Uniform Medical Plan Pre-authorization List

The Uniform Medical Plan (UMP) Pre-authorization List includes services and supplies that require pre-authorization or notification for UMP members.

Direct clinical information reviews (MCG Health)

For select CPT codes, Availity's electronic authorization tool automatically routes you to MCG Health's website where you can document specific clinical criteria for your patient. If all criteria are met, you will see the approval on the Auth/Referral Dashboard soon after you click submit. Once all criteria are documented, you will then be routed back to Availity Essentials to attach supporting documentation and submit the request. Documenting complete and accurate clinical information for your patients helps to reduce the overall time it takes to review a request. View the services that may receive automated approval (PDF).

Washington State Health Technology Clinical Committee (HTCC) Assessments

Under state law, the Uniform Medical Plans (UMP Achieve 1, UMP Achieve 2, UMP Classic, UMP Select, UMP CDHP, UMP High Deductible, UMP Plus – Puget Sound High Value Network, and UMP Plus – UW Medicine ACN) must comply with decisions made by the Health Technology Clinical Committee (HTCC). The HTCC is a committee of independent health care professionals that reviews selected health technologies (services) to determine the conditions, if any, under which the service will be included as a covered benefit and, if covered, the criteria the plan must use to decide whether the service is medically necessary. These services may include medical or surgical devices and procedures, medical equipment, and diagnostic tests. In public meetings, the HTCC considers public comments and scientific evidence regarding the safety, medical effectiveness, and cost-effectiveness of the services in making its determination. Final decisions and ongoing reviews may be accessed on the HTCC website.

Criteria established by the HTCC supersede Regence Medical Policy.

Procedures that are subject to HTCC decision and require pre-authorization can be found on the UMP Pre-authorization List below.

Procedures denied due to an HTCC decision will be member responsibility.

Important pre-authorization reminders

  1. Failure to pre-authorize services subject to pre-authorization requirements will result in an administrative denial, claim non-payment and provider and facility write-off. Members may not be balance billed.
  2. Before requesting pre-authorization, please verify member eligibility and benefits via the Availity Portal as the member contract determines the covered benefits.
  3. Verify that you are an in-network provider for each member to help reduce his or her out-of-pocket expense.
  4. If services are to be rendered in a facility, the pre-authorization request submitted should designate the facility where the treatment will occur to ensure proper reconciliation with related inpatient claims.
  5. HTCC Decisions, Medical policies, MCG and CMS criteria may be used as the basis for service coverage determinations, including length of stay and level of care. Visit MCG's website for information on purchasing their criteria, or contact us and we will be happy to provide you with a copy of guidelines for specific services.
  6. Emergency services do not require pre-authorization, but are subject to hospital admission notification requirements (see below).
  7. The member's contract language will apply.
  8. Please note that a pre-authorization does not guarantee payment for requested services. (See #2 above). Our reimbursement policies may affect how claims are reimbursed. Payment of benefits is subject to pre-payment and/or post-payment review, and all plan provisions, including, but not limited to, eligibility for benefits and our Coding Toolkit clinical edits.
  9. Investigational and cosmetic services and supplies are typically contract exclusions and are ineligible for payment. Unlisted codes may be used for potentially investigational services and are subject to review. Please refer to the Clinical Edits by Code list for additional information. View a sample non-covered member consent form (PDF).
  10. Pre-authorization requirements are not dependent upon site of service. All CPT and HCPCS codes listed on our pre-authorization lists require pre-authorization. View list below for complete requirements.
Pre-authorization review timeframes

Type of review

Timeframe

Additional time allowed for review if additional information is needed:

Expedited

72 hours

48 hours

Standard initial

15 calendar days

15 calendar days

Concurrent

24 hours
Effective September 1, 2022: Must notify within 24 hours for newborn intensive care unit (NICU) or pediatric intensive care unit (PICU) admission.
Exception: Maternity notifications are required on day 6.

72 hours

Note that additional timeframes are after receipt of the documentation or the timeframe for submission of the requested information has expired - whichever comes first.

Payment implications for failure to pre-authorize services

Failure to secure approval for services subject to pre-authorization will result in claim non-payment and provider write-off. Our members must be held harmless and cannot be balance billed.

Please note the following:

  • Hospital claims for elective services that require pre-authorization will be reimbursed based upon the member's contract only when the physician or other health care professional has completed and received approval of the pre-authorization for the services. We therefore strongly suggest that facilities develop a method to ensure that required pre-authorization requests have been submitted by the physician or other health care professional and approved prior to admission of the patient.
  • If the physician or other health care professional follows the pre-authorization requirements outlined on our pre-authorization lists, they will not be subject to any pre-authorization penalties for failure of the facility to provide the required inpatient admission and discharge notification.
  • A pre-authorization does not guarantee payment for requested services. Health Plan reimbursement policies may affect how claims are reimbursed and payment of benefits is subject to all plan provisions, including eligibility for benefits. Services must always be covered benefits and medically necessary.
  • If an elective service that requires pre-authorization needs to occur during the course of an inpatient admission, and that need could not be foreseen prior to admission, the facility or provider can request pre-authorization for the service while the member is inpatient (before the service occurs). If pre-authorization does not occur during the stay, services are subject to review post-service for medical necessity.

