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Endoscopy Procedures
Gastroenterology (91000-91299)
Hyperbaric Oxygen Therapy
Interventional Radiology
Intracardiac Electrophysiological Procedures (93600-
93668)
Neurological Testing (95812-96120)
Out-Patient Therapy *see therapy for auth rule
Pain Management Epidural 64400-64530 (ASC approval
after 3rd inject) *Performed by Anesthesiologist
Pulmonary Testing (94010-94799)
Regulated Space (Maryland only)
Sleep Studies
Surgery
Thoracic Stress Echo
Vestibular Function Test (92531-92548)
Wound Management
Hearing Exams
Non-Participating Providers except Anesthesiologists
*Refer to Pain Management
PROFESSIONAL SERVICES
Non-Participating except chiropractors
CT Scans
MRA
MRI
ALL Nuclear Medicine including Nuclear Cardiology
PET Scans
RADIOLOGY
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)
Pulmonary Rehabilitation
THERAPY /REHABILITATION
Speech Therapy (except evaluation)
