COMMERCIAL Prior Authorization & DME Benefits Matrix
Customize your policy alerts
Sign up for all westernhealthadvantage policy alerts
Know when westernhealthadvantage releases new policies or updates existing guidance.
Monitor payer policy activity
This document is a commercial-line quick-reference matrix describing prior authorization, DME benefits, co-payment categories, and review processes for Western Health Advantage providers and reviewers.
No material clinical or coverage changes in this revision.
Coverage Criteria & Matrix Guidance
General medical necessity criteria
Covered when medical necessity and member eligibility are met and not excluded by the member's Evidence of Coverage (EOC). Determinations rely on InterQual and/or MCG.
Determination uses InterQual and/or MCG; refer to member EOC for exclusions and copays
Mixed coverage criteria
Coverage and prior authorization depend on the specific item/service and meeting medical necessity or the listed conditions.
Chunks 18-19
Chunk 23
Chunk 26
Chunk 34
Selected coverage stances and criteria examples
Examples of coverage stances shown in the matrix (Benefit, P.A. requirement, Notification, Hayes criteria, Comments).
Chunk 36
Chunks 37-38
Chunk 46
Chunk 53
Matrix coverage with item-specific comments
Coverage indicated when the matrix entry is 'Y' and the applicable comments/indications are met.
Prior authorization required; Chunk 58
Chunk 60-61
Chunk 177 and 26
Chunk 73
Breast pump coverage
Breast pumps and related supplies are covered under the Women's Preventive Health Services mandate when criteria are met.
Chunks 74 and 73
Selected DME and diagnostic device coverage
Selected DME and diagnostic devices are covered when the listed clinical criteria and authorization requirements are met.
Chunk 77
Chunks 85 and 146
Chunk 145
Catheter coverage
Catheters and related supplies are a medical supply benefit with rules for initial insertion and ongoing supplies.
Chunk 83
Compression garments - coverage criteria
Compression garments and support hose are covered when prescription and fitting requirements are met.
Chunks 100 and 225
Cochlear implantation - coverage criteria
Cochlear implantation is a covered surgical/prosthetic benefit for appropriately selected patients.
Chunks 92 and 41
Colonoscopy - coverage criteria
Colonoscopy coverage and screening intervals are defined by member risk and findings.
Chunk 96
Cooling cap - coverage criteria
Scalp cooling (cooling cap) coverage is limited to specific oncology indications.
Chunk 103
CPAP/BiPAP - coverage criteria
CPAP/BiPAP devices and related accessories are covered when medical necessity criteria are met; humidifiers are covered when used with CPAP/BiPAP per documentation.
Chunks 108-109 and 202
Selected item coverage statements
Selected item coverage statements and purchase/rental rules from the matrix.
Chunk 108
Chunk 121
Chunks 121-122
Chunk 108
General DME coverage rules
General DME rules and procurement guidance.
Chunks 128 and 6
Chunk 129
DME repair and replacement
Repair and replacement guidance for DME items.
Chunk 129
Electronic nebulizers
Electronic nebulizers are DME with specific coverage conditions.
Chunk 145
Electric wheelchairs
Electric wheelchairs are covered on a case-by-case basis with authorization and procurement rules.
Chunk 137 and 129
Case-by-Case / Investigational entries
Items flagged as case-by-case or investigational are handled per Hayes/WH A review.
Chunk 152 and 68
Enteral nutrition coverage
Enteral nutrition and supplies require individualized review.
Chunks 153-154
Grid coverage excerpts
Grid excerpts summarizing coverage, PA, and exclusions for selected services.
Chunk 162
Chunk 163
Chunks 164 and 178
Chunk 167
Chunk 180
Hospital beds - standard coverage criteria
Hospital beds are covered when medical necessity for frequent positioning or bed confinement is demonstrated.
Chunk 199
Hospital bed side rails
Side rails coverage is determined case-by-case.
Chunk 199
Home health care
Home Health Care services have specific eligibility and visit limits and must be prescribed by a plan physician.
Chunk 194
Hypoglossal Nerve Stimulator (UAS) - Medical Necessity
Hypoglossal Nerve Stimulator (UAS) — implant covered only when all listed clinical criteria are met.
Chunk 205
Humidifier coverage
Humidifier coverage tied to use with medically necessary DME (e.g., CPAP) and candidate patient features.
Chunk 202
Chunk 203
Infant apnea monitors
Infant apnea monitors are covered as DME with documentation requirements for ongoing use.
Chunks 34 and 211
Insulin pumps and supplies
Insulin pumps, replacement, and insulin-related supply coverage guidance.
Chunk 216
Chunks 215 and 121
Intraocular lenses
Coverage stance for intraocular lenses.
Chunk 220
Iontophoresis
Iontophoresis coverage is restricted to specific indications.
Chunk 224
Intraspinal morphine delivery
Intraspinal morphine delivery coverage guidance.
Chunk 221
Item-level coverage statements
Item-level coverage statements and conditions from the matrix (examples).
Chunk 235
Chunks 241 and 235
Chunk 242
Chunk 251
Chunks 252-253
Segment-level coverage summary
Segment-level summary: entries indicate whether items are covered, supply vs DME, and prior authorization stance.
