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 one year. 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: January 15, 2025
Changes to medical necessity review criteria for sacral nerve stimulator (PDF)
Applies to: Commercial - HMO, POS, PPO.
Effective April 1, 2025, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the medical necessity criteria for Sacral Nerve Stimulators.
Production Date: January 15, 2025
Changes to medical necessity review criteria for responsive neurostimulation for treatment of epilepsy (PDF)
Applies to: Commercial - HMO, POS, PPO, Medicare Advantage.
Effective April 1, 2025, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are implementing new medical necessity review criteria for Responsive Neurostimulation for the Treatment of Epilepsy.
Production Date: January 15, 2025
Changes to medical necessity review criteria for single photon emission computed tomography (SPECT) (PDF)
Applies to: Commercial - HMO, POS, PPO.
Effective April 1, 2025, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating medical necessity criteria for Single Photon Emission Computed Tomography (SPECT).
Production Date: January 15, 2025
Changes to medical necessity review criteria for transthyretin amyloidosis genetic testing (PDF)
Applies to: Commercial - HMO, POS, PPO, Medicare Advantage.
Effective April 1, 2025, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating medical necessity criteria for Transthyretin (TTR) Amyloidosis genetic testing.
Production Date: January 15, 2025
Leuprolide acetate (Fensolvi) will require prior authorization approval (PDF)
Effective April 1, 2025, Leuprolide acetate (Fensolvi) 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.
Production Date: January 15, 2025
Site of care prior authorization requirement for oncology medications (PDF)
Effective April 1, 2025, Site of Care prior authorization criteria will apply to the medications noted in Table 1 and Table 2 below. 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 stand-alone clinic, infusion center, provider’s office, or home infusion. Outpatient hospital-based infusion sites are not approved sites. This letter is a notification that prior authorization is required before administering this medication under the medical benefit.
Production Date: December 11, 2024
Changes to medical necessity review criteria for shoulder arthroscopy (PDF)
Applies to: Commercial - HMO, POS, PPO, Medicare Advantage.
Effective March 1, 2025, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are implementing medical necessity review criteria for Shoulder Arthroscopy procedures.
Production Date: December 11, 2024
Changes to medical necessity review criteria for gender-affirming surgeries (PDF)
Applies to: Commercial - HMO, POS, PPO.
Effective March 1, 2025, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the Gender Affirming Surgeries medical necessity criteria.
Production Date: December 11, 2024
Changes to medical necessity review criteria for applied behavioral analysis therapy (PDF)
Applies to: Commercial - HMO, POS, PPO.
Effective March 1, 2025, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the medical necessity criteria for Applied Behavioral Analysis Therapy.
Production Date: December 11, 2024
Changes to medical necessity review criteria for sex-hormone binding globulin (PDF)
Applies to: Commercial - HMO, POS, PPO, Medicare Advantage.
Effective March 1, 2025, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are retiring the Sex-Hormone Binding Globulin (SHBG) policy.
Production Date: December 11, 2024
Changes to medical necessity review criteria for plethysmography (PDF)
Applies to: Commercial - HMO, POS, PPO.
Effective March 1, 2025, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are retiring the criteria for Plethysmography.
Production Date: December 11, 2024
Changes to medical necessity review criteria for fecal dna testing (PDF)
Applies to: Commercial - HMO, POS, PPO, Medicare Advantage.
Effective March 1, 2025, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are retiring the medical policy for Fecal DNA Testing.
Production Date: December 4, 2024
Oncology products updated prior authorization criteria (PDF)
Effective March 1, 2025, the criteria for oncology products in Table 1 and Table 2 will be updated. These products are on the non-Medicare list of office-administered drugs requiring prior authorization. This letter is a notification of the upcoming changes in coverage for these medications under the medical benefit.
Production Date: December 4, 2024
Modification Date: December 31, 2024
Modification to Letter: The effective date of March 1, 2025, has been moved to a later time.
