Pending/retired/updated medical policy list

From time to time, we make changes to our medical policies. Priority Health makes them available here for your review before they go into effect.


Effective December 1, 2018

  • Infusion Services and Equipment 91414
    Policy criteria updated to reflect when this policy does not apply and also when exceptions will be reviewed. Policy also updated to reflect for Medicaid/Healthy Michigan members Priority Health requires that patients receiving selected infusions or injections have the infusion or injection in a Priority Health-approved site of service.

Effective November 26, 2018

  • Stereotactic Radiosurgery and Stereotactic Body Radiotherapy 91127
    Language added to reflect Stereotactic Radiosurgery by Gamma Knife, CyberKnife or linear accelerator is a covered benefit for ocular melanomas not amendable to surgical excision. In addition, new section added to specifically address Stereotactic Body Radiation Therapy (SBRT) and the covered indications. Please see policy for additional details.

Effective November 1, 2018

  • Durable Medical Equipment 91110
    Criteria for the coverage of CPM devices added. CPMs are a covered benefit in the immediate post-operative rehabilitation period following rotator cuff repair or total knee replacement. CPMs are not a covered benefit for any other condition at any anatomic location (e.g. hip, ankle).  CPM is a covered benefit for 21 days and no prior is required. 

 Effective October 1, 2018


Effective September 25, 2018


Effective August 31, 2018

  • Genetics: Counseling, Testing and Screening 91540
    Criteria related to Multi-Marker Tumor Panels removed as the Multi-Marker Tumor Panels medical policy 91609 was reinstated effective July 1, 2018. 
  • Obstructive Sleep Apnea 91333
    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.
  • Surgical Treatment of Obesity 91595
    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.


Effective August 20, 2018

  • Hyperhidrosis 91451
    Criteria for the coverage of sympathectomy added and criteria updated to reflect sympathectomy is not covered if plantar hyperhidrosis is the only indication. 
  • Rehabilitative & Habilitative Medicine Services 91318
    Note indicating spinal manipulations by chiropractors are not covered for Priority Health Medicaid members age 21 or over was removed.
  • Spine Procedures 91581
    Language updated to reflect The Coflex® interlaminar stabilization device for lumbar spinal stenosis is a covered benefit.  Prior authorization is not required.
  • Vision Care 91538
    Criteria updated to reflect “FDA approved” bypass stents for the treatment of open-angle glaucoma in combination with cataract surgery are a covered benefit.


 Effective July 11, 2018

  • Spine Centers of Excellence 91531
    There is no change to the medical policy but the criteria in Clear Coverage has been updated to gather additional information related to the authorization request for a Spine Referral for Neurosurgeon or Orthopedic Surgeon Evaluation. All supporting clinical documentation must be attached, including but not limited to, H&P, complete neuro exam, MRI, PM&R and surgical consultation notes regardless of whether the request is auto approved or pends for medical review. Lack of supporting documentation may result in denial secondary to inability to verify clinical criteria. Note: This criteria is not meant to be used for conditions requiring emergent surgical intervention. 


Effective July 1, 2018

  • Mental Health Residential Treatment: Child and Adolescent 91607
    Residential treatment criteria updated to reflect residential treatment takes place in a structured facility-based setting.
  • Multi-Marker Tumor Panels 91609
    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.
  • Skin Substitutes and Soft Tissue Grafts 91560
    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.


Effective April 6, 2018

  • Home Care 91023
    Language removed addressing services rendered by a dietician or nutritionist for overall training or consultative advice to the home health agency staff.
  • Osteoarthritis of the Knee 91571
    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.
  • Platelet Rich Plasma/Platelet Rich Fibrin Matrix/Autologous Blood-Derived Products/BMAC 91553
    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.
  • Transcranial Magnetic Stimulation for Depression 91563
    Language added to reflect authorization for Transcranial Magnetic Stimulation (TMS) is determined by the clinical finding and TMS indications recommended by Behavioral Health InterQual®.


Effective March 12, 2018

  • Gastroparesis Testing & Treatment 91572
    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.


Effective January 29, 2018

  • Autism Spectrum Disorder 91615
    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.
  • Drug Testing 91611
    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.
  • Infusion Services & Equipment 91414
    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.
  • Markers for Digestive Disorders 91583
    Criteria updated to reflect vedolizumab (VDZ) and Anser VDZ are a covered benefit.
  • NEW Prostatic Artery Embolization for Benign Prostatic Hyperplasia (BPH) 91620
    Prostatic Artery Embolization (PAE) for BPH is covered when specific criteria are met. PAE for all other conditions is considered experimental and investigational and not a covered benefit.
  • Ventricular Assist Devices & Artificial Hearts 91509
    Language added to clarify percutaneous left ventricular assist devices (e.g., the TandemHeart and the Impella) are covered for FDA approved indications. Language also updated to reflect percutaneous right ventricular assist devices (e.g. Impella RP) are considered experimental and investigational and not a covered benefit. There is insufficient evidence to determine safety and efficacy for treatment of right ventricular failure.


Effective January 16, 2018

  • Hemophilia Management 91569
    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.


Effective January 1, 2018

  • Computerized Tomographic Angiography Coronary Arteries (CCTA) 91614
    Language added to reflect FFR-CT does not require prior authorization. Fractional Flow Reserve (FFR-CT) is not covered for Medicaid products.
  • Detoxification 91104
    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.
  • Orthoptic and Pleoptic Training for Medicaid Members 91500
    Prior authorization required for beneficiaries over age 21.
  • Transcathether Closure of Septal Defects 91528
    Prior authorization requirement removed for Transcatheter Closure of Septal Defects when patient is greater than 17 year old and for Transcatheter Closure of Patent Foramen Ovale.
  • Varicose Vein Treatment: Endovenous Laser Therapy, Endoluminal Radiofrequency Ablation and Sclerotherapy 91326
    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).
  • Prior authorization rules will apply to Medicare members for the following services:
    • Continuous glucose monitors
    • Dialysis
    • Insulin pumps
    • Outpatient requests for knee arthroscopy, kyphoplasty, vertebroplasty, lumbar fusion, lumbar laminectomy and orthopedic surgery (lumbar or cervical spine surgery, joint arthroscopy, hip, shoulder, knee replacement, shoulder repair) - prior to 1/1/18 authorization only required for inpatient requests


Effective December 11, 2017

  • Electro-convulsive Therapy (ECT) 91554
    Language added to clarify adjunctive ketamine in ECT has not been proven to be an effective approach and thus will not be covered through Priority Health. A list of the indications for which the use of ECT as treatment is considered experimental and investigational and thus not covered through Priority Health was also added.


Effective November 29, 2017


Effective November 10, 2017