Policy Updates Prior AuthorizationCommercialMay 31, 2023

Precertification list change notification for September 1, 2023

The following services will be added to precertification for the effective dates listed below.

Eligibility and benefits can be verified by accessing Availity Essentials* at availity.com or by calling the number on the back of the member’s identification card. Service precertification is based on member’s benefit plan or eligibility at the time the service is reviewed and approved. Benefit plans vary widely and are subject to change based on the contract effective dates. The provider is responsible for verification of member eligibility and covered benefits.

Except in the case of an emergency, failure to obtain precertification prior to rendering the designated services listed below may result in denial of reimbursement.

Added to precertification

Clinical Criteria

Criteria description

Effective date

CG-MED-73

Hyperbaric Oxygen Therapy (Systemic/Topical)

September 1, 2023

DME.00011

Electrical Stimulation as a Treatment for Pain and Other Conditions: Surface and Percutaneous Devices

September 1, 2023

DME.00012

Intrapulmonary Percussive Ventilation Devices

September 1, 2023

DME.00042

Electronic Positional Devices for the Treatment of Obstructive Sleep Apnea

September 1, 2023

DME.00048

Virtual Reality-Assisted Therapy Systems

September 1, 2023

DME.00049

External Upper Limb Stimulation for the Treatment of Tremors

September 1, 2023

MED.00122

Wilderness Programs

September 1, 2023

MED.00145

Digital Therapy Devices for Treatment of Amblyopia

September 1, 2023

OR-PR.00005

Upper Extremity Myoelectric Orthoses

September 1, 2023

SURG.00084

Implantable Middle Ear Hearing Aids

September 1, 2023

SURG.00118

Bronchial Thermoplasty

September 1, 2023

SURG.00121

Transcatheter Heart Valve Procedures

September 1, 2023

TRANS.00004

Cell Transplantation (Mesencephalic, Adrenal-Brain and Fetal Xenograft)

September 1, 2023

TRANS.00010

Autologous and Allogeneic Pancreatic Islet Cell Transplantation

September 1, 2023

TRANS.00035

Therapeutic use of Stem Cells, Blood, and Bone Marrow Products

September 1, 2023


* Availity, LLC is an independent company providing administrative support services on behalf of the health plan.

GABCBS-CM-024622-23

PUBLICATIONS: June 2023 Provider Newsletter