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Humana Healthy Horizons in Ohio Prior Authorization and Notification List (PAL)

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Lists services, procedures, and codes that require prior authorization or notification for Humana Healthy Horizons members in Ohio; affects healthcare providers submitting requests and coordinating care for covered members.

Policy Summary

PayerHumana

PolicyHumana Healthy Horizons in Ohio Prior Authorization and Notification List (PAL)

Policy CodePolicy 555201OH0924-B

Change TypeNo material changes

Effective DateJul 1, 2026

Last ReviewMay 20, 2026

Next Review Date

Key ActionRequest prior authorization for medical and behavioral health services through Availity Essentials or call Humana at 877-856-5707.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

multi-pageService categories

thresholdsPA thresholds

OhioApplies to

17+Code blocks

Services Requiring Prior Authorization or Notification

Prior authorization and notification criteria (selected examples)

Services and situations listed below require prior authorization or notification as indicated. Presented examples preserve the document's AND/OR structure and service-specific thresholds.

ALL of the following

All behavioral health inpatient admissions require prior authorization or notification as specified; providers must notify Humana of inpatient admissions within one business day (urgent/emergent services excluded).

ALL of the following

ONE of
- All residential treatment services require prior authorization.
- Substance use disorder (SUD) residential treatment — codes H2034, H2036 (prior authorization applies as listed).
- Community psychiatric support treatment — code H0036: limits apply (200 units/50 hrs per calendar year or 120 units/30 hrs per calendar year depending on modifier).
- SUD intensive outpatient program (IOP) — code H0015 (prior authorization required after 30 units per calendar year, per member).

ALL of the following

Ambulatory withdrawal services have soft caps and require PA/concurrent review after 7 consecutive units.
Therapeutic behavioral services (TBS) — codes H2019/H2020: combined TBS or PSR limited to 200 units (50 hrs) per calendar year (or 120 units/30 hrs per calendar year depending on modifier); after 30 units for certain group TBS services prior authorization applies.

ALL of the following

Codes including 96116, 96121, 96130-96137 apply; for code 96137 up to 20 hours/encounters per patient per calendar year for all psychological testing codes is allowed; prior authorization required for additional services beyond these limits.

ALL of the following

ABA therapy requires prior authorization; applicable codes include 97151–97158, 0362T, 0373T.

ALL of the following

Prior authorization begins after 30 visits; applicable codes include 97810, 97811, 97813, 97814.

ALL of the following

Prior authorization is required for drug testing requests; definitive test codes include G0480–G0483 (G0483 noted as requiring PA for all requests) and 80305–80307; thresholds: after 12 definitive drug tests per year prior authorization is required, and after 30 presumptive drug tests per year prior authorization is required.

ALL of the following

Examples include
- Auditory osseo-integrated device — code L8690 (prior authorization required).
- Standing systems/devices — codes E0637, E0638, E0641 (prior authorization required).
- Volume control ventilator — code E0465 (prior authorization required).
- Wearable cardiac device (LifeVest) — code K0606 (prior authorization required).
- Wheelchairs and scooters — extensive HCPCS lists (examples E0983–E1093 series) require prior authorization as specified.

ALL of the following

Orthotics examples include E1800, E1802, E1815; prosthetics examples include L5000 series; prior authorization applies to listed codes.

ALL of the following

Examples include
- Breast procedures — simple mastectomy and gynecomastia (codes 11971, 19300–19380, S2068) require prior authorization (radical/modified excluded from that subcategory note).
- Orthopedic major surgeries and devices — examples codes 23472, 27130 and VAD codes such as 33975 require prior authorization/notification as listed.

ALL of the following

Epidural injections (outpatient only) listed under pain management (code 64999) require prior authorization/notification.

ALL of the following

Home health/home infusion codes include G0151, G0152, G0153, G0155, G0156, G0299, G0300, T1000 and others; prior authorization/notification applies as listed.
Hyperbaric therapy — codes 99183, G0277 require prior authorization as listed.

