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HCPCS/CPT4 CODES | DESCRIPTION | COVERED BENEFITS | NON COVERED BENEFITS | PRIOR AUTHORIZATION EFFECTIVE DATE | 42975
AUTHORIZATION REQUIRED
| PR DISE DYN EVAL SLEEP DISORDERED BREATHING FLX DX | CHIP, STAR, STAR KIDS | CHIP PERINATE | 2/1/2024 | ALERTS AND LIMITATIONS | REVIEW CRITERIA | DOCUMENTATION REQUIREMENT | CRITERIA REVIEW DATE | EXCLUSIONS: AUTH REQUIRED REGARDLESS IF DHP IS A SECONDARY PAYOR | TMPPM, PROPRIETARY DISCLAIMER
HTTP://WWW.TMHP.COM/PAGES/DEFAULT.ASPX | CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY | REFER TO TMPPM | |
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HCPCS/CPT4 CODES | DESCRIPTION | COVERED BENEFITS | NON COVERED BENEFITS | PRIOR AUTHORIZATION EFFECTIVE DATE | 69714
AUTHORIZATION REQUIRED
| PR IMPLTJ OI IMPLT SKULL PERQ ATTACHMENT ESP | CHIP, STAR, STAR KIDS | CHIP PERINATE | 2/1/2024 | ALERTS AND LIMITATIONS | REVIEW CRITERIA | DOCUMENTATION REQUIREMENT | CRITERIA REVIEW DATE | EXCLUSIONS: AUTH REQUIRED REGARDLESS IF DHP IS A SECONDARY PAYOR | TMPPM, PROPRIETARY DISCLAIMER
HTTP://WWW.TMHP.COM/PAGES/DEFAULT.ASPX | CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY | REFER TO TMPPM | |