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
|
|
Not covered by some self-funded groups; contact Behavioral Health staff |
ADD/ADHD & ODD testing
|
HMO, POS, Medicaid
|
|
Not covered by some self-funded groups; contact Behavioral Health staff
|
| 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 |
|
|
| Analysis, gene expression, PA form (33KB PDF) |
HMO, POS, EPO, PPO, SF-POS,
Medicare, Medicaid |
91540
|
|
| Anesthesia, dental |
Medicaid |
|
|
| Angiography, coronary CT |
HMO, POS, EPO, PPO, SF-POS, Medicare
|
See AIM guideline
|
Not covered by Medicaid. 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 intevertebral discs |
Not covered
|
91493 |
|
| 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 |
Autistic spectrum disorders
|
Not covered |
91543 |
|
| 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
|
91519 |
|
| Autopsy |
Not covered
|
91054 |
|
| AxiaLIFTM lumbar interbody fusion |
HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid |
91549 |
|
| 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 |
Bariatric surgery: Bariatric surgery evaluation form (32KB PDF)
Bariatric surgery PA form (30KB PDF)
|
HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid |
91435 |
See forms; requires PA for evaluation and for service. |
| Bed systems, enclosed, for Medicaid members |
Medicaid |
91498 |
|
Behavioral health therapies, outpatient
|
HMO, POS, EPO, PPO, SF-POS, 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 |
91376 |
|
| Blood pressure monitors for Medicaid members |
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 |
See AIM guideline
|
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, intravascular |
Not required
|
91536 |
|
Breast cancer treatment assessment with Oncotype DXTM PA form (24KB PDF)
|
HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid
|
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 implants, silicone |
Not required
|
|
|
| Breast MRI |
HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid |
See AIM guideline
|
Prior authorization must be requested through AIM
|
| Breast reconstruction & revision |
Not required |
91545 |
Claim will adjudicate per medical policy.
|
| Brow ptosis repair / blepharoptosis |
EPO, PPO, SF POS, and Medicaid |
91376 |
|
| 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 loop recorder, implantable |
Not required
|
91496 |
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.
|
| Cardioverter defibrillator (ICD) PA form (140KB PDF) |
HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid |
91410 |
See form |
Carotid artery stenting PA form (25KB PDF)
|
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. |
| 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 |
91085 |
|
| 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 |
| Conception, artificial / assisted reproduction |
Not covered
|
91163 |
|
| Consultations with participating specialists |
Not required
|
|
|
| Contact lenses/eyeglasses |
Not required
|
91425 |
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 PA form (38KB PDF)
|
HMO, POS, EPO, PPO, SF-POS
|
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 |
See AIM guideline |
Not covered by Medicaid
Prior authorization must be requested through AIM |
| Coronary CT angiography |
HMO, POS, EPO, PPO, SF-POS, Medicare |
See AIM guideline
|
Not covered by 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
|
91095 |
|
| D |
Service
[Links to PA form, where applicable] |
Plans Requiring Prior Auth
|
Medical Policy |
Comments |
| Deep brain stimulation |
Medicare |
|
|
| 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
|
91523 |
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 |
Not required |
91543 |
|
| 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
|
91519 |
|
| Discs, artificial intevertebral |
Not covered
|
91493 |
|
| Disorders, feeding |
HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid |
91469 |
|
| DNA screening, fecal |
Not covered |
91547 |
|
| 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
|
HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid |
91110 |
See DME section of this manual for specific information.
