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COVID-19

Medicare Advantage

Below are services that require prior authorization for all Individual and Group Medicare Advantage plans including Braven Health Plans.

Medicare Advantage PPO plans do not require prior authorization for out-of-network services. Group POS plans require prior authorization for both in-and out-of-network services.

Have questions about physical therapy, occupational therapy and speech therapy?

Services Requiring Prior Authorization

  • All Inpatient Admissions (excluding maternity admissions)
  • All elective acute care admissions (excluding maternity admissions) including:
    • Elective Surgical admissions
    • Elective Medical admissions
    • All rehabilitation facility admissions (e.g., Acute Rehab, Skilled Nursing Facility (SNF) and Sub-Acute admissions)
    • Mental health , substance abuse admissions, or partial hospitalizations (Prior authorization is performed by Horizon Behavioral Health)
  • Ambulance transportation (non-emergent only) - Ground or Air
  • Bariatric Procedures (for example: Gastric Bypass)
  • Breast Reconstruction
  • Cardiac Radiology Services (Non emergent only) (Prior authorization performed by eviCore healthcare)
  • Diagnostic Cardiac Catheterization / Echo Stress (Non-emergent only) (Prior authorization performed by eviCore healthcare)
  • Cosmetic Procedures - any potentially cosmetic procedure including cosmetic dermatology services; Examples:
    • Breast Reconstruction / Reduction Mammoplasty
    • Bone Graft
    • Excision of Excessive Skin - Lipectomy
    • Gynecomastia - surgical treatment
    • Orthognathic Surgery
    • Osteotomies
    • Rhinoplasty/Rhytidectomy/Septoplasty/Sinus Surgery
    • Sclerotherapy or Surgery for Varicose Veins
    • Cosmetic Eyelid surgery (e.g., Blepharoplasty/Canthoplasty)
    • Pectus excavatum repair
  • Diabetic Supplies and Services
  • Durable Medical Equipment (DME) and Prosthetics
  • Eyelid Surgery
  • Home Health Care Services (All skilled services provided in the home)
  • Home Infusion Services
  • Home Telemonitoring
  • Hyperbaric Oxygen Treatment
  • Laboratory services that cannot be provided by participating freestanding laboratories
  • Mental Health services
  • Occupational Therapy
  • Orthognathic Jaw Surgery
  • Out-of-network requests for consideration of In-Network level of benefit when a network deficiency exists
  • Pain Management Injections (Prior authorization performed by eviCore healthcare)
  • Physical Therapy
  • Radiology services (Prior authorization performed by eviCore healthcare)
    • CT/CTA Scans
    • MRI/MRA
    • Nuclear Medicine/Nuclear Cardiology
    • PET and PET/CT Scans
  • Sinus and Nasal Surgery
  • Surgery for Sleep Apnea (e.g., Uvelopalatopharyngoplasty [UPPP]/uvelopalatoplasty [UPP])
  • Specialty Pharmaceuticals/Drugs (e.g., Botox, IVIG, Flolan and derivates; Xolair)>
  • Speech Therapy
  • Temporomandibular Joint Surgery and Jaw Surgery
  • Transgender Surgery
  • Transplant Services/Organ Transplants (excluding Corneal Transplants)

ADDITIONAL SERVICES REQUIRING PRIOR AUTHORIZATION ONLY FOR MEMBERS ENROLLED IN Horizon NJ TotalCare (HMO SNP) plans

Please note that, in addition to the above-listed services, members enrolled in the Horizon NJ TotalCare (HMO SNP) plan must also obtain Prior Authorization for the services listed below.

  • Cardiac Rehabilitation
  • Chiropractic Services
  • Dental Services (as indicated below):
    • Crowns and crown build ups (once per 5 years)
    • Dentures and periodontics
    • Orthodontics for members under the 18 years of age where medical necessity is established and/or to correct a facial abnormality
    • Prosthodontics
    • Bridgework
    • Oral Surgery
    • Root Canals
    • Sedation
  • Durable Medical Equipment and Prosthetics (above $250), Orthotics (above $500)
  • Hearing aids
  • Hospice services (palliative and curative care) for members under age 21 years
  • Hysterectomy
  • Incontinent supplies (Medline vendor authorization required for monthly count >180 ct)
  • Medical Day Care health services (Adult and Pediatric)
  • Nursing Facility Care (custodial care)
  • Nutritional supplements and foods associated with genetic disorders or inborn errors of metabolism and treatment of weight loss due a medical condition
  • Personal Care Assistant Services (PCA)
  • Private duty nursing services provided to all eligible members under age 21 years
  • Pulmonary Rehabilitation
  • Sterilization
  • MLTSS (Managed Long Term Services & Supports) services