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.
Upcoming medical policies changes
Review upcoming changes to our medical policies in the Policy changes list.
Current medical policies
Search by keyword: Enter the search term in between quotation marks for best search results. For example: "procedure"
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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
A
- Abortion: see Termination of Pregnancy - 91000
- Abortion, Recurrent Spontaneous - 91156
- Allergy Testing/Immunotherapy - 91037
- Apnea Monitors - 91497
- Artificial intervertebral discs: See Spine Procedures - 91581
- Arthroscopy and Arthroscopically Assisted Surgery: Knee, Hip & Shoulder - 91628
- Arthrotomy: Knee & Shoulder - 91629
- Assisted reproduction/artificial conception: See Infertility Diagnosis & Treatment/Assisted Reproduction/Artificial Conception - 91163
- Augmentative Communications / Speech-Generating Devices ACD) for Medicaid Members - 91499
- Augmentative Communication Device PA form (Medicaid only)
- Autism Spectrum Disorders - 91615
- Autologous Chondrocyte Implant/Meniscal Allograft/Osteochondral Replacement - 91443
- Autopsy - 91054
B
- Balloon Sinus Ostial Dilation for Chronic Sinusitis and Eustachian Tube Dilation - 91596
- Bariatric surgery: See Surgical Treatment of Obesity - 91595
- Behavioral Health Residential Treatment - 91625
- Biofeedback - 91002
- Blepharoptosis/brow ptosis repair: See Cosmetic and Reconstructive Surgery Procedures - 91535
- Blood Pressure Monitors & Ambulatory Blood Pressure Monitoring - 91503
- Bone Density Studies - 91494
- Bone Marrow Transplantation: See Stem Cell or Bone Marrow Transplantation - 91066
- Breast Related Procedures - 91545
- Breast Specific Gamma Imaging - 91568
- Bronchial Thermoplasty - 91577
C
- Capsule Endoscopy - 91476
- Cardiovascular Risk Markers - 91559
- Cardioverter Defibrillators - 91410
- Carotid and Intracranial Artery Stenting - 91495
- Category III Current Procedural Terminology (CPT®) - 91636
- Cellular and Gene Therapy - 91638
- Chelation Therapy - 91077
- Clinical Trials - 91606
- Clinical trials prior authorization form
- Advance care planning assessment form
Must be completed and returned with the clinical trial authorization request for members with Stage IV cancer or other life-threatening condition.
- Clinical Trials for Self-Funded Groups Out of PPACA - 91448
- Colorectal Cancer Screening - 91547
- Complications to Non-Covered Care - 91086
- Computerized Dynamic Posturography - 91637
- Computerized Tomographic Angiography Coronary Arteries (CCTA) - 91614
- Continuous Glucose Monitoring - 91466
- Cosmetic and Reconstructive Surgery Procedures - 91535
- Cranial Helmets - 91504
D
- Dental extractions: See Oral Surgery & Dental Extractions - 91542
- Detoxification - 91104
- Discectomy, automated percutaneous lumbar: See Spine Procedures - 91581
- Drug-Eluting Stents for Ischemic Heart Disease - 91580
- Drug Testing - 91611
- Durable Medical Equipment - 91110
E
- Electro-convulsive Therapy (ECT) - 91554
- Electroencephalography (EEG) - 91510
- Electrophysiology Testing and Catheter Ablation for Cardiac Arrhythmias - 91314
- Enclosed Bed Systems for Medicaid Members - 91498
- End stage renal disease (ESRD): Renal Dialysis - 91526
- Endometrial ablation procedures for menorrhagia: See Menorrhagia Treatment - 91575
