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 |