CurrentModa HealthPolicy N/A

Post‑Acute & Facility Care — Prior Authorization and Coverage Criteria

Governs prior authorization requirements, notification timelines, and selected service/coding lists for post-acute and facility care services for Moda Health members. Affects providers admitting or furnishing services in inpatient, SNF, IRF, LTAC, residential and behavioral health settings.

Policy Summary

PayerModa Health

PolicyPost‑Acute & Facility Care — Prior Authorization and Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionNotify Moda Health within 48 hours of urgent or emergent inpatient admissions and obtain prior authorization when required for elective inpatient, SNF, IRF, LTAC, advanced imaging or specialty drug services through the specified vendor.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

48 hoursUrgent admission notification

SNF/IRF/LTACPrior authorization required

eviCoreAdvanced imaging vendor

Magellan RxSpecialty drug vendor

No PA (examples)Select codes—no PA examples

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

T2048/H00xxBehavioral health codes cited

Coverage Criteria and Medical Necessity Mapping

Mapping to MHMNC or ASAM

Service-level mapping to criteria:

Residential mental health: Residential Mental Health codes (H0010, H0017, H0018, H0019 and T2048 where mapped) are evaluated using Moda Health Medical Necessity Criteria (MHMNC) for determination.

See MHMNC mapping in source chunks.

Residential substance use disorder: Residential Substance Use Disorder codes (H0011, H0012, H0013 and T2048 where mapped) are evaluated using ASAM criteria for determination.

See ASAM mapping in source chunks.

Partial hospitalization and IOP: Partial Hospital Program and Intensive Outpatient Program codes (H0035, H2012, S0201, S9480) are evaluated per MHMNC (partial hospital/IOP) or ASAM as indicated for substance use disorder.

Referenced mappings in source.

Applied behavioral analysis / TMS / Nutrition: Applied behavioral analysis codes (97151–97158, 0362T, 0373T), transcranial magnetic stimulation codes (90867–90869), and nutrition counseling (97802–97804) are evaluated per MHMNC where referenced.

See chunk 37 for specific mappings.

Authorization routing and criteria references

Coverage references and requirements:

Vendor-specific authorization routing: Many drugs and biologics require authorization via Magellan RX or Moda Pharmacy/HCS; advanced imaging and certain cardiology/procedural requests are handled by eviCore.

Providers must route requests to the specified vendor per group enrollment.

Clinical criteria sources: Medical necessity determinations reference Moda Health Medical Necessity Criteria (MHMNC) and MCG guidelines where indicated.

Use MHMNC/MCG references listed in the policy for procedure-specific criteria.

Specific prior authorization examples

Examples of services requiring prior authorization and clinical criteria:

Chelation therapy (home infusion): Chelation Therapy - Home Infusion (S9355) requires prior authorization for medical necessity review.

MCG/Moda criteria referenced for medical necessity.

Botulinum toxin injections: Botox and related products (J0585–J0588) require authorization via Magellan RX for fully insured groups; other groups contact Moda Pharmacy/HCS.

Drug-specific MHMNC references apply.

Authorization review assignments

Authorization review assignments (vendor responsibility may vary by group):

Magellan RX review: Requests for many specialty drugs and selected injectables are reviewed by Magellan RX for fully insured groups; other groups should contact Moda Pharmacy/HCS.

Examples and instruction in source chunks 54–62.

Moda Pharmacy/HCS review: Certain drugs and items (including some autografts and HCS-reviewed grafts) are reviewed by Moda Pharmacy/HCS or HCS as noted.

Check the policy entry for group-specific routing.

eviCore MSK prior authorization

For members enrolled in the eviCore MSK program:

eviCore joint surgery prior authorization: Knee and hip replacement and arthroscopy prior authorizations are obtained through eviCore for groups enrolled in the eviCore MSK program; check EBT for member enrollment and follow eviCore guidelines at evicore.com.

Applies only to members/groups enrolled in eviCore per source.

DME/Orthotics medical necessity

DME and orthotics coverage when reviewed for medical necessity:

DME/Orthotics medical necessity review: Orthoses and orthotics (e.g., L0450, L3671, L0622 and related L-codes) require review per the MHMNC Durable Medical Equipment (DME) General Policy and applicable MCG guidance to support medical necessity.

