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MEDICATIONS AND INJECTIBLES
Infusion Therapy (except exclusion list) *see pages 43-44
Injectibles (except Flu, Pneumococcal, Tetanus and
Hepatitis B) *see attachment pages 43-44
IMMUNIZATIONS (except Influenza,
Tetanus, Hepatitis B and Pneumovax)
Immunizations for Travel
Enhanced External Counter Pulsation (ECP) G0166 (limited
to 35 visits per 12 month period)
Hyperbaric Oxygen Therapy
Interventional Radiology
OUT-PATIENT SERVICES
Thoracic Stress Echo
RADIOLOGY
CT Scans
MRA
MRI
ALL Nuclear Medicine including Nuclear Cardiology
PET Scans
Stress Echo
RADIATION THERAPY
Intensity-Modulated Radiation Therapy (IMRT) - Prior
authorization is required only for elective admission. A
course of therapy occurring as part of an inpatient
confinement that has met medical necessity criteria and been
authorized does not require separate authorization.
Cardiac Rehabilitation
Occupational Therapy (after 1st 12 visits)
Physical Therapy (after 1st 12 visits)
THERAPY /REHABILITATION
Pulmonary Rehabilitation
Speech Therapy (except initial evaluation)
Inpatient (Place of Service 21,31,51,61)
Note: Emergency and urgent admissions do not require prior authorization. Medical necessity criteria will be
applied after facility’s notification to Bravo Health. Authorization for claims payment will only be granted to
those meeting medical necessity criteria.
The following services do require authorization as outlined below:
Diabetic Supplies (initial set up only)
DME Purchase (All Medicare Approved) >$200 Per Line
Item
All Prosthetics except mastectomy bras, colostomy
supplies, indwelling Foley catheters
Rentals (All)
DURABLE MEDICAL EQUIPMENT
Repairs & Maintenance (All)
