Authorization quick reference list

Our Auth Request tool has two portals, GuidingCare and eviCore.

Medical policies apply to commercial plans, and Medicaid if specified. If there is a discrepancy between the medical policy and the Michigan Medicaid Provider Manual, the Michigan Medicaid Provider Manual will govern.

Medicare plans must follow Medicare policy under National Coverage Determinations and/or Local Coverage Determinations or the Evidence of Coverage (EOC); if there are none, our medical policy will apply.

When Priority Health is secondary to CMS or Original Medicare, we require prior authorization on obesity-related surgery, transplant services and home infusion services.

Click a letter to jump down to that section of the list:

A | B | C | D | E | F | G | H | I | J | K | L | M | N | O | P | Q | R | S | T | U | V | W | X | Y | Z

Service Plans requiring prior auth Medical policy
A
Abdominoplasty/panniculectomy HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91444
Abortion/termination of pregnancy

Medicaid

Refer to the medical policy for coverage criteria

91000
Acupuncture

Not required

Generally not covered

May be covered with a rider or by some self-funded (SF) plans. See SF plan documents to confirm coverage

Adenotonsillectomy, pediatric (ages 0-17 only) HMO, POS, EPO, PPO, SF-POS, Medicaid
Allergy testing/immunotherapy Not required 91037
Ambulance services, air/fixed wing HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid
Ambulance services, emergent Not required
Ambulance services, non-emergent HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid
Apnea monitors and oxygen therapy, Medicaid patients under 21 only Not required 91497
Artificial intervertebral discs HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91581
Authorized through eviCore healthcare
Augmentative communications/speech-generating devices Medicare, Medicaid 91499
Applies only to Medicaid
Autism spectrum disorder treatment services, ages 0-18 only See policies for details 91615
91336
91318
Autologous chondrocyte implant/meniscal allograft/osteochondral

HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid

May not be covered by self-funded plans

91443
Authorized through eviCore healthcare
B
Service Plans requiring prior auth Medical policy
BAHA device HMO, POS, EPO, SF-POS, Medicare, Medicaid 91544
Balloon sinus ostial dilation Not required 91596
Behavioral health therapies, initial evaluation Medicaid Submit Outpatient Services Request form to Priority Health
Behavioral health therapies, outpatient Not required
Behavioral health & substance abuse therapies, inpatient HMO, POS, EPO, PPO, SF-POS, Medicare Submit Inpatient Services Request form to Priority Health
Biofeedback Not required 91002
Blepharoptosis/brow ptosis repair EPO, PPO, SF-POS, Medicaid 91535
Blood pressure monitors & ambulatory blood pressure monitoring (24 hour) Not required 91503
Bone density studies Not required 91494
Bone density studies, CT HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91494
Authorized through eviCore healthcare
Bone marrow/stem cell transplantation HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91066
Breast MRI HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91545
Authorized through eviCore healthcare
Breast reconstruction & revision procedures not billed with qualifying diagnosis HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91545
Breast specific gamma imaging (BSGI)

Not required

See policy for diagnosis limitations

91568
Bronchial thermoplasty HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91577
C
Service Plans requiring prior auth Medical policy
Capsule endoscopy

Not required

Payable for limited diagnoses, see medical policy

91476
Cardiac/pulmonary rehabilitation (visit limits apply) Not required except by some employer groups 91318
Cardiovascular risk markers Not required 91559
Cardioverter defibrillators (ICDs) HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91410
InterQual
Carotid artery stenting Not required 91495
Catheter ablation for cardiac arrhythmias HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91314
InterQual
Chelation therapy

Not required

Payable for limited diagnoses, see medical policy

91077
Chemosensitivity assays See policy for requirements 91540
Most testing authorized by eviCore healthcare
Clinical trials

HMO, POS, EPO, PPO

Medicaid: Not covered

Medical policy applies to MyPriority individual plans, fully funded commercial groups and non-grandfathered self-funded groups (verify clinical trial coverage with the individual plan document for self-funded products).

For grandfathered self-funded groups that may opt out of PPACA expanded clinical trials coverage, refer to the Clinical Trials for Cancer Care medical policy 91448, below.

