FEP Blue Focus^®

Servicios de análisis de comportamiento aplicado (ABA)

0362T, 0373T, 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158

Se requiere autorización previa para los códigos de diagnóstico del trastorno del espectro autista F840, F843, F845, F848, F849.

Servicios de modificación de rasgos sexuales

Para las excepciones de mitad de tratamiento ÚNICAMENTE, el código de diagnóstico es uno de los siguientes: F640, F641, F642, F648, F649, Z87890 Y El código de procedimiento es uno de los siguientes:

(Códigos de procedimiento de cirugía de afirmación de género) 11920, 11921, 11922, 11970, 15771, 15772, 15877, 19303, 19318, 19325, 19350, 19357, 53410, 53430, 54125, 54400, 54401, 54405, 54660, 54520, 54690, 55175, 55180, 55899, 56625, 56805, 57110, 57291, 57292, 57335, 58150, 58180, 58260, 58262, 58275, 58290, 58291, 58541, 58542, 58543, 58544, 58550, 58552, 58553, 58554, 58570, 58571, 58572, 58573, 58661, 58720, 58999, C1789, C1813, C2622, L8600 O (Cirugía facial de afirmación de género) 11950, 11951, 11952, 11954, 15769, 15770, 15773, 15774, 15775, 15776, 15780, 15781, 15782, 15783, 15788, 15789, 15792, 15793, 15820, 15821, 15822, 15823, 15824, 15825, 15826, 15828, 15829, 15876, 21025, 21120, 21121, 21122, 21123, 21125, 21127, 21137, 21138, 21139, 21141, 21142, 21143, 21145, 21146, 21147, 21150, 21151, 21154, 21155, 21159, 21160, 21172, 21175, 21179, 21180, 21188, 21193, 21194, 21195, 21196, 21208, 21209, 21210, 21215, 21230, 21235, 21244, 21245, 21246, 21248, 21249, 21270, 21899, 30400, 30410, 30420, 30430, 30435, 30450, 31599, 40799, 67900, 69300 O (Electrólisis realizada en el sitio operatorio para una cirugía de afirmación de género) 17380 O(Códigos de procedimiento de medicamentos específicos para afirmación de género) J1000, J1071, J1072, J1073, J1380, J1950, J1951, J1952, J1954, J2675, J3121, J3145, J3315, J3316, J9155, J9202, J9217, J9218, J9219, J9226, S0122, S0126, S0128O El código de procedimiento es: 55970 o 55980

Se requiere autorización previa solo para las excepciones de mitad de tratamiento. De lo contrario, los servicios de modificación de rasgos sexuales no están cubiertos.

Terapia génica e inmunoterapia celular

C9307, J1411, J1412, J1413, J1414, J3387, J3389, J3391, J3392, J3393, J3394, J3398, J3399, J3401, J3402, J3403, J9029, J9325, Q2041, Q2042, Q2043, Q2053, Q2054, Q2055, Q2056, Q2057, Q2058, S2107, 38225, 38226, 38227, 38228

Trasplantes: corazón artificial

33927, 33928, 33929

Los beneficios de ciertos trasplantes se limitan a los Blue Distinction Centers for Transplants.

Trasplantes: trasplantes de células madre de sangre o de médula ósea

(Trasplante) 38240, 38241, S2142, S2150

(Donante) 38205, 38206, 38207, 38230, 38232, S2140

Los beneficios de ciertos trasplantes se limitan a los Blue Distinction Centers for Transplants.

Trasplantes: riñón

(Trasplante) 50300, 50320, 50323, 50325, 50327, 50328, 50329, 50340, 50360, 50365, 50380

(Donante) 50547

Los beneficios de ciertos trasplantes se limitan a los Blue Distinction Centers for Transplants.

Trasplantes de órganos/tejidos

(Trasplante) 32851, 32852, 32853, 32854, 33935, 33945, 44135, 44136, 47135, 48160, 48554, 0584T, 0585T, 0586T, G0341, G0342, G0343, S2053, S2054, S2060, S2065, S2152

(Donante) 0494T, 0495T, 0496T, 0894T, 0895T, 0896T, 32850, 33930, 33940, 44132, 44133, 47133, 47140, 47141, 47142, 48550, S2055, S2061

(Backbench) 32855, 32856, 33933, 33944, 44715, 44720, 44721, 47143, 47144, 47145, 47146, 47147, 48551, 48552

Los beneficios de ciertos trasplantes se limitan a los Blue Distinction Centers for Transplants.

