These services require Pre-Authorization. | Click to View Medical Policy |
Ablation of Hepatic Lesions |
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Allergy Testing - some methods. |
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Automatic External Defibrillator (Life Vest) |
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Biofeedback * |
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Blood Pressure Monitoring - 24 Hour Ambulatory |
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Bone Density Testing members Women under 50 and Men under 70. |
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BRCA Testing |
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Cardiac Event Recorder, Insertable |
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Continuous Blood Sugar Monitoring |
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CT Imaging including CT Angiography |
High Tech Imaging (MRI, CT, PET) Criteria - administered by NIA
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Erectile Dysfunction Treatment |
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Excimer Laser Treatment |
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Genetic counseling and genetic testing (including chromosome analysis). * |
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Hypnotherapy |
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Laser Treatments * |
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Liver Neoplasms |
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Magnetic Resonance Imaging (MRI) all types including MRA. |
High Tech Imaging (MRI, CT, PET) Criteria - administered by NIA
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Mental Health & Substance Abuse Treatment |
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Negative Pressure Wound Treatment (Wound Vac) |
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Neuropsychological Testing |
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Nuclear Medicine - all imaging tests including SPECT. |
High Tech Imaging (MRI, CT, PET) Criteria - administered by NIA
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Obstetrical (OB) Ultrasound Examinations |
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Outpatient Hyperbaric Oxygen Treatment |
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P.E.T. Scan |
High Tech Imaging (MRI, CT, PET) Criteria - administered by NIA
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Prolonged EEG Monitoring |
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Psychological Testing |
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Urinary Incontinence Treatment |
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Vagus Nerve Stimulation |
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