REFERRALS CPT CODES COMMENTS

This list is subject to change. It was last updated on February 29, 2016

Gundersen Health Plan (GHP)

Procedures & Services Requiring Prior Authorization

Benefits and eligibility must be verified with the Health Plan Customer Service.

Senior Preferred: 608-775-8077 or 800-370-9718 BadgerCare Plus: 608-775-0150 or 866-537-1477

GundersenOne: 608-775-8092 or 855-685-6404

 This grid applies to all GHP members; it is intended to be a guide and does not guarantee coverage.  Medical benefit plan language supersedes the general information provided on this grid.

 The presence or absence of an item on this list does not define whether or not coverage or benefits exist for the service

or procedure and/or CPT code.

 Failure to prior authorize procedures or services on this grid may result in denial of coverage; as a result financial

responsibility may be yours.

 Senior Preferred members may see Evidence of Coverage for complete benefit information.

REFERRALS

CPT CODES

COMMENTS

Any referral to a non-participating provider/facility for non-emergent services

A signed written referral from the Health Plan is required prior to receiving services from a non participating provider/facility

Initial Low Back Pain Consults with Orthopedic or Neurosurgery

departments (follow up visits do not require prior authorization)

For State of Wisconsin ETF members. Submit supporting medical documentation. Effective 1/01/2013

EXPERIMENTAL

Experimental/Investigational Considered provider responsibility when the

member would not be reasonably expected to know that the service is experimental. The Health Plan utilizes Hayes Medical Technology Directory to determine if services are experimental/

investigational. In addition to Hayes, other

sources may be reviewed which include but are not limited to the evidence based medical literature, specialty Medical Advisory Panel, and other technology review resources.

This list is subject to change. It was last updated on February 29, 2016

MEDICAL SERVICES

CPT CODES

COMMENTS

Autism Spectrum Disorders Submit supporting medical documentation.

Continuous Passive Motion (CPM) E0935 (Coverage limited to knee only) Prior authorization required for CPM usage beyond 21 days post op. Submit supporting medical documentation

Cranial Remolding Orthotic S1040 Submit supporting medical documentation.

Durable Medical Equipment (DME) Senior Preferred

All DME purchases, rentals and repairs (no dollar threshold)

Commercial/BadgerCare Plus/ GundersenOne

DME purchases exceeding dollar threshold (varies by group) and all rentals and repairs

Senior Preferred

Call Customer Service to verify eligibility of member

Review Medicare criteria:

- If item is statutorily excluded by Medicare, notify member item is not covered by Senior Preferred; if member wants to purchase item, obtain signature on NDMC (available on website)

- If item meets Medicare criteria, dispense and bill Health Plan

- If item does not meet Medicare medical necessity criteria, submit PA to Health Plan for organizational determination

Commercial/BadgerCare Plus/GundersenOne

Call Customer Service to verify eligibility of member and prior authorization requirements (please provide HCPCS code)

Enteral Therapy B4034-B9999 Submit supporting medical documentation.

Genetic Testing Submit supporting medical documentation.

Home Health Member must be homebound and meet criteria for

home health.

Home Prothrombin Time Monitoring G0249, G0248 Submit supporting medical documentation.

Home Sleep Studies (under C-PAP

policy) Prior authorization required from a sleep disorder physician specialist or provider practicing under the supervision of a sleep disorder specialist. Submit supporting medical documentation

Hyperbaric Oxygen Therapy (HBOT) Prior authorization is required. Submit supporting

This list is subject to change. It was last updated on February 29, 2016

monitors/receivers and supplies E0784/S1030, S1031, A9276-A9278, E0607, E2100, E2101 Submit supporting medical documentation.

IV Drugs – outpatient hospital and

clinic (except EPO) Submit supporting medical documentation.

IV Infusions Home IV Therapy requires prior authorization.

Request to be received from supplier.

Mental Health, Alcohol and other drug addictions (M.H./A.O.D.A), Transitional Treatment (includes Partial Hospitalization services), Day Treatment

Submit supporting medical documentation.

BadgerCare Therapies Prior authorizations required after 35 visits per

therapy discipline; however, some services always require prior authorization per ForwardHealth Guidelines. Please refer to the ForwardHealth portal. Providers must use the PA forms available via the portal.

