Humana Healthy Horizons KY Prior Auth Policy Update

Policy Summary & Scope

This document applies to Humana Healthy Horizons enrollees in Kentucky and defines services that require preauthorization or notification for that state Medicaid plan only. It is intended for providers serving Humana Healthy Horizons members in KY and does not apply to Humana Medicare or other state Medicaid plans. Effective date: 2025-07-01; Last review: 2025-12-30.

At-a-glance stats

CPT/HCPCS/ICD/Revenue codes listed that require prior authorization or notificationMultiple (hundreds)

Advanced imaging (CT/CTA/MRI/MRA/PET/SPECT) managed by eviCoreAdvanced imaging reviewed by eviCore

Third-party managers referenced for specific service typesNew Century Health (chemo) & Tivity & Progeny partnerships

procedure and HCPCS/CPT/Q codes listed100+

JurisdictionKentucky-only

Applicable statesKY

Prior Authorization & Notification Requirements (High-Level)

Preauthorization requires providers to obtain advance approval from the plan to determine whether an item or service will be covered; notification is a separate process used to inform Humana of a planned service for care coordination and does not constitute approval or denial. The Preauthorization and Notification List describes services commonly reviewed and the circumstances in which additional clinical information may be required to adjudicate coverage for Humana Healthy Horizons in Kentucky.

Prior Authorization

Obtain preauthorization for listed services

Providers must obtain prior authorization for services listed (examples: all inpatient admissions, many DME/MSEA items, advanced imaging, specified surgeries and therapies). Failure to obtain authorization may result in financial penalties, reduced member benefits, and retrospective medical necessity review.

All inpatient admissions (hospital, rehab, LTAC, inpatient hospice, transplant, planned inpatient medical and surgical admissions)
Many DME/MSEA items (see MSEA/DME code lists)
Advanced imaging (managed by eviCore — CT/MRI/MRA/PET/SPECT examples)
Specified surgeries and therapies (examples listed throughout the PAL)

Codes Requiring Authorization / Notification

Inpatient admissions (all inpatient admission codes)CPT|HCPCSCovered

All inpatient admission codes

All inpatient admissions (hospital, rehab, LTAC, inpatient hospice, transplant, planned inpatient medical and surgical admissions) require prior authorization.

Behavioral healthCPT|HCPCSCovered

H0035	Partial hospitalization
H0015	Intensive outpatient program (IOP) SUD
S9480	IOP substance use disorder
H2012	Therapeutic behavioral health service
H2019	Day treatment
H2020	Day treatment
97151	Applied behavior analysis (ABA) initial assessment
97152	ABA assistant
97153	Adaptive behavior treatment
97154	ABA adaptive behavior treatment

1–10 of 15

1/2

CardiologyCPT|HCPCSCovered

93451-93462	Cardiac catheterizations
93593-93597	Additional cardiac catheterization codes
33206-33289	Cardiac device implantation/management
33340	Transcatheter procedures
C1779,C1785,C1786,C1817,C1898,C2619,C2620,C2621	Cardiac device HCPCS/Codes

Chiropractic servicesbilling_noteCovered

See CHFS Chiropractor Fee Schedule

Reviewed by Tivity Health — consult Kentucky CHFS fee schedule

Medical supplies, equipment and accessories (MSEA)/DME & Prosthetics/OrthoticsHCPCSCovered

E0482	Airway clearance devices
E1902,E2500,E2502,E2504,E2506,E2508,E2511,E2512,E2599,L8505,V5336	Augmentative & alternative communication systems
E0193,E0194,E0250,E0251,E0255,E0256,E0260,E0261,E0265,E0266,E0270,E0277,E0294,E0295,E0296,E0297,E0300,E0301,E0302,E0303,E0304,E0316,E0328,E0329,E0371,E0372,E0373,E0462,E0912	Beds and accessories
E0747,E0748,E0760	Bone growth stimulators
69930,L8614,L8619,L8627,L8628	Cochlear and auditory implants
A9277,A9278,A9279,S1030,S1031,S1034	Continuous glucose monitoring devices and supplies
E0470,E0471,E0472,E0601	CPAP/BiPAP
S1040	Cranial orthotics
E0784	Diabetic treatments and supplies (example code listed)
E0217,E0225,E0236,E0239	Heat/cold therapy devices

1–10 of 26

1/3

Miscellaneous/unlisted surgical codesCPTCovered

39599,42699,43659,44238,45499,45999,47379,48999,49329,49659,51999,55899,58578,58999,69399,87999

Miscellaneous/unlisted procedure codes requiring authorization

Breast surgery (cosmetic exclusions noted)CPT|HCPCSCovered

19300,19305,19306,19316,19318,19325,19328,19350,19355,19361,19364,19367,19368,19369,19370,19371,19380,19396,C1789,L8600,S2066,S2067,S2068

Breast surgery; excludes reconstruction following medically necessary mastectomy for breast cancer

Plastic/cosmetic surgery (nonemergent)CPTCovered

15820-15847,17106-17108,30400-30469,30450-30469,67900-67950, etc.