Durable medical equipment

Bone Growth Stimulation

Continuous Glucose Monitoring

  • For dates of service prior to January 1, 2022: UMP is subject to HTCC Decision (PDF): A9277, A9278, K0554, S1030, S1031
  • Continuous Glucose Monitoring device coverage and preauthorization HTCC requirements will be managed under the UMP prescription drug benefit administered by the Washington State Rx Services

Definitive Lower Limb Prostheses (PDF)

  • Effective December 1, 2022: L5610, L5611, L5613, L5614, L5616, L5700, L5701, L5702, L5703, L5710, L5711, L5712, L5714, L5716, L5718. L5722, L5724, L5726, L5728, L5780, L5810, L5811, L5812, L5814, L5816, L5818, L5822, L5824, L5826, L5828, L5830, L5840, L5848, L5856, L5857, L5858, L5930, L5970, L5972, L5974, L5976, L5978, L5979, L5980, L5981, L5982, L5984. L5985, L5986, L5987

Implantable Drug Delivery System

  • UMP is subject to HTCC Decision (PDF): C1772, C1889, C1891, C2626, E0782, E0783, E0785, E0786, 62350, 62351, 62360, 62361, 62362

Insulin Infusion Pumps, Automated Insulin Delivery and Artificial Pancreas Device Systems (PDF)

  • E0784, E0787, S1034

Microprocessor-Controlled Lower Limb Prosthetics (PDF)

  • UMP is subject to HTCC Decision (PDF)
  • K1014, L5856, L5857, L5858
  • Use Regence medical policy in addition to the HTCC to review requests regarding "functional level 2" and "experienced user exceptions".

Myoelectric Prosthetic and Orthotic Components for the Upper Limb (PDF)

  • L6026, L6693, L6715, L6880, L6881, L6882, L6925, L6935, L6945, L6955, L6965, L6975, L7007, L7008, L7009, L7045, L7180, L7181, L7190, L7191

Noninvasive Ventilators in the Home Setting (PDF)

  • E0466

Power Wheelchairs: Group 3 (PDF)

  • K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855, K0856, K0857, K0858, K0859, K0860, K0861, K0862, K0863, K0864

Stents, Drug Coated or Drug-Eluting (DES)

  • Refer to Cardiac Stenting in the Surgery section below.

Sleep Medicine

  • View the Sleep Medicine Management Program for notification or authorization requirements.
  • Review the codes requiring authorization or notification in the Sleep Medicine section.

Genetic testing

Effective January 1, 2023: In compliance with WA HB 1689, guideline-recommended biomarker testing in patients with recurrent, relapsed, refractory, or metastatic cancer (including stage 3 or 4) will not require prior authorization for Washington members. This does not include non-specific molecular pathology codes (81400-81408).

Genetic Testing for Alzheimer's Disease (PDF) - GT01

  • 81401, 81405, 81406

Genetic Testing for Hereditary Breast and Ovarian Cancer and Li-Fraumeni Syndrome (PDF) - GT02

  • 0235U, 81162, 81163, 81164, 81165, 81166, 81167, 81212, 81215, 81216, 81217, 81307, 81308, 81321, 81322, 81323, 81404, 81405, 81406, 81432, 81433, 81351, 81352

Apolipoprotein E for Risk Assessment and Management of Cardiovascular Disease (PDF) - GT05

  • 81401

Genetic Testing for Lynch Syndrome and APC-associated and MUTYH-associated Polyposis Syndromes (PDF) - GT06

  • 0238U, 81201, 81202, 81203, 81210, 81288, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81317, 81318, 81319, 81401, 81406

Genetic Testing for Cutaneous Malignant Melanoma (PDF) - GT08

  • 81404

Cytochrome p450 and VKORC1 Genotyping for Treatment Selection and Dosing (PDF) - GT10

  • 81225, 81401, 81402, 81404, 81405, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076U
  • UMP is subject to HTCC Decision (PDF) for codes 81225, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U and 0076U.
  • Codes 81225, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U and 0076U will deny as not a covered benefit when billed with the following dx: depression, mood disorders, psychosis, anxiety, ADHD and substance use disorders.

Genetic Testing; Familial Hypercholesterolemia (PDF) - GT11

  • 81401, 81405, 81406, 81407

KRAS, NRAS and BRAF Variant Analysis and MicroRNA Expression Testing for Colorectal Cancer (PDF) - GT13

  • 81210, 81275,81276, 81311, 81403, 81404, 0111U

Preimplantation Genetic Testing of Embryos (PDF) - GT18

  • 89290, 89291, 81228, 81229, 81349

Genetic Testing; IDH1 and IDH2 Genetic Testing for Conditions Other Than Myeloid Neoplasms or Leukemia (PDF) - GT19

  • 81120, 81121

Genetic and Molecular Diagnostic Testing (PDF) - GT20

  • 0232U, 0234U, 0235U, 0238U, 0244U, 81201, 81202, 81203, 81210, 81212, 81215, 81216, 81217, 81225, 81228, 81229, 81235, 81243, 81244, 81250, 81252, 81253, 81254, 81257, 81275, 81276, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81302, 81303, 81304, 81311, 81314, 81317, 81318, 81319, 81321, 81322, 81323, 81324, 81325, 81326, 81341, 81349, 81350, 81351, 81352, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81419, 81470, 81471, S3800, S3840, S3844, S3845, S3846, S3849, S3850, S3853, S3865, S3866
  • UMP is subject to HTCC Decision (PDF) for code 81225.
  • Code 81225 will deny as not a covered benefit when billed with the following dx: depression, mood disorders, psychosis, anxiety, ADHD and substance use disorders

Genetic Testing for Biallelic RPE65 Variant-Associated Retinal Dystrophy (PDF) - GT21

  • 81406

Gene Expression Profiling for Melanoma (PDF) - GT29

  • 81552

BRAF Genetic Testing to Select Melanoma or Glioma Patients for Targeted Therapy (PDF) - GT41

