HEALTH CHOICE GENERATIONS, AZ PRIOR AUTHORIZATION

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HEALTH CHOICE GENERATIONS, AZPRIOR AUTHORIZATION GRIDHELPFUL CONTACTSHEALTH CHOICE GENERATIONSPhone: 1-800-656-8991MEDICAL SERVICESFax: 1-877-424-5680PHARMACY SERVICESFax: 1-877-424-5690For more information on Prior Authorization (PA) or to view this grid online please visithttp://www.HealthChoiceGenAZ.comFor imaging and cardiac testing or procedures authorized by eviCoreEmail ClientServices@Evicore.com OR call 1-888-693-3211For details regarding PA authorization forms refer to the Health Choice Generations Provider Manual,Chapter 6 Authorizations and Notifications (http://www.HealthChoiceGenAZ.com ).THE FOLLOWING DIRECTIVES APPLY TO ALLHEALTH CHOICE GENERATIONS PRIOR AUTHORIZATIONS No Prior Authorization is required for any Health Choice Generations (HCG) and eviCore procedures whenHCG is the secondary payer, EXCEPT for Transplant services and Inpatient services which require PA fromHCGTotal OB Package, including High Risk Assessment require notification onlyOnly one Medical/Pharmacy service may be requested per PA formCodes beginning with “S” are not payable by Medicare and are considered statutory exclusionsThe member must be eligible and a member of HCG at the time the covered service is renderedThe absence of a code from this list does not indicate that no authorization is required. All codes are subjectto clinical editing based on CMS rules and regulationsAuthorizations are valid for 90 days from the date issuedExperimental/Investigational Procedures are not a covered benefitI HEALTH CHOICE GENERATIONS, AZ PRIOR AUTHORIZATION GRID I EFFECTIVE 10/01/2020. REVISED 09/01/2020

2020 PA CODE CHANGE/UPDATE 2010/01/20Category/ServiceAcupuncture is now a covered benefit for HCG97813, 97810, 97811, 97814Durable Medical Equipment (DME), Diabetic SuppliesE2500, E2502, E2504, E2506, E2508, E2510Genetic Counseling and Testing81163, 81164, 81165, 81166, 81167, 81202, 81204Home Health CareS9208, S9211, G0151, G0152, G0153Joint Replacement23470, 23473, 27130, 27447Neurology Electroencephalogram (EEG) Testing95721, 95722, 95723, 95724, 95725, 95726Pain Management64451, 64454, 64624, 64625Podiatry28107, 28108, 28110, 28118, 28119, 28120, 28122, 28124, 28344Prosthetics/OrthoticsL1904, L1907, L1932, L1940, L3020Rehabilitation Therapies & Services97032Sleep Studies and Sleep Procedures95805Spinal Surgeries27279Sterilizations58720Vein Procedures36465, 36466, 37765, 37766I HEALTH CHOICE GENERATIONS, AZ PRIOR AUTHORIZATION GRID I EFFECTIVE 10/01/2020. REVISED 09/01/2020

PRIOR AUTHORIZATION IS REQUIRED FOR SERVICES LISTED BELOW***Office visits to contracted (par) providers do not require Prior Authorization******Prior Authorization is required for all non-participating providers and hospitals***SPECIALTY/ 7813PA Required for all Services97814See EviCore grid or visit www.evicore.comAdvanced Imaging & Cardiac ImagingBariatric 4743848PA is required for listed codes43860Behavioral Health908709086790868ECT and rTMS90869Bone Growth Stimulator209742097520979E0747E0748E0749PA is required for listed codesE0760Capsule Endoscopy9111091111PA is required for listed 79339813398233990339910295T0296T0297T K0606932289322993268932709327199211PA is required for listed codes93272Chiropractic 205992129921399214992159924199242992439924499245PA is required for listed codesCosmetic, Plastic and Reconstructive Procedures [in any 92219364These are not usually covered benefits, theyinclude, but are not limited to tattoo removal,collagen injections, rhinoplasty, otoplasty, scarrevision, keloid treatments, surgical repair ofgynecomastia, pectus deformity, mammoplasty,abdominoplasty, injections, vein ligation,venous ablation, dermabrasion, Botoxinjections, circumcision, benign skin lesionremoval etc.I HEALTH CHOICE GENERATIONS, AZ PRIOR AUTHORIZATION GRID I EFFECTIVE 10/01/2020. REVISED 09/01/2020

