Loading...Loading...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 Essentials: 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
- Submit an electronic pre-authorization request, and supporting clinical documentation through Availity Essentials>Patient Registration>Authorizations & Referrals>Authorizations
- Learn more about submitting requests through Availity
- Sleep medicine: Sign in to the Carelon Medical Benefits Management (Carelon) Provider Portal
Radiology program: Sign in to the Carelon Provider Portal or choose to be routed from Availity's electronic authorization tool via single sign-on.
Note: Check the status of your requests using the same platform you used to submit the request:
- Requests submitted through Carelon are updated on Carelon's portal: ProviderPortal.com.
- Requests submitted through Availity Essentials are updated in Availity: availity.com.
Direct clinical information reviews (MCG Health)
For select CPT codes, Availity's electronic authorization tool automatically routes you to MCG Health's website where you can document specific clinical criteria for your patient. If all criteria are met, you will see the approval on the Auth/Referral Dashboard soon after you click submit. Once all criteria are documented, you will then be routed back to Availity Essentials to attach supporting documentation and submit the request. Documenting complete and accurate clinical information for your patients helps to reduce the overall time it takes to review a request. View the services that may receive automated approval (PDF).
Under state law, the Uniform Medical Plans (UMP Achieve 1, UMP Achieve 2, UMP Classic, UMP Select, UMP CDHP, UMP High Deductible, UMP Plus – Puget Sound High Value Network, and UMP Plus – UW Medicine ACN) must comply with decisions made by the Health Technology Clinical Committee (HTCC). The HTCC is a committee of independent health care professionals that reviews selected health technologies (services) to determine the conditions, if any, under which the service will be included as a covered benefit and, if covered, the criteria the plan must use to decide whether the service is medically necessary. These services may include medical or surgical devices and procedures, medical equipment, and diagnostic tests. In public meetings, the HTCC considers public comments and scientific evidence regarding the safety, medical effectiveness, and cost-effectiveness of the services in making its determination. Final decisions and ongoing reviews may be accessed on the HTCC website.
Criteria established by the HTCC supersede Regence Medical Policy.
Procedures that are subject to HTCC decision and require pre-authorization can be found on the UMP Pre-authorization List below.
Procedures denied due to an HTCC decision will be member responsibility.
- 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.
- Before requesting pre-authorization, please verify member eligibility and benefits via the Availity Portal as the member contract determines the covered benefits.
- Verify that you are an in-network provider for each member to help reduce his or her out-of-pocket expense.
- 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.
- 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.
- Emergency services do not require pre-authorization, but are subject to hospital admission notification requirements (see below).
- The member's contract language will apply.
- 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.
- 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).
- 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.
Type of review | Timeframe | Additional time allowed for review if additional information is needed*: |
|---|---|---|
Urgent/Expedited | Electronic submissions: 1 calendar day, excluding holidays Non-electronic submissions: 2 calendar days | Electronic submissions: 1 calendar day, excluding holidays Non-electronic submissions: 2 calendar days |
Standard initial | Electronic submissions: 3 calendar days, excluding holidays Non-electronic submissions: 5 calendar days | Electronic submissions: 3 calendar days, excluding holidays Non-electronic submissions: 4 calendar days |
Concurrent | 24 hours Must notify within 24 hours for newborn intensive care unit (NICU) or pediatric intensive care unit (PICU) admission. | 72 hours |
*Note that additional timeframes for review are after receipt of the requested documentation or after the timeframe for submission of the requested information has expired - whichever comes first. | ||
If Pre-Authorization requests are received requesting urgent/expedited review timeframes and the documentation provided does not meet the urgent/expedited criteria, the review will be reclassified to a standard review and standard timeframes will apply.
Urgent/expedited criteria is defined as one or more of the following:
- The member’s life, health or ability to regain maximum function is in serious jeopardy.
- The member’s psychological state is putting the life, health or safety of the member or others is in serious jeopardy.
- The member will be subjected to severe pain that cannot be adequately managed without the service.
Failure to secure approval for services subject to pre-authorization or concurrent review 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. Stays that extend beyond the pre-authorized number of days require admission notification and concurrent review. If a facility fails to receive authorization for additional days, the additional days will be provider liability.
- 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.
Administrative Guidelines to Determine Dental vs Medical Services (PDF)
21245, 21246, 21248, 21249
- 90875, 90876, 90901, 90912, 90913, E0746
We do not require pre-authorization for biofeedback for headache and migraine G43.xx, G44.201, G44.209 , G44.211, G44.219, G44.221, G44.229, R51
Bone Growth Stimulation
UMP is subject to HTCC Decision (PDF) – 20974, 20975, 20979, E0747, E0748, E0749, E0760
Continuous Glucose Monitoring
- For dates of service prior to January 1, 2022: UMP is subject to HTCC Decision (PDF): A9277, A9278, K0554, S1030, S1031
Continuous Glucose Monitoring device coverage and preauthorization HTCC requirements will be managed under the UMP prescription drug benefit administered by the Washington State Rx Services
Definitive Lower Limb Prostheses (PDF)
L5010, L5020, L5050, L5060, L5100, L5105, L5150, L5160, L5200, L5210, L5220, L5230, L5250, L5270, L5280, L5301, L5312, L5321, L5331, L5341, L5610, L5611, L5613, L5614, L5616, L5700, L5701, L5702, L5703, L5710, L5711, L5712, L5714, L5716, L5718. L5722, L5724, L5726, L5728, L5780, L5810, L5811, L5812, L5814, L5816, L5818, L5822, L5824, L5826, L5828, L5830, L5840, L5841, L5848, L5930, L5968, L5970, L5972, L5974, L5976, L5978, L5979, L5980, L5981, L5982, L5984. L5985, L5986, L5987
Implantable Drug Delivery System
UMP is subject to HTCC Decision (PDF): C1772, C1889, C1891, C2626, E0782, E0783, E0785, E0786, 62350, 62351, 62360, 62361, 62362
Insulin Infusion Pumps, Automated Insulin Delivery and Artificial Pancreas Device Systems (PDF)
S1034
Microprocessor-Controlled Lower Limb Prosthetics (PDF)
- UMP is subject to HTCC Decision (PDF)
- L5615, L5856, L5857, L5858
Use Regence medical policy in addition to the HTCC to review requests regarding "functional level 2" and "experienced user exceptions".
Myoelectric Prosthetic and Orthotic Components for the Upper Limb (PDF)
L6026, L6693, L6715, L6880, L6881, L6882, L6925, L6935, L6945, L6955, L6965, L6975, L7007, L7008, L7009, L7045, L7180, L7181, L7190, L7191
Noninvasive Ventilators in the Home Setting (PDF)
E0466
Power Wheelchairs: Group 3 (PDF)
K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855, K0856, K0857, K0858, K0859, K0860, K0861, K0862, K0863, K0864
Stents, Drug Coated or Drug-Eluting (DES)
Refer to Cardiac Stenting in the Surgery section below.
Sleep Medicine
- View the Sleep Medicine Management Program for notification or authorization requirements.
- Review the codes requiring authorization or notification in the Sleep Medicine section.
