, other imaging studies and diagnostic results, etc.)

4. Applicable CPT code

For codes 77046 and 77047:

If location being requested is an outpatient hospital, in addition to the above, provide medical notes documenting one of the

following:

1. Less than 19 years of age 2. Require obstetrical observation 3. Require perinatology services

4. Have a known contrast allergy


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5. Have a known chronic disease with prior radiology imaging procedures for the diagnosis, management or surveillance of the disease at the hospital outpatient department

6. Have pre-procedure imaging where the surgery or procedure is being

performed at the hospital

OR

7. When there are no geographically accessible appropriate alternative sites for the individual to undergo the procedure, including but not limited to the following:

a. Moderate or deep sedation or general anesthesia is required for the procedure; or

b. The equipment for the size of the individual is not available; or

c. Open magnetic resonance imaging is required because the member has a documented diagnosis of claustrophobia and/or severe anxiety

OR

8. When imaging in a physician’s office or freestanding imaging center would

reasonably be expected to delay care and adversely impact health outcome


Computed Tomographic (CT) Colonography

74261 74262 74263 Provider should call the number on the member’s ID card when referring for

radiology services 1. Medical notes documenting all of the following:

Recent history & physical Co-morbid medical condition(s)

Documentation to support medical necessity Applicable CPT code

If location being requested is an outpatient hospital, in addition to the above, provide medical notes documenting one of the following:


4. Have a known contrast allergy 5. Have a known chronic disease with prior radiology imaging procedures for

the diagnosis, management or surveillance of the disease at the hospital

outpatient department 6. Have pre-procedure imaging where the surgery or procedure is being


OR

7. When there are no geographically accessible appropriate alternative sites

for the individual to undergo the procedure, including but not limited to the following:


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b. The equipment for the size of the individual is not

available; or

c. Open magnetic resonance imaging is required because

the member has a documented diagnosis of claustrophobia and/or severe anxiety

OR



Radiology Services - CT

Abdomen/ Pelvis

72192 72193 72194 74150 74160 74170 74176 74177 74178 75635

Provider should call the number on the member’s ID card when referring for radiology services

1. Recent history & physical with documentation of medical necessity a. Reports of all recent imaging studies and applicable diagnostics

b. Relevant medication(s) taken c. Documentation of pain; including pain scale, onset, duration,

frequency, and location


1. Less than 19 years of age 2. Require obstetrical observation

3. Require perinatology services


the diagnosis, management or surveillance of the disease at the hospital outpatient department

6. Have pre-procedure imaging where the surgery or procedure is being


OR




available; or


OR


reasonably be expected to delay care and adversely impact health

outcome


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Radiology Services – CT Head

70450 70460 70470 70480 70481 70482 70486 70487 70488 70490 70491 70492


Recent history & physical with documentation of medical necessity

a. Reports of all recent imaging studies and applicable diagnostics b. Relevant medication(s) taken

c. Documentation of pain; including pain scale, onset, duration,



following:

1. Less than 19 years of age 2. Require obstetrical observation 3. Require perinatology services 4. Have a known contrast allergy


6. Have pre-procedure imaging where the surgery or procedure is being performed at the hospital

OR




c. Open magnetic resonance imaging is required because the member has a documented diagnosis of

claustrophobia and/or severe anxiety

OR



Radiology Services – MRI Breast

77046 77047 77048 77049 Provider should call the number on the member’s ID card when referring for radiology services

Recent history & physical with documentation of medical necessity a. Reports of all recent imaging studies and applicable diagnostics b. Relevant medication(s) taken

c. Documentation of pain; including pain scale, onset, duration, frequency, and location

For codes 77046 and 77047:


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OR

7. When there are no geographically accessible appropriate alternative sites for the individual to undergo the procedure, including but not limited to the

following:





OR

8. When imaging in a physician’s office or freestanding imaging center would reasonably be expected to delay care and adversely impact health outcome

Radiology Services – MRI Head

70551 70552 70553 70554 70555 70557 70558 70559


1. Recent history & physical with documentation of medical necessity a. Reports of all recent imaging studies and applicable diagnostics

b. Relevant medication(s) taken c. Documentation of pain; including pain scale, onset, duration,


For codes 70551, 70552, 70553, 70554, or 70555:


1. Less than 19 years of age

2. Require obstetrical observation 3. Require perinatology services 4. Have a known contrast allergy

5. Have a known chronic disease with prior radiology imaging procedures for



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OR


following:




OR



Radiology Services – MRI Joint Lower Extremity

73721 73722 73723 Provider should call the number on the member’s ID card when referring for radiology services

1. Recent history & physical with documentation of medical necessity a. Reports of all recent imaging studies and applicable diagnostics b. Relevant medication(s) taken c. Documentation of pain; including pain scale, onset, duration,



following:





OR


following:


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available; or



OR



Radiology Services - MRI Joint Upper Extremity


1. Recent history & physical with documentation of medical necessity

a. Reports of all recent imaging studies and applicable diagnostics b. Relevant medication(s) taken c. Documentation of pain; including pain scale, onset, duration,



following:

1. Less than 19 years of age

2. Require obstetrical observation

3. Require perinatology services 4. Have a known contrast allergy



OR




c. Open magnetic resonance imaging is required because the member has a documented diagnosis of


OR




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Radiology Services - MRI Spine

72141 72142 72146 72147 72148 72149 72156 72157 72158




c. Documentation of pain; including pain scale, onset, duration,



following:

1. Less than 19 years of age 2. Require obstetrical observation 3. Require perinatology services 4. Have a known contrast allergy



OR




available; or c. Open magnetic resonance imaging is required because

the member has a documented diagnosis of


OR

8. When imaging in a physician’s office or freestanding imaging

center would reasonably be expected to delay care and adversely impact health outcome


MRI Spine/ Pelvis



d. Reports of all recent imaging studies and applicable diagnostics e. Relevant medication(s) taken f. Documentation of pain; including pain scale, onset, duration,



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OR


following: a. Moderate or deep sedation or general anesthesia is

required for the procedure; or




OR

8. When imaging in a physician’s office or freestanding imaging center would reasonably be expected to delay care and adversely impact health outcome


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Radiology Services – MRI/ CT Scan – Site of Service

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 72191 72192 72193

72194 73200 73201 73202 73206 73700 73701 73702 73706 74150 74160 74170 74174 74175 74176 74177 74178 74261

74262 74263 75571 75572 75573 75574 75635 76380 76497 70336 70540 70542 70543 70544 70545 70546 70547 70548

70549 70551 70552 70553 70554 70555 71550 71551 71552 71555 72141 72142 72146 72147 72148 72149 72156 72157 72158 72195 72196 72197 73218 73219

73220 73221 73222 73223 73718 73719 73720 73721 73722 73723 74181 74182 74712 74713 75557 75559 75561 75563

76390 76498 77021 77046 77047 77048 77049 77084 72159 72198 73225 73725 74183 74185 C8900 C8901 C8902 C8903

C8905 C8906 C8908 C8909 C8910 C8911 C8912 C8913 C8914 C8918 C8919 C8920 C8931 C8932 C8933 C8934 C8935 C8936 G0297 S8092 S8037 S8042


Recent history & physical with documentation of medical

necessity:

a. Reports of all recent imaging studies and applicable

diagnostics

b. Relevant medication(s) taken


If location being requested is an outpatient hospital, in

addition to the above, provide medical notes documenting one of the following:

a. Less than 19 years of age

b. Require obstetrical observation

c. Require perinatology services

d. Have a known contrast allergy

e. Have a known chronic disease undergoing active treatment or surveillance for which direct comparison to prior hospital based imaging is required for care planning

f. Pre-procedure imaging which is done within 24 hours of

the interventional or surgical procedure and is an integral part of the planned procedure

OR

When there are no geographically accessible appropriate alternative sites for the individual to undergo the procedure, including but not limited to the following:

a. Moderate or deep sedation or general anesthesia is

required for the procedure; or



OR

When imaging in a physician’s office or freestanding imaging

center would reasonably be expected to delay care AND adversely impact health outcome

Radiology Services –

Positron Emission Tomography (PET)

78459 78491 78492 78608 78609 78811

78812 78813 78814 78815 78816 A9515 A9526 A9552 A9580 A9587 A9588 G0219 G0235 G0252 S8085


Recent history & physical with documentation of medical necessity




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Radiology Services - Thyroid and Parathyroid



2. Reports of all recent imaging studies and applicable diagnostics 3. Relevant medication(s) taken

4. Documentation of pain; including pain scale, onset, duration, frequency,

and location

Radiopharmaceuticals A9699 A9606 C9031 A9513 1. Current prescription



a. Member diagnosis b. Imaging reports demonstrating advancing disease c. Previous treatments rendered and response d. Requested dose, frequency, and interval

Radium RA-223 Dichloride for KS

Community Plan

A9606 1. Current Prescription 2. Name and tax ID number of the servicing provider/ facility to facilitate


a. Diagnosis

b. Documentation of no visceral metastatic disease 4. Physician treatment plan

Rebinyn

(glycopegylated)


Community Plan


Current prescription

a. Name and tax ID number of the servicing provider/ facility to facilitate claim processing

b. Physician office notes that include: c. Diagnosis d. Reason for administration

e. Physician Plan of Care

Remicade (infliximab) J1745 1. Current prescription







a. If the location is in a facility provide office notes for at least one of the following: i. Medically unstable based upon submitted clinical history

ii. Initial medication infusion of or re-initiation after more than 6



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iii. Previous experience of a severe adverse event following infusion. Examples include but are not limited to anaphylaxis, seizure, thromboembolism, myocardial infarction, renal failure



For Crohn Disease provide the following additional information:

Medical notes documenting the following: 1. Crohn’s Disease Activity Index (CDAI) ≥ 220 and ≤ 400 OR 2. History of failure, contraindication, or intolerance to at least one

conventional therapy (e.g., corticosteroids, 6-mercaptopurine, azathioprine, methotrexate, etc.)

