McLaren Health Plan Prior Auth Code Update

Policy Snapshot

This document defines McLaren Health Plan preauthorization requirements by product/line of business and lists service categories and specific procedure, DME, pharmacy and genetic codes that require prior authorization (partial list effective February 1, 2026). It applies to providers who submit authorization requests on behalf of McLaren Health Plan members and clarifies that most services and listed codes require preauthorization except where specific line-of-business exceptions apply (for example, Medicare-primary hospital services).

Effective dateAs written (effective Feb 1, 2026 for code list)

Next review2026-03-01 (check for updates)

PayerMcLaren Health Plan

Policy numberN/A

SubjectPreauthorization requirements and service codes requiring preauthorization

Codes Requiring Preauthorization or Special Billing

General rules / exceptionsmixed

NOC/unlisted/unspecified/manually priced	Requires preauthorization
Autism services and ABA therapy	Do not require authorization up to benefit limit for Community/Commercial and Health Advantage; not covered for Medicaid
BAHA hearing device codes (listed)	Medicaid only: authorization not required if provided in-network; otherwise listed codes require authorization

Auditory/Oral/Oral Surgery/Orthognathic/TMJ/OSA proceduresCPT|HCPCSCovered

69710, 69711, 69714, 69715, 69718, 69728, 69729, 69730	Auditory procedures codes requiring preauthorization (see grid)
L8627	Hearing device HCPCS listed
21025-21032, 21044-21049, 21081, 21120-21123, 21125, 21127, 21137-21139, 21141-21151, 21154-21160, 21188, 21206, 21208, 21210, 21215, 21244-21246, 21255-21263, 21267-21268, 21440, 21445, 21497, 30545, 30560, 40804, 40818, 40840-40845, 41500, 41510, 41820-41830, 41850, 41870, 41872, 42120, 42299, 42300, 42305, 42310, 42330, 42340, 42400-42409	Oral surgery/orthognathic codes requiring preauthorization
0466T, 0467T, 0468T, 21193-21199, 41512, 41530, 41599, 42145	Procedures to correct obstructive sleep apnea
61886, 64569, 64570, 64568, 64582-64584, S2080	Additional listed codes
21050, 21060, 21070, 21073, 21110, 21116, 21240, 21242, 21243, 21247, 21248, 21480, 21485, 21490	TMJ treatment codes requiring preauthorization

Behavioral HealthCPT|HCPCSCovered

90870	Electroconvulsive therapy (refer to grid)
Inpatient behavioral health / inpatient substance abuse	Medicaid benefits managed by PIHP; Commercial/Community and Health Advantage require McLaren preauthorization
Mental Health Partial Hospitalization Programs	Commercial/Community and Health Advantage only — require preauthorization
Mental Health Residential Treatment Programs	Commercial/Community and Health Advantage only — require preauthorization

Cardiac procedures and imagingCPTCovered

33249, 33264, 33270, 78452, 93306, 93458

Cardiac procedures and imaging requiring authorization (authorization requirements effective 8/1/2024 apply to Medicaid and Healthy Michigan only)

Cosmetic and reconstructive proceduresCPT|HCPCS

Blepharoplasty: 15820-15823, 67904, 67912, 67916, 67917, 67923, 67924	Medical necessity review required to determine cosmetic vs reconstructive
Breast reconstruction: 19316, 19318, 19324-19330, 19340, 19342, 19350, 19355, 19357, 19361, 19364, 19366-19371, 19380, 19396	Breast reconstruction codes listed
Cosmetic skin/vein/tattoo/lipectomy/male enhancement codes (multiple listed)	Require preauthorization or medical necessity review per category
Otoplasty 69300	Requires preauthorization
Panniculectomy 15830, 15847	Requires preauthorization

Durable Medical Equipment (DME) - Purchase and RentalHCPCS|L codes|K codesCovered

Extensive list including A4421, A4459, A4619, A5083, A6412, A6501-A6513, A6519, A6549, A6576-A6579, A6580, A7522, A9999, B4035, B4081, B4083, ...	DME purchase codes requiring preauthorization; E0483 Medicaid only exception for cystic fibrosis
E0193, E0236, E0265, E0277, E0301-E0373, E0457, E0460-E0483, E0625, E0635-E0642, E0651-E0682, ...	DME codes for rental/purchase requiring preauthorization (document contains long lists)
Thresholds by line of business	Medicaid & Healthy Michigan: items > $500 or > $1,500 depending on category; Commercial HMO & POS: items > $1,500 or > $3,000; Health Advantage: items > $3,000 or > $5,000 (varies by category). Specific thresholds provided by category in document.