Updated prior authorization criteria for ocrelizumab (Ocrevus) (PDF)
Ocrelizumab (Ocrevus) is on the non-Medicare list of office-administered drugs requiring prior authorization. Effective March 10, 2025, the criteria for ocrelizumab (Ocrevus) will be updated to require failure, contraindication, or intolerance to natalizumab. This change does not affect current authorizations for Ocrevus; however, any new authorizations are subject to the criteria below. This letter is a notification of the upcoming change in prior authorization approval required before administering this medication under the medical benefit.
Production Date: December 4, 2024
Nedosiran (Rivfloza) updated prior authorization criteria (PDF)
Nedosiran (Rivfloza) is on the non-Medicare list of office-administered drugs requiring prior authorization. Effective March 1, 2025, the criteria for nedosiran (Rivfloza) will be updated to include a quantity limit. This letter is a notification of the upcoming change in prior authorization criteria required before administering this medication in a physician’s office.
Production Date: December 4, 2024
Medicare Part B drug requiring step therapy: epcoritamab-bysp (Epkinly) (PDF)
Effective March 1, 2025, step therapy requirements will be required for the non-preferred Medicare Part B drug, epcoritamab-bysp (Epkinly). This letter is a notification of the upcoming change in step therapy approval required before administering this medication under the medical benefit.
Production Date: December 4, 2024
Medicare Part B drugs requiring prior authorization (PDF)
Effective March 1, 2025, 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 this medication under the medical benefit.
Production Date: October 21, 2024
Changes to medical necessity review criteria for fundoplication procedures (PDF)
Applies to: Commercial - HMO, POS, PPO, Medicare Advantage.
Effective February 1, 2025, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are implementing medical necessity review criteria for Fundoplication procedures.
Production Date: October 21, 2024
Changes to medical necessity review criteria for hip arthroscopy (PDF)
Applies to: Commercial - HMO, POS, PPO, Medicare Advantage.
Effective February 1, 2025, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are implementing new medical necessity criteria for Hip Arthroscopy Procedures.
Production Date: October 21, 2024
Modification Date: October 25, 2024
Modification to Postcard: Is prior authorization required? Language
Changes to medical necessity review criteria for physical, occupational, and speech therapy (PDF)
Applies to: Commercial - HMO, POS, PPO, Medicare Advantage.
Effective February 1, 2025, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are implementing new medical necessity criteria for Physical, Occupational, and Speech therapies.
Production Date: October 21, 2024
Changes to medical necessity review criteria for lumbar and thoracic MRI (PDF)
Applies to: Commercial - HMO, POS, PPO.
Effective February 1, 2025, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating medical necessity review criteria for Thoracic and Lumbar MRI.
Production Date: October 21, 2024
Changes to medical necessity review criteria for ultrasound-guided needle release of carpal tunnel (PDF)
Applies to: Commercial - HMO, POS, PPO, Medicare Advantage.
Effective February 1, 2025, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are retiring the medical policy for ultrasound-guided needle Release of Carpal Tunnel Procedure.
Production Date: October 21, 2024
Associate level mental health care (PDF)
Applies to: Commercial - HMO, POS, PPO.
Effective January 1, 2025, 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 qualified mental health provider with the rendering associate-level therapist or counselor captured as the rendering servicing practitioner on the submitted claim (including but not limited to name and NPI).
Production Date: September 30, 2024
Changes to medical necessity review criteria for Advanced Care at Home (PDF)
Applies to: Commercial - HMO, POS, PPO, Medicare Advantage.
Effective January 1, 2025, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the Advanced Care at Home policy.
Production Date: September 30, 2024
Changes to medical necessity review criteria for Knee Arthroscopy (PDF)
Applies to: Commercial - HMO, POS, PPO, Medicare Advantage.
Effective January 1, 2025, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are implementing new criteria for Knee Arthroscopy.
Production Date: September 30, 2024
Changes to medical necessity review criteria for Rhinoplasty (PDF)
Applies to: Commercial - HMO, POS, PPO.