Trasplantes: beneficios de viaje

S9992, S9994

Los beneficios de ciertos trasplantes se limitan a los Blue Distinction Centers for Transplants.

Implantes cocleares/Dispositivos protésicos/DME especializados

(Implantes cocleares) 69930, L8614, L8627, L8628, L8615, L8616, L8617, L8618, L8619

(Dispositivos protésicos) E0738, E0739, L5000, L5010, L5020, L5050, L5060, L5100, L5105, L5150, L5160, L5200, L5210, L5220, L5230, L5250, L5270, L5280, L5301, L5312, L5321, L5331, L5341, L5500, L5505, L5510, L5520, L5530, L5535, L5540, L5560, L5570, L5580, L5585, L5590, L5595, L5600, L5610, L5611, L5613, L5614, L5615, L5616, L5617, L5618, L5620, L5622, L5624, L5626, L5628, L5629, L5630, L5631, L5632, L5634, L5636, L5637, L5638, L5639, L5640, L5642, L5643, L5644, L5645, L5646, L5647, L5648, L5649, L5650, L5651, L5652, L5653, L5654, L5655, L5656, L5657, L5658, L5661, L5665, L5666, L5668, L5670, L5671, L5672, L5673, L5676, L5677, L5678, L5679, L5680, L5681, L5682, L5683, L5684, L5685, L5686, L5688, L5690, L5692, L5694, L5695, L5696, L5697, L5698, L5699, L5700, L5701, L5702, L5703, L5704, L5705, L5706, L5707, L5710, L5711, L5712, L5714, L5716, L5718, L5722, L5724, L5726, L5728, L5780, L5781, L5782, L5783, L5785, L5790, L5795, L5810, L5811, L5812, L5814, L5816, L5818, L5822, L5824, L5826, L5827, L149 5828, L5830, L5840, L5841, L5845, L5848, L5850, L5855, L5856, L5857, L5858, L5859, L5910, L5920, L5925, L5926, L5930, L5940, L5950, L5960, L5961, L5962, L5964, L5966, L5968, L5969, L5970, L5971, L5972, L5973, L5974, L5975, L5976, L5978, L5979, L5980, L5981, L5982, L5984, L5985, L5986, L5987, L5988, L5990, L5991, L5999, L6000, L6010, L6020, L6026, L6028, L6029, L6030, L6031, L6032, L6033, L205 6034, L6035, L6036, L6037, L6038, L6039, L6050, L6055, L6100, L6110, L6120, L6130, L6200, L6205, L6250, L6300, L6310, L6320, L6350, L6360, L6370, L6380, L6382, L6384, L6386, L6388, L6400, L6450, L6500, L6550, L6570, L6580, L6582, L6584, L6586, L6588, L6590, L6600, L6605, L6610, L6611, L6615, L6616, L6620, L6621, L6623, L6624, L6625, L6628, L6629, L6630, L6632, L6635, L6637, L6638, L6640, L6641, L6642, L6645, L6646, L6647, L6648, L6650, L6655, L6660, L6665, L6670, L6672, L6675, L6676, L6677, L6680, L6682, L6684, L6686, L6687, L6688, L6689, L6690, L6691, L6692, L6693, L6694, L6695, L6696, L6697, L6698, L6700, L6703, L6704, L6706, L6707, L6708, L6709, L6711, L6712, L6713, L6714, L6715, L6721, L6722, L6805, L6810, L6880, L6881, L6882, L6883, L6884, L6885, L6890, L6895, L6900, L317 6905, L6910, L6915, L6920, L6925, L6930, L6935, L6940, L6945, L6950, L6955, L6960, L6965, L6970, L6975, L7007, L7008, L7009, L7040, L7045, L7170, L7180, L7181, L7185, L7186, L7190, L7191, L7259, L7400, L7401, L7402, L7403, L7404, L7405, L7406, L7499, L7510, L7520, L7600, L7700, L8000, L8001, L8002, L8015, L8020, L8030, L8031, L8032, L8033, L8035, L8039, L8040, L8041, L8042, L8043, L8044, L8045, L8046, L8047, L8048, L8049, L8608, L8701, L8702, L8720, L8721

