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The Uniform Medical Plan (UMP) Pre-authorization List includes services and supplies that require pre-authorization or notification for UMP products in Washington state. View pre-authorization requirements for UMP members of other Regence plans:

How to submit a pre-authorization request or notification

Expedited requests

Use this process only when the member or his/her physician believes that waiting for a decision under the standard time frame could place the member's life, health or ability to regain maximum function in serious jeopardy.

  • Availity Portal: Read the information carefully to ensure your request meets the qualifications, then check the box on the form to attest that it is an expedited request
  • Via fax using the appropriate pre-authorization request form below

Online

Phone or fax

Submit the appropriate pre-authorization request form only if unable to submit online or if submitting an expedited request:

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 pre-authorization request.

This applies to pre-authorizations for our group and Individual, Uniform Medical Plan (UMP) and Blue Cross and Blue Shield Federal Employee Program® (BCBS FEP®) members. It does not currently include Medicare Advantage pre-authorizations. View the services that may receive automated approval (PDF).

Pre-authorization

Type of service/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
Inpatient rehabilitation

1 (800) 423-6884 1 (855) 848-8220

Chemical dependency
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 Quality Initiative (RQI)

Obtain an order number with AIM Specialty HealthSM:

 

Inpatient concurrent review

  Phone Fax

Notifications for:

  • Inpatient admissions
  • Inpatient discharges
1 (800) 423-6884 1 (800) 453-4341

Clinical records for:

  • Skilled nursing
  • Long term acute care
  • Inpatient rehabilitation
1 (800) 423-6884 1 (844) 629-4404

 

Important pre-authorization reminders

Washington State Health Technology Clinical Committee (HTCC) Assessments

Under state law, the Uniform Medical Plans (UMP Classic, CDHP, and UMP Plus) must follow coverage 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 appropriate coverage, if any, for the services. These 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. Determinations from the HTCC will either be covered, covered with conditions, or not covered. When the HTCC determines that a service is not covered, that means the service is not medically necessary in any circumstance. If the HTCC has determined that a service or treatment may be covered, then it will be covered only in cases where it meets the HTCC's specific coverage criteria.

Final decisions and ongoing reviews may be accessed on the HTCC website.

HTCC decisions 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:
Urgent 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 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/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.

Pre-authorization exception

There may be exceptions to obtaining pre-authorization. The six situations listed below may apply as part of our Extenuating Circumstances Policy Criteria (PDF):

  1. Member presented with an incorrect member ID card or member number or indicated they were self-pay, and that no coverage was in place at the time of treatment, or the participating provider or facility is unable to identify from which carrier or its designated or contracted representative to request a pre-authorization.
  2. Natural disaster prevented the provider or facility from securing a pre-authorization or providing hospital admission notification.
  3. Member is unable to communicate (e.g., unconscious) medical insurance coverage. Neither family nor collateral support present can provide coverage information.
  4. Compelling evidence the provider attempted to obtain pre-authorization. The evidence shall support the provider followed our policy and that the required information was entered correctly by the provider office into the appropriate system.
  5. A surgery which requires pre-authorization occurs in an urgent/emergent situation. Services are subject to review post-service for medical necessity
  6. A participating provider or facility is unable to anticipate the need for a pre-authorization before or while performing a service or surgery.

Use PreManage for notification

We receive admissions and discharge information through PreManage.

Inpatient admissions

See below for chemical dependency and mental health admissions.

Hospital admissions

Pre-authorization is required for elective inpatient admissions occurring on or after May 1, 2019. 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. Learn more about this requirement. If your facility submits electronic admission and discharge data to Collective Medical Technologies, we will receive it through PreManage/EDIE.

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. If your facility submits electronic admission and discharge data to Collective Medical Technologies, we will receive it through PreManage/EDIE.

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.

Chemical dependency and mental health

Pre-authorization is required for the services listed below. Emergency inpatient services do not require pre-authorization, but are subject to admission notification requirements.

