Commercial pre-authorization

Commercial Pre-authorization List

This Commercial Pre-authorization List includes services and supplies that require pre-authorization or notification for commercial plan products.

How to submit a pre-authorization request or notification

Expedited requests

Use this process only when the member or his/her physician believes that waiting for a decision under the standard time frame could place the member's life, health or ability to regain maximum function in serious jeopardy.

  • Availity Provider Portal: Read the information carefully to ensure your request meets the qualifications, then check the box on the form to attest that it is an expedited request.
  • Via fax using the appropriate pre-authorization request form below

Online

Note: Check the status of your requests using the same platform you used to submit the request:

  • Requests submitted through eviCore are updated on eviCore’s portal: evicore.com.
  • Requests submitted through the Availity Provider Portal are updated in Availity: availity.com.

Phone or fax

Submit the appropriate pre-authorization request form only if unable to submit online or if submitting an expedited request:

Direct clinical information reviews (MCG Health)

For select CPT codes, Availity's electronic authorization tool automatically routes you to MCG Health's website where you can document specific clinical criteria for your patient. If all criteria are met, you will see the approval on the Auth/Referral Dashboard soon after you click submit. Once all criteria are documented, you will then be routed back to the Availity Portal to attach supporting documentation and submit the request. Documenting complete and accurate clinical information for your patients helps to reduce the overall time it takes to review a pre-authorization request.

This applies to pre-authorizations for our group and Individual members. It does not currently include Medicare Advantage pre-authorizations. View the services that may receive automated approval (PDF).

Pre-authorization requests

Type of service or request

Online

Phone

Fax (only if unable to submit online)

Skilled nursing facility only

Submit an electronic pre-authorization request through the Availity Portal

1 (844) 600-4376

1 (855) 848-8220

Long term acute care and inpatient rehabilitation

1 (855) 238-9318

1 (855) 848-8220

Chemical dependency and mental health

1 (855) 522-8868

1 (888) 496-1540

Transplants

1 (855) 238-9318

1 (800) 584-0689

DME and professional services

1 (855) 238-9318

1 (855) 207-1209

Expedited requests

1 (855) 238-9318

1 (855) 240-6498

Concurrent review notification for:

  • Skilled nursing facilities
  • In-patient rehabilitation
  • Long-term acute care

1 (855) 848-8220

Notifications for:

  • Inpatient admissions
  • Inpatient discharges

1 (855) 238-9318

1 (800) 453-4341

Clinical records for:

  • Skilled nursing
  • Long term acute care
  • Inpatient rehabilitation

1 (855) 238-9318

1 (844) 629-4404

Radiology program

Codes requiring authorization are listed in the Radiology section below. Determine whether your patient's plan participates in this program by using the electronic authorization tool on the Availity Portal. View information about this program (PDF).

Obtain an order number with AIM Specialty Health:

Physical Medicine

Codes requiring authorization are listed in the Physical Medicine section below. Determine whether your patient's plan participates in this program by using the electronic authorization tool on the Availity Portal. View information about this program (PDF).

Obtain or verify an authorization with eviCore healthcare (eviCore):

Sleep Medicine

Codes requiring authorization are listed in the Sleep Medicine section below. Determine whether your patient's plan participates in this program by using the electronic authorization tool on the Availity Portal. View information about this program (PDF).

Obtain an order number with AIM Specialty Health:

Joint administration members

Group #

Pre-authorization form

Fax

Phone

#70000000

1 (877) 955-3548

1 (866) 947-9522

#70000002

1 (855) 836-3884

1 (855) 778-9047

#70000003

(503) 654-8570

(503) 654-9447 or 1 (800) 862-3338

#70000004

1 (877) 955-3548

1 (855) 258-6451

#70000005

(503) 654-8570

(503) 654-9447 or 1 (800) 862-3338

#70000007

1 (877) 955-3548

1 (866) 504-6812

#70000008

1 (855) 540-1980

1 (855) 240-3696

#70000009

1 (866) 748-6573

1 (866) 955-1490

#70000010

1 (866) 748-6574

1 (877) 955-1570

#70000011

1 (877) 955-3548

1 (833) 951-1370

Important pre-authorization reminders

  1. Failure to pre-authorize services subject to pre-authorization requirements will result in an administrative denial, claim non-payment and provider and facility write-off. Members may not be balance billed.
  2. Before requesting pre-authorization, please verify member eligibility and benefits via the Availity Portal as the member contract determines the covered benefits.
  3. Verify that you are an in-network provider for each member to help reduce his or her out-of-pocket expense.
  4. If services are to be rendered in a facility, the pre-authorization request submitted should designate the facility where the treatment will occur to ensure proper reconciliation with related inpatient claims.
  5. Medical policies, MCG and CMS criteria may be used as the basis for service coverage determinations, including length of stay and level of care. Visit MCG's website for information on purchasing their criteria, or contact us and we will be happy to provide you with a copy of guidelines for specific services.
  6. Some member contracts have specific pre-authorization requirements. The member's contract language will apply.
  7. Emergency services do not require pre-authorization, but are subject to hospital admission notification requirements (see below).
  8. Please note that a pre-authorization does not guarantee payment for requested services. (See #2 above). Our reimbursement policies may affect how claims are reimbursed. Payment of benefits is subject to pre-payment and/or post-payment review, and all plan provisions, including, but not limited to, eligibility for benefits and our Coding Toolkit clinical edits.
  9. Investigational and cosmetic services and supplies are typically contract exclusions and are ineligible for payment. Unlisted codes may be used for potentially investigational services and are subject to review. Please refer to the Clinical Edits by Code list for additional information. View a sample non-covered member consent form (PDF).
  10. Pre-authorization requirements are not dependent upon site of service. All CPT and HCPCS codes listed on our pre-authorization lists require pre-authorization. View list below for complete requirements.
  11. You will be notified when your request is approved or denied. Notification of approvals will be provided verbally or via fax to you. Please ensure that you include the proper contact phone number, with confidential voice mail, or fax number on the request. Notification of denials will be mailed to the address on the request or, if no address is included, the physical address we have on file for you. Please take time now to review your information on our Find a doctor tool and update, if needed. Note: This process does not apply to pharmacy pre-authorizations.
Pre-authorization review timeframes

Type of review

Timeframe

Additional time allowed for review if additional information is needed:

Urgent

Fully insured: 48 hours

ASO groups: 72 hours

Fully insured: Must notify within 24 hours what additional information is needed. Must give no less than 48 hours to provide. Decision is due within 48 hours of receipt of the additional information.