(DME especial) E0265, E0266, E0270, E0277, E0296, E0297, E0300, E0301, E0302, E0303, E0304, E0316, E0328, E0329, E0371, E0372, E0373, E0983, E0984, E0985, E0986, E1002, E1003, E1004, E1005, E1006, E1007, E1008, E1009, E1010, E1012, E1230, E1239, E2310, E2311, E2312, E2313, E2321, E2322, E2323, E2324, E2325, E2326, E2327, E2328, E2329, E2330, E2331, E2340, E2341, E2342, E2343, E2358, E2359, E2360, E2361, E2362, E2363, E2364, E2365, E2366, E2367, E2368, E2369, E2370, E2371, E2372, E2373, E2374, E2375, E2376, E2377, E2378, E2381, E2382, E2383, E2384, E2385, E2386, E2387, E2388, E2389, E2390, E2391, E2392, E2394, E2395, E2396, E2397, E2398, K0010, K0011, K0012, K0013, K0014, K0108, K0733, K0800, K0801, K0802, K0806, K0807, K0808, K0812, K0813, K0814, K0815, K0816, K0820, K0821, K0822, K0823, K0824, K0825, K0826, K0827, K0828, K0829, K0830, K0831, K0835, K0836, K0837, K0838, K0839, K0840, K0841, K0842, K0843, K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855, K0856, K0857, K0858, K0859, K0860, K0861, K0862, K0863, K0864, K0868, K0869, K0870, K0871, K0877, K0878, K0879, K0880, K0884, K0885, K0886, K0890, K0891, K0898 o K0899

Cirugía bariátrica

0813T, 43290, 43291, 43644, 43645, 43770, 43771, 43773, 43775, 43842, 43843, 43845, 43846, 43847, 43848, 43886, 43888, 43889, C9785

Debe realizarse en un Blue Distinction Center (BDC) for Comprehensive Bariatric Surgery.

Cirugía bucal/maxilofacial

21010, 21050, 21060, 21070, 21073, 21193, 21194, 21195, 21196, 21198, 21199, 21206, 21210, 21215, 21240, 21242, 21243, 21244, 21245, 21246, 21247, 21248, 21249, 21345, 21346, 21347, 21348, 21355, 21356, 21360, 21365, 21366, 21421, 21422, 21423, 21431, 21432, 21433, 21435, 21436, 21440, 21445, 21452, 21454, 21461, 21462, 21465, 21470, 21480, 21485, 21490, 21497,  21450, 21451, 21453, 29804, 40510, 40520, 40525, 40527, 40530, 40650, 40652, 40654, 40800, 40801, 40804, 40805, 40830, 40831, 41000, 41005, 41006, 41007, 41008, 41009, 41015, 41016, 41017, 41018, 41250, 41251, 41252, 42180, 42182, D7220, D7230, D7240, D7241, D7251, D7260, D7261, D7270**, D7272**, D7282, D7285, D7286, D7290**, D7291**, D7310**, D7311**, D7320**, D7321**, D7340**, D7350**, D7410, D7411, D7412, D7413, D7414, D7415, D7440, D7441, D7460, D7461, D7465, D7471, D7472, D7473, D7485, D7490, D7509, D7510, D7511, D7520, D7521, D7530**, D7540**, D7550**, D7560**, D7610**, D7620**, D7630**, D7640**, D7650**, D7660**, D7670**, D7671, D7680**, D7710**, D7720**, D7730**, D7740**, D7750**, D7760**, D7770**, D7771, D7780**, D7810, D7820, D7830, D7840, D7850, D7852, D7854, D7856, D7858, D7860, D7865, D7870, D7871**, D7872, D7873, D7874, D7875, D7876, D7877, D7910, D7911, D7912, D7920, D7922**, D7940**, D7941**, D7943, D7944**, D7945**, D7946**, D7947**, D7948**, D7949**, D7950**, D7951**, D7952**, D7953**, D7955**, D7956**, D7957**, D7963, D7972, D7980, D7981, D7982, D7983, D7993**, D7994**, D7995**, D7996**, D7997**

Se requiere autorización previa, excepto cuando la atención se brinda dentro de las 72 horas posteriores a una lesión accidental.

