Physical Health Prior Authorization

Review the medical and surgical utilization guidelines for an overview of services that require prior authorization.

➔ Medical and Surgical Prior Authorization List and Utilization Guidelines

Certain procedures may require prior authorization, such as those for genetic testing, outpatient and specialty services, transplants, imaging/radiology, surgical procedure, and inpatient services. Treatments subject to prior authorization include durable medical equipment, prosthetics, medical supplies, experimental investigational services and drugs, and home health.

When submitting a prior authorization request for any of these examples, you must submit appropriate documentation to support decision-making and show medical necessity.

Relevant documents include:

• Current patient history and/or physical exam notes that demonstrate the problem
• Relevant lab or radiology results
• Relevant specialty consultation notes
• Other pertinent information

Professionally Administered Drugs

Community Health Plan of Washington (CHPW) requires prior authorization for certain professionally administered medications. MCG guidelines are used to determine medical necessity in the absence of CHPW Clinical Coverage Criteria.

➔ Click here to see Professionally Administered Drugs and Medical Drug Benefits

Durable Medical Equipment and Other Supplies

Some medical equipment and other supplies require prior authorization to determine medical necessity. Coverage is determined by national or local criteria outlined by the Centers for Medicare and Medicaid Services (CMS). If none are available, CHPW uses Clinical Coverage Criteria (see policies below).

Medical equipment is defined in the following way:

Durable Medical Equipment

Durable medical equipment considered durable is equipment that can withstand repeated use, such as, the type of item that be rented. Medical supplies of an expendable nature, such as incontinence pads, lamb’s wool pads, catheters, ace bandages, elastic stockings, surgical facemask, sheets, and bags are not considered “durable” within the meaning of the definition. There are other items that, although durable in nature, may fall into other coverage categories such as supplies and orthotics and prosthetics. Orthotics and Prosthetics items include, but are not limited to, braces, artificial limbs and eyes.

Medical Equipment

Medical equipment is defined as equipment primarily and customarily used for medical purposes and is not generally useful in the absence of illness or injury. In most instances, no documentation will be needed to support whether a specific item of equipment is medical in nature. However, some cases will require documentation would include the advice of local medical organizations and facilities and specialist in the field of physical medicine and rehabilitation. If the equipment is new on the market, it may be necessary, prior to seeking professional advice, to obtain information from the supplier or manufacturer explaining the design, purpose, effectiveness and method of using the equipment in the home as well as the results of any tests or clinical studies that have been conducted.

CHPW considers durable medical equipment (DME), orthotics, and prosthetics medically necessary when the applicable criteria are met. DME items have the following characteristics and should meet the following requirements:

• Is prescribed by a physician
• The order contains the physician’s signature, not a stamp
• Can withstand repeated use
• Is primarily and customarily used to serve a medical purpose
• Is appropriate for use in the client’s place or residence
• Meets the definition of DME

Exceptions: DME order can be signed by provider other than a physician in certain circumstances:

• Medication administration or monitoring (such as, blood glucose testing, continuous glucose monitoring, or insulin pumps), or home infusions
• Respiratory supplies (such as, CPAP mask or tubing)
• Breast pumps
• DME requests while member is in a facility (SNF, Inpatient Rehab, Long Term Acute Care or hospital. Signature will be required for members in custodial care, adult family home, or long-term care.

Certain durable medical equipment, prosthetics and medical supplies require prior authorization. Below is an example of common items that require authorization. Please note that this is not an exhaustive list.

• Bone growth stimulators
• Chest compression devices
• C-Pap/Bi-Pap
• Enteral Nutrition (21 and over)
• Enteral Pumps
• Hospital beds and accessories
• Ventilators
• Wheelchair/Scooters
• Wound Vac

Special Considerations

Rental: CHPW may apply rental fees towards the eventual purchase of a device. Some DME are for purchase only. Rules regarding rental versus purchase should be checked.

Repair:

• The repair of any DME must meet relevant criteria for medical necessity, including prior authorization if required for similar new equipment.
• Repair is considered only for client-owned equipment after expiration of warranty period. Any repair for DME must meet relevant criteria for medical necessity, including prior authorization if required for similar new equipment.
• It is the provider’s responsibility to check warranty coverage before submitting a request for a DME repair. Warranty coverage will be reviewed, along with repair cost, at the time of assessment for prior authorization.
• Repairs do not require a face to face evaluation with the physician but do require a physician signature on the order

Replacement:

• Replacement of any DME must meet relevant criteria for medical necessity, including prior authorization if required for similar new equipment.
• Any requests for DME replacement must include documentation of a current (within 3 month) face-to-face evaluation by the treating physician and therapist, as applicable, showing medical need for the device by the member.
• CHPW does not pay for the replacement of equipment, devices, or supplies, which have been sold, gifted, lost, broken, destroyed, or stolen as a result of the client’s carelessness, negligence, recklessness, deliberate intent, or misuse.

More information on Care Guidelines for Durable Medical Equipment can be found in this policy.

Clinical Coverage Criteria

To view Utilization Management Policies for Medical Drug Benefits, please visit the Prior Authorization page.