ASO groups: 48 hours

Standard initial 

Fully insured: 5 calendar days

ASO groups: 15 calendar days

Fully insured: Up to 10 calendar days for total of 15 days

ASO groups: 15 calendar days

Concurrent

24 hours
Exception:
Maternity delivery notifications are required on day 6 if the member has not discharged.

Must notify within 24 hours what additional information is needed. Must give no less than 48 hours to provide. Decision is due within 48 hours of receipt of the additional information.

We will respond to your notification with the date clinical records are due. If you have granted our clinical team access to your electronic medical records (EMR) system, please ensure these records are available in your EMR system.

Investigational

Fully insured: 20 business days

ASO groups: N/A

N/A

Note that additional timeframes are after receipt of the documentation or the timeframe for submission of the requested information has expired - whichever comes first.

Payment implications for failure to pre-authorize services

Failure to secure approval for services subject to pre-authorization will result in claim non-payment and provider write-off. Our members must be held harmless and cannot be balance billed.

Please note the following:

  • Hospital claims for elective services that require pre-authorization will be reimbursed based upon the member's contract only when the physician or other health care professional has completed and received approval of the pre-authorization for the services. We therefore strongly suggest that facilities develop a method to ensure that required pre-authorization requests have been submitted by the physician or other health care professional and approved prior to admission of the patient.
  • If the physician or other health care professional follows the pre-authorization requirements outlined on our pre-authorization lists, they will not be subject to any pre-authorization penalties for failure of the facility to provide the required inpatient admission and discharge notification.
  • A pre-authorization does not guarantee payment for requested services. Health Plan reimbursement policies may affect how claims are reimbursed and payment of benefits is subject to all plan provisions, including eligibility for benefits. Services must always be covered benefits and medically necessary.
  • If an elective service that requires pre-authorization needs to occur during the course of an inpatient admission, and that need could not be foreseen prior to admission, the facility or provider can request pre-authorization for the service while the member is inpatient (before the service occurs). If pre-authorization does not occur during the stay, services are subject to review post-service for medical necessity.

Pre-authorization exception

There may be exceptions to obtaining pre-authorization. The six situations listed below may apply as part of our Extenuating Circumstances Policy Criteria (PDF):

  1. Member presented with an incorrect member ID card or member number or indicated they were self-pay, and that no coverage was in place at the time of treatment, or the participating provider or facility is unable to identify from which carrier or its designated or contracted representative to request a pre-authorization.
  2. Natural disaster prevented the provider or facility from securing a pre-authorization or providing hospital admission notification.
  3. Member is unable to communicate (e.g., unconscious) medical insurance coverage. Neither family nor collateral support present can provide coverage information.
  4. Compelling evidence the provider attempted to obtain pre-authorization. The evidence shall support the provider followed our policy and that the required information was entered correctly by the provider office into the appropriate system.
  5. A surgery which requires pre-authorization occurs in an urgent or emergent situation. Services are subject to review post-service for medical necessity.
  6. A participating provider or facility is unable to anticipate the need for a pre-authorization before or while performing a service or surgery.

Learn how to notify us about an extenuating circumstance (PDF) prior to claim submission, or how to appeal a claim that has been administratively denied.

Inpatient admissions

See below for chemical dependency and mental health admissions.

Habilitative inpatient services

  • Pre-authorization is required prior to patient admission.

Hospital admissions

  • Pre-authorization is required for elective inpatient admissions occurring on or after May 1, 2019. For more information, read our Frequently Asked Questions (PDF).
  • Notification of a hospital admission or discharge is necessary within 24 hours of admission or discharge (or one business day, if the admission or discharge occurs on a weekend or a federal holiday).
  • Notification is required via electronic medical record, when available. If electronic medical records are not available, notifications are required via fax or by calling 1 (800) 423-6884. Providers should not call Customer Service to notify of patient admissions or discharge. Learn more about this requirement in the Facility Guidelines section of our Administrative Manual.

Inpatient hospice

  • Notification of admission or discharge is necessary within 24 hours of admission or discharge (or one business day, if the admission or discharge occurs on a weekend or a federal holiday).
  • Notification is required via electronic medical record, when available. If electronic medical records are not available, notifications are required via fax. Learn more about this requirement.

Long Term Acute Care Facility (LTAC)

  • Pre-authorization is required prior to patient admission.

Rehabilitation

  • Pre-authorization is required prior to patient admission.

Skilled Nursing Facility (SNF)

  • Pre-authorization is required prior to patient admission.

Extracorporeal Circulation Membrane Oxygenation (ECMO) for the Treatment of Respiratory Failure in Adults (PDF)

  • We require the facility to specifically notify us when ECMO is initiated on an Asuris member. Subject to review.

Chemical dependency and mental health

Pre-authorization is required for the services listed below. For select CPT codes, including transcranial magnetic stimulation services, Availity's electronic authorization tool automatically connects to MCG Health's website where specific clinical criteria can be documented for your patient. If all criteria are met, an approval will be received on the Auth/Referral Dashboard. Emergency inpatient services do not require pre-authorization, but are subject to admission notification requirements.

  • Inpatient: Psychiatric or ASAM 4.0 Detoxification
    • Notification of admission must be received within 24 hours of admission or the next business day (whichever comes first). Medical necessity review will be conducted.
  • Sub-Acute Detoxification/ASAM Level 3.7
    • Requires pre-authorization before the member is admitted for services. Under certain circumstances, pre-authorization requests can be made within 24 hours of admission or the next business day.
  • Residential treatment: Psychiatric or ASAM Level 3.5 for Substance Use Disorders
    • Requires pre-authorization before the member is admitted for services. Under certain circumstances, pre-authorization requests can be made within 24 hours of admission or the next business day.
  • Partial hospitalization: Psychiatric or ASAM level 2.5 for Substance Use Disorders
    • Request for authorization is required no later than the day of admission.
  • Intensive outpatient: Psychiatric or ASAM level 2.1 for Substance Use Disorders

    • Request for authorization is required no later than the day of admission.