Los códigos de procedimiento marcados con doble asterisco (**) cuando se facturan con los códigos de diagnóstico de cáncer requieren aprobación previa

Otros servicios quirúrgicos

0054T, 0055T, 0511T, 0524T, 0717T, 0718T, 0719T, 15769, 15771, 15772, 15773, 15774, 19350, 19355, 19357, 19361, 19364, 19367, 19368, 19369, 19380, 19396, 20650, 20662, 20663, 20665, 20670, 20680, 20690, 20692, 20693, 20694, 20696, 20697, 20900, 20902, 20920, 20922, 20924, 20930, 20931, 20936, 20937, 20938, 20939, 20955, 20956, 20962, 20970, 20985, 21026, 21030, 21031, 21032, 21034, 21040, 21044, 21045, 21046, 21047, 21048, 21049, 21116, 21120, 21121, 21122, 21123, 21125, 21127, 21137, 21138, 21139, 21141, 21142, 21143, 21145, 21146, 21147, 21150, 21151, 21154, 21155, 21159, 21160, 21172, 21175, 21179, 21180, 21181, 21182, 21183, 21184, 21188, 21208, 21209, 21230, 21235, 21255, 21256, 21260, 21261, 21263, 21267, 21268, 21270, 21275, 21280, 21282, 21295, 21296, 21740, 21742, 21743, 22010, 22015, 22100, 22101, 22102, 22103, 22110, 22112, 22114, 22116, 22206, 22207, 22208, 22210, 22212, 22214, 22216, 22220, 22222, 22224, 22226, 22534, 22585, 22800, 22802, 22804, 22808, 22810, 22812, 22818, 22819, 22836, 22837, 22840, 22841, 22842, 22843, 22844, 22845, 22846, 22847, 22848, 22849, 22850, 22852, 22853, 22854, 22855, 22856, 22857, 22858, 22859, 22860, 22861, 22862, 22864, 22865, 22867, 22868, 22869, 22870, 23020, 23035, 23040, 23044, 23100, 23101, 23105, 23106, 23107, 23120, 23125, 23130, 23170, 23172, 23174, 23180, 23182, 23184, 23190, 23195, 23395, 23397, 23405, 23406, 23410, 23412, 23415, 23420, 23430, 23440, 23450, 23455, 23460, 23462, 23465, 23466, 23470, 23472, 23473, 23474, 23480, 23485, 23490, 23491, 23700, 23800, 23802, 23900, 23920, 23921, 24134, 24140, 24344, 24346, 24498, 26500, 26502, 26541, 26542, 26545, 26992, 27000, 27001, 27003, 27005, 27006, 27025, 27027, 27030, 27033, 27036, 27050, 27052, 27054, 27057, 27070, 27071, 27080, 27097, 27098, 27100, 27105, 27110, 27111, 27120, 27122, 27125, 27130, 27132, 27134, 27137, 27138, 27140, 27146, 27147, 27151, 27156, 27161, 27165, 27170, 27175, 27176, 27177, 27178, 27179, 27181, 27185, 27187, 27275, 27278, 27279, 27280, 27282, 27284, 27286, 27290, 27295, 27303, 27305, 27306, 27307, 27325, 27326, 27330, 27331, 27332, 27333, 27334, 27335, 27350, 27360, 27380, 27381, 27385, 27386, 27390, 27391, 27392, 27393, 27394, 27395, 27396, 27397, 27400, 27403, 27405, 27407, 27409, 27412, 27415, 27416, 27418, 27420, 27422, 27424, 27425, 27427, 27428, 27429, 27430, 27435, 27437, 27438, 27440, 27441, 27442, 27443, 27446, 27447, 27448, 27450, 27454, 27455, 27457, 27458, 27465, 27466, 27470, 27472, 27475, 27477, 27479, 27485, 27486, 27487, 27495, 27496, 27497, 27498, 27499, 27570, 27580, 27598, 27600, 27601, 27602, 27605, 27606, 27607, 27612, 27620, 27625, 27626, 27640, 27641, 27650, 27652, 27654, 27656, 27658, 27659, 27664, 27665, 27675, 27676, 27680, 27681, 27685, 27686, 27687, 27690, 27691, 27692, 27695, 27696, 27698, 27700, 27702, 27703, 27705, 27707, 27709, 27712, 27713, 27715, 27720, 27722, 27724, 27725, 27726, 27730, 27732, 27734, 27740, 27742, 27745, 27860, 27870, 27871, 27889, 27892, 27893, 27894, 27899, 28005, 28238, 29800, 29806, 29807, 29820, 29821, 29822, 29823, 29824, 29825, 29826, 29827, 29828, 29862, 29863, 29866, 29867, 29868, 29871, 29873, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889, 29891, 29895, 29897, 29898, 29899, 29914, 29915, 29916, 30400, 30410*, 30420*, 30430*, 30435*, 30450*, 30460, 30462, 30520, 36465, 36466, 36468, 36470, 36471, 36473, 36474, 36475, 36476, 36478, 36479, 36482, 36483, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37785, 40490, 40500, 40806, 40808, 40810, 40812, 40814, 40816, 40819, 40820, 41010, 41100, 41105, 41108, 41110, 41112, 41113, 41114, 41115, 41116, 41120, 41130, 41150, 41520, 42000, 42100, 42104, 42106, 42107, 42120, 42140, 42145, 42160, 42300, 42305, 42310, 42320, 42330, 42335, 42340, 62330, 62331, 63052, 63053, 63087, 63088, 67971, 67973, 67974, 67975, 69310, 69641, 69642, 69643, 69644, 69646, C8003, C9781