For Non-Infectious Uveitis provide medical notes documenting the following:

1. Diagnosis of refractory non-infectious uveitis that is threatening vision, AND

2. History of failure, contraindication, or intolerance to ALL topical steroids,

systemic steroids and immunosuppressive drugs (e.g., azathioprine, cyclosporine, or methotrexate)

For Plaque Psoriasis provide medical notes documenting the following: 1. Chronic severe plaque psoriasis (i.e., extensive and/ or disabling), AND 2. The member is a candidate for systemic therapy

For treatment of Rheumatoid Arthritis (RA) provide medical notes

documenting the following: 1. Moderate to severe active rheumatoid arthritis, AND

2. One of the following: a. The member is concurrently receiving Methotrexate, OR b. Methotrexate is contraindicated or member is intolerant

For Treatment of Sarcoidosis provide medical notes documenting the following: 1. History of failure, contraindication, or intolerance to corticosteroids (e.g.,

prednisone, methylprednisolone); and 2. History of failure, contraindication, or intolerance to one

immunosuppressant (e.g., methotrexate, cyclophosphamide, azathioprine)

For treatment of Ulcerative Colitis (UC) provide medical notes documenting the following:

1. Diagnosis of moderately to severely active ulcerative colitis (UC); AND 2. History of failure, contraindication, or intolerance to at least one

conventional therapy (e.g., 6-mercaptopurine, aminosalicylate, azathioprine, corticosteroids)

For treatment of adverse reactions or checkpoint inhibitor toxicities provide medical notes documenting the following:


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1. Member has recently received checkpoint inhibitor therapy [e.g., Keytruda (Pembrolizumab), Opdivo (Nivolumab); AND

2. Documentation describing the adverse event to the checkpoint inhibitor therapy

3. History of failure, contraindication, or intolerance to corticosteroids (e.g.

methylprednisolone) 4. Documentation that the diagnosis is related to one of the following: Colitis,

Pneumonitis, Acute Renal Failure, Elevated serum creatinine, Uveitis, Myocarditis, Pericarditis, Arrhythmia, Impaired Ventricular Function, Inflammatory Arthritis

Remicade (infliximab) for Iowa (IA), Louisiana (LA), and

Pennsylvania(PA) Community Plan

J1745 For IA, LA and PA Community Plan please provide the following: 1. Current prescription 2. Name and tax ID number of the servicing provider/ facility to facilitate


a. Diagnosis

b. Physician Treatment Plan and goals

Remicade (infliximab)


J1745 For KS Community Plan provide the following:


claim processing

3. Physician office notes that include: a. Member diagnosis b. Reason for treatment, including positive/ negative response to

previous treatments

c. Documentation of signs and symptoms, d. Functional Limitation(s) associated with the members condition e. Previous treatment provided including the name of all drug(s), dates,

duration course of treatment and clinical response f. Physician treatment plan include plan to reassess administration g. List all medications being taken with Infliximab products

Remicade (infliximab) for Washington (WA) Community Plan

J1745 For WA Community Plan provide the following: 1. Current prescription 2. Name and tax ID number of the servicing provider/ facility to facilitate


a. Member diagnosis

b. Reason for treatment, including positive/ negative response to previous treatments

c. Previous treatment provided including the name of all drug(s), dates

and duration course of treatment and clinical response d. Conservative treatment including therapy and all of the medications

have been tried, failed or are contraindicated e. Dose, frequency, interval since previous treatment, and the physician

treatment plan include plan to reassess administration f. Documentation of a negative TB Skin test, include the date

administered


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g. Documentation that Remicade is not being used in combination with other biologic DMARDs, janus kinase inhibitor, or phosphodiesterase 4 (PDE4) inhibitor

Renflexis (infliximab abda)

Q5104 Please provide the following for an initial request: 1. Current prescription

2. Name and specialty of the prescribing and/ or consulting provider

3. Name and tax ID number of the servicing provider/ facility if different than prescribing/ consulting provider

4. Medical notes that include:

a. Member weight b. Member diagnosis c. Medication treatments tried, failed, contraindicated. Include the dates

and reason for discontinuation

d. Dose and frequency being requested and treatment plan e. List of medications member will also be taking to treat the condition



following:





mitigated by pre-medications or infusion rate adjustments v. Physically and/or cognitively impaired AND no home caregiver

available

vi. Difficulty establishing and maintaining patent vascular access vii. Homecare or infusion provider has deemed that the patient,


In addition to the above, please also provide the following for continuation: 1. Documentation of positive response to the requested medication

Respiratory Assistive Device – Bilevel Positive

Airway Pressure (BIPAP) for Diagnosis of Obstructive Sleep Apnea

(OSA) and Other Diagnoses

E0470 E0471 E0472 For initial three (3) month trial of therapy: 1. Current prescription from physician

2. Physician office notes indicating clinical condition and the following additional details:

For Obstructive Sleep Apnea (OSA) diagnosis code of G 47.33 include:

1. Face-to-face evaluation prior to sleep test to assess for OSA 2. Sleep test report scoring using 4% definition of hypopnea

3. Documentation of a trial of E0601 (CPAP) including clinical response

For Restrictive Thoracic Disorders include:


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1. Specific neuromuscular disease or thoracic cage abnormality and respiratory co-morbidities, AND

2. Arterial blood gas PaCo2 while awake and on prescribed FIO2, OR 3. Sleep oximetry study saturation results with minimum of 2 hour nocturnal

recording while on prescribed FIO2, OR

4. For Neuromuscular disease only Maximal inspiratory pressure or forced vital capacity

For Severe COPD include:

1. Arterial blood gas PaCo2 while awake and on prescribed FIO2

2. Sleep oximetry study saturation results with minimum of 2 hour nocturnal recording while on prescribed FIO2,

3. Documented evaluation of OSA and treatment with CPAP has been considered and ruled out

For Central Sleep Apnea or Complex Sleep apnea include:

1. A complete facility-based, attended polysomnogram that confirms CSA or

CompSA, AND 2. Documents degree of improvement of the sleep-associated hypoventilation

with the use of an E0470 or E0471 device on the settings that will be

prescribed for initial use at home, while breathing the member’s prescribed FIO2

For Hypoventilation Syndrome include:

1. Arterial blood gas PaCo2 while awake and on prescribed FIO2, AND 2. FEV1/ FVC spirometry results, AND 3. Arterial blood gas PaCO2, done during sleep or immediately upon

awakening, and breathing the member’s prescribed FIO2, or a facility-based polysomnogram of nocturnal recording time (minimum recording time of two (2) hours)

For continued rent to purchase of device

1. Documentation in the member’s medical record about the progress of relevant symptoms and member usage of the device up to that time

2. A signed and dated statement completed by the treating physician no sooner than 61 days after initiating use of the device, declaring that the member is compliantly using the device (# of hours per 24 hour period)

and that the member is benefiting from its use

For Replacement submit the following information:

1. Age and type of the current PAP therapy device 2. Reason as to why the device needs to be replaced 3. A recent face-to-face evaluation by the treating physician that documents

continued compliance with benefit from the current PAP therapy

Respiratory Interleukins

J0517 - Fasenra (benralizumab) J2182 - Nucala (mepolizumab)

For an initial request: 1. Current prescription


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• CINQAIR® • FASENRA® • NUCALA®

J2786 - Cinqair® (reslizumab) 2. Medication name 3. Name and specialty of the prescribing and/ or consulting provider 4. Name and tax ID number of the servicing provider/ facility if different than



a. Member’s diagnosis b. Provide results of the Asthma Control Questionnaire (ACO) or Asthma

Control Test (ACT) if available c. Provide blood eosinophil level and date drawn (within the last 6 weeks) d. Provide results of the Forced Expiratory Volume (FEV1)

e. Asthma related emergency treatment describe the treatment provided and number of occurrences over the last 6 months

f. Documentation of treatments tried, failed, contraindicated. Include the dates and reason for discontinuation



physician office, self-administered, home health nurse) a. If the location is in a facility, provide documentation to support facility

administration



b. Current utilization of ancillary medications

c. Date the therapy was started

Retacrit (epoetin alfa –epbx)

Q5106 1. Current prescription 2. Physician office notes that support documentation of:

a. Drug dosage, route of administration and frequency including

physician’s treatment plan b. History of the medical condition requiring treatment including clinical

indications and the most recent hgb/ hct, serum erythropoietin level and other pertinent labs such as iron studies

c. Previous treatment provided including the name of the drug, course of treatment and response

d. If the member is receiving this drug as part of a clinical trial, please

provide information about the clinical trial, including the clinical trial identifier

e. Documentation of how the drug will be supplied and who will

administer the drug to the member (e.g., supplied by office/ facility, obtained by member from either a pharmacy or OptumRx Specialty Pharmacy Program)

