Authorizations

Authorization quick reference list:

Most authorization requests go through Clear Coverage unless otherwise specified.

Some services indicate PA may be required in 2018. The effective dates for these new prior authorization requirements will be communicated when finalized.

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.

When Priority Health is secondary to CMS or Original Medicare, we require prior authorization on obesity-related surgery, transplant services and home infusion services.

Click a letter to jump down to that section of the list:

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

Service Plans requiring prior auth Medical policy
A
Abdominoplasty/panniculectomy HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91444
Abortion/termination of pregnancy Medicaid*
*Refer to the medical policy for specific criteria related to coverage
91000
Acupuncture Not required*
*May be covered with a rider or by some self-funded (SF) plans. Consult SF plan documents to confirm coverage
Adenotonsillectomy, pediatric (ages 0-17 only) All except Medicare InterQual
Allergy testing/immunotherapy Not required 91037
Ambulance services, air/fixed wing HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid
Ambulance services, emergent Not required
Ambulance services, non-emergent HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid
Apnea monitors and oxygen therapy, Medicaid patients under 21 only  Not required
91497
Artificial intervertebral discs HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91581
Authorized through eviCore healthcare          
Augmentative communications/speech-generating devices Medicare, Medicaid 91499 applies only to Medicaid
Autism spectrum disorders: Treatment services, ages 0-18 only (including psychiatric, psychological and therapeutic care, i.e. evidence-based speech therapy, physical therapy, occupational therapy and ABA therapy) See policies for details 91615
91336
91318
Autologous chondrocyte implant/meniscal allograft/osteochondral HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid

May not be covered by self-funded plans
91443
Authorized through eviCore healthcare
B
Service Plans requiring prior auth Medical policy
BAHA device HMO, POS, EPO, SF-POS, Medicare, Medicaid 91544
Balloon sinus ostial dilation Not required 91596
Behavioral health therapies, initial evaluation Medicaid Submit auth request via fax to Priority Health
Behavioral health therapies, outpatient Not required
Behavioral health & substance abuse therapies, inpatient HMO, POS, EPO, PPO, SF-POS, Medicare Submit auth request via fax to Priority Health
Biofeedback Not required 91002
Blepharoptosis/brow ptosis repair EPO, PPO, SF-POS, Medicaid 91535
Blood pressure monitors & ambulatory blood pressure monitoring (24 hour) Not required 91503
Bone density studies Not required 91494
Bone density studies, CT HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91494
Authorized through eviCore healthcare
Bone marrow/stem cell transplantation HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91066
Breast MRI HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91545
Authorized through eviCore healthcare
Breast reconstruction & revision procedures not billed with qualifying diagnosis HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91545
Breast specific gamma imaging (BSGI) Not required*
See policy for diagnosis limitations
91568
Bronchial thermoplasty HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91577
C
Service Plans requiring prior auth Medical policy
Capsule endoscopy Not required*
*Payable for limited diagnoses. Please see medical policy for details
91476
Cardiac/pulmonary rehabilitation (visit limits apply) Not required except by some employer groups
91318
Cardiovascular risk markers Not required 91559
Cardioverter defibrillators (ICDs) HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91410
InterQual
Carotid artery stenting Not required 91495
Catheter ablation for cardiac arrhythmias HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91314
InterQual
Chelation therapy Not required*
*Payable for limited diagnosis.  Please see medical policy for details
91077
Chemosensitivity assays See policy for specific authorization requirements 91540
Most testing authorized by eviCore healthcare   
Clinical trials HMO, POS, EPO, PPO

This policy applies to the Individual Market, fully-funded commercial groups and non-grandfathered self-funded groups (verify clinical trial coverage with the individual plan document for self-funded products). For grandfathered self-funded groups that may opt out of PPACA expanded clinical trials coverage, refer to the Clinical Trials for Cancer Care Medical Policy #91448.

Note: Not a covered benefit for Medicaid members.
91606
Clinical trials for cancer care Policy only applies to grandfathered self-funded groups that opt out of PPACA expanded clinical trials coverage. Not covered by most self-funded plans (verify clinical trial coverage with the individual plan document).  Requires prior authorization. 91448
Cochlear implant HMO, POS, EPO, SF-POS, Medicare, Medicaid 91544
InterQual-Adult
InterQual-Pediatric
Complications to non-covered care Not required 91086
Computed tomography scanning for lung cancer screening HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid Authorized though eviCore healthcare
Contact lenses/eyeglasses Not required 91538
Continuous glucose monitoring HMO, POS, EPO, PPO, SF-POS, Medicare*
*PA required for Medicare effective 01/01/2018
Not covered for Medicaid
91466
Continuous passive motion (CPM), after day 21 HMO, POS, EPO, PPO, SF-POS, Medicaid

