Genetic testing prior authorization documentation

When requesting genetic or genomic testing, include documentation supporting medical necessity and relevance of each gene tested to the member's diagnosis or management. Prior authorization reviewers will assess analytical/clinical validity, clinical utility, and relevance of individual genes within panels. Tests deemed experimental/investigational (e.g., genome-wide association studies, many pharmacogenetic panels) are typically denied.

• Submit clinical indication, family/personal history, and how results will impact care
• If individual gene codes are submitted from within a panel, include documentation for each gene's medical necessity
• Include evidence of genetic counseling when available

TTFT prior authorization / documentation

Tumor Treating Fields Therapy (TTFT) for newly diagnosed GBM requires prior authorization and strict documentation of initial and continued benefit. Continued coverage requires re-evaluation and objective adherence evidence within specified windows.

• TTFT must be initiated within 7 weeks of last dose of chemo/radiotherapy for newly diagnosed GBM
• Initial authorization: documentation of diagnosis, prior treatments, Karnofsky ≥70, and planned average use of 18 hours/day
• Re-evaluation for continued coverage: in-person clinical re-evaluation between day 60 and day 91 after starting therapy
• Objective evidence of adherence (average 18 hours/day) must be reviewed and documented by treating practitioner

TTFT re-evaluation & adherence documentation

For continued TTFT beyond the initial period, the treating practitioner must document clinical benefit via an in-person re-evaluation AND objective adherence evidence. If re-evaluation occurs after day 91 but demonstrates benefit and adherence, continued coverage may commence from the re-evaluation date. Recurrent GBM and indications other than newly diagnosed GBM are not covered.

• In-person clinical re-evaluation by treating practitioner required (no sooner than day 60, no later than day 91)
• Objective adherence evidence (average 18 hours/day) reviewed and documented
• If re-evaluation after day 91 shows benefit/adherence, coverage may start from that date
• Use of TTFT for recurrent GBM is denied

Injection level/repeat restrictions and epidural response requirements

Subsequent epidural injections and facet procedures have response, timing, and repeat limits: prior response and minimum interval must be documented; injection levels per session are restricted.

• Previous injection must have improved pain/function by ≥50% with return of symptoms to qualify for a subsequent injection
• At least 2 weeks must have passed since the previous injection; if criteria not met, a different approach or level may be attempted (usually within 3–7 days)
• Interlaminar epidural steroid injections limited to a single level per session
• Facet (IA) injections: maximum of four sessions per covered spinal region per rolling 12 months; maximum of two levels per session per region
• Facet joint injection repeat at same anatomic site allowed if prior injection provided ≥50% pain reduction with ≥3 months duration

Facet IA documentation requirements and facet cyst aspiration documentation

Intraarticular facet (IA) injection coverage requires documented conservative therapy trials and specific imaging/clinical findings. Facet cyst aspiration has its own imaging and repeat rules.

• Patient must have completed a 6-week trial of medications (anti-inflammatories, muscle relaxants, analgesics, opioids, gabapentin/pregabalin) within the last 12 months
• Patient must have completed a 6-week trial of physical therapy or chiropractic manipulation (after current episode onset) within the last 12 months
• Must document one of the qualifying conditions (e.g., imaging-confirmed facet pathology)
• Evidence of nerve root compression due to a facet synovial cyst/large effusion on MRI or CT within the previous 12 months is required for cyst aspiration
• Cyst aspiration/rupture may be repeated once within 12 months only if prior aspiration produced ≥50% pain reduction for at least 3 months

OSA procedures exclusion

Certain OSA-related procedures are excluded as not covered or considered experimental; suppliers and clinicians must follow device coverage rules.

• Minimally invasive tongue base reduction procedures for treatment of obstructive sleep apnea are considered experimental / not covered
• Playing of wind instruments for treatment of sleep-related breathing disorders is not covered
• PAP devices, oral appliances and hypoglossal nerve stimulators remain subject to existing DME/device coverage criteria and prior authorization where applicable

DME prior authorization and order/orthosis documentation requirements

Durable Medical Equipment (DME) and TMJ items require prior authorization depending on dollar thresholds and plan benefits. New order and therapy documentation requirements apply for DME and prosthetics; custom orthoses require detailed treating-physician and orthotist documentation.

