services requiring prior authorization - Oxford Health Plans
services requiring prior authorization - Oxford Health Plans
services requiring prior authorization - Oxford Health Plans
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ADMINISTRATIVE POLICY<br />
SERVICES REQUIRING PRIOR AUTHORIZATION<br />
Policy Number: ADMINISTRATIVE 245.5<br />
Last Modified Date: January 1, 2014<br />
The <strong>services</strong> described in <strong>Oxford</strong> policies are subject to the terms, conditions and limitations of the Member’s contract<br />
or certificate. Unless otherwise stated, <strong>Oxford</strong> policies do not apply to Medicare Advantage enrollees. <strong>Oxford</strong><br />
reserves the right, in its sole discretion, to modify policies as necessary without <strong>prior</strong> written notice unless otherwise<br />
required by <strong>Oxford</strong>'s administrative procedures or applicable state law. The term <strong>Oxford</strong> includes <strong>Oxford</strong> <strong>Health</strong><br />
<strong>Plans</strong>, LLC and all of its subsidiaries as appropriate for these policies.<br />
Certain policies may not be applicable to Self-Funded Members and certain insured products. Refer to the Member's<br />
plan of benefits or Certificate of Coverage to determine whether coverage is provided or if there are any exclusions or<br />
benefit limitations applicable to any of these policies. If there is a difference between any policy and the Member’s<br />
plan of benefits or Certificate of Coverage, the plan of benefits or Certificate of Coverage will govern.<br />
PURPOSE<br />
A list of <strong>services</strong> <strong>requiring</strong> <strong>prior</strong> <strong>authorization</strong> is provided below for your reference; refer to the individual<br />
policy for complete details on applicable <strong>prior</strong> <strong>authorization</strong> guidelines.<br />
Note: The list of <strong>services</strong> <strong>requiring</strong> <strong>prior</strong> <strong>authorization</strong> does not indicate or imply coverage. Prior<br />
<strong>authorization</strong> and payment of covered <strong>services</strong> are subject to the terms, conditions and limitations of the<br />
Member’s contract or certificate of coverage, eligibility at time of service, and approval by our Clinical<br />
Services department. Prior <strong>authorization</strong> requirements may differ by individual physicians, health care<br />
professionals and ancillary providers. If additional <strong>prior</strong> <strong>authorization</strong> requirements apply, the physician or<br />
other healthcare professional will be notified in advance of the <strong>prior</strong> <strong>authorization</strong> rules being applied.<br />
A B C D E F G H I J&K L M N O P Q R S T U V W,X,Y,Z<br />
Policy<br />
Type<br />
Policy Title<br />
Effective Date<br />
Clinical 17-Alpha-Hydroxyprogesterone Caproate (17P and Makena) 08/01/2013<br />
Clinical Ablative Treatment for Spinal Pain 06/01/2013<br />
Clinical Abnormal Uterine Bleeding and Uterine Fibroids 01/01/2014<br />
Clinical Abortions (Therapeutic and Elective) 08/01/2013<br />
Clinical Acquired Rare Disease Drug Therapy Exception Process 10/01/2013<br />