In compliance with WA HB 1689, guideline-recommended biomarker testing in patients with recurrent, relapsed, refractory, or metastatic cancer (including stage 3 or 4) will not require prior authorization for Washington members. This does not include non-specific molecular pathology codes (81400-81408).
Diagnosis codes Z800-Z803, Z8041 and Z8042 will no longer be exempted from pre-authorization for Washington members.
Genetic Testing for Alzheimer's Disease (PDF) - GT01
81401, 81405, 81406
Genetic Testing for Hereditary Breast and Ovarian Cancer and Li-Fraumeni Syndrome (PDF) - GT02
0235U, 81162, 81163, 81164, 81165, 81166, 81167, 81212, 81215, 81216, 81217, 81307, 81308, 81321, 81322, 81323, 81404, 81405, 81406, 81432, 81433, 81351, 81352
Apolipoprotein E for Risk Assessment and Management of Cardiovascular Disease (PDF) - GT05
81401
Genetic Testing for Lynch Syndrome and APC-associated and MUTYH-associated Polyposis Syndromes (PDF) - GT06
0238U, 81201, 81202, 81203, 81210, 81288, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81317, 81318, 81319, 81401, 81406
Genetic Testing for Cutaneous Malignant Melanoma (PDF) - GT08
81404
Cytochrome p450 and VKORC1 Genotyping for Treatment Selection and Dosing (PDF) - GT10
- 81225, 81401, 81402, 81404, 81405, 81418, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076U, 0461U
- UMP is subject to HTCC Decision (PDF) for codes 81225, 81418, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076U and 0461U.
Codes 81225, 81418, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076U and 0461U will deny as not a covered benefit when billed with the following diagnosis: depression, mood disorders, psychosis, anxiety, ADHD and substance use disorders.
Genetic Testing; Familial Hypercholesterolemia (PDF) - GT11
81401, 81405, 81406, 81407
KRAS, NRAS and BRAF Variant Analysis and MicroRNA Expression Testing for Colorectal Cancer (PDF) - GT13
81210, 81275,81276, 81311, 81403, 81404, 0111U, 0471U
Preimplantation Genetic Testing of Embryos (PDF) - GT18
89290, 89291, 81228, 81229, 81349
81120, 81121
Genetic and Molecular Diagnostic Testing (PDF) - GT20
- 0232U, 0234U, 0235U, 0238U, 0244U, 81201, 81202, 81203, 81210, 81212, 81215, 81216, 81217, 81225, 81228, 81229, 81235, 81243, 81244, 81250, 81252, 81253, 81254, 81257, 81275, 81276, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81302, 81303, 81304, 81311, 81314, 81317, 81318, 81319, 81321, 81322, 81323, 81324, 81325, 81326, 81341, 81349, 81350, 81351, 81352, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81419, 81441, 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 diagnosis: 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
- 81522
- UMP is subject to HTCC Decision (PDF) for codes 81518, 81519, 81520, 81521, 81523, 81541, 81542, 81551, S3854, 0045U, 0047U, 0067U, 0009U, 0262U, 0497U
Apply the Regence medical policy Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer (PDF) for conditions/treatments not addressed in the HTCC decision (e.g. BluePrint, and TargetPrint.)
81243, 81244
- 81408, 81243
Genetic Testing for CADASIL Syndrome (PDF) - GT51
81406
Diagnostic Genetic Testing for α-Thalassemia (PDF) - GT52
81257, 81258, 81259, 81269, 81404
Genetic Testing; Primary Mitochondrial Disorders (PDF) - GT54
0417U, 81401, 81403, 81404, 81405, 81440, 81460, 81465
Targeted Genetic Testing for Selection of Therapy for Non-Small Cell Lung Cancer (NSCLC) (PDF) - GT56
0022U, 0478U, 81210, 81235, 81275, 81276, 81404, 81405, 81406
Genomic Microarray Testing
UMP is subject to HTCC Decision (PDF) for codes 81228, 81229, 81349, S3870, 0156U, 0209U, 0318U
Genetic Testing for Myeloid Neoplasms and Leukemia (PDF) - GT59
81120, 81121, 81351, 81352, 81401, 81402, 81403, 81450, 81451, 81455, 81456
Genetic Testing for PTEN Hamartoma Tumor Syndrome (PDF) - GT63
0235U, 81321, 81322, 81323
Genetic Testing for Evaluating the Utility of Genetic Panels (PDF) - GT64
- 81201, 81202, 81203, 81210, 81225, 81228, 81229, 81235, 81243, 81244, 81250, 81252, 81253, 81254, 81257, 81275, 81276, 81288, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81302, 81303, 81304, 81311, 81314, 81317, 81318, 81319, 81321, 81322, 81323, 81324, 81325, 81326, 81349, 81350, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81412, 81432, 81433, 81434, 81437, 81438, 81440, 81441, 81443, 81450, 81451, 81455, 81456, 81460, 81465, 81470, 81471, 0461U
- UMP is subject to HTCC Decision (PDF) for code 81225 and 0461U
Codes 81225 and 0461U will deny as not a covered benefit when billed with the following diagnosis: depression, mood disorders, psychosis, anxiety, ADHD and substance use disorders.
Genetic Testing for Methionine Metabolism Enzymes, including MTHFR (PDF) - GT65
81401, 81403, 81404, 81405, 81406
Genetic Testing for the Diagnosis of Inherited Peripheral Neuropathies (PDF) - GT66
81403, 81404, 81405, 81406, 81324, 81325, 81326, 81448
Genetic Testing for Rett Syndrome (PDF) - GT68
0234U, 81302, 81303, 81304, 81404, 81405, 81406
Genetic Testing for Duchenne and Becker Muscular Dystrophy (PDF) - GT69
0218U, 81161, 81408
Fetal Red Blood Cell Antigen Genotyping Using Maternal Plasma (PDF) - GT74
81403
Genetic Testing for Macular Degeneration (PDF) - GT75
81401, 81405, 81408
Whole Exome and Whole Genome Sequencing
UMP is subject to HTCC Decision (PDF) for 0214U, 0215U, 81415, 81416, 81417
Genetic Testing for Heritable Disorders of Connective Tissue (PDF) - GT77
81405, 81408
Invasive Prenatal Fetal Diagnostic Testing for Chromosomal Abnormalities (PDF) - GT78
81228, 81229, 81349, 81405, 0469U
Genetic Testing for the Evaluation of Products of Conception and Pregnancy Loss (PDF) - GT79
81228, 81229, 81349
Genetic Testing for Epilepsy (PDF) - GT80
0232U, 81188, 81189, 81190, 81401, 81403, 81404, 81405, 81406, 81407, 81419
Reproductive Carrier Screening for Genetic Diseases (PDF) - GT81
81161, 81243, 81244, 81250, 81252, 81253, 81254, 81257, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81412, 81434, 81443, S3844, S3845, S3846, S3849, S3850, S3853
Expanded Molecular Panel Testing of Cancers to Select Targeted Therapies (PDF) - GT83
0022U, 0037U, 0048U, 0211U, 0244U, 0250U, 0334U, 0379U, 0391U, 0444U, 0473U, 0498U, 0499U, 81120, 81121, 81162, 81210, 81235, 81275, 81276, 81292, 81295, 81298, 81311, 81314, 81319, 81321, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81445, 81449, 81455, 81456, 81457, 81458, 81459
Genetic Testing for Neurofibromatosis Type 1 or 2 (PDF) - GT84
- 81405, 81406, 81408
ClonoSEQ® Testing for the Assessment of Measurable Residual Disease (MRD) (PDF) - GT88
- 0364U
- 0239U, 0242U, 0326U, 0388U, 0409U, 0428U, 0485U, 0487U, 81462, 81463, 81464
Laboratory Tests for Organ Transplant Rejection (PDF)
- 81595
Measurement of Serum Antibiodies to Selected Biologic Agents (PDF)
80145, 80230, 80280
Elective early delivery, prior to 39 weeks' gestation, is not a covered benefit (not applicable to emergency delivery or spontaneous labor).
