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

Los trasplantes de médula ósea pueden requerir el centro de trasplantes de Blue Distinction Centers.

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

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.

Sex trait modification is not covered OR requires PA for mid-treatment exception

For mid-treatment exceptions ONLY, PA is required when the diagnosis code is one of the following: F640, F641, F642, F648, F649, Z87890 AND Procedure code is one of the following:

(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

(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

(Electrolysis performed at the operative site for a gender affirming surgery) 17380

(Gender affirming specific drug Procedure codes) J1000, J1380, J1950, J1951, J1952, J1954, J9217, J9218, J9219, J1071, J1072, J3121, J3315, J3316 or J9202

Or, the Procedure code is: 55970 or 55980

Preauth required for mid-treatment exceptions only. Otherwise sex-trait modification is not covered.

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

J1411, J1412, J1413, J1414, 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

Cirugía bariátrica

0813T, 43290, 43291, 43644, 43645, 43770, 43771, 43773, 43775, 43842, 43843, 43845, 43846, 43847, 43848, 43886, 43888, 43889, C9784, C9785

Cirugía bucal/maxilofacial

21050, 21060, 21070, 21073, 21193, 21194, 21195, 21196, 21198, 21199, 21206, 21210, 21215, 21244, 21245, 21246, 21247, 21248, 21249, 21440, 21445, 21452, 21454, 21255, 21270, 21345, 21346, 21347, 21348, 21355, 21356, 21360, 21365, 21366, 21421, 21422, 21423, 21431, 21432, 21433, 21435, 21436, 21450, 21451, 21453, 21461, 21462, 21465, 21470, 40510, 40520, 40525, 40527, 40650, 40652, 40654, 40804, 40805, 40830, 40831, 41250, 41251, 41252, 42180, 42182 o 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: 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, 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 or 0583U ANDPrincipal 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.

(Procedure code) 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

(Revenue code) 0333

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

(Revenue code) 0333

(Procedure code) 77373, 77435, G0563

Radiocirugía estereotáctica

(Revenue code) 0333

PA required when procedure code is one of the following: (Procedure code) 77371, 77372, 77432

AND 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, C9305, 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, 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, 72606002901, 72606002701, 72606002801, 25682000101, 73475304105, 83257002611, 83257002411, 83257002341, 83257002541

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

Hip, knee, or spine surgery

(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

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