  • Inpatient: Psychiatric or ASAM 4.0 Detoxification 
    • Notification of admission must be received within 24 hours of admission or the next business day (whichever comes first). Medical necessity review will be conducted.
  • Sub-Acute Detoxification/ASAM Level 3.7
    • Requires pre-authorization before the member is admitted for services. Under certain circumstances, pre-authorization requests can be made within 24 hours of admission or the next business day.
  • Residential treatment: Psychiatric or ASAM Level 3.5 for Substance Use Disorders 
    • Requires pre-authorization before the member is admitted for services. Under certain circumstances, pre-authorization requests can be made within 24 hours of admission or the next business day.
  • Partial hospitalization: Psychiatric or ASAM level 2.5 for Substance Use Disorders
    • Request for authorization is required no later than the day of admission.
  • Intensive outpatient: Psychiatric or ASAM level 2.1 for Substance Use Disorders
    • Request for authorization is required no later than the day of admission.
Medical necessity for behavioral health services is determined by:

Important information regarding specific services

Applied behavioral analysis (ABA) Therapy

ABA Therapy is for the treatment of Autism Spectrum Disorders (ASD) when medically necessary.

  • Procedure codes 0362T, 0373T, 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158
  • Procedure codes 97151, 97152, and 0362T: Pre-authorization is not required when 97151, 97152, and 0362T are used for initial ABA assessments, but pre-authorization is required when 97151, 97152, and 0362T are used for ABA reassessments.

The following clinical providers, with expertise in using evidenced-based tools to establish or confirm the diagnosis of autism and experience in developing multidisciplinary autism treatment plans, can provide the diagnostic assessment, comprehensive evaluation report, and recommend treatment approach:

  • Psychiatrist
  • Neurologist
  • Pediatric Neurologist
  • Developmental Pediatrician
  • Doctorate level psychologist
  • Advanced registered nurse practitioner

Initial pre-authorizations must contain the following information; View specific details on what each of these below items need to contain (PDF)

  • Pre-authorization request form (PDF) (or equivalent information)
  • Clinical evaluation, which includes confirmation of an ASD diagnosis, and recommended treatment approach from a clinician meeting the criteria above (clinical evaluation needs to have been completed within the 12 months prior to the initial pre-authorization request)
  • Written Clinical Order, Directive, or Prescription for ABA Therapy services from a clinician meeting the criteria above
  • ABA initial report that includes an ABA assessment treatment plan (to be completed by the Lead Behavior Therapist). This sample ABA assessment and treatment plan form (PDF) can be filled out and submitted or used as a reference tool.

A cover letter may be submitted; however, it is not required. A sample cover letter template (PDF) is provided for your reference. Other supporting documentation may be submitted.

View ABA therapy clinical considerations (PDF) for information about hours of service and documentation requirements.

Concurrent Review

The following document should be submitted within 5 business days prior to the end of a current authorization:

Following the submission of the concurrent review documentation, the plan may request additional information prepared and submitted by a clinician meeting the above clinical criteria. The plan will specify what must be included in this report which is intended to assess progress and prospective treatment in further detail and may include a written Clinical Order, Directive or Prescription for ABA Therapy services.

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 or a network mail-order 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. Exception: Self-administered growth hormone, rheumatoid arthritis and multiple sclerosis injectables are handled through Washington Rx Services.

Durable medical equipment

Bone Growth Stimulation
Continuous Glucose Monitoring
Implantable Drug Delivery System
  • UMP is subject to HTCC Decision (PDF) – C1772, C1889, C1891, C2626, E0782, E0783, E0785, E0786
Insulin Infusion Pumps and Artificial Pancreas Device System (APDS) (PDF)
  • Effective November 1, 2019: E0784
Microprocessor-Controlled Lower Limb Prosthetics (PDF)

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)
  • Effective November 1, 2019: E0466
Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Conditions (PDF)
  • E0481, E0483
Power Wheelchairs: Group 3 (PDF)
  • Effective November 1, 2019: K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855, K0856, K0857, K0858, K0859, K0860, K0861, K0862, K0863, K0864
Programmable Pneumatic Compression Pumps (PDF)
  • E0652
Stents, Drug Coated or Drug-Eluting (DES) Refer to Cardiac Stenting in the Surgery section below.

