Provider notices
The following letters contain updated Kaiser Permanente policy information or clinical reminders. Letters are in a print-friendly PDF format and will be available for two years. Please refer to the table below for a complete list of our networks.
HMO | PPO | POS | Medicare Advantage | Self-Funded |
Core | Access PPO *Mirrors Core HMO | Options | Medicare Advantage HMO Individual | Microsoft |
Production Date: April 22, 2024
Changes to medical necessity review criteria for fecal gi infusion for the treatment of c. Difficile infection (PDF)
Applies to: Commercial - HMO, POS, PPO, Medicare Advantage.
Effective August 1, 2024, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are retiring the criteria for Fecal GI Infusion for the Treatment of C. Difficile Infection.
Production Date: April 22, 2024
Changes to medical necessity review criteria for capsule endoscopy (PDF)
Applies to: Commercial - HMO, POS, PPO.
Effective August 1, 2024, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the clinical review criteria for Capsule Endoscopy.
Production Date: April 22, 2024
Changes to medical necessity review criteria for treatments for urinary incontinence (PDF)
Applies to: Commercial - HMO, POS, PPO, Medicare Advantage.
Effective August 1, 2024, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the criteria for Treatments for Urinary Incontinence.
Production Date: April 22, 2024
Changes to medical necessity review criteria for treatments for renal sympathetic nerve ablation (PDF)
Applies to: Commercial - HMO, POS, PPO, Medicare Advantage.
Effective August 1, 2024, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the criteria for Renal Sympathetic Nerve Ablation.
Production Date: April 22, 2024
Changes to medical necessity review criteria for treatments for infrared thermography (PDF)
Applies to: Commercial - HMO, POS, PPO.
Effective August 1, 2024, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the criteria for Infrared Thermography.
Production Date: April 22, 2024
Changes to medical necessity review criteria for transcranial magnetic stimulation (PDF)
Applies to: Commercial - HMO, POS, PPO.
Effective August 1, 2024, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the clinical review criteria for Transcranial Magnetic Stimulation (TMS).
Production Date: April 22, 2024
Changes to medical necessity review criteria for treatments for chelation therapy (PDF)
Applies to: Commercial - HMO, POS, PPO.
Effective August 1, 2024, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the criteria for Chelation Therapy.
Production Date: March 20, 2024
Changes to medical necessity review criteria for PET scans (PDF)
Applies to: Commercial - HMO, POS, PPO.
Effective July 1, 2024, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating clinical criteria for PET Scans.
Production Date: March 20, 2024
Changes to medical necessity review criteria for genetic screening and testing (PDF)
Applies to: Commercial - HMO, POS, PPO.
Effective July 1, 2024, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the Genetic Screening and Testing Criteria.
Production Date: March 7, 2024
Change in the method we will provide 60-day notices (PDF)
Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) is excited to share with you that we have improved our 60-day notice process for communicating upcoming changes that affect medical review criteria, pharmacy criteria and payment policies in the provider manual.
Changes to medical necessity review criteria for Apolipoprotein E (APOE) genotyping (PDF)
Applies to: Commercial - HMO, POS, PPO, Medicare Advantgage
Effective June 1, 2024, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) will implement clinical review criteria for Apolipoprotein E (APOE) Genotyping.
Changes to medical necessity review criteria for hypoglossal nerve stimulation (PDF)
Applies to: Commercial - HMO, POS, PPO
Effective June 1, 2024, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) is implementing clinical criteria for Implantable Hypoglossal Nerve Stimulation Device and the Durg-Induced Sleep Endoscopy (DISE) procedure when being requested for evaluation of Hypoglossal Nerve Stimulation Device.
Changes to medical necessity review criteria for pneumatic compression devices (PDF)
Applies to: Commercial - HMO, POS, PPO
Effective June 1, 2024, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating clinical criteria for Pneumatic Compression Devices.
Changes to medical necessity review criteria for ultrasonic bone growth stimulators (PDF)
Applies to: Commercial - HMO, POS, PPO
Effective June 1, 2024, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating clinical review criteria for Ultrasonic Bone Growth Stimulators.
Changes to medical necessity review criteria for intraosseous basivertebral nerve ablation (PDF)
Applies to: Medicare Advantage
Effective January 28, 2024, Kaiser Foundation Health Plan of Washington (Kaiser Permanente) will review requests for Intraosseous Basivertebral Nerve Ablation using CMS criteria.
Oncology products updated prior authorization criteria (PDF)
Effective June 1, 2024, the criteria for the oncology products listed in Table 1 will be updated to include quantity limits. These products are on or will be added to the non-Medicare list of office-administered drugs requiring prior authorization. This letter is a notification of the upcoming change in prior authorization criteria required before administering this medication in a physician’s office.
Enzyme replacement therapies updated prior authorization criteria (PDF)
Effective June 1, 2024, the criteria for the medical genetics listed in Table 1 will be updated to include quantity limits. These products are on or will be added to the non-Medicare list of office-administered drugs requiring prior authorization. This letter is a notification of the upcoming change in prior authorization criteria required before administering this medication in a physician’s office.
Golimumab (Simponi Aria) updated prior authorization criteria (PDF)
Golimumab (Simponi Aria) is on the non-Medicare list of office-administered drugs requiring prior authorization.
Effective June 1, 2024, the criteria for golimumab (Simponi Aria) will expand to include a quantity limit for psoriatic arthritis (PsA) and ankylosing spondylitis (AS) indications. This letter is a notification of the change in prior authorization criteria required before administering this medication under the medical benefit.
Medicare part B drugs requiring prior authorization (PDF)
Effective June 1, 2024, prior authorization will be required for the Medicare Part B drugs listed in Table 1. This letter is a notification of the upcoming change in prior authorization review required before administering these medications under the medical benefit.
Medicare part B drugs requiring step therapy (PDF)
Effective June 1, 2024, step therapy will be required for the non-preferred Medicare Part B drugs listed in Table 1. This letter is a notification of the upcoming change in step therapy approval required before administering these medications under the medical benefit.
Changes to medical necessity review criteria for home pulse oximetry and continuous passive motion (CPM) (PDF)
Effective May 1, 2024, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) is updating its payment methodology for home pulse oximetry and continuous passive motion (CPM), non-knee.
Modification to Notice: The "Is prior authorization required?" listing for KFHPWAO Preferred Provider Organization (PPO) members has changed to "Prior authorization is required."
Changes to medical necessity review criteria for MRI Brain & MRI Cervical (PDF)
Applies to: Commercial – HMO, POS, PPO
Effective May 1, 2024, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) is updating indications for Brain and Cervical MRIs for non-Medicare members
Changes to medical necessity review criteria for MRI Brain & MRI Cervical (PDF)
Applies to: Commercial – HMO, POS, PPO
Effective May 1, 2024, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) is updating indications for Brain and Cervical MRIs for non-Medicare members.
The following neurology medications not covered under the medical benefit (PDF)
Effective April 1, 2024, the medications listed in Table 1 will NOT be covered under the medical benefit. This letter is a notification of the upcoming change in coverage for these medications under the medical benefit. Pharmacy benefit coverage remains available for members who meet prior authorization criteria.
Guselkumab (Tremfya) not covered under the medical benefit (PDF)
Effective April 1, 2024, Guselkumab (Tremfya) will NOT be covered under the medical benefit. This letter is a notification of the upcoming change in coverage for this medication under the medical benefit. Pharmacy benefit coverage remains available for members who meet prior authorization criteria.
Teriparatide (Forteo) not covered under the medical benefit (PDF)
Effective April 1, 2024, Teriparatide (Forteo) will NOT be covered under the medical benefit. This letter is a notification of the upcoming change in coverage for this medication under the medical benefit. Pharmacy benefit coverage remains available for members who meet prior authorization criteria.
Applies to: Commercial – HMO, POS, PPO
Effective April 1, 2024, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) is updating indications for Applied Behavioral Analysis therapy (ABA).
Changes to medical necessity review criteria for elective cardiac defibrillator and pacemaker placements (PDF)
Applies to: Commercial – HMO, POS, PPO, Medicare Advantage
Effective April 1, 2024, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) is adding prior authorization and clinical review criteria for cardiac defibrillator and pacemaker placements.
Prolonged service add-on codes (PDF)
Applies to: Commercial – HMO, POS, PPO, Medicare Advantage
Effective March 1, 2024, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) will not reimburse E/M add-on CPT/HCPCS codes for Prolonged Services unless medical records support the time billed.
Behavioral health add-on codes (PDF)
Applies to: Commercial – HMO, POS, PPO, Medicare Advantage
Effective March 1, 2024, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) will not reimburse E/M add-on CPT codes 90833, 90836 and 90838 unless medical records support the time billed.
Changes to medical necessity review criteria for chromoendoscopy (PDF)
Applies to: Commercial – HMO, POS, PPO, Medicare Advantage
Effective March 1, 2024, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) is updating the clinical review criteria for Chromoendoscopy.
Changes to medical necessity review criteria for office-based methadone treatment (PDF)
Applies to: Commercial – HMO, POS, PPO, Medicare Advantage
Effective March 1, 2024, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) is updating its Substance Use Disorder-General criteria.
Changes to medical necessity review criteria for mri cervical, thoracic and lumbar (PDF)
Applies to: Commercial – HMO, POS, PPO
Effective March 1, 2024, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating MRI Cervical, Thoracic, and Lumbar criteria.
Oncology products updated prior authorization criteria (PDF)
Effective March 1, 2024, the criteria for the oncology products listed in Table 1 will be updated. These products are on or will be added to the non-Medicare list of office-administered drugs requiring prior authorization. This letter is a notification of the upcoming change in prior authorization criteria required before administering this medication in a physician’s office.
Pegcetacoplan (syfovre) updated prior authorization criteria (PDF)
Pegcetacoplan (Syfovre) is on the non-Medicare list of office-administered drugs requiring prior authorization.
Effective March 1, 2024, the criteria for pegcetacoplan (Syfovre) will be updated to include a quantity limit. This letter is a notification of the change in prior authorization criteria required before administering this medication under the medical benefit.
Pasireotide (signifor lar) will require prior authorization approval (PDF)
Effective March 1, 2024, pasireotide (Signifor LAR) will be added to the non-Medicare list of office administered drugs requiring prior authorization. This letter is a notification of the upcoming change in prior authorization criteria required before administering this medication under the medical benefit.
Updated prior authorization criteria for Ranibizumab (Lucentis) (PDF)
Ranibizumab (Lucentis) is on the non-Medicare list of office-administered drugs requiring prior authorization.
