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Provider Manual
Section 5.0
Utilization Management
Table of Contents
5.1 Utilization Management 5.2 Review Criteria/Standards for Review
5.3 Authorization Requirements 5.4 Online Authorization 5.5 Inpatient Admissions and Observation 5.6 Outpatient Services 5.7 High Cost Medication
5.8 Prior Authorization for Members with Original Medicare 5.9 Retrospective Authorization 5.10 Denials
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5.0 Utilization Management 5.1 Utilization Management
Utilization Management (UM) is the process of influencing the continuum of care by evaluating the
necessity and efficiency of health care services and affecting patient care decisions through assessments
of the appropriateness of care. The UM department helps to assure prompt delivery of medically-
appropriate health care services to Passport Health Plan members and subsequently monitors the
quality of care. Medically Necessary or Medical Necessity means Covered Services which are medically
necessary as defined under 907 KAR 3:130 or other applicable Kentucky law or regulation, and
provided in accordance with 42 CFR §440.230, including children’s services pursuant to 42 U.S.C.
1396d(r).
All Passport Health Plan participating providers are required to obtain prior authorization from the
Plan’s UM department for inpatient services and specified outpatient services listed in Section 5.3,
―Authorization Requirements.‖
Failure to submit an authorization or failure to submit an authorization in a timely manner may result in
a denial of services. An authorization is not a guarantee of benefits. Member eligibility should be
verified for every request of service.
The UM department is available Monday through Friday from 8:00 a.m. to 5:30 p.m. EST, except
holidays. All requests for authorization of services may be received during these hours of operation by
calling or faxing:
Department Phone Number Fax Number General Number (800) 578-0636 (502) 585-7989
Concurrent Review (502) 585-2023 (502) 585-7989
Retrospective Review (502) 585-7972 (502) 585-8207
Home Health (502) 585-7320 (502) 585-8204
DME (502) 585-7310 (502) 585-7990
Therapies/Pain
Management
(502) 585-6055
(502) 585-8205
Cosmetics
(502) 585-7069
Request can be sent via confidential email to: PassportUMCosmetics @Passporthealthplan.com
Appeals (502) 585- 7307 (502) 585-8461
High Dollar Radiology
Administered by MedSolutions
1-877-791-4099 1-888-693-3210 or on-line authorization at
www.Medsolutionsonline.com
After business hours or on holidays, a provider can leave a message and a representative will return the
call the next business day.
Passport Health Plan provides the opportunity for the provider to discuss a decision with the Medical
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Director, to ask questions about a utilization management issue, or to seek information from the nurse
reviewer about the Utilization Management process and the authorization of care by calling Utilization
Management at (800) 578-0636.
Because of frequent changes in member eligibility for Medicaid coverage, providers should verify
continued eligibility via the Plan’s web site, www.passporthealthplan.com, or by calling the IVR or
Provider Services at (800) 578-0775.
5.2 Review Criteria/Standards for Review
Passport Health Plan’s Utilization Management (UM) department is charged with ensuring that the
Plan’s members use their benefits appropriately. Passport’s UM Department uses InterQual® Criteria
during the review process. In the event InterQual® Criteria is not available for a specific request, the
reviewer may use internal medical policies which are reviewed and approved by actively practicing
practitioners in the community.
The Partnership Council approves both the use of InterQual Criteria® and Medical Polices. Criteria are
only made available to participating and non-participating providers as allowed under copyright
limitations and trademark considerations.
At the request of the practitioner, the Passport UM Department, or the Chief Medical Officer, will
provide a copy of up to three (3) InterQual® Criteria guidelines. If the guidelines are not available for
distribution, or the number of guidelines exceeds the copyright limit, the practitioner has the option to
request the guideline be read over the telephone, or review the guideline at Passport Health Plan.
Internal Medical policies are communicated to providers via the Provider Newsletter or the Passport
Health Plan web site, www.passporthealthplan.com. Providers may request a copy of a policy at any
time from the Passport UM Department or the Chief Medical Officer.
Durable medical equipment is reviewed utilizing Medicaid and Medicare guidelines as well as any
applicable Passport Health Plan internal medical policies. Medicare and Medicaid criteria/guidelines are
shared with providers upon request. These requests may be made by contacting the UM Department or
the Chief Medical Officer. Criteria are distributed to providers who have Medicare/Medicaid
practitioner numbers issued by state and federal entities.
5.3 Authorization Requirements
The Passport UM department hours of operation are 8 a.m. to 5:30 p.m., Monday through Friday. The
general UM department phone number is: (800) 578-0636. The general UM department fax number is
(502) 585-7989.
The following table lists procedures and/or services that require authorization from Passport Health
Plan’s Utilization Management (UM) department.
Services Requiring Authorization
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All Inpatient Admissions /
Hospitalizations
Maternity
Code Range: 644.XX through 665.XX ---
•If stay is less than or equal to 3 days with the above codes, no
authorization is required
AUTHORIZATION IS REQUIRED FOR:
All Cesarean Sections
All Scheduled inductions
All Non-par providers, regardless of delivery type
Rehabilitation 23 Hour Observation greater than one (1) overnight stay
Pain Management (i.e. Epidural
Blocks – Trigger Point Injections)
Home Hospice
Stem Cell/Progenitor Cell Retrieval Investigational/Experimental Procedures
Cosmetic Procedures Ocular Photodynamic Therapy/with Verteporfin (Visudyne)
Neuropsychological Testing Diabetic Education
Therapy Services Chiropractic Services
No authorization for the first 12 visits in a calendar year
Services beyond 12 visits require authorization
Benefit limit = total of 26 chiropractic visits within a calendar
period
Specified Outpatient Surgical
Procedures:
Adenoidectomy - Cardiac
Catheterization - EGD
PET Scan / MRI / MRA / CT / CTA / Select Cardiac Imaging
– Authorization administered by MSI
DME > $500 – rental or purchase All DME with E1399 Codes
Enteral Products Select Orthotics / Prosthetics
Ostomy Supplies Home Health / Skilled Nursing / Private Duty Nursing
Home Infusion – IV Therapy (IVT)
Authorization for IVT will be administered
by PBM
High Cost Medication > $400
Synagis Injections – Synagis Injections
– Authorizations administered by PBM
Nonparticipating Provider Services
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Select EPSDT Special Services Family Planning – Terminations
To determine if a service or supply, such as cosmetic procedures, is considered benefit exclusion, please
contact the Passport Utilization Management (UM) department.
The assigned authorization number must be submitted on the claim form.
Policy for Newborns:
An infant born by Normal Vaginal Delivery (NVD) does not require authorization until day four (4). If
an infant born via NVD stays <= 3 days, authorization is not required.
An infant born by C-Section does not require authorization until day six (6). If an infant born via C-
Section stays <= 5 days, authorization is not required.
Benefit inclusions/exclusions must be considered in determining eligibility for coverage for individual
cases.
To determine if a service or supply, such as cosmetic procedures, is considered a benefit exclusion,
please contact the Passport Utilization Management (UM) department.
The assigned authorization number must be submitted on the claim form.
5.4 Online Authorization
Passport Health Plan’s Utilization Management Department utilizes an online authorization system via
NaviNet. The online authorization system is a web-based auto-review system for providers to obtain
authorization for services.
For questions regarding the online authorization, contact NaviNet or your Provider Network Account
Manager.
The online authorization system also allows you, the provider, to search for authorizations by member,
authorization number, date of service and/or physician. View the following information online for each
authorization:
• Member identification number, coverage dates, and PCP
• Authorization number • Service requested
• Primary diagnosis • Treatment dates
• Status of the authorization
The use of the online authorization system via NaviNet for select services is highly encouraged.
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5.5 Inpatient Admissions
UM reviews all requests for inpatient admissions utilizing InterQual® criteria and internal medical
policies. For those requests meeting the established medical necessity criteria, an inpatient will be
authorized.
Requests not meeting the established medical necessity criteria will be referred to Passport’s Medical
Director for further review and evaluation.
When requesting a review, at a minimum, documentation must include:
• The member’s name and Passport Health Plan ID number.
• The diagnosis for which the treatment or testing procedure is being sought.
• Other treatment or testing methods that have been tried, their duration, and any outcomes.
• Additional clinical information as applicable to the requested service.
• Applicable sections of the medical record.
Some authorization requests may require a physician’s letter of medical necessity or a copy of the
medical records. These should be directed to the Utilization Management nurse who is coordinating the
specific case.
To receive authorization for an admission, contact Passport Health Plan’s Utilization Management
department at (800) 578-0636 or fax request to (502) 585-7989, Monday through Friday, between the
hours of 8 a.m. and 5:30 p.m.
5.5.1 Inpatient Admissions and Observation Requirements
All inpatient admissions require an authorization.
If a member is discharged from an inpatient level of care and subsequently re-admitted to the same
hospital within 24 hours, the UM Department continues the member's inpatient stay under the same
case reference number.
Requests for prior authorization of elective inpatient services should be received prior to the date the
requested service will be performed. Passport Health Plan will accept the hospital’s or the attending
physician’s request for prior authorization of elective hospital admissions; however, neither party
should assume that the other has obtained prior authorization.
For an urgent or emergent admission, the facility must notify the plan within one business day of the
admission.
For weekend admissions to a hospital or for services delivered on the weekend or after normal
business hours, authorization must be obtained within one business day of the admission or service
being provided.
If the member’s condition or results of evaluation and testing meet inpatient criteria after the 23-hour
observation period, the stay will be converted to inpatient beginning with the observation stay
admission date. All claims for this type of stay should be submitted with the entire length of stay as an
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inpatient.
To receive authorization for an inpatient admission, contact Passport Health Plan’s Utilization
Management department at (800) 578-0636 or fax the request to (502) 585-7989, Monday through
Friday, between the hours of 8 a.m. and 5:30 p.m. EST.
To receive authorization for an inpatient admission, contact Passport Health Plan’s Utilization
Management department at (800) 578-0636 or fax request to (502) 585-7989, Monday through Friday,
between the hours of 8 a.m. and 5:30 p.m. EST.
Failure to obtain authorization of an admission will result in an administrative denial of the admission
(see Section 2.11).
Denied authorization requests may be appealed (see Section 2.11).
Inpatient Only Codes:
In accordance with the Centers for Medicare and Medicaid Services (CMS) billing requirements, select
surgical procedures must be performed in the inpatient setting.
A detailed list of codes may be obtained at the following CMS website:
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/HospitalOutpatientPPS/downloads/cms-1427-p_addE.pdf
If a provider performs one of the listed procedures in an outpatient setting and the claim is denied,
they may submit supporting medical records documentation for review through the claims appeals
process.
5.5.2 Inpatient Admissions to Non-Participating Facilities
Requests for admission to non-participating facilities should be submitted to the Passport Health Plan
UM department for review.
To receive authorization for admission to a non-participating facility, contact Passport Health Plan’s
Utilization Management department at (800) 578-0636 or fax the request to (502) 585-7989, Monday
through Friday, between the hours of 8 a.m. and 5:30 p.m. EST.
