Medical Prior Authorization List - Health First

1 Medical Prior Authorization List For prescription drug requirements, Please refer to the plan's formularies. Effective: February 1, 2019. General Information Health First Health Plans ( Health Plans ) administers these requirements. Benefits are determined by the plan. Items listed may have limited coverage or not be covered at all. All items and services on this list require Prior Authorization regardless of the service location, plan type or provider participation status. Referrals are not required for in-network specialist care. Refer to the current Provider Directory or visit our website at for a list of network providers. Authorization is not a guarantee of payment.

2 Coverage is subject to member eligibility, as well as applicable benefit and provider contract provisions on the date of service. Contract limitations may apply and supersede any Authorization provided. This document is updated periodically, but may change at any time. Please refer to the current version by visiting our website at Changes from the last version are available on the HFHP Medical Prior Authorization List Notice of Change document, which can be accessed by visiting our website at ). How to Request Authorization With the following exceptions, Authorization requests should be submitted directly to the Health Plan AIM Specialty Health (AIM) authorizes High Tech Imaging / Echocardiograms / Sleep Disorder Testing and Treatment.

3 Visit to request Authorization and to access guidelines. Magellan Behavioral Health , Inc. (Magellan) authorizes Behavioral Health and Substance Abuse Services. Authorization may be requested by phone toll-free at or online at Palladian Health authorizes spinal Surgeries / Pain Injections / Spinal Cord Stimulation Services. Visit to request Authorization . Palladian may also be reached at Submit Authorization requests to the Health Plan using the Provider Portal or the Authorization Request Form. Please include applicable codes, descriptions, and clinical information to support the request. Out-of-Network Services HMO Members With the exception of emergency care, urgently-needed care outside the service area or renal dialysis for Medicare members, all OON services require Prior Authorization POS/PPO Members (Plans with out-of-network benefits All items and services on this list require Authorization regardless of the plan type IMPORTANT CONTACTS FOR AUTHORIZATIONS SUBMITTED TO THE Health PLAN.)

4 You can submit requests electronically using your secure account at: You can fax Authorization requests to: (toll-free) or (local). Please include applicable codes and clinical information to support the request. You can fax drug Authorization requests to: For questions, call Customer Service toll-free at Monday through Friday from 8 to 6 The following codes are authorized by AIM. Visit to request Authorization and to access guidelines. Cardiology Codes Code Code Description 75557 MRI Cardiac for morphology and function without contrast material;. 75559 MRI Cardiac for morphology and function without contrast material; with stress imaging 75561 MRI Cardiac for morphology and function without contrast material(s), followed by contrast material(s) and further sequences.

5 75563 MRI Cardiac for morphology and function without contrast material(s), followed by contrast material(s) and further sequences; with stress imaging 75565 Cardiac magnetic resonance imaging for velocity flow mapping (List separately in addition to code for primary procedure). 75571 Computed tomography, heart, without contrast material, with quantitative evaluation of coronary calcium 78451 Myocardial perfusion imaging, tomographic (SPECT). 78452 Myocardial perfusion imaging, tomographic (SPECT), multiple studies at rest and/or stress. And/or redistribution and or rest reinjection 78453 Myocardial perfusion planar single study including qualitative or quantitative wall motion, ejection fraction by 1st pass or gated technique, rest or stress 78454 Myocardial perfusion planar multiple studies including qualitative or quantitative wall motion, ejection fraction by 1st pass or gated technique, rest and/or stress 78466 Planar, infarct avid; qualitative or quantitative 78468 Planar, infarct avid; with ejection fraction by First pass technique 78469 SPECT, infarct avid; with or w/o quantification 78472 Cardiac blood pool, gated equilibrium.

6 Planar, single study, wall motion plus ejection fraction 78473 Cardiac blood pool gated equilibrium; planar, multiple studies, wall motion study plus ejection fraction 78481 Cardiac blood pool First pass tech; single study, wall motion study plus ejection fraction 78483 Cardiac blood pool First pass tech; multiple studies, wall motion study plus ejection fraction 78494 Cardiac blood pool gated equilibrium, SPECT, at rest, wall motion study plus ejection fraction 78496 Cardiac blood pool imaging, gated equilibrium, single study, at rest, with right ventricular ejection fraction by First pass technique (List separately in addition to code for primary procedure).

