AmeriHealth New Jersey services that require precertification

1 AmeriHealth New Jersey services that require precertification Applies to services performed on an elective, non-emergency basis. Gender reassignment surgery Genetically and bio-engineered skin substitutes for wound care Inpatient services Hair transplant Acute rehabilitation admissions Injectable dermal fillers Elective surgical and nonsurgical inpatient admissions Keloid removal Inpatient hospice admissions Lipectomy, liposuction, or any other excess fat-removal procedure Long-term acute care (LTAC) facility admissions Otoplasty Skilled nursing facility admissions Rhinoplasty Cardiology Proceduresa Rhytidectomy Arterial ultrasound Scar revision Diagnostic coronary angiography Skin closures including.

2 Percutaneous coronary intervention -Skin flaps -Skin grafts Procedures -Tissue grafts Bone graft substitutes and bone morphogenetic proteins for spine Surgery for varicose veins, including perforators and sclerotherapy surgerya Bronchial thermoplasty Any procedure, device, or service that may potentially be Cervical decompression with or without fusiona considered experimental or investigational including: Cervical disc arthroplastya New emerging technology/procedures Cochlear implant surgery Existing technology and procedures applied for new Hip arthroplastya uses and treatments Hip arthroscopy and open proceduresa Elective (nonemergency) ground, air, and sea ambulance Knee arthroplastya transportation Knee arthroscopy and open proceduresa Lumbar disc arthroplastya Outpatient private-duty nursing Lumbar discectomy, foraminotomy, and laminotomya Lumbar fusion and treatment of spinal deformity a (including scoliosis Day rehabilitation programs and kyphosis)

3 A Outpatient radiation therapyb Lumbar laminectomya External beam including 2D, 3D conformal, intensity-modulated Meniscal allograft transplantation of the kneea radiation therapy (IMRT), tomotherapy, image-guided radiation therapy Obesity surgery (IGRT), stereotactic body radiation therapy (SBRT), and stereotactic Shoulder arthroplastya radiosurgery (SRS). Shoulder arthroscopy and open proceduresa Brachytherapy including low-dose rate (LDR), high-dose rate (HDR), Treatment of osteochondral defectsa and outpatient intra-operative techniques (IORT). Uvulopalatopharyngoplasty (uppp), including laser-assisted Hyperthermia Vertebroplasty/kyphoplastya Neutron radiotherapy Reconstructive procedures and potentially Proton beam radiation therapy cosmetic procedures Radio-labeled drugs used for radiation therapy ( , Radium Ra 223.)

4 Blepharoplasty/ptosis repair dichloride [Xofigo ], ibritumomab tiuxetan [Zevalin ]). Bone graft, genioplasty, and mentoplasty Radiologya Breast: reconstruction, reduction, augmentation, mammoplasty, CT. mastopexy, insertion and removal of breast implants CTA. Canthopexy/canthoplasty Echocardiography Cervicoplasty -Resting transthoracic echocardiography (TTE). Chemical peels -Stress echocardiography (SE). Dermabrasion -Transesophageal echocardiography (TEE). Excision of excessive skin and/or subcutaneous tissue MRA. AmeriHealth New Jersey services that require precertification MRI Autism spectrum disorders Nuclear cardiology Applied behavioral analysis PET scans In-network level of benefits for nonparticipating All home-care services providers for non-emergent services unavailable (including infusion therapy in the home) in-network for members who have plans without an out-of-network benefit.

5 Selected durable medical equipment (DME). Bone growth stimulators (non -invasive) Drugs -Low intensity ultrasound non -invasive bone growth stimulation Antineoplastic agents: Abraxane, Adcetris, Alimta, Avastin (except -Other than spinal non -invasive electrical bone growth stimulation for ophthalmological conditions)e, Beleodaq, Blincyto, Cyramza, -Spinal non-invasive electrical bone growth stimulationa Darzalex, Erbitux, Erwinaze, Faslodex, Folotyn, Halaven, Herceptine, Bone-anchored (osseointegrated) hearing aids Imlygic, Istodax, Jevtana, Kadcyla, Kyprolis, Mvasi (except for -Bone conduction hearing aids ophthalmological conditions)