NOTE: If drug is obtain by the member prior authorization may be required

through the member’s Part D benefits

Revcovi (elepegademase

-lvlr)

C9399 J3490 J3590 Please provide the following for an initial request:



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b. Laboratory results or genetic testing to confirm diagnosis with one of

the following: i. Deficiency or absence of ADA in plasma, lysed erythrocytes,

fibroblasts (cultured from amniotic fluid), or chorionic villus ii. Increase in deoxyadenosine triphosphate (dATP) levels in

erythrocyte lysates compared to laboratory standard

iii. Decrease in ATP concentration in erythrocytes iv. Molecular genetic confirmation of mutations in both alleles of the

ADA1 gene v. Positive screening by T cell receptor excision circles (TRECs);

c. Member is not a candidate for a hematopoietic cell transplant or has failed a transplant

d. Documentation of signs and symptoms

e. Dose, frequency including the physician treatment plan 4. Location where the drug will be administered (e.g., infusion center,










Please provide the following for a continuation request: 1. Current prescription 2. Name and tax ID number of the servicing provider/ facility to facilitate


a. Positive response to medication b. Documentation of signs and symptoms

c. Dose, frequency including the physician treatment plan


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Review at Launch for New to Market Medications -C&S

• Avsola™ (infliximab-

axxq) • Adakveo®

(crizanlizumab-tmca) • Givlaari™ (givosiran) • Monoferric™ (ferric

derisonmaltose) • Tepezza™

(teprotumumab-trbw) • Reblozyl®

(luspatercept-aamt)

• Vyepti. (eptinezumab) • Vyondys 53™

(golodirsen) • Zolgensma®

(onasemnogene abeparvovec-xioi)

C9399 J3490 J3590 Applicable to Community Plans that have a prior authorization requirement For applicable coding refer please visit our Health Plans by State section of UHCprovider.com and select the appropriate state, then Community Plan


2. Name and specialty of the prescribing and/ or consulting provider 3. Name and tax ID number of the servicing provider/ facility if different

than prescribing/ consulting provider 4. Physician office notes that include:

a. Member weight





a. If the location is in a facility provide office notes for at least one of the following: i. Medically unstable based upon submitted clinical history



thromboembolism, myocardial infarction, renal failure





Review at Launch for New to Market Medications -E&I

• Adakveo®

(crizanlizumab-tmca)

• Givlaari™ (givosiran) • Monoferric™ (ferric

derisonmaltose) • Reblozyl®

(luspatercept-aamt)

• Tepezza™ (teprotumumab-trbw)

• Vyepti. (eptinezumab)

C9399 J3490 J3590 1. Current prescription 2. Name and specialty of the prescribing and/ or consulting provider 3. Name and tax ID number of the servicing provider/ facility if different

than prescribing/ consulting provider 4. Physician office notes that include:

a. Member weight




5. Location where the drug will be administered (e.g., infusion center, physician office, self-administered, home health nurse


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• Vyondys 53™ (golodirsen)









Rhinoplasty and Other Nasal Surgeries

30400 30410 30420 30430 30435 30450 30460 30462 30465 30560 30620


1. Diagnosis

2. Detailed history of nasal symptoms including evaluation and management notes for the date of service and the note for the day the decision to perform surgery was made

3. Evidence of chronic sinusitis with treatment, response, and duration 4. History of treatments tried, failed, or contraindicated 5. Specific diagnostic image(s) that show the abnormality for which surgery is

being requested. Consultation with requesting surgeon may be of benefit

to select the optimal images Note: Diagnostic images must be labeled with: a. The date taken and


Submission of diagnostic image(s) is required via the external portal at


6. Diagnostic imaging report(s) 7. Details of functional impairment, if applicable

8. Physician’s plan of care 9. High-quality color image(s) (full face photos in cases of post-traumatic

nasal deformity)

Note: All image(s) must be labeled with the: a. Date taken and b. Applicable case number obtained at time of notification, and member’s

name and ID number on the image(s) Submission of color image(s) is required via the external portal at www.uhcprovider.com/paan or via email at [email protected]; faxes will not

be accepted




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10. In addition to the above, additional documentation requirements may apply for CPT code 30560; refer to the Coverage Determination Guideline titled Cosmetic and Reconstructive Procedures

Rituxan (rituximab) For

KS Community Plan

J9311 J9312 For KS Community Plan provide the following:

Current Prescription

Name and tax ID number of the servicing provider/ facility to facilitate claim processing

Physician office notes that include the following:

Diagnosis Result of CD-20 testing Results of CBC and platelet count List of all medications taken for the condition

List of medication tried, failed or contraindicated include dates and durations

Physician treatment plan

Rituximab

• Rituxan® (rituximab) • Rituxan Hycela®

(rituximab and hyaluronidase human)*

• Ruxience® (rituximab-pvvr)

• Truxima® (rituximab-

abbs

J9311 J9312 Q5115 Please provide the following for an initial request: Current prescription






e. List medications member will be taking to treat the condition In addition to the above, please also provide the following for continuation:



Sandostatin (octreotide) J2353 Please provide the following for an initial request:




a. Member weight b. Member diagnosis c. Documentation of treatments tried, failed, contraindicated. Include the





https://www.uhcprovider.com/content/dam/provider/docs/public/policies/comm-medical-drug/cosmetic-and-reconstructive-procedures.pdf


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Seat Lifts E0172 E0627 E0628 E0629 1. Current prescription from physician

2. Physician office notes with clinical information documenting:

a. Diagnosis

b. Whether the member is completely incapable of standing up from a

regular armchair or any chair in his/ her home c. Whether the member has the ability to ambulate once standing d. Whether all appropriate therapeutic modalities to enable the member

to transfer from a chair to a standing position (e.g., medication, physical therapy) have been tried and failed

3. Make, model, and type of lift

4. Price quote

Self-Administered Drugs 90284 A9270 C9399 J0135 J0270 J0275 J0364 J0630 J0800 J0945 J1324 J1675 J1815 J2170 J2212 J2354 J2440 J2760

J2940 J2941 J3030 J3110 J3355 J3490 J3590 J9212 J9213 J9216 J9218 Q0515

Current physician office notes which include:

1. Medical Necessity for the use of a self-administered drug 2. History of medical condition requiring treatment

Simponi Aria

(golimumab)




a. Member weight


dates and reason for discontinuation d. Dose and frequency being requested including treatment plan e. List medications member will be taking to treat the condition


following:








infusion therapy


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Site of Service – Outpatient for Community Plans:

• Arizona (AZ)

• Florida (FL) • Maryland (MD)

• Michigan (MI) • Missouri (MO) • New Jersey (NJ)

• New York (NY) • Ohio (OH) • Pennsylvania (PA) • Rhode Island (RI)

• Tennessee (TN) • Washington (WA)

10061 10080 10121 11440 11441 11443 11444 11446 11450 11451 11462 11470 11604 11622 11623 11624 11626 11641 11642 11643 11730 11750 11755 11770 11772 11900 12001 12011 12032 12041

12051 13100 13120 13121 13131 13151 13152 15100 15120 15200 15240 15260 15275 15850 17110 17311 19020 19101

19110 19112 19120 19125 20205 20240 20550 20552 20553 21011 21012 21013 21014 21325 21335 21336 21337 21356

21365 21390 21554 21555 21556 21930 21932 21933 22514 22900 22901 22902 22903 23071 23075 24071 24073 24075 24200 25071 25075 25605 26392 27043

27093 27327 27337 27618 27632 28010 28035 28039 28041 28043 28045 28060 28080 28090 28092 28104 28108 28110

28113 28118 28119 28124 28160 28190 28192 28208 28285 28288 28289 28291 28292 28296 28297 28298 28299 28313

28315 28525 28645 28755 28825 29804 29805 29806 29807 29819 29820 29821 29822 29823 29824 29825 29826 29827 29828 29834 29835 29836 29837 29838

29840 29844 29845 29846 29848 29861 29862 29863 29870 29873 29874 29875 29876 29877 29879 29880 29881 29882

29884 29886 29887 29888 29889 29891 29892 29893 29894 29895 29897 29898 29914 29915 29916 30100 30130 30220

30630 30801 30802 30903 30930 31525 31526 31535 31536 31540 31541 31545 31571 31575 31591 31624 33222 36226 36227 36571 36581 36590 36821 36832

36901 36902 37248 37607 37609 37766 37785 38222 38500 38510 38525 40808 40812 41100 41112 42104 42106 42330

42410 42415 42420 42440 42808 42831 42870 43195 43200 43202 43220 43226 43229 43236 43237 43238 43240 43242

43245 43246 43247 43248 43250 43251 43254 43255 43259 43260 43270 43276 43450 43453 44360 44361 44369 44380

44382 44385 44386 44389 44394 45171

45172 45190 45334 45335 45340 45341 45346 45349 45350 45379 45381 45386


1. History 2. Physical examination including patient weight and co-morbidities

3. Surgical plan 4. American Society of Anesthesiologists (ASA) score, as applicable


of 186


45390 45398 45505 45560 45910 45915 45990 46020 46040 46050 46060 46080 46200 46220 46221 46230 46250 46255 46257 46261 46270 46275 46280 46285

