Department of Public Health and Human Services

Montana Healthcare Programs Provider Information » Prior Authorization

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Prior Authorization

Prior Authorization Information

Prior authorization refers to services that require Department authorization before they are performed. Prior authorization has specific requirements. Some services may require both Passport referral and prior authorization. If a service requires prior authorization, the requirement exists for all Medicaid members. Prior authorization is usually obtained through the Department or a prior authorization contractor.

Prior Authorization Criteria for Specific Services

Blepharoplasty

 

Service Prior Auth Contact Documentation Requirements
Blepharoplasty MPQH

Phone
406.457.5887 Local
877.443.4021, X5887 Long‑distance

Fax
406.513.1922 Local
877.443.2580 Long‑distance
Reconstructive blepharoplasty may be covered for:
  • Correct visual impairment caused by drooping of the eyelids (ptosis)
  • Repair defects caused by trauma-ablative surgery (ectropion/ entropion corneal exposure)
  • Treat periorbital sequelae of thyroid disease and nerve palsy
  • Relieve painful symptoms of blepharospasm (uncontrollable blinking).
Documentation must include:
  • Surgeon must document indications for surgery
  • When visual impairment is involved, a reliable source for visual-field charting is recommended
  • Complete eye evaluation
  • Pre-operative photographs
  • Medicaid does not cover cosmetic blepharoplasty

Breast Reconstruction

Service Prior Auth Contact Documentation Requirements
Breast Reconstruction MPQH

Phone
406.457.5887 Local
877.443.4021, X5887 Long‑distance

Fax
406.513.1922 Local
877.443.2580 Long‑distance
May be covered following a medically necessary mastectomy. The number of procedures and timing of these procedures varies, depending on the individualized treatment plan devised by the treating physician(s) and may be impacted by the overall treatment plan for the breast cancer itself.

Covered reconstructive procedures include any or all of the following:
  • Reconstructive surgery and implant insertion.
  • Procedures where muscle tissue is transposed from another site.
  • Reconstruction of the contralateral breast to achieve symmetry with reduction mammoplasty, augmentation mammoplasty with implants, or mastopexy.
Reconstructions revisions are only covered for medically necessary purposes such as infection, painful contracture of Bakers Classification of Grade III or higher, and rupture of silicone gel implants only.

Documentation must include medical records indicating a medically necessary mastectomy was done.

Cochlear Implant

Service Prior Auth Contact Documentation Requirements
Cochlear Implant MPQH

Phone
406.457.5887 Local
877.443.4021, X5887 Long‑distance
Fax
406.513.1922 Local
877.443.2580 Long‑distance
Cochlear implants may be covered for:

Adult Criteria
  • 18 years or older, with bilateral, severe to profound sensorineural hearing loss (i.e., 70dB or greater, pure-tone air (PTA) conduction average at 500, 1000, and 2000 Hz;
  • Have tried but have limited benefit from adequately fitting binaural hearing aids; or
  • Have sentence recognition scores of 50% or less in the ear to be implanted and 60% or less in the contralateral ear in best aided conditions using Hearing in Noise Test (HINT) or City University of New York (CUNY) tests.
Pediatric Criteria
  • 12 months to 17 years of age.
  • Infants age 12-24 months should have bilateral, severe to profound (greater than 70dB) hearing loss.
  • Infants and older children should demonstrate lack of progress in simple auditory skills in conjunction with appropriate auditory amplification and participation in intensive aural habilitation for 3 to 6 months. Less than 0.14520% correct on the Multi-syllabic Lexical Neighborhood Test (MLNT) or Lexical Neighborhood Test (LNT), depending on the child’s cognitive and linguistic abilities.
  • A 3 to 6 month trial of appropriate hearing aids is required. If meningitis is the cause of hearing loss or if there is radiological evidence of cochlear ossification, a shorter hearing aid trial and earlier implantation may be reasonable.
Documentation Must Include
  • A completed Cochlear Implant Compliance Criteria form
  • Hearing tests indicating hearing loss that fits within the above criteria
  • Medical records
Replacements
Components of the Cochlear Implant may be replaced no more than once in a five-year period and only if:
  • The original component has been lost or is irreparably broken after the warranty period;
  • The provider’s records document the loss or broken condition of the original component; or
  • The original component no longer meets the needs of the individual and a new component is determined to be medically necessary by a licensed audiologist.