Bioengineered Skin and Soft Tissue Substitutes and Amniotic Products (PDF)
A4100, A6460, A6461, Q4100, Q4101, Q4102, Q4105, Q4106, Q4107, Q4114, Q4116, Q4121, Q4122, Q4128, Q4132, Q4133, Q4151, Q4154, Q4159, Q4186, Q4187
Confocal Laser Endomicroscopy (PDF)
43206, 43252, 88375
Coverage of Treatments Provided in a Clinical Trial (PDF)
S9990, S9991, S9988
Digital Therapeutic Products (PDF)
98978, A9291, A9292, E1905
Digital Therapeutic Products for Attention Deficit Hyperactivity Disorder (PDF)
98978, A9291
Digital Therapeutic Products for Chronic Low Back Pain (PDF)
- 98978, A9291, E1905
Digital Therapeutic Products for Post-traumatic Stress Disorder and Panic Disorder (PDF)
- A9291
Digital Therapeutic Products for Substance Use Disorders (PDF)
98978, A9291
Digital Therapeutic Products for Amblyopia (PDF)
- A9292
- UMP is subject to HTCC Decision (PDF): 99183, G0277
- Acute/sudden sensorineural hearing loss is a covered condition for this HTCC and is no longer applicable as an exclusion.
- Note, chronic sensorineural hearing loss remains an exclusion under this HTCC.
Regence medical policy is used only to determine units of treatment, criteria for diabetic "standard wound therapy" and to address any conditions not addressed in the HTCC decisions under the HTCC "limitations of coverage" or "non-covered indicators".
In Vivo Analysis of Colorectal Lesions (PDF)
88375
Intensity Modulated Radiotherapy (IMRT)
UMP is subject to HTCC Decision (PDF): 77301, 77338, 77385, 77386, G6015, G6016
Laser Interstitial Thermal Therapy (PDF)
61736, 61737
- 97037
90875, 90876. 90901
38206, 38232, 38241
Progenitor Cell Therapy for the Treatment of Damaged Myocardium Due to Ischemia (PDF)
38205, 38206, 38240, 38241
Charged-Particle (Proton or Helium Ion) Radiotherapy
- UMP is subject to HTCC Decision (PDF) - 77520, 77522, 77523, 77525
- Pre-authorization is not required for members under 21 years of age
When the following codes are used for Charged-Particle (Proton or Helium Ion) Radiotherapy with SRS or SBRT, use HTCC Decision (PDF): 32701, 61796, 61797, 61798, 61799, 61800, 63620, 63621, 77301, 77338, 77371, 77372, 77373, 77432, 77435, G0339, G0340
Radioembolization, Transarterial Embolization (TAE) and Transarterial Chemoembolization (TACE) (PDF)
- 37243, 79445, C9797, S2095
Note: Ovarian and Internal Iliac Vein Embolization as a Treatment of Pelvic Congestion Syndrome (PDF) is considered investigational.
Sleep Medicine
- View the Sleep Medicine Management Program for notification or authorization requirements.
Review the codes requiring authorization or notification in the Sleep Medicine section.
Tinnitus: Non-invasive, non-pharmacologic treatments
- UMP is subject to HTCC Decision (PDF) for codes 0552T, 90832, 90833, 90834, 90836, 90837, 90838, 90867, 90868, 90869, 96156, 96158, 96159, 96160, 96161, 96164, 96165, 96167, 96168, 96170, 96171, S8948
- Pre-authorization is only required within tinnitus diagnosis codes: H93.11, H93.12, H93.13, H93.19, H93.A1, H93.A2, H93.A3, H93.A9
- Codes 0552T and S8948, when billed without a tinnitus diagnosis, will be denied as investigational based on Regence Medical Policy Low Level Laser Therapy
- Note: Codes 90867 and 90868, when billed with chronic migraine and chronic tension headaches, is not a covered benefit per HTCC Decision (PDF)
Transcranial Magnetic Stimulation as a Treatment of Depression and Other Disorders (PDF)
- UMP is subject to HTCC Decision (PDF) for codes 90867, 90868, 90869, 0889T, 0890T, 0891T, 0892T
- Per the HTCC, TMS for treatment resistant major depressive disorder (MDD) in UMP members age 18 or older is a covered benefit with conditions.
- TMS for treatment resistant major depressive disorder (MDD) in UMP members age 17 and younger refer to Regence medical policy.
- TMS for treatment of obsessive-compulsive disorder (OCD), generalized anxiety disorder (GAD), post-traumatic stress disorder (PTSD), smoking cessation, and substance use disorder (SUD) are not covered for all UMP members per the HTCC.
- Apply the Regence medical policy Transcranial Magnetic Stimulation as a Treatment of Depression and Other Disorders (PDF) for code 0858T.
Gender Affirming Interventions for Gender Dysphoria (PDF)
- 15769, 15772, 15775, 15776, 17380, 55970, 55980
- Codes 55970 and 55980 are non-specific. The specific procedure code(s) must be requested in place of these non-specific codes.
- 11920, 11921, 15771, 15773, 15774, 15825, 15828, 15829, 17999, 19303, 19316, 19318, 19325, 19350, 21125, 21127, 21137, 21139, 21141, 21142, 21143, 21145, 21146, 21147, 21188, 21193, 21194, 21195, 21196, 21208, 53400, 53405, 53410, 53415, 53420, 53425, 53430, 54125, 54400, 54401, 54405, 54520, 54660, 54690, 55175, 55180, 56625, 56800, 56805, 57106, 57110, 57291, 57292, 57295, 57296, 57335, 57426, 58353, 58356, 58563, C1813, C2622, L8600
- Use code 17999 to request laser hair removal.