5.5.3 Elective Participating-Hospital Transfer Policy
Elective participating facility transfers must be prior authorized by Passport Health Plan. Patient
clinical information will be required to complete the authorization process, approve the transfer, and
determine prospective length of stay.
Either the transferring or receiving facility may initiate the prior authorization; however, the
transferring facility will be able to provide the most accurate required clinical information. If a hospital
transfer request is made by another Passport Health Plan facility, the receiving facility may request that
the transferring facility obtain the authorization before the case will be accepted at the receiving facility.
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The receiving facility should contact Passport Health Plan to confirm the authorization.
In cases deemed emergent, notification of the admission is required within one business day after the
transfer.
To assist with transfers, contact Passport Health Plan’s Utilization Management department at (800)
578-0636 or fax the request to (502) 585-7989, Monday through Friday, between the hours of 8 a.m.
and 5:30 p.m.
5.5.4 Inpatient Rehabilitation Admissions
If a member requires an inpatient rehabilitation admission, the rehabilitation hospital will contact the
on-site review nurse at the acute-care facility where the member is currently an inpatient. If there is not
an on-site review nurse at the acute-care facility, the rehab hospital can contact Passport Health Plan’s
Utilization Management via phone (800) 578-0636 or fax (502) 585-7989.
Inpatient rehabilitation includes Acute Inpatient Rehab, Inpatient Cardiac Rehab and Inpatient
Pulmonary Rehab.
If the member is to be directly admitted from home or any other sub-acute facility, contact Passport
Health Plan’s Case Management department at (800) 578-0636 ext. 2024.
5.5.5 Inpatient Skilled-Nursing Facility
Passport Health Plan is not responsible for, nor does it reimburse nursing facility costs, for members at
skilled-nursing facilities. Those services are covered by the Kentucky Medicaid Program. Passport
Health Plan is responsible for costs of professional services, such as physician or therapist services that
are not part of the routine facility service. After a member is in a nursing facility for 31 days, the
disenrollment process begins for that member. Passport Health Plan’s responsibility for those non-
facility services continues for any of its members while they are still enrolled with the Plan. After the
Kentucky Medicaid Program completes the managed care disenrollment process and reinstates the
member in the fee-for-service Medicaid program, the Plan no longer has financial responsibility for any
services for that Medicaid recipient. To obtain skilled-nursing facility authorization, please call the
DMS-contracted review entity.
5.6 Outpatient Services
For authorization of select outpatient services listed in Section 5.3, ―Authorization Requirements,‖ the
PCP/specialist notifies Passport Health Plan via the online authorization system, telephonically or by
fax. Prior authorization is mandatory for select outpatient procedures / diagnostics to qualify for
payment.
When requesting a review, at a minimum, documentation submitted must include:
• The member’s name and Passport Health Plan ID number.
• The diagnosis for which the treatment or testing procedure is being sought.
• Other treatment or testing methods that have been tried, their duration, and any outcomes.
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• Additional clinical information as applicable to the requested service.
• Applicable sections of the medical record.
Some authorization requests may require a physician’s letter of medical necessity or a copy of the
medical records. These should be directed to the Utilization Management nurse who is coordinating the
specific case.
Requests for prior authorization of elective services should be received prior to the date the requested
service will be performed.
Requests for authorization of urgent and emergent services must be submitted to UM within one
business day of the procedure being performed.
Passport Health Plan will accept the hospital’s or the attending physician’s request for prior
authorization of elective hospital admissions; however, neither party should assume that the other has
obtained prior authorization.
Failure to obtain prior authorization for an elective procedure / service or failure to request
authorization of an urgent or emergent procedure / service within one business day of the procedure/
service being performed or rendered will result in an administrative denial of the service (see Section
5.10.2). Denied requests may be appealed (see Section 2.11).
The assigned prior-authorization number must be on the claim form. If practitioners wish to confirm
authorization, they may verify online via the online authorization system.
5.6.1 Outpatient Procedures / Diagnostics / Services
Providers are required to obtain prior authorization for select outpatient procedures / diagnostics from
the Plan’s Utilization Management Department.
See Table in section 5.3 for outpatient list.
For authorization of select outpatient services listed in Section 5.3, ―Authorization Requirements,‖ the
provider notifies Passport Health Plan via the online authorization system, telephonically or by fax.
The general UM department phone number is: (800) 578-0636. The general UM department fax
number is (502) 585-7989.
For Outpatient Imaging Services requiring authorization, see section 5.6.2.
5.6.2 Outpatient Radiology Services
Providers are required to obtain authorization for select radiological services through the high dollar
radiology program for advanced diagnostic imaging services. This program is administered in
partnership with MedSolutions (MSI).
Authorizations are required for select diagnostic imaging services performed in an outpatient setting.
Advanced diagnostic imaging includes:
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• Computed Tomography (CT); Computed Tomographic Angiogram (CTA)
• Magnetic Resonance Imaging (MRI); Magnetic Resonance Angiogram (MRA)
• Positron Emissions Tomography (PET)
• Nuclear Cardiac Imaging (NCM)
Authorizations are performed at MSI using their own internal criteria and medical management system.
MSI performs initial review, retrospective review, denials and 1st level appeals. Authorization is
required for advanced diagnostic imaging services performed in any outpatient setting.
Authorization is NOT required if the imaging service is performed in:
• Emergency rooms
• Inpatient settings
• 23-hour observations – Service performed in observation do not require an authorization. There are three (3) ways to request an authorization:
1. Internet: www.medsolutionsonline.com - Available 24/7
2. Phone: (877) 791-4099 Available 8 a.m. - 9 p.m. EST, Monday through Friday Toll free
3. Fax: 1-888-693-3210 Forms available at www.medsolutionsonline.com or by calling MedSolutions Customer Service at (877) 791-4099 Only MedSolutions fax forms are accepted Available 24/7
See Appendix A for a list of codes that require an authorization.
5.6.3 Durable Medical Equipment
The Department for Medicaid Services (DMS) requires that an updated Certificate of Medical
Necessity (CMN) be signed by the provider for all supplies and equipment and kept on file by the
supplier for a period of five (5) years. The only exception is oxygen for which Passport Health Plan
follows Medicare guidelines.
DME PURCHASE
DME items with billable charges greater than $500 require an authorization. Requests for authorization
of purchase MUST be received PRIOR to the end of the rental period.
DME RENTAL
Authorization requirements of rentals are determined by the billable price of the item being rented.
Rental charges will be applied to purchase price.
If the billable price of the rental is $500 or less, no authorization is required. If the billable price of the
rental is greater than $500, authorization is required.
All items requiring customization or accessories require prior authorization.
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All mini-nebulizers will be a purchase only item and do not require prior authorization.
Authorization requirements for DME purchases are based on total monthly cost or monthly quantity
of items purchased. The following is a list of purchases with authorization requirements by quantity:
Item
m
Quantity Limitations
Name Brand Diapers Regardless of quantity, all requests for name
brand diapers require authorization
Generic Diapers 180 per month require authorization
Underpads (Chux) 180 per month require authorization
Ostomy Supplies 2 boxes per month require authorization
Bedside Drainage Bags 4 per month require authorization
Syringes 100 per month require authorization
G-Tube
Compression Stockings
1 per month requires authorization
6 pair per year require authorization
* Maintenance, repair, or replacement in excess of $500 must have prior authorization from the UM
department.*
Enteral Products
• Enteral products with allowable amounts greater than $500 for a month’s supply require an authorization.
These services should be billed according to the fee schedule in your Provider Contract (Allowable
Charges).
For authorization of DME, the provider notifies Passport Health Plan via the online authorization
system, telephonically or by fax. The DME phone number is: (502) 585-7310. The DME fax number
is: (502) 585-7990.
For a list of Orthotics and Prosthetics that require an Authorization, see Appendix A.
For a list of Ostomy supplies that require an Authorization, see Appendix B.
5.6.4 Home Health Services
When medically appropriate, home health, private duty nursing, or home infusion may be a good
alternative to hospitalization.
Prior authorization of all home health / private duty nursing / hospice / home infusion services is
required. If the member is an inpatient and the facility has a Passport Health Plan on-site nurse
reviewer, the request may be given directly to the on-site review nurse.
Private duty nursing is limited to 2,000 hours per calendar year. Additional hours for children may be
obtained under EPSDT Special Services.
A request for prior authorization must be received prior to the delivery of the service for a non-urgent
request and within one business day of the service being performed for an urgent or emergent service.
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For authorization of Home Health Services, including home health care, private duty nursing and home
hospice, the provider notifies Passport Health Plan through the online authorization system,
telephonically or by fax. The Home Health phone number is: (502) 585-7320. The Home Health fax
number is: (502) 585-8204.
For authorization of home infusion, the provider should submit the infusion therapy authorization
form to Magellan via fax at (800) 229-3928. The authorization form can be found at
http://www.passporthealthplan.com/pharmacy.
5.6.5 Therapy, Chiropractic Services and Outpatient Rehab Services
Providers are required to obtain prior authorization for physical, occupational, aquatic and speech
therapy for acute and chronic conditions and chiropractic services.
• Therapy
Authorization of outpatient therapy services (physical, occupational, aquatic and speech) is required.
If the member is an inpatient and the facility has a Passport Health Plan onsite nurse reviewer, the
request may be given directly to the onsite review nurse. Review is required for the initial therapy
visit and all subsequent visits.
Requests for continuation of a service that is ongoing should be sent to the therapy department
seven days prior to the end of the authorization period. Please fax request together with progress
notes and current plan of care to (502) 585-8204.
For authorization of therapy requests, providers must notify Passport Health Plan through the online
authorization system, telephonically or by fax. The therapy phone number is: (502) 585-6055. The
therapy fax number is (502) 585-8205.
• Chiropractic Services
Authorization requests for chiropractic services are required after the 12th visit. No authorization is
required for the first 12 visits in a calendar year. The benefit limit equals the total of 26 chiropractic
visits within a 12-month calendar period.
• Outpatient Rehab Services
Authorization requests for outpatient rehab services (cardiac rehab and pulmonary rehab) are
required. If the member is an inpatient and the facility has a Passport Health Plan onsite nurse
reviewer, the request may be given directly to the onsite review nurse. For authorization of
chiropractic or outpatient rehab services, providers must notify Passport Health Plan telephonically
at (502) 585-6055 or via fax at (502) 585-8205.
5.7 High-Cost Medications
Providers are required to obtain prior authorization for High-Cost Medications greater than $400
billable amount per dose from the Utilization Management Department.
This applies to high-cost medications billed to Passport Health Plan, excluding chemotherapy. This
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does not apply to the pharmacy benefit. See Section 14 for prior authorizations related to pharmacy.
Authorizations for Synagis must be requested from Passport’s Pharmacy Benefits Manager. See section
14 for prior authorizations related to pharmacy.
For requests of high cost medications, providers may contact the UM Department at (800) 578-0636 or
fax the request to (502) 585-7989.