 

Genetic testing

Genetic Testing for Alzheimer's Disease (PDF) GT01 81401, 81405, 81406
Genetic Testing for Hereditary Breast and/or Ovarian Cancer and Li-Fraumeni Syndrome (PDF) GT02 81162, 81163, 81164, 81165, 81166, 81167, 81212, 81215, 81216, 81217, 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 Cardiac Ion Channelopathies (PDF) GT07

81413, 81414

S3861

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
KRAS, NRAS and BRAF Variant Analysis and MicroRNA Expression Testing for Colorectal Cancer (PDF) GT13 81210, 81275,81276, 81311, 81403, 81404
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, 81256, 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, 81413, 81470, 81471

S3800, S3840, S3844, S3845, S3846, S3849, S3850, S3853, S3861, 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

Biallelic RPE65 Variant-Associated Retinal Dystrophy (PDF) GT21 81406
Gene Expression Profiling for Melanoma (PDF) GT29 0081U
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

UMP is subject to HTCC Decision (PDF) for codes 81518, 81519, 81521, S3854

Genetic Testing for FMR1 and AFF2 Variants (Including Fragile X and Fragile XE Syndromes (PDF) GT43 81243, 81244
Genetic Testing for Hereditary Hemochromatosis (PDF) GT48 81256
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) for the Genetic Evaluation of Patients with Developmental Delay/Intellectual Disability, Autism Spectrum Disorder or Congenital Anomalies (PDF)

GT58

UMP is subject to HTCC Decision (PDF) for codes 81228, 81229, S3870

Myeloid Neoplasms and Leukemia (PDF) GT59

81120, 81121, 81170, 81175, 81176, 81218, 81245, 81246, 81272, 81273, 81310, 81334, 81401, 81402, 81403

0023U, 0046U, 0049U

PTEN Hamartoma Tumor Syndrome (PDF) GT63 81321, 81322, 81323

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, 81256, 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, 81413, 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.

Methionine Metabolism Enzymes, including MTHFR, for Indications Other than Thrombophilia (PDF) GT65 81401, 81403, 81404, 81405, 81406
Diagnosis of Inherited Peripheral Neuropathies (PDF) GT66 81403, 81404, 81405, 81406
Rett Syndrome (PDF) GT68 81302, 81303, 81304, 81404, 81405, 81406
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 GT75 81401, 81405, 81408
Genetic Testing for Heritable Disorders of Connective Tissue (PDF) GT77 81405, 81408

Genetic Testing; 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

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

Genetic Testing: 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
Gene Expression Profile Testing of Cancer Tissue  

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

 

Laboratory

Laboratory and Genetic Testing for use of Thiopurines (PDF)

  • 81306, 81335, 81401, 0034U
  • UMP is subject to HTCC Decision (PDF) for codes 81335 and 0034U.
  • Codes 81335 and 0034U 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 Paraspinal Surface Electromyography (EMG) (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
  • 88375
Intensity Modulated Radiotherapy (IMRT)

UMP is subject to HTCC Decision (PDF):

  • 77301, 77338, 77385, 77386
  • G6015, G6016
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
  • 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)
  • 37243, 79445
  • S2095

Note: Ovarian and Internal Iliac Vein Embolization as a Treatment of Pelvic Congestion Syndrome (PDF) is considered investigational.

Surface Electromyography (SEMG) (PDF)
  • 96002, 96004

Transgender Services (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 transgender 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, 19304, 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

UMP Transgender Services: Clinical Criteria and Policy (PDF)

 

Radiology

Contact Regence for pre-authorization for the following codes:

Cardiac Nuclear Imaging
  • UMP is subject to HTCC Decision (PDF) - 78451, 78452, 78453, 78454, 78459, 78466, 78468, 78469, 78491, 78492
Coronary Artery Calcium Scoring

Note: CPT 75571 for Cardiac Artery Calcium Scoring is not a covered benefit; reference HTCC Decision.