- Gender affirming surgical interventions for gender dysphoria require pre-authorization. Codes for specific procedures might also be listed as requiring pre-authorization in other medical policies, including but not limited to:
- Abdominoplasty - 15830
- Adipose-derived Stem Cell Enrichment in Autologous Fat Grafting to the Breast - 15771
- Breast Reconstruction - 19316, 19318, 19325, 19350, L8600
- Blepharoplasty and Brow Lift - 15820, 15821, 15822, 15823, 67900, 67901, 67902, 67903, 67904, 67906, 67908, 67909, 67950
- Chin Implants - 21120, 21121, 21122, 21123, 21209
- Collagen Injections - 11950, 11951, 11952, 11954
- Cosmetic and Reconstructive Procedures - 15771, 15773
- Endometrial Ablation - 58353, 58356, 58563
- Panniculectomy - 15830
- Reconstructive Breast Surgery, Mastopexy, and Management of Breast Implants - 15771
- Rhinoplasty - 30400, 30410, 30420, 30430, 30435, 30450
UMP has a separate vendor – Washington State Rx Services – for their prescription drug benefit. Pre-authorization is necessary for certain injectable drugs that are not normally approved for self-administration when obtained through a retail pharmacy, a network mail-order pharmacy, or a network specialty pharmacy. These drugs are indicated on the UMP Preferred Drug List.
Drugs usually payable under the member's medical benefit and pre-authorized will continue with the same Regence process.
Hemophilia clotting factor codes J7170. J7201, J7202, J7203, J7204, J7205, J7207, J7208, J7210 require pre-authorization and if approved will be covered under the Medical benefits for the following groups. For all other groups please use the pharmacy link above.
- ATI Specialty Alloys and Components (group #10015713)
- WA State Health Care Authority (group # 10003948)
- Rin Tinto (grandfathered plan codes only) (groups #10021209 & 10019119)
- OTET (group #10007445)
- Northwest Evaluation Association (NWEA) (group #10002570)
- Utah Valley University (group #10042213)
- Encoder Products (group #10040552)
Eagle Eye Produce Inc (group #10040165)
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.
Contact Regence for pre-authorization for the following codes:
Coronary Artery Calcium Scoring
- UMP is subject to HTCC Decision (PDF) : S8092
Note: 75571 for Cardiac Artery Calcium Scoring is not a covered benefit - reference HTCC Decision.
Wireless Capsule Endoscopy for Gastrointestinal (GI) Disorders (PDF)
0651T, 91110, 91111, 91113
We partner with Carelon to administer our Advanced Imaging Authorization radiology program.
- Login to Carelon's ProviderPortal
Phone 1 (877) 291-0509
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, Carelon criteria will apply.
Contact Carelon to request pre-authorization for the following codes: 70336, 70480, 70481, 70482, 70490, 70491, 70492, 70496, 70498, 70544, 70545, 70546, 70547, 70548, 70549, 70551, 70552, 70553, 71250, 71260, 71270, 71271, 71275, 71550, 71551, 71552, 71555, 72125, 72126, 72127, 72128, 72129, 72130, 72131, 72132, 72133, 72141, 72142, 72146, 72147, 72148, 72149, 72156, 72157, 72158, 72159, 72191, 72192, 72193, 72194, 72195, 72196, 72197, 72198, 73200, 73201, 73202, 73206, 73218, 73219, 73220, 73221, 73222, 73223, 73225, 73700, 73701, 73702, 73706, 73718, 73719, 73720, 73721, 73722, 73723, 73725, 74150, 74160, 74170, 74174, 74175, 74176, 74177, 74178, 74181, 74182, 74183, 74185, 74712, 75559, 75563, 75572, 75573, 75574, 75580, 75635, 76391, 77078, 77084, 78012, 78013, 78014, 78015, 78016, 78018, 78070, 78071, 78072, 78075, 78102, 78103, 78104, 78185, 78195, 78201, 78202, 78215, 78216, 78226, 78227, 78230, 78231, 78232, 78258, 78261, 78262, 78264, 78265, 78266, 78278, 78290, 78291, 78300, 78305, 78306, 78315, 78429, 78430, 78431, 78432, 78433, 78445, 78451, 78452, 78453, 78454, 78456, 78457, 78458, 78459, 78466, 78468, 78469, 78472, 78473, 78579, 78580, 78481, 78582, 78483, 78491, 78492, 78494, 78597, 78598, 78600, 78601, 78605, 78606, 78610, 78630, 78635, 78645, 78650, 78660, 78700, 78701, 78707, 78708, 78709, 78725, 78740, 78761, 78800, 78801, 78802, 78803, 78804, 78830, 78831, 78832, 93303, 93304, 93306, 93307, 93308, 93312, 93313, 93314, 93315, 93316, 93317, 93350, 93351, 0042T, 0648T, 0649T
HTCC decisions administered by Carelon:
- Breast MRI
- UMP is subject to HTCC Decision (PDF) : 77046, 77047, 77048, 77049
- HTCC criteria applies to all member requests regardless of gender
- Cardiac Magnetic Resonance Angiography (CMRA)
- UMP is subject to HTCC Decision (PDF): 75557, 75561
- Cardiac Stents
- Effective January 1, 2025 UMP is subject to HTCC Decision: 92928, 92933, 92937, 92943
- Catheter Ablation for Supraventricular Tachyarrhythmias (SVTA)
- Effective January 1, 2025 UMP is subject to HTCC Decision: 93653, 93656
- Functional Neuroimaging for Primary Degenerative Dementia or Mild Cognitive Impairment
- UMP is subject to HTCC Decision (PDF) : 70554, 70555, 78608, 78609
- Please see Carelon 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 Carelon criteria for pre-authorization requirements for indications other than Rhinosinusitis
- Noninvasive Cardiac Imaging for Coronary Artery Disease
- UMP is subject to HTCC Decision (PDF): 75574, 75580, 78429, 78430, 78431, 78432, 78433 78451, 78452, 78453, 78454, 78459, 78466, 78468, 78469, 78472, 78473, 78481, 78483, 78491, 78492, 78494, 93350, 93351
- Positron Emission Tomography (PET) Scans for Lymphoma
- UMP is subject to HTCC Decision (PDF) : 78811, 78812, 78813, 78814, 78815, 78816
We partner with Carelon to administer our Sleep Medicine program.
- Login to Carelon's ProviderPortal
- Phone 1 (877) 291-0509
View workarounds for Carelon system outages
Contact Carelon to request pre-authorization for the following codes: 95782, 95783, 95805, E0470, E0471
Carelon 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 Carelon:
- Sleep Apnea – Diagnosis and Equipment
- UMP is subject to HTCC Decisions (PDF): 95807, 95808, 95810, 95811, E0561, E0562, E0601
- Please see Carelon criteria for indications other than Sleep Apnea
We partner with Carelon to administer our cardiology program. Determine whether your patient's plan participates in this program by using the Electronic Authorization application on Availity Essentials.
- Login to Carelon's ProviderPortal
- Phone 1 (877) 291-0509
- View workarounds for Carelon system outages
Effective January 1, 2025: Contact Carelon to request pre-authorization for the following codes: C1721, C1722, C1764, C1777, C1785, C1786, C1882, C1895, C1896, C1899, C2619, C2620, C2621, E0616, G0448, K0606, 0823T, 0825T, 33206, 33207, 33208, 33212, 33213, 33214, 33221, 33227, 33228, 33229, 33230, 33231, 33240, 33249, 33270, 33271, 33274, 33285, 37220, 37221, 37224, 37225, 37226, 37227, 37228, 37229, 37230, 37231, 92920, 92924, 92928, 92933, 92937, 92943, 93228, 93229, 93454, 93455, 93456, 93457, 93458, 93459, 93460, 93461, 93650, 93653, 93654, 93656, 93880, 93882, 93922, 93923, 93924, 93925, 93926, 93930, 93931, 93978, 93979
- Retrospective review is not allowed for cardiac rhythm monitors (93228 and 33285). Retrospective review is allowed for cardiac ablation and wearable and cardioverter defibrillators if records are received within 10 business days of the date of service.
