Priority Health medical policies

Medical policies apply to commercial plans and Medicaid. Medicare plans must follow Medicare policy under National Coverage Determinations and/or Local Coverage Determinations; if there are none, our medical policy will apply.

InterQual® criteria

Priority Health has discontinued some medical policies and now uses InterQual® criteria. See the list.

Pending policy changes list

Review upcoming changes to our medical policies.

Current medical policies  

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    Knee Arthroscopy - 91587 Retired 06/2017

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  • Septoplasty/Rhinoplasty - 91506 Reviewed 02/2019
  • Sexual Dysfunction and Impotence - 91160 Reviewed 05/2019
  • Skin Conditions - 91456 Reviewed 05/2018
  • Skin Substitutes and Soft Tissue Grafts - 91560 Reviewed 05/2019
  • Sleep apnea: See Obstructive Sleep Apnea Reviewed 05/2018
  • Speech Therapy - 91336 Reviewed 11/2018
  • Sperm and Oocyte Retrieval and Storage - 91393 Revised 11/2018
  • Spine Centers of Excellence - 91531 Reviewed 08/2018
  • Spine Procedures - 91581 Reviewed 11/2018 
  • Stem Cell or Bone Marrow Transplantation - 91066 Reviewed 08/2018
  • Sterilization for Medicaid Members - 91501 Reviewed 02/2019
  • Stereotactic radiosurgery: See Radiosurgery - 91127 Reviewed 08/2018
  • Stimulation Therapy and Devices - 91468 Reviewed 05/2019
  • Surgical Treatment of Obesity - 91595 Revised 08/2018
    Summary of change: Effective Aug. 31, we're making changes to medical policy Surgical Treatment of Obesity No. 91595. Changes were made to the policy to make us compliant with Medicaid requirements and to provide further clarification. The following updates were made:
    • Criteria updated to reflect a comprehensive psychosocial evaluation conducted by a licensed behavioral specialist (psychiatrist for Medicaid/Healthy Michigan Plan members) is required to be considered for Primary Bariatric or Revisional Bariatric Surgery.
    • For members who have severe psychopathology who are currently under the care of a psychiatrist, or who are on psychotropic medications, preoperative psychiatry clearance is necessary in order to determine informed consent and an ability to comply with pre- and post-operative regimen.
    • For members who have a history of illegal drug use, there must be documented compliance with abstinence, including negative monthly urine drug screens for at least six continuous months.
    • For members that have a current history of smoking or smoking within the past two years, documented compliance demonstrating smoking cessation, including two negative cotinine levels within a 30 day time period, is required.  These levels must be taken no earlier than 6 weeks prior to requesting Bariatric Surgery.
    • Criteria for BMI > 35 updated to reflect at least one "life-endangering" obesity-related co-morbidity is required and the criteria clearly defines what is considered a life-endangering co-morbidity.
    • Clinical documentation in support of the request for surgical treatment of obesity must be included when requesting authorization.

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Note: "CPT" (Current Procedure Terminology) is a registered trademark of the American Medical Association, U.S. Patent & Trademark Office Serial #76379850. The CPT Coding Manual itself is also copyrighted, U.S. Copyright Office Serial # CSN0096041. As a result, we have included the following disclaimer on our medical policies: All Current Procedure Terminology CPT) codes, descriptions, and other data are copyrighted by the American Medical Association.