- Endoscopic Submucosal Dissection (ESD) - 91617
- Enteral Nutritional Therapy - 91278
- Enuresis Therapy - 91418
- Experimental/Investigational/Unproven Care/Benefit Exceptions - 91117
- Extracorporeal Shock Wave Therapy (ECWT) - 91527
F
- Facial scar revisions: See Cosmetic and Reconstructive Surgery Procedures - 91535
- Fecal Microbiota Transplantation/Fecal Bacteriotherapy - 91603
- Feeding Disorders - 91469
- Female erectile dysfunction therapy: See Sexual Dysfunction policy - 91160
- Fetal Surgery: Intrauterine Fetal Surgery; Fetoscopic Laser Surgery - 91120
- Foot Care - 91121
G
- Gastroesophageal Reflux Disease (GERD) and Barrett's Esophagus - 91483
- Gastroparesis Testing and Treatment - 91572
- Gender Dysphoria, Non-Surgical Treatment - 91622
- Gender Affirming Surgery - 91612
- Genetics: Counseling, Testing and Screening - 91540
- General Genetic Testing PA form for retrospective requests; most genetic labs are managed through eviCore
H
- Hearing Augmentation - 91544
- Hemophilia Management - 91569
- High Intensity Focused Ultrasound - 91601
- Home Care - 91023
- Home Prothrombin Time or INR Monitoring - 91507
- Hospice Care - 91520
- Hyperbaric Oxygen Therapy - 91151
- Hyperhidrosis - 91451
I
- IDET and other Thermal Intradiscal Procedures (TIPs): See Spine Procedures - 91581
- Implantable Heart Failure Monitors - 91610
- Implantable Loop Recorder (ILR) - 91618
- Impotence: See Sexual Dysfunction - 91160
- Incontinence Supplies for Medicaid Members - 91502
- Infertility Diagnosis and Treatment/Assisted Reproduction/Artificial Conception - 91163
- Infusion Services & Equipment - 91414
- Intensity Modulated Radiation Therapy (IMRT) - 91633
- Intraoperative Radiation Therapy (IORT) - 91556
- Intraperitoneal Hyperthermic Chemotherapy - 91548
- Intracoronary Brachytherapy - 91536
- Intravascular Lithotripsy - 91639
- Irreversible Electroporation (IRE) or Nanoknife - 91599
L
- Levonorgestrel-releasing IUD (Mirena®): See Menorrhagia Treatment - 91575
- Lipoprotein testing: See Cardiovascular Risk Markers - 91559
- Lung Volume Reduction Surgery - 91472
M
- Magnetoencephephalography (MEG) - 91627
- Markers for Digestive Disorders - 91583
- Medical Errors: Serious Reportable Events/Hospital-Acquired Conditions - 91516
- Medical Management of Obesity - 91594
- Medical Necessity Determination - 91447
- Menorrhagia Treatment - 91575
- Moderate Sedation For Interventional Pain Management - 91632
- Monochromatic Phototherapy (Anodyne therapy/MIRE therapy/low level light therapy) - 91486
- MRI of the breast: See eviCore website for clinical guidelines
- Multi-Marker Tumor Panels - 91609
N
- Neocate: See Enteral Nutrition Therapy - 91278
- Neuropsychological and Psychological Testing -91537
- Never events: See Medical Errors: Serious Reportable Events/Hospital Acquired Conditions - 91516
- Non-Acute Inpatient Services - 91332
O
- Obesity, medical management: See Medical Management of Obesity - 91594
- Obesity, surgical treatment: See Surgical Treatment of Obesity - 91595
- Obstructive Sleep Apnea - 91333
- Oral Surgery & Dental Extractions - 91542
- Orthognathic Surgery - 91273
- Orthoptic and Pleoptic Training for Medicaid Members - 91500
- Orthotics: Shoe Inserts, Orthopedic Shoes - 91420
- Orthotics/Support Devices - 91339
- Osteoarthritis of the Knee - 91571
P
- Palliative Care - 91558
- PET scans: See eviCore website for clinical guidelines.