Effective 9/1/07, ASO plans require prior auth for purchases greater than $1,000. |
| 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 |
See AIM guideline
|
Not covered by 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 |
|
| End-stage renal disease (ESRD) |
Not required
|
91526 |
|
| Endometrial ablation procedures for menorrhagia |
Not required
|
91539 |
|
| Endoscopic treatment of GERD |
Not covered
|
91483 |
Endoscopic mucosal resection for Barrett's Esophagus is covered under certain conditions; no PA required; see policy.
|
| Endoscopy, capsule |
Not required
|
91476 |
|
| Enhanced external counterpulsation (EECP) |
Not required
|
91440 |
|
Enteral nutrition therapy PA form (37KB PDF)
Enteral nutrition therapy PA form, Medicare (30KB 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 or MIChild |
| 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
|
91118 |
Claim will adjudicate per medical policy |
| Extractions, dental |
Not required
|
91523 |
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
|
91425 |
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
|
91442 |
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
|
91480 |
Claim will adjudicate per medical policy
|
| 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 (37KB PDF)
Formulas, enteral, PA form (Medicare) (30KB 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
|
| G |
Service
[Links to PA form, where applicable] |
Plans Requiring Prior Auth
|
Medical Policy |
Comments |
| Gene expression analysis PA form (33KB PDF) |
HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid |
91540
|
For breast cancer treatment assessment with Oncotype DXTM
|
| Genetic counseling, testing & screening |
HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid |
91540 |
Genetic counseling does not require prior authorization
|
| Genetic testing: pre-implantation |
HMO, POS, EPO, PPO, SF-POS, Medicare
|
91540 |
Not covered by Medicaid or MiChild
|
| GERD, endoscopic treatment of |
Not covered
|
91483 |
Endoscopic mucosal resection for Barrett's Esophagus is covered under certain conditions; no PA required; see policy. |
| Glasses / contact lenses |
Not required
|
91425 |
Claim will adjudicate per medical policy
|
Glucose monitoring, continuous (72 hours) PA form (38KB PDF)
|
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.
|
| Growth hormone replacement in adults |
HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid |
91441 |
|
| Growth hormone therapy in children |
HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid |
91460 |
|
| 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 |
HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid |
91512 |
|
Hip resurfacing, total
|
Not required
|
91530
|
|
Home care PA form (40KB PDF)
Home care discharge form (21KB PDF)
Home care IV infusion services PA form (33KB PDF)
Additional home health care services request form (146KB PDF)
|
HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid |
91023 |
Includes nursing care, rehabilitation therapies, infusion, wound pumps, tpn |
| Home hemodialysis |
HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid |
91512 |
|
| Home prothrombin time or INR monitoring |
Not required
|
91507 |
Subject to DME limits; not covered by Medicaid or MiChild |
| Hormone replacement (growth hormone) in adults |
HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid |
91441 |
|
| Hormone therapy, growth, in children |
HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid |
91460 |
|
| Hospice care |
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
|
| I |
Service
[Links to PA form, where applicable] |
Plans Requiring Prior Auth
|
Medical Policy |
Comments |
| IDET |
Not required
|
91438 |
Not covered by SF or Medicare
|
| 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 |
| 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 |
| Inpatient services, non-acute |
HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid |
91332 |
Includes skilled nursing facilities, rehabilitation, long-term acute-care hospitals
|
Intracranial angioplasty and stenting
|
Not required
|
91495
|
|
Intraoperative radiation therapy
|
HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid
|
91556
|
|
| INR monitoring or home prothrombin time |
Not required
|
91507 |
Subject to DME limits; not covered by Medicaid or MiChild |
| Insulin pumps |
HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid |
|
|
| Intevertebral discs, artificial |
Not covered |
91493 |
|
| Intranasal flu vaccine |
Not required
|
91480 |
See policy for limitations
|
| Intraperitoneal hyperthermic chemotherapy |
Not required |
91548 |
|
| Intrauterine fetal surgery |
HMO, POS, EPO, PPO, SF-POS, Medicaid |
91120 |
|
| Intravascular brachytherapy |
Not required
|
91536 |
|
Intravenous immunoglobulin (IVIG) PA form
(221KB PDF)
|
HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid |
91514 |
|
| Investigational / unproven / experimental care |
HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid |
91117 |
|
| IUD, levonorgestrel-releasing (Mirena) |
Not required |
91487 |
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 |
|
| Kyphoplasty / vertebroplasty |
Not required |
91479 |
See policy for specifics |
| L |
| 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 |
91487 |
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 |
91454 |
Up to three tests per member per year will be covered. |