  • 81210

Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer (PDF) - GT42

Diagnostic Genetic Testing for Genetic Testing for FMR1 and AFF2 Variants (Including Fragile X and Fragile XE Syndromes) (PDF) - GT43

  • 81243, 81244

Genetic Testing for CADASIL Syndrome (PDF) - GT51

  • 81406

Diagnostic Genetic Testing for α-Thalassemia (PDF) - GT52

  • 81257, 81258, 81259, 81269, 81404

Genetic Testing; Primary Mitochondrial Disorders (PDF) - GT54

  • 81401, 81403, 81404, 81405, 81440, 81460, 81465

Targeted Genetic Testing for Selection of Therapy for Non-Small Cell Lung Cancer (NSCLC) (PDF) - GT56

  • 0022U, 81210, 81235, 81275, 81276, 81404, 81405, 81406

Genomic Microarray Testing

  • UMP is subject to HTCC Decision (PDF) for codes 81228, 81229, 81349, S3870, 0156U, 0209U, 0318U

Genetic Testing for Myeloid Neoplasms and Leukemia (PDF) - GT59

  • 81120, 81121, 81351, 81352, 81401, 81402, 81403, 81450, 81455

Genetic Testing for PTEN Hamartoma Tumor Syndrome (PDF) - GT63

  • 0235U, 81321, 81322, 81323

Genetic Testing for Evaluating the Utility of Genetic Panels (PDF) - GT64

  • 81201, 81202, 81203, 81210, 81225, 81228, 81229, 81235, 81243, 81244, 81250, 81252, 81253, 81254, 81257, 81275, 81276, 81288, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81302, 81303, 81304, 81311, 81314, 81317, 81318, 81319, 81321, 81322, 81323, 81324, 81325, 81326, 81349, 81350, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81412, 81432, 81433, 81434, 81437, 81438, 81440, 81443, 81450, 81455, 81460, 81465, 81470, 81471
  • UMP is subject to HTCC Decision (PDF) for code 81225
  • Code 81225 will deny as not a covered benefit when billed with the following dx: depression, mood disorders, psychosis, anxiety, ADHD and substance use disorders.

Genetic Testing for Methionine Metabolism Enzymes, including MTHFR (PDF) - GT65

  • 81401, 81403, 81404, 81405, 81406

Genetic Testing for the Diagnosis of Inherited Peripheral Neuropathies (PDF) - GT66

  • 81403, 81404, 81405, 81406, 81324, 81325, 81326, 81448

Genetic Testing for Rett Syndrome (PDF) - GT68

  • 0234U, 81302, 81303, 81304, 81404, 81405, 81406

Genetic Testing for Duchenne and Becker Muscular Dystrophy (PDF) - GT69

  • 0218U, 81161, 81408

Fetal RHD Genotyping Using Maternal Plasma (PDF) - GT74

  • 81403

Genetic Testing for Macular Degeneration (PDF) - GT75

  • 81401, 81405, 81408

Whole Exome and Whole Genome Sequencing

Genetic Testing for Heritable Disorders of Connective Tissue (PDF) - GT77

  • 81405, 81408

Invasive Prenatal Fetal Diagnostic Testing for Chromosomal Abnormalities (PDF) - GT78

  • 81228, 81229, 81349, 81405

Genetic Testing for the Evaluation of Products of Conception and Pregnancy Loss (PDF) - GT79

  • 81228, 81229, 81349

Genetic Testing for Epilepsy (PDF) - GT80

  • 0232U, 81188, 81189, 81190, 81401, 81403, 81404, 81405, 81406, 81407, 81419

Reproductive Carrier Screening for Genetic Diseases (PDF) - GT81

  • 81161, 81243, 81244, 81250, 81252, 81253, 81254, 81257, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81412, 81434, 81443, S3844, S3845, S3846, S3849, S3850, S3853

Expanded Molecular Panel Testing of Cancers to Select Targeted Therapies (PDF) - GT83

  • 0022U, 0037U, 0048U, 0211U, 0244U, 0250U, 0334U, 81120, 81121, 81162, 81210, 81235, 81275, 81276, 81292, 81295, 81298, 81311, 81314, 81319, 81321, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81445, 81455

Genetic Testing for Neurofibromatosis Type 1 or 2 (PDF) - GT84

  • 81405, 81406, 81408

Laboratory

Measurement of Serum Antibiodies to Selected Biologic Agents (PDF)

  • 80145, 80230, 80280

Maternity

Elective early delivery, prior to 39 weeks' gestation, is not a covered benefit (not applicable to emergency delivery or spontaneous labor).

Medicine

Bioengineered Skin and Soft Tissue Substitutes and Amniotic Products (PDF)

  • A4100, A6460, A6461, C1849, Q4100, Q4101, Q4102, Q4105, Q4106, Q4107, Q4114, Q4116, Q4122, Q4128, Q4132, Q4133, Q4151, Q4154, Q4159, Q4186, Q4187

Confocal Laser Endomicroscopy (PDF)

  • 43206, 43252, 88375

Coverage of Treatments Provided in a Clinical Trial (PDF)

  • S9990, S9991, S9988

Digital Therapeutic Products (PDF)

  • 0702T, 0703T, A9291

Digital Therapeutic Products for Attention Deficit Hyperactivity Disorder (PDF)

  • 0702T, 0703T, A9291

Digital Therapeutic Products for Substance Use Disorders (PDF)

  • 0702T, 0703T, A9291

Hyperbaric Oxygen Therapy for Tissue Damage, Including Wound Care and Treatment of Central Nervous System Conditions (PDF)

  • UMP is subject to HTCC Decision (PDF): 99183, G0277
  • Regence medical policy is used only to determine units of treatment, criteria for diabetic "standard wound therapy" and to address any conditions not addressed in the HTCC decisions under the HTCC "limitations of coverage" or "non-covered indicators".

