Uniform Medical Plan Pre-authorization List

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 the Availity Portal 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).

Type of service or request

Online

Phone

Fax (only if unable to submit online)

Skilled nursing facility only

Submit an electronic pre-authorization request through the Availity Portal

1 (844) 600-4376

1 (855) 848-8220

Long term acute care

1 (800) 423-6884

1 (855) 848-8220

Chemical dependency and mental health

1 (800) 780-7881

1 (888) 496-1540

Transplants

1 (800) 423-6884

1 (844) 679-7764

Professional services and DME

1 (800) 423-6884

1 (844) 679-7763

Expedited requests

1 (800) 423-6884

1 (844) 679-7764

Radiology program

Codes requiring authorization are listed in the Radiology section below

 1 (877) 291-0509

Physical Medicine

Codes requiring authorization are listed in the Physical Medicine section below

Obtain or verify an authorization with eviCore healthcare

View workarounds for eviCore system outages

1 (855) 252-1115

1 (855) 774-1319

Sleep Medicine

Codes requiring authorization are listed in the Sleep Medicine section below

 1 (877) 291-0509

Notifications for:

  • Tertiary care settings (SNF, LTACH, RTC and inpatient rehabilitation)
  • Inpatient discharges

1 (800) 423-6884

1 (800) 453-4341

Clinical records for:

  • Skilled nursing
  • Long term acute care
  • Residential Treatment
  • Inpatient rehabilitation

1 (800) 423-6884

1 (844) 629-4404

Washington State Health Technology Clinical Committee (HTCC) Assessments

Under state law, the Uniform Medical Plans (UMP Achieve 1, UMP Achieve 2, UMP Classic, 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

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.

Inpatient admissions

See below for substance use disorder and mental health admissions.

Hospital admissions

  • Pre-authorization is required for elective inpatient admissions. For more information, read our Frequently Asked Questions (PDF).
  • Notification of a hospital admission or discharge is necessary within 24 hours of admission or discharge (or one business day, if the admission or discharge occurs on a weekend or a federal holiday).
  • Elective early delivery, prior to 39 weeks gestation, is not a covered benefit (not applicable to emergency delivery or spontaneous labor).
  • Notification is required via electronic medical record, when available. If electronic medical records are not available, notifications are required via fax or by calling 1 (800) 423-6884. Providers should not call Customer Service to notify of patient admissions or discharge. Learn more about this requirement in the Facility Guidelines section of our Administrative Manual.

Inpatient hospice

  • Notification of admission or discharge is necessary within 24 hours of admission or discharge (or one business day, if the admission or discharge occurs on a weekend or a federal holiday).
  • Notification is required via electronic medical record, when available. If electronic medical records are not available, notifications are required via fax. Learn more about this requirement.

Long Term Acute Care Facility (LTAC)

  • Pre-authorization is required prior to patient admission.

Rehabilitation

  • Pre-authorization is required prior to patient admission.

Skilled Nursing Facility (SNF)

  • Pre-authorization is required prior to patient admission.

Extracorporeal Circulation Membrane Oxygenation (ECMO) for the Treatment of Respiratory Failure in Adults (PDF)

  • 33946, 33947, 33948, 33949, 33952, 33954, 33956, 33958, 33962, 33964, 33966, 33984, 33986, 33987, 33988, 33989
  • ECMO for UMP is subject to HTCC Decision for initiation. Regence Medical Policy is used for continued use criteria not addressed in the HTCC.
  • Subject to review.

Durable medical equipment

Bone Growth Stimulation

Continuous Glucose Monitoring

Implantable Drug Delivery System

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)
  • 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

Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Conditions (PDF)

  • E0481, E0483

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

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

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

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

  • 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, 80405, 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

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

  • 81170, 81201, 81202, 81203, 81210, 81212, 81215, 81216, 81217, 81218, 81225, 81228, 81229, 81235, 81243, 81244, 81245, 81246, 81250, 81252, 81253, 81254, 81257, 81272, 81273, 81275, 81276, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81302, 81303, 81304, 81310, 81311, 81314, 81317, 81318, 81319, 81321, 81322, 81323, 81327, 81341, 81350, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 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

