Transcription of PRIOR AUTHORIZATION LIST - Paramount Health Care
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PRIOR AUTHORIZATION LIST - Paramount Health Care
SERVICE/PROCEDUREHMO/ Individual MarketplacePPO/CDHPELITE/ProMedica Medicare Plan ADVANTAGECODESMEDICAL POLICYACTIGRAPHYNON-COVEREDNON-COVEREDNO N-COVEREDNON-COVERED95803 Effective 4/1/2021 procedure 95803 is Non-Covered for ALL Product linesPG0198 Actigraphy and Accelerometry Sleep DiagnositicsACUPUNCTURENON-COVEREDNON-CO VERED Effective 01/21/2020 acupuncture services are covered with chronic low back pain. ICD-10 Up to 12 visits in 90 days, no PRIOR AUTHORIZATION is required. An additional 8 visits will be covered for those patients demonstrating an improvement, a PRIOR AUTHORIZATION is required, as of 5/1/2020. Total of 20 acupuncture treatments may be administered annually.
PG0007 Blepharoplasty, Reconstructive Eyelid Surgery, and Brow Lift BRONCHIAL THERMOPLASTY NON-COVERED NON-COVERED NON-COVERED X 31660, 31661 PG0316 Bronchial Thermoplasty
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