Citi Benefits Handbook
Precertification Requirements for Anthem BlueCross BlueShield Plans
You are required to obtain precertification for both in-network and out-of-network services. Your network doctor does not obtain precertification on your behalf.
Your plan reviews and determines whether hospitalization and non-emergency surgery are medically necessary.
In case of an unscheduled or emergency admission, you or your doctor must call your plan within two calendar days after the admission.
When traveling outside the United States, you are not required to obtain precertification for emergency hospitalization or other emergency services.
No benefits are payable unless Anthem BlueCross BlueShield determines that the services and supplies are covered under the plan.
You are required to obtain precertification for the following services:
  • Inpatient admission:
    • Inclusive of all acute inpatient, skilled nursing facility, long-term acute rehab, and OB delivery stays beyond the federal mandate minimum length of stay (including newborn stays beyond the mother's stay);
    • Emergency admissions (requires plan notification no later than two business days after admission;
  • Outpatient and surgical services:
    • Air ambulance (excludes 911 initiated emergency transport);
    • Bone-anchored and bone conduction hearing aids;
    • Cochlear implants and auditory brainstem implants;
    • Corneal collagen cross-linking;
    • Cryopreservation of oocytes or ovarian tissue;
    • Diaphragmatic/phrenic nerve stimulation pacing systems;
    • Deep brain, cortical, and cerebellar stimulation;
    • Electric tumor treatment field (TTF) for treatment of glioblastoma;
    • Immunoprophylaxis for respiratory syncytial virus (RSV);
    • Implantable middle ear hearing aids;
    • Intraocular anterior segment aqueous drainage devices (without extraocular reservoir);
    • Keratoprosthesis;
    • MRI guided high intensity focused ultrasound ablation for non-oncologic indications;
    • Occipital nerve stimulation;
    • Percutaneous neurolysis for chronic neck and back pain;
    • Photocoagulation of macular drusen;
    • Private duty nursing;
    • Presbyopia and stigmatism – correcting intraocular lenses;
    • Radiofrequency ablation to treat tumors outside the liver;
    • Transendoscopic therapy for gastroesophageal reflux disease and dysphagia;
    • Treatment of hyperhidrosis;
    • Treatments for urinary incontinence;
    • Transcatheter ablation of arrhythmogenic foci in the pulmonary veins as a treatment of atrial fibrillation (Radiofrequency and Cryoablation);
    • Transcatheter uterine artery embolization;
    • Treatment of temporomandibular disorders;
    • Vagus nerve stimulation;
  • Diagnostic testing:
    • Cardiac Ion channel genetic testing;
    • Chromosomal microarray analysis (CMA) for developmental delay, Autism Spectrum Disorder, intellectual disability (intellectual developmental disorder) and congenital anomalies;
    • Gene expression profiling for managing breast cancer treatment;
    • Genetic testing for breast and/or ovarian cancer syndrome;
    • Genetic testing for cancer susceptibility;
    • Preimplantation genetic diagnosis testing;
    • Wireless capsule for the evaluation of suspected gastric and intestinal motility disorders;
    • Prostate saturation biopsy;
  • Durable medical equipment (DME)/prosthetics:
    • Augmentative and alternative communication (AAC) devices/ speech generating devices (SGD);
    • Continuous interstitial glucose monitoring;
    • Dynamic low-load prolonged-duration stretch devices (LLPS);
    • Electrical Bone Growth Stimulation;
    • External (portable) continuous insulin infusion pump;
    • Functional electrical stimulation (FES); threshold electrical stimulation (TES);
    • Implantable infusion pumps;
    • Lower limb prosthesis and microprocessor controlled lower limb prosthesis;
    • Oscillatory devices for airway clearance including high frequency chest compression and intrapulmonary percussive ventilation (IPV);
    • Ultrasound bone growth stimulation;
    • Wheeled mobility devices: wheelchairs-powered, motorized, with or without power seating systems and power operated vehicles (POVs);
    • Prosthetics: electronic or externally powered and select other prosthetics- (myoelectric-UE);
    • Standing frame;
    • Transtympanic micropressure for the treatment of Ménière's Disease;
  • Radiation therapy/radiology services:
    • Intensity modulated radiation therapy (IMRT);
    • Single photon emission computed tomography (SPECT) scans for noncardiovascular indications;
    • Proton beam therapy;
    • Stereotactic radiosurgery (SRS) and stereotactic body radiotherapy (SBRT);
    • Transcatheter arterial chemoembolization (TACE) and transcatheter arterial embolization (TAE) for treating primary or metastatic liver tumors;
    • Transcatheter arterial chemoembolization (TACE) and transcatheter arterial embolization (TAE) for malignant lesions outside the liver- except CNS and spinal cord;
    • Wireless capsule endoscopy for gastrointestinal imaging and the patency capsule;
  • Surgical services:
    • Ablative techniques as a treatment for Barrett's esophagus;
    • Autologous cellular immunotherapy for the treatment of prostate cancer;
    • Balloon and self-expanding absorptive sinus ostial dilation;
    • Bariatric surgery and other treatments for clinically severe obesity;
    • Bronchial thermoplasty for treatment of asthma;
    • Cardio-vascular:
      • Cardiac resynchronization therapy (CRT) with or without an implantable cardioverter defibrillator (CRT/ICD) for the treatment of heart failure;
