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Provider Manual

 

 

Prior authorization reference list

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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 auth is needed, providers must still ensure that their claim meets 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.

 

Urgent requests are defined using NCQA criteria.

Urgent cases include the following:
  • A delay in care could seriously jeopardize the life or health of the patient or the patient's ability to regain maximum function.
  • In the opinion of a provider, with knowledge of the member's medical condition, a delay in care would subject the member to severe pain that cannot be adequately managed without the care or treatment requested in the prior authorization.

Retroactive prior authorization requests

Priority Health accepts retroactive prior authorization requests for services that have already occurred. The timeline for turnaround of retroactive prior authorization requests is 30 days for commercial and self funded products, and 14 days for Priority Health Medicare and Medicaid.

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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, elective Not covered except Medicaid 91000
Accupuncture Not covered

ADD/ADHD & ODD outpatient therapies Not covered

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, emergent Not required

Ambulance services, non-emergent HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid

Anesthesia, dental 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
Arthroscopy for osteoarthritis of the knee See policy
91564 Claim will adjudicate per medical policy. Retrospective review at plan discretion.
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 Not required 91543 Covered for testing and medication management only.
Not covered by the health plan for Medicaid members only.
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 Not covered 91581
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 Not covered for self-funded plans
Balloon sinus ostial dilation Not covered 91596
Bariatric surgery: Bariatric surgery evaluation form (891KB PDF) 
Bariatric surgery PA form (254KB PDF)		 HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91595 See forms; requires PA for evaluation and for service.
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 Not required 91503
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
Botulinum toxin HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91455 PA not required if administered by a neurologist or physiatrist
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 Claim will adjudicate per medical policy.
Breast MRI HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid
Prior authorization must be requested through AIM
Breast reconstruction & revision Not required 91545 Claim will adjudicate per medical policy.
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
C
Service
[Links to PA form, where applicable]		 Plans requiring prior auth Medical policy Comments
Cancer care clinical trials HMO, POS, EPO, PPO, Medicare, Medicaid 91448 Not covered by self-funded plans
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 Claim will adjudicate per medical policy
Cardiac rehabilitation Not required 91318 Claim will adjudicate per medical policy; 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 CREST or clinical trial not covered by self-funded plans; claim will adjudicate per medical policy.
Catheter ablation for cardiac arrhythmias HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91314
Chelation therapy Not required 91077 Claim will adjudicate per medical policy.
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 Not covered by self-funded plans.
Cingulotomy Not covered 91475
Circumcision Not required

Clinical trials for cancer care HMO, POS, EPO, PPO, Medicare, Medicaid 91448 Not covered by self-funded plans.
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 Claim will adjudicate per medical policy
Continuous glucose monitoring (72 hours) Not required 91466 Claim will adjudicate per medical policy. Not covered by Medicare.
Continuous glucose monitoring system
Not required 91466 Not covered by Medicare or Medicaid. Claim will adjudicate per medical policy.
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
Cosmetic & reconstructive surgery (all procedures) Medicare

Cranial helmets Not required 91504 Subject to DME limits
Craniosacral therapy Not covered

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 91543 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
Discectomy, automated percutaneous lumbar (APLD) Not covered 91581
Discs, artificial intevertebral 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.
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 Medicaid
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.
Claim with adjudicate per medical policy.
Endoscopy, capsule Not required 91476
Enteral nutrition therapy PA form (33KB PDF) 
Enteral nutrition therapy PA form, Medicare (57KB 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 Claim will adjudicate per medical policy
Experimental / investigational / unproven care HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91117
Extracorporeal shock wave therapy (ECWT) Not covered 91527
Extracorporeal immunoadsorption (ECI) Not required Claim will adjudicate per medical policy
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 Claim will adjudicate per medical policy
F
Service
[Links to PA form, where applicable]		 Plans requiring prior auth
Medical policy Comments
Facial scar revisions Not required 91535 Claim will adjudicate per medical policy
Family/marital therapy Not covered

Fecal DNA screening Not covered 91547
Feeding disorders HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91469
Female erectile dysfunction therapy Not required 91160 Claim will adjudicate per medical policy
Fetal surgery HMO, POS, EPO, PPO, SF-POS, Medicaid 91120
Flu vaccine, intranasal Not required

Fluocinolone implant HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91511
Foot care Not required 91121 Claim will adjudicate per medical policy
Formulas, enteral, PA form (33KB PDF) 
Formulas, enteral, PA form (Medicare) (57KB PDF)		 HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91278
Frenulectomy / frenectomy Not required; not covered by Medicare 91542 Claim will adjudicate per medical policy
Not covered by Medicare
G
Service
[Links to PA form, where applicable]		 Plans requiring prior auth
Medical policy Comments
Gastroparesis testing and treatment
Not required 91572 
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: 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.
Claim with adjudicate per medical policy.
Glasses / contact lenses Not required 91425 Claim will adjudicate per medical policy
Glucose monitoring, continuous (72 hours)
Not required 91466 Claim will adjudicate per medical policy. Not covered by Medicare.
Glucose monitoring systems,continuous HMO, POS, EPO, PPO, SF-POS 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
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
Hip resurfacing, total Not required 91530

Home health care forms: 
Home care PA form (538KB PDF) 
Home care IV infusion services PA form (492KB PDF) 
Home health care clinical pathways form (514KB PDF)
Palliative care PA form (466KB PDF) 
TPN (Total Parenteral Nutrition) PA form (535KB) 
Telemonitoring discharge approval form (31KB PDF)