Medical necessity for behavioral health services is determined by:

View our resources for behavioral health facilities and our behavioral health medical policies.

Applied Behavior Analysis (ABA) Therapy

  • Procedure codes 0362T, 0373T, 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158
  • Procedure codes 97151, 97152, and 0362T: Pre-authorization is not required when 97151, 97152, and 0362T are used for initial ABA assessments, but pre-authorization is required when 97151, 97152, and 0362T are used for ABA reassessments.

The following clinical providers, with expertise in using evidenced-based tools to establish or confirm the diagnosis of autism and experience in developing multidisciplinary autism treatment plans, can provide the diagnostic assessment, comprehensive evaluation report, and recommend treatment approach:

  • Psychiatrist
  • Neurologist
  • Pediatric Neurologist
  • Developmental Pediatrician
  • Doctorate level psychologist
  • Advanced registered nurse practitioner

View documentation requirements in our Applied Behavior Analysis for the Treatment of Autism Spectrum Disorder (PDF) medical policy.

Durable medical equipment

Bone Growth Stimulators, Electrical (Osteogenic Stimulation) (PDF)

  • E0747, E0748, E0749
  • Administrative services only (ASO) group requests for E0747, E0748 and E0749 require pre-authorization through Asuris.
  • For all other commercial products:

    • Requests for E0747 require pre-authorization through Asuris.
    • Requests for E0748 and E0749 are detailed in the "Physical Medicine" section and requests for authorization are submitted directly to eviCore healthcare (eviCore)

Ultrasonic Bone Growth Stimulators (Osteogenic Stimulation)

  • E0760, 20979 - MCG ACG: A-414 Visit MCG's website for information on purchasing their criteria, or contact us and we will be happy to provide you with a copy of the specific guideline.
  • Effective September 1, 2020: Ultrasonic Bone Growth Stimulators will be reviewed with Asuris Medical Policy DME #83.12 (PDF)

Insulin Infusion Pumps, Automated Insulin Delivery and Artificial Pancreas Device Systems (PDF)

  • E0784, E0787, S1034

Myoelectric Prosthetic and Orthotic Components for the Upper Limb (PDF)

  • L6026, L6693, L6715, L6880, L6881, L6882, L6925, L6935, L6945, L6955, L6965, L6975, L7007, L7008, L7009, L7045, L7180, L7181, L7190, L7191

Noninvasive Ventilators in the Home Setting (PDF)

  • E0466
  • Note: Due to the COVID-19 pandemic, pre-authorization requirements for noninvasive ventilators will be suspended until August 1, 2020

Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Conditions (PDF)

  • E0481, E0483

Power Wheelchairs: Group 3 (PDF)

  • K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855, K0856, K0857, K0858, K0859, K0860, K0861, K0862, K0863, K0864

Powered Knee Prosthesis, Powered Ankle-Foot Prosthesis, Microprocessor-Controlled Ankle-Foot Prosthesis, and Microprocessor-Controlled Knee Prostheses (PDF)

  • L5856, L5857, L5858

Sleep Medicine Program

  • Review the codes requiring authorization or notification in the Sleep medicine section on this list.

Genetic testing

Genetic Testing for Alzheimer's Disease (PDF) - GT01

  • 81401, 81405, 81406

Genetic Testing for Hereditary Breast and Ovarian Cancer and Li-Fraumeni Syndrome (PDF) - GT02

  • 81162, 81163, 81164, 81165, 81166, 81167, 81212, 81215, 81216, 81217, 81307, 81308, 81321, 81322, 81323, 81404, 81405, 81406, 81432, 81433

Apolipoprotein E for Risk Assessment and Management of Cardiovascular Disease (PDF) - GT05

  • 81401

Genetic Testing for Lynch Syndrome and APC-associated and MUTYH-associated Polyposis Syndromes (PDF) - GT06

  • 81201, 81202, 81203, 81210, 81288, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81317, 81318, 81319, 81401, 81406

Genetic Testing for Cutaneous Malignant Melanoma (PDF) - GT08

  • 81404

Cytochrome p450 and VKORC1 Genotyping for Treatment Selection and Dosing (PDF) - GT10

  • 81225, 81401, 81402, 81404, 81405, 0070U, 0071U, 0072U, 0073U, 0074U, 0075, 0076U

Genetic Testing; Familial Hypercholesterolemia (PDF) - GT11

  • 81401, 81405, 81406, 81407

KRAS, NRAS and BRAF Variant Analysis and MicroRNA Expression Testing for Colorectal Cancer (PDF) - GT13

  • 81210, 81275, 81276, 81311, 81403, 81404, 0111U

Preimplantation Genetic Testing of Embryos (PDF) - GT18

  • 89290, 89291, 81228, 81229

Genetic Testing; IDH1 and IDH2 Genetic Testing for Conditions Other Than Myeloid Neoplasms or Leukemia (PDF) - GT19

  • 81120, 81121

Genetic and Molecular Diagnostic Testing (PDF) - GT20

  • 81170, 81201, 81202, 81203, 81210, 81212, 81215, 81216, 81217, 81218, 81225, 81228, 81229, 81235, 81243, 81244, 81245, 81246, 81250, 81252, 81253, 81254, 81257, 81272, 81273, 81275, 81276, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81302, 81303, 81304, 81310, 81311, 81314, 81317, 81318, 81319, 81321, 81322, 81323, 81327, 81341, 81350, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81470, 81471, S3800, S3840, S3844, S3845, S3846, S3849, S3850, S3853, S3865, S3866

Biallelic RPE65 Variant-Associated Retinal Dystrophy (PDF) - GT21

  • 81406

Gene Expression Profiling for Melanoma (PDF) - GT29

  • 81552

BRAF Genetic Testing to Select Melanoma or Glioma Patients for Targeted Therapy (PDF) - GT41

  • 81210

Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer (PDF) - GT42

  • 81518, 81519, 81521, 81522, S3854

Genetic Testing for FMR1 and AFF2 Variants (Including Fragile X and Fragile EX Syndromes) (PDF) - GT43

