Beneficiary Online Handbook

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Exclusions
Procedures and/or Services Requiring Prior Authorization
Inpatient Hospital Stays Requiring Prior Authorization
Mental Health Care Services Requiring Prior Authorizations
Durable Medical Equipment Items Requiring Prior Authorization

Exclusions
The following services are excluded under any circumstance:
  • Acupuncture
  • Artificial insemination
  • Autopsy services or post-mortem examinations
  • Care that is not medically or psychologically necessary
  • Birth control (non-prescription)
  • Camps (such as those for diabetes or obese persons)
  • Care or supplies furnished or prescribed by an immediate family member
  • Diagnostic admissions
  • Experimental or unproven procedures
  • Foot care (routine)
  • Laser/LASIK/Refractive corneal surgery
  • Learning disabilities
  • Megavitamins and orthomolecular psychiatric therapy
  • Mind expansion and elective psychotherapy
  • Naturopaths
  • Psychiatric treatment for sexual dysfunction
  • Sex changes or sexual inadequacy treatment
  • Telephone counseling consultation

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Procedures and/or Services Requiring Prior Authorization
Effective 4/1/2006
  • Adjunctive dental
  • Home Health Services including Home Infusion
  • Extended Care Health Option (EHCO) Services
  • Hospice
  • Speech therapy
  • Transplants (solid organ and stem cell, not corneal transplant)
  • Hysterectomy (abdominal, laparoscopic, vaginal)
  • Termination of pregnancy
  • Reduction mammoplasty
  • Uvulopalatopharyngoplasty (UPPP)
  • Blepharoplasty
  • Bariatric surgery

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Inpatient Hospital Stays Requiring Prior Authorization
Effective 4/1/2006
  • Admission or transfer to SFN, Rehab, LTAC
  • Notification of acute care admission by the next working day
  • Discharge notification
  • Concurrent reviews upon request by HMHS

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Mental Health Care Services Requiring Prior Authorization
Effective 4/1/2006
  • Psychoanalysis
  • Psychological and neuropsychological testing
  • Inpatient Hospital
  • Electroconvulsive therapy (ECT)
  • Outpatient crisis intervention

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Durable Medical Equipment Items Requiring Prior Authorization for Rental or Purchase
Effective 4/1/2006
  • Power vehicle or wheelchair
  • Any DME miscellaneous code if purchase price is > $500
  • Continuous passive motion (CPM) device
  • Patient lift
  • Bone growth stimulator

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Last Reviewed: September 4, 2007