Chunks 252,253,261,268
Refer to the member's Combined Evidence of Coverage & Disclosure Form (EOC) and Copayment Summary for plan-specific exclusions, limitations, and cost-share details. The matrix is a quick-reference guide only and is not the primary source for benefit determinations; use the member's EOC to confirm whether a service or item is excluded for that plan. WHA also directs reviewers to apply clinical guidelines (e.g., InterQual or MCG) when assessing medical necessity and to follow vendor or Hayes review processes for experimental/new technology requests.
Personal comfort or convenience items are not covered benefits. Examples include household air conditioners, standard bedding (pillows, sheets), braille readers/devices and other non-medical aids. These items are routinely listed as Benefit Exclusions in the matrix and may be denied if billed as DME.
Disposable artificial larynx devices and other single-use artificial speech aids are excluded as they do not meet the durability expectations for DME. Bedding (pillows, sheets, mattress toppers) is treated as a personal comfort item and likewise listed as not a covered benefit in the matrix.
Bicycles — whether standard or stationary — are expressly identified as a Benefit Exclusion in the matrix and are not covered under the DME or medical benefits.
Over-the-counter and personal comfort items that lack a physician prescription or medical necessity are excluded. Examples called out across the matrix include exercise equipment, spas/whirlpools, computers for general use, and similar non-medical devices that are intended for conditioning, recreation, or convenience rather than treating a specific medical condition.
Common examples of OTC or personal comfort exclusions noted in the matrix include: braille readers/devices and braille teaching text (Benefit Exclusion), over-the-counter blood pressure cuffs and supplies unless the Group’s contracted supplier covers them, and support hosiery purchased without a prescription which are not covered.
Certain devices are identified as experimental or investigational and are subject to case-by-case review or denial. The policy cites examples such as many bladder stimulators and some bone stimulators (electrical stimulation of bone) which are considered investigational for indications like pain or urinary incontinence and therefore not standard covered benefits.
Retail-grade breast pumps and supplies purchased over-the-counter by the member are not reimbursable. Covered breast pumps must be prescribed and provided through a contracted DME supplier per the Women’s Preventive Health Services mandate and the matrix guidance.
The SmartPill (non-camera gastric motility capsule) is considered experimental when requested prior to a camera-based capsule endoscopy and is listed as not covered. Video capsule endoscopy (camera) may be covered with prior authorization when medically indicated.
The matrix lists several benefit exclusions and non-covered items beyond DME. Examples include cosmetic surgery (e.g., facelifts, augmentation/mammoplasty when cosmetic), non-medical transport (gurney vans, wheelchair vans, taxis), and certain experimental screening tests (for example, some DNA blood tests for routine colon cancer screening are identified as experimental in the matrix).
Support hosiery and compression items purchased over-the-counter without a prescription are not covered. Compression garments require an MD/NP prescription and vendor fitting or custom ordering to be considered a covered DME benefit.
Several items in the matrix are explicitly flagged as Benefit Exclusions or labeled ‘Not a covered benefit’ (for example, some CT/CAT scan entries and disc replacements for lumbar/thoracic levels or cervical >2 levels are noted as experimental/not covered). When an item is marked as a benefit exclusion in the matrix, claims for that item will be denied as not covered.
The matrix clarifies that non-medical DME items are excluded as benefits. Examples specifically called out include spas, whirlpools, exercise equipment, and computers, which are not covered because they are not medically necessary durable medical equipment.
Eyeglasses are excluded from medical benefits and are listed as a Benefit Exclusion in the matrix. Contact lens fitting is similarly not covered as part of the medical annual eye exam and may be covered only under a separate vision rider if the member has that benefit.
Fabric wrapping of aortic aneurysms is designated as experimental and not efficacious in the matrix and is therefore not covered; the matrix comments note high mortality associated with this approach.
Facelifts and other procedures performed for the normal aging process are treated as cosmetic and are Benefit Exclusions unless performed as part of medically necessary reconstructive surgery; such cosmetic procedures will not be covered under medical benefits.
The matrix notes that eyeglasses and services such as contact lens fitting are excluded from medical benefits. Members may have separate vision carve-outs that cover eyewear; reviewers should check the member’s EOC or vision rider for coverage specifics.
Fabric wrapping for aortic aneurysms is reiterated in the matrix as an experimental approach and therefore excluded. Similarly, certain electrical bone stimulation uses are noted as experimental or investigational and not standard covered benefits.
Overbed tables are explicitly identified as a convenience item and are not covered. Home modifications (ramps, structural assessments, construction) are also excluded from coverage and should not be billed as DME.
Room or central humidifiers are not a covered benefit. A medical humidifier may be covered, however, when prescribed in conjunction with medically necessary DME such as CPAP; heated and non-heated humidifiers (E0562/E0561) may be covered when ordered by the treating physician for use with a covered CPAP device.
CPAP-related items are treated with specific rules in the matrix. While CPAP/BiPAP coverage requires medical necessity and rental-to-purchase review, some CPAP-related cross-reference lines indicate items may be non-covered unless tied to a covered DME indication. Humidifiers are covered only when prescribed as part of medically necessary CPAP/oxygen equipment.
Hydraulic lifts (seat/sling) and certain Hoyer lift cross-references are noted as Not a covered benefit in specific entries; Hoyer-style patient lifts are otherwise referenced under DME where therapeutic use is established, but some sling/seating lifts are excluded per the matrix comments.
Premium intraocular lenses (for example Toric, Crystalens, ReStor) are considered convenience or premium items and are not covered as standard IOLs. Standard IOLs used to replace lenses removed for cataract, disease, or trauma remain a covered benefit.
