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 Jan. 1, 2020

  • Home Care - 91023
    Beginning Jan. 1, 2020, all home health visits for members with a commercial group and individual plans will require prior authorization before the first visit. Today, these visits do not require authorization for the first 30 home health visits per plan year.  

Effective Dec. 26, 2019

Effective Dec. 4, 2019

  • Behavioral Health Residential Treatment - 91625
    Medical Policy 91607, Mental Health Residential Treatment: Child & Adolescent has been merged with Medical Policy 91608, Mental Health Residential Treatment: Adult. Medical Policy number 91607 and 91608 has been retired.
  • Bone Density Studies - 91494
    Added aromatase inhibition therapy as a risk factor for osteoporosis. Individuals on aromatase inhibition therapy would be eligible for bone mineral density studies. This is an expansion in coverage which aligns with Michigan Quality Improvement Consortium (MQIC), National Osteoporosis Foundation (NOF), and International Society for Clinical Densitometry guidelines.

Effective Aug. 27, 2019

  • Mental Health Residential Treatment: Adult – 91608 
    Added "luxury treatment programs" to exclusions.
    Note: This policy was merged with 91607 on Nov. 13, 2019. Please see Behavioral Health Residential Treatment - 91625
  • Mental Health Residential Treatment: Child/Adolescent – 91607
    Added "luxury treatment programs" to exclusions.
    Note: This policy was merged with 91608 on Nov. 13, 2019. Please see Behavioral Health Residential Treatment - 91625
  • Surgical Treatment of Obesity - 91595
    Language added to broaden the type of tobacco cessation tests needed for bariatric surgery and added a description of tobacco cessation testing. 
  • Transplantation of Solid Organs - 91272
    Language added to broaden the type of tobacco cessation tests needed for bariatric surgery and added a description of tobacco cessation testing.
  • Bone Density Studies - 91494
    Language added to clarify dual-energy x-ray absorptiometry (DXA) scans do not require PA.  

Effective July 1, 2019

  • 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.
  • Enteral Nutritional Therapy - 91278
    Priority Health will begin coverage for RELiZORB™ a digestive enzyme cartridge for patients ages 5 years and above. 
  • Lung Volume Reduction Surgery - 91472
    Added coverage criteria for Bronchoscopic (non-surgical) lung volume reduction (BLVR) utilizing the Pulmonx Zephyr® Endobronchial Valves.

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.

Effective immediately

  • 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.