First Priority Health Authorizations (Fully Insured)
Effective date November 1, 2011
The following Outpatient Imaging Procedures will require precertification by National Imaging Associates (NIA):
CT/CTA/CCTA
MRI/MRA
PET Scan
Nuclear Cardiology / Stress Echo
**FOCUS Outpatient Procedure Precertification List
0075T
15830
TRNSCATH XTRACRAN
VERTB OR INTRATHOR ART
STNT PERQ; INITIAL
VESSEL
EXCISION, EXCESSIVE
SKIN AND SUBCUTANEOUS
TISSUE (INCLUDES
LIPECTOMY); ABDOMEN,
INFRAUMBILICAL
PANNICULECTOMY
1-800-962-5353
Fax # (570) 200-6799
43845
GASTRIC RESTRICTIVE PROCEDURE WITH
PARTIAL GASTRECTOMY, PYLORUSPRESERVING DUODENOILEOSTOMY AND
ILEOILEOSTOMY
27415
OSTEOCHONDRAL
ALLOGRAFT, KNEE, OPEN
43846
GASTRIC RESTRICTIVE PROCEDURE, WITH
GASTRIC BYPASS FOR MORBID OBESITY;
WITH SHORT LIMB (150 CM OR LESS) ROUXEN-Y GASTROENTEROSTOMY
27599
UNLISTED PROCEDURE,
FEMUR OR KNEE (E.G.,
MENISCAL ALLOGRAFT
TRANSPLANTATION)
43847
WITH SMALL INTESTINE RECONSTRUCTION TO
LIMIT ABSORPTION
43848
43886
27412
AUTOLOGOUS CHONDROCYTE
IMPLANTATION, KNEE
21137
REDUCTION FOREHEAD;
CONTOURING ONLY
21138
REDUCTION FOREHEAD;
CONTOUR&APPLIC
PROSTH MATL/BN GFT
29866
SCOPE KNEE SURG IMPL
OSTEOCHONDRAL GFT;
AUTOGFT
21139
REDUCTION FOREHEAD;
CONTOUR&SETBACK
FRNTL SINUS WALL
29867
OSTEOCHONDRAL ALLOGRAFT
(E.G. MOSAICPLASTY)
21175
RECON BIFRONTAL ORBIT
RIMS&LO FOREHEAD W/WO
GFTS
29868
21179
RECON MAJORITY
FOREHEAD/SUPRAORBITAL
RIMS; W/GFT
30400
21180
RECON MAJORITY
FOREHEAD/SUPRAORB
RIMS; W/AUTOGFT
30410
Revised August 1, 2011
Regardless of the setting - physician office, outpatient facility, or SPU
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
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
REMOVAL OF SUBCUTANEOUS PORT
COMPONENT ONLY
43888
REMOVAL AND REPLACEMENT OF
SUBCUTANEOUS PORT COMPONENT ONLY
47370
LAPARSCPY SURG ABLAT 1/MORE LIVR TUMR;
RADIOFREQ
21181
21182
21183
21184
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
30420
RHINOPLASTY, PRIMARY;
INCLUDING MAJOR SEPTAL
REPAIR
47371
LAPARSCPY SURG ABLAT 1/MORE LIVER
TUMR; CRYOSURG
30620
SEPTAL OR OTHER
INTRANASAL DERMATOPLASTY
47380
ABLATION OPEN 1/MORE LIVER TUMOR;
RADIOFREQUENCY
36470
INJECTION OF SCLEROSING
SOLUTION ; SINGLE VEIN
47381
ABLATION OPEN 1/MORE LIVER TUMOR;
CRYOSURGICAL
47382
ABLAT 1/MORE LIVER TUMOR PERCUT
RADIOFREQUENCY
55873
CRYOSURGICAL ABLATION OF THE PROSTATE
67900
REPAIR OF BROW PTOSIS
67906
REPR BLEPHAROPT; SUP RECTUS TECH
W/FASCL SLING
67908
REPR BLEPHAROPTOSIS; CONJUNC-TARSOMULLER’S
67909
REDUCTION OF OVERCORRECTION OF PTOSIS
67911
CORRECTION OF LID RETRACTION
91110
GASTROINTESTINAL TRACT IMAGING,
INTRALUMINAL (E.G., CAPSULE ENDOSCOPY),
ESOPHAGUS THROUGH ILEUM, WITH
PHYSICIAN INTERPRETATION AND REPORT
92974
TRNSCATH PLCMT RAD DEL DEVC SUBSQT
COR BRACHYTX
D7230
REMOVAL OF IMPACTED TOOTH – PARTIALLY
BONY ( INPATIENT SPU/ASC Only)
36471
21208
OSTEOPLASTY FACIAL
BONES; AUGMENTATION
37204
21209
OSTEOPLASTY FACIAL
BONES; REDUCTION
37500
21256
RECONSTRUCTION ORBIT
W/OSTEOTOMIES&W/BONE
GRAFTS
43644
21270
MALAR AUGMENTATION
PROSTHETIC MATERIAL
43645
21275
SEC REVISION
ORBITOCRANIOFACIAL
RECONSTRUCTION
43770
21280
MEDIAL CANTHOPEXY-SEP
PROC
43771
21282
LATERAL CANTHOPEXY
22220
OSTEOT SPN W/DISKECT
ANT APPRCH 1 VERT SEG;
CERV
22224
OSTEOT SPN W/DISKECT
ANT APPRCH 1 VERT SEG;
LUMB
Revised August 1, 2011
43772
43773
43774
INJESTION SCLEROSING
SOLUTION ; MX VEINS SAME
LEG
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 ROUX-EN-Y
GASTROENTEROSTOMY (ROUX
LIMB 150 CM OR LESS)
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
22520
PERQ VERTPLSTY 1 VERT
BODY UNI/BIL INJ;
THORACIC
22521
PERQ VERTPLSTY 1 VERT
BODY UNI/BIL INJ; LUMBAR
43842
22522
PERQ VERTPLSTY 1 VERT
BODY UNI/BIL INJ; EA ADD
43843
43775
LAPAROSCOPY , SURGICAL ,
GASTRIC RESTRICTIVE
PROCEDURE , LONGITUDINAL
GASTRECTOMY ( IE, SLEEVE
GASTRECTOMY)
GASTRIC RESTRICTIVE
PROCEDURE, WITOUT
GASTRIC BYPASS, FOR
MORBID OBESITY; VERTICALBANDED GASTROPLASTY
OTHER THAN VERTICALBANDED GASTROPLASTY
D7240
REMOVAL OF IMPACTED TOOTH –
COMPLETELY BONY (INPATIENT SPU/ASC Only)
D7241
REMOVAL OF IMPACTED TOOTH –
COMPLETELY BONY WITH UNUSUAL
SURGICAL COMPLICATIONS (INPATIENT
SPU/ASC Only)
G0166
EXTERNAL COUNTERPULSATION PER
TREATMENT SESSION
First Priority Health Authorizations