PRIOR AUTHORIZATION IS REQUIRED FOR SERVICES LISTED BELOW***Office visits to contracted (par) providers do not require Prior Authorization******Prior Authorization is required for all non-participating providers and hospitals***SPECIALTY/ PROCEDURE/SERVICESPROVISIONSDurable Medical Equipment (DME) & Diabetic 886K0890K0891A4638 A9274 A9276 A9277 A9278K0606Experimental / Investigational ProceduresDME over 500 for a single item in billedcharges and ‘By Report Codes’ requires priorauthorization. All services must go throughPreferred Homecare with the exception ofDiabetic Supplies and Continuous GlucoseMonitors.SVN’s must go through Preferred Homecare.Diabetic Supplies and Continuous GlucoseMonitors must go through contracted provider.PA Required for all ServicesGenetic Counseling and 69883738837488377 S387087999S3866High Frequency Chest Wall Oscillation Vests/Percussion VestAll Services except for prenatal diagnosis ofcongenital disorders of the unborn childthrough amniocentesis and genetic testscreening of newborns mandated by stateregulationsPA Required for all ServicesHome Healthcare99600 G0299 G0300 G0493 G0494 G0495 G0496 G0151 G0152 S9211PA Required for all ServicesQ0081 Q0084Home Infusion ServicesRefer to Coram Specialty Infusion ServicesInpatient AdmissionsAll Acute Hospital (including Maternity &Delivery), Psychiatric, Skilled Nursing Facilities(SNF), Rehabilitation, Long Term Acute Care(LTAC) FacilityJoint Replacement23470234732713027447PA is required for listed codesLabcorpAll Labs to be done using LabcorpMaternal Fetal MedicinePA Required for all ServicesI HEALTH CHOICE GENERATIONS, AZ PRIOR AUTHORIZATION GRID I EFFECTIVE 10/01/2020. REVISED 09/01/2020

PRIOR AUTHORIZATION IS REQUIRED FOR SERVICES LISTED BELOW***Office visits to contracted (par) providers do not require Prior Authorization******Prior Authorization is required for all non-participating providers and hospitals***SPECIALTY/ PROCEDURE/SERVICESPROVISIONSNerve Conduction StudiesCan only be performed by Neurologists andPhysical Medicine and Rehab Physicians; no PArequiredNeurologic Stimulation 82L8683L8684L8685L8686L8687L8688Neurology Electroencephalogram (EEG) Testing9572195722957239572495725PA is required for listed codesPA is required for listed codes95726Nutritional Supplements & Enteral FormulasRefer to Coram Specialty Infusion ServicesOutpatient Hospital (Place of Service 22)&Ambulatory Surgery Center (Place of Service 24)No PA required unless the serviceis listed on this PA GridOut of Network / Non Par Providers & FacilitiesExcluding; Emergency services, FamilyPlanning, Community Health Centers andCounty Health DepartmentsPain 648046480964818648206482164823 G0260 99241992429924399244992459920399204Including initial/new consults,sympathectomies, neurotomies, injections,infusions, blocks, pumps or implants 4464450644556463264776647786478264783Pregnancy & Pregnancy 25985559856598575981259820PA is required for listed codesPA is required for Pregnancy Terminations andtreatment for spontaneous/missed abortions(ultrasound required to note no fetalheartbeat).I HEALTH CHOICE GENERATIONS, AZ PRIOR AUTHORIZATION GRID I EFFECTIVE 10/01/2020. REVISED 09/01/2020