Effective March 1, 2024, the criteria ranibizumab (Lucentis) will be updated to reflect the preferred biosimilar, ranibizumab-nuna (Byooviz). This change does not affect current authorizations for Lucentis; however, any new authorization is subject to the criteria below. This letter is a notification of the change in prior authorization criteria required before administering this medication under the medical benefit.
Medicare Part B drugs requiring prior authorization (PDF)
Effective March 1, 2024, prior authorization will be required for the Medicare Part B drugs listed in Table 1. This letter is a notification of the upcoming change in prior authorization review required before administering these medications under the medical benefit.
Medicare Part B drugs requiring step therapy (PDF)
Effective March 1, 2024, step therapy will be required for the non-preferred Medicare Part B drugs listed in Table 1. This letter is a notification of the upcoming change in step therapy approval required before administering these medications under the medical benefit.
Changes to medical necessity review criteria for Myocardial Perfusion Imaging (MPI) (PDF)
Applies to: Commercial – HMO, POS, PPO, Medicare Advantage.
Effective February 1, 2024, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) is updating indications for exercise nuclear stress test and pharmacologic nuclear stress test for non-Medicare criteria and updating the review requirement for Medicare Advantage members.
Changes to medical necessity review criteria for prescription hearing aids (PDF)
Applies to: Commercial – HMO, POS, PPO, Medicare Advantage.
Effective February 1, 2024, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) will implement clinical review criteria for prescription hearing aids.
Changes to medical necessity review criteria for breast cancer index (PDF)
Applies to: Commercial – HMO, POS, PPO.
Effective February 1, 2024, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) will implement clinical review criteria for the Breast Cancer Index (BCI) test (CPT 81518).
Changes to medical necessity review criteria for sinus surgery (PDF)
Applies to: Commercial – HMO, POS, PPO, Medicare Advantage.
Effective February 1, 2024, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) is implementing clinical review requirements for sinus surgery to include functional endoscopic sinus surgery (FESS) and Sinuplasty.
Changes to medical necessity review criteria for Clarifix® (PDF)
Applies to: Commercial – HMO, POS, PPO, Medicare Advantage.
Effective February 1, 2024, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) is updating the former Clarifix® criteria page title to Nasal Cryoablation, Radiofrequency Ablation & Laser Treatments.
Changes to medical necessity review criteria for Endobronchial Ultrasound (PDF)
Applies to: Commercial – HMO, POS, PPO, Medicare Advantage.
Effective February 1, 2024, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) will implement clinical criteria for Endobronchial Ultrasound.
Changes to medical necessity review criteria for brain mapping (PDF)
Applies to: Commercial – HMO, POS, PPO, Medicare Advantage.
Effective February 1, 2024, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) has updated the neurobiofeedback and brain mapping clinical criteria.
Sinuplasty billed with functional endoscopic sinus surgery (FESS) (PDF)
This notification applies to the following networks: Commercial HMO, POS, PPO, and Medicare Advantage.
Effective February 1, 2024, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) will not separately reimburse for sinuplasty when billed with a Functional Endoscopic Sinus Surgery (FESS) procedure for the same member on the same date of service by the same provider.
ICD-10 cm diagnosis code combinations (PDF)
This notification applies to the following networks: Commercial HMO, POS, PPO, and Medicare Advantage.
Effective February 1, 2024, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) will not separately reimburse services billed with diagnosis codes that are mutually exclusive when billed for the same member by the same provider on the same date of service.
Changes to medical necessity review criteria for fractional flow reserve (FFR) (PDF)
This notification applies to the following networks: Commercial HMO, POS, PPO, and Medicare Advantage.
Effective January 1, 2024, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) is adding medical necessity review criteria for Fractional Flow Reserve (FFR).
Changes to medical necessity review criteria for lumbar and cervical MRI (PDF)
This notification applies to the following networks: Commercial HMO, POS, PPO.
Effective January 1, 2024, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) is updating the lumbar and cervical spine MRI medical necessity review criteria.
Changes to medical necessity review criteria for bariatric surgery (PDF)
This notification applies to the following networks: Commercial HMO, POS, PPO.
Effective January 1, 2024, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) is updating the medical necessity criteria for bariatric surgery.
Changes to medical necessity review criteria for continuous glucose monitors (PDF)
This notification applies to the following networks: Commercial HMO, POS, PPO.
Effective January 1, 2024, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) is updating the medical necessity criteria for continuous glucose monitors (CGM).
Changes to medical necessity review criteria for transition of care (PDF)
This notification applies to the following networks: Medicare Advantage.
Effective January 1, 2024, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) is updating the Transition of Care criteria.
Coreselect network discontinuation notice (PDF)
Effective January 1, 2024, Kaiser Foundation Health Plan of Washington will discontinue the HMO commercial network CORESELECT.
Reason for the discontinuation: Streamlining the number of networks will better support our members and provider groups.
Ixekizumab (taltz) will require prior authorization approval (PDF)
Effective December 1, 2023, Ixekizumab (Taltz) will be added to the non-Medicare list of office-administered drugs requiring prior authorization. This letter is a notification of the upcoming change in prior authorization criteria required before administering this medication under the medical benefit.
Cabotegravir extended release (apretude) will require prior authorization approval (PDF)
Effective December 1, 2023, Cabotegravir Extended Release (Apretude) will be added to the non-Medicare list of office administered drugs requiring prior authorization. This letter is a notification of the upcoming change in prior authorization criteria required before administering this medication under the medical benefit.
The following medications not covered under the medical benefit: adalimumab (humira), adalimumab-atto (amjevita), and etanercept (enbrel, enbrel mini) (PDF)
Effective December 1, 2023, the medications listed in Table 1 will NOT be covered under the medical benefit. This letter is a notification of the upcoming change in coverage for this medication under the medical benefit. Pharmacy benefit coverage remains available for members who meet prior authorization criteria.
New medically necessary services clinical review criteria (PDF)
Clarification regarding new medically necessary services clinical review criteria (PDF)
This notification applies to the following networks: Commercial HMO, POS, PPO, and Medicare Advantage.
Effective December 1, 2023, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) is developing general medical necessity criteria.
Modification to Notice: The prior authorization requirement for hospital grade breast pumps is also being removed. Effective date remains the same.
Changes to medical necessity review criteria breast pump (PDF)
This notification applies to the following networks: Commercial HMO, POS, PPO and Medicare Advantage.
Effective December 1, 2023, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) is removing prior authorization and clinical review requirement for hospital grade breast pumps.
Emergency department (ED) professional claim coding (PDF)
This notification applies to the following networks: Commercial HMO, POS, PPO, and Medicare Advantage.
Effective December 1, 2023, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) will reimburse emergency department claims based on the level of acuity, complexity, and severity.
Multiple procedure payment reduction (MPPR) (professional claims) (PDF)
This notification applies to the following networks: Commercial HMO, POS, PPO, and Medicare Advantage.
Effective December 1, 2023, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) will apply Multiple Procedure Payment Reduction on professional claims when billed with a CPT/HCPCS code that has a multiple procedure code indicator of 2.
Short stay / 2 midnight rule (PDF)
This notification applies to the following networks: Commercial HMO, POS, PPO, and Medicare Advantage.
Effective December 1, 2023, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) will reimburse a provider for an inpatient admission if the medical records support inpatient admission and if, at the time of or before admission, the admitting physician reasonably expects the patient’s hospital care would cross two midnights.
Unspecfied ICD-10 cm diagnosis codes (PDF)
This notification applies to the following networks: Commercial HMO, POS, PPO, and Medicare Advantage.
Effective December 1, 2023, when benefits allow, Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) will reimburse unspecified diagnosis codes when services are medically necessary, a more specific code cannot be utilized, and the level of billing is supported by the documentation.
Changes to medical necessity review criteria for Negative Pressure Wound Therapy (PDF)
This notification applies to the following networks: Commercial HMO, POS, PPO.
Effective December 1, 2023, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) is updating the Negative Pressure Wound Therapy clinical criteria for the indication of Single Use/Disposable-Negative Pressure Wound Therapy for prevention of surgical site infections.
Changes to medical necessity review criteria for High End Imaging Site of Care (PDF)
This notification applies to the following networks: Commercial HMO, POS, PPO.
Effective December 1, 2023, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) is updating clinical criteria for High End Imaging Site of Care.
Changes to medical necessity review criteria Elective Surgical Procedures Level of Care (PDF)
This notification applies to the following networks: Commercial HMO, POS, PPO, and Medicare.
Effective December 1, 2023, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) is updating the Elective Surgical Procedures-Level of Care policy.
Changes to medical necessity review criteria for Fertility Services (PDF)
This notification applies to the following networks: Commercial HMO, POS, PPO.
Effective November 1, 2023, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are changing the name of Infertility Criteria to Fertility Services Criteria and are updating clinical review criteria.
Changes to medical necessity review criteria for gender affirming surgeries (PDF)
This notification applies to the following networks: Commercial HMO, POS, PPO and Medicare Advantage.
Effective November 1, 2023, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating clinical review criteria for gender affirming surgeries.
Changes to medical necessity review criteria for Epidural Steroid Injections (ESI) (PDF)
This notification applies to the following networks: Commercial HMO, POS, PPO.
Effective November 1, 2023, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, (Kaiser Permanente) are updating clinical review criteria for Epidural Steroid Injections (ESI).
Changes to medical necessity review criteria for Breast MRI (PDF)
This notification applies to the following networks: Commercial HMO, POS, PPO and Medicare Advantage.
Effective November 1, 2023, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating clinical review criteria for Breast MRI.
Changes to medical necessity review criteria for Neonatal Intensive Care Unit (NICU) Level of Care Admissions (PDF)
This notification applies to the following networks: Commercial HMO, POS, PPO.
Effective November 1, 2023, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) is retiring the level of care criteria for NICU admissions.
Changes to medical necessity review criteria for Ambulatory Surgery Center (ASC) - site of care policy (PDF)
This notification applies to the following networks: Commercial HMO, POS, PPO.
Effective October 1, 2023, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) is expanding site of care review criteria for certain elective surgical procedures for non-Medicare members when being requested at a hospital setting.
Modifiers (PDF)
This notification applies to the following networks: Commercial HMO, POS, PPO, and Medicare Advantage.
Effective October 1, 2023, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) will not reimburse claims billed with modifier 50 when the CMS bilateral indicators are zero (0), two (2), or nine (9).
Code Editing (PDF)
This notification applies to the following networks: Commercial HMO, POS, PPO and Medicare Advantage.
