Prior Authorization Information

Artificial Disc Replacement

Criteria

Cervical

• 18-60 years of age
• Patient is skeletally mature
• Disk FDA approved
• Failure of at least six months conservative treatment (pain management, physical therapy, etc. unless patient is experiencing progressive neurological worsening despite non operative treatment)
• No previous surgical intervention at the involved level or planned procedures at adjacent levels
• Diagnosis of degenerative disc  disease or disc herniation at one level between C3-C7confirmed by patient history; and
• MRI or CT scan with confirmation of degenerative disc disease with severe spinal stenosis, cord compression, or nerve root compression and 1 or more of the following:
  • Herniated disc
  • Spondylosis, defined as the presence of osteophytes
  • Patient suffers from neck pain of discogenic origin or radiculopathy that has not responded to conservative treatment

Lumbar

• 18-60 years of age
• Disk FDA approved
• Patient is skeletally mature
• Diagnosis of degenerative disc disease at only one level confirmed by patient history and radiographic studies
• Disk replacement is planned for one level
• No more than Grade 1 spondylolisthesis at the involved level
• Patient suffers from low back pain that has not responded to at least 6 months of conservative treatment
• Patient is candidate for spine surgery (such as fusion)
• No prior lumbar spinal fusion

Prior Authorization Contact

MPQH

Phone
(406) 457-3060 Local
(877) 443-4021  Long‑distance

Fax
(406) 513-1923 Local
(877) 443-2580 Long‑distance

Blepharoplasty

Documentation Requirements:

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 blepharoplast

Prior Authorization Contact:

MPQH Call Center:
(406) 443-0320 (Helena) or
(800) 219-7035 (Toll Free)
 

Genetic Testing for BRCA-Related Cancer

Criteria

BRCA screening is allowed in the following instances:
•    Members is over the age of 18; and
•    Have at least one of the following criteria:

o    Personal history of any of the following:

 ♦    Breast cancer diagnosis at or before age 45.
 ♦    Breast cancer diagnosis at or before age 50 with any of the following:
 ♦    An additional breast cancer primary;
      •    1 or more close blood relative with breast cancer at any age;
      •    1 or more close blood relative with pancreatic cancer;
      •    1 or more close blood relative with prostate cancer with a Gleason score ≥7.

 ♦   Breast cancer diagnosis at or before age 60 with:
       •    Triple negative breast cancer.
 ♦    Breast cancer diagnosis at any age with any of the following:
       •    1 or more close relatives with breast cancer diagnosed before age 50;
       •    2 or more close blood relatives with breast cancer diagnosis at any age;
       •    1 or more close blood relative with ovarian cancer diagnosis;
       •    2 or more close blood relatives with pancreatic cancer diagnosis or prostate cancer diagnosis with a Gleason score ≥7;
       •    1 or more close blood relative diagnosed with male breast cancer.
 ♦     Male breast cancer diagnosis at any age.
 ♦     Ovarian cancer diagnosis at any age.
 ♦     Fallopian tube cancer diagnosis at any age.
 ♦     Primary peritoneal cancer diagnosis at any age.
 ♦     Prostate cancer diagnosis with a Gleason score  7 at any age with any of the following:
       •    1 or more close blood relative with ovarian cancer at any age;
       •    1 or more close blood relative with breast cancer before age 50;
       •    2 or more close blood relatives with breast,pancreatic, or prostate cancer (Gleason score  ≥7) at any age.
 ♦     Pancreatic cancer diagnosis at any age with any of the following:
       •    Ashkenazi Jewish ancestry;
       •    1 or more close blood relative with ovarian cancer at any age;
       •    1 or more close blood relative with breast cancer before age SO;
       •    2 or more close blood relatives with breast,pancreatic,or prostate cancer (Gleason score ≥7) at any age.

o    Family history of any of the following:
 

 ♦     First or second degree blood relative who meet any of the above criteria.
 ♦     Third degree blood relative who has breast cancer and/or ovarian cancer and who has 2 or more close blood relatives with breast cancer (at least one with breast cancer before age SO) and/or ovarian cancer.
 ♦     1 or more family member with a known potentially harmful mutation In the BRCAl or BRCA2 gene.

*Close blood relative includes first, second,and third degree relatives on the same side of the family.

**Breast cancer diagnosis includes invasive and ductal carcinoma in situ.

Prior Authorization Contact

MPQH Call Center:
(406) 443-0320 (Helena) or
(800) 219-7035 (Toll Free)
 

Breast Reconstruction

Criteria for Breast Reconstruction rev. 03/21/2018
 

Prior Authorization Contact

MPQH Call Center:
(406) 443-0320 (Helena) or
(800) 219-7035 (Toll Free)

Cochlear Implants

Documentation Requirements

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

Prior Authorization Contact

MPQH Call Center:
(406) 443-0320 (Helena) or
(800) 219-7035 (Toll Free)

See the Dental HLD Index and Prior Authorization Treatment Plan. 09.2013

Durable Medical Equipment (DME)

Documentation Requirements

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.