Providers must supply documentation to meet MHMNC/MCG criteria.

PET scan prior authorization

Advanced imaging (PET) coverage routing:

PET scan authorization routing: Requests for PET scans are performed by eviCore for members enrolled in eviCore; groups without eviCore obtain prior authorization through Moda Health/HCS. Follow eviCore guidelines and check EBT for enrollment.

PET CPT/HCPCS codes and eviCore lists are referenced in the policy.

Specialty drug prior authorization

Specialty drug authorization handling:

Specialty drug routing and review: Requests for authorization of many specialty drugs (specific J-codes and biologics listed in the policy) are handled by Magellan RX or Pharmacy RX for fully insured groups; other groups should contact Moda Pharmacy/HCS per the group-specific instructions.

Check each drug entry for the vendor responsible and applicable MHMNC drug criteria.

Presumptive urine drug testing (UDT) code guidance identifies specific CPT/HCPCS entries that are Not Covered effective 1/1/2021. The policy text explicitly lists 0227U as a presumptive UDT code that is not covered as of that effective date; claims for this code will be reviewed per medical necessity rules when submitted.

The residential services mapping table includes multiple lines where the T2048 mapping fields are blank or contain placeholder values (for example entries shown as "1 = ." or "2 = ."). These empty/placeholder mappings indicate unspecified or unresolved T2048 associations on those lines and should be treated as such when determining code-to-service mappings for authorization and documentation purposes.

Blepharoplasty and brow lift procedure guidance lists a group of CPT codes and states that certain related codes are considered cosmetic and not covered. Specifically, CPT 15820, 15821, and 18524 are called out as cosmetic procedures and are not covered under this policy.

Interspinous decompression and interlaminar stabilization devices (for example CPT/HCPCS codes 22867, 22868, 22869, 22870, C1821) are addressed in the policy as no longer covered and considered investigational (instruction: as of 10/1/2016 these devices are not covered).

Skin substitute guidance references the policy's Always Not Covered List for additional skin substitute codes. Providers should consult that list when evaluating coverage for bioengineered tissue grafts and related HCPCS codes.

Orthognathic surgery and related CPT/D codes are listed with an instruction to check the member handbook, since orthognathic services may be a benefit exclusion for the member's plan. Verify member-specific benefits before scheduling or seeking authorization.

Effective 1/1/2024, the policy specifies that HCPCS E0740 (urinary incontinence device) is Not Covered. Providers should not expect coverage for E0740 after that effective date and must consider alternative services or obtain benefit confirmation.

Active cooling devices (for example, commercial systems such as Game Ready) are expressly identified as not covered under this policy (entry appears with Cooling Devices guidance).

This policy reiterates that interspinous decompression and interlaminar stabilization devices are considered investigational and are therefore not covered; see the device entries and instructions noting the investigational status and lack of coverage.

Lipectomy and related body-contouring procedures (multiple CPT codes listed) are subject to review and are evaluated for medical necessity versus cosmetic purposes. The instruction indicates these procedures will be reviewed to determine whether they meet medical necessity criteria or are excluded as cosmetic.

Service and Code Lists

Behavioral health / residential / therapy / UDT / nutritional counseling codesmixed

H0010	Residential mental health / related residential services (as listed)
H0011	Inpatient substance use disorder / related inpatient services (as listed)
H0012	Residential substance use disorder (listed in document sections)
H0013	Residential substance use disorder (listed)
H0037	Intensive Outpatient Services & Supports (IOSS)
H0023	Intensive In-home Behavioral Health Treatment (IIBHT)
H2016	Early Assessment and Support Alliance (EASA)
H0240	Coordinated Specialty Programs (listed)
H0241	Coordinated Specialty Programs (listed)
T2048	Residential/psychiatric residential treatment related code

1–10 of 18

1/2

Residential service codesHCPCS

H0010	Residential Mental Health (listed group)
H0017	Residential Mental Health (listed group)
H0018	Residential Mental Health (listed group)
H0019	Residential Mental Health (listed group)
H0011	Residential Substance Use Disorder (listed group)
H0012	Residential Substance Use Disorder (listed group)
H0013	Residential Substance Use Disorder (listed group)
T2048	Residential Mental Health / Residential Substance Use Disorder modifier/group