Effective October 1, 2023, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) will not reimburse the following:
Changes to medical necessity review criteria for Monitored Anesthesia Care (MAC) for gastrointestinal endoscopic procedures (PDF)
This notification applies to the following networks: Commercial HMO, POS, PPO
Effective September 1, 2023, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the clinical review criteria for Monitored Anesthesia Care.
Explanation of the change:
Kaiser Permanente is removing the prior authorization and medical necessity review requirement for Monitored Anesthesia Care.
Changes to medical necessity review criteria for Bone Anchored Hearing System (PDF)
This notification applies to the following networks: Commercial HMO, POS, PPO, and Medicare Advantage.
Effective September 1, 2023, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the clinical review criteria for Bone Anchored Hearing System for non-Medicare members.
Changes to medical necessity review criteria for Cervical Spine MRI (PDF)
This notification applies to the following networks: Commercial HMO, POS, and PPO.
Effective September 1, 2023, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the Cervical Spine MRI Criteria.
Changes to medical necessity review criteria for Lumbar Spine MRI (PDF)
This notification applies to the following networks: Commercial HMO, POS, and PPO.
Effective September 1, 2023, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the Lumbar Spine MRI Criteria.
Changes to medical necessity review criteria for Thoracic Spine MRI (PDF)
This notification applies to the following networks: Commercial HMO, POS, and PPO.
Effective September 1, 2023, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the Thoracic Spine MRI Criteria.
Changes to medical necessity review criteria for Epidural Steroid Injections (ESI) (PDF)
This notification applies to the following networks: Commercial HMO, POS, PPO, and Medicare Advantage.
Effective August 1, 2023, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) will implement clinical review criteria for Epidural Steroid Injections (ESI) for Medicare and non-Medicare members.
Changes to medical necessity review criteria for Facet Neurotomy (PDF)
This notification applies to the following networks: Commercial HMO, POS, and PPO.
Effective August 1, 2023, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) have revised the clinical review criteria for Facet Neurotomy for non-Medicare members.
Changes to medical necessity review criteria for Facet Joint Injections (PDF)
This notification applies to the following networks: Commercial HMO, POS, and PPO.
Effective August 1, 2023, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) will implement clinical review criteria for Facet Joint Injections for Medicare and non-Medicare members.
Changes to medical necessity review criteria for Breast Reconstruction criteria (PDF)
This notification applies to the following networks: Commercial HMO, POS, and PPO
Effective July 1, 2023, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) have revised the clinical review criteria for Breast Reconstruction for non-Medicare members.
Changes to medical necessity review criteria for Peroral Endoscopic Myotomy (POEM) (PDF)
This notification applies to the following networks: Commercial HMO, POS, PPO, and Medicare Advantage
Effective July 1, 2023, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating clinical review criteria for Peroral Endoscopic Myotomy (POEM).
CLIA waived and non-waived tests in office (PDF)
This notification applies to the following networks: Commercial HMO, POS, PPO, and Medicare Advantage
Effective July 1, 2023, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) will deny CLIA waived tests when billed with place of service office (11) unless billed with a QW modifier.
Effective July 1, 2023, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) will deny CLIA non-waived tests when billed with place of service office (11).
Portable x-ray equipment transportation (PDF)
This notification applies to the following networks: Commercial HMO, POS, PPO, and Medicare Advantage
Effective July 1, 2023, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) will not reimburse the transportation of portable x-ray equipment (R0075) when billed for more than one person unless it is billed with one of the following required modifiers: UN, UP, UQ, UR, US.
Personal Protective Equipment (PPE) 99072 (PDF)
This notification applies to the following networks: Commercial HMO, POS, PPO and Medicare Advantage.
Due to the scheduled end of the COVID-19 Public Health Emergency on May 11, 2023, effective June 1, 2023, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) will no longer reimburse providers for Personal Protective Equipment (PPE) under CPT code 99072.
Anifrolumab-fnia (saphnelo) updated prior authorization criteria (PDF)
Anifrolumab-fnia (Saphnelo) is on the non-Medicare list of office-administered drugs requiring prior authorization.
Effective June 1, 2023, the criteria for anifrolumab-fnia (Saphnelo) will be updated to include a quantity limit. This letter is a notification of the change in prior authorization criteria required before administering this medication under the medical benefit.
Notice modification March 13, 2023: Quantity limit updated to include induction dosing.
Risankizumab-rzaa (Skyrizi) updated prior authorization criteria (PDF)
Risankizumab-rzaa (Skyrizi) is on the non-Medicare list of office-administered drugs requiring prior authorization.
Effective June 1, 2023, the criteria for risankizumab-rzaa (Skyrizi) will be updated to include a quantity limit for Crohn’s disease. This letter is a notification of the change in prior authorization criteria required before administering this medication under the medical benefit.
Romidepsin (Istodax) will require prior authorization approval (PDF)
Effective June 1, 2023, Romidepsin (Istodax) will be added to the non-Medicare list of office administered drugs requiring prior authorization. This letter is a notification of the upcoming change in prior authorization criteria required before administering this medication under the medical benefit.
Medicare Part B drugs requiring prior authorization (PDF)
Effective June 1, 2023, prior authorization will be required for the Medicare Part B drugs listed in Table 1. This letter is a notification of the upcoming change in prior authorization review required before administering these medications under the medical benefit.
Medicare Part B drugs requiring step therapy (PDF)
Effective June 1, 2023, step therapy will be required for the non-preferred Medicare Part B drugs listed in Table 1. This letter is a notification of the upcoming change in step therapy approval required before administering these medications under the medical benefit.
Tezepelumab-ekko (Tezspire) updated prior authorization (PDF)
Tezepelumab-ekko (Tezspire) is on the non-Medicare list of office-administered drugs requiring prior authorization.
Effective June 1, 2023, the criteria for tezepelumab-ekko (Tezspire) will be updated to include a quantity limit. This letter is a notification of the change in prior authorization criteria required before administering this medication under the medical benefit..
Changes to medical necessity review criteria for Intensity Modulated Radiation Therapy (IMRT) (PDF)
This notification applies to the following networks: Commercial HMO, POS, and PPO
Effective June 1, 2023, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) have revised the clinical review criteria for Intensity Modulated Radiation Therapy (IMRT) for non-Medicare members.
Changes to medical necessity review criteria for Stereotactic Radiation Therapy (PDF)
This notification applies to the following networks: Commercial HMO, POS, and PPO
Effective June 1, 2023, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) have revised the clinical review criteria for Stereotactic Radiosurgery for non-Medicare members.
Changes to medical necessity review criteria for PSMA PET Scans (PDF)
This notification applies to the following networks: Commercial HMO, POS, and PPO
Effective June 1, 2023, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) will implement clinical review criteria for PSMA PET Scans.
Changes to medical necessity review criteria for PluvictoTM (PDF)
This notification applies to the following networks: Commercial HMO, POS, PPO, and Medicare Advantage
Effective June 1, 2023, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) will implement clinical review criteria for the radiopharmaceutical, PluvictoTM (formerly 177Lu-PSMA), for Medicare and non-Medicare members.
Changes to medical necessity review criteria for PET scans (PDF)
This notification applies to the following networks: Commercial HMO, POS, PPO
Effective June 1, 2023, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the clinical review criteria for PET Scans.
Changes to medical necessity review criteria for total hip arthroplasty (PDF)
This notification applies to the following networks: Commercial HMO, POS, PPO, and Medicare Advantage
Effective June 1, 2023, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) will implement clinical review criteria for total hip arthroplasty for all non-Medicare members and will review Medicare members against CMS criteria.
Changes to medical necessity review criteria for miminally invasive sacroiliac joint (sij) fusions (PDF)
This notification applies to the following networks: Commercial HMO, POS, PPO, and Medicare Advantage
Effective June 1, 2023, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) will implement clinical review criteria for minimally invasive sacroiliac joint fusions for all Medicare and non-Medicare members.
Changes to medical necessity review criteria for thoracic spine Magnetic Resonance Imaging (MRI) (PDF)
This notification applies to the following networks: Commercial HMO, POS, and PPO
Effective May 1, 2023, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) will implement medical necessity criteria for MRI of the thoracic spine for non-Medicare patients.
Changes to medical necessity review criteria Pharmacogenomics (PDF)
This notification applies to the following networks: Commercial HMO, POS, and PPO
Effective May 1, 2023, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) is updating the clinical review criteria for Pharmacogenomics testing.
Changes to medical necessity review criteria for Genetic Screening and Testing (PDF)
This notification applies to the following networks: Commercial HMO, POS, and PPO
Effective April 1, 2023, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are revising existing criteria and implementing medical necessity criteria for Genetic Screening and Testing.
Changes to medical necessity review criteria for MRI cervical (PDF)
This notification applies to the following networks: Commercial HMO, POS, and PPO
Effective April 1, 2023, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the clinical review criteria for MRI of cervical spine.
Changes to medical necessity review criteria for certain elective surgical procedures (PDF)
This notification applies to the following networks: Commercial HMO, POS, and PPO, and Medicare Advantage
Effective April 1, 2023, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) will implement level of care review for certain elective surgical procedures.
Breast reconstruction free flap procedure (PDF)
This notification applies to the following networks: Commercial HMO, POS, and PPO, and Medicare Advantage
Effective April 1, 2023, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) will not reimburse services for breast reconstruction free flap procedure when billed with HCPCS codes S2066; S2067 and S2068 unless otherwise specified by the specific contract terms. These HCPCS codes are reimbursable under CPT code 19364.
Canalith repositioning procedure (PDF)
This notification applies to the following networks: Commercial HMO, POS, and PPO, and Medicare Advantage
Effective April 1, 2023, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) will reimburse Canalith repositioning procedure CPT 95992, when the procedure is billed with CMS approved diagnosis codes.
Laboratory payment policy (PDF)
This notification applies to the following networks: Commercial HMO, POS, PPO, and Medicare Advantage
Effective April 1, 2023 Claims processed by Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options; Inc. (Kaiser Permanente) will include, but are not limited to, the following criteria when processing laboratory claims.
Tralokinumab-ldrm (Adbry) updated prior authorization criteria (PDF)
Tralokinumab-ldrm (Adbry) is on the non-Medicare list of office-administered drugs requiring prior authorization.
Effective March 1, 2023, the criteria for tralokinumab-ldrm (Adbry) will be updated to include a quantity limit. This letter is a notification of the change in prior authorization criteria required before administering this medication under the medical benefit.
Ravulizumab-cwvz (Ultomiris) updated prior authorization criteria (PDF)
Ravulizumab-cwvz (Ultomiris) is on the non-Medicare list of office-administered drugs requiring prior authorization.