Ablation of Primary and Metastatic Liver Tumors (PDF)
47370, 47371, 47380, 47381, 47382, 47383
Adipose-derived Stem Cell Enrichment in Autologous Fat Grafting to the Breast (PDF)
- 15769, 15771, 15772, 11950, 11951, 11952, 11954
- Note: Codes 19380 and 19499 do not require pre-authorization but are considered, and will deny as, investigational when used for autologous fat grafting and adipose-derived stem cell enrichment for augmentation or reconstruction of the breast
Anterior Abdominal Wall (Including Incisional) Hernia Repair (PDF)
- 15734, 49591, 49593, 49595, 49613, 49615, 49617, 49621
- Pre-authorization for 15734 required only with diagnosis code K42.0, K42.1, K42.9 K43.0, K43.1, K43.2 K43.6, K43.7, K43.9, K45.0, K45.1, K45.8, K46.0, K46.1, K46.9 or M62.0 for component separation technique (CST)
Pre-authorization for codes 49591, 49593, 49595, 49613, 49615, 49617, 49621 only required with diagnoses codes K42.9, K43.2 and K43.9 for ventral hernia repair
Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions (PDF)
J7330, S2112
Balloon Dilation of the Eustachian Tube (PDF)
69705, 69706
Balloon Ostial Dilation for Treatment of Sinusitis (PDF)
31295, 31296, 31297, 31298
- 43771, 43848, 43860, 43886
- UMP is subject to HTCC Decision (PDF): 43644, 43772, 43773, 43774, 43775, 43820, 43845, 43846, 43887, 43888
- Effective January 1, 2025 UMP is subject to HTCC Decision for the following codes: 43644, 43645, 43772, 43773, 43774, 43775, 43820, 43843, 43845, 43846, 43847, 43887, 43888, C9784, C9785, S2083
- Note: Intragastric ballons will not be a covered benefit and the following codes will not be covered: 43290, 43291, 0813T
- Bariatric surgery and HTCC guidelines apply, in order to establish eligibility for surgery and medical necessity.
Benign Prostatic Hyperplasia Surgical Treatments (PDF)
0421T, 53854, C2596
Blepharoplasty, Repair of Blepharoptosis, and Brow Ptosis Repair (PDF)
15820, 15821, 15822, 15823, 67900, 67901, 67902, 67903, 67904, 67906, 67908, 67909, 67950
31647, 31648, 31649, 31651
Cardiac Stenting
- UMP is subject to HTCC Decision (PDF): 92928, 92933, 92937, 92941, 92943
- Pre-authorization is not required for members being treated for a condition other than stable angina
Effective January 1, 2025, HTCC Decision will be administered by Carelon for the following codes: 92928, 92933, 92937, 92943
Carotid Artery Stenting
UMP is subject to HTCC Decision (PDF): 37215, 37216, 37217, 37246, 37247, C7532
Catheter Ablation Procedures for Supraventricular Tachyarrhythmias (SVTA)
- UMP is subject to HTCC Decision (PDF): 93653, 93655, 93656, 93657
Effective January 1, 2025, HTCC Decision will be administered by Carelon for the following codes: 93653, 93656
Cervical Fusion for Degenerative Disc Disease
UMP is subject to HTCC Decision (PDF): 22551, 22552, 22554, 22853, 22854, 22859, 22600
15788, 15789, 15792, 15793, 17360
- For Bilateral Cochlear Implants, UMP is subject to HTCC Decision.
For Unilateral Cochlear Implants and replacement requests, UMP follows Regence Medical Policy. - For requests to treat bilateral severe to profound sensorineural hearing loss with devices that are FDA cleared for as early as 9 months of age, UMP follows Regence Medical Policy and the HTCC age criterion “Age 12 months or older” does not apply.
- Refer to the “Regulatory Status” section of the Regence Medical Policy for FDA approved devices for those as young as 9 months of age.
- All other HTCC criteria still apply for these requests.
69930, L8614, L8619, L8627, L8628
Cosmetic and Reconstructive Procedures (PDF)
- 11920, 11921, 11922, 11950, 11951, 11952, 11954, 15769, 15771, 15772, 15773, 15774, 17106, 17107, 17108, 19355, 21230, 21244, 21245, 21246, 21248, 21249, 21295, 21296, 41510, 49250, 54360, 67950, 69300, G0429
- Pre-authorization is required EXCEPT when services are rendered in association with breast reconstruction and nipple/areola reconstruction following mastectomy for breast cancer.
Note: Codes 19380 and 19499 do not require pre-authorization but are considered, and will deny as, investigational when used for autologous fat grafting and adipose-derived stem cell enrichment for augmentation or reconstruction of the breast
Cryosurgical Ablation of Miscellaneous Solid Tumors Outside of the Liver (PDF)
31641, 32994, 50542
- 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).
Note: HTCC decision applies to UMP members age 18 and older. Refer to Regence Medical Policy for UMP members age 17 and younger
Discography
UMP is subject to HTCC Decision (PDF) : 62290, 72295
58353, 58356, 58563
Facet Neurotomy
UMP is subject to HTCC Decision (PDF): 64633, 64634, 64635, 64636
Gastric Electrical Stimulation (PDF)
43647, 43881, 64590, 64595, E0765, C1767, L8679, L8680, L8685, L8686, L8687, L8688
Gastroesophageal Reflux Surgery (PDF)
43279, 43280, 43281, 43282, 43325, 43327, 43328, 43332, 43333, 43334, 43335, 43336, 43337
Hip Surgery for Femoroacetabular Impingement Syndrome (FAI)
UMP is subject to HTCC Decision (PDF): 29914, 29915, 29916
Hypoglossal Nerve Stimulation (PDF)
64568, 64582, 64583, C1767
Implantable Peripheral Nerve Stimulation and Peripheral Subcutaneous Field Stimulation (PDF)
64585, 64590, 64595, 64596, 64597, 64598, L8679, L8680, L8683
Laser Treatment for Port Wine Stains (PDF)
17106, 17107, 17108
Leadless Cardiac Pacemakers (PDF)
0823T, 0825T, 33274
Left-Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation (PDF)
33340
Lumbar Fusion for Degenerative Disc Disease (PDF)
- UMP is subject to HTCC Decision (PDF): 22533, 22558, 22612, 22630, 22633, 22853, 22854, 22859
- Lumbar Fusion for degenerative disc disease uncomplicated by comorbidities is not a covered benefit per HTCC Decision; This includes diagnosis codes M51.35, M51.36, M51.37
Note: This decision does not apply to patients with the following conditions: For indications or populations not addressed in the HTCC, the Regence Medical Policy will apply. This includes but is not limited to the following: 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
0398T, 55880
Microwave Tumor Ablation (PDF)
32998, 50592
Negative Pressure Wound Therapy for Home Use (NPWT) (PDF)
- UMP is subject to HTCC Decision (PDF): 97605, 97606, 97607, 97608, A6550, E2402
- View the HTCC Decision: Definition of "Complete Wound Therapy Program" (PDF)
View the NPWT FDA Safety Communication
Occipital Nerve Stimulation (PDF)
- 61885, 61886, 64553, 64568, 64569, 64585, 64590, 64596, 64597, 64598
- 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.
