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.
Current medical policies
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- Abortion: see Termination of Pregnancy - 91000
- Abortion, Recurrent Spontaneous - 91156 Reviewed 05/2018
- Allergy Testing/Immunotherapy - 91037 Reviewed 02/2019
- Apnea Monitors - 91497 Reviewed 02/2018
- Artificial intervertebral discs: See Spine Procedures - 91581
- Assisted reproduction/artificial conception: See Infertility Diagnosis & Treatment/Assisted Reproduction/Artificial Conception - 91163
- Augmentative Communications / Speech-Generating Devices ACD) for Medicaid Members - 91499 Reviewed 02/2018
- Augmentative Communication Device PA form Medicaid only)
- Autism Spectrum Disorders - 91615 Revised 11/2018
Summary of change: Under Diagnosis and Evaluation, the criteria was updated and reflects only the Autism Diagnostic Observation Schedule-2 (ADOS-2) for standardized behavior observational assessment. The Autism Diagnostic Observation Scale (ADOS) was removed from this criteria.
- Autologous Chondrocyte Implant/Meniscal Allograft/Osteochondral Replacement - 91443 Reviewed 08/2018
- Autopsy - 91054 Reviewed 11/2018
- Balloon Sinus Ostial Dilation - 91596 Reviewed 02/2018
- Bariatric surgery: See Surgical Treatment of Obesity - 91595
- Biofeedback - 91002 Reviewed 11/2018
- Blepharoptosis/brow ptosis repair: See Cosmetic and Reconstructive Surgery Procedures - 91535
- Blood Pressure Monitors & Ambulatory Blood Pressure Monitoring - 91503 Reviewed 11/2018
- Bone Density Studies - 91494 Reviewed 08/2018
- Bone Marrow Transplantation: See Stem Cell or Bone Marrow Transplantation - 91066
- Breast Related Procedures - 91545 Reviewed 02/2018
- Breast Specific Gamma Imaging - 91568 Reviewed 08/2018
- Bronchial Thermoplasty - 91577 Reviewed 02/2018
- Capsule Endoscopy - 91476 Reviewed 05/2018
- Cardiovascular Risk Markers - 91559 Reviewed 02/2018
- Cardioverter Defibrillators - 91410 Reviewed 08/2018
- Carotid and Intracranial Artery Stenting - 91495 Reviewed 08/2018
- Chelation Therapy - 91077 Reviewed 02/2018
- Chemosensitivity Assays - Retired 06/2017
- Cingulotomy - 91475 Reviewed 11/2018
- Clinical Trials - 91606 Reviewed 11/2018
- Clinical Trials for Cancer Care - 91448 Reviewed 11/2017
- Advance care planning assessment form Updated 12/2015
- Colorectal Cancer Screening - 91547 Reviewed 02/2018
- Complications to Non-Covered Care - 91086 Reviewed 11/2018
- Computed Tomography Scanning for Lung Cancer Screening - Retired 06/2017
- Computerized Tomographic Angiography Coronary Arteries (CCTA) - 91614 Reviewed 11/2018
Summary of change: Language added to reflect FFR-CT does not require prior authorization. Fractional Flow Reserve (FFR-CT) is not covered for Medicaid products.
- Continuous Glucose Monitoring - 91466 Reviewed 05/2018
- Coronary artery calcium score / EBCT: See eviCore website for clinical guidelines
- Cosmetic and Reconstructive Surgery Procedures - 91535 Reviewed 02/2018
- Cranial Helmets - 91504 Reviewed 08/2018
- Dental extractions: See Oral Surgery & Dental Extractions - 91542
- Detoxification - 91104 Revised 11/2018
Summary of change: Criteria updated to reflect treatment for drug and alcohol use is a covered benefit with limitations and restrictions as defined in the plan documents and Behavioral Health policies. Sub-acute detoxification and substance use disorder residential treatment must be certified by the Behavioral Health Department.
