PRIOR AUTHORIZATION LIST - Paramount Health Care

1 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.

2 Effective 10/01/17. 97810, 97811, 97813, 97814, require a PRIOR AUTHORIZATION if treatments beyond five (5) visits without proven success or treatments beyond thirty (30) visits per calendar year. Effective 04/01/2021 additional covered conditions. 97810, 97811, 97813, 97814 PG0382 AcupunctureALL OUT OF NETWORK SERVICES (EXCEPT ER)XXXXAMBULATORY EEG MONITORING REQUIRES PRIOR AUTHORIZATION FOR > 84 hoursEffective 5/1/2021, Ambulatory EEG monitoring, with or without video, requires PRIOR AUTHORIZATION for > 84 hours. See highlighted coding scheme below. Effective 5/1/2021, Ambulatory EEG monitoring, with or without video, requires PRIOR AUTHORIZATION for > 84 hours. See highlighted coding scheme 5/1/2021, Ambulatory EEG monitoring, with or without video, requires PRIOR AUTHORIZATION for > 84 hours.

3 See highlighted coding scheme 5/1/2021, Ambulatory EEG monitoring, with or without video, requires PRIOR AUTHORIZATION for > 84 hours. See highlighted coding scheme x 4, 95709 x 4, 95710 x 4, 95714 x 4, 95715 x 4, 95716 x 4, 95719 x 4, 95720 x 4, 95725, 95726PG0333 Ambulatory EEG MonitoringASSERTIVE COMMUNITY THERAPYXXXXH0039, H0040PG0503 Assertive Community TherapyPRIOR AUTHORIZATION LISTPRIOR AUTHORIZATION REQUIRED = XUpdated 03/22/2022 Call Paramount 's Provider Inquiry Department at 419-887-2564 or toll-free at submission is preferred. Fax PRIOR AUTHORIZATION request to the appropriate fax number or toll-free at 1-866-214-2024. PRIOR authorizations can be emailed to Paramount 's Utilization Management staff at Imaging procedures can be submitted through the web-based PRIOR AUTHORIZATION submission tool (McKesson's Clear Coverage), via as of 2/1/18.

4 Note: All products/benefit packages may not require PRIOR AUTHORIZATION . Providers: Please call Provider Inquiry at 419-887-2564 or toll-free at 1-888-891-2564. Members: Please call Member Services at 419-887-2525 or toll-free 1-800-462-3589. TTY service for the hearing impaired is available at 419-887-2526 or toll-free at 1-888-740-5670. Hours of operation are Monday through Friday (excluding holidays) are: Commercial products 8am to 5pm; Paramount Advantage 7am-7pm; Paramount Elite 8am to 8pm. NOTE: PRIOR Authorizations are required for payment for primary, secondary, or tertiary coverage. Retro- AUTHORIZATION reviews/provider appeals for denied claims for failure to follow precertification requirements will be considered for review for the following exception: the member represented as a self-pay.

5 As a registered user to the Paramount Portal, you may also verify Paramount eligibility on Participating Providers are required to obtain PRIOR AUTHORIZATION for all nonemergent services before services are rendered. Paramount will not pay claims for services in which PRIOR AUTHORIZATION is required, but not obtained by the provider. Services will be denied with NO PATIENT LIABILITY. Paramount provides an easy hassle free process to requires PRIOR Authorizations electronically. Please visit Call Paramount 's Utilization/ Case Management Department at 419-887-2520 or toll-free at 1-800-891-2520.

6 CHILDREN'S ADAPTIVE BEHAVIOR SERVICESXXNON-COVERED X97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 0362T, 0373 TPG0335 Children's Adaptive Behavior Services. 10/01/19: 2019 Adaptive Behavior Services Update. Changed Title from Children s Intensive Behavioral Service/ Applied Behavioral Analysis (ABA) to Children s Adaptive Behavior Service. This reflects the 2019 AMA CPT Code nomenclature. ARTIFICIAL INTERVERTEBRAL DISC REPLACEMENT - CERVICAL ARTIFICIAL DISC REPLACEMENT AT MORE THAN ONE LEVEL XXXX22858PG0027 Artificial Intervertebral Disc ReplacementARTIFICIAL INTERVERTEBRAL DISC REPLACEMENT - LUMBAR ARTIFICIAL DISC REPLACEMENT AT ONE LEVELXXXX22857PG0027 Artificial Intervertebral Disc ReplacementAUTISM TREATMENT: Refer to Medical Policy PG0335 Children s Adaptive Behavior Services XXXXPG0335 Children's Adaptive Behavior ServicesAVISE PG NON-COVEREDNON-COVEREDXNON-COVERED84999P G0194 Avise PGBINAURAL HEARING AIDS and SINGLE HEARING AIDS NO PRIOR AUTHORIZATION Required.