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

Genetic Testing for α-Thalassemia (PDF) - GT52

  • 81257, 81258, 81259, 81269, 81404

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

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

Chromosomal Microarray Analysis (CMA) or Copy Number Analysis for the Genetic Evaluation of Patients with Developmental Delay, Intellectual Disability, Autism Spectrum Disorder or Congenital Anomalies

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

  • 81120, 81121, 81170, 81175, 81176, 81218, 81245, 81246, 81272, 81273, 81310, 81334, 81401, 81402, 81403, 0023U, 0046U, 0049U

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

  • 81321, 81322, 81323

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

  • 81162, 81163, 81164, 81165, 81166, 81167, 81170, 81175, 81176, 81201, 81202, 81203, 81210, 81212, 81215, 81216, 81217, 81218, 81225, 81228, 81229, 81235, 81243, 81244, 81245, 81246, 81250, 81252, 81253, 81254, 81257, 81272, 81273, 81275, 81276, 81288, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81302, 81303, 81304, 81310, 81311, 81314, 81317, 81318, 81319, 81321, 81322, 81323, 81327, 81341, 81350, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81412, 81432, 81433, 81434, 81437, 81438, 81443, 81450, 81455, 81470, 81471, S3854
  • 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

Genetic Testing for Rett Syndrome (PDF) - GT68

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

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

  • 81161, 81408

Genetic Testing for Predisposition to Inherited Hypertrophic Cardiomyopathy (PDF) - GT72

  • 81403, 81405, 81406, 81407, 81439, S3865, S3866

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 (PDF) - GT76

  • 81415, 81416

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

  • 81405, 81408

Invasive Prenatal Fetal Diagnostic Testing Using Chromosomal Microarray Analysis (CMA) (PDF) - GT78

  • 81228, 81229, 81405

Chromosomal Microarray (CMA) Testing for the Evaluation of Products of Conception and Pregnancy Loss (PDF) - GT79

  • 81228, 81229

Genetic Testing for Epilepsy (PDF) - GT80

  • 81188, 81189, 81190, 81401, 81403, 81404, 81405, 81406, 81407

Reproductive Carrier Screening for Genetic Diseases (PDF) - GT81

  • 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, 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

Gene Expression Profile Testing of Cancer Tissue

  • UMP is subject to HTCC Decision (PDF) for codes 0009U, 81518, 81519, 81520, 81521, 81542, S3854, 81541, 81551, 0045U, 0047U, 0053U and 0067U

Laboratory

Laboratory and Genetic Testing for use of Thiopurines (PDF)

  • 81306, 81335, 81401, 0034U, 0169U
  • UMP is subject to HTCC Decision (PDF) for codes 81335, 0034U and 0169U.
  • Codes 81335, 0034U and 0169U will deny as not a covered benefit when billed with the following dx: depression, mood disorders, psychosis, anxiety, ADHD and substance use disorders.

Maternity

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

Medicine

Confocal Laser Endomicroscopy (PDF)

  • 43206, 43252, 88375

Coverage of Treatments Provided in a Clinical Trial (PDF)

  • S9990, S9991, S9988

Gait Analysis (PDF)

  • 96000, 96001, 96002, 96003, 96004
  • Gait analysis may be considered medically necessary in children and adolescents with cerebral palsy to select surgical or other therapeutic interventions for gait improvement. All other indications for gait analysis and Surface Electromyography (SEMG) Including Paraspinal SEMG (PDF); are considered investigational.

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 Polyps (PDF)

  • 88375

Intensity Modulated Radiotherapy (IMRT)

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

  • 38206, 38232, 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 Regence medical policy (PDF) criteria: 32701, 61796, 61797, 61798, 61799, 61800, 63620, 63621, 77371, 77372, 77373, 77432, 77435, G0339, G0340

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

Surface Electromyography (SEMG) Including Paraspinal SEMG (PDF)

  • 96002, 96004

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.

