Commercial Criteria
All commercial (non-Medicare) plans have developed criteria that require prior authorization. You can find the latest updates for Florida Blue coverage guidelines by visiting mcgs.bcbsfl.com. The following Capital Health Plan-developed criteria require prior authorization:
- Applied Behavioral Analysis Services
- Colonoscopies
- Long Term Acute Care Hospitalization
- Magnetic Resonance Imaging (MRI) Cervical Spine
- Magnetic Resonance Imaging (MRI) Lumbar Spine
- Residential Eating Disorders Treatment
- Residential Substance Abuse Treatment
- Skilled Nursing Facilities
- Sleep Studies
- Thoracic Outlet Syndrome
- Weight Control Services
- Wound Treatment Centers
Florida Blue Adopted Criteria
Capital Health Plan has adopted the Florida Blue medical coverage policies as our criteria for Commercial members. Coverage policies that require prior authorization are listed below. To obtain the necessary medical coverage guidelines, please visit mcgs.bcbsfl.com.
For coverage policies that contain a Certificate of Medical Necessity (CMN) you may complete the CMN in lieu of submitting records. Please submit these by fax to Capital Health Plan's Care Coordination Department at (850) 383-3310. Do not fax the CMN or records to Florida Blue.
This list is not all-inclusive:
- Analysis of Human DNA as a Technique for Colorectal Cancer Screening – includes Cologuard Testing
- Bio-Engineered Skin and Soft Tissue Substitutes; Amniotic Membrane and Amniotic Fluid
- Cervical Spine Surgery
- Cochlear Implants
- Continuous Glucose Monitoring
- Continuous Passive Motion Device
- Computed Tomographic Colonography (Virtual Colonoscopy or CT Colonoscopy)
- Deep Brain Stimulation
- External Insulin Infusion Pumps and Supplies
- Functional Neuromuscular Stimulation
- Genetic Testing:
- Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer
- Cologuard Testing - Analysis of Human DNA as a Technique for Colorectal Cancer Screening
- Genetic Testing
- Genetic Testing for Hereditary Breast or Ovarian Cancer
- Genetic Testing for Lynch Syndrome and Other Inherited Colon Cancer Syndromes
- KRAS, NRAS, and BRAF Variant Analysis (Including Liquid Biopsy & MicroRNA Expression Testing) in Metastatic Colorectal Cancer
- Multigene Expression Assay for Predicting Recurrance in Colon Cancer
- Tumor/Genetic Markers
- Hyperbaric Oxygen (HBO) Therapy
- Hyperthermic Intraperitoneal Chemotherapy (HIPEC)
- Implantable Hearing Devices
- Intracept (Nuerolysis/Ablation)
- Kyphoplasty and Vertebroplasty
- Left Atrial Appendage Closure
- Lumbar Spine Surgery
- Negative Pressure Wound Therapy Pump
- Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Disorders
- Osteogenesis Stimulators
- Percutaneous Tibial Nerve Stimulation
- Power Wheelchairs
- Quantitative Electroencephalography (QEEG)
- Reconstructive Surgery and Cosmetic Surgery:
- Blepharoplasty/Ptosis Repair Surgery
- Mastectomy for Gynecomastia
- Orthognathic Surgery
- Panniculectomy and Abdominoplasty
- Prosthetics
- Reduction Mammoplasty (Breast Reduction)
- Rhinoplasty
- Surgery for Clinically Severe Obesity (Bariatric Surgery)
- Speech Generating Devices
- Spinal Cord Stimulation
- Subcutaneous Implantable Cardioverter Defibrillators
- Transcranial Magnetic Stimulation
- Vagus Nerve Stimulation
- Vertiflex (Interspinous and Interlaminar Spacers and Fusion Devices)
- Wearable and Non-Wearable Cardioverter-Defibrillators (WCD)
Prior Authorization
Effective 1/1/2017, the Florida Legislature amended a statute to require all insurers use the Universal Prior Authorization Form. Therefore, as of 1/1/2017, 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.