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 July 1, 2019
- Gastroesophageal Reflux Disease (GERD) and Barrett's Esophagus - 91483
Criteria added for high-resolution manometry (HRM) distal esophageal motility metrics for magnetic sphincter augmentation (MSA) with the LINX device.
- Thyroid-Related Procedures - 91621
Thyroidectomy was previously considered not medically necessary for all non-obstructive nodules with Bethesda Class II cytopathology regardless of nodule size. Thyroidectomy is now considered medically necessary for Bethesda Class II nodules when ≥ 4 cm.
- Hyperbaric Oxygen Therapy - 91151
Added irradiation cystitis as a covered indication.
- Enteral Nutritional Therapy - 91278
Priority Health will begin coverage for RELiZORB™ a digestive enzyme cartridge for patients ages 5 years and above.
- Implantable Loop Recorder (ILR) - 91618
Added a clause to all other indications for these devices as experimental and investigational.
- Lung Volume Reduction Surgery - 91472
Added coverage criteria for Bronchoscopic (non-surgical) lung volume reduction (BLVR) utilizing the Pulmonx Zephyr® Endobronchial Valves.
- Stimulation Therapy and Devices - 91468
Clarification: Pulsed Electrical Stimulation (BioniCare®) is not covered for any indication.
Effective June 27, 2019
- Hearing Augmentation - 91544
Priority Health added coverage for unilateral conductive hearing loss and mixed hearing loss. In addition, criteria were added for audiology conductive and mix hearing loss and unilateral sensorineural hearing loss.
Clarification added around coverage for Medicaid and Healthy Michigan Plan members.
- Genetics: counseling, testing and screening - 91540
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.
Effective May 1, 2019
- Clinical trials - 91606
Effective May 1, 2019, the prior authorization requirement for drug-related clinical trials for Priority Health commercial and Medicare Advantage members have been removed. Instead, in-network providers will need to inform us that the member is participating in a clinical trial via Clear Coverage.
When billing a claim to Priority Health, providers should bill the appropriate Q0 and Q1 modifier to indicate the service was part of a clinical trial. Providers must bill according to the clinical trial medical policy.
The exceptions to this rule are for out of network (non-par) providers, prior authorization is still required.
This is not a covered benefit for Medicaid.
Effective April 1, 2019
- Continuous glucose monitoring - 91466
Effective April 1, 2019, Priority Health will begin coverage of personal use continuous glucose monitoring systems (CGMSs) for Medicaid members. Prior authorization is required of all ages, including infants and toddler (age 5 and under). The request for authorization for all ages is to ensure standards of coverage and documentation requirements are met.