Orthotics / Prosthetics / Hearing AidsL codes|V codesCovered

Orthotics L-codes listed (L0112, L0170, L0457, ... L3649, etc.)	Many orthotic codes listed; authorizations not required for some codes for Medicaid/Healthy Michigan only (L3649 example)
Prosthetics L-codes listed (L0720, L5010... up through many L5xxx codes)	Thresholds apply by line of business; many prosthetic HCPCS codes require preauthorization
Hearing aids V5030-V5299 (multiple V-codes)	Preauthorization not required up to benefit limit for CSHCS/Healthy Michigan/Medicaid in-network and Commercial/Community up to benefit limit; see grid for additional info

Vision services and contact lensesCPT|V codesCovered

92065-92066, V2500-V2599, V2744-V2745

Authorization requirements for CSHCS, Medicaid and Healthy Michigan only; consult plan documents for Community/Health Advantage

Continuous Glucose Monitors (CGMs) and Insulin PumpsHCPCSCovered

A4239, A9277, E0784, E2102, E2103, A9278 (effective 1/1/25)

All CGM, insulin pump and associated supplies require preauthorization, with Medicaid-specific exceptions effective May 1, 2023 for certain populations

GI and Ophthalmic procedures (outpatient hospital vs ASC)CPTCovered

GI: 43235, 43239, 43249, 45378, 45380, 45384, 45385	For Medicaid and Community/On Exchange, outpatient hospital setting procedures require prior authorization effective 4/1/2025; ASCs do not require prior auth
Ophthalmic: 65426, 65710, 65820, 65855, 66170, 66250, 66710-66711, 66761, 66821, 66825, 66982, 66984-66988, 67010, 67028, 67036, 67040-67042, 67105, 67108, 67113, 67228, 67311-67312, 67840, 68110, 68115, 68320, 68720, 68815	For Medicaid and Community/On Exchange, listed outpatient hospital procedures require prior auth effective 4/1/2025; ASCs in-network do not

Genetic and Molecular Testing codesCPT|Proprietary codesCovered

Broad list of 80000/811xx/812xx/813xx/814xx and many U/0xx codes

All genetic testing codes may require medical director review and preauthorization; document lists many specific codes (e.g., 81161-81298, 81400-81482, 81500-81599, 86146-86148 with noted exceptions for pregnant women >40 in-network)

Inpatient, home health, hospice, rehab, SNF, LTACH, LT servicesbilling types/revenue codesCovered

Inpatient stays	All inpatient stays require authorization except routine delivery without sterilization (notification only). Medicaid: professional services during inpatient psych stay require preauthorization
Home care	For Medicaid only: first 24 billed home care visits per calendar year do not require prior auth; additional visits require authorization
Skilled Nursing Facility	Billed on institutional claims type of bill 211-289 and revenue codes 0110, 0120, 0130
Hospice	Billed on institutional claim type of bill 811-899 and revenue codes 0651, 0652, 0655, 0656, 0658
Inpatient rehabilitative services, LTACH	Require preauthorization

Laboratory testing / definitive drug testingCPT|G codesCovered

80307, G0480, G0481, G0482, G0483

Definitive drug testing codes requiring preauthorization effective 10/1/2024 for all lines of business

NeurostimulatorsCPTCovered

Trial and permanent device codes: e.g., 43647, 43648, 43881, 43882, 61850, 61860, 61863-61868, 61870, 61880, 61885-61886, 63650, 63661, 63663, 63664, 63685, 64550, 64555, 64565-64566, 64568-64570, 64575, 64580-64581, 64590

Two separate authorizations required: one for trial and one for permanent insertion

Rehabilitation services (OT/PT/ST)CPTCovered

Occupational therapy, physical therapy, speech therapy

Preauthorization not required up to benefit limit across lines of business; preauthorization required for requests over benefit limit. Medicaid PT/OT: max 144 billed units per calendar year

Reproductive / Infertility / GYNCPT|S codes|T codesCovered

GYN: 58353, 58356	GYN procedure codes listed
Infertility: 0058T, 0357T, 54900, 54901, 55200, 55300, 58321-58323, 58350, 58578, 58752, 58760, 58970, 58974, 58976, 58999, 76948, 89250-89291, 89290-89300, 89322-89331, 89335, 89337, 89342, 89344, 89346, 89352-89356, 89398, S4011-S4040, S4035, S4037, S4040	Extensive list of infertility and reproductive service codes requiring preauthorization
Termination of pregnancy: 59812, 59820-59821, 59830, 59840-59841, 59850-59857, 59866, 59870, 59897-59899	Health Advantage preauthorization not required
Voluntary sterilization: 55250, 55450, 58565, 58600-58615, 58670-58673, 58679, 58700, 58720, 58740, 58750, 58770, 58800, 58820, 58822, 58825, 58900, 58920, 58925, 58940, A4264	Medicaid requires preauthorization, signed consent, 30-day waiting period; Health Advantage preauthorization not required; Commercial/Community requires preauthorization

