Clinical Criteria
A clinical criteria, or medical guideline, is a document guiding medical decisions regarding diagnosis, management, and treatment in specific areas of health care. Below you will find information about Capital Health Plan’s clinical criteria for our Employer Group Plans, Individual and Family Plans, and Medicare Plans.
Universal Prior Authorization
Effective 1/1/2017, the Florida Legislature amended a statute to require all insurers use the Universal Prior Authorization Form. Therefore, as of 1/1/2017, Capital Health Plan will only accept this form when submitted and completely filled out as directed by the instructions. Incomplete forms will not be considered a valid request for services and therefore will not be processed.
Commercial Criteria
All non-Medicare plans such as Employer Group and Individual and Family are also known as Commercial plans, and these health plans have developed criteria that require prior authorization. As an independent licensee of the BCBS Association, we can share the latest updates for coverage guidelines from BCBSF. The following Capital Health Plan-developed criteria require prior authorization:
- Applied Behavioral Analysis Services
- Colonoscopies
- Long Term Acute Care Hospitalization
- Magnetic Resonance Imaging (MRI) Cervical Spine
- Magnetic Resonance Imaging (MRI) Lumbar Spine
- Residential Eating Disorders Treatment
- Residential Substance Abuse Treatment
- Skilled Nursing Facilities
- Thoracic Outlet Syndrome
- Weight Loss Services
- Wound Treatment Centers
Additionally, Capital Health Plan has a partnership with Carelon Medical Benefits Management to provide utilization management for our Radiation Oncology Program.
Florida Blue Adopted Criteria
Capital Health Plan has adopted the Florida Blue medical coverage policies as our criteria for Commercial members. Coverage policies that require prior authorization are listed below. To obtain the necessary medical coverage guidelines, please visit mcgs.bcbsfl.com.
This list is not all-inclusive:
- Bio-Engineered Skin and Soft Tissue Substitutes; Amniotic Membrane and Amniotic Fluid
- Cervical Spine Surgery
- Cochlear Implants
- Continuous Glucose Monitoring
- Continuous Passive Motion Device
- Computed Tomographic Colonography (Virtual Colonoscopy or CT Colonoscopy)
- Deep Brain Stimulation
- External Insulin Infusion Pumps and Supplies
- Functional Neuromuscular Stimulation
- Genetic Testing:
- Analysis of Human DNA as a Technique for Colorectal Cancer Screening
- Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer
- Genetic Testing
- Genetic Testing for Hereditary Breast/Ovarian Cancer Syndrome and Other High-Risk Cancers (BRCA1, BRCA2, PALB2)
- Genetic Testing for Lynch Syndrome and Other Inherited Colon Cancer Syndromes
- KRAS, NRAS, and BRAF Variant Analysis (Including Liquid Biopsy & MicroRNA Expression Testing) in Metastatic Colorectal Cancer
- Multigene Expression Assay for Predicting Recurrence in Colon Cancer
- Tumor/Genetic Markers
- Hyperbaric Oxygen (HBO) Therapy
- Hyperthermic Intraperitoneal Chemotherapy (HIPEC)
- Implantable Hearing Devices
- Intracept (Neurolysis/Ablation)
- Left Atrial Appendage Closure
- Lumbar Spine Surgery
- Negative Pressure Wound Therapy Pump
- Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Disorders
- Osteogenesis Stimulators
- Percutaneous Tibial Nerve Stimulation
- Percutaneous Vertebroplasty, Kyphoplasty, and Sacroplasty
- Power Wheelchairs
- Quantitative Electroencephalography (QEEG)
- Reconstructive Surgery and Cosmetic Surgery:
- Bariatric Surgery
- Blepharoplasty/Brow Surgical Procedures
- Mastectomy for Gynecomastia
- Orthognathic Surgery
- Panniculectomy and Abdominoplasty
- Prosthetics
- Reduction Mammoplasty (Breast Reduction)
- Rhinoplasty
- Speech Generating Devices
- Spinal Cord and Dorsal Root Ganglion Stimulation
- Subcutaneous Implantable Cardioverter Defibrillators
- Transcranial Magnetic Stimulation
- Vagus Nerve Stimulation
- Vertiflex (Interspinous and Interlaminar Spacers and Fusion Devices)
- Wearable and Non-Wearable Cardioverter-Defibrillators (WCD)
Medicare Criteria
All Medicare plans require that you follow certain developed criteria that require prior authorization. You can access and read the Centers for Medicare & Medicaid Services “What’s New” reports for the latest updates on Original Medicare coverage guidelines for National Coverage Decisions (NCD) and Local Coverage Decisions (LCD) at any time. The following Capital Health Plan Medicare Advantage (HMO) developed criteria below require prior authorization:
Additionally, Capital Health Plan has a partnership with Carelon Medical Benefits Management to provide utilization management for our Radiation Oncology Program.
