CurrentHumanaPolicy N/A

Humana Healthy Horizons in Kentucky Prior Authorization and Notification List

Lists services that commonly require prior authorization or notification for Humana Healthy Horizons enrollees in Kentucky and describes how providers request authorization and notifications.

Policy Summary

PayerHumana

PolicyHumana Healthy Horizons in Kentucky Prior Authorization and Notification List

Policy CodePolicy N/A

Change TypeMinor/No material changes

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionRequest prior authorization online via Availity Essentials, by phone at 800-444-9137, or fax 833-974-0059.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Manyservice categories listed

$750MSEA retro-review threshold

Online/Phone/Faxrequest methods

Urgent/exempturgent services

Hundredscodes enumerated

Coverage requirements and service categories

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Coverage requirements and administrative rules (selected)

Covered when the following coverage and administrative requirements are met:

All inpatient admission codes (hospitals, rehabilitation facilities, long-term acute care, inpatient hospice, transplant, and planned inpatient medical and surgical admissions) require prior authorization.

Transplant prior authorization requests are reviewed by Humana's National Transplant Network and can be submitted via Availity.

Behavioral health inpatient, residential treatment, and partial hospitalization services require prior authorization (example partial hospitalization code: H0035; IOP SUD example code: H0015).

All MSEA items costing more than $750 are subject to retrospective review. A signed clinical record must be submitted with the claim for retro-review; claims submitted without clinical records are denied and are only reconsidered through the claim appeal process with pertinent clinical records.

Authorization requirements by service category — includes delegation to EviCore where applicable

Services listed below require prior authorization or notification; certain categories are managed by delegated vendors (e.g., EviCore) as noted.

Advanced imaging (CT, CTA, MRA, MRI, PET, SPECT, 3D rendering) requires prior review and is reviewed by EviCore per the listed codes.

Molecular diagnostic and genetic testing require prior authorization/notification per the codes enumerated on the list.

Radiation therapy modalities (including brachytherapy, proton beam, stereotactic radiation) require prior authorization/notification per the list.

Cellular, CAR T, genetic, tissue and transplant therapies require prior authorization/notification for the codes enumerated.

Plastic and cosmetic surgical procedures listed (including breast and other reconstructive/cosmetic procedures) require prior authorization for listed procedure codes.

Bariatric surgery procedures listed require prior authorization.

Listed services requiring prior authorization/notification — selected codes and subcategories

Selected procedure and device subcategories and example codes that require prior authorization/notification:

Bariatric and gastrointestinal procedures (examples)

43631, 43632, 43633, 43634, 43644, 43770-43775, 43842-43848, 43886-43888 require prior authorization/notification.

Foot surgeries (bunionectomy, hammertoe) (examples)

26535, 26536, 28110, 28240, 28285, 28289, 28291-28299, 28306, 28308, 28310, 28740, 28750, L8641 require prior authorization/notification.

Laparoscopic hiatal hernia repair (examples)

43280, 43281, 43282 require prior authorization/notification.

Neurostimulator and neuromodulation procedures (examples)

Codes and code groups

Behavioral health codes (examples)CPT | HCPCS | mixed

H0035	Partial hospitalization (behavioral health)
H0015	Intensive outpatient program (IOP) SUD
97151-97158	ABA service codes (examples listed)

Cardiology procedural and device codesCPT | HCPCS | mixed

93451-93462, 93593-93597	Cardiac catheterization codes listed
33206-33289, 33340, C1779, C1785, C1786, C1817, C1898, C2619	Cardiac device/pacing codes listed

MSEA / Orthotics codesHCPCS | CPT | mixed

E1902, E2500-E2512, E2599, L8505	Augmentative and alternative communication systems and related MSEA codes
L0456-L0488, L0631-L0640, L0700-L0750	Orthotics codes (selected examples)

Wheelchairs / Miscellaneous codesHCPCS | CPT | mixed

K0002-K0898, E0968-E1237	Wheelchairs, scooters and accessory codes listed
39599, 42699, 43659, 44238, 45499, 45999, 47379, 48999, 49329, 49659, 51999, 55899, 58578, 58999, 69399, 87999	Miscellaneous/unlisted procedure codes

Plastic surgery / cosmetic (breast and other cosmetic/reconstructive services)CPT

19300
19305
19306
19316
19318
19325
19328
19350

Advanced imaging (CT, CTA, MRA, MRI)CPT

70450
70460
70470
72125
72191
73200
73700
74150
75571
76380

1–10 of 13

1/2

Radiation therapy and brachytherapyCPT

77520
77522
77523
77525
77371
77750
77761

Molecular diagnostic / genetic testing (many CPT and U-codes listed)mixed

81162
81163
81164
81165
81166
81200
81201
81374
81503
0001U

1–10 of 11

1/2

Procedure/Device code groupsmixedCovered

43631-43888 (selected)	Bariatric and related gastrointestinal procedure CPT codes
26535-28750, L8641 (selected)	Foot surgery (bunionectomy, hammertoe) CPT and L-code
61850-64595, 95970-95972, C1823 (selected)	Neurostimulator and neuromodulation procedure codes
23472-27487 (selected)	Orthopedic hip/knee/shoulder arthroplasty codes
29805-29999 (selected)	Arthroscopy and pain infusion pump related codes
C2626, E0782, E0783, 20999, 22100-22899, 27279-27280, 62287, 62380, 63001-63308, 0274T, C1821, C2614, C9757	Spinal, neurosurgical, and ventricular assist device (VAD) related codes

MSEA retro-review threshold

MSEA retro-review thresholdAll MSEA items costing more than $750 are subject to retrospective review; a signed clinical record must be submitted with the claim; claims submitted without clinical records are denied and reconsidered only through the claim appeal process.