Senior Preferred Part B Therapies . All Part B therapies require prior authorization. Refer the Health Plan website for detailed instructions.

Skilled Nursing Facility Prior authorization required from facility.

Swing Bed Prior authorization required prior to admission.

TheraSphere/Sir-Spheres Treatment CPT: 77790, 36245, 75726, 77778, 79445

HCPCS: C2616, Q3001, S2095 Submit supporting medical documentation and appropriate codes.

PROCEDURES\SURGICAL

TREATMENTS

CPT CODES

COMMENTS

Abortions 59840-59869 Only if medically necessary as determined by the

Health Plan.

Artificial Intervertebral Disc Replacement for Cervical and

Lumbar Degenerative Disc Disease

0092T, 0095T, 0098T, 0163T, 0164T, 0165T,

22856-22865 Member must be 18 or over. Medicare does not provide coverage for patients over age 60. Coverage will be limited to the cost of the procedure and the cost of one artificial intervertebral disc.

Bone Anchored Hearing Aide (BAHA) Submit supporting medical documentation.

Bariatric surgical treatment for

Severe Obesity 43770-43774, 43842-43848, 43644-43645 43659, S2083, 43886,43888 Submit supporting medical documentation.

Blepharoplasty 15820-15823

67900-67908

Upper and lower lid blepharoplasty will be subject to prior authorization. Photos and visual fields will be required.

This list is subject to change. It was last updated on February 29, 2016

CardioMems C97412, C2624 Submit supporting medical documentation.

Chorionic Villus Sampling (CVS) 59015 Submit supporting medical documentation.

Cochlear Implants 69930,

69714-69718 Required for members age 18 and over.

LINX Reflux Management System 43289 Submit supporting medical documentation

PROCEDURES/SURGICAL

TREATMENTS CONTINUED

CPT CODES

COMMENTS

Deep Brain Stimulation 61850-61888, 95961-95962

L8680-L8689 Submit supporting medical documentation.

High Tech Radiology Tests CT & CTA:

70450,70460,70470,70480-70482,70486-70488,70490-70492, 70496, 70498, 71250, 71260, 71270, 71275, 72125-72133, 72191-72194, 73200-73202, 73206,73700, 73702, 737206, 74150, 74160, 74170,74175-74178,74261-74263, 75571- 75574, 75635, 76380, 77078,77079,S8092

MRI & MRA: 70336, 70540, 70542-0555,

71550-71552,71555, 72141, 72142, 72146-72149, 72156-72159, 72195-72198,73218-73223,73225, 73718-73723,73725,74181-74183, 74185, 75557, 75559, 75561, 75563, 75565, 77058, 77059, 77084, S8037, PET: 78608, 78609, 78811-78816, G0235, 0159T, S8037, 74181- 74183,

Nuclear Stress Test: 78451-78454, 78481,

78483, 78499, 93015-93018

For State of Wisconsin ETF members. Submit supporting medical documentation. Effective 1/01/2013.

Hyperhidrosis, Surgical Treatment 32664 Submit supporting medical documentation.

Reduction Mammoplasty 19318 Submit supporting medical documentation.

Refractive Surgery 65765, S0800, S0810, S0812 Submit supporting medical documentation.

Rhinoplasty or Rhino portion of Septorhinoplasty

30400-30450 Submit supporting medical documentation.

Surgical Removal of Redundant Skin 15824-15839, 15847 Submit supporting medical documentation.

Surgical Treatment of Obstructive Sleep Apnea(OSA)

Submit supporting medical documentation. Pillar Implants are not covered for Commercial or GundersenOne members.

This list is subject to change. It was last updated on February 29, 2016

Excavatum and Carinatum Syndrome 21740-21743 Submit supporting medical documentation. Transmyocardial Revascularization

(TMR) 33140-33141 Submit supporting medical documentation.

Transplants (excluding corneal transplants)

A referral request is required for all members.

Surgical/Laser Treatment of Scars Submit supporting medical documentation.

Vagus Nerve Stimulation 64581

61885,64553 95974

Submit supporting medical documentation.

Varicose Vein Treatment (excludes