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Prior authorization reference list

Find which services require prior authorization from Priority Health under which plans.

THIS INFORMATION DOES NOT INDICATE A MEMBER'S COVERAGE.

  • Out-of-network services will generally require prior authorization.
  • When no authorization is needed, providers must still meet the guidelines set out in any applicable policy.
  • Use the Medical Prior Authorization form (522KB PDF) when a service does not have a specific form. Complete online and save it for your records, then print and fax it to Priority Health.

Medical policies apply to commercial and Medicaid plans, and to our Medicare plans IF there is no applicable Medicare national or local coverage determination. Reference the CMS website for Medicare policies.

Quick search: With your cursor anywhere on the page, click CTRL+F, then enter the term you're looking for.

Click a letter to jump down to that section of the list:

A | B | C | D | E | F | G | H | I | J | K | L | M | N | O | P | Q | R | S | T | U | V | W | X | Y | Z

Service
[Links to PA form, where applicable]
Plans requiring prior auth Medical policy* Comments
A
Abdominoplasty HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91444
Abortion

Medicaid
See comments

91000 Please refer to the medical policy for specific criteria related to coverage
Acupuncture Not required*
*Only covered for MIChild and some self-funded (SF) plans.  Please consult SF plan documents to confirm coverage
ADD/ADHD & ODD outpatient therapies Not required* *Covered for ages 0-12 for fully-funded, Medicaid and self-funded (SF) plans (unless excluded per SF plan documents)
ADD/ADHD & ODD testing Not required Not covered by some self-funded groups; contact Behavioral Health staff
Medicaid plan requires prior auth for initial evaluation but no prior auth for testing
Allergy testing/immunotherapy Not required 91037
Allograft, meniscal HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91443 May not be covered by self-funded plans
Ambulance services, air/fixed wing HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid
Ambulance services, emergent Not required
Ambulance services, non-emergent HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid
Angiography, coronary CT HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid See AIM resources PA not required for inpatient or emergent care. Prior authorization must be requested through AIM
Anodyne therapy / monochromatic phototherapy Not covered 91486
Apnea monitors and oxygen therapy form, Medicaid patients under 21 only (21KB PDF) Not required 91497 Notification form required for Medicaid patients under 21
Artificial conception/assisted reproduction Not covered 91163
Artificial intervertebral discs, cervical HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91581 Single level disc covered
Artificial intervertebral discs, lumbar Not covered 91581
Assisted reproduction/artificial conception Not covered 91163
Audiologists, participating, for medical conditions Not required

Augmentative communications/speech-generating devices for Medicaid members PA form (117KB PDF) Medicaid 91499 See PA form. Medical policy only applies to Medicaid members.
Autistic spectrum disorders: Evaluation & diagnostic testing Not required except evaluations for Medicaid members 91579
Autism spectrum disorders: Treatment services (including health treatment, pharmacy, psychiatric, psychological and therapeutic care (i.e. evidence-based speech therapy, physical therapy and occupational therapy) See policy for details 91579
Autograft and allograft replacement, osteochondral HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91443 Not covered for ankles. May not be covered by self-funded plans
Autologous chondrocyte implant/meniscal allograft HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91443 May not be covered by self-funded plans
Automated percutaneous lumbar discectomy (APLD) Not covered 91581
Autopsy Not covered 91054
AxiaLIFTM lumbar interbody fusion HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91590

*Medical policies apply to commercial plans and Medicaid. Medicare plans must follow Medicare policy under National Coverage Determinations and/or Local Coverage Determinations.

B
Service
[Links to PA form, where applicable]
Plans requiring prior auth Medical Policy* Comments
BAHA device HMO, POS, EPO, SF-POS, Medicare, Medicaid 91544 May not be covered for self-funded plans
Balloon sinus ostial dilation Not required 91596
Bariatric surgery PA form (254KB PDF) HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91595 See forms; requires PA.
Bed systems, enclosed, for Medicaid members Medicaid 91498
Behavioral health therapies, outpatient Medicaid Prior authorization only required for Medicaid; contact Behavioral Health staff
Behavioral health & substance abuse therapies, inpatient HMO, POS, EPO, PPO, SF-POS, Medicare Not covered for Medicaid; contact Behavioral Health staff
Biofeedback Not required 91002 Not covered for Medicaid; not covered for mental health diagnosis
Blepharoptosis/brow ptosis repair EPO, PPO, SF-POS, Medicaid 91535
Blood pressure monitors & ambulatory blood pressure monitoring (24 hour) Not required 91503 Ambulatory blood pressure monitoring is not covered for Priority Health Medicaid members
Bone density studies Not required* 91494 *Prior authorization must be requested through AIM for CT bone density studies
Bone density studies by bone mineral densitometry/quantitative CT HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid Prior authorization must be requested through AIM
Bone marrow/ peripheral stem cell or blood cell transplantation HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91066
Brachytherapy, intracoronary Not required 91536
Breast cancer treatment assessment with Oncotype DXTM Not required 91540
Breast & ovarian cancer screening by molecular testing PA form (24KB PDF) HMO, POS, EPO, PPO, SF-POS, Medicare 91540 Not covered for Medicaid; see form
Breast ductal lavage Not required
Breast implant removal Not required 91545
Breast MRI HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid Prior authorization must be requested through AIM
Breast reconstruction & revision Not required* 91545 *Covered when billed with qualifying diagnosis; otherwise specific procedures require prior authorization
Breast specific gamma imaging (BSGI) Not covered 91568 May be covered when part of an IRB approved clinical trial which requires medical director review
Bronchial thermoplasty HMO, POS, EPO, PPO, SF-POS 91577 Not covered for Medicare or Medicaid
Brow ptosis repair/blepharoptosis EPO, PPO, SF POS, and Medicaid 91535