- 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 diagnosis 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)
UMP is subject to HTCC Decision (PDF): 27415, 27416, 29866, 29867
Ovarian, Internal Iliac and Gonadal Vein Embolization, Ablation, and Sclerotherapy (PDF)
37241
Percutaneous Angioplasty and Stenting of Veins (PDF)
37238, 37239, 37248, 37249
15830
Pectus Excavatum and Carinatum Surgery (PDF)
21740, 21742, 21743
Phrenic Nerve Stimulation for Central Sleep Apnea (PDF)
C1823
Radiofrequency Ablation (RFA) of Tumors Other Than the Liver (PDF)
20982, 31641, 32998, 50542, 50592, 58580, 58674
Reconstructive Breast Surgery/Mastopexy, and Management of Breast Implants (PDF)
- 11920, 11921, 15769, 15771, 15772, 19316, 19318, 19325, 19328, 19330, 19340, 19342, 19350, 19355, 19370, 19371, L8600
- Pre-authorization is required EXCEPT when services are rendered in association with breast reconstruction and nipple/areola reconstruction following mastectomy for breast cancer. However, if autologous fat grafting with adipose-derived stem cell enrichment is used for augmentation or reconstruction of the breast it would be considered investigational.
Note: Codes 19380 and 19499 do not require pre-authorization but are considered, and will deny as, investigational when used for autologous fat grafting and adipose-derived stem cell enrichment for augmentation or reconstruction of the breast.
19318
Responsive Neurostimulation (PDF)
61850, 61860, 61863, 61864, 61885, 61886, 61889, 61891, L8680, L8686, L8688
30120, 30400, 30410, 30420, 30430, 30435, 30450
Sacral Nerve Neuromodulation (Stimulation) for Pelvic Floor Dysfunction (PDF)
- 0786T, 0787T, 0788T, 0789T, 64561, 64581, 64585, 64590, 64595, 64596, 64597, 64598, 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.
Treatment of chronic neuropathic pain is not a covered benefit, per HTCC Decision for codes 0786T, 0787T, 0788T, 0789T
- UMP is subject to HTCC Decision (PDF): 27278, 27280, 27279
For indications not addressed in the HTCC, the Regence Medical Policy will apply
Spinal Cord and Dorsal Root Ganglion Stimulation (PDF)
- 0784T, 0785T, 0786T, 0787T, 0788T, 0789T, 63650, 63655, 63685, C1767, C1820, C1822, C1826, 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 for the following procedure and device codes; 0784T, 0785T, 0786T, 0787T, 0788T, 0789T, 63650, 63655, 63685, C1767, C1820, C1822, C1826, L8679, L8680, L8685, L8686, L8687, L8688 when associated diagnosis codes are included:
- G60.9
- G89.28-G89.29
- M47.20-M47.28
- M47.811-M47.819
- M48.062
- M50.10-M50.13
- M50.121-M50.123
- M54.10-M54.13
- M51.14-M51.17
- M54.16-M54.17
- M54.30-M54.32
- M54.40-M54.42
- M54.5
- M79.2
- G89.4
- M96.1
- If treatment is for other than this indication, Regence medical policy applies.
Effective January 1, 2025: Spinal cord stimulation for the treatment of complex regional pain syndrome is not a covered benefit, per HTCC Decision for the following procedure and device codes; 0784T, 0785T, 0786T, 0787T, 0789T, 63650, 63655, 63685, C1767, C1820, C1822, C1826, L8679, L8680, L8685, L8686, L8687, L8688 when associated diagnosis codes are included: G56.40, G56.41, G56.42, G56.43, G57.70, G57.71, G57.72, G57.73, G90.50, G90.511, G90.512, G90.513, G90.519, G90.521, G90.522, G90.523, G90.529, G90.59
Spinal Injections
- Spinal Injections for UMP members are subject to HTCC Decision (PDF)
Notes:
- CPT 62292 for Therapeutic Medial Branch Nerve Block, Intradiscal and Facet Spinal Injections are not a covered benefit, reference the HTCC Decision (PDF) :
- CPT 27096, 62320, 62321, 62322, 62323, 64451, 64479, 64480, 64483, 64484, 64490, 64491, 64492, 64493, 64494, 64495 and G0260 may be subject to HTCC Decision. Pre-authorization is not required but may be subject to HTCC Decision (PDF) and require a provider attestation.
- Attestation is needed for timely and accurate processing of claims
- Use the electronic authorization tool on the Availity Portal and select the attestation criteria during the clinical documentation process on MCG Health
- If an attestation is not completed pre-service using the Availity tool, fax the completed attestation form (PDF) to 1 (877) 357-3418
- This coverage policy does not apply to those with systemic inflammatory disease such as ankylosing spondylitis, psoriatic arthritis or enteropathic arthritis
Spinal Surgery - Artificial Disc Replacement
- UMP is subject to HTCC Decision (PDF): 22856, 22858, 22861, 0095T, 0098T
Lumbar artificial disc is not a covered benefit: 22857, 22860, 22862, 22865, 0163T, 0164T, 0165T
Stereotactic Radiation Surgery and Stereotactic Body Radiation Therapy
- UMP is subject to HTCC Decision (PDF): 32701, 61796, 61797, 61798, 61799, 61800, 63620, 63621, 77301, 77338, 77371, 77372, 77373, 77432, 77435, C9794, C9795, G0339, G0340
- This determination is specific to the treatment of localized prostate cancer, non-small cell and small cell lung cancer, pancreatic adenocarcinoma, oligometastatic disease, hepatocellular carcinoma, cholangiocarcinoma, Central Nervous System (CNS) primary and metastatic tumors, cancers of spine/paraspinal structures, as well as primary bone, head and neck, adrenal, melanoma, Merkel cell, breast, ovarian, and cervical cancers.