Effective March 1, 2023, the criteria for ravulizumab-cwvz (Ultomiris) will be updated to include a quantity limit for the indication Myasthenia Gravis (MG). This letter is a notification of the change in prior authorization criteria required before administering this medication under the medical benefit.
Medicare Part B: Rituximab-Abbs (Truxima) requiring step therapy (PDF)
Effective March 1, 2023, step therapy will be required for rituximab-abbs (Truxima), where patients must demonstrate trial and failure, intolerance, or contraindication to the preferred drug, rituximab-arrx (Riabni), before the nonpreferred drug, rituximab-abbs (Truxima), is covered. This letter is a notification of the upcoming change in step therapy approval required before administering this medication under the medical benefit.
Medicare Part B: Difelikefalin (Korsuva) requiring prior authorization (PDF)
Effective March 1, 2023, prior authorization will be required for difelikefalin (Korsuva). This letter is a notification of the upcoming change in prior authorization review required before administering this medication under the medical benefit.
Contracted providers of Kaiser Foundation Health Plan of Washington
In October 2022, the OIC finalized rule making regarding the requirement under RCW 48.43.735(1)(a)(v) and WAC 284-170-433(1)(b), effective 1/1/2023, every participating provider contract must require that a covered person has an established relationship with a provider prior to receiving telemedicine services. The requirements related to having an established relationship must be clearly communicated to providers as they vary by service.
As defined in RCW 48.43.735(9)(d), "Established relationship" means…
See letter for full description (PDF)
Changes to medical necessity review criteria for Monitored Anesthesia Care (MAC) for Gastrointestinal Endoscopic Procedures (PDF)
This notification applies to the following networks: Commercial HMO, POS, and PPO
Effective March 1, 2023, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) is updating medical necessity criteria for Monitored Anesthesia Care (MAC).
Past notice revisions – Effective September 1, 2020
Modification to link for MCG Guideline Index
Changes to medical necessity review criteria for Neonatal Intensive Care Unit (NICU) admissions (PDF)
Effective September 1, 2020, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) will implement medical necessity criteria for NICU admissions.
Changes to medical necessity review criteria for Lumbar Spine MRI (PDF)
This notification applies to the following networks: Commercial HMO, POS, and PPO
Effective March 1, 2023, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the Lumbar Spine MRI criteria.
Changes to medical necessity review criteria for Cervical Spine MRI (PDF)
This notification applies to the following networks: Commercial HMO, POS, and PPO
Effective March 1, 2023, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the Cervical Spine MRI criteria.
Changes to medical necessity review criteria for Cervical Spine Fusion (PDF)
This notification applies to the following networks: Commercial HMO, POS, PPO, and Medicare Advantage
Effective March 1, 2023, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the Cervical Spinal Fusion criteria.
Changes to medical necessity review criteria for Lumbar Spinal Fusion (PDF)
This notification applies to the following networks: Commercial HMO, POS, PPO, and Medicare Advantage
Effective March 1, 2023, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the Lumbar Spinal Fusion criteria.
Changes to medical necessity review criteria for Applied Behavioral Analysis Therapy (ABA) (PDF)
This notification applies to the following networks: Commercial HMO, POS, and PPO
Effective March 1, 2023, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the Applied Behavioral Analysis Therapy (ABA).
Changes to medical necessity review criteria for Bariatric Surgery (PDF)
This notification applies to the following networks: Commercial HMO, POS, and PPO
Effective March 1, 2023, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the Bariatric Surgery criteria.
Changes to medical necessity review criteria for Next Generation Sequencing for Advanced Cancer (PDF)
This notification applies to the following networks: Commercial HMO, POS, PPO, and Medicare Advantage
Effective February 1, 2023, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) is updating Next Generation Sequencing for Advanced Cancer criteria.
Changes to medical necessity review criteria for Genetic Panel Testing (PDF)
This notification applies to the following networks: Commercial HMO, POS, PPO, and Medicare Advantage
Effective February 1, 2023, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) is updating medical necessity criteria for Genetic Panel Testing.
Modifier 26 (PDF)
This notification applies to the following networks: Commercial HMO, POS, PPO, and Medicare Advantage
Effective January 1, 2023, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) will not reimburse a Professional Component when a diagnostic laboratory service is provided either manually or with automated equipment, as these codes are not subject to the Professional Component/Technical Component (PC/TC) concept or are Technical Component only codes.
Site of care prior authorization requirement (PDF)
Effective January 1, 2023, Site of Care prior authorization criteria will apply to the products noted in Table. These products are on the non-Medicare list of office-administered drugs requiring prior authorization. Site of Care is a prior authorization for the location at which an infused medication is administered under the medical benefit. When Site of Care is applied to a medication, the following site of care types are acceptable: an outpatient standalone clinic, infusion center, provider’s office, or home infusion. Outpatient hospital-based infusion sites are not approved sites. This letter is notification that prior authorization approval is required before administering this medication under the medical benefit.
New medical necessity review criteria for Advanced Care at Home (PDF)
This notification applies to the following networks: Commercial HMO, POS, PPO, and Medicare Advantage
Effective January 1, 2023, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) is implementing Advanced Care at Home Criteria.
Ketamine will require prior authorization approval (PDF)
Effective December 1, 2022, Ketamine will be added to the list of office-administered drugs requiring prior authorization for both commercial and Medicare lines of business. This letter is a notification of the upcoming change in prior authorization criteria required before administering this medication under the medical benefit.
Alglucosidase (Lumizyme) updated prior authorization criteria (PDF)
Alglucosidase (Lumizyme) is on the non-Medicare list of office-administered drugs requiring prior authorization. Effective December 1, 2022, the criteria for Alglucosidase (Lumizyme) will be updated to include a quantity limit. This letter is a notification of the change in prior authorization criteria required before administering this medication under the medical benefit.
Capsaicin (Qutenza) will require prior authorization approval (PDF)
Effective December 1, 2022, Capsaicin (Qutenza) will be added to the non-Medicare list of office-administered drugs requiring prior authorization. This letter is a notification of the upcoming change in prior authorization criteria required before administering this medication under the medical benefit.
Changes to medical necessity review criteria for Cervical Fusion (PDF)
This notification applies to the following networks: Commercial HMO, POS, and PPO, and Medicare Advantage
Effective December 1, 2022, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) will implement medical necessity criteria for Cervical Fusion.
Changes to medical necessity review criteria for cochlear implant (PDF)
This notification applies to the following networks: Commercial HMO, POS, and PPO
Effective December 1, 2022, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the clinical review criteria for cochlear implants for non-Medicare members.
Revenue code billed without required procedure code (PDF)
This notification applies to the following networks: Commercial HMO, POS, PPO, and Medicare Advantage
Effective December 1, 2022, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) will not separately reimburse for annual wellness visit and initial/periodic comprehensive preventive medicine evaluation visit when billed for the same member on the same date of service by the same provider.
Changes to medical necessity review criteria for home pulse oximetry (PDF)
This notification applies to the following networks: Commercial HMO, POS, and PPO
Effective November 1, 2022, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) will no longer cover home pulse oximetry.
Changes to medical necessity review criteria for lumbar spine fusion (PDF)
This notification applies to the following networks: Commercial HMO, POS, and PPO
Effective November 1, 2022, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are revising the clinical review criteria for lumbar spine fusion.
Changes to the code check tool for phototherapy (PDF)
This notification applies to the following networks: Commercial HMO, POS, and PPO
Effective November 1, 2022, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are removing the excluded ICD-10 diagnosis codes from UVB/UVA therapy in the Dermatology Services clinical review criteria.
Changes to medical necessity review criteria for minimally invasive lumbar decompression (mild) (PDF)
This notification applies to the following networks: Commercial HMO, POS, and PPO
Effective November 1, 2022, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are revising the CPT codes in the Minimally Invasive Lumbar Decompression criteria.
Changes to medical necessity review criteria for percutaneous vertebral augmentation of vertebral compression fractures (PDF)
This notification applies to the following networks: Commercial HMO, POS, and PPO
Effective October 1, 2022, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are revising the clinical review criteria for percutaneous vertebral augmentation of vertebral compression fractures.
Changes to medical necessity review criteria for total knee arthroplasty (PDF)
Modification to notice: Effective date delayed until October 25, 2022
This notification applies to the following networks: Commercial HMO, POS, and PPO
Effective October 1, 2022, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) is revising criteria for total knee arthroplasty for non-Medicare members.
Revenue code billed without required procedure code (PDF)
This notification applies to the following networks: Commercial HMO, POS, PPO, and Medicare Advantage
Effective October 1, 2022, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) will not reimburse revenue codes when submitted without the required procedure or HCPCS code.
Site of care prior authorization requirement for oncology medications (PDF)
Modifications to notice: The last 2 digits for the HCPC code for Bortezomib (Velcade) is switched inadvertently. It should be J9041 not J9014.
Effective September 1, 2022, Site of Care prior authorization criteria will apply to the products noted in Table 1 and 2 in the PDF (above). These products are on the non-Medicare list of office-administered drugs requiring prior authorization. This letter is notification that prior authorization approval is required before administering this medication under the medical benefit.
Effective September 1, 2022, Site of Care prior authorization criteria will apply to the products noted in Table 1 and 2 in the PDF (above). These products are on the non-Medicare list of office-administered drugs requiring prior authorization. This letter is notification that prior authorization approval is required before administering this medication under the medical benefit.
Changes to medical necessity review criteria for genetic testing (PDF)
This notification applies to the following networks: Commercial HMO, POS, and PPO
Effective September 1, 2022, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the clinical review criteria for Genetic Testing & Screening related to hereditary ovarian cancer.
Changes to medical necessity review criteria for high-end imaging site of care (PDF)
This notification applies to the following networks: Commercial HMO, POS, and PPO
Effective September 1, 2022, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the clinical review criteria for High-End Imaging Site of Care for non-Medicare members.
Changes to medical necessity review criteria for continuous glucose monitors (PDF)
This notification applies to the following networks: Commercial HMO, POS, and PPO
Effective September 1, 2022, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the clinical review criteria for continuous glucose monitors (CGM) for non-Medicare members.
Changes to medical necessity review criteria for negative pressure wound therapy (PDF)
This notification applies to the following networks: Commercial HMO, POS, and PPO
Effective August 1, 2022, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating criteria for negative pressure wound therapy.
RETRO EFFECTIVE NOTICE to meet regulatory requirement
Changes to medical necessity review criteria for gender affirming surgeries (PDF)
This notification applies to the following networks: Commercial HMO, POS, PPO, and Medicare Advantage
Effective April 5, 2022, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are implementing clinical review criteria for vocal cord surgery for members with gender dysphoria.
