Updated Focus Outpatient Precertification Listings
First Priority Health has updated the listings of FPH Focus Outpatient procedures/treatments that require a
precertification. FPH Precertification can be conducted either by phone at 1-800-962-5353 or via NaviNet. The revisions
are effective June 1, 2013.
Focus Outpatient Precertification List
June 1, 2013
Code
0075T
Description
TRNSCATH XTRACRAN VERTB OR INTRATHOR ART STNT PERQ; INITIAL VESSEL
15830
EXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE (INCLUDES LIPECTOMY); ABDOMEN,
INFRAUMBILICAL PANNICULECTOMY
21137
REDUCTION FOREHEAD; CONTOURING ONLY
21138
REDUCTION FOREHEAD; CONTOUR&APPLIC PROSTH MATL/BN GFT
21139
REDUCTION FOREHEAD; CONTOUR&SETBACK FRNTL SINUS WALL
21175
RECON BIFRONTAL ORBIT RIMS&LO FOREHEAD W/WO GFTS
21179
21180
21181
21182
21183
21184
21208
21209
RECON MAJORITY FOREHEAD/SUPRAORBITAL RIMS; W/GFT
RECON MAJORITY FOREHEAD/SUPRAORB RIMS; W/AUTOGFT
RECON CONTOUR BEN TUMOR CRANIAL BONES XTRACRAN
RECNSTR ORB FLW EXC BEN TUMR; BN GFT < 40 SQ CM
RECNSTR ORB FLW EXC TUMR;BN GFT > 40 BUT<80 SQ CM
RECNSTR ORB FLW EXC BEN TUMR; BN GFT > 80 SQ CM
OSTEOPLASTY FACIAL BONES; AUGMENTATION
OSTEOPLASTY FACIAL BONES; REDUCTION
21256
21270
21275
RECONSTRUCTION ORBIT W/OSTEOTOMIES&W/BONE GRAFTS
MALAR AUGMENTATION PROSTHETIC MATERIAL
SEC REVISION ORBITOCRANIOFACIAL RECONSTRUCTION
21280
MEDIAL CANTHOPEXY-SEP PROC
21282
22220
22224
22520
22521
22522
27412
27415
27599
29866
29867
30420
30620
LATERAL CANTHOPEXY
OSTEOT SPN W/DISKECT ANT APPRCH 1 VERT SEG; CERV
OSTEOT SPN W/DISKECT ANT APPRCH 1 VERT SEG; LUMB
PERQ VERTPLSTY 1 VERT BODY UNI/BIL INJ; THORACIC
PERQ VERTPLSTY 1 VERT BODY UNI/BIL INJ; LUMBAR
PERQ VERTPLSTY 1 VERT BODY UNI/BIL INJ; EA ADD
AUTOLOGOUS CHONDROCYTE IMPLANTATION, KNEE
OSTEOCHONDRAL ALLOGRAFT, KNEE, OPEN
UNLISTED PROCEDURE, FEMUR OR KNEE (E.G., MENISCAL ALLOGRAFT TRANSPLANTATION)
SCOPE KNEE SURG IMPL OSTEOCHONDRAL GFT; AUTOGFT
OSTEOCHONDRAL ALLOGRAFT (E.G. MOSAICPLASTY)
MENISCAL TRANSPLANTATION (INCLUDES ARTHROTOMY FOR MENISCAL INSERTION), MEDIAL OR
LATERAL
RHINOPLASTY, PRIMARY; LATERAL AND ALAR CARTILAGES AND/OR ELEVATION OF NASAL TIP
RHINOPLASTY, PRIMARY; COMPLETE, EXTERNAL PARTS INCLUDING BONY PYRAMID, LATERAL AND ALAR
CARTILAGES, AND/OR ELEVATION OF NASAL TIP
RHINOPLASTY, PRIMARY; INCLUDING MAJOR SEPTAL REPAIR
SEPTAL OR OTHER INTRANASAL DERMATOPLASTY
36470
36471
INJECTION OF SCLEROSING SOLUTION ; SINGLE VEIN
INJESTION SCLEROSING SOLUTION ; MX VEINS SAME LEG
37204
37500
TRANSCATH OCCLUD/EMBOLIZAT PERQ NON CNS/HEAD
VASCULAR ENDOSCOPY, SURGICAL WITH LIGATION OF PERFORATOR VEINS, SUBFASCIAL (SEPS)
LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE ; WITH GASTRIC BYPASS AND ROUXEN-Y GASTROENTEROSTOMY (ROUX LIMB 150 CM OR LESS)