46288 46320 46505 46606 46607 46615

46700 46750 46910 46924 46930 46946 46947 49250 49406 49422 49521 49525

49550 49553 49570 49572 51040 51610 51705 51715 52214 52276 52287 52315 52320 52341 52344 52354 52500 53450

53665 54057 54060 54150 54162 54163 54164 54530 54640 54700 54830 54840 55041 55060 55100 56515 56620 56700 56740 56810 57100 57135 57200 57240

57250 57260 57287 57410 57421 57461 57505 57513 57520 57530 58561 58562 62273 63661 63663 64561 64585 64612

64640 64642 64646 64650 64680 64776 64782 65400 65710 65779 65820 65875 65920 66172 66185 66250 66710 66711

66762 66825 66850 66852 66985 66986 67005 67010 67039 67041 67042 67105 67107 67108 67113 67121 67145 67210 67314 67412 67515 67700 67810 67840

67875 67880 68110 68115 68320 68700

68720 68815 68840 69000 69110 69145 69205 69421 69433 69610 69620 69632

69633 69635 69641 69642 69643 69644 69645 69646 69660 69661 69662 69801 0249T G0260

Sleep Apnea Treatment and Surgeries

21685 41512 41530 41599 42145 42299 S2080

Physician office notes that include history of condition:

1. Sleep study indicating a diagnosis of sleep apnea 2. Respiratory Disturbance Index

3. Documentation of excessive daytime sleepiness a. Documented using Epworth Sleepiness Scale or other validated scale b. Documentation that it interferes with daily activity or work (e.g.,

causes safety issues) c. Documentation indicating failed response or intolerance to CPAP usage

or other non-invasive treatment with involvement of qualified sleep

specialist d. Documented counseling by Physician trained in sleep disorders about

the benefits and risks of surgery e. Documentation if weight not a concern, or if weight loss was tried and

failed

For uvulopalatopharyngoplasty to correct OSA include the following additional information :


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1. Evidence of retrolingual obstruction as the cause of OSA or previous failure of Uvulopalatopharyngoplasty to correct the Obstructive Sleep Apnea

For maxillomandibular osteotomy and advancement include the following additional information :

1. Craniofacial disproportion or deformities, with evidence of maxillomandibular deficiency

2. Use and failure of an oral appliance; or documentation that the dental device is inappropriate given the member’s anatomy

For mandibular osteotomy to correct OSA include the following additional information:

1. Functional obstruction mostly retrolingual or lower pharyngeal 2. Use and failure of an oral appliance; or documentation that the dental

device is inappropriate give the member’s anatomy 3. Physician plan of care with proposed procedures including expected

outcome

Sodium Hyaluronate NON-Preferred Products C&S & E&I

• GenVisc 850 • Hyalgan • Supartz

• Supartz FX • Visco-3, • Hymovis

• Orthovisc • Gel-One • Monovisc

• Synojyont • Synvisc • Synvisc One • Triluron

• TriVisc

J3490 J7320 J7321 J7322 J7324 J7325 J7326 J7327 J7329 J7331 J7332

For initial requests for Sodium Hyaluronate therapy: 1. Current prescription 2. Name and tax ID number of the servicing provider/facility to facilitate


a. Member diagnosis of OA of the knee or temporomandibular joint (TMJ) or TMJ Disc displacement

b. Conservative treatment of at least 3 months, including response c. Signs and symptoms d. Current functional limitations

e. Complete report(s) of diagnostic imaging (X-ray, CT, or MRI reports) i. Both of the following:

(1) History of a trial of adequate dose and duration of Durolane,

Gelsyn-3, and Euflexxa with minimal response, AND

(2) Attestation that the clinical response would be expected to be superior than experienced with Durolane, Euflexxa, and

Gelsyn-3 OR

ii. Both of the following:

(1) History of intolerance, contraindication, or adverse event to Durolane, Euflexxa, and Gelsyn-3;

AND

(2) Physician attests that, in his/her clinical opinion, the same the same intolerance, contraindication, or adverse event would not be expected to occur with GenVisc 850, Hyalgan, Supartz, Visco-3, Hymovis, Orthovisc, Synvisc or Synvisc-One, Gel-

One, Monovisc, TriVisc, or Synojoynt 4. Physician treatment plan


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For continuation of therapy requests for Sodium Hyaluronate products: 1. Reason for treatment, including positive response to previous treatments 2. Date duration of last treatment

Sodium Hyaluronate NON-Preferred Products

for Medicare &

Retirement (M&R)

• Euflexxa

• Gel-One, • GenVisc 850 • Hyalgan • Hymovis

• Monovisc • Orthovisc, • Supartz

• Supartz F • Synojyont • Triluron

• TriVisc • Visco-3, • Orthovisc,

J3490 J7320 J7321 J7322 J7323 J7324 J7326 J7327 J7329 J7331 J7332

For initial requests for Sodium Hyaluronate product therapy (using non-preferred products: Euflexxa, , GenVisc 850, Hyalgan/ Supartz/ Supartz

FX/Visco-3, Hymovis Orthovisc, Gel-One, Monovisc, TriVisc or Synojyont):

Current prescription a. Name and tax ID number of the servicing provider/facility to facilitate

claim processing

b. Medical notes documenting all of the following: c. Member diagnosis of OA of the knee or temporomandibular joint (TMJ)

or TMJ Disc displacement d. Conservative treatment of at least 3 months, including response

e. Signs and symptoms f. Current functional limitations g. Complete report(s) of diagnostic imaging (X-ray, CT, or MRI reports)

i. ALL of the following:

(1) History of a trial of adequate dose and duration of Durolane, Gelsyn-3, or Synvisc orSynvisc One with minimal response,

AND

(2) Attestation that the clinical response would be expected to be superior than experienced with Durolane, Synvisc orSynvisc One and Gelsyn-3

OR

ii. ALL of the following:

(1) History of intolerance or adverse event to Durolane, Synvisc

or Synvisc One, and Gelsyn-3;

AND

(2) Attestation that in the physicians clinical opinion, the same

intolerance, or adverse event would not be expected to occur with GenVisc 850, Hyalgan, Supartz, Visco-3, Hymovis, Orthovisc, Euflexxa, Gel-One, Monovisc, TriVisc, or Synojoynt;

AND

h. Documentation that clearly indicates the reason that the patient cannot use all of the above preferred products

For continuation of therapy requests for Sodium Hyaluronate (using non-preferred products Euflexxa, GenVisc 850, Hyalgan/ Supartz/ Supartz FX/Visco-3, Hymovis Orthovisc, Gel-One, Monovisc, TriVisc or Synojyont:

Reason for treatment, including positive response to previous treatments a. Date duration of last treatment

Sodium Hyaluronate Preferred Products for

Community and State (C&S) & Commercial

(E&I) Products

J7318 J7323 J7328 1. Current prescription 2. Name and tax ID number of the servicing provider/facility to facilitate

claim processing 3. Physician office notes documenting:


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• Durolane • Euflexxa • Gelsyn

a. Member diagnosis of OA of the knee or temporomandibular joint (TMJ) or TMJ disc displacement

b. Conservative treatment tried for at least 3 months including response c. Signs and symptoms

d. Current functional limitations

e. Complete report(s) of diagnostic imaging (X-ray, CT, or MRI reports) f. Previous sodium hyaluronate treatment provided including the brand

name of the drug, course of treatment and response g. Dose, frequency, interval since previous sodium hyaluronate treatment h. Physician treatment plan

Sodium Hyaluronate Preferred Products for Medicare & Retirement

(M&R) – Initial & Continuation

• Durolane • Synvisc or Synvisc One • Gelsyn

J7318 J7325 J7328 1. Current prescription

2. Name and tax ID number of the servicing provider/facility to facilitate

claim processing

3. Medical notes documenting all of the following:

a. Member diagnosis of OA of the knee or temporomandibular joint (TMJ)

or TMJ disc displacement b. Conservative treatment tried for at least 3 months including response c. Signs and symptoms

d. Current functional limitations e. Complete report(s) of diagnostic imaging (X-ray, CT, or MRI reports) f. Previous sodium hyaluronate treatment provided including the brand

name of the drug, course of treatment and response g. Dose, frequency, interval since previous sodium hyaluronate treatment h. Physician treatment plan

Soliris (eculizumab) Initial & Continuation

J1300 Please provide the following for an initial request: 1. Current prescription 2. Name and tax ID number of the servicing provider/ facility

3. Physician office notes that include: a. Member weight a. Member diagnosis

b. Labs to support the diagnosis of atypical hemolytic uremic syndrome (aHUS)1. Please include CBC with differential, laboratory evidence of hemolysis, evidence of uremia, verification of the diagnosis, verification of exclusion of diagnoses of STEC-HUS and TTP with ADAMTS13

c. Labs to support the diagnosis of Paroxysmal Nocturnal Hemoglobinuria (PNH) and Hemoglobin and Hematocrit

d. Results of serologic test for anti-AChR antibodies to support diagnosis

of Myasthenia Gravis and one of the following: i. Results of Single Fiber electromyography (SFEMG) ii. Positive anticholinesterase test

e. Current symptoms experienced f. Dose and frequency being requested including the Physicians

Treatment Plan 4. Location where the drug will be administered (e.g., infusion center,


following:


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available




2. Physician office notes that include: a. Member weight a. Member diagnosis

b. Date the therapy was started c. Member response to therapy with the requested medication d. Labs to support the diagnosis of atypical hemolytic uremic syndrome