Reducción/aumento de senos

15777, 19316, 19318, 19325, 19328, 19330, 19340, 19342

NO se requiere autorización previa para el tratamiento del cáncer de mama.

Cirugía de columna vertebral

22532, 22533, 22548, 22551, 22552, 22554, 22556, 22558, 22586, 22590, 22595, 22600, 22610, 22612, 22614, 22630, 22632, 22633, 22634, 22830, 63001, 63003, 63005, 63011, 63012, 63015, 63016, 63017, 63020, 63030, 63032, 63030, 63032, 63035, 63045, 63046, 63047, 63050, 63051, 63052, 63053, 63055, 63056, 63064, 63075, 63076, 63077, 63081, 63082, 63087, 63088

Tomografía computarizada/Resonancia magnética/Tomografía por emisión de positrones (PET)

0042T, 0332T, 0588T, 0609T, 0610T, 0611T, 0612T, 0633T, 0634T, 0635T, 0636T, 0637T, 0638T, 0648T, 0649T, 0697T, 0698T, 0742T, 0808T, 0865T, 0866T, 0899T, 0900T, 0946T, 0947T, 61715, 70336, 70450, 70460, 70470, 70471, 70472, 70473, 70480, 70481, 70482, 70486, 70487, 70488, 70490, 70491, 70492, 70496, 70498, 70540, 70542, 70543, 70544, 70545, 70546, 70547, 70548, 70549, 70551, 70552, 70553, 70554, 70555, 70557, 70558, 70559, 71250, 71260, 71270, 71271, 71275, 71550, 71551, 71552, 71555, 72125, 72126, 72127, 72128, 72129, 72130, 72131, 72132, 72133, 72141, 72142, 72146, 72147, 72148, 72149, 72156, 72157, 72158, 72159, 72195, 72196, 72197, 72198, 72191, 72192, 72193, 72194, 73200, 73201, 73202, 73206, 73218, 73219, 73220, 73221, 73222, 73223, 73225, 73700, 73701, 73702, 73706, 73718, 73719, 73720, 73721, 73722, 73723, 73725, 74150, 74160, 74170, 74174, 74175, 74176, 74177, 74178, 74181, 74182, 74183, 74185, 74261, 74262, 75571, 75572, 75573, 75574, 75580, 75635, 76014, 76015, 76016, 76017, 76018, 76019, 76376, 76377, 76380, 76390, 76391, 76497, 77011, 77012, 77013, 77078, 78072, 74712, 74713, 75557, 75559, 75561, 75563, 75565, 76498, 77021, 77022, 77046, 77047, 77048, 77049, 77084, 78071, 78429, 78430, 78431, 78432, 78433, 78434, 78451, 78452, 78459, 78469, 78491, 78492, 78494, 78608, 78609, 78811, 78812, 78813, 78814, 78815, 78816, 78830, 78831, 78832, 78835, 78803, C8903, C8905, C8906, C8908, C9762, C9763, C9791, G0219, G0235, G0252, G0288, S8092

