Effective for dates of service on or after January 1, 2012, we will implement
important changes to the list of services and drugs that require
precertification for Medicare Advantage HMO and PPO members.
The following precertification requirements will be added for Medicare
Advantage products in all settings:
potentially cosmetic procedures (please refer to the complete list);
pain management procedures (i.e., paravertebral facet joint injections,
transforaminal epidural injections,epidural injections);
hyperbaric oxygen treatments;
additional medical infusion/injectable drugs (please refer to the complete
list);
cataract surgery;
cochlear implant surgery;
uvulopalatopharyngoplasty (UPPP or UP3).
The following precertification requirements will be removed for Medicare
Advantage products in all settings:
sleep studies
cardiac rehabilitation
pulmonary rehabilitation
As we proceed through this transition, it is very important for providers to
continue to refer to the most current precertification requirements lists or to
use the NaviNet? web portal to verify member-specific requirements. Failure to
obtain precertification for any of the services or drugs that require it may
result in a reduction in payment or nonpayment for the services not
precertified.
Please call 1-800-ASK-BLUE if you have any
questions about these upcoming changes.
Potentially cosmetic procedures that will require precertification
Blepharoplasty/ptsosis repair
Hair transplant
Rhinoplasty
Breast: reconstruction, reduction, augmentation, mammoplasty, mastopexy,
insertion, and removal of breast implants
Injectable dermal fillers
Rhytidectomy
Canthopexy/canthoplasty
Keloid removal
Scar revision
Cervicoplasty
Labiaplasty
Skin closures including: skin grafts, skin flaps, and tissue grafts
Chemical peels
Lipectomy, liposuction, or any other excess fat removal procedure
Sex reassignment surgery
Dermabrasion
Orthognathic surgery procedures including, but not limited to: bone graft,
genioplasty, osteoplasty, mentoplasty, osteotomies
Surgical treatment of gynecomastia
Excision of excessive skin and/or subcutaneous tissue
Otoplasty
Surgery for varicose veins, including perforators and sclerotherapy
Genetically and bio-engineered skin substitutes for wound care
Additional infusion drugs that will require precertification
Abraxane?
Enzyme replacement (Lumizyme?, Replagal?*, Uplyso?*, VPRIV?)
Istodax?
Alimta?
Flolan?
Jevtana?
Alpha 1 inhibitors (Aralast NPTM,GlassiaTM, Prolastin? C, Zemaira?)
Folotyn?
Provenge?
ArzerraTM
Gammaplex? (IVIG)
Psoriasis/rheumatoid arthritis (Actemra?)
Belatacept
HalavenTM
Remodulin?
Benlysta?
Hemophilia factors
Soliris?
C1 esterase inhibitors (Berinert?, Cinryze?)
Herceptin? DM1*
YervoyTM
CorifactTM (factor drug)
Additional injectable drugs that will require precertification
Kalbitor?
MakenaTM
Stelara?
Lucentis?
OmparoTM*
XgevaTM
Macugen?
Prolia?
Xolair?