PRIOR AUTHORIZATION IS REQUIRED FOR SERVICES LISTED BELOW***Office visits to contracted (par) providers do not require Prior Authorization******Prior Authorization is required for all non-participating providers and hospitals***SPECIALTY/ PROCEDURE/SERVICESPROVISIONSProsthetics / 3904L3905PA required for the following but is not limitedto: Orthopedic footwear / orthotics / footinserts Customized orthotics, prosthetics, braces Bone anchored/Cochlear ImplantsNOTE: Customized P&O requests need to beordered by the referring physicians; all otherL4060 L4070 L4080 L4090 L4100 L4110 L4130 L4205 L4210 L4360 requests need to go through a contractedL4386 L4392 L4394 L4396 L4631 L5010 L5020 L5050 L5060 L5100 950L6955L6960I HEALTH CHOICE GENERATIONS, AZ PRIOR AUTHORIZATION GRID I EFFECTIVE 10/01/2020. REVISED 09/01/2020

PRIOR AUTHORIZATION IS REQUIRED FOR SERVICES LISTED BELOW***Office visits to contracted (par) providers do not require Prior Authorization******Prior Authorization is required for all non-participating providers and hospitals***SPECIALTY/ PROCEDURE/SERVICESPROVISIONSProsthetics / Orthotics Rehabilitation Therapies & 79894667All Physical, Occupational, Speech Therapy andCardiac & Pulmonary Rehab require PA97032 97033 97034 97035 97036 97039 97110 97112 97113 971669716797168 G0237 G0283 G0422 G0423 G0424S9152Do not require authorization unless otherwiselisted on this gridRoutine Office-Based ProceduresSleep Studies and Sleep Apnea ProceduresG0398 G0399 G0400 95807957839580095801Spinal Cord Stimulators (including implant)6365063655PA Required for all ServicesPA is required for listed codes63685Spinal 522727963030630426304563047630566308158150 PA required for members under 21. Signed federalSterilizationPA is required for listed codesSterilization for permanent birth 275 consent form needs to be submitted with 5358954589565913559525request.Members 21 and over – no PA required. Signed58544 58548 58550 58552 58553 58554 58570 58571 58572 58573 Federal Consent Form must be submitted with claim.Hysterectomy:PA is required (member of any age).I HEALTH CHOICE GENERATIONS, AZ PRIOR AUTHORIZATION GRID I EFFECTIVE 10/01/2020. REVISED 09/01/2020

PRIOR AUTHORIZATION IS REQUIRED FOR SERVICES LISTED BELOW***Office visits to contracted (par) providers do not require Prior Authorization******Prior Authorization is required for all non-participating providers and hospitals***SPECIALTY/ PROCEDURE/SERVICESPROVISIONSTransplant Evaluation and 13244133Including Solid Organ and Bone 950340(Corneal transplant does not sted, Miscellaneous 99429Should an unlisted or miscellaneous code berequested, medical necessity documentation69979 76496 76497 76498 76499 76999 77299 77399 77499 77799and rationale must be submitted with the prior78099 78199 78399 78499 78699 78799 78999 79999 81479 84999authorization request.9949999600A0999 A4335 A4421 A4649 A4913 A9280 A9900 A9999B9999C9399E0769E1399E1699E2599 L8499L8699Q0507Q0508 Q0509 Q4050 Q4051 Vein 003771837722377653776637780PA Required for all Services. Venous injections,vein ligation, and venous ablationWound Therapy976079760899183G0277 G0281 G0460PA is required for listed codesI HEALTH CHOICE GENERATIONS, AZ PRIOR AUTHORIZATION GRID I EFFECTIVE 10/01/2020. REVISED 09/01/2020

INPATIENT SERVICES REQUIRING PRIOR AUTHORIZATION All non-emergency hospital admissions for Inpatient Acute, Inpatient Psychiatric Hospital, Psychiatric SubAcute Facility, Level I Behavioral Health Inpatient Facility (RTC), Rehabilitation, Long Term Acute Care, SkilledNursing Facilities, Hospice and Observation require prior authorization.All facilities must notify HCA of admissionsFax Inpatient Notifications to 480-760-4732Fax Behavioral Health Hospital/Sub-Acute, Behavioral Health Inpatient Facilities and ECT/Rtms to 855-4083401In the event acute or behavioral health inpatient hospitalization services delivered are to evaluate andstabilize an emergency medical condition, the plan must be notified of the admission within 1 calendar day.IMAGING/PROCEDURESPrior Authorizations for these services must be obtained through EviCoreAll "high-tech" radiology services: MRI, MRA, CT AND PET Ultrasounds: vascular, high-tech radiology & obstetricalNuclear cardiac stress testingEchocardiography, TEE/TTEHeart catheterizations, diagnostic, interventional & electrophysiologyVenous ablation proceduresPrior Authorizations can be obtained the following ways:WEB PORTAL:https://myportal.medsolutions.com Initiate a request, check status, review guidelines, and morePHONE:888-693-3211 from 7am to 8pm CSTI HEALTH CHOICE GENERATIONS, AZ PRIOR AUTHORIZATION GRID I EFFECTIVE 10/01/2020. REVISED 09/01/2020