Documentation required for retro-reviewSigned clinical record must accompany the claim for retro-review of MSEA items > $750.

Denial and appeal processClaims for MSEA items > $750 submitted without clinical records are denied; denials are reconsidered only through the claim appeal process with pertinent clinical records.

Obstetrical notification thresholds

Vaginal delivery notification thresholdNotify Humana if obstetrical admission exceeds 48 hours for vaginal deliveries.

Cesarean delivery notification thresholdNotify Humana if obstetrical admission exceeds 96 hours for cesarean sections.

Purpose of notificationHumana requests notification to conduct concurrent review for care coordination and discharge planning.

How to request authorization, notifications, and provider responsibilities

Prior Authorization

Prior Authorization Required

How to request prior authorization: Except where otherwise noted, providers may request prior authorization online, by phone, or by fax. Online: Availity Essentials (registration required). Phone: Humana interactive voice response at 800-444-9137. Fax: submit the prior authorization form to 833-974-0059. Certain specialty requests are managed by delegated vendors — follow the vendor submission instructions (eviCore for advanced imaging, New Century Health for chemotherapy agents, Tivity for Whole Health Living). Notification differs from prior authorization: notification is for Humana’s care coordination and does not represent an approval or denial.

Online via Availity Essentials™
Phone: 800-444-9137
Fax: 833-974-0059
Advanced imaging prior authorization managed by eviCore (see Advanced Imaging callout)
Transplant prior authorizations submitted via Availity and reviewed by Humana's National Transplant Network

Prior Authorization

Inpatient Admissions and Transplant Prior Authorization

All inpatient admission codes (hospitals, rehab facilities, long-term acute care, inpatient hospice, transplant, planned inpatient medical and surgical admissions) require prior authorization. Transplant prior authorization requests are reviewed by Humana's National Transplant Network and can be submitted via Availity. Urgent/emergent services do not require prior authorization.

All inpatient admission codes require prior authorization
Transplant prior authorization submissions via Availity; reviewed by Humana's National Transplant Network
Urgent/emergent services are exempt from prior authorization

Documentation Required

Retro-review Requirement for MSEA Items > $750

Items in the MSEA (medical/surgical equipment and assistive devices) category with a purchase price greater than $750 are subject to retroactive review. A signed clinical record must be submitted with the claim; claims submitted without clinical records for these services will be denied. Denials are reconsidered only through the claim appeal process with pertinent clinical records.

All MSEA items > $750 are subject to retro-review
A signed clinical record must be submitted with the claim
Claims without required clinical records are denied and may only be reconsidered via the appeals process

Prior Authorization

Advanced Imaging Prior Authorization

Advanced imaging services (CT, CTA, MRA, MRI, PET, and other listed advanced modalities) require prior authorization and are reviewed by eviCore. Providers must follow eviCore submission processes (online portal, phone, fax) for authorization determinations.

Advanced imaging requests reviewed by eviCore
Includes but not limited to CT, CTA, MRA, MRI, PET and listed CPT/HCPCS codes in the plan’s Advanced Imaging list

Prior Authorization

Cellular / Genetic / Transplant Therapies

Cellular, genetic, and transplant therapies (including listed procedure and molecular/genetic codes) require prior authorization or notification as indicated in the code list. Submit requests per the instructions for specialty services; transplants are reviewed by Humana’s National Transplant Network.

Transplant procedure and related codes require prior authorization
Genetic/cellular therapy codes listed in the transplant/therapy code group require authorization/notification

Prior Authorization

Radiation Therapy Prior Authorization

Radiation therapy services such as proton beam therapy, stereotactic radiation, and other specialized radiation modalities require prior authorization. Include relevant treatment details when requesting authorization.

Proton beam therapy codes: 77520, 77522, 77523, 77525
Stereotactic radiation and related codes: 32701, 61796–61799, 63620, 77371–77373

Prior Authorization

Nursing and Pediatric Extended Care Authorization/Notification

Private duty nursing (PDN) and prescribed pediatric extended care require prior authorization/notification. Submit requests using the standard prior authorization channels and include clinical justification and plan of care.