- Discectomy, automated percutaneous lumbar: See Spine Procedures - 91581
- Drug-Eluting Stents for Ischemic Heart Disease - 91580 Reviewed 08/2018
- Drug Testing - 91611 Reviewed 11/2018
Summary of change: Language added to reflect when presumptive (qualitative; semi-quantitative) urine drug testing is a covered benefit. In addition, language added to clarify definitive (confirmatory; quantitative) urine drug testing purpose and when it is a covered benefit. Additional language also added to reflect not covered benefits.
- Durable Medical Equipment - 91110 Reviewed 08/2017
- Eating Disorders - 91007 Reviewed 05/2018
- Electro-convulsive Therapy (ECT) - 91554 Reviewed 11/2018
- Electrophysiology Testing and Catheter Ablation for Cardiac Arrhythmias - 91314 Reviewed 05/2018
- Enclosed Bed Systems for Medicaid Members - 91498 Reviewed 02/2018
- End stage renal disease (ESRD): Renal Dialysis - 91526 Reviewed 08/2018
- Endometrial ablation procedures for menorrhagia: See Menorrhagia Treatment - 91575
- Endoscopic Submucosal Dissection (ESD) - 91617 Reviewed 05/2018
- Enteral Nutritional Therapy - 91278 Reviewed 08/2018
- Enuresis Therapy - 91418 Reviewed 02/2018
- Experimental/Investigational/Unproven Care/Benefit Exceptions - 91117 Revised 11/2018
- Advance care planning assessment form Updated 12/2015
- Extracorporeal Shock Wave Therapy (ECWT) - 91527 Reviewed 02/2018
- Facial scar revisions: See Cosmetic and Reconstructive Surgery Procedures - 91535
- Fecal Microbiota Transplantation/Fecal Bacteriotherapy - 91603 Reviewed 11/2018
- Feeding Disorders - 91469 Reviewed 11/2018
- Female erectile dysfunction therapy: See Sexual Dysfunction policy - 91160
- Fetal Surgery: Intrauterine Fetal Surgery; Fetoscopic Laser Surgery - 91120 Reviewed 08/2018
- Foot Care - 91121 Reviewed 02/2018
- Gastroesophageal Reflux Disease (GERD) and Barrett's Esophagus - 91483 Reviewed 11/2018
- Gastroparesis Testing and Treatment - 91572 Revised 03/2018
Summary of change: Botulinum toxin (Botox) is no longer covered for gastroparesis. Botulinum toxin (Botox) is considered to be experimental and investigational. Policy was updated to reflect the July 2017 P & T Committee decision for non-coverage.
- NEW Gender Dysphoria, Non-Surgical Treatment - 91622 Effective 9/25/2018
New policy developed to clarify coverage criteria for non-surgical treatments for gender dysphoria. Prior authorization is required for certain pharmaceuticals.
- Gender Reassignment Surgery - 91612 Updated 11/2017
- Genetics: Counseling, Testing and Screening - 91540 Revised 08/2018
Summary of change: Criteria related to Multi-Marker Tumor Panels removed as the Multi-Marker Tumor Panels medical policy 91609 was reinstated effective July 1, 2018.
- General Genetic Testing PA form for retrospective requests; most genetic labs are managed through eviCore
- Hearing Augmentation - 91544 Reviewed 08/2018
- Hemophilia Management - 91569 Revised 01/2018
Summary of change: Language added to clarify coverage criteria. Criteria now reads: The following criteria apply to Priority Health members for all drugs (e.g. Hemlibra), including replacement factor, used for the non-emergent treatment of hemophilia and related clotting disorders.
- High Intensity Focused Ultrasound - 91601 Reviewed 05/2018
- Home Care - 91023 Revised 11/2018
Summary of change: Language removed addressing services rendered by a dietician or nutritionist for overall training or consultative advice to the home health agency staff.
- Home Prothrombin Time or INR Monitoring - 91507 Reviewed 05/2018
- Hospice Care - 91520 Reviewed 08/2018
- Hyperbaric Oxygen Therapy - 91151 Reviewed 08/2018
- Hyperhidrosis - 91451 Revised 08/2018
Summary of change: Criteria for the coverage of sympathectomy added and updated to reflect sympathectomy is not covered if plantar hyperhidrosis is the only indication.