*Medical policies apply to commercial plans and Medicaid. Medicare plans must follow Medicare policy under National Coverage Determinations and/or Local Coverage Determinations.

C
Service
[Links to PA form, where applicable]
Plans requiring prior auth Medical policy* Comments
Cancer risk-reduction surgery, prophylactic HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91508
Cancer screening by molecular testing, breast & ovarian, PA form (24KB PDF) HMO, POS, EPO, SF-POS, Medicare 91540 Not covered by Medicaid; see form
Capsule endoscopy Not required 91476 Payable for limited diagnoses.  Please see medical policy for details
Cardiac rehabilitation Not required 91318 PA may be required by some employer groups
Cardiac therapy at a participating hospital/provider Not required Priority Health will cover a maximum number of visits per contract year as shown in the member's Certificate of coverage/Policy/Summary of Plan Benefits. PA may be required by some employer groups.
Cardiovascular risk markers Not required 91559
Cardioverter defibrillator (ICD) PA form (140KB PDF) HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91410 See form
Carotid artery stenting Not required 91495
Catheter ablation for cardiac arrhythmias HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91314
Chelation therapy Not required 91077 Payable for limited diagnoses.  Please see medical policy for details
Chemosensitivity assays Not required 91566 ChemoFx® is currently the only assay covered if criteria are met
Chemotherapy, intraperitoneal hyperthermic Not required 91548
Chrondrocyte implants HMO, POS, EPO, PPO, Medicare, Medicaid 91544 May not be covered by self-funded plans
Cingulotomy Not covered 91475
Circumcision Not required
Clinical trials HMO, POS, EPO, PPO  91606

This policy applies to the Individual Market, fully-funded commercial groups and non-grandfathered self-funded groups (verify clinical trial coverage with the individual plan document for self-funded products). For grandfathered self-funded groups that may opt out of PPACA expanded clinical trials coverage, please refer to the Clinical Trials for Cancer Care Medical Policy #91448.

Not a covered benefit for Medicaid members.

Clinical trials for cancer care See comments 91448 Policy only applies to grandfathered self-funded groups that opt out of PPACA expanded clinical trials coverage. Not covered by most self-funded plans (verify clinical trial coverage with the individual plan document).  Requires prior authorization.
Cochlear implant HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91544
Colonoscopy, virtual HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91547 Prior authorization must be requested through AIM
Communications / speech-generating devices, augmentative, for Medicaid members PA form (117KB PDF) Medicaid 91499 See form
Complications to non-covered care Not required 91086
Comprehensive pain and headache programs HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid Prior authorization required for consult and services
Computed tomography scanning for lung cancer screening Not covered 91600 CT scanning for the screening of lung cancer is not a covered service. Please note that American Imaging Management (AIM) provides prior authorization medical necessity review services for high-tech radiology services on behalf of Priority Health for participating providers. Prior authorization for out-of- network providers must be requested through Priority Health.
Conception, artificial/assisted reproduction Not covered 91163
Consultations with participating specialists Not required
Contact lenses/eyeglasses Not required 91538
Continuous glucose monitoring (72 hours) Not required 91466 Not covered by Medicare
Continuous glucose monitoring system
Not required 91466 Not covered by Medicare or Medicaid
Continuous passive motion (CPM) HMO, POS, EPO, PPO, SF-POS, Medicaid Prior auth for CPM not required until day 22
Medicare: Only covered for 21 days, no prior auth required
Coronary artery calcium score/EBCT HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid Prior authorization must be requested through AIM
Coronary CT angiography HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid PA not required for inpatient or emergent care. Prior authorization must be requested through AIM
CPAP & other equipment to treat sleep apnea & upper airway resistance syndrome
CPAP equipment PA form (42KB PDF)
HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91333 Effective 10/01/2012 - Prior authorization for CPAP equipment is waived for the first three months of use. Prior authorization requests for continued use must include evidence of compliance as defined in the medical policy.
Cranial helmets Not required 91504 Subject to DME limits
Craniosacral therapy Not covered

*Medical policies apply to commercial plans and Medicaid. Medicare plans must follow Medicare policy under National Coverage Determinations and/or Local Coverage Determinations.

