| Item requiring auth | Notes |
|---|
| Augmentative & alternative communications devices |
Get evaluation form (139KB PDF) (Priority Health Medicaid patients only) |
| Apnea monitor |
Get notification form (414KB PDF) (for Priority Health Medicaid patients under 21 years of age)
Prior auth not required |
| Bilirubin light |
(After 7 days of use authorization is required) |
| Blood pressure kit |
(For Priority Health Medicaid) |
| Bone growth stimulator - electric |
Medical criteria must be met |
| Bone growth stimulator - ultrasound |
Medical criteria must be met
Not covered for Priority Health Medicaid members |
| Continuous Passive Motion (CPM) machine |
Prior auth required after 21 days
Ongoing use approved for 7 days at a time |
| CPAP/BiPAP |
|
| Dialysis units, home |
|
| Enteral feeding pumps & supplies |
Pump is 10 month capped rental
Formula and supplies purchased with approval |
| Helmets, cranial reshaping |
|
| Hospital beds |
Medical criteria must be met
Allow for up to 10 month capped rental |
| Hoyer lifts |
10 month capped rental with approval |
Infusion pumps, implantable & external
|
Prior authorization is not required for insulin pumps - ambulatory and code C2626, infusion pump, nonprogrammable, temporary (implantable) or E0617 chemo infusion pumps. |
| Lymphedema compression devices - pumps/Reid sleeves |
E0652 - Lymphedema Pump requires prior auth - 1 month rental then convert to purchase
Reid sleeve requires PA as over $1,000 limit
Note: Stockings/garments do not require prior auth |
Negative pressure wound therapy pump
(wound vac) |
Medical criteria must be met
Allow up to 4 months |
| Neuromuscular electrical stimulators |
Medical criteria must be met |
| Oral appliances |
For sleep apnea only - must be contracted provider |
| Orthotic shoe inserts |
Medical criteria must be met |
| Oxygen therapy |
Get notification form (414KB PDF) (for Priority Health Medicaid patients under 21 years of age)
Prior auth not required. |
| Orthopedic shoes |
Medical criteria must be met |
| Orthotics/support devices |
Medical criteria must be met
Prior auth if >$500 for Medicaid
Prior auth if >$1000 for Medicare
Note: Commercial and self-funded plans do not require prior auth for knee, foot & ankle, upper extremity, and thoracic lumbar orthotics/support devices |
| Power-operated vehicles |
Medical criteria must be met |
| Prosthetics and orthotics |
Prior auth if >$500 for Medicaid
Prior auth if >$1000 for Commercial/Medicare/Self-Funded
Note: Orthotics/Support Devices info above |
| Pulse oximetry for home use |
Prior auth required after three months |
| Repairs |
Prior auth if >$500 for Medicaid
Prior auth if >$1000 for Commercial/Medicare/Self-Funded |
| Secretion clearing devices |
Medical criteria must be met
Prior auth not required for suction pumps |
| Standing frame |
Medical criteria must be met |
Strollers, adaptive
|
Medical criteria must be met
Custom strollers are purchase items |
| Support surfaces |
10 month capped rental for most |
| Mattresses, specialty |
See rental limits
Note: Clinitron power overlay mattresses - rent by the day |
| Transcutaneous electrical nerve stimulation (TENS) |
See rental limits
Note: The use of TENS for a two-month trial for any diagnosis does not require prior auth. For use beyond the two month trial, prior authorization is required for all codes except: 722.52, 724.2, 724.5 and 724.6
|
| Ultraviolet light purchase |
For specific skin conditions |
| Ventilators |
Continued rental 1 unit/month
No back up ventilators allowed
|
| Wheelchair, manual |
|
| Wheelchair, power/standing wheelchair |
See rental limits
For custom equipment medical criteria must be met and equipment is a purchase item |
| Wheelchair seating systems |
(custom/non-custom)
Custom seating systems are purchase items |