Clinical Afinitor ® , Afinitor Disperz (Everolimus) 10/01/2013<br />
Clinical Agents for Migraine - Triptans 01/01/2014<br />
Clinical Amitiza (Lubiprostone) and Linzess (Linaclotide) 10/01/2013<br />
Services Requiring Prior Authorization 1<br />
©1996-2014, <strong>Oxford</strong> <strong>Health</strong> <strong>Plans</strong>, LLC
Clinical Ampyra (Dalfampridine) 08/15/2013<br />
Clinical Anemia Drugs: Darbepoetin Alfa and Epoetin Alfa 10/01/2013<br />
Clinical<br />
Anticonvulsants - Depakote ER®, Keppra®, Keppra XR®, Lamictal®,<br />
Lamictal XR®, Generic Levetiracetam XR, Lamictal ODT®, Lamotrigine<br />
Extended-Release, Oxtellar XR, Topamax®, Stavzor®, Banzel®, 01/01/2014<br />
Potiga, Vimpat® , Trokendi XR and Lamotrigine Oral Disintegrating<br />
Tablets<br />
Clinical Apheresis 01/01/2014<br />
Clinical Arcalyst (Rilonacept) 10/01/2013<br />
Clinical Assisted Administration of Clotting Factors and Coagulant Blood Products 01/01/2014<br />
Clinical Athletic Pubalgia Surgery 08/01/2013<br />
Clinical Auditory Integration Training 07/01/2013<br />
Clinical Autologous Chondrocyte Transplantation in the Knee 01/01/2013<br />
B<br />
Clinical Bariatric Surgery 01/01/2014<br />
Clinical Becaplermin Gel (Regranex) 11/15/2012<br />
Clinical Biofeedback 01/01/2013<br />
Clinical Biologics in the Treatment of Skin, Joint and Gastrointestinal Conditions 01/01/2014<br />
Clinical Blepharoplasty, Blepharoptosis and Brow Ptosis Repair 04/01/2013<br />
Clinical Boceprevir (Victrelis) and Telaprevir (Incivek) 11/15/2012<br />
Clinical Bone or Soft Tissue Healing and Fusion Enhancement Products 05/01/2013<br />
Clinical Bosulif® (Bosutinib) 01/01/2014<br />
Clinical Botulinum Toxins A and B 01/01/2014<br />
Clinical Breast Reconstruction Post Mastectomy 01/01/2014<br />
Clinical Breast Reduction Surgery 12/01/2012<br />
Clinical Breast Repair/Reconstruction (Not Following Mastectomy) 01/01/2013<br />
Clinical Brilinta (Ticagrelor) 01/01/2014<br />
Clinical Bronchial Thermoplasty 09/01/2013<br />
C<br />
Clinical Cardiovascular Disease Risk Tests 01/01/2013<br />
Clinical Caprelsa® (Vandetanib) 10/01/2013<br />
Clinical Cardiology Procedures for CareCore National Arrangement 10/01/2013<br />
Clinical Cardiology Procedures Requiring Precertification 10/01/2013<br />
Clinical Cardiovascular Disease Risk Tests 01/01/2014<br />
Clinical Cayston (Aztreonam for Inhalation Solution) 08/15/2013<br />
Clinical Chelation Therapy for Non-Overload Conditions 06/01/2013<br />
Clinical Chemosensitivity and Chemoresistance Assays in Cancer 08/01/2013<br />
Clinical Chromosome Microarray Testing 01/01/2014<br />
Clinical Clinical Trials 01/01/2014<br />
Services Requiring Prior Authorization 2<br />
©1996-2014, <strong>Oxford</strong> <strong>Health</strong> <strong>Plans</strong>, LLC
Clinical Clotting Factors and Coagulant Blood Products 01/01/2014<br />
Clinical CNS Stimulants 01/01/2014<br />
Clinical Cochlear Implants 06/01/2013<br />
Clinical Collagen Crosslinks and Biochemical Markers of Bone Turnover 06/01/2013<br />
Clinical Cometriq (Cabozantinib) 09/01/2013<br />
Clinical Compounds and Bulk Powders 01/01/2014<br />
Clinical Computerized Dynamic Posturography 05/01/2013<br />
Clinical Connecticut Clinical Trials 01/01/2014<br />