Partial hospitalization / IOP codesHCPCS

H0035	Partial Hospital Program Mental
H2012	Partial Hospital Program Mental/Substance Use
S0201	Partial Hospital Program Mental
S9480	Intensive Outpatient Treatment

Applied Behavioral Analysis codesCPT

97151	Applied Behavioral Analysis assessment
97152	Applied Behavioral Analysis
97153	Applied Behavioral Analysis
97154	Applied Behavioral Analysis
97155	Applied Behavioral Analysis
97156	Applied Behavioral Analysis
97157	Applied Behavioral Analysis
97158	Applied Behavioral Analysis
0362T	Applied Behavioral Analysis (temporary code)
0373T	Applied Behavioral Analysis (temporary code)

TMS codesCPT

90867	Transcranial Magnetic Stimulation
90868	Transcranial Magnetic Stimulation
90869	Transcranial Magnetic Stimulation

Nutrition counseling codesCPT

97802	Nutritional Counseling for Eating Disorders
97803	Nutritional Counseling for Eating Disorders
97804	Nutritional Counseling for Eating Disorders

IOP substance use (special case)HCPCS

H0015

Intensive Outpatient Treatment—Substance Use Disorder (OON Alaska individual members effective 12/1/2023)

Partial Hospital Program and IOPCPT | HCPCS

H0035	Partial Hospital Program Mental
H2012	Partial Hospital Program Mental / Substance Use Disorder
S0201	Partial Hospital Program

Selected surgical CPT codesCPT

22860	Artificial Disc Replacement (effective 1/1/2023)
29848	Carpal Tunnel Release (mentioned later)

Selected drug J-codesHCPCS

J9264	Abraxane
J0178	Eylea
J0179	Beovu

Spinal pain injectionsCPT

64479	Epidural/facet/medial branch blocks
64483	SI joint injections (reviewed by Moda Health)

External insulin pumpsHCPCSCovered

E0784	External infusion insulin pumps
A9274	External infusion insulin pumps

Drugs requiring authorization (examples)HCPCSCovered

J0881	Erythropoiesis stimulating agent
J0885	Erythropoiesis stimulating agent
J0882	Erythropoiesis stimulating agent
J0887	Erythropoiesis stimulating agent
J0888	Erythropoiesis stimulating agent

Specialty drugsHCPCSCovered

J0178	Eylea
C9161	Eylea HD (facility only) effective 1/1/2024
J0180	Fabrazyme (Agalsidase Beta)
J0638	Ilaris (canakinumab)
J9347	Imjudo (tremelimumab-actl) effective 4/1/2023

Knee/Joint surgery codesmixedCovered

27440	Knee replacement
27441	Knee replacement
27442	Knee replacement
27443	Knee replacement
29868	Knee arthroscopy
eviCore Joint Surgery prior auth list	List referenced for knee prior authorization

Dermatologic laser and wart removal codes (select no-PA)CPT

17106	Laser procedure
17107	Laser procedure
17108	Laser procedure
17110	Laser procedure
17111	Laser procedure
17000	Wart removal
17003	Wart removal

Laser/dermatology CPT/HCPC codesCPT

11200	Laser treatment derm/skin lesions
17106	Laser treatment - port wine stain / skin lesion
17107	Laser treatment - skin lesion
17108	Laser treatment - skin lesion
17110	Laser treatment - skin lesion
17111	Laser treatment - skin lesion
17380	Laser treatment - skin lesion

Low air loss products and select drugsmixed

E0181	Low air loss mattress
E0182	Low air loss mattress
J0221	Lumizyme (Alglucosidase alfa)

Orthoses / Orthotics codesHCPCS

L0450	Spinal orthosis
L3671	Shoulder/wrist/hand orthosis
L0622	Orthotic component