• Prior authorization required for DME depending on dollar threshold; benefits limited to single purchase of a type of DME every three years
• Standard Written Order (SWO) must include member name/ID, order date, description (or HCPCS/brand), quantity, treating practitioner name/NPI and signature, and be written prior to delivery
• For custom fabricated orthoses, treating physician records must document why a custom device is required over a prefabricated orthosis and be corroborated by orthotist functional evaluation
• Repairs versus replacements: repairs are part/ labor on base item; replacement due to significant change in condition requires documentation

Conservative therapy requirements and prerequisites

Conservative therapy prerequisites apply across several interventions (e.g., facet injections, custom orthoses, TMJ treatment, microprocessor-controlled prosthetics): document trials and failures of less invasive treatments before advanced/interventional care is authorized.

• Documented trial of conservative measures (e.g., medications, physical therapy, activity modification) is required prior to many interventions
• For facet IA injections: 6-week medication trial and 6-week PT/chiropractic trial within last 12 months
• Custom orthoses: prefabricated orthotics must have been tried and failed unless custom need is documented (contracture, deformity, abnormal limb contour, minimal muscle mass, etc.)
• TMJ: trial of up to a total of four PT/OT visits related to TMJ condition; intra-oral appliance prolonged use requires documentation of 1-year trial failure/contraindication
• Microprocessor-controlled prosthetics: patient must have used a standard lower limb prosthesis for minimum three months and meet rehabilitation/prosthetist documentation requirements

Order and therapy documentation requirements; modifier-based billing rule

Therapy orders and session documentation must include a Plan of Care (POC), evaluation, treatment session notes, and discharge criteria when indicated; detailed session-level documentation is required and billing must reflect active treatment.

• POC must include functional/physical impairments, measurable short- and long-term goals, treatment frequency/duration, and anticipated session length
• Progress notes must document date, specific treatments matching CPT codes billed, session length, patient response, skilled reassessment, objective progress toward goals, problems/POC changes, caregiver/home program involvement, and provider signature/date
• Reimbursement limited to maximum 60 minutes per date of service; prior authorization required for PT (after 10 visits) and other therapies (after 8 visits) for medical necessity review
• Spinal manipulation/chiropractic services must be billed with AT modifier for Active Treatment; absence of AT modifier can result in denial as maintenance care

Non‑contrast MRI allowed for specified trauma/fracture indications

For trauma/fracture imaging, non‑contrast MRI is considered medically necessary for suspected acute/occult scaphoid, talus, tarsal navicular, and great toe sesamoid fractures and for certain post‑operative evaluations when other findings suggest infection or delayed union/nonunion.

Advanced imaging within 12 months required to show cyst/effusion causing nerve‑root compression

Evidence of nerve‑root compression from a facet synovial cyst or large effusion must be demonstrated on MRI or CT performed within the previous 12 months and correlate with clinical findings to support intraarticular facet injection.

All CT scans require prior authorization

All CT scans require prior authorization effective 1/1/26; obtain PA before scheduling to comply with payer policy.

Lab‑based genetic/genomic testing requires prior authorization before completion

All laboratory‑based genetic/genomic testing requires prior authorization BEFORE testing is completed; do not perform tests prior to receiving PA approval.

DME prior authorization and single‑purchase limitation (3 years)

Durable medical equipment prior authorization may be required depending on the plan's dollar threshold; benefits are subject to one purchase per DME type every three years (including repairs/replacements).

DME/spinal orthoses and TMJ treatments require prior authorization per dollar threshold

Prior authorization is required for DME, custom spinal orthoses, and TMJ treatments depending on dollar thresholds—verify PA requirements and submit required clinical documentation before dispensing.

Imaging for therapy/chiropractic must be supported by H&P; therapy PA rules apply separately

Imaging ordered to support therapy or chiropractic services must be supported by history and physical exam; separate therapy prior authorization rules (visit limits, documentation) apply to therapies referenced in imaging requests.