Updated FPH MRI and Focus Outpatient Precertifi cation Listings
First Priority Health has updated the listings of FPH MRI and Focus Outpatient procedures that require a precertification.
Please discard the listings that appeared in the June 2005 issue of the Provider Bulletin and use the listings below for
your reference. FPH Precertification can be conducted either by phone at 1-800-962-5353 or via NaviNet. The revisions
are effective August 1, 2005.
FPH Focus Outpatient Procedure Precertifi cation List
August 2005
Code
21137
21138
21139
21175
21179
21180
21181
21182
21183
21184
21208
21209
21256
21270
21275
21280
21282
22220
22224
22520
22521
22522
30520
30620
30801
30802
36470
36471
36475
36476
36478
36479
Description
RDUCTION FOREHEAD; CONTOURING ONLY
RDUC FOREHEAD; CONTOUR&APPLIC PROSTH
MATL/BN GFT
RDUC FOREHEAD; CONTOUR&SETBACK FRNTL SINUS
WALL
RECON BIFRONTAL ORBIT RIMS&LO FOREHEAD W/WO
GFTS
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
RECONSTRUCTION ORBIT W/OSTEOTOMIES&W/BONE
GRAFTS
MALAR AUGMENTATION PROSTHETIC MATERIAL
SEC REVISION ORBITOCRANIOFACIAL
RECONSTRUCTION
MEDIAL CANTHOPEXY-SEP PROC
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
SEPTPLSTY/SUBMUCOS RES W/WO CART SCOR/REPL
W/GFT
SEPTAL OR OTHER INTRANASAL DERMATOPLASTY
CAUT&/ABLAT MUCOS TURBINS UNI/BIL SEP PROC;
SUP
CAUT&/ABLAT MUCOS TURB UNI/BIL SEP
PROC;INTRMURL
INJECTION OF SCLEROSING SOLUTION; SINGLE VEIN
INJECTION SCLEROSING SOLUTION; MX VEINS SAME
LEG
ENDOVENUS ABLAT TX INCOMPETENT VEIN EXT RF; 1
VN
ENDOVEN ABLAT TX VEIN EXT RF; 2&>VNS 1 EXT EA
ENDOVEN ABLAT TX INCMPETNT VEIN EXT LASR;1 VEIN
ENDOVEN ABLAT TX VEIN EXT LASR; 2&>VNS 1 EXT EA
37204
42145
43644
43645
43842
43843
43848
43846
43847
47370
47371
47380
47381
47382
52510
55873
67900
67901
67902
67903
67904
67906
67908
67909
67911
92974
0075T
29866
29867
29868
0027T
TRANSCATH OCCLUD/EMBOLIZAT PERQ NON
CNS/HEAD
PALATOPHARYNGOPLASTY
LAP GASTR RSTRCIV PROC; GASTR BYPS & ROUX-EN-Y
LAP GASTR RSTRCIV PROC; GASTR BYPS&SM INTST
RECON
GASTRIC RESTRICT NO BYP-MORBID OBES; VERTCL
BAND
GAST RESTRICT W/O BYP-MORBID OBES; NOT VERT
BAND
REV GASTR RETSRCTV PROC FOR MORBID OBES
GASTR RSTRC PROC W/GASTR BYPS; SHRT LMB
ROUX-EN-Y
GASTR RESTIRCT W/BYPS MORBID OBES; W/SB RECON
LAPARSCPY SURG ABLAT 1/MORE LIVR TUMR;
RADIOFREQ
LAPARSCPY SURG ABLAT 1/MORE LIVER TUMR;
CRYOSURG
ABLATION OPEN 1/MORE LIVER TUMOR;
RADIOFREQUENCY
ABLATION OPEN 1/MORE LIVER TUMOR;
CRYOSURGICAL
ABLAT 1/MORE LIVER TUMOR PERCUT
RADIOFREQUENCY
TRANSURETHRAL BALLOON DILATION PROSTATIC
URETHRA
CRYOSURGICAL ABLATION OF THE PROSTATE
REPAIR OF BROW PTOSIS
REP BLEPHAROPT; FRNTLIS MUSC TECH W/SUT/OTH
MATL
REPR BLEPHAROPT; FRNTLIS MUSC TECH W/FASCL
SLING
REP BLEPHAROPT; LEVATOR RES/ADVMENT INTRL
APPRCH
REPR BLEPHAROPT; LEVATOR RES/ADVMENT EXT
APPRCH
REPR BLEPHAROPT; SUP RECTUS TECH W/FASCL
SLING
REPR BLEPHAROPTOSIS; CONJUNC-TARSO-MULLER’S
REDUCTION OF OVERCORRECTION OF PTOSIS
CORRECTION OF LID RETRACTION
TRNSCATH PLCMT RAD DEL DEVC SUBSQT COR
BRACHYTX
TRNSCATH XTRACRAN VERTB OR INTRATHOR ART
STNT PERQ;
NIT
SCOPE KNEE SURG IMPL OSTEOCHONDRAL GFT;
AUTOGFT
SCOPE KNEE SURG IMPL OSTEOCHONDRAL GFT;
ALLOGFTS
MENISCAL TRANSPLANTATION MEDIAL OR LATERAL
KNEE
ENDO LYSIS EPIDURL ADHES W/DIR VISLIZATION
MRI Precert List August 2005
Code
70544
70551
Description
MRA Angiography Head w/o Dye
MRI Brain w/o Dye
70552
MRI Brain w/ Dye
70553
MRI Brain w/ and w/o Dye
72141
MRI Neck Spine w/o Dye
72142
72146
72148
MRI Neck Spine w/ Dye
MRI Thoracic Spine w/o Dye
MRI Lumbar Spine w/o Dye
72149
MRI Lumbar Spine w/ Dye
72156
MRI Neck Spine w/ and w/o Dye
72157
MRI Thoracic Spine w/ and w/o Dye
72158
73221
MRI Lumbar Spine w/ and w/o Dye
MRI Joint Upper Extremity w/o Dye
73222
MRI Joint Upper Extremity w/ Dye
73721
MRI Joint Lower Extremity w/o Dye
73722
MRI Joint Lower Extremity w/ Dye
76390
Magnetic Resonance Spectroscopy
72147
73223
MRI Thoracic Spine w/Dye
MRI Joint Upper Extremity w/and w/o Dye
73723
MRI Joint Lower Extremity w/ and w/o Dye