Iontophoresis is recognized as standard of care for hyperhidrosis only. Most other indications for iontophoresis remain experimental/investigational and require WHA review, and are not routinely covered.
Cosmetic procedures and services (for example liposuction, mammoplasty augmentation, and facelifts) are generally listed as Benefit Exclusions unless performed as part of a medically necessary reconstructive procedure. Cosmetic indications are not covered under medical benefits.
Three-dimensional (3D / tomosynthesis) mammography is considered investigational or not medically necessary for most indications; the matrix allows use in evaluation of dense breasts but otherwise marks 3D mammography as investigational in the table.
A nocturnal airway patency device is specifically listed as Not a covered benefit in the matrix and should not be billed as covered DME.
DME & Device Medical Necessity Rules
DME general medical necessity
DME is covered when medically necessary and consistent with applicable guidelines and plan eligibility.
Chunks 5,6; WHA uses InterQual/MCG
DME medical necessity examples
Examples of DME medical necessity requirements for common items.
Chunk 34
Chunk 26
DME medical necessity examples
Certain DME items and supplies require documentation of medical necessity and context of use.
Chunk 46
Chunk 47
DME medical necessity nodes
Select DME items require meeting specific indications or custom documentation.
Chunk 58
Chunk 60
Chunk 64
Breast pump necessity
Breast pump medical necessity and replacement rules.
Chunks 74 and 73
Mobility/orthotic devices
Mobility and orthotic device necessity rules.
Chunk 77
Chunk 80
Compression garments - DME necessity
Compression garment medical necessity requirements.
Chunks 100 and 225
CPAP/BiPAP - DME necessity
CPAP/BiPAP medical necessity and rental-to-purchase guidance.
Chunks 109 and 108
Device-specific necessity examples
Device-specific clinical necessity examples that guide coverage decisions.
Chunk 108
Chunk 205
Nebulizer medical necessity
Nebulizer medical necessity example.
Chunk 145
Wheelchair medical necessity
Wheelchair coverage is conditional and requires prior authorization and device specification adherence.
Chunks 137,129,180
DME medical necessity examples
Additional DME examples with noted coverage conditions.
Chunks 38 and 146
DME conditional coverage
Examples where coverage is conditional on device specification or clinical severity.
Chunk 177
Chunk 180
DME medical necessity examples
Equipment-specific medical necessity examples and technical requirements.
Chunks 252 and 199
Chunk 180
Humidifier candidate examples
Examples of patients who may benefit from humidification when using CPAP/oxygen.
Chunk 202
Insulin pump replacement
Insulin pump replacement criteria.
Chunk 216
Jobst pneumatic appliances
Jobst pneumatic appliance coverage requires prescription and demonstration of need.
Chunk 225
Knee immobilizer
Knee immobilizer coverage conditions and typical duration.
Chunk 228
DME medical necessity statements
Examples of clinical references and equipment-specific notes used to establish medical necessity.
Chunk 242
Chunk 261
MEDICAL NECESSITY
Examples of equipment-specific notes from the matrix segment.
Chunk 252
Chunk 261
Prior Authorization, Documentation & Provider Steps
Obtain prior authorization when matrix indicates P.A Req.
The matrix identifies which services and DME require prior authorization; providers must request authorization when the matrix marks P.A Req. = Y. Authorization decisions are made based on medical necessity and applicable clinical criteria (e.g., InterQual and/or MCG).
- Request prior authorization for any item/service with P.A Req. = Y in the matrix.
- Document medical necessity per InterQual/MCG when submitting PA requests.
Check per-item PA requirement in the matrix
Prior authorization requirements vary by specific item and service—some entries show PA required, some not; review the matrix entry for the item (examples include aero‑chamber, air beds, alternating pressure pads, amino acid modified products).
- Always check the matrix line for the specific item to determine whether PA is required.
- If entry shows Y or Y* follow PA routing and documentation notes in the comments.
Confirm PA per service entry
Many procedures and services carry a PA requirement depending on the service; confirm PA status on the matrix and follow medical necessity criteria for authorization decisions.
- Verify P.A Req. flag for the specific procedure before scheduling.
- Provide clinical documentation supporting medical necessity per the matrix comments.
PA and case‑by‑case review for select surgical/DME procedures
Certain high‑resource surgical procedures and related DME (e.g., Autologous Chondrocyte Transplant) are marked P.A Req. = Y and require case‑by‑case review; obtain prior authorization and prepare case documentation.
- Submit PA with clinical documentation demonstrating failure of conservative therapy and indication per comments.
- Expect case‑by‑case review and Hayes/MD review when noted.
Route behavioral health PA through OptumHealth and notify per matrix
Behavioral health inpatient admissions require authorization and notification routing; use participating behavioral health providers and follow OptumHealth Behavioral Solutions routing as noted.
- For elective behavioral health detox/rehab admissions, obtain PA (P.A Req. = Req) and notify within one business day for concurrent review.
- Refer to OptumHealth Behavioral Solutions of California for participating provider requirements.
Obtain PA for items marked P.A Req. = Y
Several listed items are explicitly marked P.A Req. = Y in the matrix; providers must obtain prior authorization for those items to be eligible for coverage.
- Examples in the matrix include BAHA and certain DEXA/brace entries—follow the PA flag on the item line.
