Appendix C: Services and Products That Require Preauthorization 

Preauthorization is a determination of medical necessity before a service is performed or a product is provided. It is not a guarantee of payment. At the time the participant’s claims are submitted, they will be reviewed in accordance with the terms of the Alliance Coal Health Plan. The final determination of whether services or products are eligible expenses is subject to all conditions, exclusions, and limitations of the Plan.

If you have any questions about preauthorization, please call the Utilization Management (UM) Department at (877) 563-7427.

Inpatient Services

All inpatient admissions require preauthorization. For purposes of the preauthorization requirements, following are examples of facility types considered to be “inpatient admissions.” This list is not exhaustive and may change from time to time.

  • Birthing Center (Place of Service code 25)
  • Comprehensive Inpatient Rehabilitation Facility (61)
  • End-Stage Renal Disease Treatment Facility (65)
  • Hospice (34)
  • Inpatient Hospital (21)
  • Inpatient Psychiatric Facility (51)
  • Residential Substance Abuse Treatment Facility (55)
  • Psychiatric Residential Treatment Facility (56)
  • Skilled-Nursing Facility (31)

Outpatient Services

The following outpatient services require preauthorization.

  • Dialysis (effective July 15, 2017)
  • Genetic testing (effective July 15, 2017; CPT codes 81400-81478, except not required for CPT code 81420 if the patient is age 35 or older)
  • Home health care services, including but not limited to:

    • Home occupational, physical, or speech therapy (limited to 25 visits per year for each type of therapy)
    • Home infusion therapy
    • Hospice care

  • Infusion services (e.g., chemotherapy, biological therapy)
  • MRI, CT, echocardiography (unless performed in a doctor’s office), and other imaging*
  • Outpatient procedures (see “Common Outpatient Procedures Requiring Preauthorization” below)
  • Oxygen (home and/or portable)
  • Private-duty nursing

*Preauthorization is not required for X-rays or routine ultrasounds (see SPD for coverage limits on ultrasounds). Echocardiography and venous Doppler studies are not considered “ultrasound” for purposes of preauthorization requirements.

Durable Medical Equipment

Preauthorization is required for the following types of durable medical equipment items:

  • Automated External Defibrillator (AED)
  • Bone-growth stimulators
  • Cochlear/auditory brainstem implants
  • Continuous glucose monitoring systems
  • Continuous Positive Airway Pressure Device (CPAP)
  • External defibrillator vests
  • High frequency chest compression and high frequency chest wall oscillation devices
  • Home infusion pumps
  • Home ventilator equipment
  • Hospital bed of any type (manual, electric, crib, low air loss)
  • Insulin pumps
  • Mattresses/mattress overlays (eggcrate and sheep-skin overlays do not require preauthorization)
  • Negative pressure wound therapy device (wound vac)
  • Oral appliances for obstructive sleep apnea
  • Oxygen therapy (bottled or concentrator)
  • Patient lifts
  • Prosthetic limbs
  • Respiratory assist device, bi-level pressure capability (BiPAP)
  • Spinal-cord stimulators
  • Suction pumps (excluding breast pumps)
  • Traction equipment
  • Wheelchair or scooter of any type

Centers of Expertise Reminder

Please be aware that to be reimbursed at 100%, the Alliance Coal Health Plan requires cochlear implants and certain cardiothoracic and spinal procedures to be performed at a Center of Expertise (in addition to satisfying the Plan’s medical necessity requirements). Please see CoalBenefits.com/coe for more details.

Robotic Surgery Reminder

Charges for the use of a robotic surgical system (for example, robot-assisted prostate surgery) are not eligible expenses, unless such charges are specifically preauthorized.

Common Outpatient Procedures Requiring Preauthorization

The following list represents some of the most common procedures that require preauthorization as requested by specialty. This list is not exhaustive and may change at any time.

