FEP Blue Standard™/ FEP Blue Basic™

Trasplantes: corazón artificial

33927, 33928, 33929

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

(Trasplante) 38240, 38241, S2142, S2150

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

Bone marrow transplants may require Blue Distinction Centers for Transplants facility.

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

Trasplantes: riñón

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

(Donante) 50547

Applied behavior analysis (ABA) services

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

For mid-treatment exceptions only, the diagnosis code is one of the following: F640, F641, F642, F648, F649, Z87890

Y

El código de procedimiento es uno de los siguientes:

(Gender Affirming Surgery Procedure Codes) 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

(Gender Affirming Facial Surgery) 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

(Gender Affirming Specific Drug Procedure Codes) J1000, J1071, J1072, J1073, J1380, J1950, J1951, J1952, J1954, J2675, J3121, J3145, J3315, J3316, J9003, J9155, J9202, J9217, J9218, J9219, J9226, S0122, S0126, S0128

O

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.

Estudios del sueño en centros ambulatorios

95782, 95783, 95803, 95805, 95807, 95808, 95810, 95811

Se requiere autorización previa para los estudios del sueño realizados en el consultorio de un proveedor, centro del sueño, clínica, cualquier tipo de centro ambulatorio o cualquier otro lugar que no sea el hogar.

Terapia génica e inmunoterapia celular

38225, 38226, 38227, 38228, J1411, J1412, J1413, J1414, J3387, J3389, J3391, J3392, J3393, J3394, J3398, J3399, J3401, J3402, J3403, J3404, J3405, J9029, J9325, J9601, Q2041, Q2042, Q2043, Q2053, Q2054, Q2055, Q2056, Q2057, Q2058, S2107

Cirugía bariátrica

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

Oral/maxillofacial surgery

21050, 21060, 21070, 21073, 21193, 21194, 21195, 21196, 21198, 21199, 21206, 21210, 21215, 21244, 21245, 21246, 21247, 21248, 21249, 21255, 21270, 21345, 21346, 21347, 21348, 21355, 21356, 21360, 21365, 21366, 21421, 21422, 21423, 21431, 21432, 21433, 21435, 21436, 21440, 21445, 21450, 21451, 21452, 21453, 21454, 21461, 21462, 21465, 21470, 40510, 40520, 40525, 40527, 40650, 40652, 40654, 40804, 40805, 40830, 40831, 41250, 41251, 41252, 42180, 42182 or 40530, D7530, D7540, D7610, D7620, D7630, D7640, D7650, D7660, D7670, D7671, D7680, D7710, D7720, D7730, D7740, D7750, D7760, D7770, D7771, D7780, D7910, D7911, D7912, D7920, D7946, D7947, D7948, D7949, D7993, D7994, D7995, D7996

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

Pruebas genéticas

PA required when procedure code is one of the following: 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, 0582U, 0583U, 0616U, 0617U, 0618U, 0619U, 0622U, 0627U, 0631U, 0633U, 0651U, 0653U, 0657U, 0658U, 0659U, 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, S3852, S3861

Y

Principal diagnosis code is one of the following diagnosis codes: 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 or Z8489

Transporte en ambulancia aérea (no de emergencia)

(Revenue Code) 0545; or revenue code is one of the following: 0540, 0541, 0542, 0543, 0544, 0546, 0547, 0548, 0549, and procedure code is listed below.