Gender Affirming Interventions for Gender Dysphoria: Clinical Criteria and Policy (PDF)

  • 17380, 19325, 55970, 55980
  • Note: Codes 55970 and 55980 are non-specific. The specific procedure code(s) must be requested in place of these non-specific codes.
  • Surgical treatments of gender dysphoria require pre-authorization. Check codes for specific procedures listed in other areas of this pre-authorization list (for example, breast reconstruction, blepharoplasty, rhinoplasty and abdominoplasty) that require pre-authorization, which also apply to gender affirmation surgical services. Pre-authorization is not required for mastectomy related to breast cancer or for breast reconstruction and nipple/areola reconstruction following procedure related to breast cancer.
  • 00103, 15820, 15821, 15822, 15823, 19303, 19316, 19318, 19324, 19325, 19350, 30400, 30410, 30420, 30430, 30435, 30450, 31551, 31552, 31553, 31554, 31580, 31584, 31587, 31591, 53400, 53405, 53410, 53415, 53420, 53425, 53430, 54520, 54690, 54125, 54660, 55175, 55180, 56625, 56800, 56805, 57106, 57110, 57291, 57292, 57295, 57296, 57335, 57426, 58150, 58180, 58260, 58262, 58270, 58275, 58290, 58291, 58541, 58542, 58543, 58544, 58550, 58552, 58553, 58554, 58570, 58571, 58572, 58573, C1813

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.

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.

Physical Medicine

We partner with eviCore healthcare to administer our Physical Medicine program.

  1. Verify member benefits and eligibility on the Availity Portal
  2. Review this entire page for similar services that require pre-authorization
  3. Obtain or verify an authorization with eviCore:

    1. Sign in to eviCore's portal
    2. Phone (855) 252-1115
    3. Fax (855) 774-1319
    4. View workarounds for eviCore system outages

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, eviCore criteria will apply.

Effective March 1, 2020: Physical therapy, speech therapy, occupational therapy (PT/ST/OT)

  • Members aged 17 and younger: Select pediatric diagnosis codes are excluded from the program (PDF).
  • We require authorization from eviCore for these codes: 92507, 92508, 92521, 92522, 92523, 92524, 92526, 92597, 92607, 92608, 92609, 92610, 92626, 92627, 92630, 92633, 95851, 95852, 96105, 97012, 97014, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036, 97039, 97110, 97112, 97113, 97116, 97129, 97130, 97139, 97150, 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 97530, 97542, 97750, 97755, 97760, 97761, 97763, 97799, G0151, G0152, G0157, G0158, G0159, G0160, G0283, S8950, S9128, S9129, S9131, S9152

Effective March 1, 2020: HTCC decisions administered by eviCore related to physical therapy, speech therapy, occupational therapy

  • Treatment of chronic migraine and chronic tension-type headache

    • UMP is subject to HTCC Decision (PDF): 97140
    • Note: Code 97140, when billed with chronic migraine and chronic tension headaches, is not a covered benefit

Pain management

  • We require authorization from eviCore for these codes: 00640, 27096, 61790, 61791, 62320, 62321, 62322, 62323, 62324, 62325, 62326, 62327, 62350, 62351, 62360, 62361, 62362, 64405, 64510, 64520, 72275, G0259, G0260

HTCC decisions administered by eviCore related to pain management:

  • Discography
  • Facet Neurotomy
  • Spinal Injections

    • UMP is subject to HTCC Decision (PDF): 62320, 62321, 62322, 62323, 64479, 64480, 64483, 64484, 64490, 64491, 64492, 64493, 64494, 64495
    • This coverage policy does not apply to those with systemic inflammatory disease such as ankylosing spondylitis, psoriatic arthritis or enteropathic arthritis

Joint management

  • We require authorization from eviCore for these codes: 23470, 23472, 23473, 23474, 27125, 27130, 27132, 27134, 27137, 27138, 27442, 27443, 27486, 27487, 27488, 27580, 29805, 29806, 29807, 29819, 29820, 29821, 29822, 29823, 29824, 29825, 29826, 29827, 29828, 29860, 29861, 29862, 29863, 29868, 29870, 29871, 29873, 29875, 29876, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889, 29891, 29892, 29893, 29894, 29895, 29897, 29898, 29899, 29904, 29905, 29906, 29907

HTCC decisions administered by eviCore related to joint management:

  • Hip Surgery for Femoroacetabular Impingement Syndrome (FAI)
  • Knee Arthroscopy for Osteoarthritis of the Knee
  • Total Knee Arthroplasty

