Humana Dual Michigan Prior Auth & Policy Update

Coverage and Routing Rules

General coverage stance

Services and medications listed require prior authorization prior to provision; investigational and experimental procedures are usually not covered and may require confirmation via Evidence of Coverage or an Advance Coverage Determination (ACD).

Prior authorization is required for services and medications listed on this document prior to being provided or administered (prior authorization defined as advance approval from the plan).

Services must be provided according to Medicare coverage guidelines and must be medically necessary per CMS guidance.

Investigational and experimental procedures and devices usually are not covered; for coverage determination or clarification providers may request an Advance Coverage Determination (ACD).

Failure to obtain required prior authorization or to provide requested supporting clinical information may result in delayed, adverse, or retrospective review decisions and potential financial penalties per provider contract and member Evidence of Coverage.

CMS rule (effective Jan 1, 2026) requires certain prior authorization decisions within 7 days; submit supporting clinical information at time of request to support timely adjudication.

Vendor-managed categories

Selected service categories are managed by third‑party vendors and require submission through those vendors' portals, phone lines, or fax numbers for authorization.

Certain clinical categories (for example: cardiac devices/procedures, cellular/CAR‑T/genetic/transplant therapies, selected surgical services, diagnostic/cardiac imaging, orthopedic arthroplasty and related services) are managed by external vendors and must be submitted to the named vendor for prior authorization.

When a category is vendor‑managed, submit prior authorization requests via the vendor's portal, phone, or fax as indicated in the list; expedited/urgent cases may be submitted and monitored on the vendor portal where supported.

Authorization requirements and routing

Services and codes listed require prior authorization or notification per category; some categories are routed to named third‑party vendors with specific submission instructions.

Prior authorization required

Provider must obtain prior authorization before providing the service when the code appears on the list and is not otherwise noted as notification-only or excluded.
If the code/category is designated as managed by an external vendor (e.g., Cohere Health, Evolent, One Home Care), submit the prior authorization request to that vendor using the portal/phone/fax listed; do not submit to Humana's general portal for vendor-managed categories.

Notification required

When the list indicates 'notification required' for a service (for example: observation, transplant evaluation), the provider must notify Humana of intent to provide the service; Humana does not issue an approval or denial for notifications.

Cohere Health-managed services

Services that are managed by Cohere Health require prior authorization through Cohere Health's submission channels.

Categories managed by Cohere Health include (but are not limited to) orthopedic hip, knee and shoulder arthroplasty; shoulder arthroscopy; pain infusion pump; percutaneous lumbar intravertebral disc injection; diagnostic and cardiac imaging; spinal procedures and spinal cord stimulators; certain nasal/sinus surgical and therapy services; and selected therapy services.

Submit prior authorization requests for Cohere Health‑managed services via Cohere Health's portal (online), by phone at 833-283-0033 (Mon‑Fri 8 a.m.‑8 p.m. ET), or by fax to 857-557-6787. Expedited/urgent cases can be submitted and monitored on the Cohere Health portal.

Evolent-managed services

Prostate surgeries and radiation therapy preauthorization requests are managed by Evolent (formerly New Century Health) and must be submitted to Evolent.

Evolent will manage preauthorization requests for specified prostate surgeries (prostatectomy codes listed) and radiation therapy codes shown on the list.

Submit preauthorization requests for Evolent‑managed services via Evolent's website or by calling 844-926-4528, option 5. Evolent offers live representative support Mon‑Fri 8 a.m.‑8 p.m. ET; oncology submissions may accept eFax (213-596-3783) and dedicated eFax email addresses as indicated in the list.

Observation notification

Observation services require notification.

Observation status/services are designated as 'notification required' on the list; providers must submit a notification to Humana when observation services are provided.

Breast reconstruction Q-code preauthorization exception

Exception for specific Q-codes related to breast reconstruction:

For Q-codes Q4116, Q4122 and Q4128, no preauthorization is required when used for breast reconstruction following a medically necessary mastectomy for breast cancer.

