Citi Benefits Handbook
Precertification/notification helps ensure that you obtain the most appropriate care for your condition in the most appropriate setting, and that your health care costs and Citi's costs are kept under control. If you do not precertify, your claim may be denied in whole or in part. The following sections describe the precertification/notification features of each plan. Be sure to read the sections that apply to the plan in which you enroll.
Precertification Requirements for Aetna Plans
If you are enrolled in the Aetna In-Network Only Plan, Choice Plan or High Deductible Plan with HSA, you must call Aetna to precertify any inpatient surgery or hospitalization and certain outpatient diagnostic/surgical procedures. Scheduled inpatient services and non-emergency outpatient procedures must be precertified at least 14 days in advance. Aetna must be notified of emergency admissions within 48 hours of the admission.
You are not required to notify Aetna of emergency hospitalization or other emergency services occurring outside the United States.
Inpatient Confinements
For inpatient confinement, you must call Aetna for precertification at least 14 days prior to the scheduled admission date. An admission date may not have been set when the confinement was planned. You must call Aetna again as soon as the admission date is set.
You must obtain precertification for:
  • A scheduled hospital admission;
  • A scheduled admission to a skilled-nursing hospice care or rehabilitation facility;
  • Home health care, including psychiatric home care services;
  • Private-duty nursing;
  • Outpatient hospice care;
  • Amytal interview (used with medical procedures as part of testing for prediction of memory dysfunction that may be a result of brain surgery);
  • Biofeedback;
  • Psychological testing;
  • ABA — applied behavior analysis;
  • Electroconvulsive therapy;
  • Neuropsychological testing;
  • Bariatric services;
  • Cardiovascular services;
  • Musculoskeletal services; and
  • Gender affirmation surgery.
In case of an unscheduled or emergency admission, you or your doctor must call Aetna within 48 hours after the admission.
Mental Health/Substance Abuse
You must call Aetna for precertification before you obtain covered inpatient mental health and/or substance abuse treatment, including stays in a residential treatment facility or a partial hospitalization program, outpatient detoxification, Transcraninal Magnetic Stimulation (TMS), or psychiatric home care services.
Organ/Tissue Transplants
You must notify Aetna before the scheduled date of any of the following:
  • The evaluation;
  • The donor search;
  • The organ procurement/tissue harvest; and
  • The transplant.
See organ/tissue transplants in "Covered Services and Supplies" for information about precertification requirements. Aetna will then complete the utilization review. You, the physician and the facility will receive a letter confirming the results of the utilization review.
Pregnancy is subject to the following notification time periods:
  • Aetna should be notified during the first trimester (12 weeks) of pregnancy. This early notification makes it possible for the mother to participate in a prenatal program;
  • You must notify the plan to certify inpatient confinement for delivery of a child. This is to certify a length of stay that exceeds:
    • 48 hours following a vaginal delivery; or
    • 96 hours following a cesarean section.
  • For inpatient care (for either the mother or child) that continues beyond the 48/96-hour limits stated above, Aetna must be notified before the end of these time periods noted above; and
  • Non-emergency inpatient confinement during pregnancy but before the admission for delivery requires notification as a scheduled confinement.
If you or your physician does not agree with Aetna's determination, you may appeal the decision. For information about the claims appeal process, see "Claims and Appeals for Aetna Medical Plans."
Precertification Requirements for Anthem BlueCross BlueShield Plans
You are required to obtain precertification for in-network services (as well as out-of-network services under the Choice Plan and High Deductible Plan with HSA). Your network doctor does not obtain precertification on your behalf. You must contact the Plan to satisfy this requirement.
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:
    • Aduhelm - Aduhelm is a human monoclonal IgG1 anti-amyloid beta antibody. Used for the treatment of Alzheimer's disease.
    • 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;
    • Genetic Testing for Inherited Diseases: Addresses testing for certain diseases with an established genetic basis. Used to confirm the diagnosis of a disorder when genetic testing may lead to changes in clinical management for those with uncertain clinical features;
    • Genetic Testing for Lynch Syndrome, Familial Adenomatous Polyposis (FAP) Attenuated FAP and MYH-Associated Polyposis: Addresses genetic testing for hereditary colorectal cancer.
    • Home Parenteral Nutrition: Addresses parenteral nutrition that is given in the home setting;
    • Implanted Port Delivery Systems to Treat Ocular Disease;
    • Implantable Peripheral Nerve Stimulation Devices as a Treatment for Pain;
    • Implanted Artificial Iris Devices;
    • Immunoprophylaxis for respiratory syncytial virus (RSV);
    • Intraocular anterior segment aqueous drainage devices (without extraocular reservoir);
    • Keratoprosthesis;
    • Leadless Pacemaker;
    • Microprocessor Controlled Knee-Ankle-Foot Orthosis;
    • Minimally Invasive Treatment of the Posterior Nasal Nerve to Treat Rhinitis;
    • MRI guided high intensity focused ultrasound ablation for non-oncologic indications;
    • 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;
    • Transanal Hemorrhoidal Dearterialization;
    • Transcatheter ablation of arrhythmogenic foci in the pulmonary veins as a treatment of atrial fibrillation (Radiofrequency and Cryoablation);
    • Transendoscopic therapy for gastroesophageal reflux disease and dysphagia;
    • Treatments for urinary incontinence;
    • Treatment of temporomandibular disorders;
    • Vagus nerve stimulation;
    • Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling;
  • Diagnostic 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;
    • Testing for Biochemical Markers for Alzheimer's Disease;
    • 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;
    • 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);
    • Pneumatic Compression Devices for Lymphedema;
    • Prosthetics: electronic or externally powered and select other prosthetics- (myoelectric-UE);
    • Standing frame;
    • Ultrasonic Diathermy Devices
    • Ultrasound bone growth stimulation;
    • Wheeled mobility devices: wheelchairs-powered, motorized, with or without power seating systems and power operated vehicles (POVs);
  • Radiation therapy/radiology services:
    • Intensity modulated radiation therapy (IMRT);
    • Single photon emission computed tomography (SPECT) scans for noncardiovascular indications;
    • Proton beam therapy;
    • Radioimmunotherapy and Somatostatin Receptor Targeted Radiotherapy (Azedra, Lutathera, Pluvicto, Zevalin);
    • 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;
    • Xofigo (Radium Ra 223 Dichloride);
  • 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 Contractility Modulation Therapy
      • 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;
      • Cervical and Thoracic Discography;
      • 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;
      • Intracardiac Ischemia Monitoring;
      • Mechanical circulatory assist devices (ventricular assist devices, percutaneous ventricular assist devices and artificial hearts);
      • 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;
      • Wireless Cardiac Resynchronization Therapy for Left Ventricular Pacing;
    • Cryosurgical ablation of solid tumors outside the liver;
    • Electrophysiology-Guided Noninvasive Stereotactic Cardiac Radioablation
    • Focal Laser Ablation for the Treatment of Prostate Cancer
    • Functional endoscopic sinus surgery;
    • Lower esophageal sphincter augmentation devices for the treatment of gastroesophageal reflux disease (GERD);
    • Locally ablative techniques for treating primary and metastatic liver malignancies;
    • Musculoskeletal surgeries:
      • Axial lumbar interbody fusion;
      • 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 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.