CPT CODEEVICORE CPT CODE DESCRIPTION70336MRI Temporomandibular Joint(s)70450CT Head without contrast70460CT Head with contrast70470CT Head with & without contrast70480CT Orbit, et al without contrast70481CT Orbit, et al with contrast70482CT Orbit, et al W & W/O70486CT Maxillofacial area, (sinus) without contrast70487CT Maxillofacial area, (sinus) with contrast70488CT Maxillofacial area, (sinus) W &W/O70490CT Soft-tissue Neck without contrast70491CT Soft-tissue Neck with contrast70492CT Soft-tissue Neck with & without contrast W & W/O70496CTA HEAD, with contrast, including non-contrast images, if performed, & image post-processing70498CTA NECK, with contrast, including non-contrast images, if performed, & image post-processing70540MRI Orbit, Face and/or Neck without contrast70542MRI Orbit, Face and/or Neck with contrast70543MRI Orbit, Face and/or Neck W &W/O70544MR Angiography (MRA) Head without contrast70545MR Angiography (MRA) Head with contrast70546MR Angiography (MRA) Head with and without contrast W & W/O70547MR Angiography (MRA) Neck without contrast70548MR Angiography (MRA) Neck with contrastI HEALTH CHOICE GENERATIONS, AZ PRIOR AUTHORIZATION GRID I EFFECTIVE 10/01/2020. REVISED 09/01/2020

CPT CODEEVICORE CPT CODE DESCRIPTION70549MR Angiography (MRA) Neck with and without contrast W & W/O70551MRI Brain (Head) without contrast70552MRI Brain (Head) with contrast70553MRI Brain (Head) with and without contrast W & W/O70554MRI Brain, functional MRI; including test selection and administration of repetitive body partmovement and/or visual stimulation, not requiring physician or psychologist70555MRI, Brain, functional MRI; requiring physician or psychologist administration of entire neurofunctional testing71250CT Chest without contrast71260CT Chest with contrast71270CT Chest with and without contrast W &W/O71275CTA CHEST, (non-coronary), with contrast, including non-contrast images, if performed, & image postprocessing71550MRI Chest without contrast71551MRI Chest with contrast71552MRI Chest with and without contrast W &W/O71555MR Angiography (MRA) Chest (excluding myocardium)- W or W/O72125CT Cervical Spine without contrast72126CT Cervical Spine with contrast72127CT Cervical Spine with and without contrast W & W/O72128CT Thoracic Spine without contrast72129CT Thoracic Spine with contrast72130CT Thoracic Spine with and without contrast W & W/O72131CT Lumbar Spine without contrast72132CT Lumbar Spine with contrast72133CT Lumbar Spine with and without out contrast W & W/O72141MRI Cervical Spine without contrast72142MRI Cervical Spine with contrastI HEALTH CHOICE GENERATIONS, AZ PRIOR AUTHORIZATION GRID I EFFECTIVE 10/01/2020. REVISED 09/01/2020

