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 |
|
|
| Anesthesia, dental |
Medicaid |
|
|
| Angiography, coronary CT |
HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid |
See AIM guideline |
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 |
Not required |
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 |
91493 |
Single level disc covered> |
| Artificial intervertebral discs, lumbar |
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. Medical policy only applies to Medicaid members. |
| Autistic spectrum disorders |
Not required* |
91543 |
*Prior authorization (by member only) required for initial evaluation.
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 |
91519 |
|
| Autopsy |
Not covered |
91054 |
|
| AxiaLIFTM lumbar interbody fusion |
Not covered |
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 (891KB PDF)
Bariatric surgery PA form (254KB 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 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. |
| Breast specific gamma imaging (BSGI) |
Not covered |
91568 |
May be covered when part of an IRB approved clinical trial which requires medical director review. |
| 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. |
| 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 |
| 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, Medicaid |
See AIM guideline |
Prior authorization must be requested through AIM |
| Coronary CT angiography |
HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid |
See AIM guideline |
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 |
| 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, including autistic spectrum disorders |
Not required* |
91543 |
*Prior authorization (by member only) required for initial evaluation. |
| 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. |
| 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 |
See AIM guideline |
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 and Barrett’s Esophagus |
Not required |
91483 |
|
| Endoscopy, capsule |
Not required |
91476 |
|
| Enhanced external counterpulsation (EECP) |
Not required |
91440 |
|
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 |
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
(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 |
| 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 forms for Breast Cancer Treatment Assessment with Oncotype Dx and 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 |
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 |
Not required |
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 |
Not required |
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, 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 |
91438 |
|
| 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 code C2626, infusion pump, nonprogrammable, temporary (implantable). |
| 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 covered |
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 |
|
|
| 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 (117KB 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 |
|
| Knee arthroscopy for osteoarthritis |
Not required |
91564 |
Claim will adjudicate per medical policy. Retrospective review at plan discretion. |
| Kyphoplasty / vertebroplasty |
Not required |
91479 |
See policy for specifics |
| 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 |
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 |
91559 |
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 (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 |
| 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 |
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 |
91438
91519 |
|
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, 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: 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. |
| 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 |
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 |
|
| 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 in the home |
HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid |
91517 |
|
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 |
*Prior authorization (by member only) required for initial evaluation.
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 |
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 |
|
| 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 |
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 artery stenosis |
Not required |
91561 |
|
| 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 |
| 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 |
Policy effective March 1, 2009 |
| 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, PA form |
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 (891KB PDF)
Surgery, bariatric, PA form (254KB 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) (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, 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 |
|
| 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 |
|
| 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 |
91480 |
See policy for limitations
Claim will adjudicate per medical policy
Also see flu shots billing information |
| 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 (VADs) and artificial hearts |
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 (273KB PDF) |
HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid |
91435 |
See form |
