Geisinger Health Plan (GHP) uses medical policies as guidelines for coverage decisions made within the insured individuals' written benefit documents. Coverage may vary by line of business and providers and members are encouraged to verify benefit questions regarding eligibility before applying the terms of the policy.
Cohere Guidelines are created from an adaptation of peer-reviewed clinical research, medical society guidelines, and coordinated peer reviews. Medical Necessity Criteria and Site of Service Criteria are derived from this knowledge base within the guidelines and serve as a decision support tool to help approve prior authorizations for the most appropriate treatment, setting, and help assure consistency of care for each individual. These guidelines do not replace payer-specific policies, NCDs or LCDs.
Please use this article as a reference to review the appropriate policies prior to submitting an authorization. Click the links below to view the most up-to-date policies.
Medicare
What are NCDs and LCDs?
Both NCDs (National Coverage Determinations) and LCDs (Local Coverage Determinations) help determine if a service or item is covered by Medicare. CMS directly develops NCDs, whereas MACs (Medicare Administrative Contractors) are responsible for the development of LCDs. While NCDs supersede LCDs, it is still important to review related LCDs as they often expand on the applicable NCDs.
What if there is not an NCD, LCD, or related article?
It is the expectation that appropriate published clinical practice guidelines, statutes, regulations, manuals, specific medical necessity criteria, published evidence, instructions for use, etc. are followed. These factors will be taken into consideration for authorizations.
Orthopedic Footwear (LCD L33641)
Ankle-Foot/Knee-Ankle-Foot Orthosis (L33686)
Knee Orthoses (L33318)
Spinal Orthoses: TLSO and LSO (L33790)
Geisinger Policy
Foot Orthotics (MP034)
Cranial Remodeling Orthotic (MP125)
Submit authorization for Medicaid members through Cohere for the following codes: A5500, A5501, A5503, A5504, A5505, A5506, A5507, A5508, A5510, A5512, A5513, A5514, A8000, A8001, A8002, A8003, A8004, A9283, D7880, E0485, E0486, K0672, K0903, K1015, L0112, L0220, L0452, L0480, L0482, L0484, L0486, L0622, L0624, L0629, L0632, L0634, L0636, L0638, L0640, L0700, L0710, L0810, L0820, L0830, L0859, L0861, L0999, L1000, L1005, L1010, L1020, L1025, L1030, L1040, L1050, L1060, L1070, L1080, L1085, L1090, L1100, L1110, L1120, L1200, L1210, L1220, L1230, L1240, L1250, L1260, L1270, L1280, L1290, L1300, L1310, L1499, L1630, L1640, L1680, L1685, L1700, L1710, L1720, L1730, L1755, L1834, L1840, L1844, L1846, L1860, L1900, L1904, L1907, L1920, L1980, L1990, L2000, L2005, L2010, L2020, L2030, L2034, L2036, L2037, L2038, L2040, L2050, L2060, L2070, L2080, L2090, L2106, L2108, L2126, L2128, L2627, L2628, L2999, L3001, L3002, L3003, L3020, L3030, L3031, L3040, L3050, L3070, L3080, L3090, L3160, L3201, L3202, L3203, L3204, L3206, L3207, L3208, L3209, L3211, L3212, L3213, L3214, L3215, L3216, L3217, L3219, L3221, L3222, L3224, L3225, L3230, L3250, L3251, L3252, L3253, L3254, L3255, L3257, L3260, L3265, L3300, L3310, L3320, L3330, L3332, L3334, L3340, L3350, L3360, L3370, L3380, L3390, L3400, L3410, L3420, L3430, L3440, L3450, L3455, L3460, L3465, L3470, L3480, L3485, L3500, L3510, L3520, L3530, L3540, L3550, L3560, L3570, L3580, L3590, L3595, L3600, L3610, L3620, L3630, L3640, L3649, L3671, L3674, L3702, L3720, L3730, L3740, L3763, L3764, L3765, L3766, L3806, L3808, L3891, L3900, L3901, L3904, L3905, L3906, L3913, L3919, L3921, L3933, L3935, L3956, L3961, L3967, L3971, L3973, L3975, L3976, L3977, L3978, L3995, L3999, L4000, L4002, L4205, L4210, L4631, S1040 |