Attachment A - MCUP3041

Attachment A - MCUP3049

Attachment B - MCUG3007

(TAR to be submitted by the provider performing the service) Revised06/13/2018

A.Hospitalization

1.ThehospitalmustnotifyPHCofanyadmissionwithin24hoursoftheadmission.

2.Authorizationforelectiveadmissionmustberequestedby theadmittingphysician prior to the admission.

B.LongTermCare

TheLTCfacilitiesmustnotifyPHCofanyadmissions,transfer,bedhold/leaveofabsence,or changeinpayorstatuswithinoneworkingday.(ExamplesincludeMedicarenon-coverageor exhaustionofbenefits/hospiceelection.)

C.OutpatientSurgicalProcedures–seeCPTsRequiringTARlist

D.PainManagement–seeCPTsRequiringTARlist

E.OutpatientHemo/PeritonealDialysis

(Note:initialauthorizationwillbelimitedto90daysanda lifetime TARwillbegrantedonlyaftersubmissionofMedicaredetermination.)

F.DrugsandPharmaceuticals–ATARisrequiredforallprescriptiondrugs,over-the-counter drugsandinjectabledrugs(includingdrugscompoundedforIVinfusiontherapy)notonthe PHCformulary.

PLEASEREFERTOPHCFORMULARY

G.DiagnosticStudies

♦CTScans (Except 76497)

♦MRI (Except 76494, 76380, 76506)

♦Cardiac MRI - 75561 only (effective 08/01/2017)

♦MRA

♦PETscan

♦TranscranialDoppler

♦SleepStudies/Polysomnography

H.Ancillary/SupportServices

RAFauthorizesonevisitonly.Requestsforadditionalvisitsrequiretheancillaryservice providertosubmitcopiesofinitialevaluationandtreatmentplanattachedtoTAR.TAR mustincludetotalvisitsrequestedincludinginitialvisit.

♦ / Acupuncturist / / SpeechTherapy
♦ / Chiropractor / / OccupationalTherapy
♦ / FaithHealer / / HomeInfusionTherapy(NursingComponentOnly)
♦ / PhysicalTherapy / / HomeHealthCare

I.HospiceCare (Inpatient Only)

J.PulmonaryRehabilitation

K.HyperbaricOxygenPressurization

L.Non-EmergencyMedicalTransportation

M.EPSDT(EarlyandPeriodicScreening,DiagnosisandTreatment)SupplementalServices

N.Phototherapyfordermatologicalcondition

O.DentalAnesthesia

P.CCS/GHPP-Authorizationforservicesrelatedtoeligiblecondition(s)mustberequestedfrom

CCSorGHPPoffice(s).

Q.Supplies/Equipment

♦Orthotics–Cumulativecostsforrepair/maintenanceorpurchaseexceeds$250/item

♦Prosthetics–Cumulativecostsforrepair/maintenanceorpurchaseexceeds$500/item

Andanyunlisted/ miscellaneouscodeincluding:

-L0999 Additiontospinalorthosis,nototherwisespecified

-L1499 Spinalorthosis,nototherwisespecified

-L2999 Lowerextremityorthosis,nototherwisespecified

-L3649 Orthoticshoe,modification,additionortransfer,nototherwisespecified

-L3999 Upperlimborthosis,nototherwisespecified

-L5999 Lowerextremityprosthesis,nototherwisespecified

-L7499 Upperextremityprosthesis,nototherwisespecified

-L8039 Breastprosthesis,nototherwisespecified

-L8499 Unlistedprocedureformiscellaneousprostheticservices

-L8699 Prosthetic implant, not otherwise specified

ANYCUSTOMMADEITEMTHATDOESNOTHAVEAMEDI-CALRATE (BY-REPORTORBY-INVOICE)

♦OstomySupplies–Ifmonthlycumulativecostforallrelatedsuppliesexceeds$150

♦HearingAid–Allpurchases,rentalsorrepairsexceeding$50/item

(Batteriesarenon-coveredexceptsomeCCS/EPSDTcases,inwhichcaseTARis required)

♦Oxygenandrelatedsupplies

♦DiabeticSuppliesaretobeprovidedbyPharmaciesONLY

♦Nebulizers– When the billed price including tax is $100 or more

♦MedicalSupplies– (IfdispensedbyPHARMACY,pleaserefertoformulary)

♦DME– (IfdispensedbyPHARMACY,pleaserefertoformulary)

-Repairsor maintenanceover$250.00/item(Outofguaranteerepairsaretobe guaranteedforatLEASTthree(3)monthsfromthedateofrepair. Reimbursement willNOTbeallowedforpartsorlaborduringaguaranteeperiod ifduetoadefectin materialorworkmanship)

-Purchaseitemswhen the cumulative cost of items within a group exceeds $100.00 within the calendar month.Providers may refer to the Durable Medical Equipment (DME): Billing Codes and Reimbursement Rates section in the Medi-Cal manual to determine if items are related within a group. Items grouped together under specific headings, such as “Hospital Beds” or “Bathroom Equipment,” are considered within the same group. (Vendor toguaranteeforaMINIMUMofsix(6)monthsfromthedateofpurchase)

-Rentalitemswhen the cumulative cost of rental for items within the group exceeds $50.00within a 15-month period.This includes any daily amount that an individual item, or a combination of a similar group of DME items, exceeds the $50 threshold. The 15-month period begins on the date the first item is rented. (Rentalrateincludesequipmentrelated supplies.)