Regence medical policies:
Surgery for Lumbar Radiculopathy
- UMP is subject to HTCC Decision (PDF): CPT 62380, 63030, 63035, 63042, 63044, 63047, 63048, 63056, 63057, 63090, 63091
- Notes:
- Pre-authorization is required only with diagnosis codes M47.20, M47.25, M47.26, M47.27, M47.28, M51.15, M51.16, M51.17, M51.26, M51.27, M54.10, M54.15, M54.16, M54.17, M54.18, M54.30, M54.31, M54.32, M54.40, M54.41, M54.42
- CPT 62380 when billed without one of the listed diagnosis will be denied as an investigational denial based on Regence Medical Policy Automated Percutaneous and Percutaneous Endoscopic Discectomy
Surgical Site of Care - Hospital Outpatient
- Effective January 1, 2025: Pre-authorization will be required on codes 10060, 10061, 10080, 10081, 10120, 10121, 10140, 10160, 10180, 11000, 11010, 11012, 11042, 11044, 11200, 11310, 11402, 11403, 11404, 11406, 11420, 11421, 11422, 11423, 11424, 11426, 11440, 11441, 11442, 11443, 11444, 11446, 11450, 11451, 11462, 11463, 11470, 11471, 11601, 11602, 11603, 11604, 11606, 11620, 11621, 11622, 11623, 11624, 11626, 11640, 11641, 11642, 11643, 11644, 11646, 11730, 11750, 11755, 11760, 11765, 11770, 11772, 11900, 12001, 12002, 12011, 12020, 12031, 12032, 12034, 12035, 12037, 12041, 12042, 12051, 13120, 13121, 13131, 13132, 13151, 13152, 13160, 14020, 14040, 14060, 15120, 15220, 15240, 15760, 15851, 17000, 17110, 17111, 17311, 17313, 19020, 19101, 19110, 19112, 19120, 19125, 20200, 20205, 20220, 20225, 20240, 20912, 21011, 21012, 21013, 21014, 21029, 21030, 21031, 21040, 21046, 21048, 21315, 21320, 21325, 21330, 21335, 21336, 21337, 21356, 21550, 21552, 21554, 21555, 21556, 21557, 21920, 21930, 21931, 21932, 22900, 22901, 22902, 22903, 23030, 23071, 23075, 23140, 23150, 24000, 24006, 24065, 24066, 24071, 24073, 24075, 24076, 24101, 24110, 24120, 24130, 24147, 24200, 24201, 24366, 25071, 25073, 25075, 25076, 25085, 25109, 25120, 25130, 25350, 26070, 26105, 26110, 26111, 26113, 26115, 26180, 26200, 26210, 26357, 26432, 26433, 26500, 26530, 26542, 26841, 26862, 27006, 27043, 27045, 27047, 27048, 27062, 27310, 27323, 27324, 27327, 27328, 27329, 27337, 27339, 27340, 27345, 27347, 27613, 27614, 27618, 27632, 27634, 27638, 27640, 27720, 28011, 28039, 28041, 28043, 28045, 28047, 28100, 28103, 28104, 28126, 28666, 29835, 29900, 29901, 30000, 30020, 30100, 30110, 30115, 30117, 30118, 30130, 30140, 30220, 30310, 30520, 30580, 30630, 30801, 30802, 30901, 30903, 30930, 31020, 31030, 31032, 31200, 31205, 31525, 31238, 31526, 31528, 31529, 31530, 31535, 31536, 31540, 31541, 31545, 31570, 31571, 31574, 31575, 31576, 31578, 31591, 31611, 31622, 31623, 31624, 31625, 31628, 31652, 31820, 32408, 32555, 32557, 36010, 36215, 36246, 36556, 36569, 36571, 36581, 36582, 36589, 36590, 37607, 38221, 38222, 38500, 38505, 38510, 38520, 38525, 38740, 38760, 40490, 40510, 40520, 40525, 40530, 40808, 40810, 40812, 40814, 40816, 41010, 41100, 41105, 41108, 41110, 41112, 41113, 41116, 42100, 42104, 42106, 42330, 42335, 42405, 42408, 42410, 42415, 42420, 42425, 42440, 42450, 42500, 42650, 42800, 42804, 42808, 42810, 42821, 42826, 42831, 42870, 43191, 43195, 43197, 43211, 43212, 43213, 43214, 43215, 43216, 43217, 43220, 43226, 43227, 43229, 43231, 43232, 43233, 43240, 43241, 43243, 43244, 43245, 43246, 43247, 43248, 43249, 43250, 43251, 43253, 43254, 43260, 43261, 43266, 43270, 43450, 43453, 44340, 44360, 44361, 44364, 44369, 44376, 44377, 44380, 44381, 44382, 44385, 44386, 44388, 44389, 44391, 44392, 44394, 44408, 45100, 45171, 45172, 45190, 45305, 45330, 45331, 45332, 45333, 45334, 45335, 45337, 45338, 45340, 45341, 45342, 45346, 45347, 45349, 45350, 45378, 45379, 45380, 45381, 45382, 45384, 45385, 45386, 45388, 45389, 45390, 45391, 45392, 45393, 45398, 45505, 45541, 45560, 45905, 45910, 45915, 45990, 46020, 46030, 46040, 46045, 46050, 46060, 46080, 46083, 46200, 46220, 46221, 46230, 46250, 46255, 46257, 46258, 46260, 46261, 46262, 46270, 46275, 46280, 46285, 46288, 46320, 46606, 46607, 46610, 46612, 46615, 46700, 46750, 46910, 46917, 46922, 46924, 46930, 46940, 46945, 46946, 47000, 49082, 49083, 49422, 49500, 49505, 49507, 49520, 49521, 49525, 49550, 49553, 49650, 49651, 49900, 50435, 50575, 50590, 50688, 51040, 51102, 51600, 51610, 51702, 51710, 51715, 51720, 51726, 51728, 51729, 52000, 52001, 52005, 52007, 52204, 52214, 52224, 52234, 52235, 52240, 52260, 52265, 52275, 52276, 52281, 52282, 52283, 52285, 52287, 52300, 52310, 52315, 52317, 52318, 52320, 52325, 52327, 52330, 52332, 52341, 52344, 52351, 52352, 52353, 52354, 52356, 52450, 52500, 52601, 52630, 52640, 53020, 53200, 53230, 53260, 53265, 53270, 53440, 53445, 53450, 53500, 53605, 53665, 54001, 54055, 54057, 54060, 54065, 54100, 54110, 54150, 54161, 54162, 54163, 54164, 54300, 54450, 54512, 54530, 54600, 54620, 54640, 54700, 54830, 54840, 54860, 55000, 55040, 55041, 55060, 55100, 55110, 55120, 55250, 55400, 55500, 55520, 55540, 55700, 56405, 56420, 56440, 56441, 56442, 56501, 56515, 56605, 56620, 56700, 56740, 56810, 56821, 57000, 57061, 57065, 57100, 57130, 57135, 57210, 57240, 57250, 57260, 57268, 57282, 57283, 57287, 57300, 57400, 57410, 57415, 57420, 57421, 57425, 57452, 57454, 57456, 57461, 57500, 57505, 57510, 57513, 57520, 57522, 57530, 57700, 57720, 57800, 58100, 58120, 58263, 58558, 58560, 58561, 58565, 58662, 58670, 58671, 58700, 58925, 59200, 62270, 63661, 63663, 64600, 64647, 64702, 64718, 64719, 64721, 64774, 64776, 64782, 64784, 64788, 64795, 64831, 64835, 65275, 65400, 65420, 65426, 65435, 65436, 65710, 65730, 65750, 65755, 65756, 65772, 65778, 65779, 65780, 65800, 65815, 65820, 65850, 65855, 65865, 65875, 65920, 66020, 66170, 66172, 66179, 66180, 66183, 66184, 66185, 66250, 66682, 66710, 66711, 66761, 66762, 66821, 66825, 66840, 66850, 66852, 66982, 66983, 66984, 66985, 66986, 66987, 66988, 67005, 67010, 67015, 67025, 67028, 67031, 67036, 67039, 67040, 67041, 67042, 67043, 67101, 67105, 67107, 67108, 67110, 67113, 67120, 67121, 67141, 67145, 67210, 67218, 67220, 67221, 67228, 67311, 67312, 67314, 67316, 67318, 67345, 67400, 67412, 67414, 67420, 67445, 67550, 67560, 67700, 67800, 67801, 67805, 67808, 67810, 67825, 67840, 67875, 67935, 67961, 67966, 67971, 67973, 67975, 68100, 68110, 68115, 68135, 68320, 68440, 68530, 68700, 68720, 68750, 68761, 68801, 68811, 68815, 69000, 69100, 69110, 69140, 69145, 69205, 69222, 69310, 69320, 69440, 69450, 69502, 69505, 69550, 69602, 69610, 69620, 69631, 69632, 69633, 69635, 69636, 69641, 69642, 69643, 69644, 69645, 69646, 69650, 69660, 69661, 69662, 69666, 69801, 69805, 69806, G0104, G0105, G0106, G0120, G0121, G0122