D
Service
[Links to PA form, where applicable]
Plans requiring prior auth Medical policy* Comments
Defibrillator, implantable cardioverter (ICD) PA form (140KB PDF) HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91410 See form
Dental anesthesia Medicaid
Dental extractions Not required 91542 Covered in very limited circumstances; see policy for details
Not covered by Medicaid, MIChild
Dental services Medicare
Detoxification HMO, POS, EPO, PPO, SF-POS, Medicare 91104
Detoxification for Medicaid members Not covered 91104 Not paid for by PH; managed by CMH and paid for by Medicaid FFS
Developmental disorders, pervasive, including autistic spectrum disorders Not required 91579 Covered for testing and medication management only.
Not covered by health plan for Medicaid members only
Diagnostic testing at participating facilities Not required* *Prior authorization must be requested through AIM for high-tech services
Dialectical behavior therapy (DBT) Not required 91555 Not covered by the health plan for Medicare, Medicaid, MIChild and self-funded plan members
Discectomy, automated percutaneous lumbar (APLD) Not covered 91581
Disorders, feeding HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91469
DNA screening, fecal Not covered 91547
Drug-eluting stents for ischemic heart disease  Not required 91580
Drugs, injectable HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid Certain drugs require prior authorization from the pharmacy department. See Drug PA forms section.
Durable medical equipment (DME) purchases >$1000; Medicaid DME purchases >$500; all rentals; use the DME/P&O Authorization form (474KB PDF) HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91110 See DME section of this manual for specific information.

*Medical policies apply to commercial plans and Medicaid. Medicare plans must follow Medicare policy under National Coverage Determinations and/or Local Coverage Determinations.

E
Service
[Links to PA form, where applicable]
Plans requiring prior auth Medical policy* Comments
Earlobe repair Not required
Eating disorders HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91007
EBCT/coronary artery calcium score HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid Prior authorization must be requested through AIM
ECT (electroconvulsive therapy) HMO, POS, EPO, PPO, SF-POS, Medicare 91554 Not covered by the health plan for Medicaid or MIChild; managed by CMH and paid for by Medicaid FFS
Emergency room services Not required
Enclosed bed systems for Medicaid members Medicaid 91498
Endoscopic Treatment of GERD and Barrett’s Esophagus Not required 91483 See policy for specific coverage criteria
Endoscopy, capsule Not required 91476
Enteral nutrition therapy PA form (33KB PDF) HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91278 See form
Enuresis therapy Not required 91418 Subject to DME limits; not covered by Medicaid
Erectile dysfunction therapy, female  Not required 91160
Experimental/investigational/unproven care HMO, POS, EPO, PPO 91117

Not covered by most self-funded plans (verifiy coverage with individual plan document)

Not a covered benefit for Medicaid members

Extracorporeal shock wave therapy (ECWT) Not covered 91527 Payable for limited diagnoses.  Please see medical policy for details
Extracorporeal immunoadsorption (ECI) Not required Payable for limited diagnoses.  Please see medical policy for details
Extractions, dental Not required 91542 Covered in very limited circumstances; see policy for details
Not covered by Medicaid, MIChild
Eye exams, routine, from participating optometrists Not required When member has vision coverage
Eyeglasses/contact lenses Not required 91538

*Medical policies apply to commercial plans and Medicaid. Medicare plans must follow Medicare policy under National Coverage Determinations and/or Local Coverage Determinations.

F
Service
[Links to PA form, where applicable]
Plans requiring prior auth
Medical policy* Comments
Facial scar revisions Not required 91535
Family/marital therapy Not covered
Fecal DNA screening Not covered 91547
Fecal Microbiota Transplantation/Fecal Bacteriotherapy Not required 91603
Feeding disorders HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91469
Female erectile dysfunction therapy Not required 91160
Fetal surgery HMO, POS, EPO, PPO, SF-POS, Medicaid 91120 Some procedures may not be covered for Medicare and Medicaid
Flu vaccine, intranasal Not required
Fluocinolone implant

HMO, POS, EPO, PPO, SF-POS, Medicaid

91511 Medicare does not require prior authorization
Foot care Not required 91121 Payable for limited diagnoses.  Please see medical policy for details
Formulas, enteral, PA form (33KB PDF)
HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91278
Frenulectomy / frenectomy Not required; not covered by Medicare 91542 Not covered by Medicare

*Medical policies apply to commercial plans and Medicaid. Medicare plans must follow Medicare policy under National Coverage Determinations and/or Local Coverage Determinations.

