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Medical Policy, Clinical UM Guidelines, and Pre-Cert Requirements

View requirements for Local Plan and BlueCard Out-of-Area members.

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Federal Employee Program Clinical Data Submission Tools

PW_E175939
 
A Pre-certification or Predetermination Tool is used by the provider to submit clinical information for an authorization request (precert or predetermination). If a provider uses this tool, chart records and letters of medical necessity will not be needed unless the tool is selected for auditing.  
The Clinical Data Submission Tools on this site may be used to submit clinical information for either a pre-service review (pre-certification or pre-determination) or Post Service review, including pre or post claim submission.  
The patient's demographic information should be completed in the first section of the tool.
The patient's clinical information should be completed in the second section of the tool by checking the series of boxes all that applies to the patient's medical condition.
After completion of the Clinical Data Submission Tools-, the information should be submitted to the Utilization Management address or fax number referenced in this contact list. If you would like to submit the tool via e-mail, please contact the Utilization Management Department to obtain the appropriate address to submit the tool. If you are not set up for secure E-Review and would like to be, please contact the Utilization Management Department.
The information, when filled out completely, should provide Utilization Management the necessary clinical information, including condition and history, to determine if the case meets the medical necessity criteria.
In some select situations, you may be asked to submit medical records (such as random auditing), or additional information such as photographs or visual fields, as an example.
Please make sure that physician or physician representative signs and checks the attestation at the bottom of the Clinical Data Submission Tool before submitting for review.
 
For a list of services requiring prior approval as per the Member’s Service Benefit plan, click HERE. The Federal Employee Program also offers optional Advanced Benefit Determinations for guarantee of payment for other services. Information on this process may also be accessed using the link above. 
 
Some of the links on this page can only be viewed using Adobe Acrobat Reader. If you don't have Adobe Acrobat Reader, you can download a free copy by clicking HERE
 
Ancillary  
Cosmetic and Reconstructive Services of the Head and Neck
Cosmetic and Reconstructive Services of the Trunk and Groin
Cosmetic and Reconstructive Services: Skin Related
 
Durable Medical Equipment  
Augmentative and Alternative Communication (AAC) Devices/Speech Generating Devices (SGD)
Continuous Passive Motion Devices
Electrical Bone Growth Stimulator
External (Portable) Continuous Insulin Infusion Pump
Glucose Monitoring and Related Supplies
Home Oxygen Therapy
Hospital Beds & Accessories
Lower Limb Prosthesis
Myoelectric Upper Extremity Prosthetic Devices
Oscillatory Devices for Airway Clearance including High Frequency Chest Compression (Vest Airway Clearance System) and Intrapulmonary Percussive Ventilation (IPV)
Prothrombin Time Self-Monitoring Devices
Spinal Orthoses – Thoracic-Lumbar-Sacral, Lumbar-Sacral and Lumbar
Stretching Devices for the Treatment of Joint Stiffness and Contracture
Ultrasound Bone Growth Stimulation
Vacuum Assisted Wound Therapy
Wheeled Mobility Devices: Manual Wheelchairs - Standard, Heavy Duty and Lightweight
Wheeled Mobility Devices: Wheelchairs-Powered, Motorized, With or Without Power Seating Systems and Power Operated Vehicles (POVs)
 
Genetics  
Cardiac Ion Channel Genetic Testing
Diagnostic Genetic Testing for Potentially Affected Individual (Adult or Child)
Gene Expression Profiling for Managing Breast Cancer Treatment
Genetic Testing for Cancer Susceptibility
Genotype Testing for Genetic Polymorphisms
Preconceptional or Prenatal Genetic Testing of a Parent or Prospective Parent
 