Note: For Medicare no prior auth required but service only covered for 21 days
InterQual
CPAP & other equipment to treat sleep apnea (i.e. ASV, APAP, BiPAP, oral appliances), after three months of use HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid

Note: Prior authorization for PAP equipment is waived for the first three months of use
91333
InterQual
Cranial helmets, purchases greater than $1000 HMO, POS, EPO, PPO, SF-POS, Medicaid 91504
InterQual
D
Service Plans requiring prior auth Medical policy
Dental anesthesia Medicaid
Dental extractions Not required*
*Covered in very limited circumstances; see policy for details

Note: Not covered by Medicaid
91542
Dental services Medicare
Detoxification HMO, POS, EPO, PPO, SF-POS, Medicare

Note: Not covered by the health plan for Medicaid; managed by CMH and paid for by Medicaid FFS
91104
Submit auth request via fax to Priority Health
Developmental disorders, pervasive See policy for details 91318
Dialysis access, permanent  All except Medicare*
*PA required for Medicare effective 01/01/2018
91526
Dialysis for end stage renal disease All except Medicare*
*PA required for Medicare effective 01/01/2018
91526
Drug-eluting stents for ischemic heart disease  Not required 91580
Drug testing, in-network labs Not required 91611
Drug testing, out-of-network labs HMO, EPO

Note: POS plans do not require prior auth, however, all OON labs will be processed at the member's out-of-network benefit level.
91611
Drugs, injectable HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid Certain drugs require prior authorization from the pharmacy department. See the drug PA forms list.
Durable medical equipment (DME) purchases >$1000, Medicaid DME purchases >$500,
all rentals
HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91110
E
Service Plans requiring prior auth Medical policy
Eating disorders HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91007
Echocardiography - transesophogeal, transthoracic, Doppler  Not required*
*PA may be required in 2018 - effective date to be determined
 
Electroconvulsive therapy (ECT) Not required*
*Not covered by the health plan for Medicaid; managed by CMH and paid for by Medicaid FFS
91554
Enclosed bed systems for Medicaid members Medicaid 91498
Endoscopic submucosal dissection (ESD) Not required 91617
Enteral nutrition therapy HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91278
Enuresis therapy Not required*
*Subject to DME limits; not covered by Medicaid
91418
Experimental/investigational/unproven care

HMO, POS, EPO, PPO

Note: Not covered by most self-funded plans (verify coverage with individual plan document)

Not a covered benefit for Medicaid members

91117
F
Facial scar revisions Not required 91535
Fecal DNA screening (Cologuard) Not required 91547
Fecal microbiota transplantation/fecal bacteriotherapy Not required 91603
Feeding disorders HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91469
Fetal surgery HMO, POS, EPO, PPO, SF-POS, Medicaid

Note: Some procedures may not be covered for Medicare and Medicaid
91120
Foot care Not required*
*Payable for limited diagnoses.  Please see medical policy for details
91121
Frenulectomy/frenectomy Not required*
*Age limitations apply
91542
G
Service Plans requiring prior auth Medical policy
Gastroparesis testing Not required 91572
InterQual
Gastroparesis treatment (not testing) HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91572
InterQual
Gender reassignment surgery  All plans 91612
Genetic counseling, testing & screening See policy for specific authorization requirements

Note:  Genetic counseling does not require prior auth
91540
Authorized through eviCore healthcare
Genetic testing & screening, by out-of-network providers All plans 91540
Authorized through eviCore healthcare
H
Home health care, after first 30 RN home visits/first 5 MSW visits* per plan year
*MSW visits are not covered for Medicaid
HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91023
Home health care: Home infusion services, nursing care, palliative care, total parental nutrition HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91023
Hospice care, home  Medicaid*
*PA required after 182 units
91520
Submit auth request via fax to Priority Health 
Hospice care, inpatient HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid

Note:  See policy for specifics
91520
Submit auth request via fax to Priority Health
Hyperbaric oxygen therapy Not required*
*Payable for limited diagnoses. Please see medical policy for details
91151
Hyperhidrosis, botox treatment and inpatient surgery only HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91451
I
Service Plans requiring prior auth Medical policy
Implantable heart failure monitors HMO, POS, EPO, PPO, SF-POS, Medicaid, Medicare 91610
Impotence and sexual dysfunction Not required
           
91160
InterQual
Incontinence supplies, Medicaid members Not required*
*See policy for limitations
91502
Infertility and assisted reproduction See policy for coverage limitations 91163
Infusion services & equipment HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91414
Submit auth request via fax to Priority Health
Inpatient care services: All admissions* including behavioral health and substance abuse HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid *Some elective procedures do not require health plan review (i.e. OB deliveries, colectomy, etc.), but do require an auth for claims payment.  Other elective procedures require health plan review and specific criteria must be met (i.e. bariatric surgery, ventricular assist device, etc.).