Prior Authorization Contact

MPQH Call Center:
(406) 443-0320 (Helena) or
(800) 219-7035 (Toll Free)

Eye Prosthesis

Documentation Requirements

• 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.

Prior Authorization Contact

MPQH Call Center:
(406) 443-0320 (Helena) or
(800) 219-7035 (Toll Free)

Hearing Aid and Dispensing Fee for Both Adults and Members Under 21 Years of Age

Document Requirements

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.

Prior Authorization Contact

Health Policy and Services Division
Medicaid Services Bureau
DPHHS
P.O. Box 202951
Helena, MT 59620-2951

(406) 444-1861 Fax

Home Infusion Therapy Prior Authorization Request Form 11/2017

Maxillofacial/Cranial Surgery

Document Requirements

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

Prior Authorization Contact

MPQH Call Center:
(406) 443-0320 (Helena) or
(800) 219-7035 (Toll Free)

Medical Surgical Procedures

Documentation Requirements

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.

Prior Authorization Contact

MPQH Call Center:

(406) 443-0320 (Helena) or

(800) 219-7035 (Toll Free)

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.

Orthognathic Surgery

Other Reviews Referred by Medicaid Program Staff

Documentation Requirements

• 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.

Prior Authorization Contacts

MPQH Call Center:
(406) 443-0320 (Helena) or
(800) 219-7035 (Toll Free)

Out-of-State Hospital Inpatient

Documentation Requirements

Prior Authorization Request - Out of State Inpatient Admissions Form 

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.

Prior Authorization Contact

MPQH Call Center:
(406) 443-0320 (Helena) or
(800) 219-7035 (Toll Free)

Excising Excessive Skin/Subcutaneous Tissue (Panniculectomy) Criteria June 2018

Pharmacy Preferred Drug Information can be found here: 19 (mt.gov)

Prior Authorization Criteria and required forms can be found here:
Mountain-Pacific Quality Health – Medicaid Pharmacy (mpqhf.org)

 Instructions for Physician Administered Drug Prior Authorization:

1. Please check posted criteria before submitting a prior authorization request. See below for list of drugs requiring prior authorization. Criteria can be found at Mountain-Pacific Quality Health – Medicaid Pharmacy (mpqhf.org). Make sure preferred drugs have been tried first and that there is documentation supporting this.
2. Physician Administered Drug Prior Authorization requests must be submitted through the Qualitrac Portal at the following link: https://www.mpqhf.org/corporate/medicaid-portal-home/medicaid-portal-document-library/ 
3. For questions, please contact Mountain-Pacific Quality Health Call Center:
   (406) 443-0320 (Helena) or
   (800) 219-7035 (Toll Free)

Reminders: 

• Montana Medicaid does not reimburse for convenience, off label or experimental use of drugs, per Administrative Rules of Montana (ARM) 37.85.207. 
• In general, drugs billed with unlisted codes require prior authorization from the State.
• NDC must be rebateable.

Drugs with specific criteria sets:

Reduction Mammoplasty

Documentation Requirements

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):

• 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.

Prior Authorization Contact

MPQH Call Center:
(406) 443-0320 (Helena) or
(800) 219-7035 (Toll Free)

Rehabilitation Services

Montana Medicaid requires prior authorization for pulmonary and cardiac rehabilitation and for out-of-state inpatient rehabilitation. 

Documentation Requirements

Required information includes:

• Member’s name
• Member’s Medicaid ID number
• State and hospital where member is going (for inpatient rehabilitation services)
• Documentation that supports medical necessity. This varies based on circumstances. MPQH will instruct providers on required documentation on a case-by-case basis.

Prior Authorization Contact

MPQH Call Center:
(406) 443-0320 (Helena) or
(800) 219-7035 (Toll Free)

Rhinoplasty Septorhinoplasty

Documentation Requirements

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.

Medicaid does not cover rhinoplasty or septoplasty in the following circumstances:

•  Cosmetic rhinoplasty done alone or in combination with a septoplasty
•  Septoplasty to treat snoring

Documentation requirements include a letter from the attending physician documenting:

• Member’s condition
• Proposed treatment
• Reason treatment is medically necessary 

Prior Authorization Contact

MPQH Call Center:
(406) 443-0320 (Helena) or
(800) 219-7035 (Toll Free)

Temporomandibular Joint (TMJ) Arthroscopy/Surgery

Documentation Requirements

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

Prior Authorization Contact

MPQH Call Center:
(406) 443-0320 (Helena) or
(800) 219-7035 (Toll Free)

Transplant Services, All

Documentation Requirements

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.

Prior Authorization Contact

MPQH Call Center:
(406) 443-0320 (Helena) or
(800) 219-7035 (Toll Free)

Transportation Services

Documentation Requirements

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.

Prior Authorization Contact

MPQH

Phone
Local
(406) 457-5850 
(800) 292-7114

Fax
Local
(406) 443-0684
Long-distance
(800) 291-7791