5.8 Prior Authorization for Members with Medicare
Prior authorization is not required for services listed on the prior authorization list when the member
has Medicare as the primary payer and benefits under Medicare have not been exhausted. This applies
to both inpatient and outpatient services. When benefits are exhausted, or if the service is not a benefit
covered under Medicare, and Passport Health Plan becomes the primary payer, prior authorization
requirements apply for both outpatient and inpatient services.
For those members who have exhausted their Medicare Part A inpatient lifetime reserve days, prior
authorization of inpatient services must be obtained. If a member’s lifetime reserve days are exhausted
during an inpatient hospitalization, notification to Passport Health Plan must be made within one
business day of the notification to the facility of the exhaustion of benefits by Medicare.
5.9 Retrospective Authorization
Retrospective review of inpatient services is performed when the patient was not a member of Passport
Health Plan prior to or at the time of the service. Outpatient services do not require retrospective
review by Utilization Management for members whose eligibility is determined retrospectively.
Providers have 60 days from the notification of eligibility on retrospectively enrolled members to submit
medical records for review and utilization management authorization request. If the practitioner does
not provide documentation, the card issue date, segment date, and claims history are used. A decision
and written notification is provided within ten (10) business days of receipt of the medical information
for the retrospective review request. An administrative denial is issued for retrospective requests when
the provider fails to request a utilization management review of the medical record within the timeframe
specified.
The provider is notified of all decisions regarding retrospective reviews. In cases of denial, a written
notification is provided.
Requests received beyond 60 days from the card issue date or from the provider’s documentation of the
date when they were aware of the member’s eligibility will be administratively denied.
Send requests for retrospective review to:
Utilization Management Retrospective Review
5100 Commerce Crossings Drive Louisville, KY 40229
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The phone number for retrospective review is: (502) 585-7972 or fax to: (502) 585-8207 (for large chart
review, please send records via mail).
5.10 Denials
An authorization request for a service may be denied for failure to meet guidelines, protocols, medical
policies, or failure to follow administrative procedures outlined in the Provider Contract or this Provider
Manual.
Members may not be billed by participating providers for deductibles, copays, and coinsurance except
those allowed by DMS. If pre-authorization criteria are not met resulting in a denied claim, members
must be held harmless for denied services.
To speak with the Medical Director or to the nurse reviewer regarding a denial, please contact
Utilization Management at (800) 578-0636.
5.10.1 Medical Necessity Denials
Utilization Management utilizes InterQual® Guidelines, medical policies and protocols to render
review decisions. Requests not meeting the guidelines, protocols, or policies are referred to a Medical
Director for clinical review.
A Passport Health Plan Medical Director renders all medical necessity denial decisions. Whenever a
denial is issued, Utilization Management provides the name, telephone number, title, and office hours
of the Medical Director who rendered the decision. The Passport Health Plan Medical Director is
available to discuss any decision rendered with the attending practitioner.
5.10.2 Administrative Denials
An administrative denial is issued for those services for which the provider has not followed the
requirements set forth in the Provider Contract or this Provider Manual. For example, an administrative
denial may be issued for failure to prior authorize an elective service, procedure, or admission. It may
also be issued for failure to notify Utilization Management within one business day of an emergency
service, procedure, or admission.
A provider may appeal an administrative denial by submitting the appeal request in writing to:
Clinical Appeals Department
5100 Commerce Crossings Drive
Louisville, KY 40229
Appendix A: Radiology Codes The codes on the list below require authorization through MedSolutions
CPT
® Category
CPT® Code
CPT® Description
MRI TMJ 70336 MRI Temporomandibular Joint (s)
CT 70450 CT Head without contrast
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CPT
® Category
CPT® Code
CPT® Description
CT 70460 CT Head with contrast
CT 70470 CT Head with & without contrast
CT 70480 CT Orbit, et al without contrast
CT 70481 CT Orbit, et al with contrast
CT 70482 CT Orbit, et al W & W/O
CT 70486 CT Maxillofacial area, (sinus) without contrast
CT 70487 CT Maxillofacial area, (sinus) with contrast
CT 70488 CT Maxillofacial area, (sinus) W & W/O
CT 70490 CT Soft-tissue Neck without contrast
CT 70491 CT Soft-tissue Neck with contrast
CT 70492 CT Soft-tissue Neck with & without contrast W & W/O
CT Angiography (CTA) 70496 CTA HEAD, with contrast, including noncontrast images, if performed, & image post-processing
CT Angiography (CTA) 70498 CTA NECK, with contrast, including noncontrast images, if performed, & image post-processing
MRI 70540 MRI Orbit, Face and/or Neck without contrast
MRI 70542 MRI Orbit, Face and/or Neck with contrast
MRI 70543 MRI Orbit, Face and/or Neck W & W/O
MRA 70544 MR Angiography (MRA) Head without contrast
MRA 70545 MR Angiography (MRA) Head with contrast
MRA 70546 MR Angiography (MRA) Head with and without contrast W & W/O
MRA 70547 MR Angiography (MRA) Neck without contrast
MRA 70548 MR Angiography (MRA) Neck with contrast
MRA 70549 MR Angiography (MRA) Neck with and without contrast W & W/O
MRI 70551 MRI Brain (Head) without contrast
MRI 70552 MRI Brain (Head) with contrast
MRI 70553 MRI Brain (Head) with and without contrast W & W/O
Functional MRI (fMRI) 70554 MRI Brain, functional MRI; including test selection and administration of repetitive body part movement and/or visual stimulation, not requiring physician or psychologist administration
Functional MRI (fMRI) 70555 MRI, Brain, functional MRI; requiring physician or psychologist administration of entire neurofunctional testing
CT 71250 CT Chest without contrast
CT 71260 CT Chest with contrast
CT 71270 CT Chest with and without contrast W & W/O
CT Angiography (CTA) 71275 CTA CHEST, (non-coronary), with contrast, including noncontrast images, if performed, & image post-processing
MRI 71550 MRI Chest without contrast
MRI 71551 MRI Chest with contrast
MRI 71552 MRI Chest with and without contrast W & W/O
MRA 71555 MR Angiography (MRA) Chest (excluding myocardium)- W or W/O
CT 72125 CT Cervical Spine without contrast
CT 72126 CT Cervical Spine with contrast
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CPT
® Category
CPT® Code
CPT® Description
CT 72127 CT Cervical Spine with and without contrast W & W/O
CT 72128 CT Thoracic Spine without contrast
CT 72129 CT Thoracic Spine with contrast
CT 72130 CT Thoracic Spine with and without contrast W & W/O
CT 72131 CT Lumbar Spine without contrast
CT 72132 CT Lumbar Spine with contrast
CT 72133 CT Lumbar Spine with and without out contrast W & W/O
MRI 72141 MRI Cervical Spine without contrast
MRI 72142 MRI Cervical Spine with contrast
MRI 72146 MRI Thoracic Spine without contrast
MRI 72147 MRI Thoracic Spine with contrast
MRI 72148 MRI Lumbar Spine without contrast
MRI 72149 MRI Lumbar Spine with contrast
MRI 72156 MRI Cervical Spine with and without contrast W & W/O
MRI 72157 MRI Thoracic Spine with and without contrast W & W/O
MRI 72158 MRI Lumbar Spine with and without contrast W & W/O
MRA 72159 MR Angiography (MRA) Spinal Canal and contents -with or w/o contrast
CT Angiography (CTA) 72191 CTA PELVIS, with contrast, including noncontrast images, if performed, & image post-processing
CT 72192 CT Pelvis without contrast
CT 72193 CT Pelvis with contrast
CT 72194 CT Pelvis with and without contrast W & W/O
MRI 72195 MRI Pelvis without contrast
MRI 72196 MRI Pelvis with contrast
MRI 72197 MRI Pelvis with and without contrast W & W/O
MRA 72198 MR Angiography (MRA) Pelvis -with or without contrast
CT 73200 CT Upper Extremity without contrast
CT 73201 CT Upper Extremity with contrast
CT 73202 CT Upper Extremity with and without contrast W & W/O
CT Angiography (CTA) 73206 CTA Upper Extremity, with contrast, including noncontrast images, if performed, & image postprocessing
MRI 73218 MRI Upper Extremity-other than joint-without contrast
MRI 73219 MRI Upper Extremity-other than joint-with contrast
MRI 73220 MRI Upper Extremity-other than joint-W & W/O
MRI 73221 MRI Any Joint of Upper Extremity--without contrast
MRI 73222 MRI Any Joint of Upper Extremity--with contrast
MRI 73223 MRI Any Joint of Upper Extremity—W & W/O
MRA 73225 MR Angiography (MRA) Upper Extremity -with or without contrast
CT 73700 CT Lower Extremity without contrast
CT 73701 CT Lower Extremity with contrast
CT 73702 CT Lower Extremity with and without contrast W & W/O
CT Angiography (CTA) 73706 CTA Lower Extremity, with contrast, including noncontrast images, if performed, & image postprocessing
MRI 73718 MRI Lower Extremity-other than joint-without contrast
MRI 73719 MRI Lower Extremity-other than joint-with contrast
Page 17 of 39
CPT
® Category
CPT® Code
CPT® Description
MRI 73720 MRI Lower Extremity-other than joint- W & W/O
MRI 73721 MRI Any Joint of Lower Extremity--without contrast
MRI 73722 MRI Any Joint of Lower Extremity--with contrast
MRI 73723 MRI Any Joint of Lower Extremity—W & W/O
MRA 73725 MR Angiography (MRA) Lower Extremity-with or without contrast
CT 74150 CT Abdomen without contrast
CT 74160 CT Abdomen with contrast
CT 74170 CT Abdomen with and without contrast W & W/O
CT Angiography (CTA) 74174 Computed tomographic angiography; abdomen and pelvis; with contrast material(s), including noncontrast images, if performed, and image postprocessing
CT Angiography (CTA) 74175 CTA ABDOMEN, with contrast, including noncontrast images, if performed, & image postprocessing
CT 74176 CT Abdomen & Pelvis, without contrast
CT 74177 CT Abdomen & Pelvis, with contrast
CT 74178 CT Abdomen & Pelvis, with and without contrast
MRI 74181 MRI Abdomen without contrast
MRI 74182 MRI Abdomen with contrast
MRI 74183 MRI Abdomen with and without contrast W & W/O
MRA 74185 MR Angiography (MRA) Abdomen-with or without contrast
Diagnostic CT Colonography (CTC)
74261 Computed tomographic (CT) colonography, diagnostic, including image postprocessing; without contrast material
Diagnostic CT Colonography (CTC)
74262 Computed tomographic (CT) colonography, diagnostic, including image postprocessing; with contrast material(s) including non- contrast images, if performed
CT Colonography (CTC) for Screening
74263 Computed tomographic (CT) colonography, screening, including image postprocessing
Cardiac MRI 75557 Cardiac MRI for morphology and function without contrast
Cardiac MRI 75559 Cardiac MRI for morphology and function without contrast material; with stress imaging
