NJ Direct

SERVICES REQUIRING PRIOR AUTHORIZATION

Accidental Dental Injuries

Air Ambulance

Cancer Clinical Trials

Cardiac Procedures

  • Echo Stress Tests
  • Diagnostic Left Heart Catheterization

Cochlear Implants

Durable Medical Equipment (DME), Prosthetics and Orthotics (referenced below)

  • Electric, customized or motorized wheelchairs and scooters, and powered accessories
  • Electric beds/Clinitron/Powered Hospital beds/Air mattresses/Powered Accessories
  • Enteral Formula
  • Bone stimulators
  • Neurostimulators
  • Limb and Torso prosthetics
  • Voice Prosthetic Devices
  • Lymphadema Pumps
  • External defibrillators
  • All rentals

Inpatient Admissions:

  • All acute care confinements, exclusive of maternities, including:
    1. Surgical admissions
    2. Medical admissions
    3. Hospice admission
    4. All Skilled Nursing Facility (SNF) confinements
  • All Rehabilitation facility confinements
  • All Sub-Acute confinements
  • Mental health and substance abuse confinements (including Residential, Partial Hospitalizations and Intensive Out-Patient Admissions.)

Home Health Care Services

  • Home Hospice Services
  • Hospital Based Weight Loss Programs
  • Hyperbaric Oxygen Therapy

Infertility Services

  • Gamete intrafallopian transfer
  • InVitro Fertilization
  • Zygote intrafallopian transfer
  • Artificial insemination
  • Hysterosalpingography

Home Infusion (IV) Therapy

Mental Health and Alcohol and Substance Abuse Outpatient Services

Specific Medications administered in a physician's office or dialysis center (review performed by eviCore National)

  • Aranesp
  • Epogen
  • Procrit

Pain Management

Private Duty Nursing in the Home (Inpatient PDN is ineligible)

Reconstructive Procedures That May Be Considered Cosmetic:

  • Blepharoplasty/Canthopexy/Canthoplasty
  • Excision of excessive skin due to weight loss
  • Rhinoplasty/rhytidectomy
  • Pectus excavatum repair
  • Breast reconstruction/enlargement
  • Breast reduction/mammoplasty
  • Lipectomy or excess fat removal
  • Sclerotherapy or surgery for varicose veins
  • Facial reconstruction or repair including:
    • Orthognathic surgery
    • Bone grafts
    • Osteotomies
    • Surgical management of temporomandibular joint
  • Any other potentially cosmetic procedure

Radiology (review services performed by eviCore National)

  • CT/CTA Scans
  • MRI/MRA
  • Nuclear Medicine/Nuclear Cardiology
  • PET and PET/CT Scans

Spinal Disc Surgeries (including but not limited to):

  • Percutaneous Laser Discectomy
  • Nucleoplasty
  • Spinal Fusion

Surgery for Morbid Obesity (including but not limited to):

  • Gastroplasty
  • Gastric Bypass
  • Bariatric Procedures

Therapy Services:

  • Cognitive Therapy
  • Occupational Therapy
  • Physical Therapy
  • Speech Therapy

Transplants

  • Lung
  • Liver
  • Heart
  • Pancreas
  • Autologous Bone Marrow
  • Cornea
  • Kidney
  • Autologous Condrocyte Transplants

Uvulopalatopharyngoplasty (UPPP)