  • 81243, 81244

Genetic Testing for CADASIL Syndrome (PDF) - GT51

  • 81406

Genetic Testing for α-Thalassemia (PDF) - GT52

  • 81257, 81258, 81259, 81269, 81404

Targeted Genetic Testing for Selection of Therapy for Non-Small Cell Lung Cancer (NSCLC) (PDF) - GT56

  • 0022U, 81210, 81235, 81275, 81276, 81404, 81405, 81406

Chromosomal Microarray Analysis (CMA) or Copy Number Analysis for the Genetic Evaluation of Patients with Developmental Delay Intellectual Disability, Autism Spectrum Disorder or Congenital Anomalies (PDF) - GT58

  • 81228, 81229, 0156U, S3870

Myeloid Neoplasms and Leukemia (PDF) - GT59

  • 81120, 81121, 81170, 81175, 81176, 81218, 81245, 81246, 81272, 81273, 81310, 81334, 81401, 81402, 81403, 0023U, 0046U, 0049U

PTEN Hamartoma Tumor Syndrome (PDF) - GT63

  • 81321, 81322, 81323

Evaluating the Utility of Genetic Panels (PDF) - GT64

  • 81162, 81163, 81164, 81165, 81166, 81167, 81170, 81175, 81176, 81201, 81202, 81203, 81210, 81212, 81215, 81216, 81217, 81218, 81225, 81228, 81229, 81235, 81243, 81244, 81245, 81246, 81250, 81252, 81253, 81254, 81257, 81272, 81273, 81275, 81276, 81288, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81302, 81303, 81304, 81310, 81311, 81314, 81317, 81318, 81319, 81321, 81322, 81323, 81327, 81341, 81350, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81412, 81432, 81433, 81434, 81437, 81438, 81443, 81450, 81455, 81470, 81471, S3854

Genetic Testing for Methionine Metabolism Enzymes, including MTHFR (PDF) - GT65

  • 81401, 81403, 81404, 81405, 81406

Diagnosis of Inherited Peripheral Neuropathies (PDF) - GT66

  • 81403, 81404, 81405, 81406

Genetic Testing for Rett Syndrome (PDF) - GT68

  • 81302, 81303, 81304, 81404, 81405, 81406

Duchenne and Becker Muscular Dystrophy (PDF) - GT69

  • 81161, 81408

Genetic Testing: Predisposition to Inherited Hypertrophic Cardiomyopathy (PDF) - GT72

  • 81403, 81405, 81406, 81407, 81439, S3865, S3866

Genetic Testing; Fetal RHD Genotyping Using Maternal Plasma (PDF) - GT74

  • 81403

Genetic Testing; Genetic Testing for Macular Degeneration (PDF) - GT75

  • 81401, 81405, 81408

Whole Exome and Whole Genome Sequencing (PDF) - GT76

  • 81415, 81416

Genetic Testing for Heritable Disorders of Connective Tissue (PDF) - GT77

  • 81405, 81408

Genetic Testing; Invasive Prenatal Fetal Diagnostic Testing Using Chromosomal Microarray Analysis (CMA) (PDF) - GT78

  • 81228, 81229, 81405

Chromosomal Microarray (CMA) Testing for the Evaluation of Products of Conception and Pregnancy Loss (PDF) - GT79

  • 81228, 81229

Genetic Testing for Epilepsy (PDF) - GT80

  • 81188, 81189, 81190, 81401, 81403, 81404, 81405, 81406, 81407

Reproductive Carrier Screening for Genetic Diseases (PDF) - GT81

  • 81250, 81252, 81253, 81254, 81257, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81412, 81434, 81443, S3844, S3845, S3846, S3849, S3850, S3853

Genetic Testing: Expanded Molecular Panel Testing of Cancers to Select Targeted Therapies (PDF) - GT83

  • 0022U, 0037U, 0048U, 81120, 81121, 81162, 81210, 81235, 81275, 81276, 81292, 81295, 81298, 81311, 81314, 81319, 81321, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81445, 81455

Genetic Testing for Neurofibromatosis Type 1 or 2 (PDF) - GT84

  • 81405, 81406, 81408

Laboratory

Laboratory and Genetic Testing for use of Thiopurines (PDF)

  • 81306, 81335, 81401, 0034U, 0169U

Medicine

Charged-Particle (Proton) Radiotherapy (PDF)

  • 32701, 61796, 61797, 61798, 61799, 61800, 63620, 63621, 77371, 77372, 77373, 77432, 77435, 77520, 77522, 77523, 77525, G0339, G0340

Confocal Laser Endomicroscopy (PDF)

  • 43206, 43252, 88375

Extracorporeal Circulation Membrane Oxygenation (ECMO) for the Treatment of Respiratory Failure in Adults (PDF)

  • Please see the Inpatient admissions section for further information.

Gait Analysis (PDF)

  • 96000, 96001, 96002, 96003, 96004
  • Gait analysis may be considered medically necessary in children and adolescents with cerebral palsy to select surgical or other therapeutic interventions for gait improvement. All other indications for gait analysis and Paraspinal Surface Electromyography (EMG) (PDF) are considered investigational.

Gender Affirming Interventions for Gender Dysphoria(PDF)

  • 15775, 15776, 17380, 55970, 55980
  • Codes 55970 and 55980 are non-specific. The specific procedure code(s) must be requested in place of these non-specific codes.
  • 17999, 19303, 19316, 19318, 19324, 19325,19350, 53400, 53405, 53410, 53415, 53420, 53425, 53430, 54125, 54520, 54660, 54690, 55175, 55180, 56625, 56800, 56805, 57106, 57110, 57291, 57292, 57295, 57296, 57335, 57426, 58150, 58180, 58260, 58262,58270, 58275, 58290, 58291, 58353, 58356, 58541, 58542, 58543, 58544, 58550, 58552, 58553, 58554, 58563, 58570, 58571, 58572, 58573, C1813, L8600
  • Use code 17999 to request laser hair removal.
  • Gender affirming surgical interventions for gender dysphoria require pre-authorization. Codes for specific procedures might also be listed as requiring pre-authorization in other medical policies, including but not limited to abdominoplasty, breast reconstruction, blepharoplasty, brow lift, chin implants, collagen injections, endometrial ablation, panniculectomy, and rhinoplasty. Check for codes in other areas of this pre-authorization list.