| Lumbar interbody fusion, AxiaLIFTM |
HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid |
91549 |
|
| 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 (25KB PDF) |
EPO, PPO, SF-POS, Medicaid |
91545 |
See form
|
Marital/family therapy
|
Not covered
|
|
|
| Mastectomy for intractable breast pain |
Not covered |
91545 |
|
| Medical weight-loss program PA form (30KB 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 |
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, PA form (38KB PDF)
|
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 |
See AIM guideline
|
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 |
Not covered by Medicaid
|
Neuropsychological psychological testing
|
HMO, POS, EPO, PPO, SF-POS, Medicaid
|
91537
|
Not covered for mental health diagnosis
|
| 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
|
|
| Nucleoplasty |
Not required
|
91438
91519 |
|
Nutrition therapy PA form, enteral (37KB PDF)
Nutrition therapy PA form, enteral, Medicare (30KB PDF)
|
HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid |
91278 |
See form |
| Nutrition therapy, parenteral, in the home |
HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid |
91517 |
|
| 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 |
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. |
| Obstetric precertification form (85KB PDF) |
|
|
See precertification form |
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 PA form (24KB PDF)
|
HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid
|
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 purchased >$1000; Medicaid >$500 |
HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid |
91420
91339 |
Self-funded plans require prior auth for purchases greater than $1,000 (previously $500).
|
| 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 |
|
|
| 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 |
See AIM guideline
|
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 |
|
| Palivizumab / Synagis |
HMO, POS, EPO, PPO, SF-POS, Medicaid |
91429 |
|
| Panniculectomy |
HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid |
91444 |
|
| Parenteral nutrition therapy in the home |
HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid |
91517 |
|
| Penile implants |
Medicaid |
91160 |
Organic origins only |
Pervasive developmental disorders, including autistic spectrum disorders
|
Not covered |
91543 |
|
| 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 Benefits. |
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 |
91413 |
Claim will adjudicate per medical policy
|
| Power vehicles |
HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid |
91110
|
|
| Prolotherapy |
Not covered
|
91301 |
|
| 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 |
Effective 9/1/07, ASO plans require prior auth for purchases greater than $1,000 (previously $500).
|
| 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 |
|
| 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 |
91541
|
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
|
|
| Recorder, cardiac loop, implantable |
Not required |
91496 |
|
| 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 disease, end stage
|
Not required
|
91526
|
|
| 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 |
|
Robotically assisted surgery
|
Not required
|
91522
|
|
| 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 |
91442 |
|
| 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
|
| 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.
|
| 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 Benefits.
|
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, PA form (25KB PDF)
|
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
|
HMO, POS, EPO, PPO, SF-POS
|
|
Not covered by Medicaid
Contact Behavioral Health staff
|
Surgery, back
|
HMO, POS, EPO, PPO, SF-POS, Medicaid
|
91531
|
Covered in Spine Centers of Excellence policy
|
Surgery, bariatric, evaluation form (32KB PDF)
Surgery, bariatric, PA form (30KB PDF)
|
HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid |
91435 |
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 |
|
Surgery, robotically assisted
|
Not required
|
91522
|
|
| Synagis / Palivizumab |
HMO, POS, EPO, PPO, SF-POS, Medicaid |
91429 |
|
| 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 |
91095 |
|
Therapy, enteral nutrition, PA form (37KB PDF)
Therapy, enteral nutrition, PA form (Medicare) (30KB 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, growth hormone, in children |
HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid |
91460
|
|
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 |
|
| Transplantation of solid organs |
HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid |
91272 |
|
| 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 |
91480 |
See policy for limitations
Claim will adjudicate per medical policy
Also see billing information on Flu Shots
|
| Vagal nerve stimulation for depression |
HMO, POS, EPO, PPO, SF-POS, Medicaid
|
91524 |
|
| 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 |
HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid |
91509 |
|
| Vertebroplasty / kyphoplasty |
Not required |
91479 |
See policy for specifics |
| 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 (30KB PDF) |
HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid |
91435 |
See form |