- IDET and other Thermal Intradiscal Procedures (TIPs): See Spine Procedures - 91581
- Implantable Heart Failure Monitors - 91610 Reviewed 05/2018
- Implantable Loop Recorder (ILR) - 91618 Reviewed 05/2018
- Impotence: See Sexual Dysfunction - 91160
- Incontinence Supplies for Medicaid Members - 91502 Reviewed 02/2018
- Infertility Diagnosis and Treatment/Assisted Reproduction/Artificial Conception - 91163 Reviewed 05/2018
- Infusion Services & Equipment - 91414 Revised 01/2018
Summary of change: Criteria updated to reflect the Drugs in Appendix A of the policy may be covered in the home, a hospital outpatient infusion center, or an alternative Priority Health-approved site of service for Medicaid/Healthy Michigan members. Appendix A updated 7/2018.
- Intraoperative Radiation Therapy (IORT) - 91556 Reviewed 11/2018
- Intraperitoneal Hyperthermic Chemotherapy - 91548 Reviewed 02/2018
- Intracoronary Brachytherapy - 91536 Reviewed 05/2018
- Intravenous Immunoglobulin (IVIG): Use the IVIG drug authorization form
- Irreversible Electroporation (IRE) or Nanoknife - 91599 Reviewed 05/2018
- Knee Arthroscopy - 91587 Retired 06/2017
- Levonorgestrel-releasing IUD (Mirena®): See Menorrhagia Treatment - 91575
- Lipoprotein testing: See Cardiovascular Risk Markers - 91559
- Lumbar Fusion - 91590 Retired 06/2017
- Lumbar Laminectomy - 91591 Retired 06/2017
- Lung Volume Reduction Surgery - 91472 Reviewed 11/2018
- Markers for Digestive Disorders - 91583 Reviewed 11/2018
Summary of change: Criteria updated to reflect vedolizumab (VDZ) and Anser VDZ are a covered benefit.
- Medical Errors: Serious Reportable Events/Hospital-Acquired Conditions - 91516 Reviewed 11/2018
- Medical Management of Obesity - 91594 Reviewed 02/2018
- Medical Necessity Determination - 91447 Reviewed 05/2018
- Menorrhagia Treatment - 91575 Revised 10/2018
Summary of change: Microwave added to the list of endometrial ablation procedures that are a covered benefit.
- Mental Health Residential Treatment: Adult - 91608 Reviewed 05/2018
- Mental Health Residential Treatment: Child & Adolescent - 91607 Revised 07/2018
Summary of change: Residential treatment criteria updated to reflect residential treatment takes place in a structured facility-based setting.
- Monochromatic Phototherapy (Anodyne therapy/MIRE therapy/low level light therapy) - 91486 Reviewed 08/2018
- MRI of the breast: See eviCore website for clinical guidelines
- Multi-Marker Tumor Panels - 91609 Reinstated Effective 7/1/18
This policy was retired in June 2017 and is being reinstated effective July 1, 2018. The updated policy more clearly defines the coverage criteria for multi-marker tumor panels using next generation sequencing in the diagnosis and treatment of cancer and reflects broader coverage. The authorization process will continue to be managed by eviCore utilizing the criteria in this policy.
- Neocate: See Enteral Nutrition Therapy - 91278
- Neuropsychological and Psychological Testing - 91537 Reviewed 08/2018
- Never events: See Medical Errors: Serious Reportable Events/Hospital Acquired Conditions - 91516
- Non-Acute Inpatient Services - 91332 Reviewed 08/2018
- Obesity, medical management: See Medical Management of Obesity - 91594
- Obesity, surgical treatment: See Surgical Treatment of Obesity - 91595
- Obstructive Sleep Apnea - 91333 Revised 08/2018
Summary of change: Criteria for the coverage of an attended sleep study or polysomnogram (PSG) for periodic limb movement disorder (PLMD) updated. Updated criteria requires complaints by the patient or an observer, of repetitive limb movement during sleep, and a) frequent awakenings, or b) fragmented sleep, or c) difficulty maintaining sleep, or d) excessive daytime sleepiness. Additionally, the patient must have at least one additional risk factor for PMLD including, but not limited to, the following: a) iron deficiency anemia, b) renal disease, c) medication that cannot be discontinued, d) spinal injury, e) peripheral neuropathy or f) diabetes mellitus. If the patient is currently being treated for diagnosed OSA, the criterion for an additional risk factor for PLMD does not apply. Also, individual currently being treated with a dental appliance with moderate to severe OSA (AHI >15) at baseline removed as a qualifier for PSG for individuals with suspected OSA as determined by clinical symptoms.