Laboratory  
None  
 
Medicine  
Allergy Testing
Central Bone Density Measurement and Screening for Vertebral Fractures
Diagnosis of Sleep Disorders
Diaphragmatic/Phrenic Nerve Stimulation
Electrical Stimulation and Electromagnetic Therapy for Wound Healing
Enhanced External Counterpulsation (EECP) in Outpatient Setting
Hyperbaric Oxygen Therapy
Inpatient Admission for Radiation Therapy for Cervical or Thyroid Cancer
Light Therapy, including Ultraviolet Light, Ultraviolet Laser and Visible Light Laser for Treatment of Skin Disorders
Manipulation Under Anesthesia of Spine and Joints other than the Knee
Ophthalmologic Techniques for Evaluating Glaucoma
Treatment of Hyperhidrosis
Treatment of Obstructive Sleep Apnea in Adults
Wearable Cardioverter Defibrillators
 
Orthotics-Prosthetics 
Custom Made Knee Braces
Microprocessor Controlled Lower Limb Prostheses
 
Radiology  
Brachytherapy for Oncologic IndicationsUse SHIFT+ENTER to open the menu (new window).
Intensity Modulated Radiation Therapy
Intraoperative Radiation Therapy
Neutron Beam Radiotherapy
Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy
Single Photon Emission Computed Tomography (SPECT) Scans for Noncardiovascular Indications
Transcatheter Arterial Chemoembolization (TACE) and Transcatheter Arterial Embolization (TAE) for Treating Primary or Metastatic Liver Tumors
Ultrasound Evaluation of Breast Disease
 
Rehabilitation  
None  
 
Surgery  
Ablative Techniques as a Treatment of Barrett's Esophagus
Autologus, Allogenic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting
Blepharoplasty, Blepharoptosis Repair, and Brow Lift
Bone Anchored Hearing Aids
Breast Procedures including Reconstructive Surgery, Implants and Other Breast Procedures
Cardiac Resynchronization Therapy with or without an Implantable Cardioverter (CRT/ICD) for Treatment of Heart Failure
Carotid, Vertebral, Intercranial Angioplasty with or without Stent Placement
Cochlear Implants & Auditory Brainstem Implants
Cryosurgical Ablation of Tumors outside the Liver
Deep Brain Stimulation
Endothelial Keratoplasty
Endovascular, Endoluminal Repair of Aortic Aneurysms
Fetal Surgery for Prenatally Diagnosed Malformations
Functional Endoscopic Sinus Surgery
Gastric Electrical Stimulation
Implantable Cardioverter Defibrillator (ICD)
Implantable Infusion Pumps
Implanted Spinal Cord Stimulators
Intraocular Anterior Segment Aqueous Drainage Devices (without extraocular reservoir)
Locally Ablative Techniques for Treating Primary and Metastatic Liver Malignancies
Mandibular/Maxillary (Orthognathic) Surgery
Mastectomy for Gynecomastia
Maze Procedure
Panniculectomy, Abdominoplasty
Penile Prosthesis Implantation
Percutaneous Neurolysis for Chronic Back Pain
Percutaneous Spinal Procedures (Vertebroplasty, Kyphoplasty and Sacroplasty)
Radiofrequency Ablation to Treat Tumors Outside the Liver
Reduction Mammaplasty
Radiofrequency and Pulsed Radiofrequency Neurolysis for Trigeminal Neuralgia (TGN)
Radiofrequency Ablation Outside the Liver
Refractive Surgery
Sacral Nerve Stimulation as a Treatment of Neurogenic Bladder Secondary to Spinal Cord Injury
Septoplasty
Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiotherapy (SBRT)
Surgery for Clinically Severe Obesity SURG.00024 - Prior Approval Request
Surgery for Clinically Severe Obesity SURG.00024 - Post Service Request
Temporomandibular Disorders CG-SURG-09
Total Ankle Replacement SURG.00081
Treatment of Osteochondral Defects of Knee and Ankle SURG.00093
Treatment of Varicose Veins SURG.00037
Transcatheter Closure of PatentForamen Ovale and Left Atrial Appendage for Stroke Prevention SURG.00032
Transcatheter Uterine Artery Embolization CG-SURG-28
Treatments for Urinary Incontinence and Urinary Retention SURG.00010
Vagus Nerve Stimulation Therapy SURG.00007
 
Transplant  
None  
 
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