Examples of cosmetic/reconstructive surgery codes requiring authorization (not all-inclusive)

Ancillary services — EEG / Endoscopy / PT/OT/ST / Respiratory therapy / Home health & infusions / Genetic testing / Lab panelsCPT|HCPCS|G-codes|S-codes|U-codesCovered

95812,95813,95822	EEG
43191,43193,43197,43198,43202,43239	Diagnostic EGD or esophagoscopy for patients younger than 59
Numerous PT/OT/ST and therapy codes (90901-97799 etc., G0151-G2169, S-codes listed)	Physical, occupational and speech therapy codes requiring authorization; long list included
G0239	Respiratory therapy
99344,B9002,B9004,B9006,B9998,B9999,G0155,G0299,G0300,G0494-G0495,S5100-S9214,T1004,T1019-T1031,T1502-T1503	All home health and home infusions codes
81162-81479,81503-81554,81596,81599,86305,0001U-0414U,0633T-0713T,70450-70498,71250-71275,72125-72194,73200-73223,73700-73723,74150-74178,75571-75635	Extensive laboratory, molecular diagnostic, genetic testing and imaging codes requiring authorization

Advanced imaging (managed by eviCore)CPT|HCPCS|T-codes|C-codesCovered

75572-75573	Computed Tomography Angiography (CTA)
0623T-0626T	Coronary CT Angiography (CCTA)
70544-70549,71555,72159,72191-72194,73225,74185,C8900-C8936	Magnetic Resonance Angiography (MRA)
0697T,0698T,70336,70540-70555,71550-71552,72141-72149,72156-72158,72195-72197,73218-73223,73718-73723,74181-74183,74712-74713,75557-75565,76391,76498,77021-77022	MRI codes requiring prior authorization via eviCore
C8905,C8906,C8908,S8037,S8042,78429-78433,78459,78491-78492,78608,78811-78813	PET codes requiring prior authorization
78814-78816,G0235,78451,78452,78469	SPECT codes requiring prior authorization

Advanced imaging CTCPT|HCPCSCovered

70450-70482,70486-70498,70490-70492,70496,70498,71250-71275,72125-72133,72191-72194,73200-73206,73700-73706,74150-74178,75571,75574,75635,76380,76497,77078,S8092

CT and other imaging codes listed (authorization required)