Pruebas genéticas

Se requiere una PA cuando el código de procedimiento es uno de los siguientes: S3852, S3861, 0012M, 0091U, 0094U, 0101U, 0102U, 0103U, 0129U, 0130U, 0133U, 0134U, 0136U, 0137U, 0157U, 0158U, 0159U, 0160U, 0161U, 0162U, 0212U, 0213U, 0214U, 0215U, 0231U, 0235U, 0237U, 0238U, 0265U, 0335U, 0336U, 0368U, 0400U, 0405U, 0410U, 0421U, 0425U, 0426U, 0464U, 0469U, 0474U, 0616U, 0617U, 0618U, 0619U, 0622U, 0627U, 81201, 81203, 81206, 81207, 81208, 81220, 81222, 81223, 81225, 81226, 81227, 81242, 81243, 81244, 81245, 81252, 81257, 81258, 81259, 81288, 81291, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81301, 81307, 81317, 81322, 81324, 81325, 81326, 81327, 81351, 81352, 81353, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81412, 81413, 81414, 81415, 81416, 81417, 81419, 81430, 81431, 81432, 81435, 81437, 81439, 81441, 81443, 81455, 81456, 81460, 81465, 81470, 81471, 81479, 81528, 81599, 0582U o 0583U Y El código de diagnóstico principal es uno de los siguientes códigos de diagnóstico: Z0000, Z00110, Z00111, Z00121, Z00129, Z008, Z01419, Z120, Z1210, Z1211, Z1212, Z1213, Z122, Z1231, Z1239, Z124, Z125, Z126, Z1271, Z1272, Z1273, Z1279, Z1281, Z1282, Z1283, Z1289, Z129, Z1401, Z141, Z148, Z1501, Z1502, Z1503, Z1504, Z1505, Z1507, Z1509, Z15060, Z15068, Z151, Z152, Z153, Z1581, Z1589, Z3009, Z308, Z309, Z3141, Z31430, Z31438, Z31440, Z31448, Z3149, Z315, Z3161, Z3162, Z3169, Z317, Z3181, Z3182, Z3183, Z3184, Z3189, Z319, Z3200, Z3201, Z3202, Z331, Z7183, Z7189, Z719, Z800, Z801, Z802, Z803, Z8041, Z8042, Z8043, Z8049, Z8051, Z8052, Z8059, Z806, Z807, Z808, Z809, Z810, Z811, Z812, Z813, Z814, Z818, Z820, Z821, Z822, Z823, Z8241, Z8249, Z825, Z8261, Z8262, Z8269, Z8271, Z8279, Z828, Z830, Z831, Z832, Z8341, Z8342, Z83430, Z83438, Z8349, Z83511, Z83518, Z8352, Z836, Z83710, Z83711, Z83718, Z83719, Z8372, Z8379, Z840, Z8411, Z8419, Z842, Z843, Z8481, Z8482 o Z8489

Transporte en ambulancia aérea (no de emergencia)

(Código de Ingresos) 0545; O el código de ingresos es uno de los siguientes 0540, 0541, 0542, 0543, 0544, 0546, 0547, 0548, 0549 y el código de procedimiento se enumera a continuación.

(Código de procedimiento) A0430, A0431, A0435, A0436

NO se requiere autorización previa para el transporte en ambulancia aérea relacionado con la atención inmediata de una emergencia médica o lesión accidental.

