Page 6 - 2022 Arabella Advisors Benefit Guide
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Medical Coverage – Pre-certification
Services that requireprecertification:
1. Inpatient confinements (except hospice) 19. Nonparticipating freestanding ambulatory surgical
For example, surgical and nonsurgical stays, stays in a facility services, when referred by a participating
skilled nursing facility or rehabilitation facility, and provider
maternity and newborn stays that exceed the 20. Orthognathic surgery procedures, bone grafts,
standard length of stay (LOS). (See #6 in the osteotomies and surgical management of the
General Information section.) temporomandibular joint
2. Ambulance 21. Osseo integrated implant
Precertification required for transportation by fixed- 22. Osteochondral allograft/knee
wing aircraft (plane) 23. Private duty nursing
3. Arthroscopic hip surgery to repair impingement 24. Proton beam radiotherapy
syndrome including labral repair Also see Special Programs; Radiation Oncology
4. Autologous chondrocyte implantation 25. Reconstructive or other procedures that maybe
5. Cataract surgery – precertification required considered cosmetic, such as:
effective 7/1/2021. See special programs for • Blepharoplasty/canthoplasty
additional guidance. • Breast reconstruction/breast enlargement
6. Chiari malformation decompression surgery • Breast reduction/mammoplasty
7. Cochlear device and/or implantation • Excision of excessive skin due to weight loss
8. Coverage at an in-network benefit level • Gastroplasty/gastric bypass
for out-of-network provider or facility unless services • Lipectomy or excess fat removal
are emergent. • Surgery for varicose veins, except stab
Some plans have limited or no out-of-network phlebectomy
benefits. 26. Shoulder Arthroplasty including revision procedures
9. Dentalimplants 27. Spinal procedures, such as:
10. Dialysis visits • Artificial intervertebral disc surgery (cervical
When a participating provider initiates a spine)
request and dialysis is to be performed at a • Arthrodesis for spine deformity
nonparticipating facility. • Cervical laminoplasty
11. Dorsal column (lumbar) neurostimulators: • Cervical, lumbar and thoracic laminectomy
trial or implantation and\or laminotomy procedures
12. Electric or motorized wheelchairs and • Kyphectomy
scooters • Laminectomy with rhizotomy
13. Endoscopic nasal balloon dilation procedures • Spinal fusion surgery – precertification
14. Functional endoscopic sinus surgery (FESS) required for sacroiliac joint fusion surgery
15. Gender affirmation surgery effective 7/1/2021
16. Hyperbaric oxygen therapy
• Vertebral corpectomy – precertification is
17. Infertility services and pre-implantation genetic
required effective 7/1/2021.
testing
29. Ventricular assist devices
18. Lower limb prosthetics, such as microprocessor-
controlled lower limb prosthetics 30. Video electroencephalograph (EEG)
31. Whole exomesequencing
https://www.aetna.com/health-care-
professionals/precertification/precertifica
tion-lists.html
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