A Prior Authorization, Non-participating Authorization, or Precertification is not a guarantee of payment by FPH. The authorization is for medical necessity
as long as it is a benefit for the member.
Prior Authorization is required for:


Emergency Room services if directed to the ER by the Primary Care Physician or BlueCare HMO in advance of service and the service could have been
provided at the PCP office.
All services by non-participating providers
Check member eligibility/benefits prior to any service by accessing NaviNet or by calling Provider Services Unit at 1-800-822-8752, Monday through Friday, 8:00
a.m. to 5:00 p.m.
Non-participating Authorizations are required for all services by non-participating specialists and/or facilities.




Medical Director approval is required prior to services being rendered. No authorizations will be approved retroactively.
Request may be made by either the network specialist or the PCP, using the appropriate form or by phone to 1-800-962-5353
All requests must contain complete information; You will be notified if additional information is required.
Please use only BlueCard providers (www.bcbs.com “Find doctors or hospitals nationwide”)
Fax completed forms & necessary documentation to (570) 200-6840
Precertification is required for:
# 1-800-962-5353 Fax # (570) 200-6799

Inpatient admissions to: acute care, rehab, and skilled nursing facilities

Home Health Visits
Revised August 1, 2011

Home Health Therapy Services (Physical, Occupational, Speech Therapy) effective with group renewals beginning 07/01/2008

**Select Surgical Procedures. (See procedure list)

All transplant surgeries

Inpatient Behavioral Health Care Services for the following ICD-9 diagnosis codes: 290 – 319 require precertification. For Outpatient services please
verify precertification requirements by calling Community Behavioral Healthcare of Northeastern Pa (CBHNP) at 1-800-577-3742.
Pharmacy Prior Authorization Program:
1-800-722-4062
Fax #: (570) 200-6870

Home Infusion Services - TPN, IVIG, Enteral feedings, Neupogen given intravenously, and Rocephin for Lyme disease require approval through the FPH Pharmacy

Department via the Prior Authorization form.
Refer to formulary for the current list of drugs requiring prior authorization – www.bcnepa.com
Revised August 1, 2011