91606
Clinical trials for cancer care Applies only to grandfathered self-funded groups that opt out of PPACA expanded clinical trials coverage. Not covered by most self-funded plans (verify clinical trial coverage with the individual plan document). 91448
Cochlear implant HMO, POS, EPO, SF-POS, Medicare, Medicaid 91544
InterQual-Adult, Pediatric
Complications to non-covered care Not required 91086
Computed tomography scanning for lung cancer screening HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid Authorized though eviCore healthcare
Contact lenses/eyeglasses Not required 91538
Continuous glucose monitoring

HMO, POS, EPO, PPO, SF-POS, Medicare

PA required for Medicare effective 01/01/2018

Medicaid: Not covered

91466
Continuous passive motion (CPM), after day 21

HMO, POS, EPO, PPO, SF-POS, Medicaid

Medicare: No prior auth required but service only covered for 21 days

CPAP & other equipment to treat sleep apnea (i.e. ASV, APAP, BiPAP, oral appliances)

HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid

For participating providers only, prior authorization is waived for the first three months of use

91333
InterQual
Cranial helmets

HMO, POS, EPO, PPO, SF-POS, Medicaid

DME limits apply

91504
InterQual
D
Service Plans requiring prior auth Medical policy
Dental anesthesia Medicaid
Dental extractions

Not required, but covered in limited circumstances; see policy for detail

Medicaid: Not covered

91542
Dental services Medicare
Detoxification

HMO, POS, EPO, PPO, SF-POS, Medicare

Medicaid: Not covered by the health plan; managed by CMH and paid for by Medicaid FFS

91104
Submit auth request via fax to Priority Health
Developmental disorders, pervasive See policy for details 91318
Dialysis access, permanent

HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid

PA required for Medicare effective 01/01/2018

91526
Dialysis for end stage renal disease

HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid

PA required for Medicare effective 01/01/2018

91526
Drug-eluting stents for ischemic heart disease  Not required 91580
Drug testing, in-network labs Not required 91611
Drug testing, out-of-network labs

HMO, EPO

POS, PPO plans: Not required. All OON labs will be processed at the member's out-of-network benefit level.

91611
Drugs, injectable HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid Certain drugs require prior authorization from the pharmacy department. See the drug PA forms list.
Durable medical equipment (DME)

HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid

PA required for purchases >$1000, Medicaid DME purchases >$500, all rentals

91110
E
Service Plans requiring prior auth Medical policy
Eating disorders HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91007
Echocardiography - transesophogeal, transthoracic, Doppler Not required
Electroconvulsive therapy (ECT)

Not required

Medicaid: Not covered by the health plan; managed by CMH and paid for by Medicaid FFS

91554
Enclosed bed systems for Medicaid members Medicaid 91498
Endoscopic submucosal dissection (ESD) Not required 91617
Enteral nutrition therapy HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91278
Enuresis therapy

Not required

Subject to DME limits

Medicaid: Not covered

91418
Experimental/investigational/unproven care

HMO, POS, EPO, PPO

Not covered by most self-funded plans (verify coverage with individual plan document)

Medicaid: Not covered

91117
F
Facial scar revisions Not required 91535
Fecal DNA screening (Cologuard) Not required 91547
Fecal microbiota transplantation/fecal bacteriotherapy Not required 91603
Feeding disorders HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91469
Fetal surgery

HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid

Some procedures may not be covered for Medicare and Medicaid

91120
Foot care

Not required

Payable for limited diagnoses, see medical policy

91121
Frenulectomy/frenectomy

Not required

Age limitations apply

91542
G
Service Plans requiring prior auth Medical policy
Gastroparesis testing Not required 91572
InterQual
Gastroparesis treatment (not testing) HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91572
InterQual
Gender dysphoria, non-surgical treatment  Required for certain pharmaceuticals. 91622
Gender reassignment surgery

All plans

Gender reassignment surgery may be covered when all plan and clinical criteria from the medical policy is met, as determined through authorization review.

91612
Genetic counseling, testing & screening

See policy for authorization requirements

Genetic counseling does not require prior auth

91540
Authorized through eviCore healthcare
Genetic testing & screening, by out-of-network providers HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91540
Authorized through eviCore healthcare
H
Home health care: Home visits

Medicare, Medicaid required for all home health care visits - RN, PT, OT, ST, HHA, MSW*, RD*

*Medicaid: Not covered for MSW and RD visits

HMO, POS, EPO, PPO, SF-POS require prior authorization before the first visit

91023
Home health care: Home infusion services, nursing care, palliative care, total parental nutrition HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91023
Hyperbaric oxygen therapy

Not required

Payable for limited diagnoses, see medical policy

91151
Hyperhidrosis, botox treatment and inpatient surgery only HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91451
I
Service Plans requiring prior auth Medical policy
Implantable heart failure monitors HMO, POS, EPO, PPO, SF-POS, Medicaid, Medicare 91610
Impotence and sexual dysfunction Not required 91160
InterQual
Incontinence supplies, Medicaid members