-Anyunlistedor miscellaneouscode

-PurchaseofanywheelchairsforMedi-Medimembers

♦IncontinenceSupplies

-Incontinencesuppliesifmonthlycumulativecostforallrelatedsuppliesexceeds

$125.00

-Washesandcreamsformemberswithincontinencewillonlybeauthorizedifthe physicianjustifiesmedicalnecessity

♦NutritionalSupplements (Submit TAR to Pharmacy)

♦AND anyunlistedor miscellaneouscode

R.Genetic Testing– A TAR is required for certain genetic testing as outlined in Attachment A of the Genetic Testing policy MCUP3131.

S. Gender Dysphoria– A TAR is required for all procedures related to gender dysphoria.

T. Fecal Microbiota Transplant (FMT)

Outpatient SurgicalProcedures-CPTsRequiringTAR

CPTCode / Description
10040 / AcneSurgery
15788Thru15793 / ChemicalPeel,FacialEtAl
15810-11 / Salabrasion
15820Thru15823 / RevisionOfLowerOrUpperEyelid
15845 / SkinAndMuscleRepair,Face
17360 / SkinPeelTherapy
17999 / SkinTissueProcedure
19140 / MastectomyForGynecomastia
19300 / MastectomyForGynecomastia
19316 / Mastopexy
19318 / ReductionMammoplasty
19324/25 / BreastAugment;W/OProstheticImplant
19355 / CorrectionOfInvertedNipples
19380 / ReviseBreastReconstruction
19396 / DesignCustomBreastImplant
19499 / UnlistedProcedure,Breast
20999 / MusculoskeletalSurgery
21208 / AugmentationOfFacialBones
22899 / SpineSurgeryProcedure
22999 / AbdomenSurgeryProcedure
28290Thru28299 / CorrectionOfBunion
28300Thru28345 / Osteotomy/Repair/ Reconstruction
30400Thru30520 / ReconstructOfNose
30520 / RepairNasalSeptum
32999 / ChestSurgeryProcedure
36299 / VesselInjectionProcedure
37700 / LigationAndDivisionOfLongSaphenousVeinAtSaphenofemoralJunction,OrDistal
Interruptions
37718 / Ligation,Division,AndStripping,ShortSaphenousVein
37722 / Ligation,Division,AndStripping,Long(Greater)SaphenousVeinsFromSaphenofemoral
JunctionToKneeOrBelow
37735 / LigationAndDivisionAndCompleteStrippingOfLongOrShortSaphenousVeinsWithRadical ExcisionOfUlcerAndSkinGraftAnd/orInterruptionOfCommunicatingVeinsOfLowerLeg, WithExcisionOfDeepFascia
37760 / LigationOfPerforatorVeins,Subfascial,Radical(LintonType)IncludingSkinGraft,When
Performed,Open,1Leg
37761 / LigationOfPerforatorVein(S),Subfascial,Open,IncludingUltrasoundGuidance,When
Performed,1Leg
37765 / StabPhlebectomyOfVaricoseVeins,1 Extremity;10-20StabIncisions

OutpatientSurgicalProcedures -CPTsRequiringTAR(Continued)

CPTCode / Description
37766 / MoreThan20Incisions
37780 / LigationAndDivisionOfShortSaphenousVeinAtSaphenopoplitealJunction(Separate
Procedure)
37785 / Ligation,Division,And/orExcisionOfVaricoseVeinCluster(S)1Leg
38206,38231 / StemCellHarvesting
38230 / BoneMarrowHarvesting
36511 / TherapeuticApheresisOfWBC‘s
36512 / TherapeuticApheresisOfRBCs
38204 / UnrelatedHarvestingOfCells
38205 / StemCellHarvestingFromSiblings
38207 / StemCellStorage
41899 / GumSurgeryProcedure
43770 / Laparoscopy,Surgical,GastricRestrictiveProcedure
43771 / Laparoscopy,Surgical,RevisionOfAdjustGastricBand
43772 / Laparoscopy,Surgical,RemovalOfAdjustableGastricBand
43773 / Laparoscopy,Surgical,Removal& PlacementOfAdjGastricBand
43774 / Laparoscopy,Surgical,RemovalOfAdjustableGastricBand
43775 / Lap Sleeve Gastrectomy
43842 / Gastroplasty,VerticalBanded,ForMorbidObesity
43843 / Gastroplasty,OtherThanVertical-Banded,ForMorbidObesity
43845 / Gastroplasty
43846 / GastricBypassForObesity
43847 / GastricRestrictiveProcedureWithGastricBypass
43848 / RevisionOfGastricRestrictive
43886 / GastricRestrictiveProcedure
43887 / GastricRestrictiveProcedure,RemovalOfSubcutaneousPortComponent
43888 / GastricRestrictiveProc,RemovalReplacementOfSubcutaneousPort
43999 / Stomach Surgery Procedure
49999 / AbdomenSurgeryProcedure
54161 / Circumcision –TAR not required if patient < 4 months of age (See policy MCUP3121 Neonatal Circumcision
54360 / PenisPlasticSurgery
54400Thru54440 / PenileProsthesis/PlasticProcedureForPenis
55175/80 / RevisionOfScrotum
55200 / IncisionOfSpermDuct
56800 / RepairOfVagina
58150Thru58294, 58570 / Hysterectomy
58350 / ReopenFallopianTube
58550Thru58554 / Laparoscopy,Surgical;WithVaginalHysterectomyWithOrWithoutRemovalOfTube(S),With
OrWithoutRemovalOfOvary(S)(LaparoscopicAssistedVaginalHysterectomy)

