General Prior Authorization Requirements
Providence Health Plan (PHP), Providence Health Assurance (PHA), and Providence Health Plan Partners (PPP) Medical Policies serve as guidance for the administration of plan benefits. Medical policies do not constitute medical advice nor a guarantee of coverage. PHP, PHA, and PPP Medical Policies are reviewed annually and are based upon published, peer-reviewed scientific evidence and evidence-based clinical practice guidelines that are available as of the last policy update. PHP, PHA, and PPP reserve the right to determine the application of Medical Policies and make revisions to its Medical Policies at any time. Providers will be given 60-days’ notice of policy changes that are restrictive in nature.
The scope and availability of all plan benefits are determined in accordance with the applicable coverage agreement. Any conflict or variance between the terms of the coverage agreement and PHP, PHA, and PPP Medical Policy will be resolved in favor of the coverage agreement.
- Allergy Testing (All Lines of Business Except Medicare)
- Allergy Testing (Medicare Only)
- Ambulance Transport
- Anesthesia Care with Diagnostic Endoscopy
- Athletic Pubalgia Surgery
- Auricular Electrostimulation
- Autologous Fat Transfer
- Automatic External Defibrillators (AED)
- Back: Ablative Procedures to Treat Back and Neck Pain (All Lines of Business Except Medicare)
- Back: Artificial Intervertebral Discs
- Back: Cervical and Thoracic Spine Surgery
- Back: Discography
- Back: Epidural Steroid Injections (All Lines of Business Except Medicare)
- Back: Epidural Steroid Injections (Medicare Only)
- Back: Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy (Medicare Only)
- Back: Implantable Spinal Cord and Dorsal Root Ganglion Stimulation (All Lines of Business Except Medicare)
- Back: Implantable Spinal Cord and Dorsal Root Ganglion Stimulation (Medicare Only)
- Back: Intradiscal Procedures for Low Back Pain (All Lines of Business Except Medicare)
- Back: Intradiscal Procedures for Low Back Pain (Medicare Only)
- Back: Lumbar Spine Surgery
- Back: Lysis of Epidural Adhesions
- Back: Percutaneous Thermal Intradiscal Treatment for Low Back Pain (All Lines of Business Except Medicare)
- Back: Percutaneous Thermal Intradiscal Treatment for Low Back Pain (Medicare Only)
- Back: Sacroiliac Joint Fusion or Stabilization (All Lines of Business Except Medicare)
- Back: Sacroiliac Joint Fusion or Stabilization (Medicare Only)
- Back: Stabilization Devices and Interspinous Spacers
- Back: Vertebroplasty and Kyphoplasty (All Lines of Business Except Medicare)
- Back: Vertebroplasty and Kyphoplasty (Medicare Only)
- Balloon Dilation of the Sinuses or Eustachian Tubes
- Bariatric Surgery (All Lines of Business Except Medicare)
- Bariatric Surgery (Medicare Only)
- Blood Brain Barrier Disruption and Bypass
- Bone Growth Stimulators (All Lines of Business Except Medicare)
- Bone Growth Stimulators (Medicare Only)
- Breast Cancer: Focused Microwave Phased Array Thermotherapy
- Breast Cancer: Radiofrequency Ablation of Breast Tumors
- Breast Implant Removal
- Breast Reconstruction
- Breast Surgery: Reduction Mammoplasty (All Lines of Business Except Medicare)
- Breast Surgery: Reduction Mammoplasty (Medicare Only)
- Bronchial Thermoplasty
- Cardiac: Disease Risk Screening (All Lines of Business Except Medicare)
- Cardiac: Disease Risk Screening (Medicare Only)
- Cardiac: External Ambulatory Electrocardiography (All Lines of Business Except Medicare)
- Cardiac: External Ambulatory Electrocardiography (Medicare Only)
- Cardiac: Implantable Loop Recorder
- Cardiac: Left Atrial Appendage Devices (All Lines of Business Except Medicare)
