Pre-authorization Form

Transcription

1 Virginia Mason This Preauthorization list only applies to Non-Virginia Mason Providers 2014 Please verify services not listed below on the pre-authorization list with Benefits and Eligibility (Customer Service) to determine coverage Preauthorization lists do not reflect benefit limitation information or exclusions. Pre-authorization Form Experimental and Investigational services are not covered except as outlined under the Clinical Trials benefit. If a service could be considered experimental and investigational for a given condition, we recommend a benefit determination in advance. Pre-Authorization List Ambulance Air and inter-facility transport require preauthorization, except in life-threatening circumstances Chemical Dependency and Mental Health Inpatient Admissions Residential Treatment Partial Hospitalization Clinical Trials Any treatment provided under a clinical trial Dental Trauma Services Follow up services Dialysis (Hemodialysis) For chronic kidney disease Notes of care provided in transit (ambulance notes) ER notes of care prior to transit if appropriate. Last 3 days of nursing notes/ physician s orders prior to transfer (for inter-facility) Transfer summary for inter-facility transport why private vehicle is not safe s for ambulance transport Diagnosis/treatment information (primary diagnosis, proposed treatment(s), procedure(s) or service(s), proposed length of stay Facility name, location, address Clinical info as soon as available clinical reasons for request request Supporting literature/research related to the request Documentation of circumstances surrounding the dental trauma (accidental injury). Documentation of planned treatment, including length of time to complete treatment Clinical Evaluation Treatment Plan Virginia Mason Page 1 of 8

2 Durable Medical Equipment, Medical Supplies and Prosthetics When purchase exceeds $2000; or, When rental exceeds $500 per month Eyelid Surgery Example: Blepharoplasty Genetic Testing All (no dollar limit) Hearing Cochlear Implants (covered under surgical benefit) BAHA - Bone Anchored Hearing Aid (covered under surgical benefit) Home Health Care Services Home Health care Visits Name of Dialysis Center Type of access Documentation of specific reasons for requested equipment equipment.. Anticipated length of need for DME. In the case of equipment with component parts, i.e., wheelchairs statement of medical necessity for individual components (per HCPCS code) History and physical exam which documents: o Frontal and lateral pupil level photographs (straight gaze and lateral) documenting lid and brow position at rest o Visual fields conducted with and without brow/lid taping, with clear documentation of angle of visual field limitation in report Letter of request documenting the functional disorder requiring resolution and justifying the procedure proposed. This should be consistent with the objective record. Specific tests being requested Supporting clinical documentation with diagnosis clinical reasons for request. request. Physician order to include diagnosis Specific disciplines requested, i.e. (RN, PT, OT) and number of visits requested for each discipline Duration/frequency of services for each discipline (i.e., H&P, discharge summary), if available. Documentation of homebound status Virginia Mason Page 2 of 8

3 Home Infusion Therapy Enteral Intravenous Hospice Care Outpatient Inpatient Respite Care Hyperbaric Therapy Physician order, to include diagnosis, specific drug, formula, dose, length of treatment, codes for drugs/supplies/discipline Specific disciplines requested, i.e., RN, RD for each discipline (i.e., H&P, discharge summary), if available Physician order, to include diagnosis, anticipated length of hospice services (prognosis) Specific disciplines requested, i.e. (RN, PT, OT) number and frequency of visits requested for each discipline for each discipline (i.e. H&P, discharge summary), if available and plan of care. clinical reasons for request. request. Imaging Inpatient Hospital Admissions Chemical dependency and mental health admissions (including residential) Hospice* Rehabilitation* Medical/Surgical (excluding routine delivery Skilled Nursing/LTAC* *See individual entries for specific documentation requirements Inpatient Rehabilitation Admissions See PET Scans Patient demographics (name, plan ID number, date of birth) PCP/attending physician name Diagnosis/treatment information (primary diagnosis, proposed treatment(s), procedure(s) or service(s), proposed length of stay Facility name, location, address Clinical info as soon as available Anticipated d/c date Physiatry evaluation D/C summary from medical unit/facility, if available Documentation of medical necessity of inpatient rehab to include: diagnosis, prognosis, anticipated plan/duration of care Specific disciplines requested, i.e. (RN, PT, OT) number and frequency of visits requested for each discipline for each discipline, i.e., H&P Virginia Mason Page 3 of 8

