This list does not pertain to Medicare products.

Previous Lists

• Effective August 1, 2011
• Effective November 1, 2010
• Effective February 1, 2010

Important pre-authorization reminders

1. Before requesting pre-authorization, please verify eligibility and benefits via the Provider Center.
2. Verify that you are an in-network provider for each member to help reduce his or her out-of-pocket expense.
3. Verification of member eligibility is valid if obtained within five business days of service except in the case of misrepresentation.
4. Pre-authorizations obtained within 30 business days prior to service are valid except in the case of misrepresentation.
5. Medical policies related to specific pre-authorization requirements are available at http://blue.regence.com/trgmedpol/index.html.
6. Potentially investigational services may also be considered medically necessary for select diagnoses. Please refer to the Asuris Clinical Edits by Code list for additional information.Unlisted codes may be used for potentially investigational services and are subject to review. 
7. Some member contracts have specific pre-authorization requirements. The member's contract language will apply.
8. Urgent/Emergent services do not require pre-authorization.
9. Pharmacy prior authorization information and forms can be found at the AsurisRx Physician Web site.
10. Please note that a pre-authorization does not guarantee payment for requested services. Asuris reimbursement policies may affect how claims are reimbursed and payment of benefits is subject to all plan provisions, including eligibility for benefits.
11. Pre-authorization approval will be communicated by phone and a pre-authorization approval number will be provided.
12. Pre-authorization denials will be communicated both in writing and by phone.

Pre-authorization for investigational services and supplies is not required as such charges are typically contract exclusions and ineligible for payment.  Charges for investigational services and supplies are denied with financial responsibility assigned to the member.

Potentially investigational services are services that are considered investigational, but for select diagnoses, may also be considered medically necessary, please refer to the Asuris Clinical Edits by Code list for additional information. Unlisted codes may be used for potentially investigational services and are subject to review. 

• View investigational and potentially investigational procedures on the current Asuris Clinical Edits by Code list. Note: This list does not apply to Medicare products.
• View a sample non-covered member consent form (PDF).

Asuris uses Milliman Care Guideline as the basis for determining medical necessity for Mental Health and Substance Abuse services. Visit Milliman’s website for information on purchasing their criteria, or contact Asuris at the phone number(s) above and we will be happy to provide you with a copy of guidelines for specific services. 

• Detox/Inpatient/Partial admissions: Notification upon admission required. Concurrent review will occur after 2 days.
• Chemical dependency intensive outpatient: Notification upon admission required. Concurrent review will occur after 8 weeks.
• Outpatient mental health, outpatient chemical dependency, and intensive outpatient mental health: Concurrent review will occur after 20 visits.
• Residential Treatment Center (RTC): Pre-authorization is required prior to patient admission.

20974, 20975, E0747, E0748, E0749

View the Medical Policy at http://blue.regence.com/trgmedpol/dme/dme10.html

Asuris uses Milliman Care Guideline as the basis for determining medical necessity on the following procedures. Visit Milliman’s website for information on purchasing their criteria, or contact Asuris at the phone number(s) above and we will be happy to provide you with a copy of the specific guideline.   

E0760, 20979- Milliman Care Guideline ACG: A-414

A9276, A9277, A9278, S1030, S1031

View the Medical Policy at http://blue.regence.com/trgmedpol/dme/dme77.html

E0983-4, E0986, E1002 - E1008, E1009 - E1010, E1220, E2230, E2295, E2300, E2301, E2310 - E2311, E2331, E2340 - E2343, E2609, E2610, E2617, K0005, K0009 - K0014, K0669, K0813 - K0816, K0820 - K0843, K0848 - K0864, K0868 - K0886, K0890 - K0891, K0898

View the Medical Policy at http://blue.regence.com/trgmedpol/dme/dme37.html

K0606, 93292, 93745

View the Medical Policy at http://blue.regence.com/trgmedpol/dme/dme61.html

E0481, E0483, E0484, S8185

View the Medical Policy at http://blue.regence.com/trgmedpol/dme/dme45.html

Please refer to the Asuris Clinical Edits by Code list for additional DME code information.