(aHUS)1. Please include CBC with differential, laboratory evidence of

hemolysis, evidence of uremia, verification of the diagnosis, verification

of exclusion of diagnoses of STEC-HUS and TTP with ADAMTS13 e. Labs to support the diagnosis of Paroxysmal Nocturnal Hemoglobinuria

(PNH) and Hemoglobin and Hematocrit or documentation of reduced transfusion

f. Results of serologic test for anti-AChR antibodies to support diagnosis

of Myasthenia Gravis and one of the following: i. Results of Single Fiber electromyography (SFEMG) ii. Positive anticholinesterase test

g. Dose and frequency being requested

h. Member response to therapy with the requested medication 3. Name and tax ID number of the servicing provider/ facility 4. Location where the drug will be administered (e.g., infusion center,


following:





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infusion therapy

Speech Therapy (ST) –

For Community Plans

Applicable to Community Plans that have a prior

authorization requirements • Arizona (AZ)

• Florida (FL) • Louisiana (LA) • Mississippi (MS)

• New Jersey (NJ) • Nebraska (NE) • New York (NY) – HARP

only

• Ohio (OH)

• Tennessee’s (TN)

For applicable coding refer please visit our

Health Plans by State section of UHCprovider.com and select the appropriate state, then Community Plan to view codes included in the program

For Community Plan members for a service request for speech therapy must

be generated by an in-network physician. Please provide required documentation indicated in the applicable UHC Community Plan Coverage Determination Guidelines for speech therapy/ language pathology services

Request for the initial referral / order prior to the speech language pathology or audiology evaluation. The order should include the following: 1. Physician referral dated within 30 days of the request

2. Name and tax ID number of the servicing provider/facility 3. Medical notes documenting all of the following:

a. Diagnosis and ICD-10 code(s) pertinent to Speech Therapy request

b. History & physical, including history of condition and limitations include the date of onset of illness and or injury, or exacerbation and any prior therapy treatment

c. Describe the functional impairment that impact health, safety and

independence d. Provide a comparison of the prior level of function to the current level

of function

e. Specialized/standardized assessments including name of the assessment, assessment scores and dates administered

f. Short and long-term therapeutic goals and objectives:

g. Treatment frequency, duration, and anticipated length of treatment session(s) if applicable

h. Evaluation reports must include: 4. Documentation of collaboration with early intervention, head start, and

public school programs (Individualized Family Service Plan (IFSP) or individualized education plan (IEP) may be required

5. If the current IEP is not available, the requesting therapist must include a

description of the goals and objectives from both therapists 6. In addition to the above ,if the member is bilingual or multilingual also

include:

a. Documentation of the member’s primary language and identify any other languages spoken in the home

Requests for continuation of therapy visits should include medical notes

documenting:

1. Clinically significant and measurable improvement of the member’s condition

2. Start of care date



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3. Time period covered by the report 4. Changes in prognosis, plan of care and/ or goals, with reason for change Request for re-evaluation should include the elements required for an initial

evaluation (above) as well as:

1. Update in prognosis, plan of care, goals and clearly established discharge criteria with reasons for update

2. Updated plan of care must not be older than 90 days AND 3. Goals must be measurable, functional and time based

If the Site of Service requested is an Outpatient Hospital clinic in addition to the above, provide medical notes documenting the following: 1. Why an in network freestanding clinic is not an option 2. Whether the therapy is part of an annual or semi-annual Comprehensive

Care Management assessment clinic visit for any of the following: paraplegia, quadriplegia, or traumatic brain injury

3. Whether the therapy is due to a complication of the following: major

multiple trauma, recent amputation, post-acute stroke, or severe burn injury

Spinal Stimulator for Pain Management

63650 63655 63685 63688 63661 63662 63663 63664 L8680 L8682 L8685 L8686 L8687 L8688


1. Specific device to be implanted including all documentation

2. Indicate if this request is for a trial or permanent placement 3. Physician office notes including:


b. Physical examination c. Treatments tried and failed including:

i. Spine surgery ii. Physical therapy iii. Medications

iv. Injections 4. Documentation of physical evaluation 5. Documentation of psychological evaluation

For permanent placement include

1. Documentation of pain relief with temporary implant


For revision or removal

1. Specific device to be implanted including all documentation

2. Indicate if this request is for a trial or permanent placement

3. Physician office notes including:

a. Condition requiring procedure b. Physical examination

c. Treatments tried and failed including:

i. Spine surgery ii. Physical therapy


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iii. Medications iv. Injections

4. Documentation of physical evaluation

5. Documentation of psychological evaluation

6. Documentation that device has failed and cannot be modified and or

repaired

For permanent placement include documentation of :

1. pain relief with prior implant


Spinal Surgery –

Scoliosis

22843 22844 22845 22849 22850 22852 1. Physician office notes including:

a. Degree of curvature(s) b. Progression of curvature c. History and co-morbid medical condition(s) d. Member’s symptoms and functional impairment

e. Physical exam, including neurologic exam f. Results of relevant test(s)

i. Diagnostic imaging

ii. Pulmonary function test(s) g. History and duration of previous therapy, when applicable

i. Physical therapy

ii. Bracing iii. Medications/ injections iv. Previous surgery

v. Other attempted treatments

2. Which of the following allograft products will you be using? Provide brand names, if applicable a. None

b. Autograft c. Cadaver allograft d. Animal allograft

e. Demineralized bone matrix; please indicate which of the following: i. Allograft DBM ii. Synthetic DBM

f. Amniotic tissue membrane

g. Bone morphogenetic protein-7 (BMP-7)Bone morphogenetic protein-2 (BMP-2); please indicate which of the following: i. Infuse bone graft/ LT-cage lumbar tapered fusion device

ii. Infuse bone graft/ interfix threaded fusion device iii. Infuse bone graft/ interfix RP threaded fusion device iv. Other cage type (for example PEEK or other);

h. Ceramic-based products; please indicate which of the following: i. Beta tricalcium phosphate (b-TCP) ii. Other; must provide the brand name

3. Cell-based products; please indicate which of the following:

a. Mesenchymal stem cells b. Infuse/ mastergraft posterolateral revision device system


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c. Optimesh d. Platelet-rich plasma (PRP)

For removal of instrumentation:

1. Physician office notes addressing reason for removal

2. Operative report for insertion of instrumentation

Spinal Ultrasonography 76856 76857 76881 76882 Clinical Notes documenting the following: 1. Suspected Spinal disorders such as congenital cord anomaly, spinal cord

tumor, vascular malformation and birth-related trauma


Spinraza (nusinersen) J2326 Please provide the following for initial request:

1. Current prescription 2. Physician office notes supporting the diagnosis and Type (I, II, or III) of

Spinal Muscular Atrophy (SMA) including: a. Documentation with laboratory values describing the type of mutation

or deletion of genes in Chromosome 5q b. Documentation that member has 2 copies of SMN2 c. Documentation that member is dependent on an invasive ventilation/

tracheostomy or a noninvasive ventilation beyond use for naps and nighttime sleep

d. The drug is being prescribed by or in consultation with a neurologist

with expertise in diagnosis of SMA e. Dosing of Spinraza for SMA is in accordance with the FDA-approved

labeling (maximum dosing of 12mg)

f. Spinraza administered intrathecally by, or under the direction of,

healthcare professionals experienced in performing lumbar punctures 3. Provide medical records (e.g., chart notes, laboratory values) of the

baseline exam of at least one of the following exams (based on member

age and motor ability) to establish baseline motor ability: a. Hammersmith Infant Neurological Exam (HINE),infant to early

childhood

b. Hammersmith Functional Motor Scale Expanded (HFMSE) c. Upper Limb Module (ULM) Test, non-ambulatory d. Children’s Hospital of Philadelphia Infant Test of Neuromuscular

Disorders (CHOP INTEND)

Please provide the following for a continuation request: 1. New prescription

2. Diagnosis and Type (I, II, or III) of Spinal Muscular Atrophy (SMA) including: a. Documentation with laboratory values describing the type of mutation

or deletion of genes in Chromosome 5q b. Documentation that member has 2 copies of SMN2 c. Documentation that member has any dependencies on invasive

ventilation/ tracheostomy or a noninvasive ventilation beyond use for

naps and nighttime sleep d. The drug is being prescribed by or in consultation with a neurologist


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e. Dose being requested and frequency including treatment plan 3. Medical records (e.g., chart notes, laboratory values) with the most recent

results (< 1 month prior to request) documenting a positive clinical response from pretreatment baseline status to Spinraza therapy as

demonstrated any of the following:

a. Follow up HINE milestones b. Follow up HFMSE

c. Follow up ULM d. Follow up CHOP INTEND

Spravato (esketamine) C9399 J3490 J3590 Provide the following for an initial request: 1. Current prescription 2. Name and tax ID number of the servicing provider/ facility to facilitate

claim processing

3. Physician office notes that include: a. Diagnosis b. Documentation that the medication is prescribed or in consultant with

a psychiatrist c. Scoring results for one of the following:

i. Hamilton Rating Scale for Depression (HAMD17)

ii. Quick Inventory of Depressive Symptomatology (QIDS-C16) iii. Montgomery-Asberg Depression Rating Scale (MADRS)

d. List of anti-depressant medications tried, failed or contraindicated for the condition, include the duration tried

e. List of anti-depressant medications to be taken for the condition 4. Physicians Treatment Plan

