Effective for dates of service on or after January 1, 2012, we will implement important changes to the list of services and drugs that require precertification for Medicare Advantage HMO and PPO members.

The following precertification requirements will be added for Medicare Advantage products in all settings:

potentially cosmetic procedures (please refer to the complete list);

pain management procedures (i.e., paravertebral facet joint injections, transforaminal epidural injections,epidural injections);

hyperbaric oxygen treatments;

additional medical infusion/injectable drugs (please refer to the complete list);

cataract surgery;

cochlear implant surgery;

uvulopalatopharyngoplasty (UPPP or UP3).

The following precertification requirements will be removed for Medicare Advantage products in all settings:

sleep studies

cardiac rehabilitation

pulmonary rehabilitation

As we proceed through this transition, it is very important for providers to continue to refer to the most current precertification requirements lists or to use the NaviNet? web portal to verify member-specific requirements. Failure to obtain precertification for any of the services or drugs that require it may result in a reduction in payment or nonpayment for the services not precertified.

Please call 1-800-ASK-BLUE if you have any questions about these upcoming changes.

Potentially cosmetic procedures that will require precertification Blepharoplasty/ptsosis repair Hair transplant Rhinoplasty Breast: reconstruction, reduction, augmentation, mammoplasty, mastopexy, insertion, and removal of breast implants Injectable dermal fillers Rhytidectomy Canthopexy/canthoplasty Keloid removal Scar revision Cervicoplasty Labiaplasty Skin closures including: skin grafts, skin flaps, and tissue grafts Chemical peels Lipectomy, liposuction, or any other excess fat removal procedure Sex reassignment surgery Dermabrasion Orthognathic surgery procedures including, but not limited to: bone graft, genioplasty, osteoplasty, mentoplasty, osteotomies Surgical treatment of gynecomastia Excision of excessive skin and/or subcutaneous tissue Otoplasty Surgery for varicose veins, including perforators and sclerotherapy Genetically and bio-engineered skin substitutes for wound care
Additional infusion drugs that will require precertification Abraxane? Enzyme replacement (Lumizyme?, Replagal?*, Uplyso?*, VPRIV?) Istodax? Alimta? Flolan? Jevtana? Alpha 1 inhibitors (Aralast NPTM,GlassiaTM, Prolastin? C, Zemaira?) Folotyn? Provenge? ArzerraTM Gammaplex? (IVIG) Psoriasis/rheumatoid arthritis (Actemra?) Belatacept HalavenTM Remodulin? Benlysta? Hemophilia factors Soliris? C1 esterase inhibitors (Berinert?, Cinryze?) Herceptin? DM1* YervoyTM CorifactTM (factor drug)
Additional injectable drugs that will require precertification Kalbitor? MakenaTM Stelara? Lucentis? OmparoTM* XgevaTM Macugen? Prolia? Xolair?

*This drug is pending approval from the U.S. Food and Drug Administration.

NaviNet? is a registered trademark of NaviNet, Inc., an independent company.