Pruebas de BRCA

0138U, 81162, 81163, 81164, 81165, 81166, 81167, 81212, 81215, 81216, 81217

Servicios de rehabilitación cardíaca

(Código de ingresos) 0943 o cualquier código de ingresos cubierto que no sea de alojamiento y comida

(Código de procedimiento) 93797, 93798, S9472, G0422, G0423

Servicios de rehabilitación pulmonar

(Código de ingresos) 0948 o cualquier código de ingresos cubierto que no sea alojamiento y comida

(Código de procedimiento) 94625, 94626, S9473, G0237, G0238, G0239

Terapia con haz de protones

(Código de ingresos) 0333

Se requiere una PA cuando el código de procedimiento es uno de los siguientes: (Código de procedimiento) 77520, 77522, 77523, 77525, G0563

Y El código de diagnóstico NO es uno de los siguientes: (Código de diagnóstico) C37, C710, C711, C712, C713, C714, C715, C716, C717, C718, C719, C720, C721, C7220, C7221, C7222, C7230, C7231, C7232, C7240, C7241, C7242, C7250, C7259, C729, C7A091, C7931, C7949, C8100, C8101, C8102, C8103, C8104, C8105, C8106, C8107, C8108, C8109, C8110, C8111, C8112, C8113, C8114, C8115, C8116, C8117, C8118, C8119, C8120, C8121, C8122, C8123, C8124, C8125, C8126, C8127, C8128, C8129, C8130, C8131, C8132, C8133, C8134, C8135, C8136, C8137, C8138, C8139, C8140, C8141, C8142, C8143, C8144, C8145, C8146, C8147, C8148, C8149, C8170, C8171, C8172, C8173, C8174, C8175, C8176, C8177, C8178, C8179, C8190, C8191, C8192, C8193, C8194, C8195, C8196, C8197, C8198, C8199, C8200, C8201, C8202, C8203, C8204, C8205, C8206, C8207, C8208, C8209, C8210, C8211, C8212, C8213, C8214, C8215, C8216, C8217, C8218, C8219, C8220, C8221, C8222, C8223, C8224, C8225, C8226, C8227, C8228, C8229, C8230, C8231, C8232, C8233, C8234, C8235, C8236, C8237, C8238, C8239, C8240, C8241, C 8242, C8243, C8244, C8245, C8246, C8247, C8248, C8249, C8250, C8251, C8252, C8253, C8254, C8255, C8256, C8257, C8258, C8259, C8260, C8261, C8262, C8263, C8264, C8265, C8266, C8267, C8268, C8269, C8280, C8281, C8282, C8283, C8284, C8285, C8286, C8287, C8288, C8289, C8290, C8291, C8292, C8293, C8294, C8295, C8296, C8297, C8298, C8299, C8300, C8301, C8302, C8303, C8304, C8305, C8306, C8307, C206, C 8308, C8309, C8310, C8311, C8312, C8313, C8314, C8315, C8316, C8317, C8318, C8319, C8330, C8331, C8332, C8333, C8334, C8335, C8336, C8337, C8338, C8350, C8351, C8352, C8353, C8354, C8355, C8356, C8357, C8358, C8359, C8370, C8371, C8372, C8373, C8374, C8375, C8376, C8377, C8378, C8379, C8380, C8381, C8382, C8383, C8384, C8385, C8386, C8387, C8388, C8389, C8390, C8391, C8392, C8393, C8394, C262, C 8395, C8396, C8397, C8398, C8399, C8400, C8401, C8402, C8403, C8404, C8405, C8406, C8407, C8408, C8409, C8410, C8411, C8412, C8413, C8414, C8415, C8416, C8417, C8418, C8419, C8440, C8441, C8442, C8443, C8444, C8445, C8446, C8447, C8448, C8449, C8460, C8461, C8462, C8463, C8464, C8465, C8466, C8467, C8468, C8469, C8470, C8471, C8472, C8473, C8474, C8475, C8476, C8477, C8478, C8479, C847A, C84A0, C84A1, C84A2, C84A3, C84A4, C84A5, C84A6, C84A7, C84A8, C84A9, C84Z0, C84Z1, C84Z2, C84Z3, C84Z4, C84Z5, C84Z6, C84Z7, C84Z8, C84Z9, C8490, C8491, C8492, C8493, C8494, C8495, C8496, C8497, C8498, C8499, C8510, C8511, C8512, C8513, C8514, C8515, C8516, C8517, C8518, C8519, C8520, C8521, C8522, C8523, C8524, C8525, C8526, C8527, C8528, C8529, C8580, C8581, C8582, C8583, C8584, C8585, C 8586, C8587, C8588, C8589, C8590, C8591, C8592, C8593, C8594, C8595, C8596, C8597, C8598, C8599, D330, D331, D332, D333, D334, D337, D339, D420, D421, D429, D430, D431, D432, D433, D434, D438, D439, D496

NO se requiere autorización previa para pacientes menores de 21 años, o relacionados con el tratamiento de neoplasias del sistema nervioso, incluidos el cerebro y la médula espinal; neoplasias malignas del timo; linfomas de Hodgkin y no Hodgkin.