Changes to medical necessity review criteria for Myocardial Strain Imaging (PDF)
Effective July 1, 2022, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) will implement clinical review criteria for Myocardial Strain Imaging.
Changes to medical necessity review criteria for left atrial appendage closure therapy (PDF)
Effective July 1, 2022, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the clinical review criteria for left atrial appendage closure (LAAC) therapy.
Changes to medical necessity review criteria for brain magnetic resonance imaging (MRI) (PDF)
Effective July 1, 2022, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) will implement medical necessity criteria for MRI of the brain for non-Medicare patients.
Changes to medical necessity review criteria for Eustachian Tube balloon dilation (PDF)
Effective July 1, 2022, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) will implement clinical review criteria for Eustachian tube balloon dilation.
Fracture care in emergency department without manipulation (PDF)
Effective July 1, 2022, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) will not reimburse fracture care billed without a manipulation procedure code when billed on a professional claim by a physician in the Emergency Department (ED) setting.
Modifiers 54 & 57 (PDF)
Effective July 1, 2022, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) will not reimburse professional surgical services in place of service 23 (emergency room) when billed without modifier 54.
Changes to medical necessity review criteria for gender affirming surgeries (PDF)
Effective March 1, 2022, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) is updating criteria for facial and body hair removal for members with gender dysphoria.
Medicare Part B drugs requiring prior authorization (PDF)
Implementation modification: Effective date/implementation of the Medicare Part B drugs prior authorization requirement notice is delayed until September 1, 2022.
Modifications to notice: Denosumab, Prolia, Code J0897 was removed from Table 1, Medicare Part B drugs list.
Effective May 1, 2022, prior authorization will be required for the Medicare Part B drugs listed in Table 1. This letter is a notification of the upcoming change in prior authorization review required before administering these medications under the medical benefit.
Colony stimulating factor updates to coverage under medical benefit (PDF)
Modifications to notice Criteria for pegfilgrastim products in Table 2 was updated.
Effective May 1, 2022, new authorizations for the filgrastim products in Table 1 will NOT be covered under the medical benefit. These drugs will be added to the non-Medicare list of office-administered drugs requiring prior authorization. Pharmacy benefit coverage remains available for members who meet prior authorization criteria.
Effective May 1, 2022, the criteria for pegfilgrastim products in Table 2 will be updated. These products are on the non-Medicare list of office-administered drugs requiring prior authorization.
Medicare Part B drugs requiring step therapy (PDF)
Modifications to notice Infliximab and Pegfilgrastim products were removed from Table 1, Medicare Part B drugs list.
Effective May 1, 2022, step therapy will be required for the non-preferred Medicare Part B drugs listed in Table 1. This letter is a notification of the upcoming change in step therapy approval required before administering these medications under the medical benefit.
Lanreotide (Somatuline Depot) updates to coverage under the medical benefit (PDF)
Effective May 1, 2022, Lanreotide (Somatuline Depot) will be added to the non-Medicare list of office-administered drugs requiring prior authorization. This letter is a notification of the upcoming change in prior authorization criteria required before administering this medication under the medical benefit. This new prior authorization requirement will not affect patients already established on lanreotide.
Esketamine (Spravato) updates to coverage under the medical benefit (PDF)
Effective May 1, 2022, the criteria for esketamine (Spravato) will be updated to include quantity limits. Esketamine (Spravato) is on the non-Medicare list of office-administered drugs requiring prior authorization. This letter is a notification of the upcoming change in prior authorization criteria required before administering this medication under the medical benefit.
Changes to medical necessity review criteria for chromosomal microarray testing (PDF)
This notification applies to the following networks: Commercial HMO, POS, and PPO
Effective May 1, 2022, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the clinical review criteria for Chromosomal Microarray Testing for patients undergoing invasive prenatal testing.
Changes to medical necessity review criteria for ConfirmMDx and SelectMDx (PDF)
This notification applies to the following networks: Commercial HMO, POS, and PPO
Effective May 1, 2022, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) will implement clinical review criteria for ConfirmMDx and SelectMDx testing for prostate cancer. Although Kaiser Permanente has not covered these services historically, this postcard serves as formal notification of this new non-coverage policy for non-Medicare members.
Changes to medical necessity review criteria for InPen Smart Insulin Pen (PDF)
This notification applies to the following networks: Commercial HMO, POS, PPO, and Medicare Advantage
Effective June 1, 2022, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the clinical review criteria for the InPen Smart Insulin Pen.
Changes to medical necessity review criteria for knee magnetic resonance imaging (MRI) (PDF)
This notification applies to the following networks: Commercial HMO, POS, and PPO
Effective May 1, 2022, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) will implement medical necessity criteria for MRI of the knee for non-Medicare patients.
Changes to medical necessity review criteria for autologous chondrocyte implantation (PDF)
This notification applies to the following networks: Commercial HMO, POS, PPO, and Medicare Advantage
Effective May 1, 2022, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the clinical review criteria for autologous chondrocyte implantation (ACI) in the knee.
We heard you – authorization no longer required for mental health therapy or psychiatry (PDF)
Effective February 15, 2022, authorizations and re-authorizations will no longer be required for outpatient mental health therapy or psychiatry.
Split night sleep study (PDF)
This notification applies to the following networks: Commercial HMO, POS, PPO, and Medicare Advantage
Effective April 1, 2022, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) will not separately reimburse for CPT codes 95810 and 95811 when billed within 30 days of each other.
Initial hospital e&m upcoding (PDF)
This notification applies to the following networks: Commercial HMO, POS, PPO, and Medicare Advantage
Effective April 1, 2022, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) will not reimburse CPT 99223 billed with place of service 21 for dates of service one day prior to or on the date of discharge unless documentation is provided that substantiates the use of 99223.
7th character ICD-10 and therapy codes (PDF)
This notification applies to the following networks: Commercial HMO, POS, PPO, and Medicare Advantage
Effective April 1, 2022, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) will not reimburse subsequent PT, OT, SLP therapy visits when billed with ICD-10 code(s) where the seventh character of “A” is billed in any position.
Changes to medical necessity review criteria for gynecomastia (PDF)
This notification applies to the following networks: Commercial HMO, POS, and PPO
Effective April 1, 2022, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the clinical review criteria for mastectomy for gynecomastia.
Changes to medical necessity review criteria for insulin pump (PDF)
This notification applies to the following networks: Commercial HMO, POS, and PPO
Effective April 1, 2022, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the clinical review criteria for insulin pumps for non-Medicare members.
Changes to medical necessity review criteria for spinal muscular atrophy carrier testing (PDF)
This notification applies to the following networks: Commercial HMO, POS, and PPO
Effective April 1, 2022, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the clinical review criteria for Spinal Muscular Atrophy (SMA) carrier testing.
Changes to medical necessity review criteria for vagus nerve stimulation (vns) (PDF)
This notification applies to the following networks: Commercial HMO, POS, and PPO
Effective April 1, 2022, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the clinical review criteria for vagus nerve stimulation (VNS) for non-Medicare members.
Botox products updated prior authorization criteria (PDF)
Effective March 1, 2022, the criteria for the products listed in Table 1 will be updated to include new cumulative quantity limits. These products are on the non-Medicare list of office-administered drugs requiring prior authorization. This letter is a notification of the upcoming change in prior authorization criteria required before administering this medication in a physician’s office.
Omalizumab (Xolair) updates to coverage under the medical benefit (PDF)
Effective March 1, 2022, omalizumab (Xolair) subcutaneous vials and syringes will NOT be covered under the medical benefit after the initial 3 doses. Omalizumab (Xolair) is on the non-Medicare list of office-administered drugs requiring prior authorization. This letter is a notification of the upcoming change in coverage for this medication under the medical benefit. Pharmacy benefit coverage remains available for members who meet prior authorization criteria, but Xolair will no longer be covered under the medical benefit.
Abatacept (Orencia) updates to coverage under the medical benefit (PDF)
Effective March 1, 2022, abatacept (Orencia) subcutaneous prefilled-syringes and auto-injectors will NOT be covered under the medical benefit. Abatacept (Orencia) is on the non-Medicare list of office-administered drugs requiring prior authorization. This letter is a notification of the upcoming change in coverage for this medication under the medical benefit.
Changes to medical necessity review criteria for low-dose computed tomography screening for lung cancer (PDF)
This notification applies to the following networks: Commercial HMO, POS, and PPO
Effective March 1, 2022, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the clinical review criteria for low dose computed tomography (CT) screening for lung cancer.
Changes to medical necessity review criteria for bariatric surgery (PDF)
This notification applies to the following networks: Commercial HMO, POS, and PPO
Effective March 1, 2022, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the clinical review criteria for Bariatric Surgery for non-Medicare members.
Shoulder arthroscopy (PDF)
This notification applies to the following networks: Commercial HMO, POS, PPO, and Medicare Advantage
Effective March 1, 2022, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) will not separately reimburse for multiple shoulder arthroscopy procedures billed on the same day; by the same provider; for the same side of the body.
Changes to medical necessity review criteria for restorative and cosmetic procedures (PDF)
This notification applies to the following networks: Commercial HMO, POS, and PPO
Effective February 1, 2022, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the clinical review criteria for panniculectomy for non-Medicare members.
Changes to medical necessity review criteria for AlloSure (PDF)
This notification applies to the following networks: Commercial HMO, POS, PPO
Effective January 1, 2022, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the clinical review criteria for Donor-derived Cell-free DNA for Kidney Transplant Rejection (AlloSure).
Changes to medical necessity review criteria for Virtual/CT Colonography (PDF)
This notification applies to the following networks: Medicare Advantage
Effective January 1, 2022, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the clinical review criteria for Virtual/CT Colonography for Medicare Advantage members.
Changes to medical necessity review criteria for External Trigeminal Nerve Stimulation for ADHD (PDF)
This notification applies to the following networks: Commercial HMO, POS, PPO, and Medicare Advantage
Effective January 1, 2022, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the clinical review criteria for External Trigeminal Nerve Stimulation (eTNS) for ADHD.
Changes to medical necessity review criteria for Cell-Free Fetal DNA Analysis for Trisomies (PDF)
This notification applies to the following networks: Commercial HMO, POS, PPO, and Medicare Advantage
Effective January 1, 2022, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are making a permanent change to the clinical review requirements for Cell-Free Fetal DNA Testing for Trisomies. This change was implemented temporarily April 1, 2020 – December 31, 2021 due to the COVID pandemic.