(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

Terapia con haz de protones

(Código de ingresos) 0333

PA required for members 22 years of age and older, when the procedure code is one of the following:

(Código de procedimiento) 77520, 77522, 77523, 77525, G0563

AND, the diagnosis code is NOT one of the following: 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, C8242, 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, C8308, 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, C8395, 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, C8490, C8491, C8492, C8493, C8494, C8495, C8496, C8497, C8498, C8499, C84A0, C84A1, C84A2, C84A3, C84A4, C84A5, C84A6, C84A7, C84A8, C84A9, C84Z0, C84Z1, C84Z2, C84Z3, C84Z4, C84Z5, C84Z6, C84Z7, C84Z8, C84Z9, 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, C8586, 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

PA required when procedure code is one of the following:

(Código de procedimiento) 77371, 77372, 77432

Y

Diagnosis code is NOT one of the following:

(Diagnosis Code) 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 del cuerpo coroideo y ciliar; neoplasias benignas de los nervios craneales, la hipófisis, el cuerpo aórtico o los paraganglios; neoplasias del conducto craneofaríngeo y tumores yugulares glomus; neuralgias del trigémino, esclerosis temporal, ciertas afecciones epilépticas o malformaciones arteriovenosas.

Medicamentos de beneficios médicos

C9257, J0177, J0178, J0179, J0222, J0223, J0224, J0225, J0881, J0885, J0897, J1299, J1303, J1442, J1447, J1449, J1459, J1551, J1552, J1553, J1554, J1555, J1556, J1557, J1558, J1559, J1560, J1561, J1566, J1568, J1569, J1572, J1575, J1576, J1577, 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, J9145, J9256, J9271, J9277, 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, Q5161, Q5162, Q5164, Q5165, Q5166, Q5167, Q5168, Q5169, Q5170, Q5171, 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:

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.

Fertilización in vitro

58323, 58970, 58974, 58976, 76948, 89250, 89251, 89253, 89254, 89255, 89257, 89258, 89259, 89260, 89261, 89264, 89268, 89272, 89280, 89281, 89290, 89291, 89335, 89337, 89342, 89343, 89344, 89346, 89352, 89353, 89354, 89356, S4011, S4013, S4014, S4015, S4016, S4017, S4018, S4020, S4021, S4022, S4027, S4028, S4030, S4031, S4037 o S4040, S4042

***Opción estándar SOLAMENTE

Servicios de audífonos

92634, 92635, 92636, 92637, V5011, V5030, V5040, V5050, V5060, V5070, V5080, V5090, V5100, V5110, V5120, V5130, V5140, V5150, V5160, V5171, V5172, V5181, V5190, V5200, V5211, V5212, V5213, V5214, V5215, V5221, V5230, V5240, V5241, V5242, V5243, V5244, V5245, V5246, V5247, V5248, V5249, V5250, V5251, V5252, V5253, V5254, V5255, V5256, V5257, V5258, V5259, V5260, V5261, V5264, V5265, V5267, V5275, V5298, V5299

Medicamentos para la inseminación artificial (IA)

J0725, J1675, J1950, J1951, J1952, J2675, J3315, J3316, J9003, 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

Cirugía de cadera, rodilla o columna vertebral

(Hip Procedure Codes) 27125, 27130

(Knee Procedure Codes) 27437, 27438, 27440, 27441, 27442, 27443, 27445, 27446, 27447

(Spine Procedure Codes) 22532, 22533, 22534, 22548, 22551, 22552, 22554, 22556, 22558, 22585, 22586, 22590, 22595, 22600, 22610, 22612, 22614, 22630, 22632, 22633, 22634, 22800, 22802, 22804, 22808, 22810, 22812, 22818, 22819, 22856, 22857, 22867, 22869, 63001, 63003, 63005, 63011, 63012, 63015, 63016, 63017, 63020, 63030, 63032, 63040, 63042, 63043, 63044, 63045, 63046, 63047, 63050, 63051, 63052, 63055, 63056, 63064, 63075, 63077, 63081, 63085, 63087, 63090, 63101, 63102, 63170, 63172, 63173, 63185, 63190, 63191, 63197, 63200, 63250, 63251, 63252, 63265, 63266, 63267, 63268, 63270, 63271, 63272, 63273, 63275, 63276, 63277, 63278, 63280, 63281, 63282, 63283, 63285, 63286, 63287, 63290, 63300, 63301, 63302, 63303, 63304, 63305, 63306, 63307