Spine proceduresCPT|0200T etc.Covered

0200T, 22100-22102, 22110, 22112, 22114, 22206-22214, 22220, 22224, 22510-22515, 22532-22533, 22548, 22551, 22554, 22556, 22558, 22586, 22590, 22595, 22600, 22610, 22612, 22630, 22633, 22800, 22802, 22804, 22808, 22810, 22812, 22818, 22819, 22830, 22849-22852, 22855-22856, 22861, 22899, 63001, 63003, 63005, 63011-63017, 63020, 63030, 63040, 63042, 63045-63047, 63050, 63055-63056, 63064, 63075, 63077, 63081, 63085, 63087, 63090, 63101-63102, 63170, 63172-63173, 63185, 63190-63191, 63200, 63250-63252, 63265, 63267-63272, 63286, 63300-63308

For Medicaid and Community/On Exchange, auth required for procedures performed in ALL settings including inpatient

Transplant ServicesCPTCovered

Cornea: 00144, 65710, 65750, 65755	Cornea transplant notes (Medicaid: cornea transplant auth not required; inpatient authorization required if during hospital stay)
Heart: 33927-33929, 33933, 33944-33945	Heart transplant codes
Intestine: 44715, 44720, 44721, 44132-44137	Intestine transplant codes
Islet: 48160, G0341-G0343	Islet transplant codes
Kidney: 50320, 50323, 50325, 50327-50329, 50340, 50360, 50365, 50370, 50380	Kidney transplant codes (Medicaid: auth not required for kidney transplant; inpatient authorization required if during hospital stay)
Liver: 47135-47147	Liver transplant codes
Lung: 32850-32856, 33933	Lung transplant codes
Marrow: 38240, 38242	Marrow transplant codes
Pancreas: 48550-48556	Pancreas transplant codes
Stem cell: 38205, 38206, 38208-38215, 39208, 38240, 38242	Stem cell transplant codes

Transportation / AmbulanceHCPCS|A codesCovered

Emergency air ambulance A0430, A0431, A0435, A0436	Requires retroactive medical necessity review
Non-emergency ambulance A0021, A0380, A0382, A0384, A0390, A0392, A0394, A0396, A0398, A0420, A0424, A0432, A0433, A0434, A0888, A0999	Require authorization per category and line of business rules
Transport revenue/type of bill codes A0080-A0210	Refer to preauthorization grid

Wound care specialty dressingsHCPCS Q-codesCovered

Q4113-Q4332

Specialty wound care dressings and supplies requiring preauthorization

Medical Pharmacy - Buy & Bill (selected J-codes)J codesCovered

J0217	velmanase alfa-tycv 1 mg (Lamzede) - added 4/1/2024
J0738	lenacapavir 1 mg (Yeztugo) - FDA approved for HIV PrEP only; added 10/1/2025
J0739	cabotegravir 1 mg (Apretude) - added 7/1/2022
J0741	cabotegravir/rilpivirine - Cabenuva - added 10/1/2021
J0752	oral lenacapavir 300 mg (Yeztugo oral) - FDA approved for HIV PrEP only; added 10/1/2025
J0799	HIV prep NOC - for FDA-approved PrEP only; added 10/1/2025
J1322	elosulfase alfa (Vimizim) 1 mg - added 4/1/2019
J1411	etranacogene dezaparvovec-drlb (Hemgenix) per therapeutic dose - added 1/1/2024
J1413	delandistrogene moxeparvovec (Elevidys) per therapeutic dose - added 1/1/2024
J1426	casimersen (Amondys) 10 mg - added 10/1/2021

1–10 of 11

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Buy & Bill / Medicaid Only - Carved out C, J, S, Q codesHCPCS

J0217, J0738, J0739, J0741, J0752, J0799, J1322, J1411, J1413, J1426, J1427, J1428, J1429, J1746, J1961, J2326, J3392, J3393, J3394, J3398, J3399, J3401, Q2041, Q2042, Q2053, Q2054, Q2055, Q2056, Q2057, Q2058

Selected carved-out C/J/S/Q codes that must be billed Fee-For-Service for Medicaid per document (many listed; dates and notes in source)

Specialty medications / injections (selected examples and authorization notes)HCPCS

C9046	Goprelto (cocaine hydrochloride nasal solution) 1 mg; notes: added 7/1/2020
C9047	Cablivi (caplacizumab-yhdp) 1 mg; notes: added 7/1/2020
C9293	Voraxaze (glucarpidase) 10 units; notes: added 7/1/2020; annotation: No auth when primary diagnosis = cancer for in-network facilities
C9305	Imaavy (nipocalimab-aahu) 3 mg; notes: added 10/1/2025