- Include required clinical evidence when requesting PA.
PA required for capsule endoscopy; SmartPill experimental
Video capsule endoscopy (small bowel) is covered when medically necessary but requires prior authorization; SmartPill (no camera) is considered experimental and not covered.
- Submit PA for capsule endoscopy with indication and prior test results.
- Do not submit PA for SmartPill expecting coverage—document as experimental per matrix comments.
Canes covered as DME—PA not required
Canes and replacement parts are covered as DME when the patient's condition impairs ambulation; the matrix indicates prior authorization is not required for canes.
- Provide documentation that ambulation is impaired to justify device as DME.
- No prior authorization required when the matrix line shows P.A Req. = N.
Obtain PA for H‑Wave stimulators when criteria met
H‑Wave stimulators are listed as DME and require prior authorization when applicable criteria are met; coverage is contingent on meeting clinical criteria.
- Obtain PA and provide documentation that criteria for chronic intractable pain are met.
- Expect InterQual/MCG review as supporting criteria for PA decision.
Confirm and obtain PA for cardiac services
Many cardiac services and cardiac monitoring devices list prior authorization requirements in the matrix; confirm PA status and submit supporting medical necessity documentation for cardiac event monitoring, EECP, pacemaker‑related services, etc.
- For EECP submit PA (P.A Req. = Y) with indication that patient meets severe chronic stable angina criteria.
- Submit PA for intraoperative ventricular mapping and other cardiac procedures marked P.A Req. = Y.
Colonoscopy — obtain PA when indicated and document screening vs diagnostic
Colonoscopy preventive and diagnostic indications are listed in the matrix and colonoscopy is marked P.A Req. = Y; obtain prior authorization when the line requires it and document indication (screening vs diagnostic) per guidance.
- For average‑risk screening follow frequency guidance (e.g., every 10 years after age 50) and indicate screening vs diagnostic on submission.
- If matrix shows P.A Req. = Y submit PA with supporting clinical rationale.
Request PA for cooling caps with chemotherapy indication
Scalp cooling (cooling cap) is listed as covered for adults undergoing chemotherapy with high alopecia risk but requires prior authorization; document chemotherapy regimen and alopecia risk when requesting PA.
- Include chemotherapy regimen details showing high risk of complete alopecia with PA submission.
- PA required per the matrix (P.A Req. = Y).
Follow CPAP/BiPAP PA/notification and humidifier rules
CPAP/BiPAP entries include PA and notification distinctions (court/law enforcement ordered care noted); humidifiers are covered only in conjunction with CPAP/BiPAP—document medical necessity and follow PA/notification guidance in the matrix.
- For CPAP purchase, document effectiveness during rental and meet Group criteria before approval.
- Humidifier coverage requires prescription and is permitted only with medically necessary CPAP/BiPAP.
Obtain PA for DME/services flagged P.A Req. = Y
Many DME and services in the matrix are marked P.A Req. = Y; providers must obtain prior authorization before delivering services/equipment listed with PA required.
- Review the matrix entry for each item to determine if PA is required (P.A Req. = Y).
- Submit PA with clinical documentation of medical necessity when indicated.
Obtain PA for rental‑versus‑purchase decisions
Decisions about rental versus purchase require prior authorization; if long‑term need is anticipated WHA may recommend purchase and rental cost cannot exceed purchase cost.
- Provide documentation of anticipated duration of need and medical necessity to support rental vs purchase decisions.
- PA required for rental‑vs‑purchase determinations (matrix marks P.A Req. = Y).
PA required for electric wheelchairs
Electric wheelchairs are covered on a case‑by‑case basis and require prior authorization; failure to obtain PA may delay or result in denial.
- Submit PA with justification for electric wheelchair and documentation supporting long‑term medical need.
- Expect additional review and notification flags per matrix comments.
Obtain PA for electronic nebulizers
Electronic nebulizers are DME and require prior authorization; coverage is for patients with severe impairment of breathing or other documented clinical necessity.
- Include pulmonary function or clinical evidence that patient's breathing is severely impaired when requesting PA.
- Electronic nebulizer PA is required per the matrix (P.A Req. = Y).
Prior authorization required for DME service contracts
DME service contracts require prior authorization; groups typically decide and WHA notes purchasing may be more cost‑effective than service contracts.
- Obtain PA for DME service contracts (P.A Req. = Y).
- Provide cost rationale when requesting approval of a service contract vs purchase.
Obtain PA for EECP with documented indication
EECP (external counterpulsation) is categorized as DME and requires prior authorization; submit clinical documentation showing severe chronic stable angina and that the patient is not a candidate for revascularization when requesting PA.
- EECP PA is required (P.A Req. = Y) per the matrix.
- Include documentation that conventional interventions are not suitable and that angina persists despite therapy.
PA required for therapeutic apheresis
Therapeutic apheresis (extracorporeal immunoadsorption) requires prior authorization; submit clinical indication and prior treatment history as part of the PA request.
- PA is required (P.A Req. = Y) for therapeutic apheresis.
- Document prior therapies and reason for apheresis (e.g., ITP after other treatments fail).
Obtain PA for ECMO and provide clinical justification
ECMO (extracorporeal membrane oxygenation) for adults/infants with acute respiratory distress requires prior authorization; notify per matrix details and include clinical urgency and supporting documentation.
- Submit PA (P.A Req. = Y) and notify WHA per matrix if ECMO is being considered.
