Currentpriority healthPolicy NO. 91086-R6

COMPLICATIONS TO NON-COVERED CARE

Defines coverage stance for treatment of medical complications that arise from care or services that are not covered under the member's plan; applies to Priority Health members and providers subject to member-specific benefits.

Policy Summary

Payerpriority health

PolicyCOMPLICATIONS TO NON-COVERED CARE

Policy CodePolicy NO. 91086-R6

Change TypeNo material change

Effective Date12/01/2025

Next Review Date

Key ActionVerify individual plan documents for applicable prior authorization and plan-specific coverage rules.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2025-12-01effective date

11/2025last review

15ICD-10 codes

1policy id present

Coverage Criteria for Complications to Non-Covered Care

Medical Necessity Criteria

Covered when the following apply:

Main coverage conditions: A. Complications to non-covered care are covered if determined to be medically necessary.

Medical necessity determined by plan/medical director

Non-covered service rule: 1. Care or services normally expected to precede or follow non-covered care are not a covered benefit. Services that are normally performed as part of the non-covered care are not a covered benefit, regardless of the reason for the service.

These services remain non-covered even if related to non-covered care.

Unexpected complications: 2. Treatment of unexpected medical complications of non-covered care is a covered benefit.

Coverage applies only for unexpected complications and is subject to medical necessity.

Policy Summary

Payerpriority health

PolicyCOMPLICATIONS TO NON-COVERED CARE

Policy CodePolicy NO. 91086-R6

Change TypeNo material change

Effective Date12/01/2025

Next Review Date

Key ActionVerify individual plan documents for applicable prior authorization and plan-specific coverage rules.

SourceLink

On This Page

ICD-10 Codes that May Support Medical Necessity

ICD-10 Codes that may support medical necessityICD-10

H59.88	Other intraoperative complications of eye and adnexa, not elsewhere classified
H59.89	Other post procedural complications and disorders of eye and adnexa, not elsewhere classified
L76.81	Other intraoperative and post procedural complications of skin and subcutaneous tissue
L76.82	Other intraoperative and post procedural complications of skin and subcutaneous tissue
M96.89	Other intraoperative and post procedural complications and disorders of the musculoskeletal system
N98.0	Complications associated with artificial fertilization
N98.9	Complications associated with artificial fertilization (unspecified)
T80.0xxA	Complications following infusion, transfusion and therapeutic injection
T80A9XS	Complications following infusion, transfusion and therapeutic injection (alternate formatting present in doc)
T81.10xA	Complications of procedures, not elsewhere classified

1–10 of 15

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Provider Actions and Verification Requirements

Prior Authorization

Verify plan-specific authorization and coverage

Check the member's plan-specific documents for any prior authorization or plan exclusions that may affect coverage for complications related to non-covered care. Prior authorization requirements vary by product type (HMO/EPO, POS, PPO, ASO, Individual, Medicare, Medicaid) and by group/self-funded contract.

Applies to insured HMO/EPO, POS, PPO plans — consult individual plan documents for state-mandated benefits or conflicts
ASO (self-funded) and Individual plans — the applicable plan document governs when in conflict
Medicare — CMS determinations govern; if none adopted, this policy applies
Medicaid/Healthy Michigan Plan — Michigan Medicaid Provider Manual and Fee Schedule govern; Priority Health contract with Michigan Medicaid applies when guidance is lacking

Note

Benefit verification required

Confirm member eligibility and benefit details before providing care. Coverage of complications to non-covered care depends on the member's specific benefits and any applicable group policy, and eligibility is determined by the plan in effect on the service date.

Benefit verification required — coverage is subject to member-specific benefits and group-specific policy
Eligibility and benefits determined by the terms of the member's plan in effect on the date services are rendered

Denial Risk

Denial triggers and documentation risks

Document the clinical rationale when billing for treatment of complications arising from non-covered care. Services normally performed as part of non-covered care are not covered; treating expected components of non-covered care risks denial.

Services normally expected to precede or follow non-covered care are not covered, even if performed separately
Treatment of unexpected medical complications of non-covered care may be covered if medically necessary and documented
The medical director will determine when coverage resumes following non-covered care — retain documentation to support medical necessity determinations

Documentation Required

Provider documentation requirements

When coverage for complications is sought, provide complete clinical records and justification that the condition represents an unexpected medical complication and meets medical necessity criteria.

Include clinical notes describing why the complication was unexpected and not part of the planned non-covered care
Attach relevant operative reports, imaging, labs, and consult notes supporting the need for treatment
Be prepared for case-by-case review by the medical director

Definitions

Complications to non-covered care

DefinitionTreatment of unexpected medical complications of non-covered care.

Coverage conditionComplications to non-covered care are covered if determined to be medically necessary.

Non-covered services ruleCare or services normally expected to precede or follow non-covered care are not a covered benefit; services normally performed as part of the non-covered care are not covered regardless of reason.

Scope of covered complicationsOnly unexpected medical complications of non-covered care are considered a covered benefit.

Decision authorityThe medical director will determine, on a case-by-case basis, when coverage resumes following non-covered care.

OpenPayer

COMPLICATIONS TO NON-COVERED CARE

Coverage Criteria for Complications to Non-Covered Care

ICD-10 Codes that May Support Medical Necessity

Provider Actions and Verification Requirements

Background

Definitions