SHBP

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, including 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) including but not limited to 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 graft, Osteotomies, Surgical management of temporomandibular joint, and any other potentially cosmetic procedure

  • Radiology services (review performed by eviCore) 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)