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Office Wise

Changes to 2010 National Precertification list

The following additions, modifications and deletions to Aetna’s National

Precertification List will take January 1, 2010:

effect on

Additions: n Acthar Gel* (CPB #0762) Erbitux* (CPB #0748) Vectibux* (CPB #0684) R n n i t u x a n * ( C P B # 0 3 1 4 e x c l u d i n g approved Oncology indications – V42.0, 200.00 – 200.88, 201.00 – 201.78, 202.00 – 202.88, 204.10 – 204.12, 238.77, 273.3, 283.0, 287.31, and 694.4) n

n

Spinal Fusion: Add on code 22632

*To precertify these drugs, call 1-866-503-0857, or fax the corresponding Medication Request Form to 1-888-267-3277. Forms are available by logging into our secure provider website via NaviNet. Visit www.aetna.com to log in, then select “Aetna Support Center” from the Aetna Plan Central home page and choose “Forms Library” then “Pharmacy Forms.

Modifications: Growth Hormone precertification n

  • -

    Step-therapy edit for Genotropin – trial of any 2 of 3 preferred growth hormone injectables including Humatrope, Nutropin or Tev-Tropin is required prior to use of Genotropin.

  • -

    Step-therapy edit for Norditropin – trial of any 2 of 3 preferred growth hormone injectables including Humatrope, Nutropin or Tev-Tropin is required prior to use of Norditropin.

Deletions (including associated codes):

n

Intensity-modulated radiation therapy (IMRT) (77301, 77371, 77372, 77373, 77418, 77432, 77435)

n

Supplies associated with hospital beds (E0265, E0266, E0270, E0296, E0297, E0339)

n

Lab test (83003)

n

Breast reconstruction (19361, 19364, 19366, 19367, 19368, 19369, S2068)

n

Intersex surgery (57335)

n

Upper limb prosthetics (L6646, L6647, L6648)

n

Negative pressure wound therapy (97605, 97606, E2402)

n

Spinal fusion (22614)

Aetna’s precert policy Precertification approvals are valid for six months from the date of issue, unless stated otherwise at the time. For the four drugs under “Additions” with an asterisk, approvals are valid for 12 months from the date of issue.

Precertification requirements apply to all Aetna plans, except for Traditional Choice® and the Aetna Medicare OpenSM Plan, which is our Medicare Private Fee-for-Service plan. We will update the precertification list online before January 1, 2010.

Precert Code Search Tool You can also use our Precertification Code Search Tool to determine if a specific code needs precertification by entering a valid five-digit CPT code. Access the tool via www.aetna.com – choose “Health Care Professionals,” then “Medical” and then “Precertification List.”

Precertification and step-therapy programs are not available in all service areas. For example, precertification programs do not apply to commercial members in Indiana. Step-therapy does not apply to fully insured commercial members in Indiana and New Jersey. California HMO members who are receiving coverage for medications added to the precertification or step-therapy lists will continue to have those medications covered, for as long as the treating physician continues prescribing them, provided that the drug is appropriately prescribed and is considered safe and effective for treating the enrollee’s medical condition. The term “precertification” does not mean a reliable representation of payment of care or services to fully insured HMO and PPO members. This material is provided for informational purposes only and is not intended to direct treatment decisions.

How to bill for Gardasil®

Proper billing for the vaccine Gardasil will help you get faster and more accurate reimbursement.

When Gardasil is administered at the time of a routine gynecologic exam, report the following codes: Preventive gyn exam codes (99381-97) n Administration of the vaccine (90471) The Gardasil vaccine (90649) n n

If you encounter a problem during the preventive exam that requires significant extra work, report the E&M code billed with Modifier 25.

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