- Provide clinical documentation of respiratory failure and rationale for ECMO.
No PA required for annual eye exam; contact lens fitting not covered medically
Annual eye examinations (when the member has the benefit) do not require prior authorization; contact lens fitting is not covered under the medical benefit.
- Do not submit PA for routine annual eye exams (P.A Req. = N).
- Refer patients seeking contact lens fitting to vision benefit/carve‑out—not covered under medical benefit.
PA indicated for some eye prosthesis entries
Eye prostheses are standardly covered but some prosthesis entries indicate prior authorization is required; check the matrix line and submit PA when P.A Req. = Y.
- If the matrix line for eye prosthesis shows P.A Req. = Y, submit PA with documentation.
- Standard eye prosthesis coverage exists; follow PA routing when indicated.
Obtain PA for fertility preservation
Fertility preservation services require prior authorization; include documentation that the member will undergo medically necessary treatment that can result in infertility and meet age/storage criteria.
- PA is required (P.A Req. = Y) for fertility preservation.
- Provide documentation of planned treatment that may cause infertility and patient age/date of retrieval/storage details.
PA required for select fetal monitoring items
Certain fetal monitoring entries (e.g., fetal fibronectin, electronic fetal monitoring) indicate prior authorization is required; check the matrix and submit PA with clinical indication when marked P.A Req. = Y.
- Verify P.A Req. flag for fetal monitoring items before providing service.
- Include clinical criteria (e.g., signs of preterm labor) when submitting PA.
Obtain PA where matrix indicates prior authorization
Request authorization when the matrix indicates P.A Req. = Y; providers should use the matrix to identify PA needs and follow the documented PA process.
- If P.A Req. = Y on the matrix line, submit PA prior to service delivery.
- Use member EOC and matrix comments to assemble required evidence.
Obtain PA and physician prescription for home health when required
Home health services generally must be prescribed by a plan physician and may require prior authorization per the member's EOC; verify PA requirements before initiating home health services.
- Confirm PA requirements and the member's eligibility/visit limits in the EOC before starting home health.
- Provide physician prescription and clinical justification with any PA request.
Verify PA for listed services and devices (e.g., blood glucose monitors)
Many entries and devices in the matrix are marked P.A Req. = Y (including some vaccines, blood glucose monitors, and devices); verify the specific item line and obtain PA as indicated.
- Blood glucose monitors require PA and must be obtained from the Group's contracted supplier.
- Check the matrix and member EOC for vaccine PA rules and pharmacy prior auth criteria.
PA and criteria documentation required for Hypoglossal Nerve Stimulator (UAS)
Hypoglossal Nerve Stimulator (UAS) implantation requires prior authorization and must meet specified clinical criteria (age, BMI, polysomnography findings, CPAP failure/intolerance, DISE findings); include the full criteria documentation with PA request.
- Submit diagnostic sleep study (NPSG) and CPAP monitoring evidence with PA request.
- Document BMI, central apnea proportion, DISE findings and prior CPAP trial as required.
PA required for standard IOLs; premium IOLs are not standard benefit
Standard intraocular lenses require prior authorization per the matrix; premium IOLs (Toric, Crystalens, ReStor) are convenience items and are not covered as standard benefits.
- Submit PA for standard IOLs when matrix shows P.A Req. = Y.
- Do not expect coverage for premium IOLs as part of standard benefit—document as patient‑paid option.
PA required for intraoperative ventricular mapping
Intraoperative ventricular mapping is marked P.A Req. = Y; obtain prior authorization and include clinical rationale that mapping is needed to locate tachycardia focus for operative intervention.
- Submit PA with indication and operative plan when intraoperative ventricular mapping is requested.
- Follow matrix PA routing and notification flags.
PA and indication required for iontophoresis (hyperhidrosis standard only)
Iontophoresis is standard of care for hyperhidrosis but other indications are considered experimental; some entries show P.A Req. = Y for specific uses—obtain PA as indicated and document indication.
- For hyperhidrosis document medical necessity; for other uses submit PA for case‑by‑case review or expect investigational determination.
- If matrix shows P.A Req. = Y, include supporting clinical evidence with the PA.
Obtain PA for laser procedures when matrix requires it
Laser procedures (e.g., laser prostatectomy, trabeculoplasty) show P.A Req. = Y in many settings; obtain prior authorization when the procedure entry requires it and demonstrate that criteria for the procedure are met.
- Submit PA demonstrating failure of medical therapy or other listed criteria for laser procedures.
- If entry marks P.A Req. = Y, do not proceed without authorization.
PA required for MRI surface coils and MR venography
MRI surface coil devices and magnetic resonance venography are shown with P.A Req. = Y; obtain prior authorization and reference MCG/InterQual or radiology guidelines when requested.
- Submit PA with clinical indication and relevant radiology criteria per InterQual/MCG.
- Do not perform these advanced MRI services without confirming PA when flagged.
PA required for diagnostic 3D mammogram when indicated
3D/tomosynthesis diagnostic mammography is marked P.A Req. = Y for many diagnostic uses; verify the matrix line and obtain prior authorization when indicated.
- For diagnostic 3D mammogram submit PA with indication (e.g., dense breasts or diagnostic necessity).
- Recognize that 3D mammography may be considered experimental for other indications and require PA/case review.