Hyperbaric Oxygen Therapy (PDF)

  • 99183, G0277

Intensity Modulated Radiotherapy (IMRT)

Orthopedic Applications of Stem-Cell Therapy, Including Bone Substitutes Used with Autologous Bone Marrow (PDF)

  • 38206, 38232, 38241

Radioembolization, Transarterial Embolization (TAE), and Transarterial Chemoembolization (TACE) (PDF)

Surface Electromyography (SEMG) (PDF)

  • 96002, 96004

Transcranial Magnetic Stimulation as a Treatment of Depression and Other Disorders(PDF)

  • 90867, 90868, 90869

In Vivo Analysis of Colorectal Polyps (PDF)

  • 88375

Coverage of Treatments Provided in a Clinical Trial (PDF)

  • S9990, S9991, S9988

Sleep Medicine Program

Pharmacy

View pharmacy pre-authorization requirements.

Intra-articular Hyaluronic Acid Derivatives (PDF)

  • All intra-articular hyaluronic acid derivatives require pre-authorization; however, they are generally considered investigational or not medically necessary. Intra-articular hyaluronic acid derivatives include, but are not limited to, the following codes: J0223, J0791, J0896, J1429, J1558, J3399, J7169, J7204, J7318, J7320, J7321, J7322, J7323, J7324, J7325, J7326, J7327, J7328, J7329, J7331, J7332, J9177, J9358, C9061, C9063, Q5119, Q5121
  • A member consent form must be signed by our member indicating that he or she understands the specific services and/or supplies may be considered investigational, not medically necessary or non-covered and will result in financial liability to him or her.

Physical Medicine

We partner with eviCore healthcare to administer our Physical Medicine program.

Authorization is not required for an initial evaluation and management visit and up to a total of six consecutive treatment visits in a new episode of care for group and Individual members on any of our Washington-issued products for the following Physical Medicine program services:

  • Chiropractic
  • Acupuncture
  • Speech therapy
  • Physical therapy
  • Massage therapy
  • Occupational therapy

This authorization change applies to our group and Individual members.

It does not apply to the following members:

  • Medicare Advantage
  • Administrative services only

eviCore will identify members who have coverage issued in Washington state and who do not require an authorization until after the sixth consecutive treatment visit.

  1. Review this entire page for similar services that require pre-authorization
  2. Verify member benefits, eligibility and pre-authorization requirements on the Availity Portal
  3. Determine whether your patient's plan participates in this program by using the electronic authorization tool on the Availity Portal
  4. Obtain or verify an authorization with eviCore:

    1. Sign in to eviCore's portal
    2. Phone (855) 252-1115
    3. Fax (855) 774-1319
    4. View workarounds for eviCore system outages

Physical therapy, speech therapy, occupational therapy (PT/ST/OT); chiropractic, complementary and alternative medicine

  • View information about this program (PDF)
  • Members aged 17 and younger: Select pediatric diagnosis codes are excluded from the program (PDF).
  • We require authorization from eviCore for these codes: 92507, 92508, 92521, 92522, 92523, 92524, 92526, 92597, 92607, 92608, 92609, 92610, 92626, 92627, 92630, 92633, 95851, 95852, 96105, 97012, 97014, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036, 97039, 97110, 97112, 97113, 97116, 97124, 97129, 97130, 97139, 97140, 97150, 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 97530, 97542, 97750, 97755, 97760, 97761, 97763, 97799, 97810, 97811, 97813, 97814, 98940, 98941, 98942, 98943, G0151, G0152, G0157, G0158, G0159, G0160, G0283, S8950, S9128, S9129, S9131, S9152

Pain management

  • View information about this program (PDF)
  • We require authorization from eviCore for these codes: 00640, 22510, 22511, 22512, 22513, 22514, 22515, 27096, 61790, 61791, 62290, 62291, 62320, 62321, 62322, 62323, 62324, 62325, 62326, 62327, 62350, 62351, 62360, 62361, 62362, 63650, 63655, 63685, 64405, 64479, 64480, 64483, 64484, 64490, 64491, 64492, 64493, 64494, 64495, 64510, 64520, 64633, 64634, 64635, 64636, 72275, 72285, 72295, G0259, G0260

Joint management

  • Some ASO groups may require authorization through either 1) our Physical Medicine program administered by eviCore, or 2) our Surgery authorization program.
  • To determine whether your patient's plan participates in this program, use the electronic authorization tool on the Availity Portal.
  • We require authorization from eviCore for these codes: 23470, 23472, 23473, 23474, 27125, 27130, 27132, 27134, 27137, 27138, 27416, 27438, 27440, 27441, 27442, 27443, 27445, 27446, 27447, 27486, 27487, 27488, 27580, 29805, 29806, 29807, 29819, 29820, 29821, 29822, 29823, 29824, 29825, 29826, 29827, 29828, 29860, 29861, 29862, 29863, 29866, 29867, 29868, 29870, 29871, 29873, 29874, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889, 29891, 29892, 29893, 29894, 29895, 29897, 29898, 29899, 29904, 29905, 29906, 29907, 29914, 29915, 29916

Spine

  • Some ASO groups may require authorization through either 1) our Physical Medicine program administered by eviCore, or 2) our Surgery authorization program.
  • To determine whether your patient's plan participates in this program, use the electronic authorization tool on the Availity Portal.
  • We require authorization from eviCore for these codes: 20931, 20937, 20938, 22100, 22101, 22102, 22103, 22110, 22112, 22114, 22116, 22206, 22207, 22208, 22210, 22212, 22214, 22216, 22220, 22222, 22224, 22226, 22325, 22326, 22327, 22328, 22510, 22511, 22512, 22513, 22514, 22515, 22532, 22533, 22534, 22548, 22551, 22552, 22554, 22556, 22558, 22585, 22590, 22595, 22600, 22610, 22612, 22614, 22630, 22632, 22633, 22634, 22800, 22802, 22804, 22808, 22810, 22812, 22818, 22819, 22830, 22840, 22842, 22843, 22844, 22845, 22846, 22847, 22848, 22849, 22850, 22852, 22853, 22854, 22855, 22856, 22858, 22859, 63001, 63003, 63005, 63011, 63012, 63015, 63016, 63017, 63020, 63030, 63035, 63040, 63042, 63043, 63044, 63045, 63046, 63047, 63048, 63050, 63051, 63055, 63056, 63057, 63064, 63066, 63075, 63076, 63077, 63078, 63081, 63082, 63085, 63086, 63087, 63088, 63090, 63091, 63101, 63102, 63103, 63170, 63172, 63173, 63180, 63182, 63185, 63190, 63191, 63194, 63195, 63196, 63197, 63198, 63199, 63200, 63250, 63251, 63252, 63265, 63266, 63267, 63268, 63270, 63271, 63272, 63273, 63275, 63276, 63277, 63278, 63280, 63281, 63282, 63283, 63285, 63286, 63287, 63290, 63295, 63300, 63301, 63302, 63303, 63304, 63305, 63306, 63307, 63308, E0748, E0749, S2350, S2351