Cardiac MRI 75561 Cardiac MRI for morphology and function without contrast, followed by contrast W & W/O
Cardiac MRI 75563 Cardiac MRI for morphology and function without contrast, followed by contrast; with stress imaging
Cardiac MRI 75565 Cardiac magnetic resonance imaging for velocity flow mapping
(List separately in addition to code for primary procedure)
Cardiac CT Calcium Scoring
75571 CT, heart, without contrast with quantitative
Cardiac CT 75572 CT, heart, with contrast material, for evaluation of cardiac structure and morphology (including 3D image post processing, assessment of cardiac function, and evaluation of venous structures, if performed)
Page 18 of 39
CPT
® Category
CPT® Code
CPT® Description
Cardiac CT 75573 CT, heart, with contrast material, for evaluation of cardiac structure and morphology in the setting of congenital heart disease (including 3D image post processing, assessment of cardiac LV function, RV structure and function and evaluation of venous structures, if performed)
CT Coronary Angiography (CTCA)
75574 CT, 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 venous structures, if performed)
CT Angiography (CTA) 75635 CTA ABDOMINAL AORTA and bilateral iliofemoral lower extremity runoff, with contrast, including noncontrast images, if performed, and image post-processing
3D Rendering 76376 3D Rendering with interpretation and reporting of CT,
3D Rendering 76377 3D Rendering with interpretation and reporting of CT,
CT 76380 CT Limited or Localized follow-up
MR Spectroscopy (MRS) 76390 MR Spectroscopy (MRS)
Unlisted CT 76497 Unlisted CT procedure (eg, diagnostic, interventional)
Unlisted MR 76498 Unlisted MR procedure (eg, diagnostic, interventional)
CT guidance 77011 CT guidance stereotactic localization
CT guidance 77012 CT guidance needle placement (eg, biopsy, aspiration, injection, localization device)
CT guidance 77013 CT Guidance for, and monitoring of, parenchymal tissue
MR Guidance 77021 MR guidance for needle placement (eg, for biopsy,
MR Guidance 77022 MR guidance for, and monitoring of, parenchymal tissue
Breast MRI 77058 MRI BREAST, without and/or with contrast UNILATERAL
Breast MRI 77059 MRI BREAST, without and/or with contrast BILATERAL
CT Bone Density 77078 CT BONE MINERAL DENSITY study, 1 or more sites, axial
skeleton MRI Bone Marrow 77084 MRI Bone Marrow blood supply
Nuclear Cardiac Imaging 78451 Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study, at rest or stress (exercise or pharmacologic)
Nuclear Cardiac Imaging 78452 Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection
Nuclear Cardiac Imaging 78453 Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); single study, at rest or stress (exercise or pharmacologic)
Page 19 of 39
CPT
® Category
CPT® Code
CPT® Description
Nuclear Cardiac Imaging 78454 Myocardial perfusion imaging, planar (including qualitative or quantitative wall motion, ejection fraction by first pass or gated technique, additional quantification, when performed); multiple studies, at rest and/or stress (exercise or pharmacologic) and/or redistribution and/or rest reinjection
Cardiac PET 78459 PET Cardiac (myocardial imaging) – metabolic evaluation
Nuclear Cardiac Imaging 78466 Myocardial Imaging, infarct avid, planar; qualitative or quantitative
Nuclear Cardiac Imaging 78468 Myocardial Imaging, infarct avid, planar; w/ EF by first pass technique
Nuclear Cardiac Imaging 78469 Myocardial Imaging, infarct avid, planar; tomographic SPECT
Nuclear Cardiac Imaging 78472 Cardiac Blood Pool imaging, gated equilibrium; planar, single study at rest or stress
Nuclear Cardiac Imaging 78473 Cardiac Blood Pool imaging, gated equilibrium; multiple studies, wall motion plus ejection fraction, at rest and stress
Nuclear Cardiac Imaging 78481 Cardiac Blood Pool imaging, (planar), first pass technique; single study, at rest or with stress, wall motion study plus ejection fraction
Nuclear Cardiac Imaging 78483 Cardiac Blood Pool imaging, (planar), first pass technique; multiple studies at rest and with stress, wall motion study plus ejection fraction
Cardiac PET 78491 PET Cardiac (myocardial imaging), perfusion single study at rest or stress
Cardiac PET 78492 PET Cardiac (myocardial imaging), perfusion multiple studies rest/stress
Nuclear Cardiac Imaging 78494 Cardiac Blood Pool imaging, gated equilibrium, SPECT
Nuclear Cardiac Imaging 78496 Cardiac Blood Pool imaging, gated equilibrium, RV EF by first pass
Unlisted Nuclear Cardiology
78499 Unlisted Nuclear Cardiology diagnostic nuclear
Non-Cardiac PET 78608 PET Brain – metabolic evaluation
Non-Cardiac PET 78609 PET Brain – perfusion evaluation
Non-Cardiac PET 78811 PET imaging; limited area (eg, chest, head/neck)
Non-Cardiac PET 78812 PET imaging; skull base to mid-thigh
Non-Cardiac PET 78813 PET imaging; whole body
Non-Cardiac PET 78814 PET imaging with concurrently acquired CT for attenuation correction and anatomical localization; limited area (eg, chest, head/neck)
Non-Cardiac PET 78815 PET imaging with concurrently acquired CT for attenuation correction and anatomical localization; skull base to mid-thigh
Non-Cardiac PET 78816 PET imaging with concurrently acquired CT for attenuation correction and anatomical localization; whole body
Ceberal Perfusion 0042T Ceberal Perfusion Analysis using CT with contrast
Analysis
CAD for Breast MRI 0159T CAD, including computer algorithm analysis, BREAST
Magnetic Source Imaging
S8035 Magnetic Source Imaging
Page 20 of 39
CPT
® Category
CPT® Code
CPT® Description
MRCP S8037 MRCP (Magnetic ResonancE)
MRI Low field S8042 MRI Low field
Cardiac CT Calcium Scoring
S8092 CT ELECTRON BEAM (Ultrafast CT) for calcium scoring
Page 21 of 39
Appendix B – Orthotics and Prosthetics (L codes)
AUTHORIZATION REQUIRED HCPCS Description HCPC
S
Description
L0113 Cranial cervical orthosis, torticollis type, w/wo joint, w/o soft interface, prefab. Incl. fitting & adj.
L5460 Postop app non-wgt bear dsg
L0130 Flex thermoplastic collar molded to patient
L5500 Init bk ptb plaster direct
L0170 Cervical collar molded to pt L5505 Init ak ischal plstr direct
L0220 Thor rib belt custom fabrica L5510 Prep BK ptb plaster molded
L0430 Spinal orthosis, Dewall posture protector
L5520 Perp BK ptb thermopls direct
L0452 TLSO flexible, provides trunk support, upper thoracic region, customized
L5530 Prep BK ptb thermopls molded
L0456 TLSO, flexible thoracic region, prefab L5535 Prep BK ptb open end socket
L0460 TLSO, triplanar control prefab L5540 Prep BK ptb laminated socket
L0462 TLSO, triplanar control, prefab L5560 Prep AK ischial plast molded
L0464 TLSO, triplanar control 4 piece rigid plastic with interface, prefab
L5570 Prep AK ischial direct form
L0480 TLSO, triplanar control, one piece rigid plastic shell
L5580 Prep AK ischial thermo mold
L0482 TLSO, triplanor, custom fabricated, one piece rigid plastic shell, each
L5585 Prep AK ischial open end
L0484 TLSO, triplanor control, two piece L5590 Prep AK ischial laminated
L0486 TLSO, triplanor control 2 piece rigid plastic with interface, custom
L5595 Hip disartic sach thermopls
L0488 TLSO triplanor, one piece, prefab L5600 Hip disart sach laminat mold
L0491 TLSO 2 rigid plastic shells, pre fab L5610 Above knee hydracadence
L0622 Sacroiliac orthosis, flexible, custom L5611 Ak 4 bar link w/fric swing
L0623 Sacroiliac orthosis, rigid or semi-rigid, pre fab
L5613 Ak 4 bar ling w/hydraul swig
L0624 Sacroiliac orthosis, rigid or semi-rigid, custom
L5614 4-bar link above knee w/swng
L0629 Lumbar-sacral orthosis, flexible, custom L5616 Ak univ multiplex sys frict
L0631 Lumbar-sacral orthosis, sagittal control, pre fab
L5639 Below knee wood socket
L0632 Lumbar-sacral orthosis, sag. Control, rigid ant./post. Custom
L5643 Hip flex inner socket ext fr
L0634 Lumbar-sacral orthosis, sag. Control, rigid post., custom
L5645 Ak flexibl inner socket ext
Page 22 of 39
L0635 Lumbar-sacral orthosis, sag-coronal control, prefab
L5647 Below knee suction socket
L0636 Lumbar-sacral orthosis, sag-coronal control, custom
L5648 Above knee air cushion socket
L0637 Lumbar-sacral orthosis, sag-coronal control, rigid ant/post., prefab
L5649 Isch containmt/narrow m-l so
L0638 Lumbar-sacral orth, sag-coronal control, rigid ant./post., custom
L5651 Ak flex inner socket ext fra
L0639 Lumbar-sacral orthosis, sag.-coronal control, rigid post. Prefab
L5670 Bk molded supracondylar susp
L0640 Lumbar-sacral orthosis, sag-coronal control, rigid post., custom
L5673 below knee/above knee socket insert, silicone gel or elastomeric w/locking mech, custom
L0700 Ctlso a-p-l control molded L5679 below knee/above knee socket insert, silicone gel or elastomeric no locking mech, custom
L0710 Ctlso a-p-l control w/ inter L5681 below knee/above knee, custom fab. Socket inset initial only for cong. Or atypical
L0810 Halo cervical into jckt vest L5682 Bk thigh lacer glut/ischia molded
L0820 Halo cervical into body jack L5683 below knee/above knee, custom fab, socket inset, initial only not cong.or atypical
L0830 Halo cerv into milwaukee typ L5700 Replace socket below knee
L0999 Addition to spinal orthosis, NOS L5701 Replace socket above knee
L1000 Ctlso milwauke initial model L5702 Replace socket hip
L1001 Cervical TLSO, infant, prefab L5704 Custom shape covr below knee
L1200 Furnsh initial orthosis only L5705 Custom shape cover above knee
L1300 Body jacket mold to patient L5706 Custom shape cvr knee disart
L1310 Post-operative body jacket L5707 Custom shape cover hip disart
L1499 Spinal orthosis NOS L5716 Knee-shin exo mech stance ph
L1500 Thkao mobility frame L5718 Knee-shin exo frct swg & sta
L1510 Thkao standing frame L5722 Knee-shin pneum swg frct exo
L1520 Thkao swivel walker L5724 Knee-shin exo fluid swing ph
L1680 Pelvic & hip control thigh c L5726 Knee-shin ext jnts fld swg e
L1685 Post-op hip abduct custom fa L5728 Knee-shin fluid swg & stance
L1686 HO post-op hip abduction L5780 Knee-shin pneum/hydra pneum
L1690 Combination bilateral LS/hip/femur L5781 Addt. to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system
L1700 Legg perthes orth toronto typ L5782 Addt. To lower leg prosth. Vacuum
L1710 Legg perthes orth newington L5790 Exoskeletal ak ultra-light m
L1720 Legg perthes orthosis trilat L5795 Exoskel hip ultra-light mate
Page 23 of 39
L1730 Legg perthes orth scottish L5811 Endo knee-shin mnl lck ultra
L1755 Legg perthes patten bottom L5814 Endo knee-shin hydral swg ph
L1832 KO adj jnt pos rigid support L5816 Endo knee-shin polyc mch sta
L1834 KO w/0 joint rigid molded to L5818 Endo knee-shin frct swg & st
L1840 KO derot ant cruciate custom L5822 Endo knee-shin pneum swg frc
L1843 KO single upright thigh & calf- prefabricated, each
L5824 Endo knee-shin fluid swing p
L1844 KO w/adj jt rot cntrl molded L5826 Miniature knee joint
L1845 KO w/ adj flex/ext rotat cus L5828 Endo knee-shin fluid swg/sta
L1846 KO w adj flex/ext rotat mold L5830 Endo knee-shin pneum/swg pha
L1860 KO supracondylar socket mold L5840 Multi-axial knee/shin system
L1904 AFO molded ankle gauntlet L5845 Knee-shin sys stance flexion
L1907 supramalleolar w/straps w/wo interface/pads, custom fabricated
L5848 Knee-shin system dampening feature
L1932 AFO, rigid anterior tibial section,pre fab, incl. Fitting & adj.