Provide the following for a continuation request: 1. Current prescription 2. Name and tax ID number of the servicing provider/ facility to facilitate


a. Diagnosis b. Documentation that the medication is prescribed or in consultant with

a psychiatrist c. Documentation that Spravato will be used with an anti-depressant

medication

d. Results of the initial and repeat scoring for one of the following: i. Hamilton Rating Scale for Depression (HAMD17) ii. Quick Inventory of Depressive Symptomatology (QIDS-C16)

iii. Montgomery-Asberg Depression Rating Scale (MADRS) 4. Physicians Treatment Plan

Stelara (ustekinumab)


Community Plan

J3357 J3358 Please provide the following: 1. Current prescription 2. Name and tax ID number of the servicing provider/ facility to facilitate

claim processing



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b. Member weight c. Documentation of signs, symptoms and severity d. Medications tried, failed and contraindicated, include drugs and

duration

e. Dose, frequency being requested including the physician treatment

plan

Stress Echocardiogram 93350 93351 1. Current prescription 2. Physician office notes that include:

a. An electrical STRESS test alone is not useful or effective, and a

STRESS echocardiogram is needed. Include results old electrical STRESS test

b. Reports of all recent imaging studies and applicable diagnostics (i.e. EKG/ ECG)

c. Documentation of signs and symptoms; including onset, duration, and frequency

d. The member has significant valvular heart disease or high risk for CAD

e. Provide the significance or the extent of myocardial ischemia (or scar), or to assess myocardial viability

f. Relevant history & physical, including any planned surgery.

g. Documentation that the service is requires to aid in diagnosis of hypertrophic or dilated cardiomyopathy or differentiate ischemic from non-ischemic cardiomyopathy

h. List of medication(s) and treatment plan

Sublocade

(buprenophine)

Q9991 Q9992 For an initial request provide medical notes documenting the following: 1. Current prescription

2. Name and tax ID number of the servicing provider/facility 3. Weight 4. Diagnosis

5. Provide the date and dosage the member started oral, sublingual, or transmucosal buprenorphine

6. Provider's unique dentification number specific to the prescription of

medication assisted therapy (DEA-X) 7. Dose and frequency being requested including the treatment plan 8. Provide list of medications that will be used to treat this condition

Request for continuation should include the elements required for an initial request (above) as well as medical notes documenting all of the following: 1. Positive clinical response to initial treatment

2. Updated treatment plan

Supprelin LA (histrelin)


J9226 For KS Community Plan member, provide the following:



a. Diagnosis b. Results of LH (luteinizing hormone) level


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c. Documentation that bone age is advanced one year beyond the chronological age


Surgical and Ablative Procedures for Venous

Insufficiency and

Varicose Veins

36473 36475 36478 37700 37718 37722 37780


1. Evaluation and complaints

2. Pain/other symptoms that interfere with daily activities related to vein disease

3. Functional impairment specifics (preparing meals, ability to walk, how long

member can stand, getting dressed, driving) 4. Which extremity (right, left or both) and veins that will be treated 5. Specific diagnostic studies that show the abnormality for which surgery is

being requested. Consultation with requesting surgeon may be of benefit to select the optimal images

Note: Diagnostic studies must be labeled with: a. The date taken and


Submission of diagnostic study(ies) is required via the external portal at


6. Diagnostic study reports

7. Vein diameter and duration of reflux 8. Prior conservative treatment and duration 9. Pulses

10. Documentation stating presence or absence of DVT (deep vein thrombosis),

aneurysm, and/or tortuosity 11. Proposed treatment plan with procedure code 12. For inpatient requests, clinical documentation supporting the intent to

admit the member to the inpatient level of care

Surgical Treatment for

Spine Pain

0200T 0201T 0202T 0219T 0220T 0221T 0222T 0274T 0275T 22100 22101 22102

22103 22110 22112 22114 22116 22206 22207 22208 22216 22220 22222 22224 22226 22532 22533 22534 22548 22551 22552 22554 22556 22558 22585 22590

22595 22600 22610 22612 22614 22630 22632 22633 22634 22800 22802 22804 22808 22810 22812 22818 22819 22830

22840 22841 22842 22843 22844 22845 22846 22847 22848 22853 22854 22855 22856 22857 22859 22899 63001 63003

63005 63011 63012 63015 63016 63017 63020 63030 63040 63042 63043 63044 63045 63046 63047 63048 63050 63051

63055 63056 63057 63064 63075 63076

63077 63078 63081 63082 63085 63086 63087 63088 63090 63091 63101 63102


1. Condition requiring procedure 2. History and co-morbid medical condition(s) 3. Documentation of:

a. Member’s symptoms, pain, location, and severity including functional impairment that is interfering with activities of daily living (meals, walking, getting dressed, driving)

b. Failure of Conservative Therapy through lack of clinically significant improvement between at least two measurements, on a validated pain or function scale or quantifiable symptoms despite concurrent

Conservative Therapies (see definition below), if applicable c. Progressive deficits with clinically significant worsening based on at

least two measurements over time, if applicable d. Disabling Symptoms, if applicable


being requested which may include MRI, CT scan, X-ray and/or bone scan Consultation with requesting surgeon may be needed to select the optimal

images



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63103 63170 63172 63173 63180 63182 63185 63190 63191 63194 63195 63196 63197 63198 63199 63200

Note: Diagnostic images must be labeled with: a. The date taken and b. Applicable case number obtained at time of notification, or member's


Submission of diagnostic imaging is required via the external portal at


5. Diagnostic imaging report(s) 6. Physical exam, including neurologic exam, including degree and

progression of curvature (for scoliosis), if applicable

7. Whether the surgery will be performed with direct visualization or only with endoscopic visualization

8. Complete report(s) of diagnostic tests 9. Describe the surgical technique(s) planned [e.g., AxialLIF®, XLIF, ILIF,

OLIF, LALIF, image-guided minimally invasive lumbar decompression (mild®), percutaneous endoscopic discectomy with or without laser, etc.]

10. If applicable, specify the brand-named device to be used:

a. Spinal decompression and interspinous process decompression systems for the treatment of lumbar spinal stenosis

b. Spinal stabilization systems

c. Stand-alone facet fusion without an accompanying decompressive procedure

11. If applicable, specify the allograft product [including brand name(s)] to be used:

a. Autograft

b. Demineralized bone matrix (DBM) allograft c. Allograft (cadaver, etc.)

d. Bone morphogenetic protein-2 (BMP-2) [e.g., Infuse® Bone Graft or Infuse/MASTERGRAFT™ or Posterolateral Revision Device system)

e. Amniotic tissue membrane

f. Bone morphogenetic protein-7 (BMP-7) g. Amniotic tissue membrane h. Ceramic-Based Products [e.g., Beta tricalcium phosphate (b-TCP),

etc.]

i. Cell-based products (e.g., Mesenchymal stem cells) j. Optimesh k. Platelet-rich plasma (PRP)

Taxel (onxal paclitaxel) J9264 J9267 Please provide the following for an initial request: Current prescription







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Temporomandibular

Joint Disorders

21240 21242 E1399 Medical notes documenting all of the following:

1. Comprehensive physician office notes identifying with the history of the medical condition(s) requiring treatment or surgical intervention; this

documentation must include all of the following: a. A well-defined physical and/or physiological abnormality (e.g.,

congenital abnormality, functional or skeletal impairments) resulting in a medical condition that has required or requires treatment;

b. The physical and/or physiological abnormality has resulted in a functional deficit; and

c. The functional deficit is recurrent or persistent in nature

2. Appropriate clinical studies addressing: a. The physical and/or physiological abnormality that confirm its presence b. The degree to which the abnormality is causing impairment,

c. Applicable TMJ radiological films and/ or reports such as AP radiograph, panoramic radiograph, CT Scans and/ or MRI

3. Treating physician’s plan of care including surgical treatment objectives,

which must include the expected outcome for the improvement of the

functional deficit 4. History of previous non-surgical and surgical treatment

Therapeutic Embolization; Endometrial

Ablation/Cryoablation

58356 58563 Provide the following:

1. Physician office notes to include

2. Diagnosis being treated

3. Medical history, and

4. Treatment plan

Therapeutic Procedures 97010 97012 97014 97016 97018 97022 97026 97028 97033 97034 97039 97110

97112 97113 97116 97124 97140




a. Member diagnosis requiring therapeutic procedures b. Previous treatments rendered, dates of treatments and response c. Treatment plan

Thorascopy – Sympathectomy for

Treatment of Hyperidrosis

32644 1. Physician office notes indicating condition requiring treatment and symptoms

2. Prior conservative treatments tried and failed, or not appropriate

Total Artificial Disc

Replacement

0095T 0098T 0164T 22856 22857 22858

22861 22862 22864 22865 22899

For Cervical and Lumbar Surgery




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2. History and co-morbid medical condition(s) 3. Documentation of member’s symptoms, pain, location, and severity

including functional impairment that is interfering with activities of daily living (eating or preparing meals, walking, getting dressed, driving)


being requested, which may include MRI, CT scan, X-ray and/or bone scan. Consultation with requesting surgeon may be of benefit to select the

optimal images a. Diagnostic images must be labeled with:

i. The date taken and

ii. Applicable case number obtained at time of notification, or member's name and ID number on the image(s)