Not required

See policy for limitations

91502
Infertility and assisted reproduction See policy for coverage limitations 91163
Infusion services & equipment HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91414
Submit auth request via fax to Priority Health
Inpatient care services: All admissions* including behavioral health and substance abuse

HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid

*Some elective procedures do not require health plan review (i.e. OB deliveries, colectomy, etc.), but do require an auth for claims payment. Other elective procedures require health plan review and specific criteria must be met (i.e. bariatric surgery, ventricular assist device, etc.).

Behavioral health and substance abuse inpatient services not covered for Medicaid.

INR monitoring or home prothrombin time

Not required

Subject to DME limits

Medicaid: Not covered

91507
Insulin pumps, ambulatory

HMO, POS, EPO, PPO, SF-POS, Medicaid, Medicare*

*PA required for Medicare effective 01/01/18

Prior auth is required for both newly prescribed and replacement pumps

91414
Intraoperative radiation therapy HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91556
Intraperitoneal hyperthermic chemotherapy Not required 91548
Intracoronary brachytherapy Not required 91536
K
Knee arthroscopy HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid
Authorized through eviCore healthcare
Kyphoplasty/vertebroplasty HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid
91581
Authorized through eviCore healthcare
L
Service Plans requiring prior auth Medical policy
Lumbar fusion HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid
91581
Authorized through eviCore healthcare
Lumbar laminectomy HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid
91581
Authorized through eviCore healthcare
Lung volume reduction surgery

Not required

Medicare: Only covered at certain facilities

91472
M
Male gynecomastia PPO, EPO, SF-POS, Medicaid 91545
InterQual
Markers for digestive disorders HMO and EPO OON providers 91583
Submit auth via fax to Priority Health
Medical oncology (OP chemotherapy) Not required
 
Menorrhagia treatment/Mirena Not required 91575
Methadone maintenance

Not required

Medicaid, Medicare: Not covered

Multi-marker tumor panels HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91609
Authorized through eviCore healthcare
N
Neuropsychological psychological testing Not required 91537
Non-acute inpatient services at skilled nursing, rehabilitation, and acute-care facilities HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91332
Submit auth via fax to Priority Health
Nutritional counseling Not required
Service Plans requiring prior auth Medical policy
O
Obesity-related services, medical management

Not required

Self-funded plans: May not be covered

91594
Obesity-related services, surgical treatment

HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid

Self-funded plans: May not be covered

91595
Observation

HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid

Only required for non-participating facilities

Obstetric services/GYN care

Medicaid

Only required for non-participating providers.

Call our Provider Locator Line to find in-network resources

 
Oral surgery See policy 91542
Orthognathic surgery Medicaid 91273
InterQual
Orthopedic surgery (lumbar or cervical spine surgery, joint arthroscopy, hip, shoulder, knee replacement, shoulder repair) HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid
Authorized through eviCore healthcare
Orthoptic and pleoptic training Medicaid requires prior auth for beneficiaries over age 21 91500
Orthotics: Shoe inserts, orthopedic shoes HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91420
InterQual
Orthotics/support device purchases, commercial/Medicare >$1000; Medicaid >$500 Medicare, Medicaid 91420
91339
InterQual
Oxygen therapy

Not required

P
Service Plans requiring prior auth Medical policy
Pacemakers, cardiac

Not required

 
Pain management (injection procedures)

Not required

 
Palliative care, inpatient or home HMO, POS, EPO, PPO, SF-POS 91558
Parenteral nutrition therapy HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91517
Penile implants (organic origins only) Medicaid 91160
InterQual
Percutaneous left atrial appendage closure HMO, POS, EPO, PPO, SF-POS, Medicare 91605
Peroral endoscopic myotomy (POEM) Not required 91616
Pharmacogenomic testing See policy for authorization requirements 91540
Most testing authorized through eviCore healthcare
Port wine stains and vascular malformation Not required 91535
Power vehicles HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91110
InterQual
Prophylactic cancer risk-reduction surgery HMO, POS, EPO, PPO, SF-POS, Medicaid 91508
Prostatic artery embolization for benign prostatic hyperplasia (BPH)  Not required 91620
Prosthetics, purchase >$1000 for most plans; Medicaid >$500 HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91306
Psychological evaluation and management of non-mental health disorders Not required 91546
Pulse oximetry for home use, after first three months of use HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91452
Pumps, implantable & external infusion HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91414
Q
Quantitative electroencephalogram (QEEG) Not required 91510
R
Service Plans requiring prior auth Medical policy
Radiation oncology

