Skip to main content

New preapproval requirements for Western New York members effective January 1, 2019


Our Enhanced Clinical Review Program will begin January 1, 2019. The program requires authorization for certain procedures and will be administered by CareCore National doing business as eviCore healthcare. It will affect Western New York members in our commercial and Medicare Advantage HMO/PPO Aetna-branded products. Below are the services that will and will not require preapproval under this program.

 

Services that will require preapproval
 

  • High-tech outpatient diagnostic imaging procedures; these include MRI/MRA, nuclear cardiology, and PET scan and CT scan, including CTA.
  • Nonemergent outpatient stress echocardiography.
  • Nonemergent outpatient diagnostic left and right heart catheterization.
  • Insertion, removal and upgrade of elective implantable cardioverter-defibrillators (ICDs), cardiac resynchronization therapy defibrillators (CRT-Ds) and implantable pacemakers.
  • Polysomnography (attended sleep studies).
  • Interventional pain management.
  • Musculoskeletal large joint (hip and knee) arthroplasty procedures.

 

For a complete list of procedures requiring an authorization, visit eviCore healthcare.

 

Services that will not require preapproval
 

  • Inpatient radiology.
  • Emergency room radiology.
  • Outpatient radiology other than those services listed above.

 

How to request prior authorizations

 

  • Visit eviCore healthcare.
  • Call 1-888-622-7329 during normal business hours.
  • Fax a request form (available online) to: 

 

          – 1-800-540-2406 (radiology)

          – 1-888-444-1562 (cardiology)

          – 1-888-511-0403 or 866-999-3510 (sleep studies)

 

Have questions or need information?

 

See eviCore healthcare’s criteria and get request forms.