Check PA requirements for maternity care and follow EOC guidance
Maternity care/delivery lines indicate PA in some contexts (P.A Req. = Y*); after pregnancy diagnosis many routine prenatal/postpartum services have no co-pay—confirm member‑specific rules and obtain PA where the matrix or EOC requires it.
- Check the matrix and member EOC for whether PA is required for specific maternity services.
- Document pregnancy diagnosis and follow comments re: no co‑pays for covered prenatal/postnatal services.
Obtain PA before providing listed DME/services
Many DME and services within the matrix require prior authorization (P.A Req. = Y); providers must obtain authorization before providing those items to avoid denial or delay.
- When P.A Req. = Y on the matrix line, submit PA with required supporting documentation before service delivery.
- Verify member benefit limits in the EOC as PA does not override plan exclusions.
Route experimental/new technology requests to Hayes/IMR per WHA process
WHA uses Hayes New Technology Assessment and may route experimental or new technology requests for independent medical review; follow WHA routing for experimental/new technology requests and expect additional review steps.
- For items rated investigational/experimental (Hayes C/D), route per WHA instructions—may require IMEDECS/Kepro or independent review.
- Discuss rare life‑saving exceptions with WHA Assistant Medical Director when indicated.
PA required for amino acid modified products when essential
Special amino‑acid modified nutrient preparations may be covered when essential for management of inborn errors of metabolism; prior authorization and notification flags apply per the matrix.
- Submit PA documenting diagnosis of inborn error and why the preparation is essential (coverage like insulin basis).
- Follow notification/PA flags in the matrix when present.
No formal step‑therapy rules defined in matrix
No explicit step‑therapy pathways are defined in the matrix excerpts; WHA relies on case‑by‑case and referenced criteria (Hayes/InterQual/MCG) rather than formal step therapy in this document.
- Do not assume a formal step‑therapy sequence from this matrix—follow PA criteria and external guidelines referenced.
- Use Hayes/InterQual/MCG where the matrix refers to external criteria for ordering/approval logic.
Check for concurrent CGRP antagonist use before approving Botox for migraine
Before approving Botox for migraine, reviewers should check medication lists for concurrent CGRP antagonist use since the matrix notes lack of evidence for combined use; document medication history in the PA submission.
- Include current medication list showing whether CGRP antagonists are being used when requesting Botox for migraines.
- If CGRP antagonist is present, note caution per matrix comments and expect reviewer scrutiny.
Authorization cadence: dialysis may be authorized in 12‑month blocks
Authorizations for dialysis may be issued in blocks of 12 months; for ongoing dialysis services verify standing referrals and coordinate with Medicare rules when applicable.
- PA/authorization for dialysis may be authorized up to 12 months per matrix guidance.
- Coordinate eligibility/Medicare conversion timing per matrix comments.
Verify plan‑specific infertility benefits before PA
Verify infertility/infertility‑related benefits on a plan‑specific basis before obtaining authorization; member coverage for infertility services varies by plan and may be a rider.
- Always confirm member‑specific infertility benefits in the EOC prior to PA submission.
- Infertility benefits vary; obtain PA and network approvals when required.
Provide member EOC/HCPCS and use Medicare criteria if WHA guideline absent
Refer to the member's Combined Evidence of Coverage & Copayment Summary for plan exclusions, limitations, and co‑pay details; use HCPCS/Medicare guidelines when WHA lacks item‑specific criteria.
- Provide member EOC and HCPCS code when querying coverage or submitting PA.
- When WHA has no specific guideline, reviewers use Medicare criteria as the reference standard.
Submit medical necessity documentation for DME requiring case‑by‑case review
Many DME items require PA or case‑by‑case justification with ongoing use sometimes requiring MD review (examples: air beds, alternating pressure systems, apnea monitors); submit medical necessity documentation with PA requests.
- For air beds/pressure systems include documentation that device prevents prolonged hospitalization or meets decubitus criteria.
- For apnea monitors include short‑term use justification and plan for ongoing review if long‑term use is requested.
Document medical necessity for bathtub lifts
Medical necessity must be substantiated for bathtub lifts and other items flagged for medical review; include clinical justification demonstrating need and functional limitation in the PA or review submission.
- Provide clinical notes describing functional impairment and why the lift is required.
- Expect WHA medical review when bathtub lifts are requested.
Document home health involvement or bed confinement for supply coverage
Supply benefits may be contingent on home health involvement or bed confinement; document home health plan or bed confinement status when requesting coverage for supplies.
- If supplies are claimed under DME/supply benefit because of home health, include home health order/plan.
- For bandages and related supplies, indicate whether used in conjunction with home health to support coverage.
Obtain review/authorization and supporting imaging for braces/orthoses
Many braces and orthoses entries state 'Review required'—obtain medical review/authorization and supporting clinical evidence (e.g., imaging or specialist notes) to avoid denial.
- Submit X‑rays or surgical notes when requested to support brace/orthosis PA.
- If matrix line states 'Review required', do not assume automatic coverage without review.
Breast pumps require prescription and contracted DME supplier; OTC purchases not reimbursed
Breast pumps (rented or purchased) must have a prescription and be provided through a contracted DME provider; retail OTC pumps and supplies purchased by the member are not reimbursable.
- Include a physician prescription and ensure pump is supplied via contracted DME vendor for coverage.
- Retail/OTC breast pumps and supplies purchased OTC are not covered—advise members accordingly.
