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. Log in to see them.

Current medical policies  

Jump down to a specific section by clicking a letter.

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





  • Dental extractions: See Oral Surgery & Dental Extractions - 91542
  • Detoxification - 91104 Revised 01/2018
    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 08/2017
  • Drug Testing - 91611 Revised 01/2018
    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





  • Hearing Augmentation - 91544 Reviewed 08/2017
  • Hemophilia Management - 91569 Revised 01/2018
    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 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












  • Vagal nerve stimulation as a treatment of depression: See Stimulation Therapy and Devices - 91468
  • Varicose Vein Treatment - 91326 Revised 1/2018
    Summary of change: 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).
  • Ventricular Assist Devices (VADs) and Artificial Hearts - 91509 Revised 01/2018
    Summary of change: 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.
  • Virtual colonoscopy: See Colorectal Cancer Screening - 91547
  • Vision Care - 91538 Reviewed 05/2017

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.