Associate Level Mental Health Care (PDF)
Applies to: Commercial HMO, POS, PPO
Effective January 1, 2022, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) will not directly reimburse for care provided by associate level therapists or counselors (LMFTA, LMHCA or LICSWA). Care provided by associate level therapists or counselors must be supervised and billed by a licensed therapist or counselor.
Brivaracetam (Briviact) updated prior authorization criteria (PDF)
Effective December 1, 2021, Brivaracetam (Briviact) will be added to the non-Medicare list of office-administered drugs requiring prior authorization. This letter is a notification of the upcoming change in prior authorization criteria required before administering this medication in a physician’s office.
Irinotecan liposome (Onivyde) updated prior authorization criteria (PDF)
Effective December 1, 2021, Irinotecan liposome (Onivyde) will be added to the non-Medicare list of office-administered drugs requiring prior authorization. This letter is a notification of the upcoming change in prior authorization criteria required before administering this medication in a physician’s office.
Abatacept (Orencia) updated prior authorization criteria (PDF)
Abatacept (Orencia) is on the non-Medicare list of office-administered drugs requiring prior authorization.
Effective December 1, 2021, the quantity limit for abatacept (Orencia) has been updated to specify the frequency used during induction. This letter is a notification of the change in prior authorization criteria required before administering this medication in a physician’s office.
Tocilizumab (Actemra) updated prior authorization criteria (PDF)
Tocilizumab (Actemra) is on the non-Medicare list of office-administered drugs requiring prior authorization.
Effective December 1, 2021, the quantity limit for tocilizumab (Actemra) has been updated to specify the frequency of use for cytokine release syndrome. This letter is a notification of the change in prior authorization criteria required before administering this medication in a physician’s office.
Vedolizumab (Entyvio) updated prior authorization criteria (PDF)
Vedolizumab (Entyvio) is on the non-Medicare list of office-administered drugs requiring prior authorization.
Effective December 1, 2021, the quantity limit for Vedolizumab (Entyvio) will be updated to specify the frequency of use. This letter is a notification of the upcoming change in prior authorization criteria required before administering this medication in a physician’s office.
Ustekinumab (Stelara) updates to coverage under the medical benefit (PDF)
Effective December 1, 2021, ustekinumab (Stelara) subcutaneous vial and syringes will NOT be covered under the medical benefit. This letter is a notification of the upcoming change in coverage for this medication under the medical benefit. Pharmacy benefit coverage remains available for members who meet prior authorization criteria but Stelara will no longer be covered under the medical benefit for self-administration formulations.
Benralizumab (Fasenra) and Mepolizumab (Nucala) will not be covered under the medical benefit (PDF)
Effective December 1, 2021, Benralizumab (Fasenra) and Mepolizumab (Nucala) will NOT be covered under the medical benefit. This letter is a notification of the upcoming change in coverage for this medication under the medical benefit. Pharmacy benefit coverage remains available for members who meet prior authorization criteria but Fasenra and Nucala will no longer be covered under the medical benefit.
Changes to medical necessity review criteria for eating disorders and outpatient mental health services (PDF)
Effective December 1, 2021, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating criteria for medical necessity reviews for Eating Disorders Treatment and Outpatient Mental Health services.
Changes to medical necessity review criteria for bariatric surgery (PDF)
This notification applies to the following networks: Commercial HMO, POS, and PPO.
Effective November 1, 2021, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the clinical review criteria for Bariatric Surgery for non-Medicare members. Additionally, effective January 1, 2022, requests for bariatric surgery for PEBB members will be reviewed using the Kaiser Permanente non-Medicare criteria.
Changes to medical necessity review criteria for Positron Emission Tomography (PET) Scan (PDF)
This notification applies to the following networks: Commercial HMO, POS, and PPO.
Effective November 1, 2021, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the clinical review criteria for PET scans for non-Medicare members.
Changes to medical necessity review criteria for substance use disorder treatment (PDF)
Effective October 1, 2021, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) is adopting established guidelines from the American Society of Addiction Medicine (ASAM) for medical necessity reviews for substance use disorder treatment for Medicare Advantage members.
Changes to medical necessity review criteria for dermal fillers for facial lipoatrophy (PDF)
This notification applies to the following networks: Commercial HMO, POS, and PPO. A listing of all networks can be found on the provider website.
Effective October 1, 2021, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the clinical review criteria for dermal fillers for facial lipoatrophy for non-Medicare members.
Changes to medical necessity review criteria for dermatology services (PDF)
This notification applies to the following networks: Commercial HMO, POS, and PPO. A listing of all networks can be found on the provider website.
Effective October 1, 2021, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the clinical review criteria for Dermatology Services for non-Medicare members.
Changes to prior authorization requirements for diagnostic services (PDF)
CPT codes updates – diagnostic services (PDF)
This notification applies to the following networks: Commercial HMO and Medicare Advantage. A listing of all networks can be found on the provider website.
Effective October 1, 2021, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) will require preauthorization for additional diagnostic services in the following categories: Cardiac MRI, certain venography procedures, EKG and Echocardiography, Pacemaker Checks, and Neurology and Neuromuscular diagnostic testing.
Changes to medical necessity review criteria for genetic testing (PDF)
This notification applies to the following networks: Commercial HMO, POS, and PPO. A listing of all networks can be found on the provider website.
Effective October 1, 2021, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the clinical review criteria for Genetic Testing & Screening and Pharmacogenomic Testing.
Changes to medical necessity review criteria for basivertebral nerve ablation (PDF)
This notification applies to the following networks: Commercial HMO, POS, PPO, and Medicare Advantage. A listing of all networks can be found on the provider website.
Effective October 1, 2021, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) will implement clinical review criteria for basivertebral nerve ablation.
Changes to medical necessity review criteria for Magnetic Resonance Enterography (PDF)
This notification applies to the following networks: Commercial HMO, POS, PPO, and Medicare Advantage. A listing of all networks can be found on the provider website.
Effective October 1, 2021, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the clinical review criteria for Magnetic Resonance Enterography.
Changes to medical necessity review criteria for Renal Sympathetic Nerve Ablation (PDF)
This notification applies to the following networks: Commercial HMO, POS, PPO, and Medicare Advantage. A listing of all networks can be found on the provider website.
Effective October 1, 2021, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) will implement new medical necessity criteria for Renal Sympathetic Nerve Ablation.
Applied Behavior Analysis criteria and payment policy changes (PDF)
This notification applies to the following networks: Commercial HMO, POS, and PPO. A listing of all networks can be found on the provider website.
Effective October 1, 2021, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) will require that only category 1 CPT codes for ABA services may be used in order to streamline Applied Behavior Analysis (ABA) services. The clinical review criteria and payment policy for ABA have been modified to reflect this change.
Botox products updated prior authorization criteria (PDF)
Effective September 1, 2021, the criteria for the products listed in Table 1 will be updated to include new quantity limits for chronic migraine. These products are on the non-Medicare list of office-administered drugs requiring prior authorization. This letter is a notification of the upcoming change in prior authorization criteria required before administering this medication in a physician’s office.
Eculizumab (SOLIRIS) and Ravulizumab (ULTOMIRIS) updated prior authorization criteria (PDF)
Effective September 1, 2021, the criteria for the products listed in Table 1 will be updated to include quantity limits. These products are on the non-Medicare list of office-administered drugs requiring prior authorization. This letter is a notification of the upcoming change in prior authorization criteria required before administering this medication in a physician’s office.
Eculizumab (SOLIRIS) and Ravulizumab (ULTOMIRIS) restricted to administration by Kaiser Permanente Specialty Home Infusion when infused in the home setting (PDF)
Effective September 1, 2021, criteria for the infusion products listed in Table 1 will change. For home infusion, these specialty drug products and administration of these products is limited to Kaiser Permanente Specialty Home Infusion for non-Medicare Health Maintenance Organization (HMO) members. For patients who currently have an authorization to receive these products through a network home infusion provider, the criteria will go into effect when the provider authorization expires.
Changes to medical necessity review criteria for facet neurotomy (PDF)
This notification applies to the following networks: Commercial HMO, POS, and PPO.
Effective September 1, 2021, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the clinical review criteria for facet neurotomy for non-Medicare members.
Changes to medical necessity review criteria for lung and liver transplant (PDF)
This notification applies to the following networks: Commercial HMO, POS, and PPO.
Effective September 1, 2021, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) has adopted updates to the Kaiser Permanente National Patient Referral Guidelines for Lung Transplant and Liver Transplant for non-Medicare members.
Chromoendoscopy and Narrow Band Imaging (PDF)
This notification applies to the following networks: Commercial HMO, POS, PPO and Medicare Advantage. A listing of all networks can be found on the provider website.
Effective August 15, 2021, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) will not separately reimburse for chromoendoscopy, chromoscopy, chromocolonoscopy or narrow band imaging as a part of services provided during a diagnostic or surveillance colonoscopy or endoscopy.
Changes to medical necessity review criteria for certain elective surgical procedures (PDF)
This notification applies to the following networks: Commercial HMO, POS, and PPO. A listing of all networks can be found on the provider website.
Effective August 1, 2021, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) will implement site of care review criteria for certain elective surgical procedures for non-Medicare members. This will be implemented using a phased approach, starting with Benton, Kitsap, Spokane, and Whatcom counties.
Changes to medical necessity review criteria for breast MRI (PDF)
This notification applies to the following networks: Commercial HMO, POS, PPO, and Medicare Advantage. A listing of all networks can be found on the provider website.
Effective August 1, 2021, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating medical necessity criteria for breast MRI.
Changes to medical necessity review criteria for coronary artery calcium (PDF)
This notification applies to the following networks: Commercial HMO, POS, and PPO. A listing of all networks can be found on the provider website.
Effective August 1, 2021, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the clinical review criteria for coronary artery calcium (CAC) scoring for non-Medicare members.
Changes to medical necessity review criteria for cochlear implants (PDF)
This notification applies to the following networks: Commercial HMO, POS, and PPO. A listing of all networks can be found on the provider website.
Effective August 1, 2021, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the clinical review criteria for cochlear implants for non-Medicare members.
Changes to medical necessity review criteria for enteral formula (PDF)
This notification applies to the following networks: Commercial HMO, POS, and PPO. A listing of all networks can be found on the provider website.
Effective August 1, 2021, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the clinical review criteria for enteral formula for non-Medicare members.
Changes to medical necessity review criteria for Intensity Modulated Radiation Therapy (IMRT) (PDF)
This notification applies to the following networks: Commercial HMO, POS, and PPO. A listing of all networks can be found on the provider website.
Effective August 1, 2021, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the clinical review criteria for IMRT for non-Medicare members.