Note: Submission of diagnostic imaging is required via the external portal at www.uhcprovider.com/paan or via email at [email protected]; faxes will

not be accepted 5. Diagnostic imaging report(s) 6. Physical exam, including neurologic exam

7. History and duration of previous therapy, when applicable including: a. Physical therapy b. Medications/injections

c. Previous spinal surgery d. Other attempted treatments

8. Specify the brand-named tools to be used

For Lumbar Surgery, in addition to the above, provide medical notes

documenting all of the following: 1. Provide psychological face to face evaluation

2. Documentation of instability (listhesis-, spondylolisthesis and grade) 3. Provide the surgical technique to be used and the number of levels

involved and their location

Total Artificial Heart 33927 33928 For any services related to total artificial heart, the provider should call the number on the member’s ID card

Transcatheter Heart Valve Procedures

33361 33362 33363 33364 33365 33366 33369 33477

For aortic heart valve replacement provide medical notes documenting the following: 1. Name of device being used, if available

2. Predicted Risk of Mortality (PROM) score 3. Diagnosis 4. One of the following:

a. Mean aortic valve gradient b. Peak aortic jet velocity c. Aortic valve area

5. New York Heart Association [NYHA] classification 6. Whether the member is a candidate for open valve replacement 7. Co-morbidities

8. Treatments tried, failed or contraindicated




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For pulmonary heart valve replacement provide medical notes documenting the following: 1. Name of device being used, if available 2. Diagnosis

3. Right ventricular outflow tract (RVOT) gradient OR

4. Pulmonary regurgitation rate 5. Co-morbidities

6. Treatments tried, failed or contraindicated 7. Physician treatment plan

Transcutaneous Electrical Nerve Stimulation (TENS)

E0720 E0730 E0731 Provide the following


2. Physician office notes that address the member’s condition:

For acute post-operative pain include:

1. Date of surgery 2. Nature of the surgery

3. Location and severity of the pain

For chronic pain include:

1. Location of the pain 2. Severity of the pain 3. Duration of time the member has had the pain 4. Presumed etiology of the pain

5. Prior treatment and results of that treatment

6. Re-evaluation of the member at the end of the trial period, must indicate: a. How often the member used the TENS unit

b. Typical duration of use each time c. Results (effectiveness of therapy)

7. For chronic lower back pain include the name of clinical study in which the member is enrolled

For E0731 include the following:

1. Area and sites to be stimulated; and 2. Reason that conventional electrodes cannot be used; or

3. Medical condition that precludes the application of conventional electrodes

TransCyte - Skin and

Soft Tissue Substitute

Q4182 Medical notes documenting all of the following:

1. Documentation of a surgically excised full-thickness thermal burn wound(s) and deep partial-thickness thermal burn wound(s) before autograft

placement (include the wound size, location and measurements) 2. Specific diagnostic image(s) that show the abnormality for which surgery is

being requested. Consultation with requesting surgeon may be of benefit

to select the optimal images Note: Diagnostic images must be labeled with:

a. The date taken b. Applicable case number obtained at time of notification, or member's



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Transection or Avulsion

of Greater Occipital Nerve

64744 Physician office notes containing:

1. Member history

2. Previous treatments tried

3. Current treatment plan

Transplant of Tissue or

Organs

All codes For new transplants or for transplants within the last year

Provider should call the number on the member’s ID card when referring for any transplant service

For all other transplant-related requests include:

1. Member history

2. Previous treatments tried

3. Current treatment plan

Trelstar (triptorelin) for

KS Community Plan

J3315 J3316 Provide the following:


claim processing


b. Physician treatment plan

For Treatment for Central Precocious Puberty, include: 1. If Central Precocious Puberty is Idiopathic or Neurogenic, and 2. Provide one of the following to validate diagnosis:

a. Result of basal level Luteinizing Hormone (LH) b. Result of Luteinizing Hormone (LH) response to a GnRH stimulation

test

3. Documentation that the bone age advanced one year beyond the chronological age

4. Documentation that includes the onset age of secondary sexual characteristics

Tremfya (guselkumab)


J1628 Provide the following: 1. Current Prescription



a. Diagnosis b. List of all medications taken for the condition

List of therapies tried, failed and contraindicated for the condition


Triptodur (triptorelin)

J3315 J3316 Please provide the following: 1. Current prescription



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2. Name and tax ID number of the servicing provider/facility to facilitate claim processing

3. Physician office notes that include the following: a. Drug Dose and frequency being requested

b. Physicians treatment plan

4. Documentation that treatment is for Central Precocious Puberty, include if Central Percocious Puberty is Idiopathic or Neurogenic

a. Provide one of the following to validate diagnosis: i. Pubertal basal level of luteinizing hormone (based on laboratory

reference ranges)

ii. A pubertal luteinizing hormone response to a GnRH stimulation test

iii. Bone age advanced one year beyond the chronological age b. Documentation that includes the onset age of secondary sexual

characteristics 5. Documentation that request is for palliative treatment of Advanced

Prostate Cancer







v. Physically and/or cognitively impaired and no home caregiver



infusion therapy

Trogarzo™ (ibalizumab-

uiyk)


Community Plan



claim processing

3. Physician office notes that include: a. Member diagnosis b. Laboratory results to confirm diagnosis c. Documentation of signs and symptoms

d. Dose, frequency including the physician treatment plan



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Tysabri (natalizumab) J2323 Please provide the following for an initial request:



Physician office notes that include: a. Member weight




In addition to the above, please also provide the following for continuation: Documentation of positive response to the requested medication Date the therapy was started

Ultomiris (ravulizumab) J1303 Please provide the following for an initial request: 1. Current prescription




of 186


a. Member weight b. Member diagnosis c. Labs to support the diagnosis of Atypical hemolytic uremic syndrome

(aHUS)1. Please include CBC with differential, laboratory evidence of

hemolysis, evidence of uremia, verification of the diagnosis, verification

of exclusion of diagnoses of STEC-HUS and TTP with ADAMTS13 d. Labs to support the diagnosis of Paroxysmal Nocturnal Hemoglobinuria

(PNH) and Hemoglobin and Hematocrit e. Current symptoms experienced f. Dose and frequency being requested


following:








infusion therapy Please provide the clinical for a continuation request:



c. Date the therapy was started d. Member response to therapy with the requested medication e. Labs to support the diagnosis of atypical hemolytic uremic syndrome

(aHUS)1. Please include CBC with differential, laboratory evidence of hemolysis, evidence of uremia, verification of the diagnosis, verification of exclusion of diagnoses of STEC-HUS and TTP with ADAMTS13

f. Labs to support the diagnosis of Paroxysmal Nocturnal Hemoglobinuria (PNH) and Hemoglobin and Hematocrit or documentation of reduced transfusion

g. Dose and frequency being requested

h. Member response to therapy with the requested medication 3. Name and tax ID number of the servicing provider/ facility


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following:








infusion therapy

Ultraviolet Cabinet E0691 E0692 E0693 E0694 1. Current prescription from physician

2. Physician office notes with clinical documentation that includes:

a. Presence of generalized intractable psoriasis b. Dates of prior conservative treatments with objective clinical

outcomes; and

c. Factors that justify treatment at home rather than at alternative outpatient sites

Upper Gastrointestinal Endoscopy with Delivery

of Thermal Energy for Treatment of Gastroesophageal

Reflux Disease

43257 This procedure is considered unproven

To request a review please submit physician office notes which include:

1. History of the medical condition requiring treatment

2. Previous treatments tried and response

Vagus and External Trigeminal Nerve

Stimulation

61885 64553 64568 64570 E0770 E1399 L8680 L8682 L8685 L8686 L8687 L8688


1. Specific diagnosis/condition

2. Medical and surgical history

3. Prior pharmacological agents tried to which the seizures have been refractory

4. Onset date of seizures

5. Frequency of seizures/monthly

6. Documentation as to whether the member is not a candidate for epilepsy surgery, has failed surgery or refuses epilepsy surgery after Shared

Decision Making discussion

7. Quality of Life assessment with quantifiable measures of date-to-life

besides the occurrence of seizures

8. Indicate whether the member has a progressive disorder (e.g., malignant brain neoplasm, metabolic or degenerative disorder)


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Varubi (rolapitant)


J2797 Provide the following: 1. Current Prescription 2. Name and tax ID number of the servicing provider/ facility to facilitate

claim processing


a. Diagnosis b. List of all medications taken for the condition


Velcade (bortezomib) J9041 Please provide the following for an initial request:

Current prescription Medication name Name and specialty of the prescribing and/ or consulting provider Name and tax ID number of the servicing provider/ facility if different than


a. Member weight






Ventavis (iloprost) Q4074 Please provide the following for an initial request: Current prescription Medication name








Ventavis (iloprost) for KS Community Plan

Q4074 For KS Community Plan provide the following: Please include the following:


a. Member diagnosis


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b. Documentation that the medication is prescribed by or in consultation with a pulmonologist, cardiologist or specialized treatment center


Ventilator E0465 E0466 1. Current prescription from physician including ventilator settings and hours of use per day