Clinical<br />
Continuous Glucose Monitoring and Insulin Delivery for Managing<br />
Diabetes<br />
07/01/2013<br />
Clinical Core Decompression for Avascular Necrosis 01/01/2014<br />
Clinical Corneal Hysteresis and Intraocular Pressure Measurement 07/01/2013<br />
Clinical Cosmetic and Reconstructive Procedures 01/01/2014<br />
Clinical Cystaran (Cysteamine) Ophthalmic Solution 01/01/2014<br />
Clinical Cytological Examination of Breast Fluids for Cancer Screening 09/01/2013<br />
D<br />
Clinical Daliresp® (Roflumilast) 01/01/2014<br />
Clinical Deep Brain Stimulation 04/01/2013<br />
Clinical Dental and Oral Surgical Procedures 01/01/2014<br />
Clinical Diabetes Supply Coverage 09/01/2013<br />
Clinical<br />
Diabetes Supply Coverage for New Jersey Small Group and Individual<br />
<strong>Plans</strong><br />
07/01/2013<br />
Clinical Diabetic Insulins 08/01/2013<br />
Clinical Diabetic Test Strips 08/01/2013<br />
Clinical Diagnostic (Basic) Procedures for Infertility 10/01/2013<br />
Clinical Dialysis Services 01/01/2014<br />
Clinical Discogenic Pain, Treatment 01/01/2014<br />
Clinical DPP4 Inhibitors (Janumet, Januvia, Janumet XR) 01/01/2014<br />
Clinical Drug Coverage Criteria - New and Therapeutic Equivalent Medications 01/01/2014<br />
Clinical Drug Coverage Guidelines 01/01/2014<br />
Clinical<br />
Durable Medical Equipment, Orthotics, Ostomy Supplies, Medical<br />
Supplies, and Repairs/Replacements<br />
01/01/2014<br />
Clinical Dutasteride (Avodart) 11/01/2012<br />
E<br />
Clinical Egrifta (Tesamorelin for Injection) 10/01/2013<br />
Clinical Elbow Replacement Surgery (Arthoplasty) 01/01/2014<br />
Clinical Electrical and Ultrasound Bone Growth Stimulators 01/01/2014<br />
Clinical Electrical Bioimpedance for Cardiac Output Measurement 10/01/2013<br />
Clinical Electrical Stimulation and Electromagnetic Therapy for Wounds 02/01/2013<br />
Services Requiring Prior Authorization 3<br />
©1996-2014, <strong>Oxford</strong> <strong>Health</strong> <strong>Plans</strong>, LLC
Clinical Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation 05/01/2013<br />
Clinical Elidel ® (pimecrolimus) and Protopic ® (tacrolimus) 02/15/2013<br />
Clinical Endoscopic Therapies for Gastroesophageal Reflux Disease (GERD) 01/01/2014<br />
Clinical Epidural Steroid and Facet Joint Injections for Spinal Pain 08/01/2013<br />
Clinical<br />
Epiduroscopy, Epidural Lysis of Adhesions and Functional Anesthetic<br />
Discography<br />
03/01/2013<br />
Clinical<br />
Erectile Dysfunction Agents (Viagra, Levitra, Cialis, Staxyn, Muse,<br />
Caverject, and Edex)<br />
01/01/2013<br />
Clinical Erivedge (Vismodegib) 01/01/2014<br />
Clinical Exjade (Deferasirox) and Ferriprox (Deferiprone) 10/01/2013<br />
Clinical Experimental/Investigational Treatment 01/01/2013<br />
Clinical Experimental/Investigational Treatment for NJ <strong>Plans</strong> 01/01/2013<br />
Clinical Extracorporeal Shock Wave Therapy (ESWT) 07/01/2013<br />
F<br />
Clinical Fecal Calprotectin Testing 04/01/2013<br />
Clinical Fecal DNA Testing 05/01/2013<br />
Clinical Femoroacetabular Impingement Syndrome Treatment 02/01/2013<br />
Clinical Follicle Stimulating Hormones (FSH) Used in the Treatment of Infertility 11/01/2012<br />
Clinical Fulyzaq (Crofelemer) 05/15/2013<br />