29868
30400
30410
43644
Focus Outpatient Precertification List
June 1, 2013
Code
43645
43770
43771
43772
43773
43774
Description
WITH GASTRIC BYPASS AND SMALL INTESTINE RECONSTRUCTION TO LIMIT ABSORPTION
LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; PLACEMENT OF ADJUSTABLE GASTRIC
RESTRICTIVE DEVICE
REVISION OF ADJUSTABLE GASTRIC RESTRICTIVE DEVICE COMPONENT ONLY
REMOVAL OF ADJUSTABLE GASTRIC RESTRICTIVE DEVICE COMPONENT ONLY
REMOVAL AND REPLACEMENT OF ADJUSTABLE GASTRIC RESTRICTIVE DEVICE COMPONENT ONLY
REMOVAL OF ADJUSTABLE GASTRIC RESTRICTIVE DEVICE AND SUBCUTANEOUS PORT COMPONENTS
43886
LAPAROSCOPY , SURGICAL , GASTRIC RESTRICTIVE PROCEDURE , LONGITUDINAL GASTRECTOMY ( IE,
SLEEVE GASTRECTOMY)
GASTRIC RESTRICTIVE PROCEDURE, WITOUT GASTRIC BYPASS, FOR MORBID OBESITY; VERTICALBANDED GASTROPLASTY
OTHER THAN VERTICAL-BANDED GASTROPLASTY
GASTRIC RESTRICTIVE PROCEDURE WITH PARTIAL GASTRECTOMY, PYLORUS-PRESERVING
DUODENOILEOSTOMY AND ILEOILEOSTOMY
GASTRIC RESTRICTIVE PROCEDURE, WITH GASTRIC BYPASS FOR MORBID OBESITY; WITH SHORT LIMB
(150 CM OR LESS) ROUX-EN-Y GASTROENTEROSTOMY
WITH SMALL INTESTINE RECONSTRUCTION TO LIMIT ABSORPTION
REVISION, OPEN, OF GASTRIC RESTRICTIVE PROCEDURE FOR MORBID OBESITY, OTHER THAN
ADJUSTABLE GASTRIC RESTRICTIVE DEVICE (SEPARATE PROCEDURE)
GASTRIC RESTRICTIVE PROCEDURE, OPEN; REVISION OF SUBCUTANEOUS PORT COMPONENT ONLY
43887
43888
REMOVAL OF SUBCUTANEOUS PORT COMPONENT ONLY
REMOVAL AND REPLACEMENT OF SUBCUTANEOUS PORT COMPONENT ONLY
47370
47371
LAPARSCPY SURG ABLAT 1/MORE LIVR TUMR; RADIOFREQ
LAPARSCPY SURG ABLAT 1/MORE LIVER TUMR; CRYOSURG
47380
ABLATION OPEN 1/MORE LIVER TUMOR; RADIOFREQUENCY
47381
ABLATION OPEN 1/MORE LIVER TUMOR; CRYOSURGICAL
47382
ABLAT 1/MORE LIVER TUMOR PERCUT RADIOFREQUENCY
55873
67900
67906
CRYOSURGICAL ABLATION OF THE PROSTATE
REPAIR OF BROW PTOSIS
REPR BLEPHAROPT; SUP RECTUS TECH W/FASCL SLING
67908
REPR BLEPHAROPTOSIS; CONJUNC-TARSO-MULLER’S
67909
67911
REDUCTION OF OVERCORRECTION OF PTOSIS
CORRECTION OF LID RETRACTION
GASTROINTESTINAL TRACT IMAGING, INTRALUMINAL (E.G., CAPSULE ENDOSCOPY), ESOPHAGUS
THROUGH ILEUM, WITH PHYSICIAN INTERPRETATION AND REPORT
TRNSCATH PLCMT RAD DEL DEVC SUBSQT COR BRACHYTX
REMOVAL OF IMPACTED TOOTH – PARTIALLY BONY ( INPATIENT SPU/ASC Only)
REMOVAL OF IMPACTED TOOTH – COMPLETELY BONY (INPATIENT SPU/ASC Only)
REMOVAL OF IMPACTED TOOTH – COMPLETELY BONY WITH UNUSUAL SURGICAL COMPLICATIONS
(INPATIENT SPU/ASC Only)
EXTERNAL COUNTERPULSATION PER TREATMENT SESSION
HYPERBARIC OXYGEN THERAPY (HBO)
43775
43842
43843
43845
43846
43847
43848
91110
92974
D7230
D7240
D7241
G0166
99183, C1300
63650, 63655,
63685
E0747, E0748,
20974, 20975
77301, 77418,
0073T
DORSAL COLUMN STIMULATORS
BONE GROWTH STIMULATORS
IMRT