2. Face – to – face evaluation which includes a. Medical history and respiratory condition supporting the need for a

ventilator versus CPAP or BIPAP b. Other therapies with settings trialed, failed or ruled out and clinical

justification of failure

3. Additional testing to support need for ventilator vs. CPAP or BiPAP a. ABGs b. PFTs c. Overnight Oximetry

d. Sleep Study 4. Physician Office Notes that include the following:

a. Plan of Care to include the use as intermittent or continuous

b. Member compliance with the current treatment plan, including compliance report

c. Prognosis

Ventricular Assist Devices

All codes Provider should call the number on the member’s identification card when referring for any requests for ventricular assist devices

Vimizim (elosulfase alfa)




a. Member diagnosis

b. Laboratory results or genetic testing to confirm diagnosis c. Documentation of signs and symptoms d. Dose, frequency including the physician treatment plan


following:





v. Physically and/or cognitively impaired AND no home caregiver

available



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Von Willebrand Factor

(recombinant)

• Vonvendi® [von

Willebrand factor (recombinant)]

J7179 1. Current Prescription

2. Physician office notes that include the following: a. Members age, b. Diagnosis of von Willebrand's disease




VPRIV (Velaglucerase

alfa)

J3385 Request for an initial start:


claim processing


a. Diagnosis confirmed as Type 1 Gaucher disease b. Describe the clinical signs and symptoms c. Dose and frequency being requested, including the treatment plan

d. List medications member will be taking to treat the condition 4. Location where the drug will be administered (e.g., infusion center,












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Request for a continuation request: 1. New prescription 2. Name and tax ID number of the servicing provider/ facility to facilitate

claim processing

3. Physician office notes that include: a. Member response to therapy with the requested medication

b. Date the therapy was started c. Dose and frequency being requested, including the treatment plan



following: i. Medically unstable based upon submitted clinical history









WBC Stimulator for KS Community Plan

• Granix (tbo- filgrastim) • Neupogen (filgrastim)

J1442 J1447 Please provide the following: 1. Current prescription

2. Name and tax ID number of the servicing provider/ facility to facilitate claim processing a. Physician office notes that include: b. Member diagnosis

c. List of all medications for condition being taken with the medication

WBC Stimulators

• Granix (tbo- filgrastim) • Fulphila (pegfilgrastim-

jmdb) • Leukine

(sargramostim)

• Neupogen (filgrastim) • Neulasta®

(pegfilgrastim)

• Nivestym™ (filgrastim-

aafi)

C9058 J1442 J1447 J2505 J2820 Q5101 Q5108 Q5110 Q5111


2. Name and tax ID number of the servicing provider -facility to facilitate claim processing


a. Member diagnosis b. Medication treatments tried, failed, contraindicated. Include the dates

and reason for discontinuation

c. Documentation that injectable was prescribed by or in consultation with an hematologist oncologist

d. ANC laboratory results

e. Dose, frequency, duration, including the physician treatment plan



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• Udenyca (pegfilgrastim-cbqv)

• Zarxio (filgrastim-sndz) • Ziextenzo™

(pegfilgrastim-bmez)

Wheelchair – Manual E1037 E1050 E1070 E1084 E1085 E1086 E1087 E1089 E1093 E1100 E1110 E1130


E1237 E1238 E1250 E1270 E1280 E1285 E1290 E1295 E2227 E2228 E2230 E2626

For an initial request:


2. Specific HCPCS codes for each item requested including make, model and price quotation

3. Member’s weight

4. Physician office notes that supporting medical need for a

manual wheelchair for home mobility:

a. Current ambulation

b. Transfer status c. Functional limitations as related to ADLs d. Estimated duration of use

e. Documentation of sufficient upper extremity function and other physical and mental capabilities to safely self-propel the wheelchair

5. Primary setting of wheelchair use (e.g., home, community)

6. Description of member’s ability to operate a manual wheelchair 7. Description of member’s capability to safely operate the control of the

equipment

8. Mobility assistance devices currently used

9. Home/ safety evaluation assessment

For replacement – same type/group


2. Date the member acquired the chair and original payer

3. Make, model, configuration and serial number of the existing chair

4. Detailed equipment repair quote

5. If stolen, include police report

For replacement – different type /group

1. Date the member acquired the chair and model

2. Plus all requirements listed for initial request

For repair:

1. Date the member acquired the chair and original payer

2. Make, model , configuration and serial number of the existing chair

3. Detailed equipment repair quote including:

a. Repair estimate (including diagnostic codes) and reason for repair b. For repairs over $1000, include replacement cost

Xolair® (omalizumab) for Treating Asthma



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b. Member diagnosis

c. Documentation of the severity of symptoms includes frequency of exacerbations, provide the rescue medications and systemic

corticosteroids utilized during the exacerbation(s) d. Provide results of the Asthma Control Questionnaire (ACO) or Asthma


e. Baseline plasma immunoglobulin E (IgE) level prior to therapy start date

f. Provide results of skin testing or in vitro reactivity to a perineal aero allergen

g. Provide result Forced Expiratory Volume (FEV1) h. The drug is being prescribed by or in consultation with a pulmonologist

or allergist/ immunologist

i. Asthma related emergency treatment describe the treatment provided and number of occurrences over the last 6 months

j. Documentation of treatments tried, failed, contraindicated. Include the

dates and reason for discontinuation k. Dose and frequency being requested including the treatment plan l. List medications member will be taking to treat the condition. Include

if the member will be taking Xolair in combination with Cinqair,

Fasenra or Nucala

Please provide the following for a continuation request:

1. New prescription 2. Name and tax ID number of the servicing provider/ facility to facilitate

claim processing

3. Physician office notes that include: a. Member weight b. Member response to therapy with the requested medication c. Date the initial therapy was started

d. Provide Forced Expiratory Volume ( FEV1) results prior to initial treatment and results with the continued therapy

e. Dose and frequency being requested include the treatment plan

f. List medications member will be taking to treat the condition. Include is the member will be taking Xolair in combination with Cinqair, Fasenra or Nucala

Xolair® (omalizumab) for Treating Uticaria


claim processing


b. Member diagnosis


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c. Documentation describing the symptoms d. If the drug is being prescribed by or in consultation with an allergist,

immunologist or dermatologist e. Documentation of treatments tried, failed, contraindicated. Include the

date range the medication was used and reason for discontinuation.

f. Dose and frequency being requested include the treatment plan

Please provide the following for a continuation request: 1. New prescription 2. Name and tax ID number of the servicing provider/ facility to facilitate


a. Member weight b. Member response to therapy with the requested medication

c. Date the initial therapy was started d. Dose and frequency being requested include the treatment plan

Yervoy (ipilimumab) J9228 Please provide the following for an initial request: Current prescription Medication name




c. Documentation of treatments tried, failed, contraindicated. Include the




Yescarta (axicabtagene ciloleucel)

Q2041 For all other Plans: Coverage reviews for CAR-T therapy are managed by Optum Transplant

Resource Services through the same process as the transplant of tissue or organs. Care providers will be required to contract with Optum Transplant Resource Services in order to receive prior authorization and bill for CAR-T

therapy. Care Providers can contact Optum Transplant Resource Services at 1-888-936-7246.

Yescarta (axicabtagene ciloleucel) for KS Community Plan

Q2041 Provide the following: 1. Current prescription 2. Name and tax ID number of the servicing provider/facility to facilitate

claim processing

3. Physician office notes that include: a. Diagnosis and specify the type of B-cell lymphoma b. Documentation that member does not have CNS Lymphoma


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c. That the mediation is prescribed or in consultation with an oncologist/ hematologist

d. That the member has failed 2 or more lines of systemic therapy e. That the member is free from active infection or active inflammatory

process

f. Results of a negative pregnancy test, including documentation that the member has been advised not to become pregnant during treatment

g. Documentation of previous CAR-T therapy 4. Physician Treatment Plan and goals

Zemaira (alpha1-proteinase inhibitor (human))


claim processing

3. Physician office notes that include: a. Member diagnosis b. Laboratory results of alpha1-antitrypsin (AAT) level and genetic

testing to confirm diagnosis c. Current Pulmonary function test results d. Documentation of signs and symptoms

e. List of medications being taken for this condition f. Documentation that member is a nonsmoker, g. Dose, frequency including the physician treatment plan



following:






available



infusion therapy

For a continuation request provide the following:






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Zinplava

(bezlotoxumab)

J0565 Please provide the following for the initial administration:


claim processing

3. Physician office notes that include: a. Member diagnosis b. Laboratory results to confirm diagnosis



For a continuation request provide the following:


claim processing

3. Physician office notes that include: a. Documentation with member’s response to therapy b. Dose, frequency including the physician treatment plan


Zolgensma® (Onasemnogene

Abeparvovec-Xioi)

C9399 J3490 J3590 Please provide the following: 1. Current prescription



a. Member diagnosis b. Type I SMA diagnosis has been determined by or in consultation with a

neurologist

c. Results of chromosome 5q testing d. Results of SMN2 testing, include how many copies e. List of medications tried, failed for the condition f. List of medication to be given for the condition, include administration

of prophylactic prednisolone (or glucocorticoid equivalent) prior to and after the drug is administered

g. The dates and duration Spinraza has been tried, include the response

to Spinraza h. Documentation that member is not dependent on either of the

following:

i. Invasive ventilation or tracheostomy ii. Use of non-invasive ventilation beyond use for naps and

nighttime sleep 4. Physician Treatment Plan to include testing that member has presence of

anti-AAV antibodies with the plan to manage