G<br />
Clinical Gait Analysis 06/01/2013<br />
Clinical Gastrointestinal Motility Disorders, Diagnosis and Treatment 09/01/2013<br />
Clinical Gattex (Teduglutide [Rdna Origin]), for Injection, for Subcutaneous Use 05/15/2013<br />
Clinical Gene Expression Tests 01/01/2014<br />
Clinical<br />
Genetic Testing for Hereditary Breast and/or Ovarian Cancer Syndrome<br />
(HBOC)<br />
05/01/2013<br />
Clinical Gilotrif (Afatinib) 01/01/2014<br />
Clinical Glaucoma Surgical Treatments 01/01/2014<br />
Clinical Gleevec ® (Imatinib Mesylate) 10/01/2013<br />
Clinical Growth Hormone and Growth Stimulating Products 12/01/2012<br />
Clinical Gynecomastia 07/01/2013<br />
H<br />
Clinical High Frequency Chest Wall Compression Devices 01/01/2014<br />
Clinical Hip Replacement Surgery (Arthoplasty) 01/01/2014<br />
Clinical Hip Resurfacing Arthroplasty 04/01/2013<br />
Clinical Home <strong>Health</strong> Care 01/01/2014<br />
Clinical Home Hemodialysis 05/01/2013<br />
Clinical Home Traction Therapy 08/01/2013<br />
Clinical Hospice Care 08/01/2013<br />
Services Requiring Prior Authorization 4<br />
©1996-2014, <strong>Oxford</strong> <strong>Health</strong> <strong>Plans</strong>, LLC
Clinical Hycamtin ® (Topotecan Hydrochloride) 10/01/2013<br />
I<br />
Clinical Icatibant (Firazyr) and C1 Esterase Inhibitors Human (Berinert) 02/15/2013<br />
Clinical Iclusig (Ponatinib) 01/01/2014<br />
Clinical Immune Globulin (IVIG and SCIG) 01/01/2014<br />
Clinical<br />
Implantable Beta-Emitting Microspheres for Treatment of Malignant<br />
Tumors<br />
01/01/2014<br />
Clinical<br />
Implantable/Non-Implantable Hearing Devices and Bone Anchored<br />
Hearing Aids<br />
11/01/2012<br />
Clinical Implanted Electrical Stimulator for Spinal Cord 08/01/2013<br />
Clinical In Utero Fetal Surgery 05/01/2013<br />
Clinical Infertility Procedures Requiring Notification and/or Precertification 11/01/2012<br />
Clinical<br />
Injectable Chemotherapy Drugs: Application of NCCN Clinical Practice<br />
Guidelines<br />
05/01/2013<br />
Clinical Inlyta (Axitinib) 09/01/2013<br />
Clinical<br />
In-Network Exceptions for Breast Reconstruction Surgery Following<br />
Mastectomy<br />
01/01/2014<br />
Clinical Interferon Alphas 08/15/2013<br />
Clinical Intermittent Intravenous Insulin Therapy 05/01/2013<br />
Clinical Intrastromal Corneal Ring Segments 04/01/2013<br />
Clinical Isotretinoin Oral Products 01/01/2014<br />
J & K<br />
Clinical Jakafi (Ruxolitinib) 09/01/2013<br />
Clinical Juxtapid (Lomitapide) and Kynamro (Mipomersen Sodium) 05/01/2013<br />
Clinical Kalydeco (Ivacaftor) 04/01/2013<br />
Clinical Knee Replacement Surgery (Arthoplasty) 01/01/2014<br />
Clinical Korlym (mifepristone) 07/01/2013<br />
Clinical Kuvan (Sapropterin Dihydrochloride) 01/01/2014<br />
L<br />
Clinical Laser Therapy for Cutaneous Vascular Lesions and Pilonidal Disease 08/01/2013<br />
Clinical Lithotripsy for Salivary Stones 10/01/2013<br />
Clinical Lotronex (Alosteron) 01/01/2014<br />
Clinical Lupron-Depot (leuprolide acetate) 08/01/2013<br />
Clinical Lyme Disease 11/01/2012<br />
M<br />
Clinical Macular Degeneration and Ocular Tumor Treatment 01/01/2014<br />
Clinical Magnetic Resonance Spectroscopy (MRS) 10/01/2012<br />
Clinical<br />
