Appeal requests are categorized according to the type of service that is being requested. Listed below are the categories used by OPP and examples of the types of services that fall into each category.

 

Behavioral health services includes all mental health and substance abuse services, including inpatient, outpatient, partial hospitalization, and residential treatment.

 

Cosmetic/Reconstructive includes services that the health plan has determined to be for the purpose of altering appearance rather than for treatment of an illness or injury. Examples are scar revision, breast reduction mammoplasty, abdominoplasty, and laser treatment of port wine stains.

 

Dental means procedures performed on teeth and gums, such as dental implants, root canals, oral surgery, and orthodontic services.

 

Diagnostic services includes tests such as laboratory, x-rays, MRI, etc.

 

Durable medical equipment includes wheelchairs, braces, home monitoring equipment, etc.

 

Emergency care includes ambulance and emergency room services.

 

Excluded services are services that are explicitly excluded from coverage in the carrier's evidence of coverage. Examples are massage therapy, acupuncture, liposuction, and surrogacy. Requests for cosmetic/reconstructive and experimental treatment are generally not considered to be excluded services for the purpose of external review.

 

Experimental means services and supplies that the carrier has determined are investigational or experimental based on clinical studies, expert opinion, safety, efficacy, and standards of care.

 

Infertility includes services and supplies to diagnose and treat infertility, such as invitro fertilization, donor egg, and intrauterine inseminations.

 

Inpatient includes care rendered in inpatient settings such as acute care hospitals and skilled nursing facilities, for other than mental health conditions.

 

Outpatient includes those services rendered in outpatient settings that do not fall under any of the other categories (e.g., chiropractic, specialty consultation).

 

Pharmacy includes requests for prescription medications.

 

Rehab services includes physical therapy, speech therapy, and occupational therapy.