- Cardiac: Left Atrial Appendage Devices (Medicare Only)
- Cardiac: Percutaneous Aortic Valve Replacement for Aortic Stenosis
- Cardiac: Transcatheter Aortic Valve Replacement (TAVR) (All Lines of Business Except Medicare)
- Cardiac: Transcatheter Aortic Valve Replacement (TAVR) (Medicare Only)
- Cardiac: Ventricular Assist (VAD.LVAD) and Artificial Heart Devices (BIVAD)
- Cefaly Device for Treatment of Migraine Headaches
- Celiac Disease Serologic Testing
- Chelation Therapy for Non Overload Conditions
- Chemoresistance and Chemosensitivity Assays
- Chiropractic Care
- Circulating Tumor Cell Assays For Cancer Management
- Clinical Trials and Devices (All Lines of Business Except Medicare)
- Clinical Trials and IDE Studies (Medicare Only)
- Cold Therapy and Cooling Devices in the Home Setting
- Colorectal Cancer Screening: FIT and Fecal DNA
- Compression: Bandages, Stockings, and Wraps
- Compression: Outpatient Pneumatic Devices
- Continuous Passive Motion Device in the Home Setting
- Cosmetic and Reconstructive Surgery
- Deep Brain Stimulation (All Lines of Business Except Medicare)
- Deep Brain Stimulation (Medicare Only)
- Definition: Confined to the Home
- Definition: Experimental and Investigational
- Definition: Medical Necessity
- Definition: Mobility Assistive Equipment (MAE)
- Definition: Urgent Care (Out of Area)
- Dental Anesthesia Services
- Dental Services: Administrative Guideline (All Lines of Business Except Medicare)
- Dental Services: Administrative Guideline (Medicare Only)
- Dermal Injections for the treatment of Facial Lipodystrophy Syndrome (Medicare Only)
- Diabetes: APDS and Other Integrated Systems (All Lines of Business Except Medicare)
- Diabetes: Artificial Pancreas Devices and Other Integrated Systems (Medicare Only)
- Diabetes: Blood Glucose Monitors and Supplies
- Diabetes: Continuous Glucose Monitors (CGM) (All Lines of Business Except Medicare)
- Diabetes: Continuous Glucose Monitors (Medicare Only)
- Diabetes: Insulin Infusion Pumps (External and Implanted)
- Direct-to-Consumer Testing
- Drug, Botulinum Toxin Types A and B
- Durable Medical Equipment
- Electrothermal Capsular Shrinkage
- Exhaled Breath Tests (All LOB Except Medicare)
- Exhaled Breath Tests (Medicare Only)
- Eye: Automated Evacuation of Meibomian Gland
- Eye: Blepharoplasty, Blepharoptosis Repair, and Brow Lift (All Lines of Business Except Medicare)
- Eye: Blepharoplasty, Blepharoptosis Repair, and Brow Lift (Medicare Only)
- Eye: Corneal Collagen Cross-Linking (All Lines of Business Except Medicare)
- Eye: Retinopathy Telescreening
- Fecal Incontinence: Treatments (All Lines of Business Except Medicare)
- Fecal Incontinence: Treatments (Medicare Only)
- Fecal Microbiota Transplantation
- Ganglion Impar Blocks
- Gastric Electrical Stimulation
- Gastroesophageal Reflux Disease: Endoscopic Treatments (All Lines of Business Except Medicare)
- Gastroesophageal Reflux Disease: Endoscopic Treatments (Medicare Only)
- Gastroesophageal Reflux: Magnetic Esophageal Ring
- Gastrointestinal Ecology Profiles & Gastrointestinal Comprehensive Profiles
- Gender Affirming Interventions
- General PA Requirements: Medicare HMO POS
- General PA Requirements: PEBB Statewide and PEBB Choice
- General PA Requirements: PPO
- General PA Requirements: Standard
- General PA Requirements: PHS, Swedish, Kadlec, PacMed
- General PA Requirements: OHP
- Genetic Studies and Counseling
- Genetic Testing for BCR-ABL1 Negative Myeloproliferative Neoplasms (All Lines of Business Except Medicare)
- Genetic Testing for BCR-ABL1 Negative Myeloproliferative Neoplasms (Medicare Only)