Cardiothoracic

  • Any intravascular coronary procedure (PCI, stenting, etc.) (92920-92944)
  • Cardiac catheterization (93451-93505)
  • Cardiac CT (75571-75574)
  • Cardiac MRI (75557-75565)
  • Cardioversion (elective) (92960)
  • Echocardiography (93303-93352) (unless performed in a doctor’s office) including transthoracic, transesophageal and stress
  • Electrophysiology study (EPS) (93619-93642)
  • Implantable loop recorder (33282-33284)
  • Intracardiac ablation (93650-93657)
  • Nuclear cardiology (78414-78499)
  • Percutaneous Transluminal Angioplasty (PTA) - non-coronary (35471-35476)
  • Permanent pacemaker and/or defibrillator placement and related procedures (33206-33249)
  • Transcatheter aortic valve replacement (TAVR) (33361-33365)
  • Ultrafiltration (for congestive heart failure) (90945-90947)
  • Vena cava filter (37191-37193)
  • Venous doppler studies (93922-93971)

Gastroenterology

  • Capsule endoscopy (91110-91112)
  • Colonoscopy (45355-45392)
  • Endoscopic Retrograde Cholangiopancreatography (ERCP) (43260-43278)
  • Esophageal reflux testing (including Bravo wireless monitoring) (91030-91040)
  • Esophagogastroduodenoscopy (EGD) (43191-43270)
  • Sigmoidoscopy (45300-45345)

Genetic Testing

  • CPT codes 81400-81478 (effective July 15, 2017), except not required for CPT code 81420 if the patient is age 35 or older

Hematology/Oncology

  • Brachytherapy (77750-77799)
  • Hyperthermia cancer treatment (tumor ablation) (77600-77620)
  • Injection/infusion of chemotherapy and other complex drugs (96401-96549)
  • Radiation therapy (77261-77525)

Nephrology

  • Dialysis, effective July 15, 2017

Neurology

  • Electroencephalogram (EEG) (95812-95830)
  • Electromyelogram (EMG) with/without nerve conduction studies (95860-95887)
  • Nerve conduction studies (95905-95913)
  • Neurotransmission studies (SSEP, VEP) (95925-95943)

Ophthalmology

  • Cataract extraction/intraocular lens implant (66820-66986)
  • Intravitreal injection/implantation (67025-67028)

Pain Management

  • Epidural steroid injection (62310-62319)
  • Facet block (64490-64495)
  • Neurostimulation (including Omega procedure) (61850-61888, 64550-64595)
  • RF ablation of nerve (64620-64640)

Pulmonary

  • Bronchoscopy (31615-31651)
  • Sleep study (95782-95811)

Radiology/Imaging

  • Arterial radiography (arteriogram) (75600-75791)
  • CT (including angiography) (70450-70498, 71250-71275, 72125-72133, 72191-72194, 73200-73206, 73700-73706, 74150-74178)
  • Discogram (72285, 72295)
  • MRI (including angiography) (70540-70555, 71550-71555, 72141-72159, 72195-72198, 73218-73225, 73718-73725, 74181-74185)
  • Myelogram (72240-72270)
  • Nuclear medicine studies (78012-79999) including:

    • HIDA scan (78226-78227)
    • VQ scan (78582)
    • Gastric emptying study (78262-78264)
    • Thyroid/parathyroid/adrenal scan (78012-78099)

  • PET scan (78811-78999)

Urology

  • Cystoscopy (52000-52700) if requiring sedation or anesthesia
  • Prostate Biopsy (55700-55725)

Spine/Musculoskeletal

  • Percutaneous vertebroplasty/kyphoplasty/annuloplasty (22520-22527, 72291-72292)

Also see Pain Management

Wound Care

    • Genetically and bio-engineered skin substitutes (15271-15278)
    • Hyperbaric oxygen therapy (99183)
    • Skin closures including skin grafts, skin flaps and tissue grafts (15570-15731)
    • Surgery for varicose veins, including perforators and sclerotherapy (37700-37785)