G
Service
[Links to PA form, where applicable]
Plans requiring prior auth
Medical policy* Comments
Gastroparesis testing and treatment Not required* 91572 
*Prior authorization is required for gastric pacing (gastric pacemaker) and gastric electrical stimulation
Genetic counseling, testing & screening HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91540 Genetic counseling does not require prior authorization
See PA form for Breast and Ovarian Cancer Screening by Molecular Testing
Genetic testing by OON providers requires prior authorization
Genetic testing: pre-implantation HMO, POS, EPO, PPO, SF-POS, Medicare 91540 Not covered by Medicaid or MIChild
GERD, endoscopic treatment of (including Barrett's Esophagus)
Not required 91483 See policy for specific coverage criteria
Glasses/contact lenses Not required 91538
Glucose monitoring, continuous (72 hours)
Not required 91466 Not covered by Medicare
Glucose monitoring systems, continuous Not required 91466 Not covered by Medicare or Medicaid
Gynecological care, routine annual from participating OB/Gyn Not required
Gynecomastia, male PPO, EPO, SF-POS, Medicaid 91545

*Medical policies apply to commercial plans and Medicaid. Medicare plans must follow Medicare policy under National Coverage Determinations and/or Local Coverage Determinations.

H
Service
[Links to PA form, where applicable]
Plans requiring prior auth
Medical policy* Comments
Headache and pain programs, comprehensive HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid Prior authorization required for consult and services
Health education materials Not required
Helmets, cranial Not required 91504 Subject to DME limits
Hemodialysis, home Not required 91526
High-intensity focused ultrasound Not covered 91601  For MRI-guided ultrasound ablation of uterine fibroids, see Uterine Fibroid Treatment - 91573 medical policy.
Hip resurfacing, total Not required
Home health care forms: HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91023

Includes nursing care, infusion, wound pumps, tpn, and palliative care

Effective 2/4/13, no prior authorization is required for the first 30 RN home health skilled nursing visits and the first 5 MSW visits (not covered for Medicaid) in a plan year. Additional visits will require prior authorization. Prior authorization has also been removed for speech, occupational and physical therapy home visits (benefit limits apply).

These changes affect commercial, Medicare, Medicaid and self-funded plans. Call the Provider Helpline at 800.942.4765, option 2, to confirm benefits in advance. Please note that although the prior authorization changes apply to Medicare, the medical policy criteria does not. Priority Health Medicare plans follow the Centers for Medicare & Medicaid Services (CMS) rules for coverage as found in Chapter 7, Home Health Services, Medicare Benefits Policy Manual as found at www.cms.gov.

Prior authorization is still required for home infusion, palliative care, telemonitoring, inpatient hospice and any service billed by a home infusion provider.

Home hemodialysis Not required 91526
Home prothrombin time or INR monitoring Not required 91507 Subject to DME limits; not covered by Medicaid or MIChild
Hospice care, inpatient HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91520 See policy for specifics
Hyperbaric oxygen therapy Not required 91151 Payable for limited diagnoses. Please see medical policy for details
Hyperhidrosis HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91451 Prior authorization only required for botox treatment and inpatient surgery

*Medical policies apply to commercial plans and Medicaid. Medicare plans must follow Medicare policy under National Coverage Determinations and/or Local Coverage Determinations.

I
Service
[Links to PA form, where applicable]
Plans requiring prior auth
Medical policy* Comments
IDET and Other Thermal Intradiscal Procedures (TIPs) Not covered 91581
Immunotherapy/allergy testing Not required 91037
Implant, fluocinolone HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91511
Medicare does not require prior authorization
Implantable cardioverter defibrillator (ICD) PA form (140KB PDF) HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91410 See form
Implants, chrondrocyte HMO, POS, EPO, PPO, Medicare, Medicaid 91443 May not be covered by self-funded plans
Implants, cochlear HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91544
Implants, penile Medicaid 91160 Organic origins only
Impotence and sexual dysfunction Not required 91160 Drug therapy not covered by Medicaid
Incontinence supplies, Medicaid members Not required 91502 See policy for limitations
Infertility diagnosis and treatment Not required 91163 See policy for limitations
Infusion pumps, implantable & external HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91414 Subject to DME limits. Note: Prior authorization is not required for insulin pumps - ambulatory or for code C2626, infusion pump, nonprogrammable, temporary (implantable) or E0617 chemo infusion pumps
Injectable drugs HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid Certain injectable drugs require prior authorization from our pharmacy department
Inpatient care services: all elective admissions including behavioral health and substance abuse HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid Medical necessity criteria must be met for these procedures: ventricular assist devices, lung reduction surgery and hyperhidrosis
Behavioral Health and Substance Abuse inpatient services not covered for Medicaid.
Inpatient services, non-acute HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91332 Includes skilled nursing facilities, rehabilitation, long-term acute-care hospitals
INR monitoring or home prothrombin time Not required 91507 Subject to DME limits; not covered by Medicaid or MIChild
Insulin pumps Not Required 91414
InterQual® insulin pump - ambulatory criteria must be met
Intracranial angioplasty and stenting Not covered 91495
Intraoperative radiation therapy HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91556
Intraperitoneal hyperthermic chemotherapy Not required 91548
Intrauterine fetal surgery HMO, POS, EPO, PPO, SF-POS, Medicaid 91120 Some procedures may not be covered for Medicare and Medicaid
Intracoronary brachytherapy Not required 91536
Intravenous immunoglobulin (IVIG) PA form (68KB PDF) HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid
Investigational/unproven/experimental care HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91117
Irreversible Electroporation (IRE) or Nanoknife Not covered 91599  
IUD, levonorgestrel-releasing (Mirena) Not required 91575 IUDs for contraception (including the levonorgestrel-releasing intrauterine system Mirena®) are a covered benefit for Medicaid and MIChild members and for commercial groups who have purchased contraceptive riders. Also covered if plan falls under the Women's Preventive Health provisions of the Affordable Care Act.