Prescribed pediatric extended care codes: T1025, T1026
Private duty nursing (PDN) code: T1000

Prior Authorization

Procedure Codes Requiring Authorization/Notification (Selected)

Selected procedure codes require prior authorization or notification. Examples include bariatric surgery, foot surgeries (bunionectomy, hammertoe), and laparoscopic hiatal hernia repair. Verify the applicable codes and submit full clinical documentation with the authorization request.

Bariatric surgery example codes: 43631–43634, 43644, 43770–43775, 43842–43848, 43886–43888
Foot surgery example codes: 26535, 26536, 28110, 28240, 28285, 28289, 28291–28299, 28306, 28308, 28310, 28740, 28750, L8641
Laparoscopic hiatal hernia repair codes: 43280–43282

Prior Authorization

Neurostimulator and Orthopedic Arthroplasty Authorization

Neurostimulator implantation and orthopedic arthroplasty (hip, knee, shoulder) require prior authorization. Include device details, trial documentation (if applicable), and clinical indications when submitting authorization requests.

Neurostimulator example codes: 61850, 61860, 61880, 61885–61888, 63650, 63655, 63661–63664, 63685, 63688, 64553, 64555, 64561, 64566, 64568–64570, 64575, 64580–64595, 95970–95972, C1823
Orthopedic arthroplasty example codes: 23472–23474, 27125, 27130, 27132, 27134, 27137–27138, 27437–27447, 27486–27487

Prior Authorization

Arthroscopy, Spinal, VAD and Related Procedure Authorization

Arthroscopy, spinal procedures (fusion, decompression, kyphoplasty/vertebroplasty), pain infusion pumps, ventricular assist devices (VADs), and related codes require prior authorization. Submit complete operative and clinical documentation with the authorization request. Failure to obtain required authorization for these procedures may result in claim denial or payment delay.

Arthroscopy codes (selected): 23929, 27299, 27412, 27599, 29805–29807, 29819–29828, 29850–29876
Pain infusion pump codes (selected): 29877–29889, 29914–29916, 29999
Spinal fusion/decompression/kyphoplasty/vertebroplasty codes (selected): C2626, E0782, E0783, 20999, 22100–22103, 22116, 22206–22216, 22222, 22226, 22510–22515, 22526–22534, 22548, 22551–22558, 22585–22595, 22600–22614, 22630–22634, 22800–22819, 22830–22849, 22853–22862, 22867–22870, 22899, 27279–27280, 62287, 62380, 63001–63066, 63075–63103, 63170–63173, 63185, 63190–63197, 63200–63251
Ventricular assist device (VAD) codes (selected): 63252, 63265–63278, 63280–63283, 63285–63287, 63290, 63295, 63300–63308, 0274T, C1821, C2614, C9757

Note

NICU / Special Care Nursery Notification and Obstetrical Admission Thresholds

For infants admitted to a NICU or Special Care Nursery, providers must notify Progeny Health. Notifications can be submitted by fax to 866-610-2034. For obstetrical admissions, Humana requests notification when lengths of stay exceed 48 hours for vaginal deliveries and 96 hours for cesarean deliveries to support concurrent review, care coordination, and discharge planning.

NICU / Special Care Nursery notification fax: 866-610-2034
Obstetrical admission notification thresholds: >48 hours for vaginal deliveries; >96 hours for cesarean sections

Key definitions

Prior authorization (definition)

DefinitionPrior authorization (also called precertification or preadmission) is a process requiring healthcare providers to obtain advance approval from the plan to determine whether an item or service may be covered.

Also known asPrecertification; preadmission.

ApplicabilityUsed to determine coverage before providing the item or service; urgent/emergent services are exempt from prior authorization per the policy notes.

Notification (definition)

DefinitionNotification is the process by which a healthcare provider notifies Humana of the intent to provide an item or service; Humana does not issue an approval or denial related to a notification.

PurposeRequests notification help Humana coordinate care for covered patients; differs from prior authorization because no approval/denial is issued.

When usedUsed for services where the plan requests awareness for care coordination rather than pre-approval.

EviCore (definition)

DefinitionEviCore is the delegated clinical review vendor that reviews advanced imaging services (CT, CTA, MRA, MRI, PET, SPECT, 3D rendering) per the list.

ScopeHandles clinical review for advanced imaging services listed in the PAL.

Submission noteAdvanced imaging services are reviewed by EviCore per the PAL; providers should follow EviCore submission channels where applicable.

Miscellaneous / unlisted procedure codes (definition)

DefinitionMiscellaneous/unlisted procedure codes refer to unlisted procedure codes (e.g., 39599, 42699, 43659, etc.) that are included on the authorization list.

ExamplesExamples of miscellaneous/unlisted codes listed include: 39599, 42699, 43659, 44238, 45499, 45999.

Authorization implicationThese miscellaneous/unlisted codes are included on the PAL and require prior authorization/notification per the list.

Progeny Health (definition)

DefinitionProgeny Health is the third-party notification service to be notified for infants admitted to the NICU and Special Care Nursery.

How to notifyNotifications to Progeny Health can be submitted by fax to 866-610-2034.

ScopeUsed specifically for NICU and Special Care Nursery admissions to enable care coordination.