Radiology

Contact Asuris for pre-authorization for the following codes:

Computed Tomography to Detect Coronary Artery Calcification (PDF)

  • S8092

AIM Specialty Health

We partner with AIM to administer our radiology program which has two components: Radiology Quality Initiative (RQI) and Advanced Imaging Authorization. Please note, ASO groups who do not participate in the Advanced Imaging component still require an order number through the RQI component. Determine whether your patient's plan participates in this program by using the electronic authorization tool on the Availity Portal.

  • Sign in to AIM's ProviderPortal
  • Phone 1 (877) 291-0509
  • View workarounds for AIM system outages
  • Contact AIM to obtain an order number for the following codes: 70336, 70450, 70460, 70470, 70480, 70481, 70482, 70486, 70487, 70488, 70490, 70491, 70492, 70496, 70498, 70540, 70542, 70543, 70544, 70545, 70546, 70547, 70548, 70549, 70551, 70552, 70553, 70554, 70555, 71250, 71260, 71270, 71275, 71550, 71551, 71552, 71555, 72125, 72126, 72127, 72128, 72129, 72130, 72131, 72132, 72133, 72141, 72142, 72146, 72147, 72148, 72149, 72156, 72157, 72158, 72159, 72191, 72192, 72193, 72194, 72195, 72196, 72197, 72198, 73200, 73201, 73202, 73206, 73218, 73219, 73220, 73225, 73718, 73719, 73720, 73721, 73722, 73723, 73725, 73221, 73222, 73223, 73700, 73701, 73702, 73706, 74150, 74160, 74170, 74174, 74175, 74176, 74177, 74178, 74181, 74182, 74183, 74185, 74712, 75557, 75559, 75561, 75563, 75572, 75573, 75574, 75635, 76391, 77046, 77047, 77048, 77049, 77078, 77084, 78429, 78430, 78431, 78432, 78433, 78451, 78452, 78453, 78454, 78459, 78466, 78468, 78469, 78472, 78473, 78481, 78483, 78491, 78492, 78494, 78608, 78609, 78811, 78812, 78813, 78814, 78815, 78816, 93303, 93304, 93306, 93307, 93308, 93312, 93313, 93314, 93315, 93316, 93317, 93350, 93351, G0297, 0501T, 0502T, 0503T, 0504T

Sleep medicine

We partner with AIM to administer our Sleep Medicine program. Determine whether your patient's plan participates in this program by using the electronic authorization tool on the Availity Portal.

  • Login to AIM's ProviderPortal
  • Phone 1 (877) 291-0509
  • View workarounds for AIM system outages
  • Contact AIM to obtain an order number for the following codes: 95782, 95783, 95800, 95801, 95805, 95806, 95807, 95808, 95810, 95811, E0470, E0471, E0561, E0562, E0601, G0398, G0399, G0400

Surgery

Ablation of Primary and Metastatic Liver Tumors (PDF)

  • 47370, 47371, 47380, 47381, 47382, 47383

Adipose-derived Stem Cell Enrichment in Autologous Fat Grafting to the Breast (PDF)

  • 15769, 15771, 15772, 19366
  • Notes:

    • Codes 11950, 11951, 11952, 11954, 15769, 15771, 15772, and 19366 require pre-authorization authorization (see other sections of this pre-authorization list) except when used for autologous fat grafting and adipose-derived stem cell enrichment for augmentation or reconstruction of the breast, where it is considered, and will deny as, investigational
    • Codes 19380 and 19499 do not require pre-authorization but are considered, and will deny as, investigational when used for autologous fat grafting and adipose-derived stem cell enrichment for augmentation or reconstruction of the breast

Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions (PDF)

  • 27412, J7330, S2112

Balloon Ostial Dilation for Treatment of Sinusitis (PDF)

  • 31295, 31296, 31297, 31298

Bariatric surgery (PDF)

  • 43644, 43770, 43771, 43772, 43773, 43774, 43775, 43820, 43846, 43848, 43860, 43886, 43887, 43888

Blepharoplasty and Brow Ptosis Repair (PDF)

  • 15820, 15821, 15822, 15823, 67900, 67901, 67902, 67903, 67904, 67906, 67908, 67909, 67950
  • Effective October 1, 2020: Updating medical policy title to Blepharoplasty, Repair of Blepharoptosis, and Brow Ptosis Repair

Chemical Peels (PDF)

  • 15788, 15789, 15792, 15793, 17360

Cochlear Implant (PDF)

  • 69930, L8614, L8619, L8627, L8628

Cosmetic and Reconstructive Surgery (PDF)

  • 11920, 11921, 11922, 11950, 11951, 11952, 11954, 15769, 15771, 15772, 15773, 15774, 19355, 21244, 21245, 21246, 21248, 21249, 21295, 21296, 41510, 49250, 54360, 69300, G0429, Q2026, Q2028
  • Pre-authorization is required EXCEPT when services are rendered in association with breast reconstruction and nipple/areola reconstruction following mastectomy for breast cancer.
  • Notes:

    • Codes 11950, 11951, 11952, 11954, 15769, 15771, 15772 and 19366 require pre-authorization (see other sections of this pre-authorization list) except when used for autologous fat grafting and adipose-derived stem cell enrichment for augmentation or reconstruction of the breast, where it is considered, and will deny as, investigational
    • Codes 19380 and 19499 do not require pre-authorization but are considered, and will deny as, investigational when used for autologous fat grafting and adipose-derived stem cell enrichment for augmentation or reconstruction of the breast