*Medical policies apply to commercial plans and Medicaid. Medicare plans must follow Medicare policy under National Coverage Determinations and/or Local Coverage Determinations.

K
Service
[Links to PA form, where applicable]
Plans requiring prior auth
Medical policy* Comments
Keratoplasty/Lasik Not covered 91529
Knee arthroscopy Not required 91587
Kyphoplasty/vertebroplasty HMO, POS, EPO, PPO, SF-POS, Medicaid 91581 Vertebroplasty is not covered for osteoporotic spinal compression fractures.

*Medical policies apply to commercial plans and Medicaid. Medicare plans must follow Medicare policy under National Coverage Determinations and/or Local Coverage Determinations.

L
Service
[Links to PA form, where applicable]
Plans requiring prior auth Medical policy* Comments
Laparoscopic radical prostatectomy Not required

Laser-assisted uvulopalatoplasty (LAUP) and uvulopalatopharyngoplasty (UPPP) Not required 91333 LAUP is not covered
Lasik/refractive keratoplasty Not covered 91529
Lavage, breast ductal Not required
Levonorgestrel-releasing intra-uterine device (Mirena) Not required 91575 IUDs for contraception (including the levonorgestrel-releasing intrauterine system Mirena®) are a covered benefit for Medicaid and MIChild members and for commercial groups who have purchased contraceptive riders. Also covered if plan falls under the Women's Preventive Health provisions of the Affordable Care Act.
Light therapy (low level), see Monochromatic phototherapy Not covered 91486
Lipoprotein testing Not required 91559 Up to three tests per member per year will be covered.
Lumbar fusion Not required* 91590  *Prior authorization is required for procedures utilizing the AxiaLIFTM device
Lumbar interbody fusion, AxiaLIFTM HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91590
Lumbar laminectomy Not required 91591  
Lung volume reduction surgery Not required 91472 Only covered at certain facilities for Medicare

*Medical policies apply to commercial plans and Medicaid. Medicare plans must follow Medicare policy under National Coverage Determinations and/or Local Coverage Determinations.

M
Service
[Links to PA form, where applicable]
Plans requiring prior auth Medical policy* Comments
Male gynecomastia PPO, EPO, SF-POS, Medicaid 91545
Mammoplasty, reduction, PA form (508KB PDF) EPO, PPO, SF-POS, Medicaid 91545 See form
Marital/family therapy Not covered
Markers for digestive disorders Not required 91583
Mastectomy for intractable breast pain Not covered 91545
Meniscal allograft/autologous chondrocyte implant HMO, POS, EPO, PPO, Medicare, Medicaid 91443 May not be a covered benefit for self-funded members
Menorrhagia treatment Not required 91575
Methadone maintenance Not required Not covered for Medicaid or Medicare
Monitoring, continuous glucose (72 hours) Not required 91466 Not covered by Medicare
Monitoring systems, continuous glucose
Not required 91466 Not covered by Medicare or Medicaid
Monitors, blood pressure, for Medicaid members Not required 91503
Monochromatic phototherapy (anodyne therapy/MIRE therapy/low level light therapy) Not covered 91486
MRI of the breast HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid Prior authorization must be requested through AIM

*Medical policies apply to commercial plans and Medicaid. Medicare plans must follow Medicare policy under National Coverage Determinations and/or Local Coverage Determinations.

N
Service
[Links to PA form, where applicable]
Plans requiring prior auth Medical policy* Comments
Neocate HMO, POS, EPO, PPO, SF-POS, Medicare 91278 Refer to medical policy for specific Medicaid coverage information
Neuropsychological psychological testing Not required 91537 May not be covered for some diagnoses.  See medical policy for coverage detail.
Non-acute inpatient services HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91332 Includes skilled nursing facility, rehabilitation, long-term acute-care hospitals
Non-covered care, complications to Not required 91086
Non-mental health disorders, psychological evaluation and management Not required 91546
Non-participating providers HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid Authorization not required for OB physician care for Medicaid members
Call our Provider Locator Line to find in-network resources
Nucleoplasty Not required 91581
Nutrition therapy PA form, enteral (33KB PDF) HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91278 See form
Nutrition therapy, parenteral HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91517
Nutritional counseling at participating facilities Not required Not all diagnoses are covered

*Medical policies apply to commercial plans and Medicaid. Medicare plans must follow Medicare policy under National Coverage Determinations and/or Local Coverage Determinations.

