Information Regarding Services Requiring Preauthorization

Services Requiring Preauthorization

Services Requiring Preauthorization

  • Advanced Imaging
    • CT of the Neck or Spine
    • MRA Scans
    • MRI of the Neck or Spine
    • PET Scans
  • Arthroscopic Procedures (Knees, Hips, and Shoulders)
  • Autologous Chondrocye Implantations 
  • Behavioral Health Higher Level of Care
    • Inpatient services
    • Residential services
    • Partial hospitalizations
    • Intensive outpatient
    • Behavioral health day treatment
  • Back surgeries for pain
  • Continuous glucose monitors
  • Dialysis (outpatient and home dialysis) 
  • Durable medical equipment with a purchase OR rental price greater than $1,000
  • Cochlear Implants
  • Elective and/or planned inpatient stays prior to admission 
  • Electroconvulsive Therapy 
  • Genetic testing
    • Exception: the following Genetic Testing Services do not require Preauthorization: 
      • Fetal chromosomal aneuploidy genomic sequence analysis panel (81420)
      • Fetal chromosomal microdeletion(s) genomic sequence analysis (81422)
      • Fetal aneuploidy DNA sequence analysis (81507)
      • Fetal congenital abnormalities (81511)
  • Gastric Neurostimulators 
  • Home Health Services – Including Wound Care 
  • Hyperbaric Oxygen Therapy 
  • Impression and Customer Preparation; Speech Aid Prosthesis
  • Inpatient and outpatient facility usage associated with any dental services
  • Insulin Pumps
  • Intensity-Modulated Radiation Therapy (IMRT).  
  • Invasive Back Procedures 
  • Knee Scooters 
  • LINX
  • Minimally Invasive Direct Coronary Bypass Grafts
  • Neurostimulators
  • Nonsegmental pneumatic appliance
  • Nuclear Medicine – Cardiology (Myocardial Perfusion Imaging, Tomographic/Planar) 
  • Oncology Related Services:
  • Orthognathic Procedures
  • Osteochondral Autograft Knee, Open
  • Outpatient Hysterectomy   
  • Physical, speech, and occupational therapy services (excluding evaluations)
  • Pneumatic Compressor
  • Proton Beam Therapy  
  • Psychological and neuropsychological testing [Use this form when requesting authorization]
  • Reconstructive or plastic surgery such as, but not limited to:
    • Abdominoplasty
    • Blepharoplasty and ptosis repair
    • Brachioplasty
    • Breast augmentation, lift, or other breast reconstructive surgery
    • Panniculectomy
    • Prophylactic Mastectomy
    • Thighplasty
    • Treatment of varicose veins
  • Segmental pneumatic appliance
  • Skilled nursing facility care 
  • Skilled rehabilitation services
  • Sleep Studies - in a Facility (In home sleep studies do not require preauthorization)
  • Surgical Sleep Disorder Treatment 
  • Specialty drugs and high-cost drugs with unique monitoring or delivery needs
  • Tens Unit
  • Total Joint Replacement  
  • Transmagnetic Stimulation
  • Transplant evaluations, services, and procedures 
  • Treatment of temporomandibular disorders (TMD)
  • UAS Therapy
  • Ultrasound Elastography 
  • Whole Body Imaging

 




Third-party Preauthorization

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For physical, speech, and occupational therapy services (excluding evaluations) please obtain preauthorization through Magellan Healthcare (formerly HSM). 

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