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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  • Eating Disorders - 91007 Revised 08/2017
    Summary of change: Criteria updated to reflect the use of Behavioral Health InterQual® for acute psychiatric inpatient admissions and continuing care, psychiatric partial hospitalization admissions and continuing care and residential treatment admissions and continuing care for eating disorders.    
  • Electro-convulsive Therapy (ECT) - 91554 Revised 01/2017
  • Electrophysiology Testing and Catheter Ablation for Cardiac Arrhythmias - 91314 Reviewed 05/2017
  • Enclosed Bed Systems for Medicaid Members - 91498 Reviewed 02/2017
  • End stage renal disease (ESRD): Renal Dialysis - 91526 Revised 02/2017
    Summary of change: Policy has been renamed and criteria has been expanded. Beginning 02/01/2017 prior auth will be required for Renal Replacement Therapy (RRT) for end stage renal disease. Note: Hemodialysis for urgent conditions does not require prior authorization. This new prior auth requirement does not apply for Medicare members. Language updated to clarify non-coverage of wearable hemodialysis units/wearable artificial kidneys.
  • Endometrial ablation procedures for menorrhagia: See Menorrhagia Treatment - 91575
  • Endoscopic Submucosal Dissection (ESD) - 91617 Reviewed 05/2017
  • Enteral Nutritional Therapy - 91278 Revised 10/2016
    Summary of change: Criteria for the coverage of oral nutritional formula for Inborn Errors of Metabolism (IEM) has been added. Note: Medicaid/Healthy Michigan Plan members diagnosed with inborn errors of metabolism that have been authorized for and use metabolic formulas B4157 and B4162 will receive all of their Medicaid services through the Medicaid Fee-For-Service Program and should not be enrolled in a Priority Health Medicaid/Healthy Michigan Plan.Language also updated to indicate formulas (e.g. KetoCal, RCF) or supplements (e.g. MCT oil, vitamins) for a ketogenic diet are not a covered benefit. This exclusion applies to formula used for complete or supplemental nutrition. See policy for possible exceptions.
  • Enuresis Therapy - 91418 Reviewed 02/2017
  • Experimental/Investigational/Unproven Care/Benefit Exceptions - 91117 Reviewed 11/2016
  • Extracorporeal Shock Wave Therapy (ECWT) - 91527 Reviewed 02/2017



  • 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 Revised 01/2017
    Summary of change: Policy was previously Medicare-specific. In addition to Medicare, policy will now apply for fully funded commercial (individual or group) members who are newly enrolled after December 31, 2016 or will be effective on the member's renewal date in 2017.
  • Genetics: Counseling, Testing and Screening - 91540
    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 Revised 02/2017
    Summary of change: Policy updated to reflect the use of InterQual criteria for Cochlear Implantation, Adult and Pediatric.
  • 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 Reviewed 08/2016
  • Hyperbaric Oxygen Therapy - 91151 Reviewed 05/2017
  • 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 - 9158706/2017












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.