Priority Health - December 2021 Policy Updates

December 7, 2021

1) Starting January 2022, CMS is resuming the standard sequestration of 2%.

What’s changing

Bill 1868 extended the CMS sequestration suspension through Dec. 31, 2021 due to COVID. Based on current statute, CMS will resume standard sequestration reductions beginning with the January 2022 payment for Medicare Advantage.

What you need to do

There is nothing you need to do. The sequestration will be automatically withheld from your CMS Medicare Advantage payments like it was done prior to COVID-19


2)  November 2021 medical policy updates:

What’s changing

Policy Name  Change to Policy
Autism Spectrum Disorders #91615

Expanding coverage by eliminating age restrictions on Applied Behavioral Analysis (ABA) services

Colorectal Cancer Screening #91547

Expanding Commercial and Medicaid coverage by lowering age for average risk adults to being screening to 45 years old

Platelet Rich Plasma/ Platelet Rich Fibrin Matrix #91553 Expanding coverage due to a  national coverage determination (NCD) 270.3 which allows coverage for platelet rich plasma for chronic non-healing diabetic wounds up to 20 weeks. This was previously limited to coverage with evidence development (CED).
Genetic Counseling Testing Screening #91540

Non-invasive prenatal testing (NIPT) no longer requires prior authorization

Stimulation Therapy Devices #91468 We’re separating out dorsal root ganglion stimulators from spinal cord/dorsal column stimulators.
Breast Related Procedures #91545 Clarified final stage of reconstruction and revision as the achievement of symmetry.
Spine Procedures #91581 Decreasing the list of procedures that will require prior authorization in 2022.
Orthotic Shoe Inserts s#91420 Prior authorization is not required for therapeutic shoes and inserts for Medicare members with diabetes.
Spine Center of Excellence #91531

Policy will retire on Jan. 1, 2022.


3) Continuing extended prior authorizations for elective procedures delayed due to COVID-19

Considering the recent surge in COVID-19 cases in the communities we serve, we’re continuing our prior authorization extension for elective procedures which meet the following criteria: 

  • We approved the prior authorization 
  • The elective procedure was delayed due to the COVID-19 pandemic 
  • The member has continuous enrollment in their plan at the time of service 

It’s important to note that if a member switches to a different plan before the elective procedure, the provider must request prior authorization again