Preauthorization Requirements –
Effective March 1, 2027

A6614

Supplies and accessories for use with an external ocular negative pressure pump, any type, per month

E0788

Ambulatory infusion pump, specific device-drug combination, single or multiple channels, electric or battery operated, with administrative equipment, worn by patient

E2403

External ocular negative pressure pump, electric

L1330

Thoracic orthosis, sternal and/or sternocostal compression, may include anterior and/or posterior pads, panels, with or without frame, prefabricated, includes fitting and adjustment

L1972

Ankle foot orthosis, plastic or other material with ankle joint, with or without dorsiflexion assist, prefabricated, off-the-shelf

A6614

Supplies and accessories for use with an external ocular negative pressure pump, any type, per month

E0788

Ambulatory infusion pump, specific device-drug combination, single or multiple channels, electric or battery operated, with administrative equipment, worn by patient