OutpatientSurgicalProcedures -CPTsRequiringTAR(Continued)

CPTCode / Description
58578/79 / UnlistedProcedure,Uterus
58750Thru58770 / TubalRepair
61850Thru61888 / Insertion,RevisionOrRemovalOfCranialNeurostimulator
62290 thru 62291 / Discography, Lumbar (62290) and Cervical/Thoracic (62291)
63650Thru63688 / Insertion,RevisionOrRemovalOfSpinalNeurostimulator
67900Thru67924 / RepairBrow,Ptosis,Blepharoptosis,Lid
67950Thru-66 / RevisionOfEyelid
67971-75 / ReconstructionOfEyelid
67999 / UnlistedEyelidProcedure
69300 / ReviseExternalEar
69399 / OuterEarSurgeryProcedure
72285 / Cervical and Thoracic Discography
72295 / Lumbar discography

Pain ManagementCPTsRequiringTAR

CPT CODE / DESCRIPTION
27096 / Injection procedure for sacroiliac joint, arthrography and/or anesthetic/steroid
0027T / Endoscopic lysis of epidural adhesions with direct visualization using mechanical means (e.g., spinal endoscopic catheter system) or solution injection (e.g., normal saline) including radiologic localization and epidurography
0062T / Percutaneous intradiscal annuloplasty, any method, unilateral or bilateral including fluoroscopic guidance; single level
0063T / Percutaneous intradiscal annuloplasty, any method, unilateral or bilateral including fluoroscopic guidance; one or more additional levels
22521 thru 22525 / Percutaneous vertebroplasty and percutaneous vertebral augmentation
62287 / Aspiration or decompression procedure, percutaneous, of nucleus pulposus of intervertebral disk, any method, single or multiple levels, lumber (e.g. manual or automated percutaneous discectomy, percutaneous laser discectomy)
62263 / Percutaneous lysis of epidural adhesions using solution injection (e.g., hypertonic saline, enzyme) or mechanical means (e.g., catheter) including radiological localization (includes contrast when administered), multiple adhesiolysis sessions; 2 or more days
62264 / Percutaneous lysis of epidural adhesions using solution injection (e.g., hypertonic saline, enzyme) or mechanical means (e.g., catheter) including radiological localization (includes contrast when administered), multiple adhesiolysis sessions; 1 day
62360 thru 62362 / Implantable or replacement of device for intrathecal or epidural drug infusion; subcutaneous reservoir
63650 thru 63688 / Insertion, revision or removal of spinal neurostimulator
64479 / Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance (fluoroscopy or CT); cervical or thoracic, single level
64480 / Cervical or thoracic, each additional level
64483 / Lumbar or sacral, single level
64484 / Lumbar or sacral, each additional level
64490 / Injection(s), diagnostic or therapeutic agent, Paravertebral facet (zygapophyseal) joint with image guidance (fluoroscopy or CT), cervical or thoracic; single level.
64491 / Second level (List separately in addition to code for primary procedure)

Pain ManagementCPTsRequiringTAR(Continued)

64492 / Third level (List separately in addition to code for primary procedure
64493 / Injection(s), diagnostic or therapeutic agent, paravertebral facet(zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT, lumbar or sacral; single level)
64494 / Second level (List separately in addition to code for primary procedure)
64495 / Third level (List separately in addition to code for primary procedure)
64633 / Destruction by neurolytic agent, paravertebral facet joint nerve. cervical or thoracic, single level
64634 / Cervical or thoracic, each additional level
64635 / Destruction by neurolytic agent, paravertebral facet joint nerve. single level lumbar or sacral
64636 / Lumbar or sacral, each additional level
*J0585 / (If billed with 64612 & 64613) Botulinum A Toxin – 1 unit extraocular
*J0587 / (If billed with 64612 & 64613) Botulinum B Toxin – 10 units facial

* TARs generated by the Pharmacy Department

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