L5856 Addt. To lower ext. prosthesis, knee shin sys.,microprocessor, incl. Sensor, any type
L1940 AFO, plastic or other material custom L5857 Addt. To lower ext. prosth., swing phase only knee shin sys.,micro, incl. Sensor , any type
L1945 AFO molded plas rig ant tib L5858 Addt. To lower ext. prosth, knee shin sys.,micro, incl. Sens , stance phase
L1950 AFO spiral molded to pt plas L5930 High activity knee frame
L1951 spiral, IRM type, plastic or other material prefab, incl. Fitting and adj.
L5950 Endo ak ultra-light material
L1960 AFO pos solid ank plastic mo; custom L5960 Endo hip ultra-light materia
L1970 AFO plastic molded w/ankle j L5964 addt. Endoskeleton above knee, flexible protective outer surface
L1980 AFO sing solid stirrup calf custom L5966 Hip flexible cover system
L1990 AFO doub solid stirrup calf; custom L5968 Multiaxial ankle w dorsiflex
L2000 KAFO using fre stirr thi/calf; custom L5973 Endoskeletal ankle foot system, microprocessor, incl. power source
L2005 KAFO any material, single or dbl. Upright includes ankle joint custom fabricated
L5976 Energy storing foot
L2010 KAFO single upright, free ankle, solid stirrup
L5979 Multi-axial ankle/ft prosth
L2020 KAFO dbl solid stirrup band/ L5980 Flex foot system
L2030 KAFO dbl solid stirrup w/o j L5981 Flex-walk sys low ext prosth
L2034 KAFO full plastic, single upright, w/wo free motion knee,custom fabricated
L5987 Shank ft w vert load pylon
L2036 KAFO plas doub free knee mol L5988 Vertical shock reducing pylo
L2037 KAFO plas sing free knee mol L5990 addt. To lower ext. user adj. ht
L2038 KAFO w/o joint multi-axis an L5999 Lower extremity prosthesis, NOC
L2050 Hkafo torsion cable hip pelv; custom L6000 Par hand robin-aids thum rem
Page 24 of 39
L2060 Hkafo torsion ball bearing j; custom L6010 Hand robin-aids little/ring
L2070 Hkafo torsion unilat rot str; custom L6020 Part hand robin-aids no fing
L2080 Hkafo unilat torsion cable, custom L6050 Wrst MLd sck flx hng tri pad
L2090 Hkafo unilat torsion ball br, custom L6055 Wrst mold sock w/exp interfa
L2106 AFO tib fx cast plaster mold, custom L6100 Elb mold sock flex hinge pad
L2108 AFO tib fx cast molded to pt L6110 Elbow mold sock suspension t
L2116 Afo tibial fracture rigid L6120 Elbow mold doub splt soc ste
L2126 Kafo fem fx cast thermoplas L6130 Elbow stump activated lock h
L2128 Kafo fem fx cast molded to p L6200 Elbow mold outsid lock hinge
L2132 Kafo femoral fx cast soft L6205 Elbow molded w/ expand inter
L2134 Kafo fem fx cast semi-rigid L6250 Elbow inter loc elbow forarm
L2136 Kafo femoral fx cast rigid L6300 Shlder disart int lock elbow
L2232 Addt. To lower extremity orthosis, rocker bottom, custom fabricated only
L6310 Shoulder passive restor comp
L2280 Molded inner boot L6320 Shoulder passive restor cap
L2330 Lacer molded to patient, custom L6350 Thoracic intern lock elbow
L2340 Pre-tibial shell molded to p L6360 Thoracic passive restor comp
L2350 Prosthetic type socket molded L6370 Thoracic passive restor cap
L2510 Th/wght bear quad-lat brim m L6380 Postop dsg cast chg wrst/elb
L2520 Th/wght bear quad-lat brim custom L6382 Postop dsg cast chg elb dis/
L2525 Th/wght bear m-l brim mo L6384 Postop dsg cast chg shlder/t
L2526 Th/wght bear m-l brim cu L6400 Below elbow prosth tiss shap
L2540 Thigh/wght bear lacer molded L6450 Elb disart prosth tiss shap
L2627 Plastic mold recipro hip & c L6500 Above elbow prosth tiss shap
L2628 Metal frame recipro hip & ca L6550 Shldr disar prosth tiss shap
L2768 Orthotic side bar, Disconnect device, each
L6570 Scap thorac prosth tiss shap
L2861 addt. to lower ext-joint, knee or ankle, custom only, each
L6580 Wrist/elbow bowden cable mol
L2999 Lower extremity orthosis NOS L6582 Wrist/elbow bowden cbl dir f
L3060 Foot arch support, removable, premolded, longitudinal & horizontal, each
L6584 Elbow fair lead cable molded
L3201 Oxford w supinator/pronator inf each L6586 Elbow fair lead cable dir fo
L3202 Oxford w supinator/pronator child each L6588 Shdr fair lead cable molded
L3203 Oxford w supinator/pronator jun each L6590 Shdr fair lead cable direct
L3204 Hightop w supp/pronator infant each L6611 Addt. To upper ext. prosthesis, ext. pwr switch addt.
L3206 Hightop w supp/pronator child each L6623 Spring-asst. rot wrst w/ latch
L3207 Hightop w supp/pronator junior each L6624 Upper ext. addt. Flex. Ext rotation wrist
L3208 Surgical boot, each infant L6638 upper ext addt. To prosth. Electric locking only for use with manually powered elbow
Page 25 of 39
L3209 Surgical boot, each child L6686 Suction socket
L3211 Surgical boot, each junior L6689 Frame typ socket shoulder di
L3212 Benesch boot pair infant L6690 Frame typ sock interscap-tho
L3213 Benesch boot pair child L6693 Locking elbow forearm cntrbal
L3214 Benesch boot pair junior L6694 Add. To upper ext. pros.,for use with locking mechanism
L3215 Orthopedic ftwear ladies oxf each L6695 Add. To upper ext. pros., not for use with locking mechanism, custom
L3216 Orthopedic ftwear ladies depth each L6696 Add. To upper ext. pros., congenital or atypical traumatic amputees, initial only
L3217 Ladies shoes hightop depth each L6697 Add. To upper ext. pros., other than congenital or traumatic amputees, initial only
L3219 Orthopedic mens shoes oxford each L6707 term dev hook, mech vol closing, any material, any size, lined or unlined
L3221 Orthopedic mens shoes dpth each L6708 term dev, hand, mech vol opening, any material, any size
L3222 Mens shoes hightop depth inl each L6709 term dev hand, mech vol. closing, any material, any size
L3224 Woman's shoe oxford brace each L6712 Terminal device, hook,mechanical vol. closing, any material, any size, lined or unlined, Pediatric, each
L3225 Man's shoe oxford brace each L6713 Terminal device, hand, mechanical, vol. opening, any material, any size,lined or unlined, Pediatric, each
L3230 Custom shoes depth inlay each L6714 Terminal device, mechanical, vol. closing, any material, any size, Pediatric, each
L3250 Custom mold shoe remov prost each L6721 terminal device, hook or hand, hvy, dty., mechanical, vol.opening, any material, any size, lined or unlined, each
L3251 Shoe molded to pt silicone s each L6722 Terminal device, hook or hand, heavy duty, mechanical, vol. closing, any material, any size, lined or unlined, each
L3252 Shoe molded plastazote cust each L6881 Automatic grasp, addt. To upper limb elect. Prosth. Terminal device
L3253 Shoe molded plastazote cust each L6882 Microprocessor control feature, addt. To upper limb prosth. Terminal device
L3254 Orth foot non-std size/w L6895 Custom glove
L3255 Orth foot non-std size/w L6900 Hand restorat thumb/1 finger
L3257 Orth foot add charge split L6905 Hand restoration multiple fi
L3330 Lift elevation, metal extension, (skate) each
L6910 Hand restoration no fingers
Page 26 of 39
L3649 orthopedic shoe modification NOS L6915 Hand restoration replacmnt g
L3671 Shoulder othosis, cap design w/o joints L6920 Wrist disarticul switch ctrl
L3702 elbow orthosis w/o joints, may include soft interface, straps, custom fabricated incl. fitting & adj.
L6925 Wrist disart myoelectronic c
L3720 Forearm/arm cuffs free motio L6930 Below elbow switch control
L3730 Forearm/arm cuffs ext/flex a L6935 Below elbow myoelectronic ct
L3740 Cuffs adj lock w/ active con L6940 Elbow disarticulation switch
L3763 elbow wrist hand orthosis rigid w/o joints custom fab incl. fitting & adj.