CPT CODEEVICORE CPT CODE DESCRIPTION72146MRI Thoracic Spine without contrast72147MRI Thoracic Spine with contrast72148MRI Lumbar Spine without contrast72149MRI Lumbar Spine with contrast72156MRI Cervical Spine with and without contrast W & W/O72157MRI Thoracic Spine with and without contrast W & W/O72158MRI Lumbar Spine with and without contrast W & W/O72159MR Angiography (MRA) Spinal Canal and contents -with or w/o contrast72191CTA PELVIS, with contrast, including non-contrast images, if performed, & image post-processing72192CT Pelvis without contrast72193CT Pelvis with contrast72194CT Pelvis with and without contrast W & W/O72195MRI Pelvis without contrast72196MRI Pelvis with contrast72197MRI Pelvis with and without contrast W &W/O72198MR Angiography (MRA) Pelvis -with or without contrast73200CT Upper Extremity without contrast73201CT Upper Extremity with contrast73202CT Upper Extremity with and without contrast W & W/O73206CTA Upper Extremity, with contrast, including non- contrast images, if performed, & image post processing73218MRI Upper Extremity-other than joint-without contrast73219MRI Upper Extremity-other than joint-with contrast73220MRI Upper Extremity-other than joint-W &W/O73221MRI Any Joint of Upper Extremity--without contrast73222MRI Any Joint of Upper Extremity--with contrast73223MRI Any Joint of Upper Extremity-W &W/O73225MR Angiography (MRA) Upper Extremity -with or without contrastI HEALTH CHOICE GENERATIONS, AZ PRIOR AUTHORIZATION GRID I EFFECTIVE 10/01/2020. REVISED 09/01/2020

CPT CODEEVICORE CPT CODE DESCRIPTION73700CT Lower Extremity without contrast73701CT Lower Extremity with contrast73702CT Lower Extremity with and without contrast W & W/O73706CTA Lower Extremity, with contrast, including non- contrast images, if performed, & image post processing73718MRI Lower Extremity-other than joint-without contrast73719MRI Lower Extremity-other than joint-with contrast73720MRI Lower Extremity-other than joint- W & W/O73721MRI Any Joint of Lower Extremity--without contrast73722MRI Any Joint of Lower Extremity--with contrast73723MRI Any Joint of Lower Extremity-W & W/O73725MR Angiography (MRA) Lower Extremity-with or without contrast74150CT Abdomen without contrast74160CT Abdomen with contrast74170CT Abdomen with and without contrast W &W/O74174CTA ABDOMEN and PELVIS74175CTA ABDOMEN, with contrast, including non- contrast images, if performed, & image post processing74176CT Abdomen & Pelvis, without contrast74177CT Abdomen & Pelvis, with contrast74178CT Abdomen & Pelvis, with and without contrast74181MRI Abdomen without contrast74182MRI Abdomen with contrast74183MRI Abdomen with and without contrast W &W/O74185MR Angiography (MRA) Abdomen-with or without contrast74712MRI fetal, including placental and maternal pelvic imaging when preformed; single or first gestation74713MRI fetal, including placental and maternal pelvic imaging when preformed; each additional gestation (List separately inaddition to code primary procedure)I HEALTH CHOICE GENERATIONS, AZ PRIOR AUTHORIZATION GRID I EFFECTIVE 10/01/2020. REVISED 09/01/2020

CPT CODEEVICORE CPT CODE DESCRIPTION74261Computed tomographic (CT) colonography, diagnostic, including image post processing; without contrast material74262Computed tomographic (CT) colonography, diagnostic, including image post processing; with contrast material(s)including non-contrast images, if performed74263Computed tomographic (CT) colonography, screening, including image post processing75557Cardiac MRI for morphology and function without contrast75559Cardiac MRI for morphology and function without contrast material; with stress imaging75561Cardiac MRI for morphology and function without contrast, followed by contrast W & W/O75563Cardiac MRI for morphology and function without contrast, followed by contrast; with stress imaging75565Cardiac magnetic resonance imaging for velocity flow mapping (List separately in addition to code for primary procedure)75571CT, heart, without contrast with quantitative evaluation of coronary calcium75572CT, heart, with contrast material, for evaluation of cardiac structure and morphology (including 3D image postprocessing, assessment of cardiac function, and evaluation of venous structures, if performed)75573CT, heart, with contrast material, for evaluation of cardiac structure and morphology in the setting of congenital heartdisease (including 3D image post processing, assessment of cardiac LV function, RV structure and function and evaluationof venous structures, if performed)75574CT, heart, coronary arteries and bypass grafts (when present), with contrast material, including 3D image post processing(including evaluation of cardiac structure and morphology, assessment of cardiac function, and evaluation of venousstructures, if performed)75635CTA ABDOMINAL AORTA and bilateral iliofemoral lower extremity runoff, with contrast, including non- contrastimages, if performed, and image post-processing763763D Rendering with interpretation and reporting of CT, MRI, ultrasound, or other tomographic modality; not requiringimage post processing on an independent workstation763773D Rendering with interpretation and reporting of CT, MRI, ultrasound, or other tomographic modality; requiring image postprocessing on an independent workstation76380CT Limited or Localized follow-up76390MR Spectroscopy (MRS)76497Unlisted CT procedure (e.g., diagnostic, interventional)76498Unlisted MR procedure (e.g., diagnostic, interventional)77021MR guidance for needle placement (e.g. for biopsy, needle aspiration, injection, or placement of localization devise)76801Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, first trimester( 14 weeks 0 days), transabdominal approach; single or first gestationI HEALTH CHOICE GENERATIONS, AZ PRIOR AUTHORIZATION GRID I EFFECTIVE 10/01/2020. REVISED 09/01/2020

