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Medical Policy, Clinical UM Guidelines, and Pre-Cert Requirements
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Blue Preferred (HMO), Blue Preferred Plus (POS), Blue Access (PPO), Blue Access Choice (PPO)

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Inpatient Admission:  

Elective Admissions

Emergency Admissions (Anthem requires Plan notification within 24 hours)

OB Related Medical Stay(OB complications, Excludes childbirth)

Newborn Stays beyond Mother

Inpatient Skilled Nursing Facility

Rehabilitation facility admissions

 
Outpatient Services:  
UPPP surgery( uvulopalatopharyngoplasty,uvulopharyngoplasty)
Plastic/Reconstructive surgeries: (only specific procedures listed)

Blepharoplasty

Rhinoplasty

Hairplasty

Panniculectomy and Lipectomy/Diatasis Recti Repair

Insertion/Injection of Prosthetic Material Collagen Implants

Chin Implant/Mentoplasty/Osteoplasty Mandible

 
DME/Prosthetics: recommendation is to verify benefits for all DME, and medical necessity on the list below.

Wheelchairs, special size, motorized or powered, and accessories

Hospital Beds, Rocking Beds, and Air Beds

Electronic or externally powered prosthetics

Custom made and /or Custom fitted prefabricated orthotics and braces

Private Duty Nurse services in the home setting.
 
Radiology services

Nuclear Cardiac

CT Scan(includes CTA)

MRI,

MRA,

MRS

PET

 
Human Organ and Bone Marrow/Stem Cell Transplants 

All Inpatient admits for the following:

Heart transplant

Liver transplant

Lung or double lung transplant

Simultaneous Pancreas./Kidney

Pancreas transplant

Kidney transplant

Small bowel transplant

Multi-visceral transplant

Stem cell/Bone Marrow transplant (with or without myeloablative therapy)

All Outpatient services for the following: 
Stem Cell/Bone Marrow transplant (with or without myeloablative therapy)
Donor Leukocyte Infusion
Referrals: 
Out of Network Referrals (may be pre-authorized, based on network availability and or medical necessity.) 
Mental health/Substance Abuse (MHSA):  
MO products
All facility based care-
Inpatient admissions,
intensive outpatient therapy,
Partial Hospitalization,
Residential Care, and
Electric Convulsive Therapy (ECT).
©2005-2014 copyright of Anthem Insurance Companies, Inc.

Anthem Blue Cross and Blue Shield is the trade name of: In Colorado Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc. In Connecticut: Anthem Health Plans, Inc. In Indiana: Anthem Insurance Companies, Inc. In Kentucky: Anthem Health Plans of Kentucky, Inc. In Maine: Anthem Health Plans of Maine, Inc. In Missouri (excluding 30 counties in the Kansas City area): RightCHOICE® Managed Care, Inc. (RIT), Healthy Alliance® Life Insurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. In Nevada: Rocky Mountain Hospital and Medical Service, Inc. HMO products underwritten by HMO Colorado, Inc., dba HMO Nevada. In New Hampshire: Anthem Health Plans of New Hampshire, Inc. In Ohio: Community Insurance Com pany. In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. In Wisconsin: Blue Cross Blue Shield of Wisconsin ("BCBSWi"), which underwrites or administers the PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare"), which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively, which underwrite or administer the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association. Use of the Anthem Web sites constitutes your agreement with our Terms of Use