Vendor routing and submission instructions

Vendor-managed categories — submission requirements:

Radiation therapy prior authorization requests must be submitted to Evolent (formerly New Century Health) via their website or by phone at 844-926-4528 (option 5); eFax options and specified eFax email addresses for oncology submissions are provided in the list; live representative hours are Mon‑Fri 8 a.m.‑8 p.m. ET.

Spinal procedures and spinal cord stimulator authorizations are managed by Cohere Health; submit via Cohere Health's portal, phone 833-283-0033 (Mon‑Fri 8 a.m.‑8 p.m. ET), or fax 857-557-6787. Expedited/urgent cases may be submitted and monitored on the Cohere portal.

For diagnostic/cardiac imaging, orthopedic arthroplasty, nasal/sinus endoscopic procedures, and therapy services that are designated as Cohere Health‑managed, use Cohere Health's portal/phone/fax submission channels per the list instructions.

Code Lists and Limits

Covered HCPCS/HCPCS-rangeHCPCSCovered

E0469	Airway clearance device, stationary or portable
E0481	Bi-level pressure ventilator, S/T mode
E0482	Bi-level pressure ventilator, spontaneous mode
E0483	Bi-level pressure ventilator, other
E2508	Augmentative and alternative communication device, full system
E3000	Speech generating device, dedicated
A4238	Insertion device, blood glucose test
A9274	Diabetic supply, sensor
L5000	Prosthetic, lower limb, extensive list (selected)
L6695	Prosthetic foot component (selected L-codes)

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Covered CPT/Procedure/RangeCPTCovered

61860-61892	Neurosurgical/cranial neurostimulator procedure series
62324-62362	Epidural injection series (outpatient only)
64553-64598	Neurostimulator lead and device implantation series
77280-77778	Radiation therapy planning and delivery codes
70460-70498	CT imaging series (selected codes)
71260-71275	Chest CT series
93600-93656	Electrophysiology/cardiac ablation and mapping

Covered CPT/Specific CodesCPTCovered

64999	Unlisted procedure, nerve (used for certain nerve procedures)
81373	Molecular diagnostic code (covered)
81490	Molecular diagnostic code (covered)
83080	Hemoglobin A1c test
93650	Intracardiac ablation code (cardiac ablation example)
61860	Stereotactic implantation of neurostimulator
64553	Insertion or replacement of peripheral neurostimulator lead
62324	Injection, epidural; lumbar
33206	Insertion of pacemaker or cardio device (example listed under Cohere-managed devices)

How Providers Request Authorization

Documentation Required

CMS timeframe and documentation expectations

Prior authorization decisions for certain medical items and services must meet CMS timeframes effective Jan 1, 2026. Humana follows the CMS requirement to render prior authorization determinations within 7 calendar days for standard requests for the specified items/services. To support timely adjudication, submit complete and relevant clinical documentation with the initial prior authorization request. If additional information is needed, Humana will contact the requester; failure to provide requested documentation promptly may delay the decision or result in an adverse determination.

Decisions for applicable medical items/services: within 7 calendar days for standard requests per CMS rule effective 2026-01-01.
Provide all supporting clinical documentation at submission to avoid delays.
Humana will request specific additional information if required; absence of documentation may result in delayed or adverse decision.

Prior Authorization

Transplant, vascular, cardiac devices, DME and related codes

Key Terms

Prior authorization

DefinitionPrior authorization is a process requiring the physician or other healthcare provider to obtain advance approval from the plan as to whether an item or service will be covered.

When requiredRequired for services and medications listed on the prior authorization and notification list prior to being provided or administered.

Relation to MedicareServices must be provided according to CMS Medicare coverage guidelines and be medically necessary.

Notification

DefinitionNotification is the process by which the physician or other healthcare provider notifies Humana of the intent to provide an item or service; Humana does not issue an approval or denial for notifications.

PurposeHelps Humana coordinate care for Humana-covered patients.

OpenPayer

Humana Dual Highly Integrated Michigan Prior Authorization and Notification List

Coverage and Routing Rules

Code Lists and Limits

How Providers Request Authorization

Key Terms