Dental Orthodontia Services

Durable Medical Equipment (DME)

Service Prior Auth Contact Documentation Requirements
Durable Medical Equipment (DME) MPQH

Phone
406.457.5887 Helena
877.443.4021, X5887 Long‑distance

Fax
406.513.1922 Helena
877.443.2580 Long‑distance
Medical necessity documentation must include all of the following:
  • Completed DMEPOS Prior Authorization Request form
  • Supporting documentation, which must include at a minimum:
    • Prescription
    • Certificate of medical need (if required for the item)
    • Narrative summary from the prescribing authority detailing the need for the item
    • A manufacturers retail price sheet and product warranty information
For members being treated by a licensed therapist, a copy of the member’s plan of care in relation to the item/service is required; video if possible.

Excising Excessive Skin/Subcutaneos Tissue

Service Prior Auth Contact Documentation Requirements
Excising Excessive Skin/Subcutaneous Tissue MPQH

Phone
406.457.5887 Local
877.443.4021, X5887 Long‑distance

Fax
406.513.1922 Local
877.443.2580 Long‑distance
Required documentation includes the following:
  • The referring physician and surgeon must document, in the history and physical, the justification for the resection of skin and fat redundancy following massive weight loss.
  • The duration of symptoms of at least six months and the lack of success of other therapeutic measures. Provide examples of failed treatments.
  • Pre-operative photographs
This procedure is contraindicated for, but not limited to, individuals with the following conditions:
  • Severe cardiovascular disease
  • Severe coagulation disorders
  • Pregnancy
  • Medicaid does not cover cosmetic surgery to reshape the normal structure of the body or to enhance a member’s appearance.

Eye Prosthesis

Service Prior Auth Contact Documentation Requirements
Eye Prosthesis MPQH

Phone
406.457.5887 Local
877.443.4021, X5887 Long‑distance
Fax
406.513.1922 Local
877.443.2580 Long‑distance
  • Documentation that supports medical necessity.
  • Documentation regarding the member’s ability to comply with any required after care.
  • Letters of justification from referring physician.
  • Documentation should be provided at least two weeks prior to the procedure date.

Hearing Aid

Covered Service Prior Authorization Contact Requirements
Hearing Aid and Dispensing Fee Health Policy and Services Division
Medicaid Services Bureau
DPHHS
P.O. Box 202951
Helena, MT 59620-2951

406.444.1861 Fax
Medical necessity documentation must include all of the following:
  • Completed Request for Prior Authorization form.
  • Completed CMN form.
  • Supporting documentation, which must include, at a minimum:
    • A copy of the physician or mid-level practitioner’s referral.
    • An audiogram.
    • A report from the licensed audiologist.
Hearing Aid for Members under 21 Years of Age

 

 

 

 

Maxillofacial /Cranial Surgery

Service Prior Auth Contact Documentation Requirements
Maxillofacial/Cranial Surgery MPQH

Phone
406.457.5887 Local
877.443.4021, X5887 Long‑distance

Fax
406.513.1922 Local
877.443.2580 Long‑distance
Surgical services are only covered when done to restore physical function or to correct physical problems resulting from:
  • Motor vehicle accidents
  • Accidental falls
  • Sports injuries
  • Congenital birth defects
Documentation requirements include a letter from the attending physician documenting:
  • Member’s condition
  • Proposed treatment
  • Reason treatment is medically necessary Medicaid does not cover these services for:
  • Improvement of appearance or self-esteem (cosmetic)
  • Dental implants
  • Orthodontics

Medical Surgical Services

Service Prior Auth Contact Documentation Requirements
Medical Surgical Procedures MPQH

Phone
406.457.5887 Local
877.443.4021, X5887 Long‑distance

Fax
877.443.2580
Required information includes:
  • Member’s name
  • Member’s Medicaid ID number
  • State and hospital where member is going
  • Documentation that supports medical necessity. This varies based on circumstances. MPQH will instruct providers on required documentation on a case-by-case basis.