No-auth cancer diagnosis exceptions (examples)HCPCSCovered

C9293	Voraxaze - No auth when primary dx = cancer in-network
C9142	Previously listed biosimilars/agents that had 'No auth Cancer diagnosis, in network facilities' annotations before being removed/changed
J0013	Spravato (esketamine) - No auth cancer diagnosis annotation (added 1/1/2026 entry)
J0129	Orencia (abatacept) - No auth cancer diagnosis annotation
J0180	Fabrazyme (agalsidase beta) - No auth cancer diagnosis annotation

Large list of J-codes for biologics, enzyme therapies, gene therapies, immune globulins, etc. (selected)HCPCS

J0218, J0219, J0220, J0256, J0391, J0490, J0567, J0596, J0597, J0725, J0739, J0752, J0799, J1322, J1411, J1413, J1426, J1427, J1428, J1429, J1746, J1961, J2326, J3392, J3393, J3394, J3398, J3399, J3401

Selected entries from the long list of specialty J-codes with notes and effective dates as listed in document

Specialty medications / injectable J-codes (selected from this part)HCPCS|J-code|Q-code|S-code

J7318	Durolane/Orthovisc, intra-articular products (listed entry)
J7330	Carticel - Autologous cultured chondrocytes, implant
J7352	Scenesse - Afamelanotide implant
J7402	Sinuva - Mometasone furoate sinus implant
J7686	Tyvaso - Treprostinil inhalation solution (unit dose)
J7999	Compounded drug, not otherwise classified
J9144	Daratumumab/hyaluronidase (Darzalex Faspro)
J9271	Pembrolizumab (Keytruda)
J9312	Rituximab (Rituxan)
Q2041	Yescarta (axicabtagene ciloleucel)

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Site-of-care restricted drugs (selected examples)HCPCS|J-code

J0129	Orencia (abatacept) - site-of-care requirement
J0172	Aduhelm (aducanumab) - site-of-care requirement
J0174	Leqembi (lecanemab) - site-of-care requirement
J0256	Alpha-1 proteinase inhibitor (J0256) - must bill S9346 Home Infusion for J0256
J3241	Tepezza (teprotumumab) - site-of-care requirement

Specific procedure code mentionedCPT

55880

Urological procedure referenced as requiring authorization when exceeding benefit limit

DME purchase threshold - Medicaid & Healthy MichiganItems > $500 (category dependent)

DME purchase threshold - Commercial/Community HMO & POSItems > $1,500 or > $3,000 depending on category

DME purchase threshold - Health AdvantageItems > $3,000 or > $5,000 depending on category

Medicaid Home Care visits without prior authFirst 24 billed home care visits per calendar year

Medicaid Occupational/Physical Therapy unitsMaximum of 144 billed units per calendar year (Medicaid)

DME Rental (Medicaid / some categories)Items > $500/month (some categories)

What Providers Must Do

Prior Authorization

Preauthorization required for most services

Preauthorization is required by McLaren for all products for both primary or secondary payer unless Medicare is the primary payer (for hospital services only). Providers must submit prior authorization for services and codes listed in the document and consult the preauthorization grid for line-of-business specific rules and exceptions.

Submit prior authorization for services and codes listed in this document.
Consult the preauthorization grid for line-of-business specific rules and exceptions.
Medicare-primary hospital services are excluded from this preauthorization requirement.

Prior Authorization

Neurostimulator authorizations

Terms Used in This Policy

NOCNot Otherwise Classified; unlisted/unspecified codes requiring preauthorization

CSHCSChildren’s Special Health Care Services (refer to plan for hearing aid benefit limits)

ASCAmbulatory Surgical Center

OONOut-of-Network

Buy & BillProvider purchases the drug and bills the payer directly for the drug (applies to certain outpatient-administered drugs).

No auth Cancer diagnosis (in-network facilities)Annotation indicating preauthorization is waived for that code when the primary diagnosis on the claim is cancer and the service is provided at an in-network facility.

Site-of-care requirementA restriction indicating where a drug may be administered (e.g., not in hospital-affiliated infusion centers; home infusion or non-hospital infusion center required).

Policy Updates

Important Operational Reminders

The code and service lists are maintained regularly and the list is updated at least quarterly. For the most current version and any updates after the effective date, providers should check McLarenHealthPlan.org and may contact McLaren Customer Service at (888) 327-0671 for questions.

Applies to providers submitting authorizations for McLaren Health Plan members: this policy guides preauthorization submission and requirements for services across McLaren products and lines of business (Medicaid/Healthy Michigan, Health Advantage, Community/Commercial).

OpenPayer

MHP Service Codes Requiring Preauthorization - Effective February 1, 2026