Coronary Computed Tomographic Angiography (CTA)
Discography
Dopamine Transporter Imaging Single-Photon Emission Computed Tomography (DAT-SPECT) (PDF)
  • A9584, 78607
Imaging for Rhinosinusitis
  • UMP is subject to HTCC Decision (PDF) - 70450, 70460, 70470, 70486, 70487, 70488, S8042
  • Please see AIM criteria for pre-authorization requirements for indications other than Rhinosinusitis for codes 70450, 70460, 70470, 70486, 70487, 70488

Single Photon Emission Computed Tomography (SPECT) of the Brain (PDF)

  • UMP is subject to HTCC decision (PDF): 78607, A9584
  • Functional neuroimaging for primary degenerative dementia or mild cognitive impairment is not a covered benefit for 78607

Radiology Quality Initiative

Check for specific HTCC pre-authorization requirements documented under Cardiac Nuclear Imaging and Imaging for Rhinosinusitis.

We partner with AIM to administer our Radiology Quality Initiative (RQI) program.

Contact AIM to obtain an order number for the following codes:

70336, 70450, 70460, 70470, 70480, 70481, 70482, 70486, 70487, 70488, 70490, 70491, 70492, 70496, 70498, 70540, 70542, 70543, 70544, 70545, 70546, 70547, 70548, 70549, 70551, 70552, 70553, 70554*, 70555*, 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, 75574, 75635, 77046, 77047, 77048, 77049, 77078, 77084, 78451, 78452, 78453, 78454, 78459, 78466, 78468, 78469, 78472, 78473, 78481, 78483, 78491, 78492, 78494, 78608*, 78609*, 78811, 78812, 78813, 78814, 78815, 78816, 93303, 93304, 93306, 93307, 93308, 93312, 93313, 93314, 93315, 93316, 93317, 93350, 93351

G0297, 0501T, 0502T, 0503T, 0504T

*UMP is subject to HTCC Decision (PDF): 70554, 70555, 78607, 78608. Functional neuroimaging for primary degenerative dementia or mild cognitive impairment is not a covered benefit for 70554, 70555, 78607, 78608, 78609

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)
  • 19366

Notes:

  • Codes 11950, 11951, 11952, 11954, 19366, 19380, 19499, and 20926 are considered investigational when used for autologous fat grafting and adipose-derived stem cell enrichment for augmentation or reconstruction of the breast and will deny as investigational. 
  • Codes 11950, 11951, 11952, 11954, and 19366 require pre-authorization for other services on this pre-authorization list.
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, 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
Carotid Artery Stenting

UMP is subject to HTCC Decision (PDF):

  • 37215, 37216, 37217, 37246, 37247
Catheter Ablation Procedures for Supraventricular Tachyarrhythmias (SVTA)

UMP is subject to HTCC Decision (PDF):

  • 93653, 93655, 93656, 93657
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, 19355, 21244, 21245, 21246, 21248, 21249, 21295, 21296, 41510, 49250, 54360, 69300
  • G0429, Q2026, Q2028
  • Codes 11950, 11951, 11952, 11954 are considered investigational when used for autologous fat grafting and adipose-derived stem cell enrichment for augmentation or reconstruction of the breast and will deny as investigational. Please see the Adipose-derived Stem Cell Enrichment in Autologous Fat Grafting to the Breast section.
  • Pre-authorization is required EXCEPT when services are rendered in association with breast reconstruction and nipple/areola reconstruction following mastectomy for breast cancer.
  • Transgender services must also meet transgender policy requirements.
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
Facet Neurotomy
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
Hip Surgery for Femoroacetabular Impingement Syndrome (FAI)
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 Transgender Services medical policy (PDF)

Transcutaneous Bone Conduction and Bone-Anchored Hearing Aids (PDF)
  • 69714, 69710, 69715, 69717, 69718
  • L8690, L8691, L8692, L8694
Implantable Cardiac Defibrillator (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
Magnetic Resonance (MR) Guided Focused Ultrasould (MRgFUS) and High Intensity Focused Ultrasound (HIFU) Ablation (PDF)
  • C9747, 0398T

Microwave Tumor Ablation

  • 32998, 50592
Negative Pressure Wound Therapy for Home Use (NPWT) (PDF)

View the HTCC Decision: Definition of "Complete Wound Therapy Program" (PDF)

View the NPWT FDA Safety Communication

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 and Autograft Transplantation (OAT)

UMP is subject to HTCC Decision (PDF):

  • 27415, 27416, 29866, 29867
  • J7330, S2112
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 of Tumors (RFA) 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, 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.