PET scan CPT/HCPC codesCPTCovered

78459	PET scan code
78811	PET brain/other PET codes (grouped)
G0235	PET related code

Select specialty infusion drugsHCPCSCovered

J1745	Remicade (Infliximab)
Q5104	Renflexis (infliximab-abda)
J9312	Rituxan (Rituximab)

Skin substitutes - bioengineered tissue graftsHCPCSCovered

Q4100	Skin substitute
Q4199	Skin substitute (effective 1/1/2022)

Selected entries from Scar revision / Simponi Ariamixed

15786	Scar revision
31830	Scar revision
J1602	Simponi Aria

Skin substitutes, sleep studies, Skyrizimixed

Q4100	Skin Substitute
Q4199	Skin Substitute (effective 1/1/2022)
95807	Polysomnogram in lab
95810	Polysomnogram in lab
J2327	Skyrizi

Specialty drugs, imaging, spinal surgery, SCSmixed

J1300	Soliris (Eculizumab)
78803	SPECT scan
63003	Lumbar diskectomy/related spinal surgery list (partial)
63662	Spinal surgery code
L8680	Neurostimulator/implantable device supply

Additional specialty drugs and injectablesmixed

J2326	Spinraza (nusinersen)
J1627	Sustol
J2779	Susvimo
J2777	Vabysmo
J7318	Viscosupplementation hyaluronic acid derivatives (example)

Durable medical equipment and drugsmixed

K0003	Wheelchair - manual base
J0775	Xiaflex
J9332	Vyvgart
J9352	Yondelis
J9400	Zaltrap

Urine Drug Testing (UDT) limits

UDT limitsLimits of 12 presumptive and 12 definitive urine drug tests per period (applies as of 6/1/16).

Presumptive UDT codes referenced

What Providers Must Do

Prior Authorization

Prior authorization required for many facility admissions

Prior authorization is required for inpatient elective admissions to acute care facilities, skilled nursing admissions, inpatient rehabilitation, long-term acute care, transplant evaluations/events and many other facility-based services. Urgent/emergent inpatient admissions must be reported to Moda Health within 48 hours of admission. Failure to notify within 48 hours may violate notification/contract requirements.

Inpatient elective admissions: prior authorization required.
Skilled Nursing, Inpatient Rehabilitation Facility, Long Term Acute Care: prior authorization required prior to admission.
Transplants: prior authorization required for evaluation and transplant event.
Urgent/Emergent admissions: notify Moda Health within 48 hours.

Prior Authorization

Specialty drug prior authorization

Requests for authorization of many specialty and self-injectable drugs are routed to Magellan RX Management for fully insured groups. Self-injectables administered under the pharmacy benefit are handled by Moda Pharmacy/Pharmacy RX (contact Pharmacy Customer Service). For ASO/other group arrangements, authorization may be handled by Moda Pharmacy/HCS — check the member/group setup.

Key Definitions and External Guidance

MHMNC (Moda Health Medical Necessity Criteria)

Definition - MHMNCModa Health Medical Necessity Criteria (MHMNC) — used to determine medical necessity for mental health services and referenced throughout behavioral health and related coverage determinations.

Use in policyMHMNC is applied to partial hospitalization, IOP, TMS, ABA, orthoses/DME, and other services as noted in the document.

Reference guidancePolicy text directs reviewers to MHMNC (and MCG where noted) for clinical criteria and medical necessity decisions.

ASAM (American Society of Addiction Medicine criteria)

Definition - ASAMAmerican Society of Addiction Medicine (ASAM) criteria — referenced for determination of residential substance use disorder services (e.g., H0011, H0012, H0013 mapping to ASAM).

Scope of use

Admission and Facility Criteria

inpatient (urgent/emergent)

Notification for urgent/emergent admissions: All urgent/emergent inpatient admissions require notification to Moda Health within 48 hours of admission.48 hours

Failure to notify within 48 hours may violate contract/notification requirements.

SNF | IRF | LTAC | acute inpatient (elective)

Prior authorization required admissions: Prior authorization is required prior to admission for Skilled Nursing Facility (SNF), Inpatient Rehabilitation Facility (IRF), and Long Term Acute Care (LTAC). Prior authorization is also required prior to elective inpatient admissions to an acute care facility.

