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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  • Gastroesophageal Reflux Disease GERD) and Barrett's Esophagus - 91483 Revised 01/2017
    Summary of change: Criteria added for the coverage of magnetic sphincter augmentation (MSA) with the LINX device for the treatment of GERD. Prior authorization is required.
  • Gastroparesis Testing and Treatment - 91572 Revised 02/2017
    Summary of change: Policy updated to reflect the use of InterQual criteria for Gastric Stimulation.
  • Gender Reassignment Surgery - 91612 Updated 11/2017
  • Genetics: Counseling, Testing and Screening - 91540 Updated 06/2017
    Policy updated to reflect genetic testing covered according to eviCore guidelines effective 6/19/17. Please note some genetic testing will continue to be managed by Priority Health. Refer to the table in Section V, Coding Information, to determine if your code is covered, requires prior auth and who manages the code (eviCore or Priority Health). The following medical policies have been retired as all coverage criteria have been incorporated into this policy: Chemosensitivity Assays 91566, Multi-Marker Tumor Panels 91609, Pharmacogenomics Testing 91570 and Tumor Markers 91562. 


  • Hearing Augmentation - 91544 Reviewed 08/2017
  • Hemophilia Management - 91569 Reviewed 02/2017
  • High Intensity Focused Ultrasound - 91601 Revised 08/2017
    Summary of change: Language updated to reflect the NCCN Clinical Practice Guidelines in Oncology, Prostate Cancer, to indicate high intensity focused ultrasound (HIFU) is included among the salvage therapeutic options for localized prostate cancer.
  • Home Care - 91023 Reviewed 05/2017
  • Home Prothrombin Time or INR Monitoring - 91507 Reviewed 05/2017
  • Hospice Care - 91520 Revised 11/2017
    Summary of change: Language removed that explained number of inpatient respite days for Medicaid and Healthy Michigan Plan.
  • Hyperbaric Oxygen Therapy - 91151 Reviewed 08/2017
  • Hyperhidrosis - 91451 Revised 08/2017
    Summary of change:  Language updated to reflect treatment of primary hyperhidrosis with iontophoresis (electrophoresis, Drionic device) is considered experimental/investigational and is not a covered benefit.  Language also added to reflect sympathectomy is not a covered benefit.



    Knee Arthroscopy - 91587 Retired 06/2017








  • NEW Radical Prostatectomy Effective 02/01/2017
    Summary of change: InterQual has been adopted by Priority Health and prior auth is required beginning 02/01/2017. Providers must be logged in to view InterQual.
  • 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 05/2017
  • Refractive Keratoplasty/Lasik - 91529 Revised 11/2017
    Language added to clarify performance of PTK in combination with collagen cross-linkage is considered experimental and investigational.
  • Rehabilitative & Habilitative Medicine Services - 91318 Revised 11/2017
    Summary of change: Language added to clarify Biofeedback is not a covered benefit for Medicaid and Healthy Michigan.
  • Renal Artery Stenosis - 91561 Reviewed 11/2016
  • Respite Care - 91321 Reviewed 05/2017
  • Robotically Assisted Surgeries - 91522 Reviewed 08/2017





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.