CPT CODEEVICORE CPT CODE DESCRIPTION76802. . . each additional gestation (List separately in addition to code for primary procedure)76805Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation, after first trimester( or 14 weeks 0 days), transabdominal approach; single or first gestation76810. . . each additional gestation (List separately in addition to code for primary procedure)76811Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetalanatomic examination, transabdominal approach; single or first gestation76812. . . each additional gestation (List separately in addition to code for primary procedure)76813Ultrasound, pregnant uterus, real time with image documentation, first trimester fetal nuchal translucencymeasurement, transabdominal or transvaginal approach; single or first gestation76814Ultrasound, pregnant uterus, real time with image documentation, first trimester fetal nuchal translucencymeasurement, transabdominal or transvaginal approach; each additional gestation76815Ultrasound, pregnant uterus, real time with image documentation, limited (eg, fetal heartbeat, placental location,fetal position and/or qualitative amniotic fluid volume), one or more fetuses76816Ultrasound, pregnant uterus, real time with image documentation, follow-up (eg, re-evaluation of fetal size bymeasuring standard growth parameters and amniotic fluid volume, re-evaluation of organ system(s) suspected orconfirmed to be abnormal on a previous scan), transabdominal approach, per fetus76817Ultrasound, pregnant uterus, real time with image documentation, transvaginal76818Fetal biophysical profile; with non-stress testing76819Fetal biophysical profile; without non-stress testing76820Doppler velocimetry, fetal; umbilical artery76821Doppler velocimetry, fetal; middle cerebral artery76825Echocardiography, fetal, cardiovascular system, real time with image documentation (2D), with or without M- moderecording;76826Echocardiography, fetal, cardiovascular system, real time with image documentation (2D), with or without M- moderecording; follow-up or repeat study76827Doppler echocardiography, fetal, pulsed wave and/or continuous wave with spectral display; complete76828Doppler echocardiography, fetal, pulsed wave and/or continuous wave with spectral display; follow-up or repeat study76978Ultrasound, targeted dynamic microbubble sonographic contrast characterization (non-cardiac); initial lesion76979Ultrasound, targeted dynamic microbubble sonographic contrast characterization (non-cardiac); each additional lesion withseparate injection (List separately in addition to code for primary procedure)76391Magnetic resonance (eg, vibration) elastography77022Magnetic resonance imaging guidance for, and monitoring of, parenchymal tissue ablationI HEALTH CHOICE GENERATIONS, AZ PRIOR AUTHORIZATION GRID I EFFECTIVE 10/01/2020. REVISED 09/01/2020

CPT CODEEVICORE CPT CODE DESCRIPTION77046Magnetic resonance imaging, breast, without contrast material; unilateral77047Magn

Jan 20, 2010 · HEALTH CHOICE GENERATIONS PRIOR AUTHORIZATIONS No Prior Authorization is required for any Health Choice Generations (HCG) and eviCore procedures when HCG is the secondary payer, EXCEPT for Transplant services and Inpatient services which require PA from HCG T

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