Clinical documentation must support medical necessity per referenced criteria.

Utilization and Day Limits

Day limits — Urine Drug Testing

Day limits for UDTUrine Drug Testing (Therapeutic Drug Monitoring) limit: 12 presumptive and 12 definitive per period (applies as of 6/1/16).

Supporting codesPresumptive and definitive UDT codes cited include G0480 and G0481 in policy text.

Review processUDT claims without prior authorization are reviewed with claim submission for medical necessity as noted.

Background and Scope

This section maps residential mental health and residential substance use disorder service codes to the payer's clinical guidelines. Services are mapped to either the Moda Health Medical Necessity Criteria (MHMNC) or the ASAM criteria as appropriate; these mappings drive medical necessity determinations and authorization review for residential and related behavioral health services.

Policy Summary

PayerModa Health

PolicyPost‑Acute & Facility Care — Prior Authorization and Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

G0480 listed as presumptive urine drug testing code in policy text.

Definitive UDT codes referencedG0481 listed as definitive urine drug testing code in policy text.

DME prior authorization threshold

DME prior authorization thresholdDurable medical equipment requests of $500 or more require prior authorization or may be reviewed for medical necessity upon claim submission.

Unlisted DME codesDurable Medical Equipment unlisted or unclassified codes are reviewed for plan benefit availability and/or medical necessity.

CMS guidelinesCMS guidelines are applied for prior authorization unless otherwise stated in Moda Health criteria.

Outpatient surgery prior authorization change

Outpatient hernia surgery PA changeEffective 10/1/2020: No prior authorization required for outpatient hernia repair codes listed (e.g., 49520, 49521, 49560, 49561, 49565, 49566, 49581).

Check member enrollment/vendor routingConfirm member enrollment (e.g., eviCore) and applicable routing; lack of correct routing may risk denial or delay.

Related noteThis change applies specifically to outpatient surgery setting as of the effective date provided.

Effective date additions

Q4199 effective dateHCPCS code Q4199 (skin substitute) effective 1/1/2022.

Instruction sourcePolicy text cites MHMNC Skin and Tissue Substitutes – Engineered for instructions.

Drug code effective dates

J9314 effective dateDrug code J9314 effective 1/1/2023.

J9294, J9296, J9297 effective dateDrug codes J9294, J9296, J9297 effective 4/1/2023.

J9322, J9323 effective dateDrug codes J9322 and J9323 effective 7/1/2023.

Magellan RX handles many specialty drug prior authorizations for fully insured groups: https://specialtydrug.magellanprovider.com
Self-injectables under pharmacy benefit: contact Moda Pharmacy Customer Service at 1-888-361-1610 or Pharmacy RX.
Other groups/ASO: contact Moda Pharmacy/HCS for authorization routing.

Prior Authorization

Prior authorization required

Prior authorization is required for residential mental health and related behavioral health services; authorization routing and drug/behavioral program reviews reference Magellan RX and Magellan behavioral health processes where shown.

Residential mental health and related services (e.g., H0011, T2048): prior authorization required.
Partial hospital, intensive outpatient, ABA, TMS and other BH services reference Moda Health Medical Necessity Criteria or MCG and may require authorization through the behavioral health/vendor specified.

Prior Authorization

Prior authorization routing

Prior authorization routing: eviCore performs prior authorization review for advanced imaging, many musculoskeletal/joint surgeries, pain injections, echocardiography and certain cardiology procedures for groups enrolled in eviCore programs. Magellan RX or Moda Pharmacy/HCS handle many specialty drug authorizations. Check EBT/EBT portal and vendor websites for member enrollment and vendor-specific routing.

eviCore: advanced imaging (MRI, MRA, CT, CTA), PET, SPECT, MSK/joint surgery and interventional pain lists — authorization via www.evicore.com if member is enrolled.
Magellan RX: many specialty and physician-administered drugs for fully insured groups.
Moda Pharmacy/HCS or Pharmacy RX: handles pharmacy benefit self-injectables and other group-specific drug authorizations.
Check EBT/EBT and vendor portals to confirm which vendor manages prior authorization for the member/group.