ALL of the following

NPWT services and codes (97605, 97606, A6550, E2402) require prior authorization/notification.

ALL of the following

Observation prior authorization is not required but notification is requested; observation stays are limited to 72 hours.

Prior authorization/notification code categories

Catalog-style listing of item and service categories with representative codes; full HCPCS/CPT/Q-code lists are included in the PAL.

Durable Medical Equipment & Mobility Devices

Representative codes: E0637, E0638, E0641 (standing systems/devices); E0465 (volume control ventilator); K0606 (wearable cardiac device); extensive wheelchair/scooter HCPCS (examples E0983–E1093, E1161, etc.).

Home health, infusion & related services

Representative codes: G0151 (home health), 99503–99512 series, G0152–G0156, G0299, G0300, T1000 (home health/home infusion).

Orthopedic and major surgeries

Representative codes: shoulder/arm/hip arthroplasty and related procedures — examples include 23472, 27130 and a broader list in the PAL (see full list for exact codes).

Skin and tissue substitutes / wound care

Representative codes: skin/tissue substitutes A2002, Q4101, Q4369; NPWT codes 97605, 97606, A6550, E2402 are included under wound therapy.

Cardiac & device codes

Representative codes: wearable cardiac device K0606; cardiac procedures and device-related codes (e.g., 93229 for wearable cardiac monitoring).

Molecular, genetic & specialized testing

Representative codes: molecular diagnostic/genetic testing examples include 81161 and a larger set of molecular codes listed in the PAL.

Pain management & spine procedures

Representative codes: epidural and related injections (e.g., 64999) and an extensive list of spine procedure codes (see full PAL listing including codes in the 20000–63000 series).

Codes, Code Groups, and Thresholds

Definitive drug testing (requires PA after 12/year)CPTCovered

G0480	Drug test definitive drug testing, multiple drug classes, any method
G0481	Drug test definitive, single drug class, any method
G0482	Drug test definitive, each additional drug class

Presumptive drug testing (requires PA after 30/year)CPTCovered

80305	Drug test(s), presumptive, any number of drug classes; non-quantitative, e.g., immunoassay
80306	Drug test(s), presumptive, multiple drug classes, non-quantitative; each additional drug class
80307	Drug test(s), presumptive, definitive method, confirmation

Breast procedures (Prior authorization required)CPTCovered

11971	Replacement of tissue expander with permanent implant
19300	Mastectomy, partial
19303	Mastectomy, subcutaneous
19306	Mastectomy, radical
19316	Mastopexy
19318	Reduction mammoplasty
19325	Breast augmentation with implant
19330	Immediate insertion of breast prosthesis following mastopexy, etc.
19340	Immediate insertion of breast prosthesis following total mastectomy
19342	Immediate insertion of breast prosthesis following partial mastectomy

1–10 of 18

1/2

Wheelchairs, Mobility & Seating (extensive HCPCS list)HCPCSCovered

E0983	Power wheelchair, group 2
E0986	Power wheelchair, group 3
E1002	Power wheelchair, tilt-in-space
E1003	Power wheelchair, recline
E1004	Power wheelchair, power elevating seat
E1005	Power wheelchair, power seating
E1006	Power wheelchair, power seat functions
E1007	Power wheelchair, specialty controls
E1008	Power wheelchair, heavy duty
E1009	Power wheelchair, pediatric

1–10 of 77

1/8

Additional DME / Mobility HCPCS (continued)HCPCSCovered

E0637	Standing frame
E0638	Standing system
E0641	Standing system accessory
E0465	Ventilator, volume control
K0606	Wearable cardiac defibrillator

Major surgeries and devices (orthopedic, VAD, transplant)CPTCovered

23472	Total shoulder arthroplasty
23473	Revision shoulder arthroplasty
23474	Hemiarthroplasty
33975	Ventricular assist device implantation
33976	VAD replacement
33979	VAD other
32851	Liver transplant
33927	Heart transplant

