Please access the Highmark Wholecare Provider Portal via Navinet to determine if a drug/HCPCS code requires authorization and to submit authorization requests. View drug authorization requirements/submit authorization requests here: https://navinet.navimedix.com.

Name
Type
State
Effective
4Kscore Test Algorithm (L37792) Medical Policy PA Medicare 03/01/2024
Acupuncture for Chronic Low Back Pain (NCD 30.3.3) Medical Policy PA Medicare 01/01/2024
Ambulance Services (Air) Medical Policy PA Medicare 08/01/2023
Ambulatory Blood Pressure Monitor (NCD 20.19) Medical Policy PA Medicare 09/01/2023
Assessing Patient’s Suitability for Electrical Nerve Stimulation Therapy (160.7.1 & 160.7) Medical Policy PA Medicare 02/01/2024
Automatic External Defibrillators (AED) (L33690) Medical Policy PA Medicare 07/01/2023
Biomarkers Overview (L35062) Medical Policy PA Medicare 01/01/2024
Blood Glucose Testing (NCD 190.20) Medical Policy PA Medicare 03/01/2023
Bronchial Thermoplasty Medical Policy PA Medicare 09/01/2023
Cardiac Event Detection Monitoring (L34953) Medical Policy PA Medicare 04/01/2023
Cardiac Rhythm Device Evaluation (L34833) Medical Policy PA Medicare 04/01/2023
Carpal Tunnel Surgery Medical Policy PA Medicare 10/01/2022
Cataract Extraction (including Complex Cataract Surgery) Medical Policy PA Medicare 04/01/2023
Chromosomal Microarray Analysis: Comparative Genomic Hybridization (CGH) and Single Nucleotide Polymorphism (SNP) Medical Policy PA Medicare 08/01/2023
Cochlear Implantation (NCD 50.3) Medical Policy PA Medicare 05/01/2023
Controlled Substance Monitoring and Drugs of Abuse Testing (L35006) Medical Policy PA Medicare 09/01/2023
Cosmetic and Reconstructive Surgery (L35090) Medical Policy PA Medicare 08/01/2023
Electrocardiographic (EKG or ECG) Monitoring (Holter or Real-Time Monitoring) (L34636) Medical Policy PA Medicare 08/01/2023
Electrocardiographic Services (NCD 20.15) Medical Policy PA Medicare 04/01/2023
Fecal Microbiota Transplant Medical Policy PA Medicare 02/01/2024
Gastrointestinal Pathogen (GIP) Panels Utilizing Multiplex Nucleic Acid Amplification Techniques (NAATs) (L38229) Medical Policy PA Medicare 05/01/2023
Home Oxygen Therapy (L33797) Medical Policy PA Medicare 10/01/2022
Hyperbaric Oxygen Therapy (HBOT) (NCD 20.29) Medical Policy PA Medicare 12/01/2023
Hypoglossal Nerve Stimulation for the Treatment of Obstructive Sleep Apnea (L38385) Medical Policy PA Medicare 04/01/2023
Magnetic-Resonance-Guided Focused Ultrasound Surgery (MRgFUS) for Essential Tremor (L38495) Medical Policy PA Medicare 01/01/2024
Medication Prior Authorization Criteria Part B Medical Policy PA Medicare 01/01/2024
Implantable Continuous Glucose Monitors (I-CGM) (L38617) Medical Policy PA Medicare 02/01/2024
Inpatient Only Medical Policy PA Medicare 10/01/2023
Micro-Invasive Glaucoma Surgery (MIGS) (L38223) Medical Policy PA Medicare 04/01/2023
Negative Pressure Wound Therapy (NPWT) Pumps (L33821) Medical Policy PA Medicare 10/01/2023
Non-Invasive Peripheral Venous Studies (L35451) Medical Policy PA Medicare 07/01/2023
Observation Care (Hospital Outpatient) Medical Policy PA Medicare 10/01/2023
Osteogenic Stimulators (150.2) Medical Policy PA Medicare 11/01/2023
Percutaneous Transluminal Angioplasty (PTA) (NCD 20.7) Medical Policy PA Medicare 07/01/2023
Peripheral Nerve Stimulation (L37360) Medical Policy PA Medicare 04/01/2023
Pharmacogenomic Testing for Warfarin Response (NCD 90.1) Medical Policy PA Medicare 11/01/2023
Pulmonary Rehabilitation (PR) Medical Policy PA Medicare 07/01/2023
Repetitive Transcranial Magnetic Stimulation (rTMS) in Adults with Treatment Resistant Major Depressive Disorder (LCD 34998) Medical Policy PA Medicare 05/01/2023
Scanning Computerized Ophthalmic Diagnostic Imaging (L35038) Medical Policy PA Medicare 07/01/2023
Speech-Generating Devices ((L33739) Medical Policy PA Medicare 02/01/2024
Spinal Cord Stimulation (Dorsal Column Stimulation) (L35450) Medical Policy PA Medicare 04/01/2023
Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) (NCD 20.35) Medical Policy PA Medicare 12/01/2023
Testing for Genetic Disease Medical Policy PA Medicare 11/01/2023
Upper Gastrointestinal Endoscopy (Diagnostic and Therapeutic) (L35350) Medical Policy PA Medicare 04/01/2023
Vitamin D Deficiency Screening Medical Policy PA Medicare 07/01/2023


Highmark Wholecare Policy Disclaimer

  • The Policies neither constitutes nor substitutes for medical advice. Highmark Wholecare’s Policies should not be construed as providing medical advice or treatment or guaranteeing the outcome or results of any medical services/treatments and/or procedures Providers are responsible for providing medical advice and treatment, are independent contractors, and are not employees or agents of Highmark Wholecare. If members have a specific question about their medical condition, they should consult with their provider.
  • In the event of a conflict between the Policy and Member Handbook or Evidence of Coverage, the express terms of the Member Handbook or Evidence of Coverage will govern. The existence of a medical guideline is not an authorization, certification, explanation of benefits, or a contract for the service (or supply) that is referenced in the medical guideline.  The Policies are used in making decisions as to medical necessity only and they do not guarantee payment of services. Policies serve as one of the sets of guidelines for coverage decisions.
  • The information on this website may not reflect a recent policy change or all of the applicable medical guidelines.
Last updated on 2/16/2024 1:41:56 PM

 

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