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:
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 our Medicare members. You can access Original Medicare's coverage policies in the list 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 Surgeries: Vertebroplasty/Kyphoplasty Vertiflex (Percutaneous Image-guided Lumbar Decompression for Lumbar Spinal Stenosis) | LCD L34976 NCD 150.13 |
| 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: Pharmacogenomics Testing BRCA1 & BRCA2 Genetic Testing for Cardiovascular Disease Lynch Syndrome Molecular Pathology Procedures Next Generation Sequencing Pharmacogenomics Testing | LCD L39073 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 |
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. This form may also be used for Medicare members, but it is not a requirement.