Magnetic Resonance Angiography (MRA) / Advanced ImagingCPT|HCPCS

70544
70545
70546
70547
70548
70549
71555
72159
72198
73225

1–10 of 29

1/3

Magnetic Resonance Imaging (MRI) / Advanced ImagingCPT|HCPCS

0697T
0698T
70336
70540
70542
70543
70551
70552
70553
70554

1–10 of 52

1/6

PET (Positron Emission Tomography)CPT|HCPCS

C8905
C8906
C8908
S8037
S8042
78429
78430
78431
78432
78433

1–10 of 17

1/2

SPECT / Nuclear MedicineCPT|HCPCS

78814
78815
78816
G0235
78451
78452
78469

3D RenderingCPT

76376
76377

CAR-T TherapyHCPCS

T1025
T1026

Prescribed Pediatric Extended CareCPT|HCPCS|ICD-10|Other

0087U
0088U
0118U
0319U
0320U
0584T
0585T
0586T
0664T
02WA3QZ

1–10 of 43

1/5

Transplant ServicesHCPCS

T1000

Private Duty Nursing (PDN)CPT|HCPCS

0524T
36465
36466
36468
36470
36471
36473
36474
36475
36476

1–10 of 26

1/3

Vein ProceduresCPT

01966
59100
59812
59840
59841
59850
59851
59852
59855
59856

1–10 of 11

1/2

Termination of Pregnancy / AbortionCPT

62320
62321
62323
64479
64480
64483
64484
64999

Epidural Injections (Outpatient Only)CPT

0213T
0214T
0215T
0216T
0217T
0218T
64490
64491
64492
64493

1–10 of 17

1/2

Facet InjectionsCPT

27096

Sacroiliac JointCPT

20552
20553

Trigger-Point Injections / Radiation Planning CodesCPT|HCPCS

77385
77386
77401
77402
77407
G6012
G6013
G6015

Radiation Therapy - Brachytherapy, Neutron, Proton, StereotacticCPT|HCPCS

19296
19297
19298
77750
77761
77762
77763
77767
77768
77770

1–10 of 31

1/4

Durable Medical Equipment / Prosthetics (selected A-, C-, Q- codes)HCPCS|CPT

A2001
A2002
A2004
A2005
A2006
A2007
A2008
A2009
A2010
A2011

1–10 of 160

1/16

Skin and Tissue Substitutes / Bariatric Surgery Related CodesCPT

43631
43632
43633
43634
43644
43770
43771
43772
43773
43774

1–10 of 20

1/2

Foot Surgeries (bunionectomy, hammertoe)CPT

26535
26536
28110
28240
28285
28289
28291
28292
28295
28296

1–10 of 19

1/2

Laparoscopic Hiatal Hernia RepairCPT

43280
43281
43282

NeurostimulatorCPT|HCPCS

61850
61860
61880
61885
61886
61888
63650
63655
63661
63662

1–10 of 31

1/4

Orthopedic Surgeries: Arthroplasty and Arthroscopy (hip, knee, shoulder)CPT

23472
23473
23474
27125
27130
27132
27134
27137
27138
27437

1–10 of 20

1/2

Orthopedic Arthroscopy (hip/knee/shoulder arthroscopy)CPT

23929
27299
27412
27599
29805
29806
29807
29819
29820
29821

1–10 of 44

1/5

Pain Infusion PumpCPT|HCPCS

62324
62325
62326
62327
62350
62351
62360
62361
62362
64999

1–10 of 15

1/2

Spinal Fusion, Decompression, Kyphoplasty, VertebroplastyCPT

20999
22100
22101
22102
22103
22116
22206
22207
22208
22210

1–10 of 96

1/10

Ventricular Assist Devices (VADs)CPT|HCPCS

63045
63046
63047
63048
63050
63051
63055
63056
63057
63064

1–10 of 68

1/7

Billing Rule

Nonemergent medical transportation

Nonemergent medical transportation services require prior authorization.

A0430
A0431
T2005

Note

Use correct submission channels

Submit preauthorization requests via Availity Essentials, Humana IVR, or fax unless otherwise specified; some services use third‑party managers with separate submission routes.

Availity Essentials (online)
Humana IVR: 800-444-9137

Operational Requirements & How to Submit Requests

Providers are expected to obtain prior authorization for services listed in this PAL (examples include all inpatient admissions, many DME/MSEA items, advanced imaging, specified surgeries and therapies). Submit requests through the channel specified for the service: general preauthorizations via Availity Essentials, Humana IVR or fax; advanced imaging and many therapy requests via eviCore; chemotherapy via New Century Health; chiropractic review via Tivity/WholeHealthPro; and transplant requests routed to Humana's National Transplant Network. Failure to obtain required authorization may result in financial penalties, reduced member benefits, and retrospective medical necessity review.

Note

Use correct submission channels (managed-service routing)

Use the correct submission channels and routing for managed services; note specific third-party managers and fax routing for PT/OT/ST.

eviCore — advanced imaging and PT/OT/ST (portal or phone 866-672-8115); PT/OT/ST fax: 855-774-1319
New Century Health — chemotherapy (portal/phone)
Tivity/WholeHealthPro — chiropractic reviews via WholeHealthPro portal
Progeny Health — NICU/Special Care Nursery notifications via fax 866-610-2034

Key Terms

Definitions

PreauthorizationProcess requiring providers to obtain advance approval from the plan to determine whether an item or service may be covered (also called prior authorization, precertification, preadmission).

NotificationProcess by which a provider notifies Humana of intent to provide an item or service; used for care coordination and does not constitute an approval or denial.

Numeric & Documentation Thresholds

Thresholds

MSEA cost threshold for retro-review$750

Retro-review documentation requirementSigned clinical record must be submitted with the claim for MSEA items costing more than $750; claims without clinical records are denied and reconsidered only through appeal.

Scope of retro-reviewApplies in addition to items specifically identified in the MSEA list (DME/services/rentals/repair).

Policy Dates & Change Log

2025-07-01Effective Date

Policy became effective for Humana Healthy Horizons in Kentucky Preauthorization and Notification List.

2025-12-30Last ReviewLatest

Document revision date; policy content last reviewed and updated on this date.

OpenPayer

Humana Healthy Horizons in Kentucky Preauthorization and Notification List (PAL)

Policy Summary & Scope

Prior Authorization & Notification Requirements (High-Level)

Codes Requiring Authorization / Notification

Operational Requirements & How to Submit Requests

Key Terms

Numeric & Documentation Thresholds

Policy Dates & Change Log

Humana Healthy Horizons in Kentucky Preauthorization and Notification List (PAL)

Policy Summary & Scope

Prior Authorization & Notification Requirements (High-Level)

Codes Requiring Authorization / Notification

Operational Requirements & How to Submit Requests

Key Terms

Numeric & Documentation Thresholds

Referenced Third-Party & Related Policies

Policy Dates & Change Log