These services require Pre-Authorization. | Click to View Medical Policy |
Abortions |
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Botox |
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Cancer Prevention Surgery |
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Cartilage Transplants, Lower Extremities |
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Dental Anesthesia |
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Dorsal Column Stimulator |
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Eyelid Surgery |
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Hip Resurfacing Arthroplasty |
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Intervertebral Disk Prosthesis |
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Liver Neoplasms Treatment |
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Neurostimulator - Implantable Electrodes |
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Penetrating Keratoplasty other than Corneal Transplant. |
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Penile Implants |
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Percutaneous Kyphoplasty |
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Percutaneous Transluminal Sep0tal Myocardial Ablation |
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Percutaneous Vertebroplasty |
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Peripheral Atherectomy |
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Prophylactic or Preventive Surgery |
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Proton Beam Radiotherapy |
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Radiofrequency Ablation of Lesions |
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Reconstruction of the intact breast after contralateral mastectomy for cancer. |
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Reconstructive surgery and all potentially cosmetic surgery. |
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Stereotactic Radiosurgery (eg: Gamma Knife) |
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Strabismus Surgery over 6 years of age. |
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TMJ, services for the diagnosis or treatment. |
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Total Disk Arthroplasty--Cervical or Lumbar |
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Transcatheter Pulmonary Valve Implantation (TPVI) |
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Urinary incontinence treatment with devices and artificial sphincter. |
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Varicose Vein Surgery |
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