Home health, hyperbaric, molecular diagnosticmixedCovered

99183	Hyperbaric oxygen therapy, per session
G0277	Hyperbaric oxygen treatment
81161	Molecular diagnostic codes (representative)
99503	Home health services codes (representative)

How Providers Request Authorization and Required Notifications

Prior Authorization

How to request prior authorization (medical & behavioral health)

Except where otherwise noted on the following pages, healthcare providers can request prior authorization for medical and behavioral health services through Availity Essentials™. For registration issues, call Availity Client Services at 800-AVAILITY (282-4548), Monday - Friday, 8 a.m. - 8 p.m., Eastern time. Providers may also call Humana Healthy Horizons in Ohio at 877-856-5707, Monday - Friday, 7 a.m. - 8 p.m., Eastern time.

Prior Authorization

How to request dental prior authorization

Except where otherwise noted on the following pages, healthcare providers can request dental prior authorization through Availity Essentials. For registration issues, call Availity Client Services at 800-AVAILITY (282-4548), Monday - Friday, 8 a.m. - 8 p.m., Eastern time.

Prior Authorization

How to request vision prior authorization

Except where otherwise noted on the following pages, healthcare providers can request vision prior authorization through Availity Essentials. For registration issues, call Availity Client Services at 800-AVAILITY (282-4548), Monday - Friday, 8 a.m. - 8 p.m., Eastern time.

Documentation Required

Urgent/emergent and notification rules

Important: Urgent/emergent services do not require referrals or prior authorization. Observation prior authorization is not required; notification is requested to assist with discharge planning and follow-up. Observation periods cannot exceed three days (72 hours). Providers are required to submit notification of all inpatient admissions within one business day of the date of admission. Failure to obtain required prior authorization or notifications may result in financial penalties, reduced member benefits per contract and EOC, and retrospective medical necessity review. Providers should verify member benefits and prior authorization requirements with Humana prior to providing services.

Prior Authorization

Drug testing prior authorization rules

Prior authorization is required for drug testing requests. Note: definitive drug testing has a threshold — prior authorization is required after 12 definitive drug tests. Contact Availity or Humana for submission details.

Prior Authorization

Medical inpatient admissions

All inpatient (medical) admissions require notification within one business day of admission. This applies to acute hospital, skilled nursing, rehabilitation and long-term acute care admissions. Providers should follow notification and concurrent review requirements to avoid administrative or payment issues.

Prior Authorization

Pain management – epidural injections (outpatient)

For certain outpatient pain management procedures (including epidural injections) and many other services listed on the Prior Authorization Notification List (PAL), prior authorization is required. Refer to the PAL for specific CPT/HCPCS codes and subcategory notes, and submit requests through Availity Essentials.

Prior Authorization

Wound therapy – NPWT

Negative pressure wound therapy (NPWT) requires prior authorization. Refer to the PAL for applicable codes (e.g., 97605, 97606, A6550, E2402) and submit requests through Availity Essentials.

Key Terms

Prior authorization

DefinitionPrior authorization is the process providers use to obtain advance plan approval to cover an item or service.

How to request (medical & behavioral health)Providers can request prior authorization via Availity Essentials; Humana phone assistance available at 877-856-5707, Monday–Friday, 7 a.m.–8 p.m. ET.

Urgent/emergent ruleUrgent/emergent services do not require prior authorization (notification/other rules may still apply).

Notification

DefinitionNotification is the process through which a provider informs Humana of the intent to provide an item or service; Humana does not issue an approval or denial for notifications.

Inpatient notification timingProviders must notify Humana of inpatient admissions within one business day; observation stays are limited to 72 hours with notification requested.

PurposeNotification helps Humana coordinate care for covered members; it is distinct from prior authorization.

Medical IP admissions

ScopeMedical inpatient (IP) admissions include acute hospital, skilled nursing, rehabilitation and long‑term acute care settings.