In Vivo Analysis of Colorectal Lesions(PDF)

  • 88375

Intensity Modulated Radiotherapy (IMRT)

Laser Interstitial Thermal Therapy (PDF)

  • 61736, 61737

Orthopedic Applications of Stem-Cell Therapy, Including Bone Substitutes Used with Autologous Bone Marrow (PDF)

  • 38206, 38232, 38241

Progenitor Cell Therapy for the Treatment of Damaged Myocardium Due to Ischemia (PDF)

  • 38205, 38206, 38240, 38241

Charged-Particle (Proton or Helium Ion) Radiotherapy

  • UMP is subject to HTCC Decision (PDF) - 77520\, 77522\, 77523\, 77525
    • Pre-authorization is not required for members under 21 years of age
  • When the following codes are used for Charged-Particle (Proton or Helium Ion) Radiotherapy with SRS or SBRT, use HTCC Decision (PDF): 32701, 61796, 61797, 61798, 61799, 61800, 63620, 63621, 77301, 77338, 77371, 77372, 77373, 77432, 77435, G0339, G0340

Radioembolization, Transarterial Embolization (TAE) and Transarterial Chemoembolization (TACE) (PDF)

Sleep Medicine

  • View the Sleep Medicine Management Program for notification or authorization requirements.
  • Review the codes requiring authorization or notification in the Sleep Medicine section.

Tinnitus: Non-invasive, non-pharmacologic treatments

  • UMP is subject to HTCC Decision (PDF) for codes 0552T, 90832, 90833, 90834, 90836, 90837, 90838, 90867, 90868, 90869, 96156, 96158, 96159, 96160, 96161, 96164, 96165, 96167, 96168, 96170, 96171, S8948
  • Pre-authorization is only required within tinnitus diagnosis codes: H93.11, H93.12, H93.13, H93.19, H93.A1, H93.A2, H93.A3, H93.A9
  • Codes 0552T and S8948, when billed without a tinnitus diagnosis, will be denied as investigational based on Regence Medical Policy Low Level Laser Therapy
  • Note: Codes 90867 and 90868, when billed with chronic migraine and chronic tension headaches, is not a covered benefit per HTCC Decision (PDF)

Gender Affirming Interventions for Gender Dysphoria (PDF)

  • 15775, 15776, 17380, 55970, 55980
  • Codes 55970 and 55980 are non-specific. The specific procedure code(s) must be requested in place of these non-specific codes.
  • 17999, 19303, 19316, 19318, 19325, 19350, 53400, 53405, 53410, 53415, 53420, 53425, 53430, 54125, 54400, 54401, 54405, 54520, 54660, 54690, 55175, 55180, 56625, 56800, 56805, 57106, 57110, 57291, 57292, 57295, 57296, 57335, 57426, 58353, 58356, 58563, C1813, C2622, L8600
  • Use code 17999 to request laser hair removal.
  • Gender affirming surgical interventions for gender dysphoria require pre-authorization. Codes for specific procedures might also be listed as requiring pre-authorization in other medical policies, including but not limited to:
    • Abdominoplasty - 15830
    • Breast Reconstruction - 19316, 19318, 19325, 19350, L8600
    • Blepharoplasty and Brow Lift - 15820, 15821, 15822, 15823, 67900, 67901, 67902, 67903, 67904, 67906, 67908, 67909, 67950
    • Chin Implants - 21120, 21121, 21122, 21123, 21209
    • Collagen Injections - 11950, 11951, 11952, 11954
    • Endometrial Ablation - 58353, 58356, 58563
    • Panniculectomy - 15830
    • Rhinoplasty - 30400, 30410, 30420, 30430, 30435, 30450

Pharmacy

UMP has a separate vendor – Washington State Rx Services – for their prescription drug benefit. Pre-authorization is necessary for certain injectable drugs that are not normally approved for self-administration when obtained through a retail pharmacy, a network mail-order pharmacy, or a network specialty pharmacy. These drugs are indicated on the UMP Preferred Drug List.

Drugs usually payable under the member's medical benefit and pre-authorized will continue with the same Regence process.

Hemophilia Clotting Factors

Hemophilia clotting factor codes J7170. J7201, J7202, J7203, J7204, J7205, J7207, J7208, J7210 require pre-authorization and if approved will be covered under the Medical benefits for the following groups. For all other groups please use the pharmacy link above.

  • ATI Specialty Alloys and Components (group #10015713)
  • WA State Health Care Authority (group # 10003948)
  • Rin Tinto (grandfathered plan codes only) (groups #10021209 & 10019119)
  • OTET (group #10007445)
  • Northwest Evaluation Association (NWEA) (group #10002570)
  • Utah Valley University (group #10042213)
  • Encoder Products (group #10040552)
  • Eagle Eye Produce Inc (group #10040165)

Infusion Drug Site of Care

Certain provider administered infusion medications covered on the medical benefit are subject to the Site of Care Program (dru408) medication policy (PDF). This policy does not apply to members covered under UMP Plus plans.

Radiology

Contact Regence for pre-authorization for the following codes:

Coronary Artery Calcium Scoring

  • UMP is subject to HTCC Decision (PDF): S8092
  • Effective January 1, 2023: Adding pre-authorization to code 75571 and removing not a covered benefit denial
  • Note: CPT 75571 for Cardiac Artery Calcium Scoring is not a covered benefit; reference HTCC Decision.