Behavioral health and substance abuse inpatient services not covered for Medicaid.
INR monitoring or home prothrombin time Not required*
*Subject to DME limits; not covered by Medicaid
91507
Insulin pumps, ambulatory  HMO, POS, EPO, PPO, SF-POS, Medicaid, Medicare*
*PA required for Medicare effective 01/01/18

Note:  Prior auth is required for newly prescribed and replacement pumps
91414
Intraoperative radiation therapy HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91556
Intraperitoneal hyperthermic chemotherapy Not required 91548
Intracoronary brachytherapy Not required 91536
K
Knee arthroscopy HMO, POS, EPO, PPO, SF-POS, Medicare* (IP only), Medicaid
*PA required for Medicare OP procedures effective 01/01/2018
Authorized through eviCore healthcare
Kyphoplasty/vertebroplasty HMO, POS, EPO, PPO, SF-POS, Medicare* (IP Only), Medicaid
*PA required for Medicare OP procedures effective 01/01/2018
91581
Authorized through eviCore healthcare
L
Service Plans requiring prior auth Medical policy
Lumbar fusion HMO, POS, EPO, PPO, SF-POS, Medicare* (IP only), Medicaid
*PA required for Medicare OP procedures effective 01/01/2018
91581
Authorized through eviCore healthcare
Lumbar laminectomy HMO, POS, EPO, PPO, SF-POS, Medicare* (IP only), Medicaid
*PA required for Medicare OP procedures effective 01/01/2018
91581
Authorized through eviCore healthcare
Lung volume reduction surgery Not required*
*Only covered at certain facilities for Medicare
91472
M
Male gynecomastia PPO, EPO, SF-POS, Medicaid 91545
InterQual
Markers for digestive disorders HMO and EPO OON providers 91583
Submit auth via fax to Priority Health          
Medical oncology (OP chemotherapy) 

Not required*
*PA may be required in 2018 - effective date to be determined

 
Menorrhagia treatment/Mirena Not required
91575
Methadone maintenance Not required*
*Not covered for Medicaid or Medicare
N
Neuropsychological psychological testing Not required 91537
Non-acute inpatient services at skilled nursing, rehabilitation, and acute-care facilities HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91332
Submit auth via fax to Priority Health
Nutritional counseling Not required
Service Plans requiring prior auth Medical policy
O
Obesity-related services, medical management Not required*
*May not be covered by self-funded plans
91594
Obesity-related services, surgical treatment HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid

Note: May not be covered by self-funded plans
91595
Observation HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid

Note: Authorization is only required for non-participating facilities
Obstetric services/GYN care Medicaid, Healthy Michigan*
*Applies only to non-participating providers.

Call our Provider Locator Line to find in-network resources
 
Oral surgery See policy 91542
Orthognathic surgery Medicaid
           
91273
InterQual
Orthopedic Surgery (lumbar or cervical spine surgery, joint arthroscopy, hip, shoulder, knee replacement, shoulder repair) HMO, POS, EPO, PPO, SF-POS, Medicare* (IP only), Medicaid
*PA required for Medicare OP procedures effective 01/01/2018
Authorized through eviCore healthcare
Orthoptic and pleoptic training for Medicaid members Medicaid*
*Prior auth requirement for beneficiaries over age 21 beginning 01/01/2018 
91500
Orthotics: Shoe inserts, orthopedic shoes HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91420
InterQual
Orthotics/support device purchases, commercial/Medicare >$1000; Medicaid >$500 Medicare, Medicaid 91420
91339
InterQual
Oxygen therapy Not required*
*PA may be required in 2018 - effective date to be determined
P
Service Plans requiring prior auth Medical policy
Pacemakers, cardiac  Not required*
*PA may be required in 2018 - effective date to be determined 
 
Pain management (injection procedures)  Not required*
*PA may be required in 2018 - effective date to be determined
 
Palliative care, inpatient or home HMO, POS, EPO, PPO, SF-POS 91558
Parenteral nutrition therapy HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91517
Penile implants (organic origins only) Medicaid 91160
InterQual
Percutaneous left atrial appendage closure HMO, POS, EPO, PPO, SF-POS, Medicare 91605
Peroral endoscopic myotomy (POEM) Not required 91616
Pharmacogenomic testing See policy for specific authorization requirements 91540
Most testing authorized through eviCore healthcare
Port wine stains and vascular malformation Not required 91535
Power vehicles HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91110
InterQual
Prophylactic cancer risk-reduction surgery HMO, POS, EPO, PPO, SF-POS, Medicaid 91508
Prosthetics, purchase >$1000 for most plans; Medicaid >$500 HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91306
Psychological evaluation and management of non-mental health disorders Not required 91546
Pulse oximetry for home use, after first three months of use HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91452
Pumps, implantable & external infusion HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91414
Q
Quantitative electroencephalogram (QEEG) Not required 91510
R
Service Plans requiring prior auth Medical policy
Radiation oncology  Not required*
*PA may be required in 2018 - effective date to be determined 
 
