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Aetna Better Health® of Ohio would like to notify you that effective August 25, 2018, Aetna Better Health® of Ohio, for all lines of business, will require prior authorization for the following CPT/HCPCS codes before services are rendered.
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CODE
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DESCRIPTION
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0446T
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Creation of subcutaneous pocket with insertion of implantable interstitial glucose sensor, including system activation and patient training
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0447T
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Removal of implantable interstitial glucose sensor from subcutaneous pocket via incision
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0448T
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Removal of implantable interstitial glucose sensor with creation of subcutaneous pocket at different anatomic site and insertion of new implantable sensor, including system activation
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0459T
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Relocation of skin pocket with replacement of implanted aortic counterpulsation ventricular assist device, mechano-electrical skin interface and electrodes
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0460T
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Repositioning of previously implanted aortic counterpulsation ventricular assist device; subcutaneous electrode
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0461T
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Repositioning of previously implanted aortic counterpulsation ventricular assist device; aortic counterpulsation device
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0462T
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Programming device evaluation (in person) with iterative adjustment of the implantable mechano-electrical skin interface and/or external driver to test the function of the device and select optimal permanent programmed values with analysis, including review and report, implantable aortic counterpulsation ventricular assist system, per day
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0463T
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Interrogation device evaluation (in person) with analysis, review and report, includes connection, recording and disconnection per patient encounter, implantable aortic counterpulsation ventricular assist system, per day
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81539
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Oncology (high-grade prostate cancer), biochemical assay of four proteins (Total PSA, Free PSA, Intact PSA, and human kallikrein-2 [hK2]), utilizing plasma or serum, prognostic algorithm reported as a probability score
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Q4110
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SKIN SUBSTITUTE PRIMATRIX PER SQ CM
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Q4111
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SKIN SUBSTITUTE GAMMAGRAFT PER SQ CM
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Q4115
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SKIN SUBSTITUTE ALLOSKIN PER SQUARE CENTIMETER
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Q4117
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HYALOMATRIX PER SQ CM
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Q4118
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MATRISTEM MICROMATRIX 1 MG
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Q4121
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THERASKIN PER SQ CM
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Q4122
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DERMACELL PER SQ CM
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Q4123
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ALLOSKIN RT PER SQ CM
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Q4125
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ARTHROFLEX PER SQ CM
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Q4126
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MEMODERM, DERMASPAN, TRANZGRAFT OR INTEGUPLY, PER SQUARE CENTIMETER
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Q4127
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TALYMED PER SQ CM
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Q4134
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HMATRIX PER SQUARE CENTIMETER
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S3900
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SURFACE ELECTROMYOGRAPHY
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64408
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Injection, anesthetic agent; vagus nerve
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64410
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Injection, anesthetic agent; phrenic nerve
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64420
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Injection, anesthetic agent; intercostal nerve, single
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64421
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Injection, anesthetic agent; intercostal nerves, multiple, regional block
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64430
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Injection, anesthetic agent; pudendal nerve
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64505
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Injection, anesthetic agent; sphenopalatine ganglion
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33340
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Percutaneous transcatheter closure of the left atrial appendage with endocardial implant, including fluoroscopy, transseptal puncture, catheter placement(s), left atrial angiography, left atrial appendage angiography, when performed, and radiological supervision and interpretation
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Effective August 25, 2018, Aetna Better Health® of Ohio, for all lines of business, will not require prior authorization for the following CPT/HCPCS codes before services are rendered. Please note the allowable units for each service below.
Medicaid
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CODE
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DESCRIPTION
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PROFESSIONAL ALLOWABLE UNITS
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OUTPATIENT ALLOWABLE UNITS
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93260
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PRGRMG DEV EVAL IMPLANTABLE SUBQ LEAD DFB SYSTEM
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NA
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1/MONTH
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93261
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INTERROGATION EVAL F2F IMPLANT SUBQ LEAD DEFIB
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NA
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1/MONTH
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A4520
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INCONTINENCE GARMENT ANY TYPE EACH
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300/MONTH
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250/MONTH
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B4034
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ENTERAL FEEDING SUPPLY KIT; SYRINGE FED PER DAY
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1/DAY
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1/DAY
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B4035
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ENTERAL FEEDING SUPPLY KIT; PUMP FED PER DAY
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1/DAY
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1/DAY
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B4036
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ENTERAL FEEDING SUPPLY KIT; GRAVITY FED PER DAY
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1/DAY
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1/DAY
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S0311
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COMP MGMT & CARE COORD ADVANCED ILL PER CAL MO
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NA
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1/MONTH
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Medicare
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CODE
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DESCRIPTION
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PROFESSIONAL ALLOWABLE UNITS
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DME ALLOWABLE UNITS
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93260
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PRGRMG DEV EVAL IMPLANTABLE SUBQ LEAD DFB SYSTEM
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1/MONTH
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NA
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93261
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INTERROGATION EVAL F2F IMPLANT SUBQ LEAD DEFIB
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1/MONTH
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NA
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A4520
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INCONTINENCE GARMENT ANY TYPE EACH
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250/MONTH
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250/MONTH
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A9281
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REACHING/GRABBING DEVICE ANY TYPE ANY LENGTH EA
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1/YEAR
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NA
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A9282
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WIG ANY TYPE EACH
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1/YEAR
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NA
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B4034
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ENTERAL FEEDING SUPPLY KIT; SYRINGE FED PER DAY
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1/DAY
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1/DAY
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B4035
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ENTERAL FEEDING SUPPLY KIT; PUMP FED PER DAY
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1/DAY
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1/DAY
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B4036
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ENTERAL FEEDING SUPPLY KIT; GRAVITY FED PER DAY
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1/DAY
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1/DAY
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E1354
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O2 ACCESS WHEELED CART PRTBLE CYL/CONC REPL EA
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1/YEAR
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NA
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E1356
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O2 ACCESS BTTRY PACK/CRTRDGE PRTBLE CONC REPL EA
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1/YEAR
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NA
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E1357
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O2 ACCESS BATTRY CHARGER PRTBLE CONC REPL EA
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1/YEAR
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NA
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E1358
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O2 ACCESS DC POWER ADAPTER PRTBLE CONC REPL EA
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1/YEAR
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NA
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E1500
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CENTRIFUGE FOR DIALYSIS
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1/YEAR
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NA
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E1570
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ADJUSTABLE CHAIR FOR ESRD PATIENTS
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1/YEAR
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NA
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S0311
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COMP MGMT & CARE COORD ADVANCED ILL PER CAL MO
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1/MONTH
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NA
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S9110
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TELEMONITORING PT HOME ALL NEC EQUIP; PER MONTH
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1/MONTH
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NA
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S9152
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SPEECH THERAPY RE-EVALUATION
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1/MONTH
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NA
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As always, please do not hesitate to contact Aetna Better Health® of Ohio's
Provider Services Department at 1-855-364-0974, option 2, with any questions or comments.
Thanks for all you do!
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