Medicare Criteria
All Medicare plans require that you follow certain developed criteria that require prior authorization. You can access and read about the latest updates on Original Medicare coverage guidelines for National Coverage Decisions (NCD) and Local Coverage Decisions (NCD) at any time. The following Capital Health Plan Medicare Advantage (HMO) developed criteria below require prior authorization:
- Anethesia and Facility Charges for Dental Services
- Implantable Hearing Devices
- Long Term Acute Care Hospitalization
- Skilled Nursing Facilities
- Thoracic Outlet Syndrome
- Wound Treatment Centers
Original Medicare Criteria
Capital Health Plan follows Original Medicare coverage policies for our Medicare members. You can access Original Medicare's coverage policies in the list below at any time.
For coverage policies that contain a Certificate of Medical Necessity (CMN) you may complete the CMN in lieu of submitting records and fax it to Capital Health Plan's Care Coordination Department at (850) 383-3310.
| Medical Clinical Criteria | Document ID |
| Automatic External Defribilators | LCD L33690 |
| Back Surgeries: Lumbar Spinal Fusion Intraspinous Process Decompression Vertebroplasty/Kyphoplasty | LCD L33382 LCD L34006 LCD L34976 |
| Breast Reduction (Reduction Mammoplasty) | LCD L33939 |
| Cochlear Implants | NCD 50.3 |
| Colorectal Cancer Screening - Colonoscopies and Cologuard Testing Diagnostic Colonoscopies | NCD 210.3 LCD L33671 |
| Computed Tomographic Colonography (Virtual Conoloscopy or CT Colonoscopy) | LCD L33283 |
| Continuous Passive Motion Device | NCD 280.1 |
| Enteral Nutrition | LCA A52493 |
Genetic Testing: | LCD L36499 LCD L34912 LCD L34519 LCD L33586 LCD L36789 |
| Glucose Monitors | LCD L33822 |
| High Frequency Chest Wall Oscillation Devices | LCD L33785 |
| Hip Replacement Surgery: Knee Replacement and Hip Replacement | LCD L33618 |
| Hyperbaric Oxygen Therapy (HBO2) | NCD 20.29 |
| Insulin Pumps (External) | LCD L33794 |
Knee Surgery: | NCD 150.9 LCD L33618 LCD L33594 NCD 150.12 LCD L33777 |
| Magnetic Resonance Imaging (MRI) (Cervical and Lumbar Spine) Requires review | NCD 220.2 |
| Negative Pressure Wound Therapy (NPWT) Pump | LCD L33821 |
| Osteogenesis Bone Growth Stimulators | LCD L33796 |
| Ostomy Supplies | LCD L33828 |
| Panniculectomy and Abdominoplasty (Cosmetic and Reconstructive Surgery) | LCD L34698 |
| Partial Hospitalization Program for Substance Abuse Treatment | LCD L33972 |
| Percutaneous Left Atrial Appendage Closure (LAAC) | NCD 20.34 |
| Power Wheelchairs (Wheelchairs and Wheelchair Accessories) | 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 L34698 |
| Sacroiliac Fusion | LCD L36000 |
| Seat Lift Mechanisms | LCD L33801 |
| Speech Generating Devices | LCD L33739 |
| Spinal Cord Stimulation | LCD L36035 |
| Surgical Treatment for Morbid Obesity (Bariatric Surgery) | LCD L33411 |
| Transcranial Magnetic Stimulation | LCD L34522 |
| Upper Eyelid and Brow Surgical Procedures | LCD L34028 |
Prior Authorization
Effective 1/1/2017, the Florida Legislature requires all insurers to use the Universal Prior Authorization Form. Therefore, 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.