Prior Authorization

Chelation therapy prior auth

Chelation therapy (including Home Infusion S9355) and other specified therapies require prior authorization for medical necessity review.

Chelation Therapy (Home Infusion S9355): prior authorization required for medical necessity.

Prior Authorization

Authorization required for ESAs

Certain drugs such as erythropoiesis stimulating agents (ESAs) require authorization review by Magellan RX for fully insured groups; other groups should contact Moda Pharmacy/HCS for authorization direction.

ESAs (e.g., J0881, J0885, J0882, J0887, J0888): authorization via Magellan RX for fully insured groups; other groups contact Moda Pharmacy/HCS.

Prior Authorization

eviCore prior authorization for joint surgeries

eviCore prior authorization is required for knee and hip replacements and many joint surgeries for groups enrolled in the eviCore MSK/spine programs. Check EBT for member enrollment and submit requests through eviCore when applicable.

Knee and hip replacement / arthroscopy: prior authorization via eviCore for enrolled groups (see eviCore Joint Surgery prior auth list).
Total joint and other joint surgeries: some procedures require PA — check EBT and eviCore guidelines at www.evicore.com.

Prior Authorization

Authorization required for specialty drugs

Authorization is required for many specialty drugs (examples include Eylea, Fabrazyme, Ilaris, Imjudo and numerous J-codes). Magellan RX handles many of these requests for fully insured groups; other groups contact Moda Pharmacy/HCS. Failure to send drug authorizations to the correct vendor may delay care.

Examples: Eylea (J0178/C9161), Fabrazyme (J0180), Ilaris (J0638), Imjudo (J9347) — authorization routed per drug listing (Magellan RX or Moda Pharmacy/HCS).
Specialty Drugs list (J- and C-codes) referenced to Magellan and Moda Health MHMNC criteria.

Note

No prior authorization required for select codes

No prior authorization is required for select outpatient codes (e.g., many lesion removal and certain laser codes). However, some previously PA-exempt codes changed effective dates — check the listed codes and effective dates before assuming no PA is needed.

No PA required examples: lesion removal/wart removal codes (e.g., 17000, 17003) and certain laser/derm lesion codes (effective dates noted in policy).
Verify current lists for codes effective dates (e.g., 17106–17111 changes) before scheduling.

Documentation Required

Medical necessity review required for many drugs and procedures

Many services and drugs require review for medical necessity. Some ASO groups may not require prior authorization but claims will be reviewed for medical necessity at claim submission or post-payment. For drugs administered inpatient (e.g., CAR-T therapies), drug authorization is required prior to requesting inpatient admission.

Medical necessity review applies to many procedures and medications; refer to applicable MHMNC and MCG guidelines.
ASO groups: prior authorization requirements may differ; check member handbook and group-specific setup.
Drug administration inpatient (e.g., Yescarta, Kymriah): drug authorization required prior to requesting inpatient admission.

Prior Authorization

If given inpatient, authorization must be obtained prior to admission

If a therapy such as Kymriah (tisagenlecleucel) or other inpatient-administered specialty drugs is to be given in the inpatient setting, authorization for the drug and the inpatient admission must be obtained prior to admission.

Kymriah (Q2042): authorization provided by Magellan RX for fully insured groups; if given inpatient, authorization must be obtained prior to inpatient admission.
Yescarta and similar CAR-T therapies: obtain drug authorization prior to requesting inpatient admission.

Documentation Required

Coding documentation

Document services using the listed CPT/HCPCS codes and include clinical documentation to support medical necessity. For behavioral health, ABA, TMS, nutrition therapy and many other services, include appropriate chart notes and protocol documentation when requesting authorization.

Examples of codes to include on authorization requests: H0010-H0019, H0035, H2012, T2048, 97151-97158, 90867-90869, 97802-97804, and procedure-specific CPT/HCPCS codes referenced throughout the prior authorization lists.
For clinical trials: include trial number, chart notes, protocol and signed consent for Medical Director review.

Documentation Required

Clinical criteria references

Many procedures and drug authorizations reference Moda Health Medical Necessity Criteria (MHMNC) or MCG guidelines. Use the referenced clinical criteria to support authorization requests and include required documentation per the applicable MHMNC or MCG guideline.

