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;

 

 

 

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