- Oral Surgery & Dental Extractions - 91542 Reviewed 02/2018
- Orthognathic Surgery - 91273 Reviewed 11/2018
- Orthoptic and Pleoptic Training for Medicaid Members - 91500 Reviewed 02/2018
- Orthotics: Shoe Inserts, Orthopedic Shoes - 91420 Reviewed 02/2018
- Orthotics/Support Devices - 91339 Reviewed 08/2018
- Osteoarthritis of the Knee - 91571 Revised 04/2018
Summary of change: Criteria updated to reflect bone marrow aspirate concentrate (BMAC) and platelet rich plasma (PRP) injections are considered experimental, investigational, or unproven, and therefore, are not covered.
- Palliative Care - 91558 Reviewed 05/2018
- PET scans: See eviCore website for clinical guidelines.
- Brain imaging
- Cardiac imaging
- Panniculectomy/Abdominoplasty - 91444 Reviewed 08/2018
- Parenteral Nutritional Therapy - 91517 Reviewed 11/2018
- Percutaneous Left Atrial Appendage Closure - 91605 Reviewed 02/2018
Request prior authorization: Percutaneous left atrial appendage PA form.
- Peroral Endoscopic Myotomy (POEM) - 91616 Reviewed 05/2018
- Pervasive developmental disabilities: See Autism Spectrum Disorders - 91615
- Pharmacogenomics Testing - 91570 Retired 06/2017
- Platelet Rich Plasma/Platelet Rich Fibrin Matrix/Autologous Blood-Derived Products/BMAC - 91553 Revised 04/2018
Summary of change: Language added to reflect Bone Marrow Aspirate Concentrate (BMAC)/mesenchymal stem cells are considered investigational. In addition, osteoarthritis added to list of indications for which Platelet rich plasma (PRP)/Autologous blood-derived growth factors/Bone Marrow Aspirate Concentrate (BMAC)/mesenchymal stem cells are considered investigational.
- Port wine stains and vascular malformations: See Cosmetic and Reconstructive Surgery Procedures - 91535
- Prophylactic Cancer Risk Reduction Surgery - 91508 Reviewed 02/2018
- Prostatic Artery Embolization for Benign Prostatic Hyperplasia (BPH) - 91620 Reviewed 11/2018
- Prosthetics, External - 91306 Reviewed 05/2018
- Psychological Evaluation and Management of Non-Mental Health Disorders - 91546 Reviewed 08/2018
- Pulse Oximetry for Home Use - 91452 Reviewed 11/2018
- QEEG - Quantitative Electroencephalogram - 91510 Reviewed 08/2018
- Radiofrequency ablation for back pain: See Spine Procedures - 91581
- Radiosurgery - 91127 Revised 08/2017
Summary of change: National Comprehensive Cancer Network (NCCN) Guidelines language removed. In addition, criteria updated to reflect non-small cell lung cancer is considered experimental and investigational and a specific exclusion for proton beam radiotherapy.
- Recurrent Spontaneous Abortion - 91156 Reviewed 05/2018
- Refractive Keratoplasty/Lasik - 91529 Reviewed 08/2018
- Rehabilitative & Habilitative Medicine Services - 91318 Revised 08/2018
Summary of change: Note indicating spinal manipulations by chiropractors are not covered for Priority Health Medicaid members age 21 or over was removed.