Spine

  • We require authorization from eviCore for these codes: 20931, 20937, 20938, 22100, 22101, 22102, 22103, 22110, 22112, 22114, 22116, 22206, 22207, 22208, 22210, 22212, 22214, 22216, 22220, 22222, 22224, 22226, 22325, 22326, 22327, 22328, 22532, 22534, 22548, 22556, 22585, 22590, 22595, 22600, 22610, 22614, 22632, , 22634, 22800, 22802, 22804, 22808, 22810, 22812, 22818, 22819, 22830, 22840, 22842, 22843, 22844, 22845, 22846, 22847, 22848, 22849, 22850, 22852, 22855, 62380, 63001, 63003, 63005, 63011, 63012, 63015, 63016, 63017, 63020, 63040, 63043, 63045, 63046, 63050, 63051, 63055, 63064, 63066, 63075, 63076, 63077, 63078, 63081, 63082, 63085, 63086, 63087, 63088, 63101, 63102, 63103, 63170, 63172, 63173, 63180, 63182, 63185, 63190, 63191, 63194, 63195, 63196, 63197, 63198, 63199, 63200, 63250, 63251, 63252, 63265, 63266, 63267, 63268, 63270, 63271, 63272, 63273, 63275, 63276, 63277, 63278, 63280, 63281, 63282, 63283, 63285, 63286, 63287, 63290, 63295, 63300, 63301, 63302, 63303, 63304, 63305, 63306, 63307, 63308, S2350, S2351

HTCC decisions administered by eviCore related to spine:

  • Cervical Fusion for Degenerative Disc Disease
  • 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
      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
  • Surgery for Lumbar Radiculopathy
    • UMP is subject to HTCC Decision (PDF): 62380, 63030, 63035, 63042, 63044, 63047, 63048, 63056, 63057, 63090, 63091

Radiology

Contact Regence for pre-authorization for the following codes:

Coronary Artery Calcium Scoring

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, 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, 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, G0297, G0398, G0399, G0400, 0501T, 0502T, 0503T, 0504T

Effective February 9, 2020: 76391

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 Nuclear Imagining
    • 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
  • 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): 95782, 95783, 95800, 95801, 95805, 95806, 95807, 95808, 95810, 95811, E0470, E0471, 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, 19366
  • Notes:

    • Codes 11950, 11951, 11952, 11954, 15769, 15771, 15772 and 19366 require pre-authorization (see other sections of this pre-authorization list) except when used for autologous fat grafting and adipose-derived stem cell enrichment for augmentation or reconstruction of the breast, where it is considered, and will deny as, investigational
    • 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

Balloon Ostial Dilation for Treatment of Sinusitis (PDF)

  • 31295, 31296, 31297, 31298

Bariatric Surgery (PDF)

  • UMP is subject to HTCC Decision (PDF):
    • 43644, 43770, 43771, 43772, 43773, 43774, 43775, 43820, 43846, 43848, 43860, 43886, 43887, 43888
  • Bariatric surgery and HTCC guidelines apply, in order to establish eligibility for surgery and medical necessity.

Blepharoplasty and Brow Ptosis Repair (PDF)

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

Chemical Peels (PDF)

  • 15788, 15789, 15792, 15793, 17360

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)

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, 19355, 21244, 21245, 21246, 21248, 21249, 21295, 21296, 41510, 49250, 54360, 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.
  • Notes:

    • Codes 11950, 11951, 11952, 11954, 15769, 15771, 15772 and 19366 require pre-authorization (see other sections of this pre-authorization list) except when used for autologous fat grafting and adipose-derived stem cell enrichment for augmentation or reconstruction of the breast, where it is considered, and will deny as, investigational
    • 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 Organ, Pulmonary, and Breast Tumors (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).