Mental Health – Children

For information on prior authorization required for youth mental health services, please refer to the CMHB Medicaid Services Provider Manual on the Manuals and Guides webpage.

Other Reviews Referred by Medicaid Program Staff

Service Prior Auth Contact Documentation Requirements
Other Reviews Referred by Medicaid Program Staff MPQH

Phone
406.457.5887 Local
877.443.4021, X5887 Long‑distance

Fax
406.513.1922 Local
877.443.2580 Long‑distance
  • Documentation that supports medical necessity.
  • Documentation regarding the member’s ability to comply with any required after care.
  • Letters of justification from referring physician.
  • Documentation should be provided at least two weeks prior to the procedure date.

Out-of-State Hospital Inpatient Services

Service Prior Auth Contact Documentation Requirements
Out-of-State Hospital Inpatient MPQH

Phone
406.457.5850 Local
800.262.1545, X5850 Long‑distance

Fax
406.513.1922 Local
800.497.8235 Long‑distance
 
Required information includes:
  • Member’s name
  • Member’s Medicaid ID number
  • State and hospital where member is going
  • Documentation that supports medical necessity. This varies based on circumstances. MPQH will instruct providers on required documentation on a case-by-case basis.

Reduction Mammoplasty

Service Prior Auth Contact Documentation Requirements
Reduction Mammoplasty MPQH

Phone
406.457.5887 Helena
877.443.4021, X5887 Long‑distance

Fax
406.513.1922 Local
877.443.2580 Long‑distance
Referring physician and surgeon must submit documentation.

Back pain must have been documented and present for at least 6 months, and causes other than weight of breasts must have been excluded.

Indications for female member
  • Contraindicated for pregnant women and lactating mothers. A member must wait 6 months after the cessation of breast feeding before requesting this procedure.
  • Female member 16 years or older with a body weight less than 1.2 times the ideal weight.
  • There must be severe, documented secondary effects of large breasts, unresponsive to standard medical therapy administered over at least a 6- month period. This must include at least two of the following conditions:
    • Upper back, neck, shoulder pain that has been unresponsive to at least 6 months of documented and supervised physical therapy and strengthening exercises
    • Paresthesia radiating into the arms. If paresthesia is present, a nerve conduction study must be submitted.
    • Chronic intertrigo (a superficial dermatitis) unresponsive to conservative measures such as absorbent material or topical antibiotic therapy. Document extent and duration of dermatological conditions requiring antimicrobial therapy.
    • Significant shoulder grooving unresponsive to conservative management with proper use of appropriate foundation garments which spread the tension of the support and lift function evenly over the shoulder, neck, and upper back.
Documentation in the member’s record must indicate/support:
  • History of the member’s symptoms related to large, pendulous breasts.
  • The duration of the symptoms of at least 6 months and the lack of success of other therapeutic measures (e.g., documented weight loss programs with six months of food and calorie intake diary, medications for back/neck pain).
  • Guidelines for the anticipated weight of breast tissue removed from each breast related to the member’s height (must be documented):
Height Weight of tissue per breast
 < 5' 250 grams
 5  – 5'2" 350 grams
 5' 2" – 5' 4" 450 grams
 > 5'4" 500 grams
  • Preoperative photographs of the pectoral girdle showing changes related to macromastia.
  • Medication use history. Breast enlargements may be caused by various medications (e.g., sironolactone, cimetidine) or illicit drug abuse (e.g., marijuana, heroin, steroids). Although rare in women, drug effects should be considered as causes of breast enlargement prior to surgical treatment since the problem may recur after the surgery if the drugs are continued. Increased prolactin levels can cause breast enlargement (rare). Liver disease or adrenal or pituitary tumors may also cause breast enlargement and should also be considered prior to surgery if the drugs are continued. Increased prolactin levels can cause breast enlargement (rare). Liver disease and adrenal or pituitary tumors may also cause breast enlargement and should also be considered prior to surgery.
Indications for male member:
  • If the condition persists, a member may be considered a good candidate for surgery. Members who are alcoholic, illicit drug abusers (ex: steroids, heroin, marijuana) or overweight are not good candidates for the reduction procedure until they attempt to correct their medical problem first.
  • Documentation required: length of time gynecomastia has been present, height, weight, and age of the member, preoperative photographs.

