Page 6 - National Door_Benefit Guide 2021

Medical Coverage:

(Model Precertification List)

All Inpatient Admissions Outpatient and Physician: Diagnostic Services
• Acute • CT for non-orthopedic
• Long-Term Acute Care
• MRI for non-orthopedic
• Rehabilitation
• PET
• Mental Health/Substance Use Disorder
• Capsule endoscopy
• Residential Treatment Facility
• Genetic Testing, including BRCA
• Transplant
• Sleep Study
• Skilled Nursing Facility
Outpatient and Physician: Continuing
Outpatient and Physician: Surgery Care Services
• Breast and bone marrow biopsy • Chemotherapy (including oral)
• Biopsies (excluding skin)
• Radiation Therapy
• Vascular Access Devices for the Infusion of Chemotherapy • Oncology and transplant related injections, infusions and
(including, but not limited to, PICC and Central Lines) treatments (e.g. CAR-T, endocrine and immunotherapy),
• Thyroidectomy, Partial or Complete excluding supportive drugs (e.g. antiemetic and antihistamine)
• Open Prostatectomy • Dialysis
• Hyperbaric Oxygen
• Creation and Revision of Arteriovenous Fistula (AV Fistula)
• Home Health Care
or Vessel to Vessel Cannula for Dialysis
• Oophorectomy, unilateral and bilateral • Durable Medical Equipment, limited to electric/motorized
• Back Surgeries and hardware related to surgery scooters or wheelchairs and pneumatic compression
devices
• Osteochondral Allograft, knee
• Hysterectomy (including prophylactic) High Cost Drugs
• Autologous chondrocyte implantation, Carticel
• Injectables that cost $2,000 or more per drug per month
• Transplant (excluding Cornea)
• Balloon sinuplasty • Infusion Therapies that cost $2,000 or more per drug per
month
• Sleep apnea related surgeries, limited to:

— Radiofrequency ablation (Coblation, Somnoplasty)
— (UPPP), Including laser-
assisted procedures

It is recommended that pre-certification is also obtained from the plan if procedures could be considered
or are potentially cosmetic in nature (such as, but not limited to: abdominoplasty, cervicoplasty, liposuction/
lipectomy, mammoplasty, augmentation and reduction (includes removal of implant), morbid obesity procedures, septoplasty, etc.).

Pre-certification of these benefits ensures the requested service is medically necessary and appropriate. All items listed here may
not be covered under your plan even if it is determined that the requested service is medically necessary. To determine whether a
benefit is covered or excluded, please review the eligible medical benefits and/or exclusions sections of your Plan.

Note: For information on what the plans cover, please see the benefit summaries for more details.

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