40
Ambulatory Surgery Center (Place of Service 24)
Interventional Radiology
OUTPATIENT SERVICES
Pain Management Epidural 64400-64530 (ASC approval
after 3rd inject) *Performed by Anesthesiologist
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.
Home Health Services (Place of Service 12)
Diabetic Shoes
Diabetic Supplies (initial set up only required)
purchase ( Medicare Approved) >$200 Per Line Item
Prosthetics except mastectomy bras, colostomy supplies,
indwelling Foley catheters
Rentals
DURABLE MEDICAL
EQUIPMENT
Repairs & Maintenance
Diabetic Education Training
Dialysis Self Training
EDUCATION
Nutritional Education Classes (97802-97804) Diabetes and
Renal
HOME HEALTH SERVICES
Aide
Primary Care Physicians (PCPs) may see
Members in their home without prior
authorization
Dialysis in Home
Infusion
Nurse
Occupational Therapy
Physical Therapy
Specialist Physician Home Visits (except Podiatry)
Speech Therapy
Wound Management