Endometrial Ablation (PDF)

  • 58353, 58356, 58563

Gastric Electrical Stimulation (PDF)

  • 43647, 43881, 64590, 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

Hypoglossal Nerve Stimulation (PDF)

  • 64568, 0466T

Hysterectomy surgery

  • 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 the specific guideline.
  • Pre-authorization is required for:
    • MCG S-650: 58150, 58152, 58180
    • MCG S-660: 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58290, 58291, 58292, 58293, 58294
    • MCG S-665: 58541, 58542, 58543, 58544, 58550, 58552, 58553, 58554,58570, 58571, 58572, 58573
  • Pre-authorization is NOT required for:
    • Hysterectomy surgery associated with the following ICD-10 diagnoses:
    • Cancer: C53.0-C53.9, C54.0-C54.3, C54.8-C54.9, C55, C56.1-C56.9, C57.00-C57.8, C58, C79.60-C79.62, C79.82, D06.0-D06.9, D49.59
    • Uterovaginal or cervical stump prolapse: N81.2-N81.4, N81.85
  • Hysterectomy procedures for the indication of gender dysphoria are subject to the Gender Affirming Interventions for Gender Dysphoria: Clinical Criteria and Policy (PDF)

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 for Chronic Pain of Peripheral Nerve Origin (PDF)

  • 64555, 64575, 64590, 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

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

  • C9747, 0398T

Microwave Tumor Ablation (PDF)

  • 32998, 50592

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

Occipital Nerve Stimulation (PDF)

  • 61885, 61886, 64553, 64555, 64568, 64575, 64590, 0466T
  • 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 (PDF)

  • 21740, 21742, 21743

Phrenic Nerve Stimulation for Central Sleep Apnea (PDF)

  • C1823

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

  • 20982, 31641, 32998, 50542, 50592

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

  • 11920, 11921, 11950, 11951, 11952, 11954, 15769, 15771, 15772, 19316, 19318, 19324, 19325, 19328, 19330, 19340, 19342, 19350, 19355, 19366, 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.
  • Notes:

    • Codes 11950, 11951, 11952, 11954, 15769, 15771, 15772 and 19366 require pre-authorization (see other sections of this pre-authorization list)except when used for autologous fat grafting and adipose-derived stem cell enrichment for augmentation or reconstruction of the breast, where it is considered, and will deny as, investigational
    • 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, 64590, 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)

Surgeries for Snoring, Obstructive Sleep Apnea Syndrome, and Upper Airway Resistance Syndrome (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

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
    • 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 Surgery - Artificial Disc Replacement

Stereotactic Radiation Surgery and Stereotactic Body Radiation Therapy

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

Surgical Treatments for Hyperhidrosis (PDF)

  • 32664, 64818, 69676

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

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

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

  • 69714, 69710, 69715, 69717, 69718, 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.

Upper Endoscopy for Gastroesophageal Reflux Disease (GERD) and Gastrointestinal (GI) Symptoms

  • Upper Endoscopy for GERD and GI Symptoms for UMP members are subject to HTCC Decision (PDF)
  • CPT 43200, 43202, 43235, 43237, 43238, 43239, 43242 and 43259 do not require pre-authorization, but may be subject to HTCC Decision and require an Upper Endoscopy for GERD and GI Symptoms Attestation Form (PDF)
  • Notes:

    • Attestation forms may be submitted with the claim, or attestation may be completed pre-service through the Availity Portal
    • Attestation form is required for claims processing
    • Attestation form is required for adults only (member 18 years and older)

Vagus Nerve Stimulation (PDF)

  • UMP is subject to HTCC Decision (PDF): 61885, 61886, 64553, 64568, 0466T, L8679, L8680, L8682, L8683, L8685, L8686, L8687, L8688
  • The HTCC does not apply to members under age 12. Please use Regence Medical Policy for requests for members under age 12.
  • Note: Vagal Nerve Stimulation for the treatment of epilepsy and depression are subject to HTCC Decision. If treatment is for other than these indications, Regence medical policy applies.

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:

    • All varicose vein requests should be reviewed using the HTCC criteria.
    • Requests for multiple treatment sessions should refer to Regence medical policy for criteria addressing multiple treatment sessions only, and use the HTCC criteria for all other aspects of the request.
    • Code 37241 is not appropriate to use in the coding of varicose vein treatment

Ventral Hernia Repair (PDF)

  • 15734, 49560, 49565, 49652, 49654, 49656
  • Pre-authorization for 15734 required only with diagnosis code K43.2 or K43.9 for component separation technique (CST)
  • Effective March 1, 2020: 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

  • Reference our Medical Policy Manual for policies.
  • 38205, 38206, 38232, 38240, 38241, 38242, 38243, S2140, S2142, S2150

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; please submit clinical documentation and rationale for this form of transportation with your claim.