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Authorization Requirement Changes

Date: 11/30/18

Health Net Oregon 18-051

Health Net Health Plan of Oregon, Inc. and Health Net Life Insurance Company (Health Net) is implementing changes to the prior authorization requirements for Medicare Advantage products, as outlined in the tables of the Authorization Requirements.

Accessing prior authorization look-up tool

Health Net offers a convenient Medicare Pre-Auth tool at https://or.healthnetadvantage.com. By clicking a few boxes, you can determine in real time whether any service requires a prior authorization.

If you have questions regarding the information contained in this update, contact the Health Net Provider Services Center at 888-445-8913.

Prior Authorization Requirement Additions, Changes and Deletions

The table below indicates key additions, changes and deletions to prior authorization requirements, effective immediately.

DELETIONS, EFFECTIVE JANUARY 1, 2019

RequirementComments
OxygenE1390, E1392
CPAPE0601
Non emergent transportationA0100, A0426, A0428
Malignancy codesCPT 116XX Series
Suture closures following MohsCPT 131XX Series
Bundled ENT codes31253, 31255, 31257, 31259
Evaluation of the function of the larynxCPT 92520
DebridementCPT 97597

CHANGES, EFFECTIVE JANUARY 1, 2019

RequirementComments
PT/ST/OTNo authorization needed for par providers unless greater than 12 visits

*Medicare Pain Management codes require authorization for all providers unless a surgery was performed on the same date.