O
Service
[Links to PA form, where applicable]
Plans requiring prior auth Medical policy* Comments
Obesity-related services
  • Medical management
Not required 91594 May not be covered by self-funded plans. See Physician-Supervised Weight Loss Program templates.
Obesity-related services
  • Surgical treatment
HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91595 May not be covered by self-funded plans. See PA forms for Bariatric Surgery.
Obstetric precertification form (581KB PDF)
See precertification form
Observation HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid Required only for non-participating providers
Occupational therapy (OT) at a participating hospital/provider Not required Priority Health will cover a maximum number of visits per contract year as shown in the member's Certificate of coverage/Policy/Summary of Plan Benefits. PA may be required by some employer groups.
Medicare: Review/authorization required after therapy dollar cap is reached.
Oncotype DXTM for breast cancer treatment assessment Not required 91540
Oocyte and sperm retrieval and storage Not covered 91393
Optometrists, participating, for routine eye exams Not required When member has vision coverage
Oral surgery Not required* 91542 *Please refer to coding section for oral surgery procedures that require prior authorization under cosmetic, reconstructive surgery rules
Organ transplant (solid organs) HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91272
Orthognathic surgery Medicaid 91273
Orthoptic and pleoptic training for Medicaid members Not required 91500
Orthotics: Shoe inserts, orthopedic Shoes HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91420
Orthotics/support device purchases
(Medicare >$1000; Medicaid >$500)
Medicare, Medicaid 91420
91339
Commercial and self-funded plans do not require prior authorization for knee, foot & ankle, upper extremity, and thoracic lumbar orthotics/support devices
Osteochondral, autograft and allograft replacement HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91443 Not covered for ankles. May not be covered by self-funded plans
Out-of-network services HMO, POS, EPO, SF-POS, Medicare, Medicaid Prior authorization may be required for a specific service; refer to medical policies
Outpatient surgery by a participating provider at a participating facility Not required Prior authorization may be required for a specific service; refer to medical policies
Ovarian & breast cancer screening by molecular testing PA form (24KB PDF) HMO, POS, EPO, PPO, SF-POS, Medicare 91540 Not covered by Medicaid. See PA form.
Oximetry, pulse, for home use HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91452 Prior authorization required after 3 months rather than initially
Oxygen therapy Not required
Oxygen therapy, hyperbaric Not required 91151 Payable for limited diagnoses.  Please see medical policy for details

*Medical policies apply to commercial plans and Medicaid. Medicare plans must follow Medicare policy under National Coverage Determinations and/or Local Coverage Determinations.

P
Service
[Links to PA form, where applicable]
Plans requiring prior auth Medical policy* Comments
PET scans HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid
Prior authorization must be requested through AIM
Pacemaker monitoring Not required
Pain and headache programs, comprehensive HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid Prior authorization required for consult and services
Pain, intractable breast, mastectomy for Not covered 91545
Palliative care HMO, POS, EPO, PPO, SF-POS 91558

Not covered for Medicaid and Medicare

Only required for inpatient/home care

Panniculectomy HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91444
Parenteral nutrition therapy HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91517
Patellofemoral replacement for isolated osteoarthritis of the knee
Not covered
91571
Percutaneous Left Atrial Appendage Closure HMO, POS, EPO, PPO, SF-POS, Medicare 91605 Not covered for Medicaid
Penile implants Medicaid 91160 Organic origins only
Pervasive developmental disorders: Evaluation and testing Not required except evaluations for Medicaid members 91579
Pervasive developmental disorders, not including autism spectrum disorders: Treatment services Not covered 91579
Pharmacogenomic testing
Not Required
91570
All tests performed at non-par labs will require prior authorization
Pheresis Not required
Phototherapy, monochromatic (anodyne therapy/MIRE therapy/low level light therapy) Not covered 91486
Physical therapy (PT) at a participating hospital/provider Not required Priority Health will only cover the maximum number of visits for a contract year as shown in the member's Certificate of coverage/Policy/Summary of Plan Description.
Medicare: Review/authorization required after therapy dollar cap is reached.
Platelet rich plasma/platelet rich fibrin matrix Not covered 91553
Pleoptic and orthoptic training for Medicaid members Not required 91500
Port wine stains and vascular malformation Not required 91535
Power vehicles HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91110
Prolotherapy Not covered
Prophylactic cancer risk-reduction surgery HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91508
Prostatectomy, laparoscopic radical Not required
Prosthetics, purchased (>$1000 for most plans; Medicaid >$500) HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91306
Prothrombin time or INR monitoring, home Not required 91507 Subject to DME limits; not covered by Medicaid or MIChild
Psychological evaluation and management of non-mental health disorders Not required 91546
Psychological testing Not required 91537 May not be covered for some diagnoses. See medical policy for coverage detail
Pulse oximetry for home use HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91452 Prior authorization required after 3 months rather than initially
Pumps, implantable & external infusion HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91414 Subject to DME limits
Pumps, insulin HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid InterQual® insulin pump - ambulatory criteria must be met

*Medical policies apply to commercial plans and Medicaid. Medicare plans must follow Medicare policy under National Coverage Determinations and/or Local Coverage Determinations.

