|
HCPCS/CPT4 CODES | DESCRIPTION | COVERED BENEFITS | NON COVERED BENEFITS | PRIOR AUTHORIZATION EFFECTIVE DATE | 15831
AUTHORIZATION REQUIRED
| PR EXCISE EXCESS SKIN TISSUE,ABDOMEN | | CHIP, STAR, STAR KIDS, CHIP PERINATE | 10/1/2023 | ALERTS AND LIMITATIONS | REVIEW CRITERIA | DOCUMENTATION REQUIREMENT | CRITERIA REVIEW DATE | EXCLUSIONS: AUTH REQUIRED REGARDLESS IF DHP IS A SECONDARY PAYOR. THIS PROCEDURE CODE IS NOT A COVERED SERVICE BUT DHP WILL REVIEW REQUESTS FOR THIS PROCEDURE CODE ON A CASE-BY-CASE BASIS TO DETERMINE MEDICAL NECESSITY. | TMPPM, HTTPS://WWW.TMHP.COM/RESOURCES/PROVIDER-MANUALS/TMPPM | CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY | REFER TO TMPPM | |
HCPCS/CPT4 CODES | DESCRIPTION | COVERED BENEFITS | NON COVERED BENEFITS | PRIOR AUTHORIZATION EFFECTIVE DATE | 15832
AUTHORIZATION REQUIRED
| PR EXCISE EXCESS SKIN TISSUE,THIGH | | CHIP, STAR, STAR KIDS, CHIP PERINATE | 10/1/2023 | ALERTS AND LIMITATIONS | REVIEW CRITERIA | DOCUMENTATION REQUIREMENT | CRITERIA REVIEW DATE | EXCLUSIONS: AUTH REQUIRED REGARDLESS IF DHP IS A SECONDARY PAYOR. THIS PROCEDURE CODE IS NOT A COVERED SERVICE BUT DHP WILL REVIEW REQUESTS FOR THIS PROCEDURE CODE ON A CASE-BY-CASE BASIS TO DETERMINE MEDICAL NECESSITY. | TMPPM, HTTPS://WWW.TMHP.COM/RESOURCES/PROVIDER-MANUALS/TMPPM | CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY | REFER TO TMPPM | |
HCPCS/CPT4 CODES | DESCRIPTION | COVERED BENEFITS | NON COVERED BENEFITS | PRIOR AUTHORIZATION EFFECTIVE DATE | 15833
AUTHORIZATION REQUIRED
| PR EXCISE EXCESS SKIN TISSUE,LEG | | CHIP, STAR, STAR KIDS, CHIP PERINATE | 10/1/2023 | ALERTS AND LIMITATIONS | REVIEW CRITERIA | DOCUMENTATION REQUIREMENT | CRITERIA REVIEW DATE | EXCLUSIONS: AUTH REQUIRED REGARDLESS IF DHP IS A SECONDARY PAYOR. THIS PROCEDURE CODE IS NOT A COVERED SERVICE BUT DHP WILL REVIEW REQUESTS FOR THIS PROCEDURE CODE ON A CASE-BY-CASE BASIS TO DETERMINE MEDICAL NECESSITY. | TMPPM, HTTPS://WWW.TMHP.COM/RESOURCES/PROVIDER-MANUALS/TMPPM | CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY | REFER TO TMPPM | |
HCPCS/CPT4 CODES | DESCRIPTION | COVERED BENEFITS | NON COVERED BENEFITS | PRIOR AUTHORIZATION EFFECTIVE DATE | 15834
AUTHORIZATION REQUIRED
| PR EXCISE EXCESS SKIN TISSUE,HIP | | CHIP, STAR, STAR KIDS, CHIP PERINATE | 10/1/2023 | ALERTS AND LIMITATIONS | REVIEW CRITERIA | DOCUMENTATION REQUIREMENT | CRITERIA REVIEW DATE | EXCLUSIONS: AUTH REQUIRED REGARDLESS IF DHP IS A SECONDARY PAYOR. THIS PROCEDURE CODE IS NOT A COVERED SERVICE BUT DHP WILL REVIEW REQUESTS FOR THIS PROCEDURE CODE ON A CASE-BY-CASE BASIS TO DETERMINE MEDICAL NECESSITY. | TMPPM, HTTPS://WWW.TMHP.COM/RESOURCES/PROVIDER-MANUALS/TMPPM | CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY | REFER TO TMPPM | |
HCPCS/CPT4 CODES | DESCRIPTION | COVERED BENEFITS | NON COVERED BENEFITS | PRIOR AUTHORIZATION EFFECTIVE DATE | 15835
AUTHORIZATION REQUIRED
| PR EXCISE EXCESS SKIN TISSUE,BUTTOCK | | CHIP, STAR, STAR KIDS, CHIP PERINATE | 10/1/2023 | ALERTS AND LIMITATIONS | REVIEW CRITERIA | DOCUMENTATION REQUIREMENT | CRITERIA REVIEW DATE | EXCLUSIONS: AUTH REQUIRED REGARDLESS IF DHP IS A SECONDARY PAYOR. THIS PROCEDURE CODE IS NOT A COVERED SERVICE BUT DHP WILL REVIEW REQUESTS FOR THIS PROCEDURE CODE ON A CASE-BY-CASE BASIS TO DETERMINE MEDICAL NECESSITY. | TMPPM, HTTPS://WWW.TMHP.COM/RESOURCES/PROVIDER-MANUALS/TMPPM | CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY | REFER TO TMPPM | |