Changes to medical necessity review criteria for total joint arthroplasty (PDF)
This notification applies to the following networks: Commercial HMO, POS, PPO, and Medicare Advantage. A listing of all networks can be found on the provider website.
Effective August 1, 2021, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the medical necessity criteria for elective total hip, total knee and total shoulder replacements or revisions performed in a hospital inpatient status for all members.
Hospital Acquired Conditions, Adverse & Never Events (PDF)
This notification applies to the following networks: Commercial HMO, POS, PPO and Medicare Advantage. A listing of all networks can be found on the provider website.
Effective July 15, 2021, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) will not separately reimburse for Hospital-Acquired Conditions (HAC), Never or Adverse Events. Acute care inpatient hospitals are not allowed to receive or retain any reimbursement for inpatient services related to CMS-identified HACs, Adverse or Never Events. All participating acute care inpatient hospitals are required to hold members harmless for any inpatient services related to CMS-identified HACs and Never Events.
Allergen Immunotherapy (PDF)
This notification applies to the following networks: Commercial HMO, POS and PPO. A listing of all networks can be found on the provider website.
Effective July 15, 2021, when benefits allow, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) will reimburse Allergy Immunotherapy practice expenses, billed utilizing CPT code 95165, up to a maximum of 150 doses per calendar year, per patient.
Modifiers JA and JB (PDF)
This notification applies to the following networks: Commercial HMO, POS, PPO and Medicare Advantage. A listing of all networks can be found on the provider website.
Effective July 15, 2021, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente), when benefits allow, will reimburse for medications that have one J Code for multiple routes of administration. To allow for proper monitoring of dose and treatment frequency, the JA or JB modifier must be present on the claim to indicate the route of administration as either intravenous or subcutaneous.
Thirty day readmission policy (PDF)
This notification applies to the following networks: Commercial HMO, POS, PPO and Medicare Advantage. A listing of all networks can be found on the provider website.
Effective July 1, 2021, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) does not allow separate reimbursement for claims that have been identified as a readmission, within 30 days of a previous discharge, to the same hospital for the same, similar or related condition unless provider, state, federal or CMS contracts and/or requirements indicate otherwise.
Notice - This 60-Day notice TITLE has been modified. The content of this 60-Day notice has not been modified from the original version sent to you on April 6, 2021. The effective date remains unchanged.
Critical care when patient is discharged to home from facility (PDF)
This notification applies to the following networks: Commercial HMO, POS, PPO and Medicare Advantage. A listing of all networks can be found on the provider website.
Effective June 15, 2021, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) will reimburse critical care services submitted on ER outpatient facility claims only when the patient is not discharged to home (discharge status code = 01) during the same encounter.
Tocilizumab (Actemra) updated prior authorization criteria (PDF)
Effective June 1, 2021, the criteria for tocilizumab (Actemra) will be updated to include a quantity limit.
Dermatology products updated prior authorization criteria (PDF)
Effective June 1, 2021, the criteria for the dermatology products listed in Table 1 will be updated to include quantity limits.
IVIG updated prior authorization criteria (PDF)
Effective June 1, 2021, the criteria for the IVIG products listed in Table 1 will be updated to include a quantity limit.
Neurology products updated prior authorization criteria (PDF)
Effective June 1, 2021, the criteria for the neurology products listed in Table 1 will be updated to include quantity limits.
Oncology products updated prior authorization criteria (PDF)
Effective June 1, 2021, the criteria for the oncology products listed in Table 1 will change.
Site of care prior authorization requirement for Pembrolizumab (Keytruda) and Nivolumab (Opdivo) (PDF)
Effective June 1, 2021, Site of Care prior authorization criteria will apply to the medications noted in Table 1 below. Site of Care is a prior authorization for the location at which an infused medication is administered under the medical benefit. When Site of Care is applied to a medication, the following site of care types are acceptable: an outpatient standalone clinic, infusion center, provider’s office, or home infusion. Outpatient hospital-based infusion sites are not approved sites. This letter is notification that prior authorization approval is required before administering this medication under the medical benefit.
Rheumatology products updated prior authorization criteria (PDF)
Effective June 1, 2021, the criteria for the rheumatology products listed in Table 1 will be updated to include quantity limits.
Rituximab (Rituxan) and Rituximab-abbs (Truxima) updated prior authorization criteria (PDF)
Effective June 1, 2021, the criteria for rituximab (Rituxan) and rituximab-abbs (Truxima) will be updated to include specific quantity limits.
Changes to medical necessity review criteria for high-end imaging site of care (PDF)
This notification applies to the following networks: HMO, POS, and PPO. A listing of all networks can be found on the provider website.
Effective June 1, 2021, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) will implement site of care review criteria for high-end diagnostic imaging for non-Medicare members.
Changes to medical necessity review criteria for Transcatheter Mitral Valve Repair (TMVR) (PDF)
This notification applies to the following networks: HMO, POS, and PPO. A listing of all networks can be found on the provider website.
Effective June 1, 2021, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the clinical review criteria for Transcatheter Mitral Valve Repair (TMVR) for non-Medicare members.
Changes to medical necessity review criteria for Myocardial Perfusion Imaging (PDF)
This notification applies to the following networks: HMO, POS, and PPO. A listing of all networks can be found on the provider website.
Effective June 1, 2021, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) will implement medical necessity criteria for Myocardial Perfusion Imaging for non-Medicare members.
Changes to Transition of Care policy (PDF)
This notification applies to the following networks: HMO, POS, and Medicare Advantage. A listing of all networks can be found on the provider website.
Effective June 1, 2021, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating criteria in the Transition of Care policy.
Changes to medical necessity review criteria for Focused Aspiration of Scar Tissue (PDF)
Effective May 1, 2021, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the clinical review criteria for Focused Aspiration of Scar Tissue (Tenex).
Changes to medical necessity review criteria for dermatology (PDF)
Effective May 1, 2021, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the clinical review criteria for Dermatology services for non-Medicare members.
Changes to medical necessity review criteria for continuous glucose monitors (PDF)
Effective April 1, 2021, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the clinical review criteria for continuous glucose monitors (CGM) for non-Medicare members.
Changes to the preauthorization and notification requirements for Preferred Provider Organization (PPO) plans (PDF)
Effective April 1, 2021, Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the Preauthorization and notification requirements for Access PPO, Elect PPO, and Summit PPO members.
Neurology product in the home infusion setting restricted to administration by Kaiser Permanente Specialty Home Infusion (PDF)
Effective April 1, 2021, the criteria for the specialty home infusion product listed in Table 1 will change. For home infusion, this specialty home infusion product and administration of this product is limited to Kaiser Permanente Specialty Home Infusion for non-Medicare Health Maintenance Organization (HMO) members. For patients who currently have an authorization to receive this product through a network home infusion provider, the criteria will go into effect when the provider authorization expires.
Infusion products in the home infusion setting restricted to administration by Kaiser Permanente Specialty Home Infusion (PDF)
Effective April 1, 2021, the criteria for the specialty home infusion products listed in Table 1 will change. For home infusion, this specialty home infusion product and administration of these products is limited to Kaiser Permanente Specialty Home Infusion for non-Medicare Health Maintenance Organization (HMO) members. For patients who currently have an authorization to receive these products through a network home infusion provider, the criteria will go into effect when the provider authorization expires.
Changes to medical necessity review criteria for Rezum System (PDF)
Effective March 1, 2021, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating medical necessity criteria for the Rezum System for the treatment of lower urinary tract symptoms (LUTS) due to benign prostatic hypertrophy (BPH).
Vedolizumab (Entyvio) updated prior authorization criteria (PDF)
Vedolizumab (Entyvio) is on the non-Medicare list of office-administered drugs requiring prior authorization. Effective February 15, 2021, the criteria for vedolizumab (Entyvio) will be updated to include a quantity limit of 300 mg per dose.
Changes to medical necessity review criteria for electroretinography (PDF)
Effective February 1, 2021, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) will implement clinical review criteria for electroretinography.
Changes to medical necessity review criteria implanted fusion pumps (PDF)
Effective February 1, 2021, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the clinical review criteria for implanted infusion pumps for non-Medicare members.
Changes to medical necessity review criteria for cervical spine magnetic resonance imaging (MRI) (PDF)
Effective February 1, 2021, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) will implement medical necessity criteria for MRI of the cervical spine for non-Medicare patients.
Updated prior authorization criteria for: AVASTIN®, HERCEPTIN®, REMICADE®, AND RITUXAN® (PDF)
Effective February 1, 2021, the prior authorization criteria for Avastin®, Herceptin®, Remicade®, and Rituxan® will be revised. This letter is a notification of the upcoming change in the prior authorization criteria required before administering these medications in a physician’s office.
Site of Care prior authorization requirement for NUCALA (MEPOLIZUMAB), NULOJIX (BELATACEPT), FASENRA (BENRALIZUMAB), XOLAIR (OMALIZUMAB) (PDF)
Effective February 1, 2021, Site of Care prior authorization criteria will apply to the medication noted in the Drug Tables below. Site of Care is a prior authorization for the location at which an infused medication is administered under the medical benefit. When Site of Care is applied to a medication, the following site of care types are acceptable: an outpatient standalone clinic, infusion center, provider’s office, or home infusion. Outpatient hospital-based infusion sites are not approved sites.
National Drug Code (NDC) billing requirements (PDF)
Effective February 1, 2021, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) will require the billing of the National Drug Code (NDC) associated with the drug administered during a visit.
Manipulative services — AT modifier requirement (PDF)
Effective February 1, 2021, codes 98940, 98941 and 98942 must be billed with the Acute Treatment (AT) modifier to identify that the service was medically necessary acute treatment, as opposed to maintenance therapy.
Threshold decrease for pre-payment review (aka line item deduction) and medical necessity review for inpatient and outpatient claims (PDF)
Effective February 1, 2021, facility claims with billed charges of $20,000 and greater will be subject to prepayment review for billing appropriateness.
Changes to medical necessity review criteria for gender reassignment surgery (PDF)
Effective January 1, 2021, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the clinical review criteria for gender reassignment surgery.
Changes to medical necessity review criteria for bone anchored hearing system (BAHA) (PDF)
Effective January 1, 2021, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the clinical review criteria for bone anchored hearing systems (BAHA) for non-Medicare members.
Changes to medical necessity review criteria for chromoendoscopy and narrow band imaging for colonoscopy (PDF)
Effective January 1, 2021, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) will not separately reimburse for chromoendoscopy and narrow band imaging during colonoscopy. Although Kaiser Permanente has not covered these services historically, this letter serves as formal notification of this new non-coverage policy.
