Medicare Criteria

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:

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 CriteriaDocument ID
Automatic External Defribilators LCD L33690
Application of Skin Substitute Grafts for Treatment of DFU and VLU of Lower Extremities LCD L36377
Back Surgeries:
Lumbar Spinal Fusion
Intraspinous Process Decompression

LCD L33382
LCD L34006
LCD L34976
Breast Reduction (Reduction Mammoplasty)LCD L33939
Cochlear ImplantsNCD 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 NutritionLCA A52493

Genetic Testing:
Lynch Syndrome
Molecular Pathology Procedures
Oncotype DX - Breast
Oncotype DX - Prostate

LCD L36499
LCD L34912
LCD L34519
LCD L33586
LCD L36789
Glucose MonitorsLCD L33822
High Frequency Chest Wall Oscillation DevicesLCD 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:
Knee Arthroscopy for Meniscal Tears
Knee Replacement and Hip Replacement
Manipulation Under Anethesia (27570)
Meniscal Implant (G0428)
Meniscal Transplantation (29868)

NCD 150.9
LCD L33618
LCD L33594
NCD 150.12
LCD L33777
Magnetic Resonance Imaging (MRI) (Cervical and Lumbar Spine) Requires reviewNCD 220.2
Negative Pressure Wound Therapy (NPWT) PumpLCD L33821
Osteogenesis Bone Growth Stimulators LCD L33796
Ostomy SuppliesLCD L33828
Panniculectomy and Abdominoplasty (Cosmetic and Reconstructive Surgery)LCD L34698
Partial Hospitalization Program for Substance Abuse TreatmentLCD 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 FusionLCD L36000
Seat Lift MechanismsLCD L33801
Speech Generating DevicesLCD L33739
Spinal Cord StimulationLCD L36035
Surgical Treatment for Morbid Obesity (Bariatric Surgery)LCD L33411
Transcranial Magnetic Stimulation LCD L34522
Upper Eyelid and Brow Surgical ProceduresLCD 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. This form may also be used for Medicare members, but it is not a requirement.

Download the Universal Prior Authorization Form