4 Lumbar Fusion Pre-Authorization List Medical Injectables and other Drugs Abatcept (Orencia) Aflibercept (Eylea) Alpha 1 proteinase inhibitor Bevacizumab (Avastin) Blood Clotting Factors Botulinum toxin (all types & brands) Cytarabine Liposme Epoprostenol (Flolan) Growth Hormone Imiglucerase (Cerezyme) Infliximab (Remicade) Intravenous immunoglobulin (IVIG) therapy Ixabepilone Palivizumab (Synagis) Pegaptanib (Macugen) Ranibizumab (Lucentis) Rituximab (Rituxan) Sipuleucel-T (Provenge) Ustekinumab Mental Health and Chemical Dependency Inpatient Admissions Residential Treatment Partial Hospitalization Organ and Bone Marrow Transplants Includes evaluation of, services for both recipient and donor, and travel and lodging expenses History and Physical Exam to include: indications for procedure conservative treatment prior spinal surgery functional impairment mechanism of injury to include documentation of any connection to an on the job injury or possible subrogation claim, i.e. on-the-job injury, vehicular accident smoking history Office Notes (treatment) Results of Diagnostic Imaging Physician order, to include diagnosis, specific drug, dose, length of treatment, codes for drugs/supplies/discipline i.e., H&P, discharge summary, if available Facility name, location and address Patient demographics (name, plan ID number, date of birth) PCP/attending physician name Diagnosis/treatment information (primary diagnosis, proposed treatment(s), procedure(s) or service(s), proposed length of stay Facility name, location, address Clinical info as soon as available Anticipated d/c date Solid Organ: Letter from facility or transplant committee stating he/she has met their criteria Indication for transplant and what type of transplant Pre-evaluation steps The provider notes from transplant surgeon and any consulting physicians Virginia Mason Page 4 of 8

5 Psychosocial evaluation from MSW All labs, radiology tests, cardiac tests and procedures that were done in the preevaluation phase. Any follow-up tests or procedures that were a recommendation by the transplant physician or committee that needed to be done before would qualify for transplant Blood & Tissue: Detailed evaluation process and tests Cover letter from facility or transplant committee stating patient has met their criteria Indication for transplant Detailed history and physical, including current meds, physical exam, assessment and plan If proposed allogeneic HSC transplant: HLA typing and histocompatibility report Pertinent labs, including serologies, MELD (liver), PRA (if indicated) For alcoholic cirrhosis, proof of successful completion of chem. dep. program Biopsy results (showing no malignancy solid; bone marrow biopsy stem cell) Risk factors for CAD: need EKG, echo, stress test, cardiac cath PFT s (for solid lung or if indicated for pulmonary issues) Results of colonoscopy, UGI, as indicated Mammogram, pap smear, PSA, as appropriate MSW psychosocial evaluation Consultations as indicated, e.g. cardiology, anesthesiology, dietary, psych, pulmonology Dental clearance Financial/insurance coverage, including drug coverage Stem cell transplants: the synopsis of the protocol to be used for the proposed transplant Orthognathic Surgery Medical history and physical examination with reference to symptoms and functional impairment related to the orthognathic deformity Description of the specific anatomic deformity present Complete reports of lateral and anteriorposterior cephalometric radiographs. Cephalometric tracings when available Copy of medical records from treating Virginia Mason Page 5 of 8