Changes to medical necessity review criteria for hyperbaric oxygen therapy (PDF)
Effective January 1, 2021, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the clinical review criteria for hyperbaric oxygen therapy for non-Medicare members.
Changes to medical necessity review criteria for next generation sequencing (NGS) for advanced cancer (PDF)
Effective January 1, 2021, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) has selected CellNetix Pathology & Laboratories as the preferred provider for next generation sequencing (NGS) in advanced cancer.
Multiple payment policy changes effective 1/1/2021 (PDF)
Drug Waste Policy
Women's Health Policy
Surgical Codes - Anatomical Modifiers
Multiple payment policy changes effective 1/1/2021 (PDF)
High Level Evaluation and Management Services with a Diagnosis of "No Abnormal Findings"
Change of Policy Name and Addition of Medicare Specific Language
Multiple payment policy changes effective 1/1/2021 (PDF)
Diagnosis Related Group (DRG) Payment and Review
Medicare Part B drugs requiring step therapy (PDF)
Effective January 1, 2021, step therapy review will be required for the non-preferred Part B drugs.
Changes to medical necessity review criteria for reduction mammoplasty surgery (PDF)
Effective December 1, 2020, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the clinical review criteria for reduction mammoplasty surgery.
Changes to medical necessity review criteria for cardiac ambulatory monitoring for extended duration (PDF)
Effective December 1, 2020, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the clinical review criteria for cardiac ambulatory monitoring for extended duration.
Changes to medical necessity review criteria for brachytherapy (PDF)
Effective December 1, 2020, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the clinical review criteria for Brachytherapy.
Changes to medical necessity review criteria for genetic panels using Next Generation Sequencing (PDF)
Effective December 1, 2020, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the clinical review criteria for Genetic Panels using Next Generation Sequencing (NGS) when ordered for non-Medicare members.
Multiple Procedure Payment Reduction (MPPR) on Outpatient Hospital Claims (PDF)
Effective December 1, 2020, Kaiser Permanente facility outpatient claims billed with a professional revenue code will be treated like they have a 26 modifier and all other facility revenue codes will be treated as though they have a Technical Component (TC) modifier.
Innovator/Biosimilar pricing changes (PDF)
Effective December 1, 2020, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) will make changes to the KFHPWA Addendum B Fee Schedule.
Neurostimulator electrode array (PDF)
Effective November 1, 2020, Kaiser Permanente will align with the Centers for Medicare and Medicaid Services (CMS) for reimbursement for neurostimulator electrode array.
Genetic testing preferred provider is Invitae Corporation (PDF)
Effective October 1, 2020, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are directing genetic testing to Invitae Corporation (Invitae) for in-network coverage for non-Medicare members when the requested test(s) are available at Invitae.
Changes to medical necessity review criteria for phonophoresis (PDF)
Effective October 1, 2020, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) will implement medical necessity criteria for phonophoresis.
Changes to medical necessity review criteria for sports hernia surgery (PDF)
Effective October 1, 2020, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) will implement medical necessity criteria for sports hernia surgery.
Changes to medical necessity review criteria for Transcatheter Aortic Valve Replacement (TAVR) (PDF)
Effective September 1, 2020, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are changing the Transcatheter Aortic Valve Replacement (TAVR) clinical review criteria to allow coverage for all patients with documented severe, symptomatic aortic valve stenosis, regardless of operative risk.
Changes to medical necessity review criteria for Monitored Anesthesia Care during gastrointestinal endoscopic procedures (PDF)
Effective September 1, 2020, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc.(Kaiser Permanente) will enforce existing prior authorization requirements for Monitored Anesthesia Care (MAC) and a change has been made to the medical necessity criteria for MAC during gastrointestinal procedures to require an American Society of Anesthesiologists (ASA) risk-stratification of class IV.
Changes to medical necessity review criteria for Micronutrient Panel Testing (PDF)
Effective September 1, 2020, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc., (Kaiser Permanente) will implement medical necessity criteria for Micronutrient Panel Testing.
Changes to medical necessity review criteria for lumbar spine magnetic resonance imaging (MRI) (PDF)
Effective September 1, 2020, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) will implement medical necessity criteria for MRI of the lumbar spine for non-Medicare patients.
Alglucosidase (Lumizyme) & Natalizumab (Tysabri) in the home infusion setting restricted to administration by Kaisr Permanente Home Infusion (PDF)
Effective September 1, 2020, the criteria for the specialty home infusion products listed above will change.
Changes to medical necessity review criteria for microinvasive glaucoma surgery (PDF)
Effective August 1, 2020, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are changing the medical necessity criteria, by establishing clinical indications for all microinvasive glaucoma surgeries, including but not limited to iStent, Hydrus, and Xen Gel implants.
Changes to medical necessity review criteria for driving skills assessments (PDF)
Effective August 1, 2020, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. will discontinue coverage of driving skills assessments.
Infliximab products in the home infusion setting restricted to administration by Kaiser Permanete Home Infusion (PDF)
Effective August 1, 2020, the criteria for the specialty home infusion products Remicade & Inflectra will change. For home infusion, these specialty home infusion products and administration of these products is limited to Kaiser Permanente Home Infusion for non-Medicare Health Maintenance Organization (HMO) members.
Revised notification: Referrals & authorization provider site upgrade (PDF)
This upgrade was scheduled to become effective on March 20, 2020, but implementation was delayed. The revised effective date for the referrals & authorization provider site upgrade is August 15, 2020.
Referrals & authorization provider site upgrade (PDF)
We are excited to inform you that we will be rolling out an upgraded referrals and authorization provider experience on our Kaiser Permanente provider site on March 20, 2020.
Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. and Magellan Healthcare, Inc. form a partnership (PDF)
Effective July 1, 2020, Magellan will begin managing outpatient behavioral health and substance use service providers credentialing, information about your practice and member referrals.
Changes to medical necessity review criteria for elective total hip replacement in an inpatient hospital setting (PDF)
Effective April 1, 2020, Kaiser Permanente will implement medical necessity criteria for elective total hip replacements performed in an inpatient hospital setting for all members.
Claims processing practices for emergency department services (PDF)
Effective April 1, 2020, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) will begin using the Optum® Emergency Department Claim (EDC) Analyzer tool.
Changes to wound care treatment clinical review criteria: Biological and synthetic skin substitutes (PDF)
Effective April 1, 2020, Kaiser Permanente is changing the Wound Care Treatments clinical review criteria to only cover the following biological and synthetic skin substitutes.
Rituximab (Rituxan®) updated prior authorization criteria (PDF)
Effective April 1, 2020, the prior authorization criteria for rituximab (Rituxan) will be revised.
Site of Care prior authorization requirementEffective March 1, 2020, Site of Care prior authorization criteria will apply to the following medications.
Crysvita (PDF)
Exondys 51 (PDF)
Herceptin (PDF)
Ilaris (PDF)
Lemtrada (PDF)
Onpattro (PDF)
Radicava (PDF)
Truxima (PDF)
Tysabri (PDF)
Trauma activation, inpatient admissions, and pre-payment billing reimbursement changes (PDF)
Effective March 1, 2020, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are making changes regarding reimbursement of services for trauma activation, inpatient admissions, and pre-payment billing review criteria.
Trastuzumab (Herceptin®) will require prior authorization approval (PDF)
Effective February 1, 2020, prior authorization approval will be required for trastuzumab (Herceptin®) before administration of this medication in a physician's office.
Payment policy updated link (PDF)
Starting January 1, 2020, Kaiser Permanente of Washington will require notification at the time of stabilization and prior to hospital admission. This is in accordance to Washington State Legislature RCW 48.43.093.
Changes to prior authorization process for genetic lab tests (PDF)
Effective January 1, 2020, Kaiser Permanente is changing the utilization management requirement for all genetic lab tests. Prior authorization will be required for these tests in advance of submitting a claim for payment.
Changes to prior authorization process for mental health and wellness (PDF)
Changes to prior authorization process for mental health and wellness 90834 Q&A (PDF)
Effective January 1, 2020, Kaiser Permanente will implement changes to authorizations regarding outpatient psychotherapy. Outpatient psychotherapy will be authorized as CPT Code 90834, which will no longer be limited to 20 visits and reauthorization is only required annually via an abbreviated reauthorization form.
Ambulance Services payment policy (PDF)
Starting January 1, 2020, Kaiser Permanente Washington (KPWA) will enforce the existing Ambulance Services Payment Policy.
Bevacizumab (Avastin®) will require prior authorization (PDF)
Effective December 1, 2019, prior authorization review will be required for bevacizumab (Avastin®). This letter is a notification of the upcoming change in prior authorization approval required before administering this medication in a physician's office.
Clarification notification to Intraoperative Neurophysiological Monitoring (PDF)
This letter provides additional clarification to the previous letter regarding Intraoperative Neurophysiological Monitoring. The new notification does not change the effective date of September 1, 2019. This letter clarifies Medicare Advantage review for Intraoperative Neurophysiological Monitoring.
Intraoperative Neurophysiological Monitoring (PDF)
Effective September 1, 2019, Kaiser Permanente is changing the medical necessity review criteria and requiring preauthorization for coverage on some plans. Kaiser Permanente has adopted Kaiser Permanente National criteria for Intraoperative Neurophysiological Monitoring for the Washington region.
IV Immune Globulin (IVIG) in the home infusion setting will be restricted to Kaiser Washington home infusion (PDF)
Effective August 1, 2019, the criteria for the products listed will be updated. These products will be restricted to Kaiser Washington Home Infusion when administered in the home infusion setting for non-Medicare patients.
Alpha-1 Proteinase Inhibitors in the home infusion setting will be restricted to Kaiser Washington home infusion (PDF)
Effective June 1, 2019, the criteria for the products listed will be updated. These products will be restricted to Kaiser Washington Home Infusion when administered in the home infusion setting for non-Medicare patients.
Clarification notification to changes to medical cecessity review criteria for Total Knee Replacement (PDF)
This letter provides additional clarification to the previous letter regarding total knee replacement. This new notification does not change the effective date of June 1, 2019. This letter clarifies Medicare Advantage review for total knee replacements in an inpatient setting.
Changes to medical necessity review criteria for Total Knee Replacement (PDF)
Effective June 1, 2019, Kaiser Permanente will implement medical necessity criteria for Total Knee replacements performed in an inpatient setting.
Tivity/WholeHealth Network notice re: Group Summary and Fee Schedule update for Chiropractors (PDF)
The Group Summary and Fee Schedule has been updated. Reimbursement for services provided on or after 01/01/2019 will be based on the updated fee schedule for chiropractic claims.