7 The hearing aid products, dispensing fees, and repairs are covered under the hearing aid rider benefit. These are covered based on the member s benefit coverage for a specific product line or provider group. NO PRIOR AUTHORIZATION Required. The hearing aid products, dispensing fees, and repairs are covered under the hearing aid rider benefit. These are covered based on the member s benefit coverage for a specific product line or provider group. NO PRIOR AUTHORIZATION Required. The hearing aid products, dispensing fees, and repairs are covered under the hearing aid rider benefit. These are covered based on the member s benefit coverage for a specific product line or provider group.

8 Covered binaural hearing aids & related supplies require PRIOR AUTHORIZATION for Advantage. A single hearing aid for an Advantage member does not require PRIOR AUTHORIZATION . V5130, V5140, V5150, V5160, V5211, V5212, V5213, V5214, V5215, V5221, V5230, V5240, V5252, V5253, V5260, V5261, V5298PG0141 Hearing AidsMETABOLIC AND BARIATRIC SURGERYXXXX43644, 43645, 43770, 43771, 43772, 43773, 43774, 43775, 43842, 43843, 43845, 43846, 43847, 43848, 43850, 43886, 43887, 43888, S2083PG0163 Bariatric Services BLEPHAROPLASTYXXXNON-COVERED15820, 15821, 15822PG0007 blepharoplasty , Reconstructive Eyelid Surgery, and brow LiftBLEPHAROPLASTYXXXX15823PG0007 blepharoplasty , Reconstructive Eyelid Surgery, and brow LiftBROW PTOSIS, UPPER EYELID BLEPHAROPTOSIS REPAIR, LID RETRACTION XXXX67900, 67901, 67902, 67903, 67904, 67906, 67908, 67909, 67911PG0007 blepharoplasty .

9 Reconstructive Eyelid Surgery, and brow LiftBRONCHIAL THERMOPLASTYNON-COVEREDNON-COVEREDNON-CO VEREDX31660, 31661PG0316 Bronchial ThermoplastyCANDELA LASER - PULSED DYE LASER (PDL) THERAPY FOR CUTANEOUS VASCULAR LESIONSE ffective 1/1/2020 no PRIOR AUTHORIZATION required when medical necessity is indicatedEffective 1/1/2020 no PRIOR AUTHORIZATION required when medical necessity is indicatedEffective 1/1/2020 no PRIOR AUTHORIZATION required when medical necessity is indicatedEffective 1/1/2020 no PRIOR AUTHORIZATION required when medical necessity is indicated17106, 17107, 17108PG0308 Pulsed Dye Laser Therapy for Cutaneous Vascular LesionsCARDIOVASCULAR NUCLEAR STRESS TESTING-MYOCARDIAL PERFUSION IMAGINGE ffective 9/1/2020 procedures 78451, 78452, 78453 & 78454 require a PRIOR authorizationEffective 9/1/2020 procedures 78451, 78452.

10 78453 & 78454 require a PRIOR authorizationEffective 9/1/2020 procedures 78451, 78452, 78453 & 78454 require a PRIOR authorizationNo PRIOR AUTHORIZATION required when medical necessity is indicated78451, 78452, 78453, 78454 Effective 08/01/2021, an additional option for outpatient imaging PRIOR AUTHORIZATION requests from Paramount participating in-plan providers; Paramount is recognizing the Protecting Access to Medicare Act (PAMA) scores greater than or equal to a score of 8, for administrative approvals across all product lines. The request form can be located at: PG0479 Cardiovascular Nuclear Stress Testing-Myocardial Perfusion Imaging CARTICEL AUTOLOGOUS CHONDROCYTE TRANSPLANTATION (ACT)/AUTOLOGOUS CHONDROCYTE IMPLANTATION (ACI)XXXX27412, J7330PG0190 Focal Articular Cartilage of the KneeCARTICEL AUTOLOGOUS CHONDROCYTE TRANSPLANTATION (ACT)/AUTOLOGOUS CHONDROCYTE IMPLANTATION (ACI)XXNON-COVEREDNON-COVEREDS2112PG0190 Focal Articular Cartilage of the KneeCOSMETIC AND RECONSTRUCTIVE SURGERYNON-COVEREDNON-COVEREDNON-COVERED X Refer to Medical Policy PG0104 for PRIOR AUTHORIZATION coverage details.