L6945 Elbow disart myoelectronic c
L3806 WHFO, incl. 1 or more nontorsion joints. Custom
L6950 Above elbow switch control
L3808 WHFO, rigid w/o joints, custom, L6955 Above elbow myoelectronic ct
L3891 Addt. to upper ext. joint, wrist, or elbow, custom fabricated only, each
L6960 Shldr disartic switch contro
L3900 Hinge extension/flex wrist/f L6965 Shldr disartic myoelectronic
L3901 Hinge ext/flex wrist finger L6970 Interscapular-thor switch ct
L3904 Whfo electric custom fitted L6975 Interscap-thor myoelectronic
L3905 wrist/hand orthosis custom L7007 elect. Hand, myoelectric or switch, adult
L3906 Wrist hand orthosis, w/o joints, custom L7008 elect. Hand, myoelectric or switch, ped
L3907 Whfo wrist gauntlt thmb spica L7009 elect hook, switch or myoelect, adult
L3913 Hand finger orthosis, w/o joints, may include soft interface, straps, custom fabricated, incl fitting & adjustment, each
L7040 Prehensile actuator switch controlled
L3927 Finger orthosis, PIP/DIP, non-torsion w/o joint/spring, ext./flex., pre-fab, incl fitting & adj., each
L7045 Electric hook, switch or myoelectric controlled, pediatric
L3933 Finger orthosis, w/o joints, may include soft interface, custom fabricated, incl. fitting & adjustment, each
L7170 Electronic elbow hosmer swit
L3956 addt. Of joint to upper ext orth. any material, per joint
L7180 Electronic elbow utah myoele
L3960 Sewho airplan desig abdu pos L7181 electronic elbow, sim. Control of elbow and terminal device
L3962 Sewho erbs palsey design abd L7185 electronic elbow, sim. Variety Village or equal switch control
L3964 Seo mobile arm sup att to wc L7186 Electron elbow child switch
L3965 Arm supp att to wc rancho ty L7190 Elbow adolescent myoelectron
L3966 Mobile arm supports reclinin L7191 Elbow child myoelectronic ct
L3968 Friction dampening arm supp L7260 Electron wrist rotator otto
L3969 Monosuspension arm/hand supp L7261 Electron wrist rotator utah
L3971 SEHWO, shoulder cap design, custom fabricated
L7266 Servo control steeper or equ
Page 27 of 39
L3999 Upper limb orthosis, not otherwise specified
L7272 Analogue control unb or equa
L4000 Repl girdle milwaukee orth L7274 Proportional ctl 12 volt uta
L4002 Replacement strap, any orthosis, includes all components, any lgth., any type
L7499 Upper extremity prosthesis NOS
L4010 Replace trilateral socket brim L7500 Prosthetic dvc repair hourly
L4020 Replace quadlat socket brim L7510 Repair of prosthetic device, minor parts
L4030 Replace socket brim cust fit L7520 Repair prosthetic device, labor component, per 15 min
L4040 Replace molded thigh lacer L7600 Prosthetic donning sleeve, any material
L4050 Replace molded calf lacer L7900 Vacuum erection system
L4205 Repair orthotic device per 15 min labor L8000 Mastectomy bra - 5 per year
L4210 repair or replace minor parts L8001 Breast prosthesis , masectomy bra with integrated breast prothesis form, unilateral - 5 per year
L5000 Sho insert w arch toe filler L8002 Breast prosthesis, masectomy bra with integrated breast prothesis form, bilateral - 5 per year
L5010 Mold socket ank hgt w/ toe f L8020 Mastectomy form - 2 per year
L5020 Tibial tubercle hgt w/ toe f L8030 Breast prosthesis silicone/e - 2 per year
L5050 Ank symes mold sckt sach ft L8031 Breast prosthesis, silicone or equal, with intergral adhesive, each
L5060 Symes met fr leath socket ar L8035 Custom breast prosthesis
L5100 Molded socket shin sach foot L8039 Breast prosthesis, NOS
L5105 Plast socket jts/thgh lacer L8040 Nasal prothesis, provided by a non- physician
L5150 Mold sckt ext knee shin sach L8041 Midfacial prothesis, provided by a non- physician
L5160 Mold socket bent knee shin s L8042 Orbital prothesis, provided by a non- physician
L5200 Knee sing axis fric shin sach L8043 Upper facial prosthesis, provided by a non-physician
L5210 No knee/ankle joints w/ ft b L8044 Hemi-facial prosthesis, provided by a non-physician
L5220 No knee joint with artic ali L8045 Prosthetic External Ear provided by a non-physician
L5230 Fem focal defic constant fri L8046 Partial facial prosthesis, provided by a non-physician
L5250 Hip canadian sing axi cons fric L8047 Nasal septal prosthesis, provided by a non-physician
L5270 Tilt table locking hip sing L8048 Unspecified Maxillofacial Prosthesis, by a non-physician
L5280 Hemipelvect canadian sing axis L8049 Repair or modification of maxillofacial prosthesis, by a non-physician
Page 28 of 39
L5301 Below Knee molded socket, shin each foot, endosketal system
L8499 Unlisted Misc prosthetic service
L5311 Knee disarticulation , molded socket, external knee joints, shin,sach foot endo
L8500 artifical larynx
L5321 Above Knee, molded socket, open end, sach foot, endoskelttal system, single axis knee
L8501 Tracheostomy speaking valve
L5331 Hip disarticulation, Canadian type, molded socket endoskeletal system, hip joint, single
L8505 Artificial larynx replacement battery/accessory, any type, each
L5341 Hemipelvectomy, Canadian type, molded socket, endoskeletal hip joint single axis knee
L8619 cochlear implant external speech processor replacement
L5400 Postop dress & 1 cast chg bk L8627 Cochlear implant, external speech processor, component, replacement
L5410 Postop dsg bk ea add cast ch L8628 Cochlear implant, external controller component, replacement
L5420 Postop dsg & 1 cast chg ak/d L8629 Transmitting coil and cable, integrated for use with cochlear implant device, replacement
L5430 Postop dsg ak ea add cast ch L8691 auditory osseointegrated dev, ext. sound replacer, repl only
L5450 Postop app non-wgt bear dsg
AUTHORIZATION NOT REQUIRED HCPCS Description HCPC
S
Description
L0120 Cerv flexible non-adjustable L3670 Acromio/clavicular canvas&we
L0140 Cervical semi-rigid adjustab L3675 Canvas vest SO
L0150 Cerv semi-rig adj molded chn L3710 Elbow elastic with metal joi
L0160 Cerv semi-rig wire occ/mand L3760 Elbow orthosis, adj position locking joints, prefab, inc fitting and adj
L0172 Cerv col thermplas foam 2 piece L3762 Elbow orthosis rigid, w/o joints, prefab, soft interface, incl. Fitting/adj.
L0174 Cerv col foam 2 piece w thor L3807 WHFO w/o joints, prefab includes fitting and adjustments any type
L0180 Cer post col occ/man sup adj L3908 Wrist cock-up non-molded
L0190 Cerv collar supp adj cerv ba - 1 Per Year
*
L3912 Flex glove w/elastic finger
L0200 Cerv col supp adj bar & thor - 1 per L3915 WHFO, rigid with 1 or more joints,
Page 29 of 39
year * prefab,
L0450 TLSO flexible, provides trunk support, uper thoracic region, prefab
L3917 hand orthosis, metacarpal fracture orthosis, prefab, incl fitting and adj.
L0454 TLSO, Flexible, provides trunk support, sacrococcygeal juntion to T-9, prefab
L3923 Hand finger orthosis, without joint, prefab, inc fitting and adj
L0466 TLSO Sagittal control, prefab L3925 Finger orthosis, PIP/DIP, non-torsion joint/spring, ext./flex., pre-fab, incl fitting & adj., each
L0468 TLSO sagittal-coronol control, rigid posterior frame - 1 per year *
L3929 Hand finger orthosis, incl. 1 or more nontorsion joints, turnbuckles, elastic bands/spring, straps, pre-fab, incl. fitting & adj., each
L0470 TLSO triplanar control - 1 per year * L3931 Wrist, hand, finger orthosis, incl. 1 or more nontorsion joints,turnbuckles, elastic bands/springs, straps, pre-fab, incl. fitting & adj., each
L0472 TLSO, triplanar control, hyperextension prefab - 1 per year *
L3970 Elevat proximal arm support
L0490 TLSO sagittal coronal control one piece prefab
L3972 Offset/lat rocker arm w/ ela
L0492 TLSO 3 rigid plastic shells, pre fab - 1 per year *
L3974 Mobile arm support supinator
L0621 Sacroiliac orthosis, flexible, pre fab L3980 Upp ext fx orthosis humeral
L0625 Lumbar orthosis, flexible, pre fab L3982 Upper ext fx orthosis rad/ul
L0626 Lumbar orthosis, sagittal control, pre fab
L3984 Upper ext fx orthosis wrist
L0627 Lumbar orthosis, sagittal control with rigid ant./post. Panels, pre fab
L3995 Add. To upper ext. sock, fracture, or equal, each
L0628 Lumbar-sacral orthosis, flexible, pre fab L4045 Replace non-molded thigh lac
L0630 Lumbar-sacral orthosis, sag. Control, pre fab
L4055 Replace non-molded calf lace
L0633 Lumbar-sacral orthosis, sag. Control, rigid post., pre fab
L4060 Replace high roll cuff
L0970 Tlso corset front L4070 Replace prox & dist upright
L0972 Lso corset front L4080 Repl met band kafo-afo prox
L0974 Tlso full corset L4090 Repl met band kafo-afo calf/
L0976 Lso full corset L4100 Repl leath cuff kafo prox th
L0978 Axillary crutch extension L4110 Repl leath cuff kafo-afo cal
L0980 Peroneal straps pair L4130 Replace pretibial shell
L0982 Stocking supp grips set of 4 L4350 Pneumatic ankle cntrl splint
L0984 Protective body sock each L4360 Pneumatic walking splint
L1010 Ctlso axilla sling L4370 Pneumatic full leg splint
L1020 Kyphosis pad L4380 Pneumatic knee splint
L1025 Kyphosis pad floating L4386 Non-pneumatic walking boot
L1030 Lumbar bolster pad L4394 Replacement Foot Drop Splint
Page 30 of 39
L1040 Lumbar or lumbar rib pad L4396 Static AFO
L1050 Sternal pad L4398 Foot drop splint recumbent
L1060 Thoracic pad L5617 AK/BK self-aligning unit ea
L1070 Trapezius sling L5618 Test socket symes
L1080 Outrigger L5620 Test socket below knee
L1085 Outrigger bil w/ vert extens L5622 Test socket knee disarticula
L1090 Lumbar sling L5624 Test socket above knee
L1100 Ring flange plastic/leather L5626 Test socket hip disarticulat
L1110 Ring flange plas/leather molded to patient
L5628 Test socket hemipelvectomy
L1120 Covers for upright each L5629 Below knee acrylic socket
L1210 Lateral thoracic extension L5630 Syme typ expandabl wall sckt
L1220 Anterior thoracic extension L5631 Ak/knee disartic acrylic soc
L1230 Milwaukee type superstructur L5632 Symes type ptb brim design s
L1240 Lumbar derotation pad L5634 Symes type poster opening so
L1250 Anterior asis pad L5636 Symes type medial opening so
L1260 Anterior thoracic derotation pad L5637 Below knee total contact
L1270 Abdominal pad L5638 Below knee leather socket
L1280 Rib gusset (elastic) each L5640 Knee disarticulat leather so
L1290 Lateral trochanteric pad L5642 Above knee leather socket
L1600 Abduct hip flex frejka w cvr L5644 Above knee wood socket
L1610 Abduct hip flex frejka covr L5646 Below knee air cushion socket
L1620 Abduct hip flex pavlik harne L5650 Tot contact ak/knee disart s
L1630 Abduct control hip semi-flex L5652 Suction susp ak/knee disart
L1640 Pelv band/spread bar thigh c L5653 Knee disart expand wall sock
L1650 HO abduction hip adjustable L5654 Socket insert symes
L1660 HO abduction static plastic L5655 Socket insert below knee
L1810 KO elastic with joints L5656 Socket insert knee articulat
L1820 KO elas w/ condyle pads & jo L5658 Socket insert above knee
L1830 KO immobilizer canvas longit L5661 Multi-durometer symes
L1831 KO locking knee joint pre fab incl. Fitting and adj.