6 physician documenting evaluation, diagnoses, and previous management of the functional impairment. Note: Actual photographs, radiographs, and/or molds may also be requested depending on the individual circumstance of the case. PET Scans Radiation Therapy Intensity-Modulated Radiation Therapy Proton Beam Radiation Therapy Stereotactic Radiosurgery (Gamma Knife, Cyberknife) Reconstructive Procedures All procedures that may be considered cosmetic, including but not limited to: o Breast reconstruction (reduction mammoplasty)* o Eyelid surgery (i.e., blepharoplasty)* o Removal of breast implants* o Rhinoplasty* o Varicose vein procedures* *See individual entries for specific documentation requirements Reduction Mammoplasty (Breast Reduction) Diagnosis, clinical progress and treatment to date Dates of prior scans and imaging results (CAT, PET) Staging or re-staging for oncology Clinical documentation of how the results will impact future treatment decisions clinical reasons for request request Letter describing the clinical circumstances justifying the medical necessity of the service proposed Clinical documentation such as H&P and/or office notes related to the request Documentation of functional deficit resulting from a congenital anomaly, other diseases, accidental injury or prior covered surgery Letter describing the clinical circumstances justifying the proposed services History and physical exam which documents: o The size of the breasts (including photographs) o Significant functional impairment o Medical records may be requested which demonstrate a minimum of 6 weeks of medically supervised conservative treatment addressing functional conditions leading to the request for reduction mammoplasty. o Height and weight of the patient o Explicit estimates of the amount of breast tissue to be removed from each breast. Virginia Mason Page 6 of 8

7 Removal of Breast Implants Rhinoplasty Skilled Nursing Facility/LTAC Admissions Spinal Injections (with procedural sedation) Letter describing the clinical circumstances justifying the service proposed. History and physical exam which documents: o The presence or absence of evidence of leak of a silicone containing prosthesis o The clinical circumstances under which the prosthesis was initially implanted o The clinical justification for recommending the removal of the prosthesis Other supporting material at the discretion of the requesting patient or clinician Letter describing the clinical circumstances justifying medical necessity Clinical documentation such as H&P and/or office notes related to the request and prior treatment Documentation of functional deficit resulting from illness or injury resulting in the need for Rhinoplasty Patient demographics (name, plan ID number, date of birth) PCP/attending physician name, specialty/ certification status Diagnosis/treatment information (primary diagnosis, proposed treatment(s), procedure(s) or service(s), proposed length of stay and frequency/duration of service Facility Information (facility name, telephone/fax number, contact person. for Skilled Nursing Facility Admission History & Physical or transfer summary indicating admission criteria Diagnosis and Procedure (s) requested History and Physical to include o Duration of pain o Duration and type of conservative therapy o Results of imaging studies o Previous surgery or treatment Virginia Mason Page 7 of 8

8 Stereotactic Radiosurgery Example: Gamma Knife, CyberKnife Surgery BAHA-Bone Anchored Hearing Aid (surgical benefit applies) Cochlear Implants (surgical benefit applies) Lumbar Fusions Orthognathic Surgery Sleep Apnea Gynecomastia Varicose Veins Surgical Interventions for Sleep Apnea Varicose Vein Procedures Documentation of medical necessity, circumstances surrounding the request, including H&P and office notes, including Karnofsky performance rating (level of function), status of extracranial disease and results of imaging studies related to the request Documentation of planned treatment with diagnosis clinical reasons for request request The most recent sleep study report, which must be performed and interpreted by a physician specializing in sleep disorders Documentation of a complete Otolaryngology (ENT) evaluation, including a recent history and physical when certification of UPPP or other oropharyngeal surgery is requested Documentation of the absence of, or presence and severity of daytime hypersomnolence associated with sleep study findings by the requesting physician. When daytime somnolence is present, documentation that other causes of daytime somnolence have been addressed Any interventions to address CPAP intolerance, if applicable Evidence of incompetence of saphenous veins by Doppler or Duplex ultrasound (Doppler plus conventional ultrasound) study report. History of specific significant symptoms associated with varicose veins. History of prior conservative treatment (unless clearly demonstrated to be contraindicated). On occasion it may also be necessary to request medical records from the primary care provider (or some other clinician) to document the use of conservative therapy and its impact prior to referral, unless conservative therapy is clearly documented to not be indicated in the letter of request. Virginia Mason Page 8 of 8