- Genetic Testing: Breast Cancer Prognostic Assays (All Lines of Business Except Medicare)
- Genetic Testing: Breast Cancer Prognostic Assays (Medicare Only)
- Genetic Testing: CADASIL Disease (All Lines of Business Except Medicare)
- Genetic Testing: Hereditary Breast and Ovarian Cancer (All Lines of Business Except Medicare)
- Genetic Testing: Hereditary Breast and Ovarian Cancer (Medicare Only)
- Genetic Testing: Inherited Susceptibility to Colorectal Cancer (All Lines of Business Except Medicare)
- Genetic Testing: Inherited Susceptibility to Colorectal Cancer (Medicare Only)
- Genetic Testing: Inherited Thrombophilias (All Lines of Business Except Medicare)
- Genetic Testing: Inherited Thrombophilias (Medicare Only)
- Genetic Testing: Non-Covered Genetic Panel Tests (All Lines of Business Except Medicare)
- Genetic Testing: Non-Covered Genetic Panel Tests (Medicare Only)
- Genetic Testing: Pharmacogenetic Testing (All Lines of Business Except Medicare)
- Genetic Testing: Pharmacogenetic Testing (Medicare Only)
- Genetic Testing: Reproductive Planning and Prenatal Testing (All Lines of Business Except Medicare)
- Genetic Testing: Reproductive Planning and Prenatal Testing.(Medicare Only)
- Genetic Testing: Thyroid Nodules (All Lines of Business Except Medicare)
- Genetic Testing: Thyroid Nodules (Medicare Only)
- Hand/Arm Artificial Myoelectric Limb
- Hearing Aids (All Lines of Business Except Medicare)
- Hearing: Cochlear Implants and Auditory Brainstem Implants (All Lines of Business Except Medicare)
- Hearing: Cochlear Implants and Auditory Brainstem Implants (Medicare Only)
- Heating Pads and Heat Lamps
- Hip Arthroscopy
- Hip: Total Joint Arthroplasty (All Lines of Business Except Medicare)
- Hip Total Joint Arthroplasty (Medicare Only)
- Home Oxygen Therapy for Cluster Headaches
- Hyperbaric Oxygen Therapy (All Lines of Business Except Medicare)
- Hyperbaric Oxygen Therapy (Medicare Only)
- Inflammatory Bowel Disease (IBD) Serologic Testing and Therapeutic Monitoring
- Inflammatory Bowel Disease Measurement of Antibodies to Immunosuppressive Therapies
- Interferential Stimulation (IFS)
- Investigational and Non-covered Medical Technologies (All Lines of Business Except Medicare)
- Investigational and Non-covered Medical Technologies (Medicare Only)
- Joint Resurfacing
- Knee Braces (Functional)
- Knee: Ablative Procedures of Peripheral Nerves to Treat Knee Pain
- Knee: Autologous Chondrocyte Implantation (ACI) for Cartilaginous Defects
- Knee: Cartilaginous Defects of the Knee: Autologous Chondrocyte Implantation (ACI)
- Knee: Cartilaginous Defects: Procedures and Implants
- Knee: Meniscal Allograft Transplantation
- Knee: Osteochondral Allografts and Autografts for Cartilaginous Defects
- Knee: Total Joint Arthroplasty (All Lines of Business Except Medicare)
- Knee: Total Joint Arthroplasty (Medicare Only)
- Liver Tumor Treatment
- Low-Level and High-Power Laser Therapy
- Lyme Disease
- Microcurrent Electrical Nerve Stimulation (MENS)
- MR Guided Focused Ultrasound for Palliative Treatment of Bone Metastases
- Multi-spectral Digital Skin Lesion Analysis
- NanoKnife System.Irreversible Electroporation (IRE)
- Negative Pressure Wound Therapy (NPWT)
- Nerve Conduction Studies (All Lines of Business Except Medicare)
- Nerve Conduction Studies (Medicare Only)
- Neuropsychological Testing (All Lines of Business Except Medicare)
- Neuropsychological Testing (Medicare Only)
- Non-Contact Wound Therapy (All Lines of Business Except Medicare)
- Non-Contact Wound Therapy (Medicare Only)
- Non-Small Cell Lung Cancer. Molecular Testing for Targeted Therapy (All Lines of Business Except Medicare)
- Non-Small Cell Lung Cancer. Molecular Testing for Targeted Therapy (Medicare Only)