Wireless Capsule Endoscopy for Gastrointestinal (GI) Disorders (PDF)

  • 0651T, 91110, 91111, 91113

AIM Specialty Health

We partner with AIM to administer our Advanced Imaging Authorization radiology program.

Note: If HTCC criteria is used for pre-authorization, see below links to that criteria. If there are no HTCC criteria or HTCC is out of scope for request, AIM criteria will apply.

Contact AIM to obtain an order number for the following codes: 70336, 70480, 70481, 70482, 70490, 70491, 70492, 70496, 70498, 70544, 70545, 70546, 70547, 70548, 70549, 70551, 70552, 70553, 71250, 71260, 71270, 71271, 71275, 71550, 71551, 71552, 71555, 72125, 72126, 72127, 72128, 72129, 72130, 72131, 72132, 72133, 72141, 72142, 72146, 72147, 72148, 72149, 72156, 72157, 72158, 72159, 72191, 72192, 72193, 72194, 72195, 72196, 72197, 72198, 73200, 73201, 73202, 73206, 73218, 73219, 73220, 73221, 73222, 73223, 73225, 73700, 73701, 73702, 73706, 73718, 73719, 73720, 73721, 73722, 73723, 73725, 74150, 74160, 74170, 74174, 74175, 74176, 74177, 74178, 74181, 74182, 74183, 74185, 74712, 75557, 75559, 75561, 75563, 75572, 75573, 75635, 76391, 77078, 77084, 78429, 78430, 78431, 78432, 78433, 78472, 78473, 78481, 78483, 78494, 93303, 93304, 93306, 93307, 93308, 93312, 93313, 93314, 93315, 93316, 93317, 93350, 93351, 95782, 95783, 95800, 95801, 95805, 95806, 95807, 95808, 95810, 95811, E0470, E0471, E0561, E0562, E0601, G0398, G0399, G0400, 0042T, 0501T, 0502T, 0503T, 0504T, 0648T, 0649T

Effective January 1, 2023: 75574, 78451, 78452, 78453, 78454, 78459, 78466, 78468, 78469, 78491, 78492

HTCC decisions administered by AIM:

  • Breast MRI
    • UMP is subject to HTCC Decision (PDF): 77046, 77047, 77048, 77049
    • HTCC criteria applies to all member requests regardless of gender
  • Cardiac Magnetic Resonance Angiography (CMRA)
  • Cardiac Nuclear Imaging
    • UMP is subject to HTCC Decision (PDF): 78451, 78452, 78453, 78454, 78459, 78466, 78468, 78469, 78491, 78492
  • Coronary Computed Tomographic Angiography (CTA)
  • Functional Neuroimaging for Primary Degenerative Dementia or Mild Cognitive Impairment
    • UMP is subject to HTCC Decision (PDF): 70554, 70555, 78608, 78609
    • Please see AIM criteria for pre-authorization requirements for indications other than primary degenerative dementia or mild cognitive impairment
  • Imaging for Rhinosinusitis
    • UMP is subject to HTCC Decision (PDF): 70450, 70460, 70470, 70486, 70487, 70488, 70540, 70542, 70543
    • Please see AIM criteria for pre-authorization requirements for indications other than Rhinosinusitis
  • Noninvasive Cardiac Imaging for Coronary Artery Disease
    • Effective January 1, 2023: UMP is subject to HTCC Decision (PDF): 75572, 75573, 75574, 78429, 78430, 78431, 78432, 78433 78451, 78452, 78453, 78454, 78459, 78466, 78468, 78469, 78472, 78473, 78481, 78483, 78491, 78492, 78494, 93350, 93351, 0501T, 0502T, 0503T, 0504T
  • Positron Emission Tomography (PET) Scans for Lymphoma

Sleep Medicine

We partner with AIM to administer our Sleep Medicine program.

Contact AIM to obtain an order number for the following codes: 95782, 95783, 95805, E0470, E0471

AIM uses HTCC to pre-authorize sleep medicine diagnosis and equipment. Also refer to the Surgery section for additional information about pre-authorization requirements related to surgery for Sleep Apnea Diagnosis and Treatment.

HTCC decisions administered by AIM:

  • Sleep Apnea – Diagnosis and Equipment
    • UMP is subject to HTCC Decisions (PDF): 95800, 95801, 95806, 95807, 95808, 95810, 95811, E0561, E0562, E0601, G0398, G0399, G0400
    • Please see AIM criteria for indications other than Sleep Apnea

Surgery

Ablation of Primary and Metastatic Liver Tumors (PDF)

  • 47370, 47371, 47380, 47381. 47382, 47383

Adipose-derived Stem Cell Enrichment in Autologous Fat Grafting to the Breast (PDF)

  • 15769, 15771, 15772, 11950, 11951, 11952, 11954
  • Note: Codes 19380 and 19499 do not require pre-authorization but are considered, and will deny as, investigational when used for autologous fat grafting and adipose-derived stem cell enrichment for augmentation or reconstruction of the breast

Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions (PDF)

  • J7330, S2112

Balloon Dilation of the Eustachian Tube (PDF)

  • 69705, 69706

Balloon Ostial Dilation for Treatment of Sinusitis (PDF)

  • 31295, 31296, 31297, 31298

Bariatric Surgery (PDF)

  • 43771, 43848, 43860, 43886
  • UMP is subject to HTCC Decision (PDF): 43644, 43772, 43773, 43774, 43775, 43820, 43845, 43846, 43887, 43888
  • Bariatric surgery and HTCC guidelines apply, in order to establish eligibility for surgery and medical necessity.