L5665 Multi-durometer below knee
L1847 KO adjustable w air chambers L5666 Below knee cuff suspension
L1850 KO swedish type L5668 Socket insert w/o lock lower
L1900 AFO sprng wir drsflx calf bd L5671 Addition to lower extremity, below knee/above knee suspension locking mechanism
L1902 AFO ankle gauntlet L5672 Bk removable medial brim sus
L1906 AFO multiligamentus ankle su L5676 Bk knee joints single axis pair
L1910 AFO sing bar clasp attach sh L5677 Bk knee joints polycentric pair
L1920 AFO sing upright w/ adjust s L5678 Bk joint covers pair
L1930 AFO plastic or other material, includes L5680 Bk thigh lacer non-molded
Page 31 of 39
fitting & adjustment
L1971 plastic or other material w/ankle joint, prefab, incl. Fitting and adj.
L5684 Bk fork strap
L2035 KAFO plastic pediatric size L5685 Addt. To lower ext. orthosis, below knee, susp./sealing sleeve, any mat. Each
L2040 Hkafo torsion bil rot straps L5686 below knee back check extension control
L2112 AFO tibial fracture soft, pre-fab L5688 Bk waist belt webbing
L2114 AFO tib fx semi-rigid, pre-fab L5690 Bk waist belt padded and lin
L2180 Plas shoe insert w ank joint L5692 Ak pelvic control belt light
L2182 Drop lock knee L5694 Ak pelvic control belt pad/l
L2184 Limited motion knee joint L5695 Ak sleeve susp neoprene/equa
L2186 Adj motion knee jnt lerman t L5696 Ak/knee disartic pelvic join
L2188 Quadrilateral brim L5697 Ak/knee disartic pelvic band
L2190 Waist belt L5698 Ak/knee disartic silesian ba
L2192 Pelvic band & belt thigh fla L5699 Shoulder harness
L2200 Limited ankle motion ea jnt L5710 Kne-shin exo sng axi mnl loc
L2210 Dorsiflexion assist each joi L5711 Knee-shin exo mnl lock ultra
L2220 Dorsi & plantar flex ass/res L5712 Knee-shin exo frict swg & st
L2230 Split flat caliper stirr & p L5714 Knee-shin exo variable frict
L2240 Addt. To lower extremity orthosis, round caliper & plate attachment
L5785 Exoskeletal bk ultralt mater
L2250 Foot plate molded stirrup at L5810 Endoskel knee-shin mnl lock
L2260 Reinforced solid stirrup L5812 Endo knee-shin frct swg & st
L2265 Long tongue stirrup L5850 Endo ak/hip knee extens assi
L2270 Varus/valgus strap padded/li L5855 Mech hip extension assist
L2275 Plastic mod low ext pad/line L5910 Addt. Endoskeleton, below knee, alignable system
L2300 Abduction bar jointed adjust L5920 Endo ak/hip alignable system
L2310 Abduction bar-straight L5925 Above knee manual lock
L2320 Non-molded lacer L5940 Endo bk ultra-light material
L2335 Anterior swing band L5962 Below knee flex cover system
L2360 Extended steel shank L5970 Foot external keel sach foot
L2370 Patten bottom L5971 All lower extremity prosthesis, SACH foot, replacement only
L2375 Torsion ank & half solid sti L5972 Flexible keel foot
L2380 Torsion straight knee joint; L5974 Foot single axis ankle/foot
L2385 Straight knee joint heavy du L5975 Combo ankle/foot prosthesis
L2387 Addt. to lower extremity, polycentric knee joint, for custom fabricated KAFO, each joint
L5978 Ft prosth multiaxial ankl/ft
L2390 Offset knee joint each L5982 Exoskeletal axial rotation
Page 32 of 39
L2395 Offset knee joint heavy duty L5984 Endoskeletal axial rotation, w/wo adjustability
L2397 Suspension sleeve lower ext L5985 Lwr ext dynamic prosth pylon
L2405 Knee joint drop lock ea jnt L5986 Multi-axial rotation unit
L2415 Knee joint cam lock each joi L6386 Postop ea cast chg & realign
L2425 Knee disc/dial lock/adj flex L6388 Postop applicat rigid dsg on
L2430 Knee jnt ratchet lock ea jnt L6600 Polycentric hinge pair
L2492 Knee lift loop drop lock rin L6605 Single pivot hinge pair
L2500 Thi/glut/ischia wgt bearing L6610 Flexible metal hinge pair
L2530 Thigh/wght bear lacer non-mo L6615 Disconnect locking wrist uni
L2550 Thigh/wght bear high roll cu L6616 Disconnect insert locking wr
L2570 Hip clevis type 2 posit jnt L6620 Flexion-friction wrist unit
L2580 Pelvic control pelvic sling L6625 Rotation wrst w/ cable lock
L2600 Hip clevis/thrust bearing fr L6628 Quick disconn hook adapter o
L2610 Hip clevis/thrust bearing lo L6629 Lamination collar w/ couplin
L2620 Pelvic control hip heavy dut L6630 Stainless steel any wrist
L2622 Hip joint adjustable flexion L6632 Latex suspension sleeve each
L2624 Hip adj flex ext abduct cont L6635 Lift assist for elbow
L2630 Pelvic control band & belt u L6637 Nudge control elbow lock
L2640 Pelvic control band & belt b L6640 Shoulder abduction joint pai
L2650 Pelv & thor control gluteal L6641 Excursion amplifier pulley t
L2660 Thoracic control thoracic ba L6642 Excursion amplifier lever ty
L2670 Thorac cont paraspinal uprig L6645 Shoulder flexion-abduction joint, each
L2680 Thorac cont lat support upri L6650 Shoulder universal joint, each
L2750 Plating chrome/nickel pr bar L6655 Standard control cable extra
L2755 Addt. Lower ext.,high strength, custom fab. Only
L6660 Heavy duty control cable
L2760 Extension per extension per L6665 Teflon or equal cable lining
L2780 Non-corrosive finish per bar L6670 Hook to hand cable adapter
L2785 Drop lock retainer each L6672 Harness chest/shlder saddle
L2795 Knee control full kneecap L6675 Harness figure of 8 sing con
L2800 Knee cap medial or lateral p L6676 Harness figure of 8 dual con
L2810 Knee control condylar pad L6680 Test sock wrist disart/bel e
L2820 Soft interface below knee se L6682 Test sock elbw disart/above
L2830 Soft interface above knee se L6684 Test socket shldr disart/tho
L2840 Tibial length sock fx or equ L6687 Frame typ socket bel ow elbow or wrist
L2850 Femoral lgth sock fx or equa L6688 Frame typ sock above elbow or elbow disarticulation
L3000 foot insert Berkeley shell, each L6691 Removable insert each
L3001 foot insert Spenco, each L6692 Silicone gel insert or equal
L3002 foot insert, Plastazote , each L6698 Add. To upper ext. pros., lock mechanism, excludes socket insert
Page 33 of 39
L3003 foot insert, Silicone gel , each L6703 term. Device, passive hand mitt, any material, any size
L3010 Longitudinal Arch support each L6704 term. Device, sport/rec/work, any material, any size
L3020 Foot longitud/metatarsal supp L6706 term dev hook, mech vol opening, any material, any size
L3030 Foot arch support remov prem L6711 Terminal device, hook, mechanical, vol. opening, any material, any size, lined or unlined, Pediatric, each
L3040 Foot arch support remov premolded longitudinal, each
L6805 Modifier wrist flexion unit addt to terminal device
L3100 Hallus-valgus night dynamic splint L6810 Addt to terminal device, precision pinch device
L3140 Abduction rotation bar shoe L6890 Production glove
L3150 Abduction rotation bar w/o shoe L7360 Six volt battery, each
L3160 Shoe styled postioning device L7362 Battery charger, six volt, each
L3170 Foot plastic heel stablizer L7364 Twelve volt battery , each - 2 per year *
L3260 Ambulatory surgical boot each L7366 Battery charger 12 volt each - 1 per 4 years *
L3265 Plastazole sandal each L7367 lithium ion battery replacement
L3300 Lift, Elevation Heel, Tapered to Metata L7368 Lithium battery charger - 1 per 4 years *
L3310 Shoe lift elev heel/sole neo L7400 Addt. To upper ext. prosth. Ultralight material
L3320 shoe lift elev heel/sole cor L7401 Addt. To upper ext. prosthesis above elbow disart. Ultralight material
L3332 Shoe lift inside tapered up to 1/2 inch L7403 Addt. To upper ext. prosth. acrylic material
L3334 Shoe, lift elevation, heel, per inch, each L7404 addt. To upper ext prosth. Above elbow disart. Acrylic
L3340 shoe wedge sach L8010 Mastectomy sleeve
L3350 shoe sole wedge L8015 Ext breast prosthesis garment
L3360 shoe sole wedge outside sole L8300 Truss single w/ standard pad
L3370 shoe sole wedge between sole L8310 Truss double w/ standard pad
L3380 shoe clubfoot wedge L8320 Truss addition to std pad wa
L3390 shoe outflare wedge L8330 Truss add to std pad scrotal
L3400 shoe metarsal bar wedge L8400 Sheath below knee
L3410 shoe metarsal bar between L8410 Sheath above knee
L3420 full sole/heel wedge btween L8415 Sheath upper limb
L3430 shoe heel count plast reinforc L8417 Prosthetic sheath/sock, incl. gel cushion layer, below knee or above knee, each
L3440 heel leather reinforced L8420 Prosthetic sock multi ply BK
L3450 shoe heel sach cushion type L8430 Prosthetic sock multi ply AK
Page 34 of 39
L3455 shoe heel new leather standard L8435 Pros sock multi ply upper lm
L3460 shoe heel new rubber standard L8440 Shrinker below knee
L3465 shoe heel thomas with wedge L8460 Shrinker above knee
L3470 shoe heel thomas extend to B L8465 Shrinker upper limb
L3480 shoe heel pad &depress for L8470 Pros sock single ply BK
L3485 shoe heel pad removeable for L8480 Pros sock single ply AK
L3500 ortho shoe add leather insol L8485 Pros sock single ply upper l
L3510 orthopedic shoe add rub insl L8507 Tracheo-esophageal voice prosthesis, patient inserted, any type
L3520 ortho shoe add felt w leather insol L8509 Tracheo-esophageal voice prosthesis, inst. by lic. Health care provider, any type
L3530 ortho shoe add half sole L8510 Voice Amplifier
L3540 ortho shoe add full sole L8511 Insert for Indwelling T/E prosthesis with or W/O valve replacement each
L3550 ortho shoe add standard toe tap L8512 Gelatin capsules or equ. use with T/E prosthesis replacement only per 10
L3560 ortho shoe add horseshoe toe tap L8513 Cleaning device used with T/E prosthesis replacement only each
L3570 ortho shoe add instep extension L8514 T/E puncture dilator replacement only each
L3580 ortho shoe add instep velcro clos L8515 gelatin capsule application device for use with TE voice prosthesis, each
L3590 ortho shoe convert firm to soft count L8615 Headset/Headpiece for use with cochlear implant device, replacement
L3595 ortho shoe add march bar L8616 microphone for use with cochlear implant device, replacement
L3600 Trans shoe calip plate exist L8617 transmitting coil for use with cochlear implant device, replacement
L3610 Trans shoe caliper plate new L8618 transmitter cable for use with cochlear implant device, replacement
L3620 Trans shoe solid stirrup existing L8621 Zinc air battery for use with cochlear implant device, each
L3630 Trans shoe solid stirrup new L8622 Alkaline batt. For use with coch. Imp. Device, any size,each
L3640 Shoe Dennis Browne splint both L8623 Lithium ion battery coch. imp. Device speech proc.other than Ear level, ea
L3650 Shlder fig 8 abduct restrain L8624 Lithium ion battery for coch. imp. Device speech proc. Ear level, each
L3660 Abduct restrainer canvas&web L8695 ext recharging sys for battery(ext) for use with implantable neurostimulator
Page 35 of 39
Appendix C – Ostomy Supplies Any request that exceeded $500.00 will require prior authorization.