- Brain imaging
- Cardiac imaging
- Oncology
- Panniculectomy/Abdominoplasty - 91444
- Parenteral Nutritional Therapy - 91517
- Percutaneous Left Atrial Appendage Closure - 91605
- Peripheral Nerve Stimulation - 91634
- Peroral Endoscopic Myotomy (POEM) - 91616
- Pervasive developmental disabilities: See Autism Spectrum Disorders - 91615
- Platelet Rich Plasma/Platelet Rich Fibrin Matrix/Autologous Blood-Derived Products/BMAC - 91553
- Port wine stains and vascular malformations: See Cosmetic and Reconstructive Surgery Procedures - 91535
- Prophylactic Cancer Risk Reduction Surgery - 91508
- Prostatic Artery Embolization for Benign Prostatic Hyperplasia (BPH) - 91620
- Prostatic Urethral Lift & Transurethral Water Vapor Therapy for Benign Prostatic Hyperplasia - 91626
- Prosthetics, External - 91306
- Psychological Evaluation and Management of Non-Mental Health Disorders - 91546
- Pulse Oximetry for Home Use - 91452
Q
- QEEG - Quantitative Electroencephalogram: See Electroencephalography (EEG) - 91510
R
- Radiofrequency ablation for back pain: See Spine Procedures - 91581
- Radiosurgery: See Stereotactic Radiosurgery and Stereotactic Body Radiotherapy
- Recurrent Pregnancy Loss - 91156
- Refractive Keratoplasty/Lasik - 91529
- Rehabilitative & Habilitative Medicine Services - 91318
- Renal Artery Stenosis - 91561
- Respite Care - 91321
- Robotically Assisted Surgeries - 91522
S
- Septoplasty/Rhinoplasty - 91506
- Sexual Dysfunction and Impotence - 91160
- Skin Conditions - 91456
- Skin Substitutes and Soft Tissue Grafts - 91560
- Sleep apnea: See Obstructive Sleep Apnea
- Speech Therapy - 91336
- Sperm and Oocyte Retrieval and Storage - Retired 02/2022
- Spinal Cord Column and Dorsal Root Ganglion Simulation - 91635
- Spine Centers of Excellence - Retired 01/2022
- Spine Procedures - 91581
- Stem Cell or Bone Marrow Transplantation - 91066
- Sterilization for Medicaid Members - 91501
- Stereotactic Radiosurgery and Stereotactic Body Radiotherapy - 91127
- Stimulation Therapy and Devices - 91468
- Surgical Treatments of Lipedema and Lymphedema - 91631
- Surgical Treatment of Obesity - 91595
T
- Technology Assessment - 91430
- Telemedicine - 91604
- Temporomandibular Joint Disorders (TMD) - 91353
- Termination of Pregnancy - 91000
- Thermal Capsulorrhaphy - 91551
- Thermography - 91355
- Thyroid-Related Procedures 91621
- Titanium Rib - 91505
- Tinnitus Retraining Therapy - 91482
- Total Joint Replacement: Knee, Shoulder & Hip - 91630
- Transcatheter Closure of Septal Defects - 91528
- Transcatheter Heart Valve Procedures - 91597
- Transcranial Magnetic Stimulation for Depression - 91563
- Transcutaneous Electrical Acustimulation (TEAS) for Hyperemesis - 91576
- Transplantation of Solid Organs - 91272
- Transurethral Radiofrequency Micro-Remodeling (Renessa) for Stress Urinary Incontinence - Retired 08/2023
U
- Umbilical Cord Blood Testing and Storage - 91459
- Urolift Prostatic Urethral Lift: See Prostatic Urethral Lift & Transurethral Water Vapor Therapy for Benign Prostatic Hyperplasia - 91626
- Uterine Fibroid Treatment - 91573
- Uvulopalatopharyngoplasty (UPPP) & Laser-Assisted Uvulopalatoplasty (LAUP): See Obstructive Sleep Apnea - 91333
V
- Vagal nerve stimulation as a treatment of depression: See Stimulation Therapy and Devices - 91468
- Varicose Vein Treatment - 91326
- Ventricular Assist Devices (VADs) and Artificial Hearts - 91509
- Virtual colonoscopy: See Colorectal Cancer Screening - 91547
- Vision Care - 91538
- Vitamin Testing - 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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