Cryosurgical Ablation of Miscellaneous Solid Organ, Pulmonary, and Breast Tumors (PDF)

  • 31641, 32994, 50542

Deep Brain Stimulation (PDF)

  • 61850, 61860, 61863, 61864, 61867, 61868, 61885, 61886

Endometrial Ablation (PDF)

  • 58353, 58356, 58563

Extracranial Carotid Angioplasty and Stenting (PDF)

  • 37215, 37216, 37217, 37246, 37247

Femoroacetabular Impingement Surgery (PDF)

  • 29914, 29915, 29916
  • We require pre-authorization for these codes for ASO groups that do not participate in the Physical Medicine program (eviCore) above. For fully insured groups and Individual plans, please review the "Physical Medicine" section above.

Gastric Electrical Stimulation (PDF)

  • 43647, 43881, 64590, E0765

Gastroesophageal Reflux Surgery (PDF)

  • 43279, 43280, 43281, 43282, 43325, 43327, 43328, 43332, 43333, 43334, 43335, 43336, 43337

Hypoglossal Nerve Stimulation (PDF)

  • 64568, 0466T

Hysterectomy Surgery (PDF)

  • 58150, 58152, 58180, 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58290, 58291, 58292, 58293, 58294, 58541, 58542, 58543, 58544, 58550, 58552, 58553, 58554, 58570, 58571, 58572, 58573
  • Pre-authorization is only required for diagnoses related to abnormal uterine bleeding, pelvic pain (including pain related to endometriosis, Essure placement, prior endometrial ablation, and vaginal agenesis), chronic pelvic inflammatory disease, pelvic adhesive disease, pelvic venous congestion, adenomyosis, cervical intraepithelial neoplasia, and leiomyoma. Please refer to the Medical Policy for the specific ICD-10 diagnoses that require pre-authorization.
  • Note: Hysterectomy procedures for the indication of gender dysphoria are subject to the Gender Affirming Interventions for Gender Dysphoria medical policy (PDF)

Transcutaneous Bone Conduction and Bone-Anchored Hearing Aids (PDF)

  • 69714, 69710, 69715, 69717, 69718, L8690, L8691, L8692, L8694

Implantable Cardiac Defibrillator (PDF)

  • 33230, 33231, 33240, 33249, 33270, 33271, C1721, C1722, C1882
  • Pre-authorization is required EXCEPT when the member is age 17 or younger

Implantable Peripheral Nerve Stimulation for Chronic Pain of Peripheral Nerve Origin (PDF)

  • 64555, 64575, 64590

Laser Treatment for Port Wine Stains (PDF)

  • 17106, 17107, 17108

Leadless Cardiac Pacemakers (PDF)

  • 33274

Left-Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation (PDF)

  • 33340

Magnetic Resonance (MR) Guided Focused Ultrasound (MRgFUS) and High Intensity Focused Ultrasound (HIFU) Ablation (PDF)

  • C9747, 0398T

Microwave Tumor Ablation (PDF)

  • 32998, 50592

Occipital Nerve Stimulation (PDF)

  • 61885, 61886, 64553, 64555, 64568, 64575, 64590, 0466T
  • Occipital Nerve Stimulation is considered investigational for all indications, including but not limited to headaches
  • NOTE: These codes may overlap with the codes in the Vagus Nerve Stimulation Medical Policy so to ensure proper adjudication of your claim, please call for pre-authorization on all of the above codes.

Orthognathic surgery (PDF)

  • 21085, 21110, 21120, 21121, 21122, 21123, 21125, 21127, 21141, 21142, 21143, 21145, 21146, 21147, 21150, 21151, 21154, 21155, 21159, 21160, 21188, 21193, 21194, 21195, 21196, 21198, 21206, 21208, 21209, 21210, 21215, 21230, 21295, 21296
  • Codes 21145, 21196, 21198 require pre-authorization EXCEPT when the procedure is performed for oral cancer dx codes: C01, C02-C02.9, C03-C03.9, C04-C04.9, C05-C05.9, C06, C06.2, C06.9, C09-C09.9, C10-C10.0, C41-C41.1, C46.2, D00-D00.00, D10, D10.1-D10.9, D16.4-D16.5, D37-D37.0, D49-D49.0

Ovarian, Internal Iliac and Gonadal Vein Embolization, Ablation, and Sclerotherapy (PDF)

  • 37241

Panniculectomy (PDF)

  • 15830

Pectus Excavatum (PDF)

  • 21740, 21742, 21743

Percutaneous Angioplasty and Stenting of Veins (PDF)

  • 37238, 37239, 37248, 37249

Phrenic Nerve Stimulation for Central Sleep Apnea (PDF)

  • C1823

Radiofrequency Ablation of Tumors (RFA) Other Than the Liver (PDF)

  • 20982, 31641, 32998, 50542, 50592

Reconstructive Breast Surgery/Mastopexy, and Management of Breast Implants (PDF)

  • 11920, 11921, 11950, 11951, 11952, 11954, 15769, 15771, 15772, 19316, 19318, 19324, 19325, 19328, 19330, 19340, 19342, 19350, 19355, 19366, 19370, 19371, L8600
  • Pre-authorization is required EXCEPT when services are rendered in association with breast reconstruction and nipple/areola reconstruction following mastectomy for breast cancer.
  • Notes:

    • Codes 11950, 11951, 11952, 11954, 15769, 15771, 15772 and 19366 require pre-authorization (see other sections of this pre-authorization list) except when used for autologous fat grafting and adipose-derived stem cell enrichment for augmentation or reconstruction of the breast, where it is considered, and will deny as, investigational
    • Codes 19380 and 19499 do not require pre-authorization but are considered, and will deny as, investigational when used for autologous fat grafting and adipose-derived stem cell enrichment for augmentation or reconstruction of the breast

Reduction Mammoplasty (PDF)

  • 19318

Responsive Neurostimulation (PDF)

  • 61850, 61860, 61863, 61864, 61885, 61886

Rhinoplasty (PDF)

  • 30120, 30400, 30410, 30420, 30430, 30435, 30450

Sacral Nerve Neuromodulation (Stimulation) for Pelvic Floor Dysfunction (PDF)

  • 64561, 64581, 64590
  • NOTE: Please submit your pre-authorization request for the temporary trial period of sacral nerve neuromodulation AND the permanent placement at the same time, as these are treated as one combined episode.

