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:

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 CriteriaCMS Reference
Acupuncture for Chronic Low Back Pain (cLBP)NCD 30.3.3
Automatic External DefribilatorsLCD L33690

Back Surgeries:

Vertiflex (Percutanous Image-guided Lumbar Decompression for Lumbar Spinal Stenosis)

LCD L34976
NCD 150.13

Blepharoplasty, Blepharoptosis Repair and Surgical Procedures of the BrowLCD 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 SurgeryLCD L38914
Deep Brain StimulationNCD 160.24

Genetic Testing:


Genetic Testing for Cardiovascular Disease 
Lynch Syndrome
Molecular Pathology Procedures

Next Generation Sequencing


LCD L36499

LCD L39084
LCD L34912
LCD L34519

NCD 90.2

Glucose MonitorsLCD L33822
High Frequency Chest Wall Oscillation DevicesLCD L33785
Hyperbaric Oxygen Therapy (HBO2)NCD 20.29
Hyperthermia for Treatment of CancerNCD 110.1
Implantable Continuous Glucose Monitor (I-CGM)L38664/A58136
Insulin Pumps (External)LCD L33794
Leadless PacemakersNCD 20.8.4
Magnetic Resonance Imaging (MRI) (Cervical and Lumbar Spine) Requires reviewNCD 220.2
Negative Pressure Wound Therapy (NPWT) PumpLCD 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 DevicesLCD 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 MechanismsLCD L33801
Skin Substitute Grafts for Diabetic Foot Ulcers and Venous Leg UlcersLCD L36377
Speech Generating DevicesLCD L33739
Spinal Cord StimulationNCD 160.7
Surgical Treatment for Morbid Obesity (Bariatric Surgery)LCD L33411
Transcranial Magnetic Stimulation LCD L34522
Vagus Nerve StimulationNCD 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.

Download the Universal Prior Authorization Form