RequirementAll medical inpatient admissions require prior authorization/notification (All admissions listed).

Relevant codes/examplesPolicy lists 'All admissions' under medical IP admissions to indicate PA/notification requirement applies to inpatient stays generally.

NPWT

DefinitionNegative pressure wound therapy (NPWT) — wound therapy modality requiring prior authorization/notification for listed codes.

Relevant codesCPT/HCPCS 97605, 97606 and related supply codes A6550, E2402 require PA/notification.

ActionObtain prior authorization/notify Humana before initiating NPWT as specified in the PAL.

DME

DefinitionDurable medical equipment (DME) — includes standing systems, ventilators, wearable cardiac devices, wheelchairs, augmentative devices and other HCPCS-coded equipment.

PA requirementSpecified DME items and extensive HCPCS lists require prior authorization as listed (examples include L8690, E0465, K0606, E0637-E0641, numerous E0xxx wheelchair codes).

Codes/examplesExamples in PAL: L8690 (osseointegrated auditory device), E0465 (volume control ventilator), K0606 (wearable cardiac device), E0637/E0638/E0641 (standing systems).

Policy Summary

PayerHumana

PolicyHumana Healthy Horizons in Ohio Prior Authorization and Notification List (PAL)

Policy CodePolicy 555201OH0924-B

Change TypeNo material changes

Effective DateJul 1, 2026

Last ReviewMay 20, 2026

Next Review Date

Key ActionRequest prior authorization for medical and behavioral health services through Availity Essentials or call Humana at 877-856-5707.

SourceLink

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Humana Healthy Horizons in Ohio Prior Authorization and Notification List (PAL)

Customize your policy alerts

Sign up for Humana Policy 555201OH0924-B alerts

Get alerted when Policy 555201OH0924-B changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Services Requiring Prior Authorization or Notification

Prior authorization and notification criteria (selected examples)

Services and situations listed below require prior authorization or notification as indicated. Presented examples preserve the document's AND/OR structure and service-specific thresholds.

ALL of the following

All behavioral health inpatient admissions require prior authorization or notification as specified; providers must notify Humana of inpatient admissions within one business day (urgent/emergent services excluded).

ALL of the following

ONE of
- All residential treatment services require prior authorization.
- Substance use disorder (SUD) residential treatment — codes H2034, H2036 (prior authorization applies as listed).
- Community psychiatric support treatment — code H0036: limits apply (200 units/50 hrs per calendar year or 120 units/30 hrs per calendar year depending on modifier).
- SUD intensive outpatient program (IOP) — code H0015 (prior authorization required after 30 units per calendar year, per member).

ALL of the following

Ambulatory withdrawal services have soft caps and require PA/concurrent review after 7 consecutive units.
Therapeutic behavioral services (TBS) — codes H2019/H2020: combined TBS or PSR limited to 200 units (50 hrs) per calendar year (or 120 units/30 hrs per calendar year depending on modifier); after 30 units for certain group TBS services prior authorization applies.

ALL of the following

Codes including 96116, 96121, 96130-96137 apply; for code 96137 up to 20 hours/encounters per patient per calendar year for all psychological testing codes is allowed; prior authorization required for additional services beyond these limits.

ALL of the following

ABA therapy requires prior authorization; applicable codes include 97151–97158, 0362T, 0373T.

ALL of the following

Prior authorization begins after 30 visits; applicable codes include 97810, 97811, 97813, 97814.

ALL of the following

Prior authorization is required for drug testing requests; definitive test codes include G0480–G0483 (G0483 noted as requiring PA for all requests) and 80305–80307; thresholds: after 12 definitive drug tests per year prior authorization is required, and after 30 presumptive drug tests per year prior authorization is required.

ALL of the following

Examples include
- Auditory osseo-integrated device — code L8690 (prior authorization required).
- Standing systems/devices — codes E0637, E0638, E0641 (prior authorization required).
- Volume control ventilator — code E0465 (prior authorization required).
- Wearable cardiac device (LifeVest) — code K0606 (prior authorization required).
- Wheelchairs and scooters — extensive HCPCS lists (examples E0983–E1093 series) require prior authorization as specified.