  • 0227T: ANOSC HIGH RESOL DX W/BX
  • 0228T: US TFRML EDRL INJ CRV/T 1LVL
  • 0229T: US TFRML EDRL INJ CRV/T +LVL 
  • 0230T: US TFRML EDRL INJ L/S 1LVL
  • 0231T: US TFRML EDRL INJ L/S +LVL
  • 20552: INJECT TRIGGER POINT, 1 OR 2
  • 20553: INJECT TRIGGER POINTS, > 3
  • 22520: PERCUT VERTEBROPLASTY THOR
  • 22521: PERCUT VERTEBROPLASTY LUMB
  • 22522: PERCUT VERTEBROPLASTY ADDL
  • 22523: PERCUT KYPHOPLASTY, THOR
  • 22524: PERCUT KYPHOPLASTY, LUMBAR
  • 22526: PERCUTANEOUS INTRADISCAL ELECTROTHERMAL ANNULOPLASTY UNILATERAL OR BILAT
  • 27096: INJECT SACROILIAC JOINT
  • 62263: LYSIS EPIDURAL ADHESIONS
  • 62264: EPIDURAL LYSIS ON SINGLE DAY
  • 62280: INJECTION OF NEUROLYTIC SUBSTANCE; SUBARACHNOID
  • 62281: INJECTION OF NEUROLYTIC SUBSTANCE, EPIDURAL, CERVICAL OR THORACIC
  • 62282: INJECTION OF NEUROLYTIC SUBSTANCE, LUMBAR OR CAUDAL EPIDURAL
  • 62320: NJX DX/THER SBST INTRLMNR CRV/THRC W/O IMG GDN
  • 62321: NJX DX/THER SBST INTRLMNR CRV/THRC W/IMG GDN
  • 62322: NJX DX/THER SBST INTRLMNR LMBR/SAC W/O IMG GDN
  • 62323: NJX DX/THER SBST INTRLMNR LMBR/SAC W/IMG GDN
  • 62324: NJX DX/THER SBST INTRLMNR CRV/THRC W/O IMG GDN
  • 62325: NJX DX/THER SBST INTRLMNR CRV/THRC W/IMG GDN
  • 62326: NJX DX/THER SBST INTRLMNR LMBR/SAC W/O IMG GDN
  • 62327: NJX DX/THER SBST INTRLMNR LMBR/SAC W/IMG GDN
  • 62350: IMPLANTATION,REVISIONORREPOSITIONINGOFINTRATHECALOR
  • 62351: IMPLANTATION,REVISIONORREPOSITIONINGOFINTRATHECALOR
  • 62355: REMOVALOFPREVIOUSLYIMPLANTEDINTRATHECALOREPIDURAL
  • 62360: IMPLANTATIONORREPLACEMENTOFDEVICEFORINTRATHECALOR
  • 62361: IMPLANTATIONORREPLACEMENTOFDEVICEFORINTRATHECALOR
  • 62362: IMPLANTATIONORREPLACEMENTOFDEVICEFORINTRATHECALOR
  • 62365: REMOVALOFSUBCUTANEOUSRESERVOIRORPUMP,PREVIOUSLY
  • 62367: ANALYZE SPINE INFUS PUMP
  • 62368: ELECTRONICANALYSISOFPROGRAMMABLE,IMPLANTEDPUMPFOR
  • 62369: ANAL SP INF PMP W/REPRG&FILL
  • 62370: ANL SP INF PMP W/MDREPRG&FIL
  • 63650: PERCU.IMPLNT NEUROSTIM.ELEC;EPIDURL
  • 63655: LAMINCTMY,IMPLNT STIM.ELEC.EPIDURAL
  • 63661: REMOVE SPINE ELTRD PERQ ARAY
  • 63662: REMOVE SPINE ELTRD PLATE
  • 63685: INC SUBCU PLCMNT NEUROSTIM RECVR
  • 63688: RVSN OR RMVLSPNL NEUROSTIM RECVR
  • 64400: INJECTION, ANESTHETIC AGENT;TRIGEMINAL NERVE, ANY BRANCH
  • 64402: BLOCK, FACIAL NERVE
  • 64405: BLOCK, GREATER OCCIPITAL NERVE
  • 64408: BLOCK, VAGUS NERVE
  • 64410: BLOCK, PHRENIC NERVE
  • 64413: BLOCK CERVICAL PLEXUS
  • 64415: BLOCK, BRACHIAL PLEXUS
  • 64416: N BLOCK CONT INFUSE, B PLEX
  • 64417: BLOCK, AXILLARY NERVE
  • 64418: BLOCK SUPRASCAPULAR NERVE
  • 64420: BLOCK, INTERCOSTAL NERVES
  • 64421: BLOCK, INTERCOSTAL NERVES, MULTPL
  • 64430: BLOCK, PUDENAL NERVE
  • 64445: BLOCK, SCIATIC NERVE
  • 64446: N BLK INJ, SCIATIC, CONT INF
  • 64447: N BLOCK INJ FEM, SINGLE
  • 64448: N BLOCK INJ FEM, CONT INF
  • 64449: N BLOCK INJ, LUMBAR PLEXUS
  • 64450: BLOCK OTHER PERIPHERAL NERVES
  • 64461: PVB THORACIC SINGLE INJ SITE
  • 64462: PVB THORACIC 2ND+ INJ SITE
  • 64463: PVB THORACIC CONT INFUSION
  • 64479: INJ FORAMEN EPIDURAL C/T
  • 64480: INJ FORAMEN EPIDURAL ADD-ON
  • 64483: INJ FORAMEN EPIDURAL L/S
  • 64484: INJ FORAMEN EPIDURAL ADD-ON
  • 64486: TAP BLOCK UNIL BY INJECTION
  • 64487: TAP BLOCK UNI BY INFUSION
  • 64488: TAP BLOCK BI INJECTION
  • 64489: TAP BLOCK BI BY INFUSION
  • 64490: INJ PARAVERT F JNT C/T 1 LEV
  • 64491: INJ PARAVERT F JNT C/T 2 LEV
  • 64492: INJ PARAVERT F JNT C/T 3 LEV
  • 64493: INJ PARAVERT F JNT L/S 1 LEV
  • 64494: INJ PARAVERT F JNT L/S 2 LEV
  • 64495: INJ PARAVERT F JNT L/S 3 LEV
  • 64505: BLOCK; SPHENOPALATINE GANGLION
  • 64510: BLOCK, STELLATE GANGLION
  • 64517: N BLOCK INJ, HYPOGAS PLXS
  • 64520: BLOCK, LUMBAR OR THORACIC
  • 64550: APPL SURFACE NEUROSTIMULATOR
  • 64553: IMPLANT NEUROELECTRODES
  • 64555: IMPLANT NEUROELECTRODES
  • 64561: IMPLANT NEUROELECTRODES
  • 64566: NEUROELTRD STIM POST TIBIAL
  • 64585: REVISE/REMOVE NEUROELECTRODE
  • 64590: INC SUBCU PLCMNT NEUROSTMLTR RECVR
  • 64595: REVSN/RMVL PERIPHRL NEUROSTIM.RECVR
  • 64600: INJ NUROLYTIC TRIGM SUPORB ETC BRAN
  • 64620: INJ NUROLTC AGNT, INTRCOSTAL NERVES
  • 64630: INJ NUROLYTIC AGENT PUDENDAL NERVE
  • 64632: N BLOCK INJ, COMMON DIGIT
  • 64633: DESTROY CERV/THOR FACET JNT
  • 64634: DESTROY C/TH FACET JNT ADDL
  • 64635: DESTROY LUMB/SAC FACET JNT
  • 64636: DESTROY L/S FACET JNT ADDL
  • 64640: INJ NUROLYTIC AGNT OTHR PERPHL NERV
  • 64650: CHEMODENERV ECCRINE GLANDS
  • 64653: CHEMODENERV ECCRINE GLANDS
  • 64680: INJ NUROLTC AGNT GASS GANGL X-RA CO
  • 64681: INJECTION TREATMENT OF NERVE