Q
Service
[Links to PA form, where applicable]
Plans requiring prior auth Medical policy* Comments
Quantitative electroencephalogram (QEEG) Not required 91510
R
Radiofrequency ablation for back pain HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid: See comments 91581 PA required after two radiofrequency ablation procedures. See policy.
Radiology: All non-emergent outpatient diagnostic services (MRA, MRI, CT, CTA, PET scans and nuclear cardiology) HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid In-network: Prior authorization must be requested through AIM. Out-of-network providers must call Priority Health. Get details and exceptions in the Radiology section of this manual
Radiosurgery, stereotactic, and proton and neutron beam therapies HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91127
Reconstructive surgery, clinical functional impairment HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91535
Reconstructive surgery, therapeutic HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91535  
Recurrent spontaneous abortion Not covered 91156
Reduction mammoplasty PA form (25KB PDF) EPO, PPO, SF-POS, Medicaid 91545 See form
Refractive keratoplasty/Lasik Not covered 91529
Rehabilitation therapies in the home (occupational, physical and speech) Not required 91023 Effective 2/4/13, no prior authorization is required for speech, occupational and physical therapy home visits (benefit limits apply). Priority Health will cover a maximum number of visits per contract year as shown in the member's coverage documents
Rehabilitation therapy (outpatient) Not required 91318 Priority Health will only cover the maximum number of visits for a contract year as shown in the member's coverage documents. PA may be required by some employer groups
Rehabilitation, cardiac Not required 91318 Priority Health will only cover the maximum number of visits for a contract year as shown in the member's coverage documents. PA may be required by some employer groups
Removal of breast implants Not required 91545
Renal artery stenosis Not required 91561
Respite care Not covered 91321
Rhinoplasty/septoplasty HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91506 Prior authorization required for rhinoplasty with or without septoplasty
Rib, titanium HMO, POS, EPO, PPO, SF-POS,
Medicaid
91505
Routine annual gynecological care from participating OB/Gyn Not required

*Medical policies apply to commercial plans and Medicaid. Medicare plans must follow Medicare policy under National Coverage Determinations and/or Local Coverage Determinations.

S
Service
[Links to PA form, where applicable]
Plans requiring prior auth Medical policy* Comments
Scar revisions, facial Not required 91535
Septal defects, transcatheter closure of Not required 91528
Septoplasty/rhinoplasty HMO, POS, EPO, PPO, SF-POS, Medicaid 91506 Prior authorization required for rhinoplasty with or without septoplasty
Sexual dysfunction/impotence Not required 91160 Drug therapy not covered by Medicaid
Shoe inserts, orthopedic shoes, orthotics HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91420
Silicone breast implants Not required
Skin conditions Not required 91456 See policy for specifics

Sleep studies

In-center and in-center split night sleep studies PA form (58KB PDF)

CPAP Titration or PAP NAP PA form (60KB PDF)

PA is not required for home sleep studies

In-center studies: HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid

91333

Effective 01/03/2013 - Prior authorization is required for in-center sleep studies for Medicare members.

No prior authorization is required for in-center sleep studies for members less than 18 years of age.

Skin substitutes Not required 91560
Speech therapy (outpatient) Not required 91336 Medicare: Review/authorization required after therapy dollar cap is reached.
Speech therapy at a participating hospital/provider Not required 91336 Priority Health will only cover the maximum number of visits for a contract year as shown in the member's Certificate of coverage/Policy/Summary of Plan Description.
Medicare: Review/auth required after therapy dollar cap is reached.
Speech-generating / augmentative communications devices for Medicaid members PA form (117KB PDF) Medicaid 91499 See form
Sperm and oocyte retrieval and storage Not covered 91393
Stem cell or blood cell, peripheral to bone marrow transplantation HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91066
Stenting, carotid artery Not required 91495
Stereotactic radiosurgery HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91127
Sterilization, Medicaid members Not required 91501
Stimulation therapy & devices HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91468 Prior authorization is not required for TENS for commercial plans and Medicaid for the following diagnosis codes:  724.2 Lumbago; 722.52 Degeneration of lumbar or lumbosacral intervertebral disc; 724.5 Backache, unspecified; or 724.6 Disorders of sacrum.
Stimulation, deep brain Medicare
Substance abuse/behavioral health therapies, inpatient HMO, POS, EPO, PPO, SF-POS, Medicare Contact Behavioral Health staff. Not covered by Medicaid.
Substance abuse therapies, outpatient Not required Not covered by Medicaid
Surgery, spinal
Spine referral for neurosurgeon or orthopedic surgeon evaluation PA form (57KB PDF)
HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91531 Covered in Spine Centers of Excellence policy
Surgery, bariatric, PA form (254KB PDF) HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91595 See form
Surgery, fetal HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91120 Some procedures may not be covered for Medicare and Medicaid
Surgery, lung volume reduction Not required 91472 Only covered at certain facilities for Medicare
Surgery, prophylactic cancer risk-reduction HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91508
Synthesizer, voice Medicaid 91499

*Medical policies apply to commercial plans and Medicaid. Medicare plans must follow Medicare policy under National Coverage Determinations and/or Local Coverage Determinations.