6 , Perjeta, Provenge, Rituxan Hycela, -Cochlear implants Rituxan, Xofigob, Yervoy, Zevalinb Continuous positive airway pressure (CPAP) devices and bi-level Anti-PD-1/PD-L1 human monoclonal antibodiesd: Bavencio, (Bi-PAP) devices and suppliesa Imfinzi, Keytruda, Opdivo, Tecentriq Dynamic adjustable and static progressive stretching devices (excludes Bone-modifying agents: Prolia, Xgeva CPMs) Botulinum toxin agents: Botox Electric, power, and motorized wheelchairs, including custom Cardiovascular agents: Flolan, Remodulin, Veletri accessories Chemotherapy-induced nausea and vomiting (CINV) agents: External defibrillator and associated accessories Cinvantif, Emend (for injection), Sustol, Varubif Follow New Jersey orthotics and prosthetics mandate, as applicable.

7 Chimeric antigen receptor (CAR-T) therapiesd: -Items addressed by the mandate do not require precertification Kymriah, Yescarta High frequency chest wall oscillation generator system Colony stimulating factors: Neulastae, Neulasta Onpro Insulin pumps Endocrine/metabolic agents: Acthar, Makena, Manual wheelchairs with the exception of those that are rented Sandostatin LAR, Somatuline Depot Negative pressure wound therapy Enzyme replacement agentsd: Adagen, Aldurazyme, Brineura, Neuromuscular stimulators Cerezyme, Elaprase, Elelyso, Fabrazyme, Kanuma, Lumizyme, Power operated vehicles (POV) Naglazyme, Replagalf, Vimizim, VPRIV.

8 Pressure reducing support surfaces including: Hemophilia/Coagulation factorsd: BeneFIX, Coagadex, Corifact, -Air fluidized bed Eloctate, Feiba NF, Feiba VH, Fibryna, Helixate FS, Hemofil M, -Non powered advanced pressure reducing mattress Humate P, Idelvion, IXinity, Koate DVI, Kogenate FS, Kovaltry, -Powered air flotation bed (low air loss therapy) Monoclate P, Mononine, Novoeight, Novoseven, Novoseven RT, -Powered pressure reducing mattress Nuwiq, Obizur, Profilnine SD, Rebinyn, Recombinate, RiaSTAP, Push rim activated power assist devices Rixubis, Tretten, Vonvendi, Wilate, Xyntha Repair or replacement of all DME items, as well as orthoses and Hyaluronate acid products: Cingalf, Euflexxa, Gel-One, Gel-Syn, prosthetics that require precertification GenVisc 850, Hyalgan, Hymovis, Monovisc, Supartz, VISCO-3.

9 Speech generating devices Immunological agents: Actemra, Benlysta, Entyvio, Inflectra, Orencia, Remicadee, Renflexis, Simponi Aria, Stelara Medical foods Intravenous Immune Globulin/Subcutaneous Immune Hyperbaric oxygen therapy Globulin (IVIG/SCIG)d: Bivigam, Carimune NF, Cuvitru, Flebogamma, Flebogamma DIF, Gamastan S/D, Gamimune N, Gammagard, Sleep studies (Facility-based)a Gammagard Liquid, Gammagard S/D, Gammaked, Gammaplex, All transplant procedures, with the exception of corneal Gamunex, Gamunex C, Hizentra, HyQvia, Octagam, Privigen transplants Miscellaneous therapeutic agents: Ampligenf, Exenatide sustained-release ITCA 650f, Exondys-51, Luxturnaf, Radicava, Mental health/Serious mental illness Remunef, Soliris, Spinraza, Sylvant Inpatient mental illness/Serious mental illness care Multiple sclerosis agentsd.

10 Lemtrada, Ocrevus, Tysabri Partial hospitalization programs Respiratory agents: Cinqair, Nucala, Synagis, Xolair Intensive outpatient mental illness care Respiratory enzymes (Alpha-1 antitrypsin)d: Aralast, Glassia, Repetitive transcranial magnetic stimulation (RTMS) Prolastin, Zemaira Substance abusec Inpatient substance abuse treatment Partial hospitalization programs Intensive outpatient substance abuse treatment AmeriHealth New Jersey services that require precertification Genetic and genomic tests requiring precertificationb,f precertification is not a determination of eligibility or a guarantee of The following list is a guide to the types of genetic and genomic tests payment.