- Renal Artery Stenosis - 91561 Reviewed 11/2018
- Respite Care - 91321 Reviewed 05/2018
- Robotically Assisted Surgeries - 91522 Reviewed 08/2018
- Septoplasty/Rhinoplasty - 91506 Reviewed 02/2018
- Sexual Dysfunction and Impotence - 91160 Reviewed 05/2018
- Skin Conditions - 91456 Reviewed 05/2018
- Skin Substitutes and Soft Tissue Grafts - 91560 Revised 07/2018
Summary of change: Criteria added for the coverage of Grafix® CORE Multipotent Cellular Repair Cryopreserved Chorion Matrix and Grafix® PRIME Multipotent Cellular Repair Cryopreserved Amnion Matrix for use in the treatment of partial and full-thickness neuropathic diabetic foot ulcer.
- Sleep apnea: See Obstructive Sleep Apnea
- 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
Summary of change: Language updated to reflect The Coflex® interlaminar stabilization device for lumbar spinal stenosis is a covered benefit. Prior authorization is not required.
- Stem Cell or Bone Marrow Transplantation - 91066 Reviewed 08/2018
- Sterilization for Medicaid Members - 91501 Reviewed 02/2018
- Stereotactic radiosurgery: See Radiosurgery - 91127
- Stimulation Therapy and Devices - 91468 Updated 11/2017
Summary of change: Criteria added for the coverage of Dorsal Root Ganglion Stimulators. The remedē System (Respicardia Inc.) phrenic nerve stimulator for central sleep apnea added under Non-Covered Electrical Stimulation Therapies.
- 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.
- Technology Assessment - 91430 Reviewed 05/2018
- Telemedicine - 91604 Reviewed 02/2018
- Temporomandibular Joint Disorders (TMD) - 91353 Reviewed 05/2018
- Termination of Pregnancy - 91000 Reviewed 05/2018
- Thermal Capsulorrhaphy - 91551 Reviewed 05/2018
- Thermography - 91355 Reviewed 11/2018
- NEW Thyroid-Related Procedures 91621 Effective 10/1/2018
Prior authorization will be required effective 10/01/2018 for Commercial and Medicaid members and 01/01/2019 for Medicare Members.
- Titanium Rib - 91505 Reviewed 02/2018
- Tinnitus Retraining Therapy - 91482 Reviewed 05/2018
- Transcatheter Closure of Septal Defects - 91528 Reviewed 05/2018
- Transcatheter Heart Valve Procedures - 91597 Reviewed 05/2018
- Transcranial Magnetic Stimulation for Depression - 91563 Revised 04/2018
Summary of change: Language added to reflect authorization for Transcranial Magnetic Stimulation (TMS) is determined by the clinical finding and TMS indications recommended by Behavioral Health InterQual®.
- Transcutaneous Electrical Acustimulation (TEAS) for Hyperemesis - 91576 Reviewed 11/2018
- Transplantation of Solid Organs - 91272 Reviewed 08/2018
- Transurethral Radiofrequency Micro-Remodeling (Renessa) for Female Stress Urinary Incontinence - 91578 Reviewed 11/2018
- Tumor Markers - 91562 Retired 06/2017
- Umbilical Cord Blood Testing and Storage - 91459 Reviewed 05/2018
- Urolift Prostatic Urethral Lift - 91613 Reviewed 11/2018
- Uterine Fibroid Treatment - 91573 Reviewed 11/2018
- Uvulopalatopharyngoplasty (UPPP) & Laser-Assisted Uvulopalatoplasty (LAUP): See Obstructive Sleep Apnea - 91333
- Vagal nerve stimulation as a treatment of depression: See Stimulation Therapy and Devices - 91468
- Varicose Vein Treatment - 91326 Reviewed 11/2018
Summary of change: Language added to clarify sclerosant itself is included as part of the surgical procedure code(s) for sclerotherapy and is therefore not separately payable. Language also updated to reflect coverage for Venaseal/cyanoacrylate embolization (CAE).
- Ventricular Assist Devices (VADs) and Artificial Hearts - 91509 Reviewed 11/2018
- Advance care planning assessment form Updated 12/2015
- Virtual colonoscopy: See Colorectal Cancer Screening - 91547
- Vision Care - 91538 Revised 08/2018
Summary of change: Criteria updated to reflect “FDA approved” bypass stents for the treatment of open-angle glaucoma in combination with cataract surgery are a covered benefit.
- Vitamin D - 91624
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.
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