Blepharoplasty, Repair of Blepharoptosis, and Brow Ptosis Repair (PDF)

  • 15820, 15821, 15822, 15823, 67900, 67901, 67902, 67903, 67904, 67906, 67908, 67909, 67950

Bronchial Valves (PDF)

  • 31647, 31648, 31649, 31651

Cardiac Stenting

  • UMP is subject to HTCC Decision (PDF): 92928, 92933, 92937, 92941, 92943
  • Pre-authorization is not required for members being treated for a condition other than stable angina

Carotid Artery Stenting

Catheter Ablation Procedures for Supraventricular Tachyarrhythmias (SVTA)

Cervical Fusion for Degenerative Disc Disease

Chemical Peels (PDF)

  • 15788, 15789, 15792, 15793, 17360

Cochlear Implant (PDF)

  • For Bilateral Cochlear Implants, UMP is subject to HTCC Decision.
    For Unilateral Cochlear Implants and replacement requests, UMP follows Regence Medical Policy.
  • 69930, L8614, L8619, L8627, L8628

Cosmetic and Reconstructive Surgery (PDF)

  • 11920, 11921, 11922, 11950, 11951, 11952, 11954, 15769, 15771, 15772, 15773, 15774, 17106, 17107, 17108, 19355, 21244, 21245, 21246, 21248, 21249, 21295, 21296, 41510, 49250, 54360, 67950, 69300, G0429, Q2026, Q2028
  • Pre-authorization is required EXCEPT when services are rendered in association with breast reconstruction and nipple/areola reconstruction following mastectomy for breast cancer.
  • Note: Codes 19380 and 19499 do not require pre-authorization but are considered, and will deny as, investigational when used for autologous fat grafting and adipose-derived stem cell enrichment for augmentation or reconstruction of the breast

Cryosurgical Ablation of Miscellaneous Solid Tumors Outside of the Liver (PDF)

  • 31641, 32994, 50542

Deep Brain Stimulation (PDF)

  • 61850, 61860, 61863, 61864, 61867, 61868, 61885, 61886, C1820, L8679, L8680, L8685, L8686, L8687, L8688, L8682, L8683
  • Deep brain stimulation is not a covered benefit for treatment-resistant depression, per HTCC Decision (PDF).

Discography

Endometrial Ablation (PDF)

  • 58353, 58356, 58563

Facet Neurotomy

Gastric Electrical Stimulation (PDF)

  • 43647, 43881, 64590, 64595, E0765, C1767, L8679, L8680, L8685, L8686, L8687, L8688

Gastroesophageal Reflux Surgery (PDF)

  • 43279, 43280, 43281, 43282, 43325, 43327, 43328, 43332, 43333, 43334, 43335, 43336, 43337

Hip Surgery for Femoroacetabular Impingement Syndrome (FAI)

Hypoglossal Nerve Stimulation (PDF)

  • 64568, 64582, 64583
  • Effective November 1, 2022: C1767

Implantable Cardiac Defibrillators (PDF)

  • 33230, 33231, 33240, 33249, 33270, 33271, C1721, C1722, C1882
  • Pre-authorization is required EXCEPT when the member is age 17 or younger

Implantable Peripheral Nerve Stimulation and Peripheral Subcutaneous Field Stimulation (PDF)

  • 64585, 64590, 64595, L8680, L8683

Laser Treatment for Port Wine Stains (PDF)

  • 17106, 17107, 17108

Leadless Cardiac Pacemakers (PDF)

  • 33274

Left-Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation (PDF)

  • 33340

Lumbar Fusion for Degenerative Disc Disease

  • UMP is subject to HTCC Decision (PDF): 22533, 22558, 22612, 22630, 22633, 22853, 22854, 22859
  • Lumbar Fusion for degenerative disc disease uncomplicated by comorbidities is not a covered benefit per HTCC Decision; This includes DX codes M51.35, M51.36, M51.37
    Note: This decision does not apply to patients with the following conditions: radiculopathy, spondylolisthesis (>grade 1), severe spinal stenosis, acute trauma or systemic disease affecting spine, e.g., malignancy
  • UMP is subject to HTCC Decision (PDF) for Bone Morphogenic Protein
  • Bone morphogenetic protein-7 (rhBMP-7) is not a covered benefit
  • HTCC for bone morphogenetic protein does not apply to those under age 18

Magnetic Resonance (MR) Guided Focused Ultrasound (MRgFUS) and High Intensity Focused Ultrasound (HIFU) Ablation (PDF)

  • 0398T, 55880

Microwave Tumor Ablation (PDF)

  • 32998, 50592

Negative Pressure Wound Therapy for Home Use (NPWT) (PDF)

Occipital Nerve Stimulation (PDF)

  • 61885, 61886, 64553, 64568, 64569, 64585, 64590
  • C1820, L8679, L8680, L8682, L8683, L8685, L8686, L8687, L8688
  • Occipital Nerve Stimulation is considered investigational for all indications, including but not limited to headaches
  • Note: These codes may overlap with the codes in the Vagus Nerve Stimulation Medical Policy so to ensure proper adjudication of your claim, please call for pre-authorization on all of the above codes.