Magnetoencephalography and Magnetic Source Imaging for Specific<br />
Neurological Applications<br />
08/01/2013<br />
Services Requiring Prior Authorization 5<br />
©1996-2014, <strong>Oxford</strong> <strong>Health</strong> <strong>Plans</strong>, LLC
Clinical Mandibular Disorders 04/01/2013<br />
Clinical Manipulation Under Anesthesia 04/01/2013<br />
Clinical Manipulative Therapy 07/01/2013<br />
Clinical<br />
Mastectomy/Lumpectomy and Lymph Node Dissection - Place of Service<br />
and Length of Stay<br />
10/01/2013<br />
Clinical Mechanical Stretching and Continuous Passive Motion Devices 07/01/2013<br />
Clinical Mekinist (Trametinib) 01/01/2014<br />
Clinical Meniscus Implant and Allograft 11/01/2012<br />
Clinical Modafinil (Provigil) and Armodafinil (Nuvigil) 01/01/2014<br />
Clinical Motorized Spinal Traction 08/01/2013<br />
Clinical<br />
Multiple Sclerosis: Interferon B-1A (Avonex, Rebif), Interferon B-1B<br />
(Betaseron, Extavia), Glatiramer (Copaxone) and Fingolimod (Gilenya)<br />
01/01/2014<br />
N<br />
Clinical Nerve Graft to Restore Erectile Function During Radical Prostatectomy 01/01/2014<br />
Clinical Neurophysiologic Testing 03/01/2013<br />
Clinical Nexavar® (Sorafenib Tosylate) 10/01/2013<br />
Clinical<br />
Noninvasive Prenatal Diagnosis of Fetal Aneuploidy Using Cell-Free Fetal<br />
Nucleic Acids in Maternal Blood<br />
01/01/2014<br />
Clinical Non-Surgical Treatment of Obstructive Sleep Apnea 07/01/2013<br />
O<br />
Clinical Obstetrical Ultrasonography 07/01/2013<br />
Clinical Occipital Neuralgia and Cervicogenic Cluster and Migraine Headaches 06/01/2013<br />
Clinical Omega-3-Acid Ethyl Esters (Lovaza) 02/15/2013<br />
Clinical Omnibus Codes 01/01/2014<br />
Clinical Onfi (Clobazam) 07/01/2013<br />
Clinical<br />
Opioid Dependence Agents: Buprenorphine HCL and Naloxone and<br />
Buprenorphine HCL<br />
01/01/2014<br />
Clinical Oral and Nasal Fentanyl Medications 01/01/2014<br />
Clinical<br />
Oral Chemotherapy Drugs: Application of NCCN Clinical Practice<br />
Guidelines<br />
01/01/2014<br />
Clinical Orencia (Abatacept)-Intravenous Infusion 05/01/2013<br />
Clinical Orthognathic/Jaw Surgery 12/01/2012<br />
Clinical Orthopedic Services 04/01/2013<br />
Clinical Oscillatory Positive Expiratory Pressure Devices 05/01/2013<br />
Clinical Osteochondral Grafting of Knee 01/01/2014<br />
Clinical Otoacoustic Emissions Testing 07/01/2012<br />
Clinical Outpatient Cardiovascular Telemetry 05/01/2013<br />
Clinical<br />
Outpatient Physical and Occupational Therapy (Optum<strong>Health</strong> Care<br />
Solutions Arrangement)<br />
04/01/2013<br />
P<br />
Services Requiring Prior Authorization 6<br />
©1996-2014, <strong>Oxford</strong> <strong>Health</strong> <strong>Plans</strong>, LLC
Clinical Panniculectomy and Body Contouring Procedures 01/01/2013<br />
Clinical Pectus Deformity Repair 01/01/2013<br />
Clinical<br />
Physical, Occupational (Optum<strong>Health</strong> Care Solutions Arrangement) and<br />
Speech Therapy including Cognitive/ Neuropsychological Rehabilitation for 01/01/2014<br />
New Jersey Small Group and New Jersey Individual Members<br />
Clinical Plagiocephaly and Craniosynostosis Treatment 04/01/2013<br />