Radioterapia estereotáctica del cuerpo

(Código de ingresos) 0333

(Código de procedimiento) 77373, 77435, G0563

Radiocirugía estereotáctica

(Código de ingresos) 0333

Se requiere PA cuando el código de procedimiento es uno de los siguientes: (Código de procedimiento) 77371, 77372, 77432

Y El código de diagnóstico NO es uno de los siguientes: (Código de diagnóstico) C6930, C6931, C6932, C6940, C6941, C6942, C710, C711, C712, C713, C714, C715, C716, C717, C718, C719, C7931, D320, D333, D352, D356, D444, D447, G500, G9381, Q280, Q281, Q282

Se requiere autorización previa para todas las radiocirugías estereotácticas, excepto cuando se relacionan con el tratamiento de neoplasias malignas del cerebro y del ojo específicas de la coroides y el cuerpo ciliar; neoplasias benignas de los nervios craneales, la hipófisis, el cuerpo aórtico o los paraganglios; neoplasias del conducto craneofaríngeo y tumores del glomus yugular; neuralgias del trigémino, esclerosis temporal, ciertas afecciones epilépticas o malformaciones arteriovenosas.

Medicamentos de beneficios médicos

C9257,  J0222, J0223, J0224, J0177, J0178, J0179, J0225, J0881, J0885, J0897, J1299, J1303, J1442, J1447, J1449, J1459, J1551, J1552, J1554, J1555, J1556, J1557, J1558, J1559, J1560, J1561, J1566, J1568, J1569, J1572, J1575, J1576, J1602, J1745, J1748, J2323, J2326, J2327, J2329, J2350, J2351, J2506, J2777, J2778, J3241, J3357, J3358, J7318, J7320, J7321, J7322, J7323, J7324, J7325, J7326, J7327, J7328, J7329, J7331, J7332, J9035, J9042, J9144, J9271, J9299, J9306, J9311, J9312, J9332, J9333, J9334, J9354, J9355, J9356, J9358, Q5098, Q5099, Q5100, Q5101, Q5103, Q5104, Q5106, Q5107, Q5108, Q5110, Q5111, Q5112, Q5113, Q5114, Q5115, Q5116, Q5117, Q5118, Q5119, Q5120, Q5121, Q5122, Q5123, Q5124, Q5125, Q5126, Q5127, Q5128, Q5129, Q5130, Q5134, Q5136, Q5137, Q5138, Q5146, Q5147, Q5148, Q5149, Q5150, Q5151, Q5152, Q5153, Q5155, Q5156, Q5157, Q5158, Q5159, Q5160, Q9996, Q9997, Q9998, Q9999 O Código/s de medicamentos no clasificados C9399, J3490, J3590, J3591, J7699, J7799, J8498, J8499, J8597, J8999, J9999 o Q0181 SOLAMENTE cuando el NDC es: 72126000701, 72126000702, 71336100001, 71336100101, 71336100201, 71860010101, 72606002901, 72606002701, 72606002801, 25682000101, 73475304105, 83257002611, 83257002411, 83257002341, 83257002541, 84768051101, 84768051199

Almacenamiento de espermatozoides u óvulos

89343, 89344, 89346

Se requiere autorización previa para el almacenamiento de espermatozoides y óvulos en personas que enfrentan infertilidad iatrogénica.

Medicamentos para la inseminación artificial (IA)

J0725, J1675, J1950, J1951, J1952, J2675, J3315, J3316, J9155, J9202, J9217, J9218, J9225, J9226, S0122, S0126, S0128, S0132

O

Código/s de medicamentos no clasificados C9399, J3490, J3590, J3591, J7699, J7799, J8498, J8499, J8597, J8999, J9999, Q0181, S5000 o S5001 ÚNICAMENTE con un NDC aplicable (medicamento AI)

Servicios de inseminación artificial

58321, 58322, 58323, 89257, 89260, 89261, 89264, 89353, 89354, S4028, S4035, S4042