Orthognathic surgery (PDF)

  • 21085, 21110, 21120, 21121, 21122, 21123, 21125, 21127, 21141, 21142, 21143, 21145, 21146, 21147, 21150, 21151, 21154, 21155, 21159, 21160, 21188, 21193, 21194, 21195, 21196, 21198, 21206, 21208, 21209, 21210, 21215, 21230, 21295, 21296
  • Codes 21145, 21196, 21198 require pre-authorization EXCEPT when the procedure is performed for oral cancer dx codes: C01, C02-C02.9, C03-C03.9, C04-C04.9, C05-C05.9, C06, C06.2, C06.9, C09-C09.9, C10-C10.0, C41-C41.1, C46.2, D00-D00.00, D10, D10.1-D10.9, D16.4-D16.5, D37-D37.0, D49-D49.0

Osteochondral Allograft/Autograft Transplantation (OAT)

Ovarian, Internal Iliac and Gonadal Vein Embolization, Ablation, and Sclerotherapy (PDF)

  • 37241

Percutaneous Angioplasty and Stenting of Veins (PDF)

  • 37238, 37239, 37248, 37249

Panniculectomy (PDF)

  • 15830

Pectus Excavatum and Carinatum Surgery (PDF)

  • 21740, 21742, 21743

Phrenic Nerve Stimulation for Central Sleep Apnea (PDF)

  • C1823

Radiofrequency Ablation (RFA) of Tumors Other Than the Liver (PDF)

  • 0404T, 20982, 31641, 32998, 50542, 50592, 58674

Reconstructive Breast Surgery/Mastopexy, and Management of Breast Implants (PDF)

  • 11920, 11921, 15769, 15771, 15772, 19316, 19318, 19325, 19328, 19330, 19340, 19342, 19350, 19355, 19370, 19371, L8600
  • Pre-authorization is required EXCEPT when services are rendered in association with breast reconstruction and nipple/areola reconstruction following mastectomy for breast cancer. However, if autologous fat grafting with adipose-derived stem cell enrichment is used for augmentation or reconstruction of the breast it would be considered investigational.
  • Note: Codes 19380 and 19499 do not require pre-authorization but are considered, and will deny as, investigational when used for autologous fat grafting and adipose-derived stem cell enrichment for augmentation or reconstruction of the breast.

Reduction Mammaplasty (PDF)

  • 19318

Responsive Neurostimulation (PDF)

  • 61850, 61860, 61863, 61864, 61885, 61886, L8680, L8686, L8688

Rhinoplasty (PDF)

  • 30120, 30400, 30410, 30420, 30430, 30435, 30450

Sacral Nerve Neuromodulation (Stimulation) for Pelvic Floor Dysfunction (PDF)

  • 64561, 64581, 64585, 64590, 64595, C1767, L8679, L8680, L8682, L8683, L8685, L8686, L8687, L8688
  • Note: Please submit your pre-authorization request for the temporary trial period of sacral nerve neuromodulation AND the permanent placement at the same time, as these are treated as one combined episode.

Sacroiliac Joint Fusion (PDF)

Spinal Cord and Dorsal Root Ganglion Stimulation (PDF)

  • 63650, 63655, 63685, C1767, C1820, C1822, L8679, L8680, L8685, L8686, L8687, L8688
  • Note: Please submit your pre-authorization request for the temporary trial AND the permanent placement at the same time.
  • Spinal cord stimulation for the treatment of chronic neuropathic pain is not a covered benefit, per HTCC Decision when associated diagnosis codes are included:
    • G60.9
    • G89.28-G89.29
    • M47.20-M47.28
    • M47.811-M47.819
    • M48.062
    • M50.10-M50.13
    • M50.121-M50.123
    • M54.10-M54.13
    • M51.14-M51.17
    • M54.16-M54.17
    • M54.30-M54.32
    • M54.40-M54.42
    • M54.5
    • M79.2
    • G89.4
    • M96.1
  • If treatment is for other than this indication, Regence medical policy applies.

Spinal Injections

  • Spinal Injections for UMP members are subject to HTCC Decision (PDF)
  • Notes:

    • CPT 62292 for Therapeutic Medial Branch Nerve Block, Intradiscal and Facet Spinal Injections are not a covered benefit, reference the HTCC Decision (PDF):
    • CPT 62320, 62321, 62322, 62323, 64479, 64480, 64483, 64484, 64490, 64491, 64492, 64493, 64494, 64495 may be subject to HTCC Decision (PDF). Pre-authorization is not required but may be subject to HTCC Decision (PDF) and require a provider attestation.
    • Attestation is needed for timely and accurate processing of claims
      • Use the electronic authorization tool on the Availity Portal and select the attestation criteria during the clinical documentation process on MCG Health
      • If an attestation is not completed pre-service using the Availity tool, fax the completed attestation form (PDF) to 1 (877) 357-3418
    • This coverage policy does not apply to those with systemic inflammatory disease such as ankylosing spondylitis, psoriatic arthritis or enteropathic arthritis

Spinal Surgery - Artificial Disc Replacement

  • UMP is subject to HTCC Decision (PDF): 22856, 22858, 22861, 0095T, 0098T
  • Lumbar artificial disc is not a covered benefit: 22857, 22862, 22865, 0163T, 0164T, 0165T

Stereotactic Radiation Surgery and Stereotactic Body Radiation Therapy

  • UMP is subject to HTCC Decision (PDF): 32701, 61796, 61797, 61798, 61799, 61800, 63620, 63621, 77301, 77338, 77371, 77372, 77373, 77432, 77435, G0339, G0340

Surgery for Lumbar Radiculopathy

  • UMP is subject to HTCC Decision (PDF): CPT 62380, 63030, 63035, 63042, 63044, 63047, 63048, 63056, 63057, 63090, 63091
  • NOTES:

    • Pre-authorization is required only with DX codes M47.20, M47.25, M47.26, M47.27, M47.28, M51.15, M51.16, M51.17, M51.26, M51.27, M54.10, M54.15, M54.16, M54.17, M54.18, M54.30, M54.31, M54.32, M54.40, M54.41, M54.42
    • CPT 62380 when billed without one of the listed DX will be denied as an investigational denial based on Regence Medical Policy Automated Percutaneous and Percutaneous Endoscopic Discectomy

Surgical Treatments for Hyperhidrosis (PDF)

  • 32664, 64818, 69676
  • Code 32664 only requires pre-authorization for hyperhidrosis diagnoses L74.510 L74.511, L74.512, L74.513, L74.519, L74.52, R61

Sleep Apnea Diagnosis and Treatment

  • UMP is subject to HTCC Decision (PDF): 21121, 21122, 21141, 21145, 21196, 21198, 21199, 21685, 41120, 42140, 42145, 42160
  • Codes 21145, 21196, 21198, 41120, 42160 do not require pre-authorization when the procedure is performed for oral cancer dx codes: C01, C02-C02.9, C03-C03.9, C04-C04.9, C05-C05.9, C06, C06.2-C06.9, C09-C09.9, C10-C10.0, C41-C41.1, C46.2, D00-D00.00, D10, D10.1-D10.9, D16.4-D16.5, D37-D37.0, D49-D49.0
  • HTCC does not apply to those under age 18. See Regence medical policy Surgeries for Snoring, Obstructive Sleep Apnea Syndrome, and Upper Airway Resistance Syndrome (PDF)

Temporomandibular Joint (TMJ) Surgical Interventions

  • Visit MCG's website for information on purchasing their criteria, or contact us for a copy of the specific guideline.
  • 21010 - MCG A‐0522
  • 21050 - MCG A‐0523
  • 29800, 29804 - MCG A‐0492
  • 21240, 21242, 21243 - MCG A‐0523

Transcatheter Aortic-Valve Implantation for Aortic Stenosis (PDF)

  • 33361, 33362, 33363, 33364, 33365, 33366

Transcutaneous Bone Conduction and Bone-Anchored Hearing Aids (PDF)

  • 69714, 69710, 69716, 69717, 69719, 69726, 69727, L8690, L8691, L8692, L8694

Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease (GERD) (PDF)

  • 43192, 43201, 43236
  • Note: Codes 43201 and 43236 may also be used for the administration of Botox for indications unrelated to GERD. Botox requires pre-authorization by Regence. Learn more about submitting a pre-authorization request for Boxtox.

Transurethral Water Vapor Thermal Therapy and Transurethral Water Jet Ablation (Aquablation) of the Prostate (PDF)

  • 53854

Vagus Nerve Stimulation (PDF)

  • 0720T, 61885, 61886, 64553, 64568, 64569, C1822, K1020, L8679, L8680, L8682, L8683, L8685, L8686, L8687, L8688
  • UMP is subject to HTCC Decision (PDF): for treatment of epilepsy and depression: 0720T, 61885, 61886, 64553, 64568, C1822, K1020, L8679, L8680, L8682, L8683, L8685, L8686, L8687, L8688
  • If treatment is for other than these indications, Regence medical policy applies.
  • The HTCC does not apply to members under age 4. Please use Regence Medical Policy for requests for members under age 4.

Varicose Vein Treatment (PDF)

  • UMP is subject to HTCC Decision (PDF): 0524T, 36465, 36466, 36470, 36471, 36475, 36476, 36478, 36479, 36482, 36483, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37785, S2202
  • Notes:

    • Requests for multiple treatment sessions should refer to Regence medical policy
    • Code 37241 is not appropriate to use in the coding of varicose vein treatment

Ventral (Including Incisional) Hernia Repair (PDF)

  • 15734, 49560, 49565, 49652, 49654, 49656
  • Pre-authorization for 15734 required only with diagnosis code K43.0, K43.1, K43.2 K43.6, K43.7 or K43.9 for component separation technique (CST)
  • Pre-authorization for 49652 required only with diagnosis code K43.9 for ventral hernia

Transplants and ventricular assist devices

Transplants - Cell

  • 38205, 38206, 38232, 38240, 38241, 38242, 38243, S2140, S2142, S2150
  • Stem Cell Therapy for Musculoskeletal Condition is subject to HTCC Decision (PDF) criteria: 38205, 38206, 38212, 38215, 38230, 38232, 38240, 38241
  • Regence medical policy criteria will be used for codes and conditions not reviewed by the HTCC criteria

Transplants - Islet Transplantation (PDF)

  • 48160, 0584T, 0585T, 0586T, G0341, G0342, G0343

Transplants - Heart (PDF)

  • 33945

Transplants - Heart-Lung (PDF)

  • 33935

Transplants - Lung and Lobar Lung (PDF)

  • 32851, 32852, 32853, 32854, S2060

Transplants - Isolated Small Bowel Transplant (PDF)

  • 44135, 44136

Transplants - Small Bowel/Liver and Multivisceral Transplant (PDF)

  • 44135, 44136, 47135, 48554, S2053, S2054, S2152

Transplants - Liver Transplant (PDF)

  • 47135

Transplants - Pancreas Transplant (PDF)

  • 48554, S2065, S2152

Ventricular Assist Devices and Total Artificial Hearts (PDF)

  • 33927, 33928, 33929, 33975, 33976, 33977, 33978, 33979, L8698

Utilization management

Air Ambulance Transport (PDF)

  • A0435, A0430, S9960
  • Pre-authorization is required prior to elective fixed wing air ambulance transport.
  • Emergency air ambulance transports will be reviewed retrospectively for medical necessity; clinical documentation will be requested, if needed, upon receipt of the electronic claim.