 

 

 

 

 

 

 

 

 

 

 HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91023 Includes nursing care, rehabilitation therapies, infusion, wound pumps, tpn, and palliative care
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 Claim will adjudicate per medical policy
Hyperhidrosis HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91451 Prior auth only required for botox treatment and inpatient surgery
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
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 Not 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: laparoscopic radical prostatectomy, 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
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 are not covered for commercial members; IUDs for contraception are covered for Medicaid and MIChild members and groups who have purchased contraceptive riders. See policy for specifics.
K
Service
[Links to PA form, where applicable]		 Plans requiring prior auth
Medical policy Comments
Keratoplasty / Lasik Not covered 91529
Knee arthroscopy for osteoarthritis See policy 91564 Claim will adjudicate per medical policy. Retrospective review at plan discretion.
Kyphoplasty / vertebroplasty HMO, POS, EPO, PPO, SF-POS, Medicaid 91581 Vertebroplasty is not covered for osteoporotic spinal compression fractures.
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; claim will adjudicate per medical policy.
Lasik / refractive keratoplasty Not covered 91529
Lavage, breast ductal Not required

Levonorgestrel-releasing intra-uterine device (Mirena) Not required 91575 IUDs for contraception are not covered for commercial plan members; IUDs for contraception are covered for Medicaid and MIChild members and groups who have purchased contraceptive riders. See policy for specifics.
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 interbody fusion, AxiaLIFTM Not covered 91581
Lung volume reduction surgery Not required 91472 Only covered at certain facilities for Medicare.
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
Medical weight-loss program PA form (273KB PDF) HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91435 See form
Meniscal allograft / autologous chondrocyte implant HMO, POS, EPO, PPO, Medicare, Medicaid 91443 Not a covered benefit for self-funded members
Menorrhagia Treatment
Not required
91575 
Methadone maintenance Not covered

Monitoring, continuous glucose (72 hours) Not required 91466 Claim will adjudicate per medical policy. Not covered by Medicare.
Monitoring systems, continuous glucose
HMO, POS, EPO, PPO, SF-POS 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
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
Auth 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) 
Nutrition therapy PA form, enteral, Medicare (57KB PDF)		 HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91278 See form
Nutrition therapy, parenteral Not required 91517 Prior authorization only required for home parenteral nutrition
Nutritional counseling at participating facilities Not required
Not all diagnoses are covered
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 Evaluation and Bariatric Surgery.
Obesity-related services HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91435

May not be covered by self-funded plans.
See PA forms for Medical Weight Loss and Bariatric Surgery.

Effective 4/1/2012 this policy should only be used by contracted Priority Health Weight Loss Centers of Excellence. All others please refer to the new Medical Management of Obesity and Surgical Treatment of Obesity medical policies.
Obstetric precertification form (581KB PDF)

See precertification form
Observation
HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid
Required only for non-participating providers.
Obstructive sleep apnea, & upper airway resistance syndrome Not required 91333 Claim will adjudicate per medical policy.
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.
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
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 auth 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 Claim will adjudicate per medical policy
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 Only required for inpatient/home care.
Panniculectomy HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91444
Parenteral nutrition therapy Not required 91517 Prior authorization only required for home parenteral nutrition
Patellofemoral replacement for isolated osteoarthritis of the knee
Not Covered
91571
Penile implants Medicaid 91160 Organic origins only
Pervasive developmental disorders, including autistic spectrum disorders Not required 91543 Covered for testing and medication management only.
Not covered by the health plan for Medicaid members only.
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.
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 Claim will adjudicate per medical policy
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

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 and cosmetic surgery (all procedures) Medicare 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 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 Certificate of coverage/Policy/Summary of Plan Benefits. 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 Certificate of coverage/Policy/Summary of Plan Benefits. PA may be required by some employer groups.
Removal of breast implants Not required 91545 Claim will adjudicate per medical policy.
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

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; claim will adjudicate per medical policy.
Sleep apnea, obstructive, & upper airway resistance syndrome Not required 91333 Claim will adjudicate per medical policy.
Skin substitutes Not required 91560
Speech therapy (outpatient) Not required 91336
Speech therapy at a participating hospital/provider Not required 91336 Claim will adjudicate per medical policy.
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.
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 CREST or clinical trial not covered for SF; claim will adjudicate per medical policy.
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 auth is not required for TENS 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, back HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91531 Covered in Spine Centers of Excellence policy
Surgery, bariatric, evaluation form (891KB PDF) 
Surgery, bariatric, PA form (254KB PDF)		 HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91595 See forms; requires prior auth for evaluation and for service
Surgery, cosmetic and reconstructive (all procedures) Medicare

Surgery, fetal HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91120
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
T
Service
[Links to PA form, where applicable]		 Plans requiring prior auth Medical policy Comments
Temporomandibular joint disorders (TMD) Not required 91353 See policy for specifics; claim will adjudicate per medical policy
Termination of pregnancy, elective Not covered except Medicaid 91000
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) 
Therapy, enteral nutrition, PA form (Medicare) (57KB 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 Claim will adjudicate per medical policy
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.
Claim will adjudicate per medical policy.
Therapy, stimulation, & devices HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91468 Prior auth is not required for TENS 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 91530
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 and Medicaid
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.
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; claim will adjudicate per medical policy.
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 Claim will adjudicate per medical policy
Voice synthesizer Medicaid 91499
W
Weight-loss program PA form, medical (273KB PDF) HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91435 See form

Last modified: 4/25/2012
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