Sacroiliac Joint Fusion (PDF)

  • 27279, 27280

Spinal Cord and Dorsal Root Ganglion Stimulation (PDF)

  • 63650, 63655, 63685
  • NOTE: Please submit your pre-authorization request for the temporary trial AND the permanent placement at the same time.
  • We require pre-authorization for these codes for ASO groups that do not participate in the Physical Medicine program (eviCore) above. For fully insured groups and Individual plans, please review the "Physical Medicine" section above.

Spinal Surgery - Cervical Fusion

  • Visit MCG's website for information on purchasing their criteria, or contact Asuris at the phone number(s) above and we will be happy to provide you with a copy of the specific guideline.
    • 22551, 22552, 22554, 22853, 22854, 22859 - MCG ORG S-320
    • 22600 - MCG ORG S-330
  • We require pre-authorization for these codes for ASO groups that do not participate in the Physical Medicine program (eviCore) above. For fully insured groups and Individual plans, please review the "Physical Medicine" section above.

Spinal Surgery - Lumbar Fusion (PDF)

  • 22533, 22853, 22854, 22558, 22859, 22612, 22630, 22633
  • We require pre-authorization for these codes for ASO groups that do not participate in the Physical Medicine program (eviCore) above. For fully insured groups and Individual plans, please review the "Physical Medicine" section above.

Spinal Surgery - Percutaneous Vertebroplasty, Kyphoplasty, Sacroplasty, and Coccygeoplasty (PDF)

  • 22510, 22511, 22512, 22513, 22514, 22515
  • We require pre-authorization for these codes for ASO groups that do not participate in the Physical Medicine program (eviCore) above. For fully insured groups and Individual plans, please review the "Physical Medicine" section above.

Spinal Surgery - Artificial Intervertebral Disc (PDF)

  • 22856, 22858
  • We require pre-authorization for these codes for ASO groups that do not participate in the Physical Medicine program (eviCore) above. For fully insured groups and Individual plans, please review the "Physical Medicine" section above.
  • Reminder: We consider lumbar artificial discs to be investigational, and investigational services are not covered.

Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy (PDF)

Surgical Treatments for Hyperhidrosis (PDF)

  • 32664, 64818, 69676
  • Code 32664 only requires pre-authorization for hyperhidrosis diagnoses L74.510 L74.511, L74.512, L74.513, L74.519, L74.52, R61

Surgeries for Snoring, Obstructive Sleep Apnea Syndrome, and Upper Airway Resistance Syndrome (PDF)

  • 21121, 21122, 21141, 21145, 21196, 21198, 21199, 21685, 41120, 42140, 42145, 42160
  • Codes 21145, 21196, 21198, 41120, 42160 do not require pre-authorization when the procedure is performed for oral cancer dx codes: C01, C02-C02.9, C03-C03.9, C04-C04.9, C05-C05.9, C06, C06.2-C06.9, C09-C09.9, C10-C10.0, C41-C41.1. C46.2, D00-D00.00, D10, D10.1-D10.9, D16.4-D16.5, D37-D37.0, D49-D49.0

Temporomandibular Joint (TMJ) Surgical Interventions

  • Visit MCG's website for information on purchasing their criteria, or contact us and we will be happy to provide you with a copy of the specific guideline.

    • 21010 - MCG A‐0522
    • 21050 - MCG A‐0523
    • 29800, 29804 - MCG A‐0492
    • 21240, 21242, 21243 - MCG A‐0523

Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease (GERD) (PDF)

  • 43192, 43201, 43236
  • Note: Codes 43201 and 43236 may also be used for the administration of Botox for indications unrelated to GERD. Botox requires pre-authorization by Pharmacy. Learn more about submitting a pre-authorization request for Botox.

Vagus Nerve Stimulation (PDF)

  • 61885, 61886, 64553, 64568, 0466T

Varicose Vein Treatment (PDF)

  • 0524T, 36465, 36466, 36470, 36471, 36475, 36476, 36478, 36479, 36482, 36483, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37785, S2202
  • Note: Code 37241 is not appropriate to use in the coding of varicose vein treatment.

Ventral Hernia Repair (PDF)

  • 15734, 49560, 49565, 49652, 49654, 49656
    • Pre-authorization for 15734 required only with diagnosis code K43.0, K43.1, K43.2 K43.6, K43.7 or K43.9 for component separation technique (CST)
    • Pre-authorization for 49652 required only with diagnosis code K43.9 for ventral hernia

Transplants and ventricular assist devices

Transplants - Cell

  • Reference our Medical Policy Manual for policies.
  • 38205, 38206, 38232, 38240, 38241, 38242, 38243, S2140, S2142, S2150

Transplants - Islet Transplantation (PDF)

  • 48160, 0584T, 0585T, 0586T, G0341, G0342, G0343

Transplants - Heart (PDF)

  • 33945

Transplants - Heart-Lung (PDF)

  • 33935

Transplants - Lung and Lobar Lung (PDF)

  • 32851, 32852, 32853, 32854, S2060

Transplants - Isolated Small Bowel Transplant (PDF)

  • 44135, 44136

Transplants - Small Bowel/Liver and Multivisceral Transplant (PDF)

  • 44135, 44136, 47135, 48554, S2053, S2054, S2152

Transplants - Liver Transplant (PDF)

  • 47135

Transplants - Pancreas Transplant (PDF)

  • 48554, S2065, S2152

Ventricular Assist Devices and Total Artificial Hearts (PDF)

  • 33927, 33928, 33929, 33975, 33976, 33977, 33978, 33979, L8698

Utilization management

Air Ambulance Transport (PDF)

  • A0435, A0430, S9960
  • Pre-authorization is required prior to elective fixed wing air ambulance transport.
  • Emergency air ambulance transports will be reviewed retrospectively for medical necessity; clinical documentation will be requested, if needed, upon receipt of the electronic claim.