PA may be required for ongoing catheter supplies and blood glucose monitors
Initial insertion of central venous catheters may not require PA but ongoing supplies/home health support often do; submit PA for ongoing supplies when the matrix or home health plan requires it.
- For catheter supplies, indicate whether supplies are part of ongoing home health care to justify coverage.
- If blood glucose monitors are requested, obtain PA from the Group and source from the Group's contracted supplier.
Provide prescription and vendor fitting documentation for compression garments
Compression garments require an MD/NP prescription and vendor fitting (measured) or custom‑order documentation; OTC support hose without prescription is not covered.
- Include prescription and vendor measurement/fitting documentation with PA or claims for compression garments.
- OTC compression items purchased without prescription are non‑covered.
Document CPAP/BiPAP effectiveness during rental before purchase approval
CPAP/BiPAP purchase after rental requires demonstration of medical necessity and effectiveness during the rental period; document rental outcomes when requesting purchase approval.
- Document objective improvement or continued need during rental before seeking purchase approval.
- Humidifier coverage is limited to use in conjunction with CPAP/BiPAP and requires prescription.
PA and contracted‑supplier requirement for blood glucose monitors
Blood glucose monitoring devices are DME and require prior authorization from the Group and must be obtained from the Group's contracted supplier; include prescription when submitting PA.
- Obtain prior authorization from the Group for blood glucose monitors.
- Ensure device is sourced from the Group's contracted supplier and include Rx with PA.
Document medical necessity and duration to support rental vs purchase
Provide documentation of medical necessity and anticipated duration of need to support rental vs purchase decisions; use Medicare criteria when WHA lacks item‑specific guidelines and check member co‑pay in the EOC.
- When requesting purchase instead of rental include expected duration of need and cost comparison.
- Refer to Medicare/HCPCS guidance if WHA provides no specific criteria.
PA and medical necessity documentation for enteral solutions and supplies
Enteral solutions and supplies require case‑by‑case medical necessity review; if approved, solutions/supplies are covered under medical supplies and pumps under DME—submit PA and clinical justification.
- Submit clinical documentation supporting need for enteral nutrition and details of the regimen.
- Expect separate routing for solutions (medical supplies) and pump (DME) if approved.
Obtain PA for EECP and include supporting cardiac documentation
EECP requires prior authorization and is categorized as DME; obtain PA before initiating therapy and provide clinical justification that patient meets severe chronic stable angina criteria.
- Submit PA with cardiac history and documentation that the patient is not a candidate for revascularization when requesting EECP.
- EECP is DME and P.A Req. = Y per the matrix.
Rental vs Purchase & Replacement Policies
| Item | Rental vs Purchase / Rule |
|---|---|
| Air beds (fluidized and specialty) and alternating pressure pads/mattresses/pumps | Case-by-case — DME; prior authorization required; may be approved to prevent or avoid long-term hospitalization; home inspection may be required (inspection costs not payable by WHA). |
| Item | Rental vs Purchase / Rule |
|---|---|
| Specialty beds (hospital / specialty beds) | Purchase — classified as DME; reviewed case‑by‑case for medical necessity and potential to reduce inpatient admissions; prior notification/medical director review as indicated. |
| Item | Rental vs Purchase / Rule |
|---|---|
| Autologous blood transfusion/storage (patient's own blood) and related storage fees | Supply/other — storage fees referenced; typically limited units (e.g., 1–2 units) and handled as supply/group risk items per comments. |
| Item | Rental vs Purchase / Rule |
|---|---|
| Braces and orthoses (e.g., back braces: Boston, Jewett, Milwaukee; custom braces) | DME — covered when medical necessity criteria met; many models require review or prior authorization; custom-fitted devices require documentation of fitting. |
| Item | Rental vs Purchase / Rule |
|---|---|
| Breast pump (standard/manual electric) and supplies | Rental or purchase — purchase or rental considered medically necessary during pregnancy or following delivery; must have a prescription and be provided through a contracted DME provider; replacement if broken or >3 years/past warranty and replacement for subsequent pregnancies covered if needed. Retail OTC pumps/supplies not covered. |
| Item | Rental vs Purchase / Rule |
|---|---|
| H‑Wave stimulators (electronic nerve stimulators) | Capped rental / purchase — classified as DME when criteria met; prior authorization required per matrix comments; consider rental-to-purchase guidance where applicable. |
| Item | Rental vs Purchase / Rule |
|---|---|
| Clinitron bed (type of institutional air bed) and CPAP/BiPAP devices | Clinitron bed: normally institutional equipment — rental approved if Medical Director concurs. CPAP/BiPAP: rental with review; purchase may be considered after appropriate rental period if effective per group criteria; humidifier covered in conjunction with CPAP/BiPAP per criteria. |
| Item | Rental vs Purchase / Rule |
|---|---|
| CPAP / BiPAP devices | Rental — initial rental period required to demonstrate effectiveness; purchase considered only after rental and meeting Group criteria and medical necessity documentation. Humidifier coverage when used with CPAP/BiPAP. Court-ordered CPAP annotations apply per comments. |
| Item | Rental vs Purchase / Rule |
|---|---|
| General DME and wheelchairs (including rollabout chairs) | Rental or purchase — rental-vs-purchase decisions require prior authorization; rental cost cannot exceed purchase cost; if long-term need anticipated, purchase may be recommended. Rollabout chairs: purchase coverage only when plan determines medical need and prescribed in lieu of a wheelchair; must meet device specifications (casters ≥ 5 inches) and be obtained from Group's contracted supplier. |
