Humana Commercial Preauthorization and Notification List
January 2019 ~
Humana has released recent updates to its pre-authorization and notification list for all commercial fully insured plans. The list represents services and medications that require pre-authorization prior to being provided or administered. Medications include those that are delivered in the physician’s office, clinic, outpatient or home setting.
Commercial Pre-authorization and Notification List
Inpatient Admissions
· Acute Hospital (Includes Inpatient Hospice)
· Acute Rehab Facilities · Long-term Acute Care
· Mental Health, Substance Use and Partial Hospital/Residential Treatment
· Skilled Nursing Facilities
Durable Medical Equipment (DME)
· Cochlear and Auditory Brainstem Implants
· Electric Beds · High Frequency Chest CompressionVests
· Noninvasive Home Ventilators*
· Pain Infusion Pump
· Prosthetics
· StimulatorDevices
o Bone Growth
o Neuromuscular
o Spinal Cord
· Wheelchairs/Scooters
· Any other DME item greater than $750
Cosmetic/Plastic Surgery
· Abdominoplasty
· Blepharoplasty
· Breast Procedures
· Otoplasty
· Rhinoplasty “Breast Procedures” excludes breast reconstruction following medically necessary mastectomies for breast cancer.
Other Surgery
· Ablation*
· Balloon Sinuplasty
· Bunionectomy
· Decompression of Peripheral Nerve (i.e., Carpal Tunnel Surgery*)
· Diagnostic Esophagogastroduodenoscopy (EGD) or Esophagoscopy (For patients 59 and younger only. Includes site-of-service evaluation)*
· Gastric Pacing*
· Hammertoe Surgery
· Obesity Surgeries
· Oral, Orthognathic, Temporomandibular Joint
· Orthopedic Surgeries: Hip, Knee and Shoulder Arthroscopy
· Penile Implant
· Peripheral Revascularization, Lower Extremity (Atherectomy, Angioplasty)*
· Surgery for Obstructive Sleep Apnea
· Thyroid Surgeries (Thyroidectomy and Lobectomy)*
· Transplant Surgeries
· Varicose Vein: Surgical Treatment and Sclerotherapy Ablation includes: Bone, cardiac, liver, kidney and prostate cancer
Outpatient Diagnostic Testing
· Facility-based Sleep Studies (PSG)
· Infertility Testing and Treatment
· Molecular Diagnostic/Genetic Testing
Cardiac Diagnostic Testing
· Cardiac Computed Tomography Angiography (CCTA)
· Electrophysiology Study (EPS)
· Electrophysiology (EPS) with 3D Mapping
· Myocardial Perfusion Imaging Single Photon Emission Computed Tomography (MPI SPECT)
· Outpatient Transthoracic Echocardiogram (TTE)
· Transesophageal Echocardiogram (TEE)
Cardiac Procedures/ Surgeries
· Cardiac Catheterizations
· Outpatient Coronary Angioplasty/Stent
· Peripheral Revascularization, Lower Extremity (Atherectomy, Angioplasty)* (please see “Other Surgery” category)
· Transcatheter Valve Surgeries (TAVR, MitraClip)
Cardiac Devices
· Cardiac Resynchronization Therapy
· Defibrillators · Left Atrial Appendage Closure (LAAC) Device (e.g.; WatchmanTM)
· Loop Recorders
· Pacemakers
· Ventricular Assist Devices (VADs)
· Wearable Cardiac Devices (e.g., LifeVest)
Diagnostic Imaging
· Capsule Endoscopy*
· Computed Tomography (CT) Scan
· Magnetic Resonance Angiogram (MRA)
· Magnetic Resonance Imaging (MRI)
· Nuclear Stress Test · Position Emission Tomography (PET) Scan
· Single Photon Emission Computerized Tomography (SPECT) Scan
Outpatient Therapy Services
· Chiropractic Therapy ( Arizona, Georgia, Illinois, Kentucky, Ohio, South Florida only)
· Hyperbaric Therapy
Oncology
· Breast Cancer Biopsy (excisional)
· Breast Lumpectomy
· Chemotherapy Agents, Supportive Drugs and Symptom Management Drugs
· Lung Biopsy and Resection · Radiation Therapy
· Simple Mastectomy and Gynecomastia Surgery (excludes radical and modified)
Home Health Care
· Home Health/Home Infusion
Pain Management Procedures
· Epidural Injections (outpatient only)
· Facet Injections
· Spinal Surgery
o Spinal Fusion
o Other Decompression Surgeries
o Kyphoplasty
o Vertebroplasty
Behavioral Health Services
· Electroconvulsive Therapy (ECT) · Transcranial Magnetic Stimulation (TMS)
Routine Maternity Care
· Notification requested
Specialty Drugs
· Preauthorization required for the below list of specialty drugs when delivered in the physician’s office, clinic, outpatient or home setting
· To request preauthorization or provide notification, please click here to access the fax forms
For more information on these changes, as well as a complete listing of the Commercial Medication Preauthorization List, click here.
Source(s): Humana;