ALL of the following

Orthotics examples include E1800, E1802, E1815; prosthetics examples include L5000 series; prior authorization applies to listed codes.

ALL of the following

Examples include
- Breast procedures — simple mastectomy and gynecomastia (codes 11971, 19300–19380, S2068) require prior authorization (radical/modified excluded from that subcategory note).
- Orthopedic major surgeries and devices — examples codes 23472, 27130 and VAD codes such as 33975 require prior authorization/notification as listed.

ALL of the following

Epidural injections (outpatient only) listed under pain management (code 64999) require prior authorization/notification.

ALL of the following

Home health/home infusion codes include G0151, G0152, G0153, G0155, G0156, G0299, G0300, T1000 and others; prior authorization/notification applies as listed.
Hyperbaric therapy — codes 99183, G0277 require prior authorization as listed.

ALL of the following

NPWT services and codes (97605, 97606, A6550, E2402) require prior authorization/notification.

ALL of the following

Observation prior authorization is not required but notification is requested; observation stays are limited to 72 hours.

Prior authorization/notification code categories

Catalog-style listing of item and service categories with representative codes; full HCPCS/CPT/Q-code lists are included in the PAL.

Durable Medical Equipment & Mobility Devices

Representative codes: E0637, E0638, E0641 (standing systems/devices); E0465 (volume control ventilator); K0606 (wearable cardiac device); extensive wheelchair/scooter HCPCS (examples E0983–E1093, E1161, etc.).

Home health, infusion & related services

Representative codes: G0151 (home health), 99503–99512 series, G0152–G0156, G0299, G0300, T1000 (home health/home infusion).

Orthopedic and major surgeries

Representative codes: shoulder/arm/hip arthroplasty and related procedures — examples include 23472, 27130 and a broader list in the PAL (see full list for exact codes).

Skin and tissue substitutes / wound care

Representative codes: skin/tissue substitutes A2002, Q4101, Q4369; NPWT codes 97605, 97606, A6550, E2402 are included under wound therapy.

Cardiac & device codes

Representative codes: wearable cardiac device K0606; cardiac procedures and device-related codes (e.g., 93229 for wearable cardiac monitoring).

Molecular, genetic & specialized testing

Representative codes: molecular diagnostic/genetic testing examples include 81161 and a larger set of molecular codes listed in the PAL.

Pain management & spine procedures

Representative codes: epidural and related injections (e.g., 64999) and an extensive list of spine procedure codes (see full PAL listing including codes in the 20000–63000 series).

Codes, Code Groups, and Thresholds

Definitive drug testing (requires PA after 12/year)CPTCovered

G0480	Drug test definitive drug testing, multiple drug classes, any method
G0481	Drug test definitive, single drug class, any method
G0482	Drug test definitive, each additional drug class

Presumptive drug testing (requires PA after 30/year)CPTCovered

80305	Drug test(s), presumptive, any number of drug classes; non-quantitative, e.g., immunoassay
80306	Drug test(s), presumptive, multiple drug classes, non-quantitative; each additional drug class
80307	Drug test(s), presumptive, definitive method, confirmation

Breast procedures (Prior authorization required)CPTCovered

11971	Replacement of tissue expander with permanent implant
19300	Mastectomy, partial
19303	Mastectomy, subcutaneous
19306	Mastectomy, radical
19316	Mastopexy
19318	Reduction mammoplasty
19325	Breast augmentation with implant
19330	Immediate insertion of breast prosthesis following mastopexy, etc.
19340	Immediate insertion of breast prosthesis following total mastectomy
19342	Immediate insertion of breast prosthesis following partial mastectomy

