95250 - • CHIP requires authorization if greater than 12 visits Cosmetic Procedures or Surgeries External Defibrillators Hearing Aids for adults 21 and over Implantable devices (e.g., Interspinous Process Decompressors) - includes trials Insulin Pumps/Continuous Glucose Monitoring Systems , Mammoplasty (Male and Female) Otoplasty (including Microtia Repair) Rhinoplasty / Septoplasty Varicose Vein Treatment Behavioral Health (BH) / Chemical Dependency (CD) / Substance Abuse Residential Treatment (BH/CD) Inpatient Services (Includes Detox/ Rehab) Intensive Outpatient Services (Includes Outpatient Detox/ Rehab) ECT (Electro Convulsive Therapy) / TMS (Transcranial Magnetic Stimulation) Psychological / Neuropsychological Testing – if testing is greater than 8 hours/year • Bone or Spinal Cord Stimulators • Insulin Pumps/Continuous Glucose Monitoring Systems • Hospital Grade Breast Pumps – after the initial 60 day rental period Sleep Studies Personal Care Services (PCS) NA* Private Duty Nursing (PDN) Day Activity Health Services MDCP: Employment Assistance Supported Employment Flexible Family Support Services Respite Care (in home or out of home) Financial Management Services Transition Assistance Services Adaptive Aids Minor Home Modifications Vehicle Modifications Community First Choice: Personal Assistance Services Habilitation Emergency Response Services Support Management Prescribed Pediatric Extended Care Centers (PPECC) Skilled Nursing Obesity Treatment and Surgery x 2 Out-of-Network Specialists: • Any non-urgent referral for Out-of-Network specialty office visits • 2nd Opinions Out-of-Network Implantable pumps (Baclofen/fentanyl) Spinal Cord and other Nerve Stimulators – includes trials Examples includes the following medications: • Aflibercept (Eylea) • Eteplirsen (Exondys-51) • Histrelin implant (Supprelin LA) • IVIG (immune globulin) • Natalizumab (Tysabri) • Nusinersen (Spinraza) • Omalizumab (Xolair) • Onabotulinumtoxin A (Botox) • Pembrolizumab (Keytruda) • Romiplostim (NPlate) Supplies: Telemonitoring ALL Services for Transplantation: solid organ and stem cell transplants (pre-transplant evaluation and transplant procedures) Transportation

&P - Kids x Includes all: • Intraoperative Monitoring Prior Authorization required for admission to facilities/programs listed below : Abortion x 1 NA Bariatric Surgery Chiropractic Treatment • CHIP requires authorization if greater than 12 visits Cosmetic Procedures or Surgeries External Defibrillators Hearing Aids for adults 21 and over Implantable devices (e.g., Interspinous Process Decompressors) - includes trials Insulin Pumps/Continuous Glucose Monitoring Systems 95250, 95251 Mammoplasty (Male and Female) Otoplasty (including Microtia Repair) Rhinoplasty / Septoplasty Varicose Vein Treatment Behavioral Health (BH) / Chemical Dependency (CD) / Substance Abuse Residential Treatment (BH/CD) Inpatient Services (Includes Detox/ Rehab) Intensive Outpatient Services (Includes Outpatient Detox/ Rehab) ECT (Electro Convulsive Therapy) / TMS (Transcranial Magnetic Stimulation) Psychological / Neuropsychological Testing – if testing is greater than 8 hours/year • Bone or Spinal Cord Stimulators • Insulin Pumps/Continuous Glucose Monitoring Systems • Hospital Grade Breast Pumps – after the initial 60 day rental period Sleep Studies Personal Care Services (PCS) NA* Private Duty Nursing (PDN) Day Activity Health Services MDCP: Employment Assistance Supported Employment Flexible Family Support Services Respite Care (in home or out of home) Financial Management Services Transition Assistance Services Adaptive Aids Minor Home Modifications Vehicle Modifications Community First Choice: Personal Assistance Services Habilitation Emergency Response Services Support Management Prescribed Pediatric Extended Care Centers (PPECC) Skilled Nursing Obesity Treatment and Surgery x 2 Out-of-Network Specialists: • Any non-urgent referral for Out-of-Network specialty office visits • 2nd Opinions Out-of-Network Implantable pumps (Baclofen/fentanyl) Spinal Cord and other Nerve Stimulators – includes trials Examples includes the following medications: • Aflibercept (Eylea) • Eteplirsen (Exondys-51) • Histrelin implant (Supprelin LA) • IVIG (immune globulin) • Natalizumab (Tysabri) • Nusinersen (Spinraza) • Omalizumab (Xolair) • Onabotulinumtoxin A (Botox) • Pembrolizumab (Keytruda) • Romiplostim (NPlate) Supplies: Telemonitoring ALL Services for Transplantation: solid organ and stem cell transplants (pre-transplant evaluation and transplant procedures) Transportation NOTE: Emergent transport subject to retrospective medical necessity review Facility Based Hyperbaric Treatment All Wound Vac.(Negative-pressure wound therapy) to include related supplies Unlisted and Miscellaneous Codes Endnotes: BENEFIT COVERAGE MUST BE VERIFIED AT THE TIME OF THE REQUEST All rentals, including: CFHP requires standard codes when requesting authorization .

• Confirm benefit details
• Submit clinical notes if requested by the plan

• Confirm the current plan policy before submission.
• Use the insurer authorization workflow for this listed code.