Transplants, ventricular assist devices and total artificial hearts (pre-authorization not required for corneal and kidney transplants)

Transplants
G0341, G0342, G0343, S2053, S2054, S2055, S2060, S2065, S2140, S2142, S2150, S2152, 32851, 32852, 32853, 32854, 33935, 33945, 38205, 38206, 38230, 38232, 38240, 38241, 38242, 44135, 47135, 47136, 48160, 48554, 0141T, 0142T, 0143T

Ventricular assist devices and total artificial hearts
33975, 33976, 33977, 33978, 33979, 0048T, 0050T, 0051T, 0052T, 0053T

All hospital admissions require notification

Concurrent review will occur after 7 days.

Long Term Acute Care Facility (LTAC)

Pre-authorization is required prior to patient admission.

Rehabilitation

Pre-authorization is required prior to patient admission.

Skilled Nursing Facility (SNF)

Pre-authorization is required prior to patient admission.

Endometrial Ablation

Extracranial Carotid Angioplasty / Stenting

Asuris uses Milliman Care Guideline as the basis for determining medical necessity on the following procedures. Visit Milliman’s website for information on purchasing their criteria, or contact Asuris at the phone number(s) above and we will be happy to provide you with a copy of the specific guideline.   

• 22554, 22551 - Milliman Care Guideline ORG S-320
• 22600 - Milliman Care Guideline ORG S-330
• 22558, 22612, 22630. 22633 - Milliman Care Guideline ORG S-820

The following procedures use Asuris Medical Policy, Percutaneous Vertebroplasty and Kyphoplasty, as the basis for determining medical necessity:

22520, 22521, 22522, 22523, 22524, 22525, 72291, 72292, S2360, S2361

Obesity surgery

43644, 43770, 43771, 43772, 43773, 43774, 43846, 43848, 43886, 43887, 43888

View the Medical Policy at http://blue.regence.com/trgmedpol/surgery/sur58.html

Orthognathic surgery

21120, 21121, 21123, 21125, 21127, 21141, 21142, 21143, 21145, 21146, 21147, 21150, 21151, 21154, 21155, 21159, 21160, 21193, 21194, 21195, 21196, 21198, 21199, 21206, 21230, S8262

View the Medical Policy at http://blue.regence.com/trgmedpol/surgery/sur137.html

Sleep apnea surgery

Please refer to the Asuris Clinical Edits by Code list for potentially investigational procedures.

View the Medical Policy at http://blue.regence.com/trgmedpol/surgery/sur166.html

Please refer to the Asuris Clinical Edits by Code list for medical necessity review codes and potentially investigational procedures.

View the Medical Policy at http://blue.regence.com/trgmedpol/surgery/sur104.html

77301, 77338, 77418, 0073T

Please reference the following Medical Policies for further information:

• IMRT of the Breast and Lung at http://blue.regence.com/trgmedpol/medicine/med136.html
• IMRT of the Prostate at http://blue.regence.com/trgmedpol/medicine/med137.html
• IMRT of the Head and Neck Cancers and Thyroid Cancer at http://blue.regence.com/trgmedpol/medicine/med138.html
• IMRT of the Abdomen and Pelvis at http://blue.regence.com/trgmedpol/medicine/med139.html

Asuris uses Milliman Care Guideline as the basis for determining medical necessity on the following procedures. Visit Milliman’s website for information on purchasing their criteria, or contact Asuris at the phone number(s) above and we will be happy to provide you with a copy of the specific guideline.   

• 21010 - Milliman Care Guideline A‐0522
• 21050 - Milliman Care Guideline A‐0521
• 29800, 29804 - Milliman Care Guideline A‐0492
• 21240, 21242, 21243 - Milliman Care Guideline A‐0523

Potentially cosmetic procedures to restore or improve appearance that may also correct a functional impairment

Pre-authorization not required for initial breast reconstruction one or two stages and nipple/areola reconstruction following mastectomy.

Please refer to the Asuris Clinical Edits by Code list for cosmetic and potentially cosmetic procedures.

Potentially investigational services that are considered investigational, but for select diagnoses, may also be considered medically necessary.

May not be covered under the member's contract. However, pre-authorization is recommended for any policy that has specific medical necessity criteria in addition to the experimental and investigational language.

Unlisted codes may be used for potentially investigational services and are subject  to review. 

Please refer to the Asuris Clinical Edits by Code list for additional information.