Clinical Platelet-Derived Growth Factors for Treatment of Wounds 07/01/2013<br />
Clinical Pneumatic Compression Devices 05/01/2013<br />
Clinical Polamyst (Pomalidomide) 05/15/2013<br />
Clinical<br />
Polysomnography and Portable Monitoring for Evaluation of Sleep Related<br />
Breathing Disorders<br />
01/01/2014<br />
Clinical Presacral Neurectomy and Uterine Nerve Ablation for Pelvic Pain 11/01/2012<br />
Clinical Preterm Labor: Identification and Treatment 08/01/2013<br />
Clinical Preventive Care 01/01/2014<br />
Clinical Private Duty Nursing 08/01/2013<br />
Clinical Procedures for Ablation of Varicose Veins 01/01/2014<br />
Clinical Procysbi (Cysteamine Bitartrate) 10/01/2013<br />
Clinical<br />
Progesterone Products: Crinone (Progesterone Gel), Endometrin<br />
(Progesterone Vaginal Insert) and First Progesterone VGS (Progesterone 01/01/2014<br />
Vaginal Suppository USP Compounding Kit) for Non-Fertility Use<br />
Clinical Prolotherapy for Musculoskeletal Indications 06/01/2013<br />
Clinical Promacta (Eltrombopag) 05/15/2013<br />
Clinical Prostaglandin Ophthalmic Agents 01/01/2014<br />
Clinical Prosthetics 10/01/2013<br />
Clinical Proton Pump Inhibitors 07/01/2013<br />
Clinical Pulmonary Arterial Hypertension (PAH) Drug Therapy 01/01/2014<br />
Clinical Pulmozyme ® (Dornase Alfa) 01/01/2014<br />
R<br />
Clinical Radiation Therapy Procedures for CareCore National Arrangement 07/01/2013<br />
Clinical Radiation Therapy Procedures Requiring Precertification 01/01/2014<br />
Clinical<br />
Radiofrequency Therapy and Tibial Nerve Stimulation for Urinary<br />
Disorders<br />
01/01/2014<br />
Clinical Radiology Procedures for CareCore National Arrangement 07/01/2013<br />
Clinical Radiology Procedures Requiring Precertification 01/01/2014<br />
Clinical Ravicti (Glycerol Phenylbutyrate Oral Liquid) 07/01/2013<br />
Clinical Rectiv (Nitroglycerin Ointment) 01/01/2014<br />
Clinical Refractive Surgeries 11/01/2012<br />
Clinical Remicade (infliximab) 12/01/2012<br />
Clinical Repository Corticotropin Injection (H.P. Acthar Gel) 07/01/2013<br />
Clinical Restasis (Cyclosporine Ophthalmic Emulsion) 05/15/2013<br />
Services Requiring Prior Authorization 7<br />
©1996-2014, <strong>Oxford</strong> <strong>Health</strong> <strong>Plans</strong>, LLC
Clinical Revlimid® (Lenalidomide) 10/01/2013<br />
Clinical Rhinoplasty, Septoplasty and Repair of Vestibular Stenosis 07/01/2013<br />
Clinical Rituximab (Rituxan) for Non Cancer Related Indications 07/01/2013<br />
Clinical Routine Foot Care 01/01/2014<br />
S<br />
Clinical Sandostatin LAR Depot (Octreotide Acetate) 02/15/2013<br />
Clinical Sandostatin Subcutaneous Formulation (Octreotide Acetate) 02/15/2013<br />
Clinical Sedative Hypnotic Agents 01/01/2014<br />
Clinical Selzentry (Maraviroc) 05/15/2013<br />
Clinical Sensory Integration Therapy 03/01/2013<br />
Clinical Shoulder Replacement Surgery (Arthoplasty) 01/01/2014<br />
Clinical Signifor (Pasireotide Diaspartate) 05/15/2013<br />
Clinical Sodium Hyaluronate 08/01/2013<br />
Clinical Sprycel ® (Dasatinib) 01/01/2014<br />
Clinical Standing Systems 09/01/2013<br />
Clinical Stelara (Ustekinumab) 08/01/2013<br />
Clinical<br />
Stribild TM (Elvitegravir/Cobicistat/Emtricitabine/Tenofovir Disoproxil<br />
Fumarate)<br />
12/01/2013<br />
