Contact Customer Service to Confirm Coverage: 800-374-1835
| Outpatient Services | Codes |
|---|---|
| Diagnostics | |
| CT Head or Brain | 70450, 70460, 70470 |
| CT Maxillofacial | 70486, 70487, 70488 |
| CT Orbit, Sella or Posterior Fossa or Outer, Middle or Inner Ear | 70480, 70481, 70482 |
| CT Soft Tissue Neck | 70490, 70491, 70492 |
| MRA Head | 70544, 70545, 70546 |
| MRA Neck | 70547, 70548, 70549 |
| MRI Lower Extremity | 73718, 73719, 73720, 73721, 73722, 73723 |
| PET Scan Limited, and Whole Body | 78811, 78812, 78813, 78814, 78815, 78816 |
| IMRT | 77301, 77338, 77385, 77386, 77387, G6015 |
| Bariatrics Procedures | |
| Bariatric Surgery | 43644, 43645 |
| Lap Band, Gastric Sleeve | 43770-43775 |
| Gastric Bypass - Lap Band | 43842-43865 |
| Breast Related Procedures | |
| Breast- Mastectomy | 19301-19307 |
| Breast- Reduction Mammaplasty | 19318, 19316, 19324, 19325 |
| Breast- Removal of Mammary Implant or Delayed Insertion | 19328, 19330, 19340, 19342 |
| Breast- Reconstruction | 19350, 19355, 19357-19369, 19370, 19371, 19380, 19396 |
| Selected Procedures | |
| Hysterectomy | 58150-58294 |
| Laparoscopic Hysterectomy | 58541-58544, 58548-58554, 58570-58573, 58575 |
| Abdominoplasty, Panniculectomy | 15830-15839 |
| Blepharoplasty | 15820-15823 |
| Blepharoplasty - Repair of Blepharoptosis | 67900-67924 |
| Septoplasty - Nasal | 30520 |
| Rhinoplasty- If Secondary to Septoplasty | 30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462, 30465 |
| Orthopedic Procedures | |
| Artificial Disc Lumbar | 22856-22865 |
| Artificial Disc Cervical | 0095T-0098T, 0163T-0165T |
| Back Surgery- Spinal Cath with Lami | 62351 |
| Back Surgery- Laminectomy Cerv Decomp | 63001 |
| Back Surgery- Laminectomy Thor Decomp | 63003 |
| Laser Discectomy, Radiofrequency Decomp. | 62287 |
| Back Surgery - Laminectomy | 63005, 63011, 63012, 63045-63048, 63050-63066, 63173-63200 |
| Back Surgery - Laminectomy-Dec of Cord | 63015-63042, 63043, 63044 |
| Back Surgery - Spine Disk Surgery | 63075-63078 |
| Back Surgery - Removal of Vertebral Body | 63081-63103 |
| Back Surgery - Lami Myelotomy | 63170-63172 |
| Back Surgery - Lami excision Lesion Tumor | 63250-63275 |
| Back Surgery - Lami excision Lesion | 63276-63290, 63295, 63300-63308 |
| Back Surgery - Laminectomy Implnt Neurst | 63650-63688 |
| Percutaneous Intradiscal Electrothermal Annuloplasty | 22526, 22527 |
| Back Surgery - Lateral discectomy-Thoracic | 22532 |
| Back Surgery - Lateral discectomy-Lumbar | 22533, 22534 |
| Back Surgery - Cervical transoral- C1-2 | 22548, 22551, 22552 |
| Back Surgery - Ant Cervical below C2 | 22554 |
| Back Surgery - Anterior-Thoracic | 22556 |
| Back Surgery - Anterior Lumbar Fusion | 22558, 22585, 22586 |
| Back Surgery - Post or postlat Cervical Fusion | 22590, 22595, 22600 |
| Back Surgery - Post Thoracic Fusion | 22610 |
| Back Surgery - Post Lumbar Fusion | 22612-22614 |
| Back Surgery - Post Laminectomy/discect | 22630, 22632, 22633, 22634, 22800-22819 |
| Back Surgery - Exploration of Spinal Fusion | 22830 |
| Facet Joint Injection | 64490-64495 |
| Radiosurgery Procedures | |
| Cranial Stereotactic | 61790-61800 |
| Sterotactic Radiosurgery | 63610-63621, 63600, 77432-77470 |
| Vericose Vein Procedures | |
| Sclerotherapy | 36468-36471 |
| Venous Ablation | 36473-36479 |
| Venous Ligation | 37700-37785 |
| Other | |
| Gene Based Cellular Therapy | J3398, J2326, J3399 |
This material and information is intended for informational purposes only. This material and information is subject to change, at any time and without notice, by Nippon Life Insurance Company of America.
Outpatient services requiring precertification generally include the following: Complex imaging, certain cosmetic/reconstructive surgery and back surgery. For a current list of outpatient services requiring precertification, please see the Nippon Life Benefits website at (www.nipponlifebenefits.com). We ask your provider to contact us 15 days prior to the procedure being performed. The number to contact is 877-518-0770.
Nippon Life Benefits can review on an expedited basis if all the required information is received. Please be aware that approvals are based on medical necessity and if a procedure is done prior to a medical review, your claim may be denied for additional information or for medical necessity.
Clients will receive information related to the outpatient precertification process 45 days prior to plan anniversary/renewal, to share with members. Members will receive new ID cards prior to the plan anniversary/renewal to reflect the new requirement.
Yes, all outpatient services listed require precertification regardless of where the service is rendered.
Outpatient precertification is a new service that Nippon Life Benefits is offering on your plan anniversary date starting 1/1/2021. Please consult with your employer for your effective date.
Yes, the process can be completed by telephone as long as all the required information from the provider is received.
No, there is no specific form that needs to be completed.
A letter will be mailed to the provider, facility and member outlining the decision of the review.
You have the right to appeal the decision. The appeal process will be outlined in the denial letter that is sent to the provider, facility and member. You can also refer to your booklet for your individual appeal rights.