      • Carotid, vertebral and intracranial artery angioplasty with or without stent placement;
      • Endovascular techniques (percutaneous or open exposure) for arterial revascularization of the lower extremities);
      • Implantable ambulatory event monitors and mobile cardiac telemetry;
      • Implantable or wearable cardioverter-defibrillator;
      • Mechanical circulatory assist devices (ventricular assist devices, percutaneous ventricular assist devices and artificial hearts);
      • Mechanical embolectomy for treatment of acute stroke;
      • Outpatient cardiac hemodynamic monitoring using a wireless sensor for heart failure management:
      • Partial left ventriculectomy;
      • Perirectal spacers for use during prostate radiotherapy;
      • Transcatheter closure of patent foramen ovale and left atrial appendage for stroke prevention;
      • Transcatheter heart valve procedures;
      • Transmyocardial/perventricular device closure of ventricular septal defects;
      • Treatment of varicose veins (lower extremities);
      • Venous angioplasty with or without stent placement/ venous stenting;
    • Cryosurgical ablation of solid tumors outside the liver;
    • Functional endoscopic sinus surgery;
    • Lung volume reduction surgery;
    • Lower esophageal sphincter augmentation devices for the treatment of gastroesophageal reflux disease (GERD);
    • Locally ablative techniques for treating primary and metastatic liver malignancies;
    • Musculo-skeletal surgeries:
      • Axial lumbar interbody fusion;
      • Computer-assisted musculoskeletal surgical navigational orthopedic procedures of the appendicular system;
      • Extracorporeal shock wave therapy for orthopedic conditions;
      • Implanted devices for spinal stenosis;
      • Implanted (epidural and subcutaneous) spinal cord stimulators (SCS);
      • Lysis of epidural adhesions;
      • Manipulation under anesthesia of the spine and joints other than the knee;
      • Meniscal allograft transplantation of the knee;
      • Percutaneous vertebroplasty, kyphoplasty and sacroplasty;
      • Sacroiliac joint fusion;
      • Surgical interventions for scoliosis and spinal deformity;
      • Total ankle replacement;
      • Treatment of osteochondral defects of the knee and ankle;
    • Ovarian and internal iliac vein embolization as a treatment of pelvic congestion syndrome;
    • Plastic/reconstructive surgeries/treatments:
      • Abdominoplasty ,panniculectomy, diastasis recti repair;
      • Allogeneic, xenographic, synthetic and composite products for wound healing and soft tissue grafting hyperbaric oxygen therapy (systemic/topical);
      • Blepharoplasty;
      • Brachioplasty;
      • Breast procedures; including reconstructive surgery, Implants and other breast procedures;
      • Buttock/thigh lift;
      • Chin implant, mentoplasty, osteoplasty mandible;
      • Composite products for wound healing and soft tissue grafting;
      • Insertion/injection of prosthetic material collagen implants;
      • Hyperbaric oxygen therapy (systemic/topical);
      • Liposuction/lipectomy;
      • Mandibular/maxillary (orthognathic) surgery;
      • Mastectomy for gynecomastia;
      • Oral, pharyngeal and maxillofacial surgical treatment for obstructive sleep apnea or snoring;
      • Penile prosthesis implantation;
      • Procedures performed on the face, jaw or neck (including facial dermabrasion, scar revision);
      • Procedures performed on male or female genitalia;
      • Procedures performed on the trunk and groin;
      • Reduction mammaplasty;
      • Repair of pectus excavatum / carinatum;
      • Rhinoplasty;
      • Septoplasty;
      • Skin-related procedures;
      • Sacral nerve stimulation (SNS) and percutaneous tibial nerve stimulation (PTNS) for urinary and fecal incontinence and urinary retention;
      • Sacral nerve stimulation as a treatment of neurogenic bladder secondary to spinal cord injury;
      • Surgical and ablative treatments for chronic headaches;
      • Surgical and minimally invasive treatments for benign prostatic hyperplasia (BPH) and other GU conditions;
      • Surgical treatment of obstructive sleep apnea and snoring
      • Transanal hemorrhoidal dearterialization (THD);
      • Viscocanalostomy and canaloplasty;
  • Gender affirmation surgery;
  • Human organ and bone marrow/stem cell transplants;
    • Inpatient admits for ALL solid organ and bone marrow/stem cell transplants (Including kidney only transplants);
    • Outpatient: All procedures considered to be transplant or transplant related including but not limited to:
      • Stem cell/bone marrow transplant (with or without myeloablative therapy);
      • Donor leukocyte infusion;
    • Axicabtagene ciloleucel (CAR) T-cell immunotherapy treatment;
    • Gene therapy treatment & replacement
    • Intrathecal treatment of spinal muscular atrophy (SMA);
  • Out-of-network referrals:
Out-of-network services for consideration of payment at network benefit level (may be authorized, based on network availability and/or medical necessity.);
  • Mental health/substance abuse (MHSA):
      • Acute inpatient admissions;
      • Transcranial magnetic stimulation (TMS);
      • Intensive outpatient therapy (IOP);
      • Partial hospitalization (PHP);
      • Residential care;
      • Behavioral health in-home programs
  • Applied behavior analysis (ABA); and
  • Infertility treatment
If you or your physician does not agree with Anthem BlueCross BlueShield's determination, you may appeal the decision. For more information about the claims appeal process, see "Claims and Appeals for Anthem BlueCross BlueShield Medical Plan" or call 1 (855) 593-8123.