Effective January 1, 2025, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the Rhinoplasty policy.
Production Date: September 30, 2024
Changes to medical necessity review criteria for Thyroid Surgeries (PDF)
Applies to: Commercial - HMO, POS, PPO, Medicare Advantage.
Effective January 1, 2025, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are implementing a new Thyroid Surgeries policy.
Production Date: August 29, 2024
Dexmedetomidine (Igalmi) will require prior authorization approval (PDF)
Effective December 1, 2024, Dexmedetomidine (Igalmi) 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.
Production Date: August 29, 2024
Changes to Vedolizumab (Entyvio) under the medical benefit (PDF)
Vedolizumab (Entyvio) is on the non-Medicare list of office-administered drugs requiring prior authorization. Effective December 1, 2024, the criteria for intravenous vedolizumab (Entyvio) will be updated to reflect the preferred subcutaneous vedolizumab (Entyvio) for established members. In addition, subcutaneous vedolizumab (Entyvio) will NOT be covered under the medical benefit. Pharmacy benefit coverage remains available for members who meet prior authorization criteria. This change does not affect current authorizations for Entyvio; however, any new authorizations are subject to the criteria below. This letter is a notification of the upcoming change in prior authorization criteria required before administering this medication under the medical benefit.
Production Date: August 29, 2024
Medicare Part B drug requiring step therapy: Filgrastim (neupogen) (PDF)
Effective December 1, 2024, step therapy requirements will be updated for the non-preferred Medicare Part B drug, filgrastim (Neupogen). This letter is a notification of the upcoming change in step therapy approval required before administering this medication under the medical benefit.
Production Date: August 29, 2024
Updated prior authorization criteria for tocilizumab (actemra) (PDF)
Tocilizumab (Actemra) is on the non-Medicare list of office-administered drugs requiring prior authorization. Effective December 1, 2024, the criteria for intravenous tocilizumab (Actemra) will be updated to reflect the preferred biosimilar, tocilizumab-aazg (Tyenne). This change does not affect current authorizations for Actemra; however, any new authorizations are 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.
Production Date: August 29, 2024
Changes to medical necessity review criteria for chronic cerebrospinal venous insufficiency treatment (PDF)
Applies to: Commercial - HMO, POS, PPO, Medicare Advantage.
Effective December 1, 2024, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the Chronic Cerebrospinal Venous Insufficiency Treatment in Patients with Multiple Sclerosis policy.
Production Date: August 29, 2024
Modification Date: October 10, 2024
Modification to Postcard: Changed Site of Care to Level of Care
Changes to medical necessity review criteria for Elective Surgical Procedure Level of Care (PDF)
Applies to: Commercial - HMO, POS, PPO, Medicare Advantage.
Effective December 1, 2024, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the Elective Surgical Procedure Level of Care policy.
Production Date: August 29, 2024
Changes to medical necessity review criteria for Femoroacetabular Impingement Syndrome (PDF)
Applies to: Commercial - HMO, POS, PPO, Medicare Advantage.
Effective December 1, 2024, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the Femoroacetabular Impingement (FAI) Syndrome criteria.
Production Date: August 29, 2024
Changes to medical necessity review criteria for genetic screening and testing (PDF)
Applies to: Commercial - HMO, POS, PPO.
Effective December 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: August 29, 2024
Changes to medical necessity review criteria for Mobility Assistive Devices (PDF)
Applies to: Commercial - HMO, POS, PPO.
Effective December 1, 2024, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the Mobility Assistive Devices policy.
Production Date: July 25, 2024
Advanced practice healthcare providers (PDF)
Applies to: Commercial - HMO, POS, PPO, Medicare Advantage.
Effective November 1, 2024, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) will reimburse for services rendered by an Advanced Practice Provider (APP) when the APP has an NPI number and is eligible to bill directly for services rendered according to applicable laws and regulations.
Production Date: July 25, 2024
Changes to medical necessity review criteria for Shoulder Arthroplasty (PDF)
Applies to: Commercial - HMO, POS, PPO, Medicare Advantage.