11950, 11951, 11952, 11954, 19366, 19380, 20926 are considered investigational when used for autologous fat grafting and adipose-derived stem cell enrichment for augmentation or reconstruction of the breast and will deny as investigational.  Please see the Adipose-derived Stem Cell Enrichment in Autologous Fat Grafting to the Breast section.

Reduction Mammoplasty (PDF)
  • 19318
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)
  • 27280, 27279
Spinal Cord and Dorsal Root Ganglion Stimulation (PDF)
  • 63650, 63655, 63685
  • C1767, C1820, C1822, L8679, L8680, L8685, L8686, L8687, L8688
  • NOTE:  Please submit your preauthorization 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
M47.20-M47.28
M54.10-M54.13
M54.5
G89.28-G89.29
M47.811-M47.819
M54.16-M54.17
M79.2
G89.4
M50.10-M50.13
M54.30-M54.32
M96.1
 
M50.121-M50.123
M54.40-M54.42
 
 
M51.14-M51.17
 
 

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).
  • CPT 64633, 64634, 64635 and 64636 may be subject to HTCC Decision (PDF); therefore, they require pre-authorization.
  • Notes:
    • CPT 62292 for Therapeutic Medial Branch Nerve Block, Intradiscal and Facet Spinal injections are not a covered benefit; reference the HTCC Decision.
    • CPT 64490, 64491, 64492, 64493, 64494, 64495 may be subject to HTCC Decision. Pre-authorization is not required. Claims should be submitted with the Spinal Injection Additional Information Form (PDF) to certify that the provider is billing for an allowed service.
  • This coverage policy does not apply to those with systemic inflammatory disease such as ankylosing spondylitis, psoriatic arthritis or enteropathic arthritis.
Spinal Surgery - Artificial Intervertebral Disc Surgery

FDA indications and contraindications (PDF)

Effective January 1, 2019, lumbar artificial disc is not a covered benefit:

  • 22862, 22865
  • 0163T, 0164T, 0165T
Spinal Surgery - Lumbar Fusion (PDF)
  • 22533, 22558, 22612, 22630, 22633, 22853, 22854, 22859

UMP is subject to HTCC Decision – Lumbar Fusion for degenerative disc disease uncomplicated by comorbidities is not a covered benefit per HTCC Decision; this includes DX codes

M5135
M5136
M5137

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-2 (rhBMP-2) and bone morphogenetic protein-7 (rhBMP-7)
  • Note: Bone morphogenetic protein-7 (rhBMP-7) is not a covered benefit
Spinal Surgery - Cervical Fusion for Degenerative Disc Disease
Spinal Surgery - Cervical Fusion

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.

  • 22551, 22552, 22554 - MCG ORG S-320
  • 22600 - MCG ORG S-330

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
Surgery for Lumbar Radiculopathy (PDF)

UMP is subject to HTCC Decision (PDF):

  • 63030, 63035, 63042, 63044, 63047, 63048, 63056, 63057, 
    62380, 63090, 63091
  • NOTE: Pre-authorization is required only with primary Dx codes M4725, M4726, M4727, M5115, M5116, M5117, M5410, M5415, M5416, M5417, M4720, M4725, M4726, M4727
  • NOTE: 62380 when billed without one of the listed Dx will be denied as an investigational denial based on Regence medical policy (PDF).
Temporomandibular Joint (TMJ) Surgical Interventions 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.
  • 21010 - MCG A‐0522
  • 21050 - MCG A‐0523
  • 29800, 29804 - MCG A‐0492
  • 21240, 21242, 21243 - MCG A‐0523

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 Pharmacy.  Learn more about submitting a pre-authorization request for Boxtox
Upper Endoscopy for Gastroesophageal Reflux Disease (GERD) and Gastrointestinal (GI) Symptoms

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/Vagal 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.

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)
  • 49560, 49565, 49654, 49656

Effective September 1, 2019: 15734, 49652

Notes:

  • Pre-authorization for 15734 required only with diagnosis code K43.2 or K43.9 for component separation technique (CST)
  • Pre-authorization for 49652 required only with diagnosis code K43.9 for vental 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
  • 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.