In coverage situations where there is no Medicare NCD, LCD, Article, or Coverage Rule, services will be reviewed using the applicable Blue Cross Blue Shield of Florida medical coverage guideline.
Reference-Medicare Managed Care Manual – Chapter 4, Section 90.5
Original Medicare Criteria
Capital Health Plan follows Original Medicare coverage policies for CHP Medicare members. You can access Original Medicare’s coverage policies from the list and chart below at any time.
| Medical Clinical Criteria | CMS Reference |
|---|---|
| Acupuncture for Chronic Low Back Pain (cLBP) | NCD 30.3.3 |
| Automatic External Defibrillators | LCD L33690 |
| Back/Neck Surgeries: Cervical Fusion Percutaneous Image-Guided Lumbar Decompression for Lumbar Spinal Stenosis (Verteflex) Vertebroplasty/Kyphoplasty |
LCD L39799 NCD 150.13 LCD L34976 |
| Blepharoplasty, Blepharoptosis Repair and Surgical Procedures of the Brow | LCD L34028/LCA A57025 |
| Cochlear Implants | NCD 50.3 |
| Colon Testing: Colorectal Cancer Screening Diagnostic Colonoscopy |
NCD 210.3 LCD L33671 |
| Continuous Passive Motion Device | NCD 280.1 |
| Cosmetic and Reconstructive Surgery | LCD L38914 |
| Deep Brain Stimulation | NCD 160.24 |
| Genetic Testing: BRCA1 & BRCA2 Genetic Testing for Cardiovascular Disease Lynch Syndrome Molecular Pathology Procedures Next Generation Sequencing Pharmacogenomics Testing |
LCD L36499 LCD L39084 LCD L34912 LCD L34519 NCD 90.2 LCD L39073 |
| Glucose Monitors | LCD L33822 |
| High Frequency Chest Wall Oscillation Devices | LCD L33785 |
| Hyperbaric Oxygen Therapy (HBO2) | NCD 20.29 |
| Hyperthermia for Treatment of Cancer | NCD 110.1 |
| Implantable Continuous Glucose Monitor (I-CGM) | LCD L38664/A58136 |
| Insulin Pumps (External) | LCD L33794 |
| Leadless Pacemakers | NCD 20.8.4 |
| Magnetic Resonance Imaging (MRI) (Cervical and Lumbar Spine) | NCD 220.2 |
| Negative Pressure Wound Therapy (NPWT) Pump | LCD L33821 |
| Neuromuscular Electrical Stimulation (NMES) | NCD 160.12 |
| Osteogenesis Bone Growth Stimulators | LCD L33796 |
| Panniculectomy and Abdominoplasty (Cosmetic and Reconstructive Surgery) | LCD L38914 |
| Percutaneous Left Atrial Appendage Closure (LAAC) | NCD 20.34 |
| Power Mobility Devices | LCD L33789 |
| Residential Eating Disorders Treatment (Psychiatric Inpatient Hospitalization) | LCD L33975 |
| Residential Substance Abuse Treatment [Treatment of Drug Abuse (Chemical Dependency)] | NCD 130.6 |
| Rhinoplasty (Cosmetic and Reconstructive Surgery) | LCD L38914 |
| Seat Lift Mechanisms | LCD L33801 |
| Skin Substitute Grafts for Diabetic Foot Ulcers and Venous Leg Ulcers | LCD L36377 |
| Speech Generating Devices | LCD L33739 |
| Spinal Cord Stimulation | NCD 160.7 |
| Surgical Treatment for Morbid Obesity (Bariatric Surgery) | LCD L33411 |
| Transcranial Magnetic Stimulation | LCD L34522 |
| Vagus Nerve Stimulation | NCD 160.18 |