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 member’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.

This appendix provides a detailed listing of services and products for which preauthorization is required to avoid a benefit penalty. This list will be updated periodically. If you have any questions about preauthorization, please call Member Services at (855) 979-5192.

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 
• Comprehensive Inpatient Rehabilitation Facility 
• End-Stage Renal Disease Treatment Facility 
• Hospice 
• Inpatient Hospital 
• Inpatient Psychiatric Facility 
• Residential Substance Abuse Treatment Facility 
• Psychiatric Residential Treatment Facility 
• Skilled-Nursing Facility 

Outpatient Services

The following outpatient services require preauthorization.

• Botox^® or any equivalent
• Dialysis
• Genetic testing (including cologuard testing), 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
  • Home infusion therapy
  • Hospice care
• Infusion services (e.g., chemotherapy, biological therapy)
• Intensive outpatient care
• MRI, CT, and other imaging (except not required for echocardiography performed in a doctor’s office, X-rays, routine ultrasounds, or venous Doppler ultrasounds)
• Outpatient partial hospitalization
• Outpatient procedures (see “Common Outpatient Procedures Requiring Preauthorization” below)
• Oxygen (home and/or portable)

Durable Medical Equipment

Preauthorization is required for the rental (or, at the Plan's option, the purchase) of the following types of durable medical equipment items and services:

• Automated External Defibrillator (AED)
• Air-flotation beds and air-fluidized beds
• Bone-growth stimulators
• Cochlear/auditory brainstem implants
• Continuous glucose monitoring systems, entire system or the components indicated by the CPT codes A9274, A9277, A9278, A9279, or K0554.
• Continuous Positive Airway Pressure (CPAP) machines, including portable and non-portable
• Enteral nutritional therapy
• 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; also, insulin is covered under the Prescription Drug Plan and does not require preauthorization
• Mattresses/mattress overlays 
• Negative pressure wound therapy device (wound vac)
• Oral appliances for obstructive sleep apnea
• Orthopedic shoes, braces, and/or shoe modifications (inserts do not require separate authorization)
• Oxygen therapy, bottled or concentrator
• Patient lifts
• Prosthetic limbs
• Physiologic data (ECG, blood pressure, glucose monitoring, etc.) collection, storage, transmission, and/or interpretation (often referred to as “remote monitoring”)
• Respiratory assist device, bi-level pressure capability (BiPAP), including portable and non-portable
• Spinal-cord stimulators
• Suction pumps (excluding breast pumps)
• Traction equipment
• Wheelchair or scooter of any type

Centers of Expertise Reminder

Please be aware of the Plan’s Center of Expertise benefit requirement for cochlear implants and certain cardiothoracic and spinal procedures. If you choose a provider other than a Plan-approved Center of Expertise for a designated procedure, a 40% benefit penalty will apply unless that provider is specifically preauthorized by the Plan for your procedure. 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.) 
• Cardiac catheterization 
• Cardiac CT 
• Cardiac MRI 
• Cardioversion (elective) 
• Echocardiography (unless performed in a doctor’s office) including transthoracic, transesophageal and stress
• Electrophysiology study (EPS) 
• Implantable loop recorder 
• Intracardiac ablation 
• Nuclear cardiology 
• Percutaneous Transluminal Angioplasty (PTA) - non-coronary 
• Permanent pacemaker and/or defibrillator placement and related procedures 
• Transcatheter aortic valve replacement (TAVR) 
• Ultrafiltration (for congestive heart failure) 
• Vena cava filter 

Dental-Related Services Requiring Hospital Services or Ambulatory Surgical Facility Services

• Dental-related services for a member with special needs requiring hospital services or ambulatory surgical facility services

Dermatology

• Photodynamic therapy, including Levulan Kerastick when medically necessary

Gastroenterology

• Capsule endoscopy 
• Cologuard testing 
• Colonoscopy
• Endoscopic Retrograde Cholangiopancreatography (ERCP) 
• Esophageal reflux testing (including Bravo wireless monitoring) 
• Esophagogastroduodenoscopy (EGD) 
• Sigmoidoscopy 

Genetic Testing

• Genetic testing (including cologuard testing). Note: preauthorization is not required for CPT code 81420 if the member is age 35 or older
• Any genetic testing for which a CPT code has not been assigned

Hematology/Oncology

• Brachytherapy 
• Hyperthermia cancer treatment (tumor ablation) 
• Injection/infusion of chemotherapy and other complex drugs 
• Radiation therapy

Nephrology

• Dialysis

Neurology

• Electroencephalogram (EEG) 
• Electromyelogram (EMG) with/without nerve conduction studies 
• Nerve conduction studies 
• Neurotransmission studies (SSEP, VEP)

Ophthalmology

• Cataract extraction/intraocular lens implant 
• Intravitreal injection/implantation 

Orthopedics

• Electrical stimulation to aid bone healing; invasive (operative) 
• Osteogenesis stimulator, surgically implanted 

Pain Management

• Epidural steroid injection 
• Facet block 
• Neurostimulation (including Omega procedure) 
• RF ablation of nerve

Pulmonary

• Bronchoscopy 
• Sleep study 

Radiology/Imaging

• Arterial radiography (arteriogram) 
• Bone density tests, such as dual-energy x-ray absorptiometry (DXA) and other imaging to diagnose osteoporosis, if the member is under age 60
• CT (including angiography) 
• Discogram 
• Fibroscan 
• MRI (including angiography) 
• Myelogram 
• Nuclear medicine studies including:
  • HIDA scan 
  • VQ scan
  • Gastric emptying study
  • Thyroid/parathyroid/adrenal scan 
• PET scan 

Urology

• Cystoscopy if requiring sedation or anesthesia
• Prostate biopsy
• Testosterone replacement therapy 

Spine/Musculoskeletal

• Percutaneous vertebroplasty/kyphoplasty/annuloplasty 

Wound Care

• Genetically and bio-engineered skin substitutes 
•  Hyperbaric oxygen therapy 
•  Skin closures including skin grafts, skin flaps and tissue grafts 
•  Surgery for varicose veins, including perforators and sclerotherapy