Not required

Radical prostatectomy HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid InterQual 
Radiofrequency ablation for back pain, after two procedures HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91581
Radiology: All non-emergent outpatient advanced diagnostic imaging services (MRA, MRI, CT, CTA, PET scans and nuclear cardiology) HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid

In-network: Authorized through eviCore healthcare

Out-of-network: Call eviCore

Details and exceptions: See Radiology services

Radiosurgery, stereotactic, and proton and neutron beam therapies HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91127
Reconstructive/cosmetic surgery HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91535
Reduction mammoplasty, male or female EPO, PPO, SF-POS, Medicaid 91545
InterQual
Rehabilitation therapies in the home (occupational, physical and speech)

HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid require prior authorization before the first visit.

Coverage subject to visit limits

91318
Rehabilitation/habilitative therapy (outpatient)

Not required except by some employer groups

Coverage subject to visit limits

91318
Renal artery stenosis Not required 91561
Rhinoplasty (with or without septoplasty) HMO, POS, EPO, PPO, SF-POS, Medicaid 91506
S
Service Plans requiring prior auth Medical policy
Sacroiliac joint fusion HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91581
Septoplasty Not required 91506
Skin conditions Not required, see policy for specifics 91456
Sleep studies, in-center, ages 18+ HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91333
Sleep studies, in-home Not required 91333
Skin substitutes Not required 91560
Speech therapy, outpatient

Not required

Subject to visit limits

Medicare: PA required after therapy dollar cap is reached

91336
Sterilization, Medicaid members Not required 91501
Stimulation therapy & devices: TENS only

Not required for HMO, EPO, POS, PPO and Medicaid with specific diagnoses; see medical policy

Medicare: See InterQual

91468
InterQual
Stimulation therapy & devices

HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid

See medical policy for criteria and authorization requirements.

See InterQual for Stereotactic Introduction, Subcortical Electrodes (Deep Brain Stimulation), Vagal Nerve Stimulators and for TENS (Medicare only)

91468
InterQual
Substance abuse/behavioral health therapies, inpatient

HMO, POS, EPO, PPO, SF-POS, Medicare

Medicaid: Not covered

Submit auth request via fax to Priority Health
Substance abuse therapies, intensive outpatient

HMO, POS, EPO, PPO, SF-POS

Medicare, Medicaid: Not covered

Submit auth request via fax to Priority Health
Substance abuse therapies, outpatient

Not required

Medicaid: Not covered

Submit auth request via fax to Priority Health
Surgery, spinal HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91531
Authorized through eviCore healthcare
Surgical treatment of sleep apnea Not required 91333
T
Service Plans requiring prior auth Medical policy
Telemedicine Not required 91604
Temporomandibular joint disorders (TMD) Not required 91353
Titanium rib HMO, POS, EPO, PPO, SF-POS, Medicaid 91505
Thyroid-related procedures HMO, POS, EPO, PPO, SF-POS, Medicaid
Note: Medicare will require prior authorization effective 1/1/2019
91621
Tonsillectomy, pediatric, ages 0-17 HMO, POS, EPO, PPO, SF-POS, Medicaid
InterQual
Transcatheter closure of septal defects Not required 91528
Transcatheter heart valves HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91597
InterQual is utilized for Transcatheter aortic valve replacement
Transcutaneous electrical acustimulation (TEAS) for hyperemesis Not required 91576
Transcranial magnetic stimulation therapy for depression HMO, POS, EPO, PPO, SF-POS, Medicare 91563
Submit auth request via fax to Priority Health
Transplantation of solid organs HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91272
Transurethral radiofrequency micro-remodeling for female incontinence Not required 91578
Treatment of gastroesophageal reflux disease (GERD) and Barrett's esophagus PA required for some services (i.e. Magnetic Sphincter Augmentation - LINX device). See policy for coverage details. 91483
U
Service Plans requiring prior auth Medical policy
Umbilical cord blood testing & storage Not required 91459
Urolift/Prostatic urethral lift Not required 91613
Uterine fibroid treatments Not required 91573
V
Varicose vein treatment Not required 91326
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
Virtual colonoscopy HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91547
Authorized through eviCore healthcare
Vision care/eye exams Not required 91538
Voice synthesizer Medicaid 91499