Services Requiring Preauthorization

Providers:Preauthorization:Services Requiring Preauthorization

Advanced imaging scans (e.g. MRI, CT scans) of the neck and spine provided on an outpatient basis. Such scans provided while you are inpatient or provided as part of emergency care are not subject to preauthorization. *
Autologous Chondrocyte Implantations (Effective 9/1/16)
Behavioral Health Care:

Partial hospitalization
Intensive outpatient
Residential services

PET Scans
MRA Scans
Back surgeries for pain
Invasive Back Procedures
Certain high-cost durable medical equipment, prosthetics, orthotics and oxygen-related equipment and services
- CPAP, BiPAP, and VPAP machines
- Apnea monitors and oral appliances for the treatment of apnea
- Ventilators and supplies
- Oxygen concentrators
- Stimulators – bone, brain
- Home infusion
- Hyperbaric Oxygen Therapy
- Enteral Nutrition
- Home infusion/ambulatory infusion pumps
- Specialty beds and accessories
- Defibrillator vest
- Power wheelchairs and accessories
- Power operated vehicles (i.e. scooters)
- Artificial limbs
- Custom back braces
- Lower extremity braces
- Chest Compression System
Cochlear Implants (effective 9/1/16)
Continuous Glucose Monitors and Supplies
Dialysis - Outpatient and Home Dialysis

Elective and/or planned inpatient stays prior to admission
Electroconvulsive Therapy
Gastric Neurostimulators (Effective 9/1/16)
Genetic testing
Home Health Services – Including Wound Care
Impression and Customer Preparation; Speech Aid Prosthesis (Effective 9/1/16)
Insulin Pumps and Supplies
Nuclear Medicine – Cardiology (Myocardial Perfusion Imaging, Tomographic/Planar)
Orthognathic Procedures **these are still not covered for WEA Trust members in the State Health plan.
Osteochondral Autograft Knee, Open (Effective 9/1/16)
Physical, speech, and occupational therapy services (excluding evaluations)
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
- Thighplasty
- Treatment of varicose veins
Skilled nursing facility care
Skilled rehabilitation services
Sleep Studies
Surgical Sleep Disorder Treatment
Specialty drugs and high-cost drugs with unique monitoring or delivery needs
Tens Units (Effective 9/1/16)
Total Joint Replacement
Transmagnetic Stimulation
Transplant evaluations, services and procedures
Treatment of temporomandibular disorders (TMD)
Whole Body Imaging (Effective 9/1/16)

* All advanced imaging scans require preauthorization for State Health Plan members.

Third-party Preauthorization

For physical, speech, and occupational therapy services (excluding evaluations) please obtain preauthorization through Magellan Healthcare (formerly HSM). All Chiropractic claims should also be submitted to Magellan, but there is no preauthorization for chiropractic care.

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