Radical prostatectomy  HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid InterQual 
Radiofrequency ablation for back pain, after two procedures HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91581
Radiology: All non-emergent outpatient advanced diagnostic imaging services (MRA, MRI, CT, CTA, PET scans and nuclear cardiology) HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid

In-network: Authorized through eviCore healthcare

Out-of-network: Call eviCore

Details and exceptions: See Radiology services

Radiosurgery, stereotactic, and proton and neutron beam therapies HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91127
Reconstructive/cosmetic surgery HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91535
Reduction mammoplasty, male or female EPO, PPO, SF-POS, Medicaid 91545
InterQual
Rehabilitation therapies in the home (occupational, physical and speech), subject to visit limits Not required 91023
Rehabilitation/habilitative therapy (outpatient), subject to visit limits Not required except by some employer groups 91318
Renal artery stenosis Not required 91561
Rhinoplasty (with or without septoplasty) HMO, POS, EPO, PPO, SF-POS, Medicaid 91506
S
Service Plans requiring prior auth Medical policy
Sacroiliac joint fusion HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91581
Septoplasty  Not required  91506
Skin conditions Not required*
*See policy for specifics
91456
Sleep studies, in-center, ages 18+ HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91333
Sleep studies, in-home Not required 91333
Skin substitutes Not required 91560
Speech therapy, outpatient (subject to visit limits) Not required 91336
Speech therapy, outpatient, after therapy dollar cap is reached Medicare 91336
Sterilization, Medicaid members Not required 91501
Stimulation therapy & devices: TENS Only
with diagnoses of 724.2 lumbago, 722.52 degeneration of lumbar or lumbosacral intervertebral disc, 724.5 backache, unspecified, or 724.6 disorders of the sacrum
Not required for commercial plans and Medicaid  91468
Stimulation therapy & devices HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid

See medical policy for criteria and authorization requirements.
91468
InterQual is only utilized for Stereotactic Introduction, Subcortical Electrodes (Deep Brain Stimulation), Vagal Nerve Stimulators and for TENS (Medicare Only)
Substance abuse/behavioral health therapies, inpatient HMO, POS, EPO, PPO, SF-POS, Medicare

Note:  Not covered for Medicaid
Submit auth request via fax to Priority Health
Substance abuse therapies, intensive outpatient

HMO, POS, EPO, PPO, SF-POS

Note:  Not covered for Medicare or Medicaid

Submit auth request via fax to Priority Health
Substance abuse therapies, outpatient Not required*
*Not covered for Medicaid
Submit auth request via fax to Priority Health
Surgery, spinal  HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91531
Authorized through eviCore healthcare
Surgical treatment of sleep apnea Not required 91333 
T
Service Plans requiring prior auth Medical policy
Telemedicine Not required 91604
Temporomandibular joint disorders (TMD) Not required 91353
Titanium rib HMO, POS, EPO, PPO, SF-POS, Medicaid 91505
Tonsillectomy, pediatric, ages 0-17 All, except Medicare InterQual 
Transcatheter closure of septal defects, ages 18+ HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91528
Transcatheter heart valves HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91597
InterQual is utilized for Transcatheter aortic valve replacement
Transcutaneous electrical acustimulation (TEAS) for hyperemesis Not required 91576
Transcranial magnetic stimulation therapy for depression HMO, POS, EPO, PPO, SF-POS, Medicare
91563
Submit auth request via fax to Priority Health
Transplantation of solid organs HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91272
Transurethral radiofrequency micro-remodeling for female incontinence Not required 91578
Treatment of gastroesophageal reflux disease (GERD) and Barrett's esophagus Not required*
*see policy for coverage details 
91483
U
Service Plans requiring prior auth Medical policy
Umbilical cord blood testing & storage Not required 91459
Urolift/Prostatic urethral lift  Not required  91613
Uterine fibroid treatments  Not required 91573 
V
Varicose vein treatment Not required 91326
Ventilator, outpatient HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91110
Ventricular assist devices (VADs) and artificial hearts HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91509
Virtual colonoscopy HMO, POS, EPO, PPO, SF-POS, Medicare, Medicaid 91547
Authorized through eviCore healthcare
Vision care/eye exams Not required 91538
Voice synthesizer Medicaid 91499