1–10 of 18

1/2

Wheelchairs, Mobility & Seating (extensive HCPCS list)HCPCSCovered

E0983	Power wheelchair, group 2
E0986	Power wheelchair, group 3
E1002	Power wheelchair, tilt-in-space
E1003	Power wheelchair, recline
E1004	Power wheelchair, power elevating seat
E1005	Power wheelchair, power seating
E1006	Power wheelchair, power seat functions
E1007	Power wheelchair, specialty controls
E1008	Power wheelchair, heavy duty
E1009	Power wheelchair, pediatric

1–10 of 77

1/8

Additional DME / Mobility HCPCS (continued)HCPCSCovered

E0637	Standing frame
E0638	Standing system
E0641	Standing system accessory
E0465	Ventilator, volume control
K0606	Wearable cardiac defibrillator

Major surgeries and devices (orthopedic, VAD, transplant)CPTCovered

23472	Total shoulder arthroplasty
23473	Revision shoulder arthroplasty
23474	Hemiarthroplasty
33975	Ventricular assist device implantation
33976	VAD replacement
33979	VAD other
32851	Liver transplant
33927	Heart transplant

Home health, hyperbaric, molecular diagnosticmixedCovered

99183	Hyperbaric oxygen therapy, per session
G0277	Hyperbaric oxygen treatment
81161	Molecular diagnostic codes (representative)
99503	Home health services codes (representative)

How Providers Request Authorization and Required Notifications

Prior Authorization

How to request prior authorization (medical & behavioral health)

Prior Authorization

How to request dental prior authorization

Prior Authorization

How to request vision prior authorization

Documentation Required

Urgent/emergent and notification rules

Prior Authorization

Drug testing prior authorization rules

Prior Authorization

Medical inpatient admissions

Prior Authorization

Pain management – epidural injections (outpatient)

Prior Authorization

Wound therapy – NPWT

Negative pressure wound therapy (NPWT) requires prior authorization. Refer to the PAL for applicable codes (e.g., 97605, 97606, A6550, E2402) and submit requests through Availity Essentials.

Key Terms

Prior authorization

DefinitionPrior authorization is the process providers use to obtain advance plan approval to cover an item or service.

How to request (medical & behavioral health)Providers can request prior authorization via Availity Essentials; Humana phone assistance available at 877-856-5707, Monday–Friday, 7 a.m.–8 p.m. ET.

Urgent/emergent ruleUrgent/emergent services do not require prior authorization (notification/other rules may still apply).

Notification

DefinitionNotification is the process through which a provider informs Humana of the intent to provide an item or service; Humana does not issue an approval or denial for notifications.

Inpatient notification timingProviders must notify Humana of inpatient admissions within one business day; observation stays are limited to 72 hours with notification requested.

PurposeNotification helps Humana coordinate care for covered members; it is distinct from prior authorization.

Medical IP admissions

ScopeMedical inpatient (IP) admissions include acute hospital, skilled nursing, rehabilitation and long‑term acute care settings.

RequirementAll medical inpatient admissions require prior authorization/notification (All admissions listed).

Relevant codes/examplesPolicy lists 'All admissions' under medical IP admissions to indicate PA/notification requirement applies to inpatient stays generally.

NPWT

DefinitionNegative pressure wound therapy (NPWT) — wound therapy modality requiring prior authorization/notification for listed codes.

Relevant codesCPT/HCPCS 97605, 97606 and related supply codes A6550, E2402 require PA/notification.

ActionObtain prior authorization/notify Humana before initiating NPWT as specified in the PAL.

DME

DefinitionDurable medical equipment (DME) — includes standing systems, ventilators, wearable cardiac devices, wheelchairs, augmentative devices and other HCPCS-coded equipment.

PA requirementSpecified DME items and extensive HCPCS lists require prior authorization as listed (examples include L8690, E0465, K0606, E0637-E0641, numerous E0xxx wheelchair codes).

Codes/examplesExamples in PAL: L8690 (osseointegrated auditory device), E0465 (volume control ventilator), K0606 (wearable cardiac device), E0637/E0638/E0641 (standing systems).