Aetna Better Health of Ohio would like to notify you that effective March 1, 2018, Aetna Better Health of Ohio for all lines of business will require prior authorization for the following CPT codes before services are rendered:
43632 - Gastrectomy, partial, distal; with gastrojejunostomy
43633 - Gastrectomy, partial, distal; with Roux-en-Y reconstruction
43634 - Gastrectomy, partial, distal; with reconstruction of intestinal pouch
69930 - Cochlear device implantation, with or without mastoidectomy
95807 - Sleep study, simultaneous recording of ventilation, respiratory effort, ECG or heart rate, and oxygen saturation, attended by a technologist
97112 - Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities
99183 - Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session
E0424 - Stationary compressed gaseous oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing;
E0425 - Stationary compressed gas system, purchase; includes regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing
E0439 - Stationary liquid oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing
E0440 - Stationary liquid oxygen system, purchase; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing
E0617 - External defibrillator with integrated electrocardiogram analysis
E0618 - Apnea monitor, without recording feature
E0619 - Apnea monitor, with recording feature
E1390 - Oxygen concentrator, single delivery port, capable for delivering 85 percent or greater oxygen concentration at the prescribed flow rate
E1391 - Oxygen concentrator, dual delivery port, capable for delivering 85 percent or greater oxygen concentration t the prescribed flow rate, each
E1392 - Portable oxygen concentrator, rental
E1831 - Static progressive stretch toe device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories
E2101 - Blood glucose monitor with integrated lancing/blood sample
G0177 - Training and education services related to the care and treatment lf patient's disabling mental health problems per session (45 minutes or more)
K0065 - Spoke protectors, each
K0073 - Caster pin lock, each
K0105 - IV hanger, each
