Prior Authorization Required for Implantation and Related Services

Prior authorization is required for implantation procedures and related services unless otherwise specified. Providers must obtain prior authorization prior to scheduling implantations (e.g., intracorporeal VAD insertion, total artificial heart implantation) and related services except for removal or repositioning when performed as a separate service, or for interrogation services which do not require prior authorization.

• Applies to implantable VADs and total artificial hearts listed under CPT codes in this policy.
• Exemption: removal/repositioning performed as a separate service and interrogation services do not require prior authorization.

Prior Authorization for Miscellaneous Implanted VAD Supplies (Q0508)

HCPCS Q0508 (miscellaneous supply or accessory for use with an implanted ventricular assist device) requires prior authorization. Prior authorization is required when charges for replacement device, supplies, and components exceed $1,000 for commercial members and $500 for Medicaid members. Note that device and all supplies for the initial unit are included in the inpatient (IP) stay.

• Q0508 — Miscellaneous supply or accessory for use with an implanted VAD: Prior authorization required.
• Prior auth threshold: > $1,000 (commercial), > $500 (Medicaid).
• Initial device and supplies included in the inpatient stay; do not bill separately for initial unit when included in IP stay.

Advance Care Planning Assessment Required

Providers must include an advance care planning assessment with requests for VAD or total artificial heart (TAH) services. The assessment must be completed by a qualified provider and should accompany the authorization request.

• Assessment required for members receiving VADs or artificial hearts (pre- or post-operative).
• Use Appendix A template as applicable and include with prior authorization submission.

TAH Authorization Form

Requests for total artificial heart (TAH) as bridge-to-transplant should be submitted using the Solid Organ Transplant prior authorization form.

• Use the Solid Organ Transplant prior authorization form for TAH bridge-to-transplant requests.

Medical Necessity Documentation and Individual Case Review

Providers must submit documentation demonstrating medical necessity for all prior authorization requests. Individual case review may allow coverage of investigational treatments in select circumstances (e.g., terminal illness or severe, progressive disease causing serious clinical deterioration); such requests require prior plan approval and review by a Priority Health medical director or clinical pharmacist.

• Submit clinical records, diagnostic tests, InterQual® criteria if applicable, and advance care planning assessment to support medical necessity.
• Requests for investigational or unproven treatments require prior approval and will be reviewed on an individual case basis.

Benefit and Eligibility Verification

Coverage is subject to the member's specific benefits and any applicable group-specific policy. Eligibility and benefit determinations will be made based on the member's plan in effect on the date services are rendered.

• Verify member eligibility and benefits prior to requesting authorization.
• Group-specific plan provisions may supersede this medical policy.

Prior Authorization and Investigational Treatments — Denial Risk

Failure to obtain required prior authorization may result in denial of payment. Prior authorization is also required for requests seeking coverage of investigational treatments; failure to obtain plan approval for investigational or unproven therapies may result in noncoverage.

• Obtain prior authorization before rendering services that require it to avoid claim denials.
• Requests for investigational treatments require prior plan approval.