HCPCS/CPT4 CODES | DESCRIPTION | COVERED BENEFITS | NON COVERED BENEFITS | PRIOR AUTHORIZATION EFFECTIVE DATE | 15836
AUTHORIZATION REQUIRED
| PR EXCISE EXCESS SKIN TISSUE,ARM | | CHIP, STAR, STAR KIDS, CHIP PERINATE | 10/1/2023 | ALERTS AND LIMITATIONS | REVIEW CRITERIA | DOCUMENTATION REQUIREMENT | CRITERIA REVIEW DATE | EXCLUSIONS: AUTH REQUIRED REGARDLESS IF DHP IS A SECONDARY PAYOR. THIS PROCEDURE CODE IS NOT A COVERED SERVICE BUT DHP WILL REVIEW REQUESTS FOR THIS PROCEDURE CODE ON A CASE-BY-CASE BASIS TO DETERMINE MEDICAL NECESSITY. | TMPPM, HTTPS://WWW.TMHP.COM/RESOURCES/PROVIDER-MANUALS/TMPPM | CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY | REFER TO TMPPM | |
HCPCS/CPT4 CODES | DESCRIPTION | COVERED BENEFITS | NON COVERED BENEFITS | PRIOR AUTHORIZATION EFFECTIVE DATE | 15837
AUTHORIZATION REQUIRED
| PR EXCISE EXCESS SKIN TISSUE,FOREARM | | CHIP, STAR, STAR KIDS, CHIP PERINATE | 10/1/2023 | ALERTS AND LIMITATIONS | REVIEW CRITERIA | DOCUMENTATION REQUIREMENT | CRITERIA REVIEW DATE | EXCLUSIONS: AUTH REQUIRED REGARDLESS IF DHP IS A SECONDARY PAYOR. THIS PROCEDURE CODE IS NOT A COVERED SERVICE BUT DHP WILL REVIEW REQUESTS FOR THIS PROCEDURE CODE ON A CASE-BY-CASE BASIS TO DETERMINE MEDICAL NECESSITY. | TMPPM, HTTPS://WWW.TMHP.COM/RESOURCES/PROVIDER-MANUALS/TMPPM | CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY | REFER TO TMPPM | |
HCPCS/CPT4 CODES | DESCRIPTION | COVERED BENEFITS | NON COVERED BENEFITS | PRIOR AUTHORIZATION EFFECTIVE DATE | 15839
AUTHORIZATION REQUIRED
| PR EXCISE EXCESS SKIN TISSUE,OTHER | | CHIP, STAR, STAR KIDS, CHIP PERINATE | 10/1/2023 | ALERTS AND LIMITATIONS | REVIEW CRITERIA | DOCUMENTATION REQUIREMENT | CRITERIA REVIEW DATE | EXCLUSIONS: AUTH REQUIRED REGARDLESS IF DHP IS A SECONDARY PAYOR. THIS PROCEDURE CODE IS NOT A COVERED SERVICE BUT DHP WILL REVIEW REQUESTS FOR THIS PROCEDURE CODE ON A CASE-BY-CASE BASIS TO DETERMINE MEDICAL NECESSITY. | TMPPM, HTTPS://WWW.TMHP.COM/RESOURCES/PROVIDER-MANUALS/TMPPM | CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY | REFER TO TMPPM | |
HCPCS/CPT4 CODES | DESCRIPTION | COVERED BENEFITS | NON COVERED BENEFITS | PRIOR AUTHORIZATION EFFECTIVE DATE | 15877
AUTHORIZATION REQUIRED
| PR SUCT ASSIS LIPECTOMY,TRUNK | | CHIP, STAR, STAR KIDS, CHIP PERINATE | 10/1/2023 | ALERTS AND LIMITATIONS | REVIEW CRITERIA | DOCUMENTATION REQUIREMENT | CRITERIA REVIEW DATE | EXCLUSIONS: AUTH REQUIRED REGARDLESS IF DHP IS A SECONDARY PAYOR. THIS PROCEDURE CODE IS NOT A COVERED SERVICE BUT DHP WILL REVIEW REQUESTS FOR THIS PROCEDURE CODE ON A CASE-BY-CASE BASIS TO DETERMINE MEDICAL NECESSITY. | TMPPM, HTTPS://WWW.TMHP.COM/RESOURCES/PROVIDER-MANUALS/TMPPM | CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY | REFER TO TMPPM | |
HCPCS/CPT4 CODES | DESCRIPTION | COVERED BENEFITS | NON COVERED BENEFITS | PRIOR AUTHORIZATION EFFECTIVE DATE | 15878
AUTHORIZATION REQUIRED
| PR SUCT ASSIS LIPECTOMY,UP EXTREM | | CHIP, STAR, STAR KIDS, CHIP PERINATE | 10/1/2023 | ALERTS AND LIMITATIONS | REVIEW CRITERIA | DOCUMENTATION REQUIREMENT | CRITERIA REVIEW DATE | EXCLUSIONS: AUTH REQUIRED REGARDLESS IF DHP IS A SECONDARY PAYOR. THIS PROCEDURE CODE IS NOT A COVERED SERVICE BUT DHP WILL REVIEW REQUESTS FOR THIS PROCEDURE CODE ON A CASE-BY-CASE BASIS TO DETERMINE MEDICAL NECESSITY. | TMPPM, HTTPS://WWW.TMHP.COM/RESOURCES/PROVIDER-MANUALS/TMPPM | CLINICAL INFORMATION AND DOCUMENTS TO SUPPORT MEDICAL NECESSITY | REFER TO TMPPM | |