Rehabilitation Services, All

Service Prior Auth Contact Documentation Requirements
Rehabilitation Services, All MPQH

Phone
406.457.5850  Local
800.262.1545, X5850 Long‑distance


Fax
406.513.1922 Local
800.497.8235 Long‑distance
Required information includes:
  • Member’s name
  • Member’s Medicaid ID number
  • State and hospital where member is going
  • Documentation that supports medical necessity. This varies based on circumstances. MPQH will instruct providers on required documentation on a case-by-case basis.

Rhinoplasty Septorhinoplasty

Service Prior Auth Contact Documentation Requirements
Rhinoplasty Septorhinoplasty MPQH

Phone
406.457.5887 Local
877.443.4021, X5887 Long‑distance

Fax
406.513.1922 Local
877.443.2580 Long‑distance
The following do not require prior authorization:
  • Septoplasty to repair deviated septum and reduce nasal obstruction
  • Surgical repair of vestibular stenosis to repair collapsed internal valves to treat nasal airway obstruction
Medicaid covers rhinoplasty in the following circumstances:
  • To repair nasal deformity caused by a cleft lip/cleft palate deformity for members 18 years of age and younger
  • Following a trauma (e.g. a crushing injury) which displaced nasal structures so that it causes nasal airway obstruction.
Documentation requirements include a letter from the attending physician documenting:
  • Member’s condition
  • Proposed treatment
  • Reason treatment is medically necessary Not covered
  • Cosmetic rhinoplasty done alone or in combination with a septoplasty
  • Septoplasty to treat snoring

Temporomandibular Joint (TMJ) Arthroscopy Surgery

Service Prior Auth Contact Documentation Requirements
Temporomandibular Joint (TMJ) Arthroscopy/Surgery MPQH

Phone
406.457.5887 Helena
877.443.4021, X5887 Long‑distance

Fax
406.513.1922 Local
877.443.2580 Long‑distance
Nonsurgical treatment for TMJ disorders must be utilized first to restore comfort, and improve jaw function to an acceptable level. Non-surgical treatment may include the following in any combination depending on the case:
  • Fabrication and insertion of an intra-oral orthotic
  • Physical therapy treatments
  • Adjunctive medication
  • Stress management
Surgical treatment may be considered when both of the following apply:
  • Other conservative treatments have failed (must be documented), and chronic jaw pain and dysfunction have become disabling.  Conservative treatments must be utilized for six months before consideration of surgery.
  • There are specific, severe structural problems in the jaw joint. These include problems that are caused by birth defects, certain forms of internal derangement caused by misshapen discs, or degenerative joint disease. For surgical consideration, arthrogram results must be submitted for review.
Not covered:
  • Botox injections for the treatment of TMJ is considered experimental.
  • Orthodontics to alter the bite
  • Crown and bridge work to balance the bite
  • Bite (occlusal) adjustments

Transplant Services, All

Service Prior Auth Contact Documentation Requirements
Transplant Services, All MPQH

Phone
406.457.5850 Local
800.262.1545, X5850 Long‑distance

Fax
406.513.1922 Local
800.497.8235 Long‑distance

 

Required information includes:
  • Member’s name
  • Member’s Medicaid ID number
  • State and hospital where member is going
  • Documentation that supports medical necessity. This varies based on circumstances. MPQH will instruct providers on required documentation on a case-by-case basis.

 

Transportation Services

Service Prior Auth Contact Documentation Requirements
Transportation MPQH

Phone
406.457.5850 Local
800.262.1545, X5850 Long‑distance

Fax
406.513.1922 Local
800.497.8235 Long‑distance

 

Required information includes:
  • Member’s name
  • Member’s Medicaid ID number
  • State and hospital where member is going
  • Documentation that supports medical necessity. This varies based on circumstances. MPQH will instruct providers on required documentation on a case-by-case basis.