Effective November 1, 2024, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are adding criteria for Shoulder Arthroplasty.
Production Date: July 25, 2024
Changes to medical necessity review criteria for Gastric Electrical Stimulation (PDF)
Applies to: Commercial - HMO, POS, PPO, Medicare Advantage.
Effective November 1, 2024, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the criteria for Gastric Electrical Stimulation.
Production Date: July 25, 2024
Changes to medical necessity review criteria for Cytochrome P450 Pharmacogenetics (PDF)
Applies to: Commercial - HMO, POS, PPO.
Effective November 1, 2024, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the criteria for Cytochrome P450 Pharmacogenetics.
Production Date: June 28, 2024
Changes to medical necessity review criteria for high-end imaging site of care (PDF)
Applies to: Commercial - HMO, POS, PPO.
Effective October 1, 2024, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the criteria for High-End Imaging site of care.
Production Date: June 28, 2024
Changes to medical necessity review criteria for low-dose ct screening for lung cancer (PDF)
Applies to: Commercial - HMO, POS, PPO.
Effective October 1, 2024, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the criteria for low-dose ct screening for lung cancer.
Production Date: May 21, 2024
Changes to medical necessity review criteria for Bariatric Surgery (PDF)
Applies to: Commercial - HMO, POS, PPO.
Effective October 1, 2024, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the criteria for Bariatric Surgery.
Production Date: May 21, 2024
Lymphocyte immune globulin (Atgam) will require prior authorization approval (PDF)
Effective September 1, 2024, Lymphocyte immune globulin (Atgam) 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.
Production Date: May 21, 2024
Medicare Part B: mirikizumab-mrkz (Omvoh) requiring prior authorization (PDF)
Effective September 1, 2024, prior authorization will be required for mirikizumab-mrkz (Omvoh) under Medicare Part B. This letter is a notification of the upcoming change in prior authorization review required before administering this medication under the medical benefit.
Production Date: May 21, 2024
Changes to medical necessity review criteria for New and Emerging Technology (PDF)
Applies to: Commercial - HMO, POS, PPO, Medicare Advantage.
Effective September 1, 2024, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the criteria for New and Emerging Technology.
Production Date: May 21, 2024
Changes to medical necessity review criteria for treatments for Lower Limb Prostheses (PDF)
Applies to: Commercial - HMO, POS, PPO.
Effective September 1, 2024, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the criteria for Lower Limb Prostheses.
Production Date: May 21, 2024
Changes to medical necessity review criteria for treatments for Bone Lengthening Procedures (PDF)
Applies to: Commercial - HMO, POS, PPO, Medicare Advantage.
Effective September 1, 2024, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are implementing criteria for Bone Lengthening Procedure.
Production Date: May 21, 2024
Changes to medical necessity review criteria for treatments for Radiation Therapy for Palmar Fibromatosis (PDF)
Applies to: Commercial - HMO, POS, PPO, Medicare Advantage.
Effective September 1, 2024, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the criteria for Radiation Therapy for Palmar Fibromatosis.
Production Date: May 21, 2024
Changes to medical necessity review criteria for treatments for Superficial Radiation Therapy (PDF)
Applies to: Commercial - HMO, POS, PPO, Medicare Advantage.
Effective September 1, 2024, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the criteria for Superficial Radiation Therapy.
Production Date: May 21, 2024
Changes to medical necessity review criteria for treatments for Sleep Studies (PDF)
Applies to: Commercial - HMO, POS, PPO, Medicare Advantage.
Effective September 1, 2024, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are implementing criteria for Sleep Studies (Polysomnography).
Production Date: May 21, 2024
Changes to medical necessity review criteria for treatments for Transcutaneous Electrical Stimulation (TENS) devices (PDF)
Applies to: Commercial - HMO, POS, PPO.
Effective September 1, 2024, Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc. (Kaiser Permanente) are updating the criteria for TENS units.
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.