- Effective March 1, 2025: Pre-authorization will be required for codes 20520, 20525, 20670, 20680, 20693, 20694, 23415, 23450, 23460, 23465, 23515, 23550, 23615, 23630, 23655, 23665, 24105, 24305, 24340, 24341, 24342, 24343, 24345, 24346, 24357, 24358, 24359, 24505, 24516, 24530, 24538, 24545, 24546, 24546, 24575, 24579, 24586, 24605, 24620, 24635, 24655, 24665, 24666, 24685, 25000, 25107, 25111, 25112, 25118, 25210, 25215, 25240, 25260, 25270, 25280, 25290, 25295, 25310, 25320, 25360, 25390, 25447, 25505, 25515, 25545, 25565, 25574, 25575, 25600, 25605, 25606, 25607, 25608, 25609, 25628, 25645, 25652, 25825, 26011, 26020, 26055, 26080, 26121, 26123, 26145, 26160, 26236, 26320, 26340, 26350, 26356, 26370, 26410, 26418, 26426, 26440, 26445, 26480, 26516, 26520, 26525, 26540, 26541, 26608, 26615, 26650, 26665, 26676, 26725, 26727, 26735, 26746, 26756, 26765, 26785, 26850, 26860, 26951, 26952, 27335, 27424, 27605, 27606, 27612, 27620, 27625, 27626, 27650, 27652, 27654, 27659, 27675, 27676, 27680, 27685, 27687, 27690, 27691, 27695, 27696, 27698, 27705, 27752, 27762, 27766, 27769, 27781, 27784, 27786, 27788, 27792, 27810, 27814, 27818, 27822, 27823, 27840, 28002, 28005, 28008, 28010, 28022, 28035, 28060, 28062, 28080, 28086, 28090, 28092, 28110, 28112, 28113, 28116, 28118, 28119, 28120, 28122, 28124, 28160, 28190, 28192, 28200, 28208, 28230, 28232, 28234, 28238, 28250, 28270, 28272, 28285, 28288, 28289, 28291, 28292, 28295, 28296, 28297, 28298, 28299, 28300, 28304, 28306, 28308, 28310, 28313, 28315, 28322, 28415, 28445, 28465, 28475, 28476, 28485, 28505, 28515, 28525, 28555, 28585, 28615, 28645, 28715, 28725, 28740, 28750, 28755, 28810, 28820, 28825, 29834, 29837, 29838, 29844, 29846, 29848
- NOTE: Pre-authorization is not required when procedures performed in an ambulatory surgery center, physician office, or emergency facility for urgent services or when the member is age 17 or younger
Surgical Treatments for Hyperhidrosis (PDF)
- 32664, 64818, 69676
Code 32664 only requires pre-authorization for hyperhidrosis diagnoses L74.510 L74.511, L74.512, L74.513, L74.519, L74.52, R61
Surgical Treatments for Lymphedema and Lipedema (PDF)
- Code 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, 15876, 15877, 15878, 15879 requires pre-authorization for Lipedema only with diagnosis codes Q82.0, R60.0, R60.9
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 diagnosis codes: C01, C02-C02.9, C03-C03.9, C04-C04.9, C05-C05.9, C06, C06.2-C06.9, C09-C09.9, C10-C10.0, C41-C41.1, C46.2, D00-D00.00, D10, D10.1-D10.9, D16.4-D16.5, D37-D37.0, D49-D49.0
HTCC does not apply to those under age 18. See Regence medical policy Surgeries for Snoring, Obstructive Sleep Apnea Syndrome, and Upper Airway Resistance Syndrome (PDF)
Temporomandibular Joint (TMJ) Surgical Interventions
- Visit MCG's website for information on purchasing their criteria, or contact us for a copy of the specific guideline.
- 21010 - MCG A‐0522
- 21050 - MCG A‐0523
- 29800, 29804 - MCG A‐0492
21240, 21242, 21243 - MCG A‐0523
Transcatheter Aortic-Valve Implantation for Aortic Stenosis (PDF)
33361, 33362, 33363, 33364, 33365, 33366
- 0483T, 0484T
Transcutaneous Bone Conduction and Bone-Anchored Hearing Aids (PDF)
69714, 69710, 69716, 69717, 69719, 69726, 69729, 69730, 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.
- 0720T, 61885, 61886, 64553, 64568, 64569, C1822, E0735, L8679, L8680, L8682, L8683, L8685, L8686, L8687, L8688, C1827
- UMP is subject to HTCC Decision (PDF): for treatment of epilepsy and depression: 0720T, 61885, 61886, 64553, 64568, C1822, E0735, L8679, L8680, L8682, L8683, L8685, L8686, L8687, L8688, C1827
- If treatment is for other than these indications, Regence medical policy applies.
The HTCC does not apply to members under age 4. Please use Regence Medical Policy for requests for members under age 4.
- UMP is subject to HTCC Decision (PDF): 0524T, 36465, 36466, 36470, 36471, 36475, 36476, 36478, 36479, 36482, 36483, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37785, S2202
- Notes:
- Requests for multiple treatment sessions should refer to Regence medical policy
- Code 37241 is not appropriate to use in the coding of varicose vein treatment
Transplants - Cell
- 38205, 38206, 38232, 38240, 38241, 38242, S2140, S2142, S2150
- Stem Cell Therapy for Musculoskeletal Condition is subject to HTCC Decision (PDF) criteria: 38205, 38206, 38212, 38215, 38230, 38232, 38240, 38241
Regence medical policy criteria will be used for codes and conditions not reviewed by the HTCC criteria
Transplants - Islet Transplantation (PDF)
48160, 0584T, 0585T, 0586T, G0341, G0342, G0343
33945
Transplants - Heart-Lung (PDF)
33935
Transplants - Lung and Lobar Lung (PDF)
32851, 32852, 32853, 32854, S2060
Transplants - Small Bowel, 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
- A0435, A0430, S9960
- Pre-authorization is required prior to elective fixed wing air ambulance transport.
- Emergency air ambulance transports may be reviewed retrospectively for medical necessity.