| Item | Rental vs Purchase / Rule |
|---|---|
| DME service contracts | Purchase — DME service contracts are a covered benefit (group choice) but require prior authorization; generally more cost‑effective to purchase equipment per comments. |
| Item | Rental vs Purchase / Rule |
|---|---|
| Electronic nerve stimulators (TENS, H‑Wave, PENS) | Rental recommended initially — comments recommend a three-month rental trial, then consider purchase if medically necessary; prior authorization/medical review as indicated. |
| Item | Rental vs Purchase / Rule |
|---|---|
| Rollabout chairs (special chairs with large casters) | Purchase — coverage limited to rollabout chairs prescribed in lieu of a wheelchair when plan determines medical need; must meet specifications (casters ≥ 5 inches) and obtain from contracted supplier. |
| Item | Rental vs Purchase / Rule |
|---|---|
| Hearing aids and related supplies | Purchase — covered only for select groups (check member EOC); if covered, must be obtained from designated supplier (e.g., TruHearing); dollar limits and replacement wait times apply per EOC. |
| Item | Rental vs Purchase / Rule |
|---|---|
| Insulin pump (external and implantable) | Purchase — replacement pumps considered medically necessary and may be purchased when no longer under warranty, malfunctioning, and not repairable/refurbishable; implantable and external pumps addressed similarly per comments. |
| Item | Rental vs Purchase / Rule |
|---|---|
| Insulin pumps (implantable and external) - additional note | Purchase — replacements allowed when not under warranty and cannot be repaired; prior authorization and medical necessity documentation apply as indicated. |
| Item | Rental vs Purchase / Rule |
|---|---|
| Hospital bed mattress (air/floatation/pressure/gel/Maxi‑Mist) | Rental — mattress covered as DME only where a hospital bed is medically necessary; separate replacement mattress charge should not be allowed where bed with mattress is rented. Prior authorization required. |
| Item | Rental vs Purchase / Rule |
|---|---|
| Hospital mattress (air/floatation/pressure) — general mattress entries | Rental — covered only when hospital bed medically necessary; replacement mattress separate charge not allowed when bed with mattress is rented; prior authorization required as noted in matrix. |
Coding & HCPCS/CPT Guidance
| HCPCS referenced | Note: When in doubt about DME/Supply category for co-pay, refer to HCPCS codes |
| No codes listed |
| No codes listed |
| No codes listed |
| No codes listed |
| No codes listed |
| not specified | Electric wheelchairs — listed as DME with prior auth required |
| not specified | Electronic nebulizers — DME with prior auth required |
| not specified | TENS/H-Wave/PENS listed as electronic nerve stimulators covered as DME |
| not specified | Disc replacement — cervical 1-2 levels covered; 3+ cervical and all lumbar/thoracic considered experimental/ not covered |
| not specified | Electric stimulation of bone considered experimental/investigational for pain, inflammation, urinary incontinence |
| No codes listed |
| No codes listed |
Documentation Required for Authorization & Claims
Quick Coding Notes & Key Values
Background & Scope
BACKGROUND: "Medical necessity" is defined as services that are appropriate and necessary for diagnosis or treatment according to professionally recognized standards, not primarily for convenience, and represent the most appropriate supply or level of service. WHA relies on external clinical resources such as InterQual and MCG for medical necessity determinations and uses Hayes/IMEDECS/InformedDNA reviews for new or experimental technology requests.
Definitions & Matrix Symbols
Items Not Covered / Benefit Exclusions
Non-covered personal comfort items and non-medical transport are called out repeatedly as benefit exclusions. Examples include household air conditioners and room humidifiers (unless medical humidifier prescribed with CPAP), bedding and pillows, braille readers/devices, over-the-counter blood pressure cuffs, and non-medical transportation (gurney vans, wheelchair vans, taxis). Such items are routinely denied when submitted as medical benefits.
Braille readers/devices and other personal comfort or convenience items are excluded from coverage. The matrix explicitly lists braille readers, braille teaching text, and similar assistive-but-non-medical devices as Benefit Exclusions and refers members to community resources rather than covering these under medical benefits.
Over-the-counter blood pressure cuffs and related supplies are listed as Benefit Exclusions in the matrix. If a Group elects coverage, items must be obtained from the Group's contracted supplier; otherwise OTC cuffs purchased by the member are not covered.
The matrix identifies several items that are not covered, including Audio Shoe / Semi-Implantable Electromagnetic Hearing Aids and many home modifications (ramps, structural construction). Overbed tables and other convenience items are not covered; some institutional devices like Clinitron beds are managed under rental/purchase rules and may require Medical Director concurrence.
As noted in the matrix, nocturnal airway patency devices are not a covered benefit. CPAP/BiPAP coverage follows medical necessity rules, but separate devices characterized as nocturnal airway patency devices are excluded.
Meniscal allograft is listed in the matrix as investigational/experimental and recorded as not covered (Benefit = N*); WHA performs case-by-case review when no other options are available.
How to Request Authorization & Resources
Revision History & Change Log
Annual update of the Prior Authorization & DME Benefits Matrix; matrix posted on WHA website (Provider sign-in) with notices sent to key group provider UM staff when new postings or significant changes occur.
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.