Clinical criteria references: MHMNC and MCG (e.g., MHMNC Spinal Pain Injections, MCG S-700 Knee Arthroplasty).
Include clinical history, prior treatments, objective findings and any required thresholds identified in the referenced criteria.

Note

Check member handbook for provider network restriction and preauthorization requirements

Check the member handbook and group-specific plan documents for provider network restrictions, prior authorization requirements that vary by ASO group, and plan exclusions (e.g., hearing aids may be a plan exclusion for some groups).

Verify whether the member's plan includes eviCore, Magellan RX, Moda Pharmacy/HCS routing or has plan exclusions by checking the member handbook and the Moda Health website/EBT.
Some items (e.g., hearing aids/BAHA) may be excluded for certain plans — confirm in member handbook.

Documentation Required

DME/Orthotics documentation

Durable medical equipment (DME) and orthotics are subject to Moda Health DME policy and MCG guidance. Documentation must support medical necessity and include measurements, fitting notes, prior conservative care and supplier documentation where applicable.

DME/Orthotics references: MHMNC Durable Medical Equipment (DME) General Policy, MHMNC Ankle/Foot or Knee Orthotics, MCG A-0880 Lumbar orthoses, MCG A-0879 Knee Braces.
Provide supporting documentation: clinical rationale, prior therapies, measurement/fitting records and supplier documentation.

Prior Authorization

eviCore authorization requirement

For members enrolled in eviCore-managed programs (MSK, Advanced Imaging, Interventional Pain), prior authorization requests must be submitted through eviCore. Check member enrollment in EBT and use eviCore portals and guidelines for submission and review.

eviCore-managed services include: advanced imaging, PET/SPECT (for enrolled groups), joint surgery prior auth lists, interventional pain (epidural/facet/SI joint injections) and selected cardiology advanced imaging.
Confirm enrollment via EBT/EBT and follow eviCore submission processes at www.evicore.com.

ASAM is specifically cited for Residential Substance Use Disorder code mapping and authorization decisions.

Policy mappingDocumentation and code mappings in the policy indicate ASAM is applied where noted for SUD residential care.

MHMNC referenced for clinical review

MHMNC referenced for review/authorizationModa Health Medical Necessity Criteria (MHMNC) is used by reviewers to support clinical review and authorization determinations for services listed (e.g., partial hospitalization, TMS, DME).

Integration with MCGMHMNC is used alongside MCG guidelines in sections where MCG is cited (e.g., certain surgical and imaging criteria).

Vendor routing noteWhere drugs or services route to external vendors, MHMNC remains a referenced source for Moda Health reviewer determinations when applicable.

eviCore (external prior authorization vendor)

eviCore roleeviCore is the external vendor performing prior authorization reviews for advanced imaging (MRI/MRA/CT/CTA), musculoskeletal services, and certain cardiology/pain procedures; requests are obtained via evicore.com.

Check enrollmentProviders must check EBT for member enrollment to determine if eviCore routing applies.

ExceptionsSome procedures (e.g., SI joint injection 64483) are reviewed by Moda Health rather than eviCore as noted in policy text.

MCG / MHMNC (referenced guideline sources)

MCG / MHMNC as clinical guidanceMCG and Moda Health MHMNC are guideline sources used by Moda Health reviewers to determine medical necessity for procedures, testing, and equipment (e.g., orthoses, joint surgery, spine surgery references to MCG S-810/S-830 etc.).

Examples of useMCG guidance is cited for stereotactic radiosurgery, lumbar diskectomy, and other surgical decisions where MCG procedure guidelines are referenced.

Reviewer instructionProviders should reference MHMNC/MCG-relevant documentation when submitting authorization requests to support medical necessity reviews.

Referenced external clinical guidance

External clinical guidance referencedPolicy uses MCG and Moda Health MHMNC as referenced clinical guidance for medical necessity determinations across multiple service types.

ApplicationReferenced guidance applies to DME, imaging, surgical procedures, and behavioral health program criteria as indicated in the policy text.

Provider implicationInclude clinical documentation aligned with MHMNC/MCG criteria when requesting authorizations to facilitate review.