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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  • 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




  • Gastroesophageal Reflux Disease (GERD) and Barrett's Esophagus - 91483 Reviewed 11/2018
  • Gastroparesis Testing and Treatment - 91572 Revised 03/2019
    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 11/2018
    Summary of change: Effective immediately Genetics: Counseling, Testing and Screening policy requires prior notification for inpatient Rapid Whole Genome Sequencing (rWGS). Prior notification may occur prior to or in conjunction with testing.

    The policy change only affects the commercial plan. Rapid Whole Genome Sequencing (rWGS) is not a covered benefit for Priority Health Medicaid or Medicare members.


  • Hearing Augmentation - 91544 Reviewed 08/2018
  • Hemophilia Management - 91569 Reviewed 02/2019
    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.



    Knee Arthroscopy - 91587 Retired 06/2017





  • 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 02/2019
  • Orthognathic Surgery - 91273 Reviewed 11/2018
  • Orthoptic and Pleoptic Training for Medicaid Members - 91500 Reviewed 02/2019
  • Orthotics: Shoe Inserts, Orthopedic Shoes - 91420 Reviewed 02/2019
  • Orthotics/Support Devices - 91339 Reviewed 08/2018
  • Osteoarthritis of the Knee - 91571 Revised 04/2019
    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.





  • Septoplasty/Rhinoplasty - 91506 Reviewed 02/2019
  • 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 02/2019
  • 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.




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.