Predetermination for Medical Necessity - CCHS

The following list includes those services that MUST receive predetermination for medical necessity prior to being rendered EXCEPT for emergency/urgent situations.

Inpatient Services

• Acute Rehabilitation Admission
• Elective Hospital Admission*
• Out-of-Network and Out-of-Area Care (All)**
• Skilled Nursing Facility (SNF)/Transitional Care Unit (TCU)/Sub-Acute Admission

  *Elective inpatient hospitalizations require predetermination for medical necessity and may be subject to concurrent review.
  **The CHN Care Management goal is to transition all care into a Tier 1 Provider. Refusal to transition may result in the patient/member being financially responsible.

Outpatient Services

• Breast Reduction
• Capsule Endoscopies
• DXA Scan (Bone Density) under age 60 (or >every 5 years over age 60)
• Experimental or Investigational Procedures
• Head MRI
• Home Care
• Home Use of Tocolytic Agents/Home Use of Uterine Monitoring
• Human Organ or Bone Marrow Transplant
• Potentially Cosmetic Procedures
• Tilt Tables
• Durable Medical Equipment (DME)*:
  • Cochlear implants
  • Continuous passive motion machines
  • Electric wheelchairs
  • Extension/Flexion (dynamic and bi-directional) devices
  • Full spectrum light boxes
  • Fully automatic beds
  • High-end (hinged) braces
  • High-end prosthetics
  • Home oxygen therapy
  • Home CPAP or BiPap
  • Insulin pumps
  • Low air loss beds
  • Non-standard size wheelchairs – lightweight/heavyweight
  • Osteogenesis stimulators
  • Pneumatic compression devices
  • Scooters
  • Speech assistance devices

*Reimbursement for DME will be made at the established rate for standard equipment. Any rate differential for “deluxe” equipment will be the member’s responsibility.

Pharmaceuticals

• Amevive
• Botox Injections
• Enbril
• Growth Hormone
• Humira
• Kineret
• Myobloc
• Raptiva
• Respigam/Synagis
• Retin A >35 years old
• Rheumatoid Arthritis Therapies
• Xolair

Notification to CHN

• Hospice – CHN notification for authorization

Services Subject to Review

• Temporomandibular Joint Syndrome (TMJ) –is not a covered service but CHN Care Management will consider approving this service for unique individual circumstances. Any services for TMJ must be done within the Tier 1 CCHS Network of Providers. Members who choose to be evaluated for TMJ will incur the cost of the evaluation whether treatment is approved by the CCHS EHP or not.

Approval must be obtained from CHN Care Management prior to services being provided.