Clinical Stivarga ® (Regorafenib) 07/01/2013<br />
Clinical Subcutaneous Leuprolide Acetate 01/01/2014<br />
Clinical Surgical Treatment for Spine Pain 04/01/2013<br />
Clinical Surgical Treatment of Obstructive Sleep Apnea 06/01/2013<br />
Clinical Sutent ® (Sunitinib Malate) 10/01/2013<br />
Clinical Synagis (palivizumab) 10/01/2013<br />
Clinical Synarel® (Nafarelin Acetate) 11/01/2013<br />
T<br />
Clinical Tafinlar (Dabrafenib) 01/01/2014<br />
Clinical Tarceva ® (Erlotinib) 10/01/2013<br />
Clinical Tasigna ® (Nilotinib) 10/01/2013<br />
Clinical Temodar ® (Temozolomide) 09/01/2013<br />
Clinical Teriparatide (Forteo) 11/15/2012<br />
Clinical Thalomid ® (Thalidomide) 10/01/2013<br />
Clinical Thermal Capsulorrhaphy/Thermal Shrinkage Therapy 05/01/2013<br />
Clinical Thermography 05/01/2013<br />
Clinical<br />
Tobi Nebulizer Solution (Tobramycin Inhalation Solution) and Tobi ®<br />
Podhaler (Tobramycin Inhalation Powder)<br />
01/01/2014<br />
Clinical Topical Retinoids (Pharmaceutical Treatment of Acne) 01/01/2014<br />
Clinical Total Artificial Disc Replacement for Spine 01/01/2013<br />
Clinical Total Artificial Heart 10/01/2013<br />
Services Requiring Prior Authorization 8<br />
©1996-2014, <strong>Oxford</strong> <strong>Health</strong> <strong>Plans</strong>, LLC
Clinical Transcatheter Heart Valve Procedures 01/01/2014<br />
Clinical Transcranial Magnetic Stimulation 01/01/2013<br />
Clinical<br />
Transcutaneous Electrical Nerve Stimulation (TENS) for the Treatment of<br />
Nausea and Vomiting<br />
03/01/2013<br />
Clinical Transportation Services 03/01/2013<br />
Clinical Transtympanic Micropressure 08/01/2013<br />
Clinical Treatment of Infertility 10/01/2013<br />
Clinical Treatment of Infertility for Connecticut Groups 10/01/2013<br />
Clinical Treatment of Infertility for New Jersey Large Groups 10/01/2013<br />
Clinical Treatment of Infertility for New Jersey Small Groups 10/01/2013<br />
Clinical Treatment of Infertility for New York Large and Small Groups 10/01/2013<br />
Clinical Truvada (Emtricitabine/Tenofovir Disoproxil Fumarate) 11/01/2013<br />
Clinical Tykerb ® (Lapatinib) 10/01/2013<br />
Clinical Tysabri (Natalizumab) 08/01/2013<br />
U<br />
Clinical Umbilical Cord Blood Harvesting and Storage for Future Use 09/01/2013<br />
Clinical Unicondylar Spacer Devices for Treatment of Pain or Disability 11/01/2012<br />
Clinical Unlisted CPT Codes Requiring Medical Director Review 04/01/2012<br />
V<br />
Clinical Vagus Nerve Stimulation 01/01/2014<br />
Clinical Virtual Upper Gastrointestinal Endoscopy 12/01/2012<br />
Clinical Votrient (Pazopanib) 10/01/2013<br />
W, X, Y, Z<br />
Clinical Warming Therapy and Ultrasound Therapy for Wounds 01/01/2014<br />
Clinical Xalkori ® (Crizotinib) 10/01/2013<br />
Clinical Xeljanz (Tofacitinib) 10/01/2013<br />
Clinical Xolair (omalizumab) 08/01/2013<br />
Clinical Xtandi ® (Enzalutamide) 01/01/2014<br />
Clinical Xyrem (Sodium Oxybate) 05/15/2013<br />
Clinical Zelboraf (Vemurafenib) 10/01/2013<br />
Clinical Zytiga (Abiraterone Acetate) 10/01/2013<br />
Services Requiring Prior Authorization 9<br />
©1996-2014, <strong>Oxford</strong> <strong>Health</strong> <strong>Plans</strong>, LLC
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