No prior authorization required for:
- Emergency room
- Skilled nursing facility
Injectable auth/billing notes:
Medications billed with miscellaneous codes will be reviewed. Explanatory notes must accompany the claim.
Priority Health Medicare applies CMS local coverage determination criteria when available for Part B drugs.
- Group commercial HMO, EPO, POS and PPO plans
- Individual commercial ACA-compatible MyPriority® HMO, POS and PPO plans
Notes: Treatment of rheumatoid arthritis
Criteria for coverage: See PA forms
Medicare Advantage plans
Codes: Must use CPT code outlined in the CMS local coverage determination (LCD) available at www.cms.gov.
Benefit: Part B
Notes: No authorization required; covered only when billed with the following ICD-10 diagnoses:
- M05.60 – M05.69, Rheumatoid arthritis with involvement of other organs and systems
- M05.70 – M05.79, Rheumatoid arthritis with or w/o involvement of other organs and systems
- M06.00 – M06.09, Rheumatoid arthritis without rheumatoid factor
- M06.9, Rheumatoid arthritis, unspecified
- M08.20 – M08.29, Juvenile rheumatoid arthritis with systemic onset
- M08.4, Pauciarticular juvenile rheumatoid arthritis