2015/16 Prior Plan Approval List

UK-HMO

2015/16 PRIOR PLAN APPROVAL LIST

Phone: (866) 776-4793

(Effective 7-1-15)

The following Prior Plan Approval List represents services that require approval before the service is rendered. Failure to obtain prior plan approval results in 100% penalty. No retro-authorizations are allowed.

• Bone Growth Stimulator: Electrical or Ultrasound

• Communication Assisting/Speech Generating Devices

• External (Portable) Continuous Insulin Infusion Pump

• Functional Electrical Stimulation (FES); Threshold Electrical Stimulation (TES)

• Microprocessor Controlled Lower Limb Prosthesis

• Oscillatory Devices for Airway Clearance including High Frequency Chest

• Pneumatic Pressure Device with Calibrated Pressure

• Power Wheeled Mobility Devices

• Standing Frame

• Hospital inpatient admissions

• Long-term Acute Care

• Mental health and substance abuse facility inpatient, partial hospital and intensive outpatient services

• Organ transplants/blood and marrow transplants

• Orthotics — professionally fitted braces and splints costing more than $750

• Physical rehabilitation facility admissions

• Prosthetics — artificial limbs

• Skilled Nursing Facility (SNF) admissions

• Abdominoplasty

• Accidental dental and general anesthesia benefit (except anesthesia associated with wisdom teeth removal)

• Benign skin lesion removal (Auths not required for UK Providers)

• Blepharoplasty

• Breast reduction/augmentation (Breast reconstruction procedures needs no precert with diagnosis of cancer)

• Cochlear implant

• *Hyperbaric Therapy

• Medication Preauthorization List (see page 2)

• Molecular Diagnostic/Genetic Testing*

• Neuropsychological testing

• Non-participating Physician/Facility Requests

• Oral surgery (except wisdom teeth removal and associated anesthesia)

• Plastic or cosmetic surgery

• Rhinoplasty

• Sclerotherapy (except stab phlebectomies)

• Septoplasty

• Speech Therapy

• Surgery for snoring or sleep apnea (e.g. UPPP)

• Temporomandibular joint (TMJ) procedures

• Open MRIs outside UK or Samaritan Hospital (no open MRI at these facilities)
• Coronary CT angiography

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