T
Service
[Links to PA form, where applicable]
Plans requiring prior auth Medical policy* Comments
Telemedicine Not required* 91604

Telephone services are not payable for Priority Health Medicaid, Priority Health Medicare or self-funded products

*Prior authorization is required for telemonitoring 

Temporomandibular joint disorders (TMD) Not required 91353 See policy for specifics
Termination of pregnancy Medicaid
See comments
91000 Please refer to the medical policy for specific criteria related to coverage
Therapy at a participating hospital/provider (cardiac, occupational, physical, speech) Not required Priority Health will cover a maximum number of visits per contract year as shown in the member's Certificate of coverage/Policy/Summary of Plan Benefits. PA may be required by some employer groups.
Therapy, craniosacral Not covered
Therapy, enteral nutrition PA form (37KB PDF) HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91278 See form
Therapy, electro-convulsive (ECT) HMO, POS, EPO, PPO, SF-POS, Medicare 91554 Not covered by Medicaid
Therapy, enuresis Not required 91418 Not covered by Medicaid or MIChild; other plans subject to DME limits
Therapy, extracorporeal shock wave Not covered 91527
Therapy, female erectile dysfunction Not required 91160
Therapy, intraoperative radiation HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91556
Therapy, monochromatic phototherapy (anodyne therapy/MIRE/low level light) Not covered 91486
Therapy, oxygen Not required
Therapy, rehabilitation (outpatient) Not required 91318 Priority Health will only cover the maximum number of visits for a contract year as shown in the member's Certificate of coverage/Policy/Summary of Plan Benefits. PA may be required by some employer groups.
Therapy, speech (outpatient) Not required 91336 At participating hospitals/providers; Priority Health will cover a maximum number of visits per contract year as shown in the member's coverage documents. PA may be required by some employer groups.
Therapy, stimulation, & devices HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91468 Prior authorization is not required for TENS for commercial plans and Medicaid for the following diagnosis codes:  724.2 Lumbago, 722.52 Degeneration of lumbar or lumbosacral intervertebral disc, 724.5 Backache, unspecified or 724.6 Disorders of sacrum.
Therapy, tinnitus retraining Not covered 91482
Thermal capsulorrhaphy Not covered 91551
Thermography Not covered 91355
Titanium rib HMO, POS, EPO, PPO, SF-POS, Medicaid 91505
Total hip resurfacing Not required
Transcatheter closure of septal defects Not required 91528
Transcatheter heart valves HMO, POS, EPO, PPO, SF-POS 91597 Not covered for Medicaid
Transcutaneous Electrical Acustimulation (TEAS) for hyperemesis Not required 91576
Transcranial magnetic stimulation therapy for depression HMO, POS, EPO, PPO, SF-POS 91563 Not covered for Medicare, Medicaid & MIChild
Transplantation of solid organs HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91272 Subject to DME benefit limitations
Transurethral radiofrequency micro-remodeling for female incontinence Not required 91578
Tumor markers Not required 91562 For tumor markers not listed in Appendix I in the policy, please submit request for medical review and include documentation of clinical usefulness

*Medical policies apply to commercial plans and Medicaid. Medicare plans must follow Medicare policy under National Coverage Determinations and/or Local Coverage Determinations.

U
Service
[Links to PA form, where applicable]
Plans requiring prior auth Medical policy* Comments
Umbilical cord blood testing & storage Not required 91459 See policy for specifics
Unproven/experimental/investigational care HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91117
Uvulopalatopharyngoplasty (UPPP) and laser-assisted uvulopalatoplasty (LAUP) Not required 91333 LAUP is not covered

*Medical policies apply to commercial plans and Medicaid. Medicare plans must follow Medicare policy under National Coverage Determinations and/or Local Coverage Determinations.

V
Vaccine, intranasal flu Not required Also see flu shots billing information
Vagal nerve stimulation for depression Not covered 91468
Varicose vein treatment Not required 91326
Vehicles, power HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91110
Ventilator, outpatient HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91110
Ventricular Assist Devices (VADs) and artificial hearts HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91509
Vertebroplasty/kyphoplasty HMO, POS, EPO, PPO, SF-POS, Medicaid 91581 Vertebroplasty is not covered for osteoporotic spinal compression fractures
Virtual colonoscopy HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91547 Prior authorization must be requested through AIM
Vision care/eye exams Not required 91538
Voice synthesizer Medicaid 91499

*Medical policies apply to commercial plans and Medicaid, and to Medicare when no Medicare medical policy or coverage determination applies.

Last modified: 4/4/2014
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