7 93303 Transthoracic Echo cardiac anomalies 93304 Transthoracic Echo cardiac anomalies, limited 93306 Transthoracic Echo complete w color & spectral 93307 Transthoracic Echo complete wo color & spectral 93308 Transthoracic Echo limited 93312 Transesophageal Echo 93313 Transesophageal Echo probe only 93314 Transesophageal Echo interpretation 93315 Transesophageal Echo congenital 93316 Transesophageal Echo congenital, probe only 93317 Transesophageal Echo congenital interpretation 93320 Doppler echo exam of heart, complete 93321 Doppler echo exam of heart, limited 93325 Doppler color flow mapping 93350 Transthoracic Stress Echo, complete 93351 Transthoracic Stress Echo, complete w cont EKG.

8 93352 Administration of echo contrast agent Page 2 of 88. High Tech Imaging Codes Computerized Tomography (CT). Code Code Description 70450 CT head or brain; w/o contrast 70460 CT head or brain; with contrast 70470 CT head or brain; w/o contrast followed by contrast 70480 CT orbit, sella or posterior fossa; w/o contrast 70481 CT orbit, sella or posterior fossa; with contrast 70482 CT orbit, sella or posterior fossa; w/o contrast followed by contrast 70486 CT maxillofacial area; w/o contrast 70487 CT maxillofacial area; with contrast 70488 CT maxillofacial area; w/o contrast followed by contrast 70490 CT soft tissue neck; w/o contrast 70491 CT soft tissue neck; with contrast 70492 CT soft tissue neck.

9 W/o contrast followed by contrast 70496 CTA head 70498 CTA neck 71250 CT thorax; w/o contrast 71260 CT thorax; with contrast 71270 CT thorax; w/o contrast followed by contrast 71275 CTA chest 72125 CT cervical spine; w/o contrast 72126 CT cervical spine; with contrast 72127 CT cervical spine; w/o contrast followed by contrast 72128 CT thoracic spine; w/o contrast 72129 CT thoracic spine; with contrast 72130 CT thoracic spine; w/o contrast followed by contrast 72131 CT lumbar spine; w/o contrast 72132 CT lumbar spine; with contrast 72133 CT lumbar spine; w/o contrast followed by contrast 72191 CTA pelvis 72192 CT pelvis; w/o contrast 72193 CT pelvis; with contrast 72194 CT pelvis w/o contrast followed by contrast 73200 CT upper extremity; w/o contrast 73201 CT upper extremity; with contrast 73202 CT upper extremity; w/o contrast followed by contrast 73206 CTA upper extremity 73700 CT lower extremity; w/o contrast 73701 CT lower extremity; with contrast 73702 CT lower extremity; w/o contrast followed by contrast 73706 CTA lower extremity 74150 CT abdomen; w/o contrast 74160 CT abdomen; with contrast 74170 CT abdomen.

10 W/o contrast followed by contrast 74174 CTA Abd/Pelvis wo/w contrast 74175 CTA Abdomen 74176 CT Abdomen & Pelvis without contrast 74177 CT Abdomen & Pelvis with contrast 74178 CT Abdomen & Pelvis wo/w contract 74263 Computed tomographic (CT) colonography (virtual colonoscopy). Page 3 of 88. 75572 Computed tomography, heart, with contrast material, for evaluation of cardiact structure and morphology (including 3D image postprocessing, assessment of cardiac function, and evaluation of venous structures, if performed). 75573 Computed tomography, heart, with contrast material, for evaluation of cardiact structure and morphology in the setting of congential heart disease (including 3D image postprocessing, assessment of LV cardiac function, RV structure and function and evalua 75574 Computed tomographic angiography, heart, coronary arteries and bypass grafts (when present).)