AUTHORIZATION REQUIRED A4421 Ostomy supply, miscellaneous Authorization is required
A4465 Non elastic binder for extremity Authorization is required
A4466 Garment, belt, sleeve or other covering, elastic or similar stretchable material, any type, each
Authorization is required
A4483 Moisture exchanger, disposable, for use with invasive mechanical ventilation, each
Authorization is required
A4600 sleeve for intmt. Limb compression device, replac. only Authorization is required
A4601 Lithium ion battery for non-prosthetic use, repl. Only Authorization is required
A4649 Surgical Supply, Miscellaneous Authorization is required
AUTHORIZATION REQUIRED IF QUANTITY LIMIT IS
EXCEEDED A4366 Ostomy vent, any type, each Authorization required > 1 per calendar month
A4367 Ostomy belt Authorization required > 1 per calendar month
A4400 Ostomy irrigation set Authorization required > 1 per calendar month
A4404 Ostomy ring each Authorization required > 10 per calendar month
A4362 Solid skin barrier Authorization required > 20 per calander month
A4398 Ostomy irrigation bag Authorization required > 4 per year
A4399 Ostomy irrig cone/cath w brs Authorization required > 4 per year
A4402 Lubricant price is per oz. 1 oz.=1 unit Authorization required > 4 oz per calendar month
A4397 Irrigation supply sleeve Authorization required > 4 per calendar month
A4361 Ostomy face plate Authorization required > 6 per year
A4416 Ostomy pouch, closed, w/barrier att. W/filter 1 pc. Each Authorization required > 60 per calendar month
A4417 Ostomy pouch,closed, w/barrier att.,w/built-in convexity, w/filter 1 pc, each
Authorization required > 60 per calendar month
A4418 Ostomy pouch,closed, w/o barrier att. W/filter 1 pc. Each Authorization required > 60 per calendar month
A4419 Ostomy pouch, closed, use on barrier w/non-lock flange,w/filter 2pc, each
Authorization required > 60 per calendar month
A4420 Ostomy pouch, closed, use on barrier with lock flange 2 pc, each Authorization required > 60 per calendar month
Page 36 of 39
A4423 Ostomy pouch closed, 2 pc. Locking flange, each Authorization required > 60 per calendar month
A4424 Ostomy pouch, drainable,w/barrier 1 pc, each Authorization required > 60 per calendar month
A4425 Ostomy pouch drainable, non-locking flange 2 pc each Authorization required > 60 per calendar month
A4426 Ostomy pouch, drainable, with locking flange, 2 pc. Each Authorization required > 60 per calendar month
A4427 Ostomy pouch, drainable , use on barrier w/locking flange, w/filter 2 pc, each
Authorization required > 60 per calendar month
A4428 Electrodes, apnea monitor, per pair Authorization required > 60 per calendar month
A4429 Ostomy pouch, urinary w/convexity, faucet type tap, each Authorization required > 60 per calendar month
A4430 ostomy pouch urinary, ext. wear, convexity, faucet tap, each Authorization required > 60 per calendar month
A4431 ostomy pouch, urinary, w/barrier, faucet type tap, w/valve ea. Authorization required > 60 per calendar month
A4432 ostomy pouch, urinary, non-locking flange, faucet type, ea. Authorization required > 60 per calendar month
A4433 ostomy pouch, urinary, w/locking flange, ea. Authorization required > 60 per calendar month
A4434 ostomy pouch, urinary, w/locking flange, w/faucet type tap ea. Authorization required > 60 per calendar month
A4624 Tracheal suction tube Authorization required > 91 per calendar month
A4625 Trach care kit for new trach Authorization required if > 1 per calendar month
A5082 Continent stoma catheter Authorization required if > 1 per calendar month
A5093 Ostomy accessory convex inse Authorization required if
> 10 per calendar month
A4626 Tracheostomy cleaning brush Authorization required if
> 2 per calendar month
A5061 Pouch drainable w barrier at Authorization required if
> 20 per calendar month
A5062 Drnble ostomy pouch w/o barr Authorization required if > 20 per calendar month
A5063 Drain ostomy pouch w/flange Authorization required if > 20 per calendar month
A5071 Urinary pouch w/barrier Authorization required if > 20 per calendar month
A5072 Urinary pouch w/o barrier Authorization required if > 20 per calendar month
A5073 Urinary pouch on barr w/flng Authorization required if > 20 per calendar month
Page 37 of 39
A4623 Tracheostomy inner cannula Authorization required if > 31 per calendar month
A5055 Stoma cap Authorization required if > 31 per calendar month
A5081 Continent stoma plug Authorization required if > 31 per calendar month
A4455 Adhesive remover per ounce Authorization required if > 32 ounces
A5051 Pouch clsd w barr attached Authorization required if > 60 per calendar month
A5052 Clsd ostomy pouch w/o barr Authorization required if > 60 per calendar month
A5053 Clsd ostomy pouch faceplate Authorization required if > 60 per calendar month
A5054 Clsd ostomy pouch w/flange Authorization required if > 60 per calendar month
AUTHORIZATION NOT REQUIRED A4392 Urinary pouch w st wear barr No authorization required
A4363 Ostomy clamp, any type , each No authorization required
A4364 Adhesive, liquid or equal, any type, per ounce No authorization required
A4365 Ostomy adhesive remover wipe No authorization required
A4368 Ostomy filter No authorization required
A4369 Skin barrier liquid per oz No authorization required
A4371 Skin barrier powder per oz No authorization required
A4372 Ostomy Skin barrier solid 4x4 equiv No authorization required
A4373 Skin barrier with flange No authorization required
A4375 Drainable plastic pch w fcpl No authorization required
A4376 Drainable rubber pch w fcplt No authorization required
A4377 Drainable plstic pch w/o fp No authorization required
A4378 Drainable rubber pch w/o fp No authorization required
A4379 Urinary plastic pouch w fcpl No authorization required
A4380 Urinary plastic pouch w/o fp No authorization required
A4381 Ostomy pouch, urinary, for use on faceplate, plastic, each No authorization required
A4382 Urinary hvy plstc pch w/o fp No authorization required
A4383 Urinary rubber pouch w/o fp No authorization required
A4384 Ostomy faceplt/silicone ring No authorization required
A4385 Ost skn barrier sld ext wear No authorization required
A4387 Ost clsd pouch w att st barr No authorization required
A4388 Drainable pch w ex wear barr No authorization required
A4389 Drainable pch w st wear barr No authorization required
A4390 Drainable pch ex wear convex No authorization required
A4391 Urinary pouch w ex wear barr No authorization required
A4393 Urine pch w ex wear bar conv No authorization required
A4394 Ostomy pouch liq deodorant w/wo lubricant No authorization required
A4395 Ostomy pouch solid deodorant No authorization required
A4396 Ostomy belt with peristomal hernia support No authorization required
Page 38 of 39
A4405 Ostomy skin barrier, non-pectin based, paste, per oz No authorization required
A4406 Ostomy skin barrier, pectin based, per oz No authorization required
A4407 Ostomy skin barrier, with fl, extend wear, built in convexity, 4x4 or <
No authorization required
A4408 Ostomy skin barrier, with fl, extend wear, built in convexity, 4x4 or >
No authorization required
A4409 Ostomy skin barrier with flange No authorization required
A4410 Ostomy skin barrier, with fl, ex wear, without built in convexity, >4x4 ea
No authorization required
A4411 Ostomy skin barrier, solid 4x4 or eq. ext. wear, built in convexity, each
No authorization required
A4412 Ostomy pouch, drainable, high otpt, use on barrier w/ o filter each
No authorization required
A4413 Ostomy pouch, drainable, high otpt, use on barrier w/ fl with filter ea
No authorization required
A4414 Ostomy skin barrier, with fl, w/o built in convexity 4x4 or < No authorization required
A4415 Ostomy skin barrier, with fl, w/o built in convexity 4x4 or > No authorization required
A4450 Tape, non-water proof, 18 sq inches No authorization required
A4452 Tape, water proof , 18 sq inches No authorization required
A4456 Adhesive remover, wipes, any type, each No authorization required
A4481 Tracheostoma filter No authorization required
A4556 Electrodes, apnea monitor, per pair No authorization required
A4557 Lead wires, apnea monitor per pair No authorization required
A4558 Conductive paste or gel for use with electrical device E.G. tens No authorization required
A4561 Pessary, rubber, any type No authorization required
A4562 Pessary, nonrubber, any type No authorization required
A4565 Slings No authorization required
A4566 Canvas vest SO No authorization required
A4595 TENS suppl 2 lead per month No authorization required
A4604 tubing with integrated heat use with pos. airway pressure device No authorization required
A4605 Tracheal suction catheter, closed system, each No authorization required
A4606 Oximeter probe replacement No authorization required
A4608 Transtracheal oxygen catheter, each No authorization required
A4611 Heavy duty battery, Ventilator, replacement for patient owned No authorization required
A4612 Battery cables No authorization required
A4613 Battery charger No authorization required
A4614 Hand-held PEFR meter No authorization required
A4618 Breathing circuits No authorization required
A4619 Face tent No authorization required
A4627 Spacer, bag or reservoir for inhaler No authorization required
A4628 Oropharyngeal suction cath No authorization required
A4629 Tracheostomy care kit No authorization required
A4630 Repl bat t.e.n.s. own by pt No authorization required
A4635 Underarm crutch pad No authorization required
A4636 Handgrip for cane etc No authorization required
A4637 Repl tip cane/crutch/walker No authorization required
Page 39 of 39
A4640 Alternating pressure pad No authorization required
A5083 Continent device, stoma absorptive cover for continent device, each
No authorization required
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