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HealthyCT Inc.
35 Thorpe Avenue, Suite 104
Wallingford, CT 06492
PRIOR-AUTHORIZATION ADDENDUM
Effective Date: Dates of Service On Or After June 1, 2015
You need Prior-Authorization for the following:
Inpatient Services
 Medical/Surgical Inpatient Admissions
 Skilled Nursing facility Admissions
 Acute Inpatient Rehabilitation
 Residential Treatment Facilities
 Sub-Acute Care Admissions
 Inpatient Hospice
 Acute Behavioral Health Admissions
 Partial Behavioral Health Programs
Services/Procedures/Devices/Programs
 Ambulance: Non-Emergent Air and Ground
 Anesthesia for dental surgery - Dental anesthesia and facility charges
 Autism services – Physical Therapy, Occupational Therapy and Applied Behavioral Analysis
(first 10 visits annually are excluded from the prior authorization requirement)
 Behavioral Health Intensive Outpatient Program
 Blepharoplasty and Brow Ptosis Repair
 Biofeedback
 Clinical Trials
 Cosmetic Procedures (See Attachment 1)
 Cranial Remodeling Bands (Helmets)
 DME: Hospital Bed (and mattress), Custom Wheelchair
 Experimental/Investigational Procedures
 Fecal Bacteriotherapy
 Gender Dysphoria, including Gender Reassignment Surgery
 Genetic Testing: Breast, Ovarian and Colorectal cancers
 Habilitative Services (after the first 10 visits annually)
 Home Health Care: all services
 Hyperbaric Oxygen Therapy
 Infertility Services/Treatments including Pre-Implementation Genetic Testing
 Neuropsychological testing, except for children with cancer
 Non-participating provider when requesting in-network level of coverage
 Orthognathic /Jaw Surgery
 Occupational Therapy: Habilitative and Rehabilitative (after the first 10 visits annually)
 Physical Therapy: Habilitative and Rehabilitative (after the first 10 visits annually)
 Prosthetics: whole limb or part of limb
 Psychological Testing
PriorAuth
Rev. 1/2015
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HealthyCT Inc.
35 Thorpe Avenue, Suite 104
Wallingford, CT 06492
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Radiology: CT, MRI/MRA, SPECT, PET and Nuclear Cardiology
Sclerotherapy (Varicose Vein Treatment)
Septoplasty
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Sleep Studies other than location of home
Spinal Surgery: Inpatient and Outpatient
Temporomandibular joint (TMJ) surgery
Transplants: Pre-evaluation and at time of transplant (except cornea)
Uvulopalatopharyngoplasty, including laser-assisted procedures
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Uvulectomy and Laser Assisted Uvuloplasty (LAUP)
Notification Requirements
 Maternity after First Pre-Natal Visit
 Birth to Three Program
 Dialysis
Potentially Cosmetic Procedures Requiring Prior Authorization including, but not limited to:
 Breast Reduction Surgery
 Breast reduction/Mastopexy
 Breast Repair/Reconstruction (Not Following Mastectomy)
 Breast Augmentation
 Canthoopexy/Canthoplasty
 Cerivicoplasty
 Chemical Peels
 Laser Treatment for Cutaneous Vascular Lesions
 Rhinophyma Surgical/Laser Treatment
 Rhinoplasty
 Repair of Vestibular Stenosis
PriorAuth
Rev. 1/2015