- Occipital Nerve Stimulation
- Organ Transplantation
- Organic Acid Testing and Nutritional Panels
- Orthognathic Surgery
- Orthotic Foot Devices and Therapeutic Shoes
- Outpatient Physical Therapy (All Lines of Business Except Medicare)
- Ovarian Cancer: Multimarker Serum Testing
- Oxygen Therapy and Home Equipment
- Pelvic Congestion Syndrome Treatment
- Percutaneous Neuromodulation Therapy (PNT)
- Peroral Endoscopic Myotomy (POEM)
- PHA Medical Policy Medicare Manual
- Platelet-Rich Plasma (PRP) for Orthopedic Indications, Wound Care, Other Misc Conditions (All Lines of Business Except Medicare)
- Platelet-Rich Plasma (PRP) for Orthopedic Indications, Wound Care, Other Misc Conditions (Medicare Only)
- Port Wine Stain Laser Treatment
- Premature Rupture of Membranes (PROM) Testing
- Prolotherapy
- Prostate: High Intensity Focused Ultrasound (All Lines of Business Except Medicare)
- Prostate: High Intensity Focused Ultrasound (Medicare Only)
- Prostate: MRI-Transrectal Ultrasound Fusion Biopsy
- Prostate: Prostatic Urethral Lift
- Prostate: Protein Biomarkers and Genetic Testing (All Lines of Business Except Medicare)
- Prostate: Protein Biomarkers and Genetic Testing (Medicare Only)
- Prosthesis: Lower Limb
- Proton Beam Radiation Therapy
- Radiofrequency Ablation and Cryoablation for Plantar Fasciitis
- Rehabilitation: Mechanical Stretching Devices for Joints of the Extremities
- Rehabilitation: Acute Inpatient
- Rhinoplasty Functional (Non Cosmetic)
- Robotic Surgical Systems
- Salivary Hormone Testing (All Lines of Business Except Medicare)
- Salivary Hormone Testing (Medicare Only)
- Seat Lift Chair Mechanism
- Sensory Integration Therapy
- Skin Substitutes
- Sleep Apnea: Surgical Treatments
- Sleep Disorder Testing (All Lines of Business Except Medicare)
- Sleep Disorder Testing (Medicare Only)
- Sleep Disorder Treatment: Oral Appliances (All Lines of Business Except Medicare)
- Sleep Disorder Treatment: Oral Appliances (Medicare Only)
- Sleep Disorder Treatment: Positive Airway Pressure (All Lines of Business Except Medicare)
- Sleep Disorder Treatment: Positive Airway Pressure (Medicare Only)
- Speech Generating Devices
- Standing Systems
- Stem Cell Therapy for Orthopedic Applications
- Stereotactic Body Radiation Therapy and Stereotactic Radiosurgery (All Lines of Business Except Medicare)
- Stereotactic Body Radiation Therapy and Stereotactic Radiosurgery (Medicare Only)
- Stereotactic Computer Assisted Volumetric (Navigational) Procedure
- Subcutaneous Hormone Pellet Implant
- Surface Electromyography (sEMG) Testing
- Surgical Treatment for Skin Redundancy
- Surgical Treatments for Lymphedema
- Transcutaneous Electrical Nerve Stimulators (TENS) and Related Supplies
- Tumor Treatment Fields Therapy for Glioblastoma
- Urinary Incontinence Treatments (All Lines of Business Except Medicare)
- Urinary Incontinence Treatments (Medicare Only)
- Urinary Dysfunction: Vesicoureteral Reflux Treatments
- Urine Drug Testing for Therapeutic or Substance Abuse Monitoring (All Lines of Business Except Medicare)
- Urine Drug Testing for Therapeutic or Substance Abuse Monitoring (Medicare Only)
- Vagus Nerve Stimulation
- Varicose Veins (All Lines of Business Except Medicare)
- Varicose Veins (Medicare Only)
- Vectra DA Test for Rheumatoid Arthritis
- Vestibular Function Testing
- Viscosupplementation (All Lines of Business Except Medicare)
- Viscosupplementation (Medicare Only)
- Vitamin D Assay Testing
- Walkers
- Wheelchairs and Power Vehicles
- Wireless Capsule Endoscopy
- Wireless Capsule for Gastrointestinal Motility Monitoring
- Wounds: Non-Contact Wound Therapy