Services Requiring 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. 
• Arthroscopic Procedures (Knees, Hips, and Shoulders)
• Autologous Chondrocye Implantations 
• Behavioral Health Higher Level of Care
• Partial hospitalization
• Intensive outpatient
• Residential services
• PET Scans 
• MRA Scans 
• Back surgeries for pain
• Continuous glucose monitors
• Dialysis (outpatient and home dialysis) 
• Invasive Back Procedures 
• Intensity-Modulated Radiation Therapy (IMRT).   *changes effective 4/1/2019
• 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 
• Gastric Neurostimulators 
• Genetic testing
• 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
• Knee Scooters 
• LINX
• Minimally Invasive Direct Coronary Bypass Grafts 
  
• Nuclear Medicine – Cardiology (Myocardial Perfusion Imaging, Tomographic/Planar) 
• Nonsegmental pneumatic appliance
• Oncology Related Services:

  • WEA will review all oncology related treatment plans for medical concordance

• Orthognathic Procedures   *these are still not covered for WEA Trust members in the State Health plan
• Osteochondral Autograft Knee, Open
• Outpatient Hysterectomy   *changes effective 4/1/2019
• Physical, speech, and occupational therapy services (excluding evaluations)
• Pneumatic Compressor
• Proton Beam Therapy   *changes effective 4/1/2019
• 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
• Segmental pneumatic appliance
• 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 Unit
• Total Joint Replacement  
• Transmagnetic Stimulation
• Transplant evaluations, services, and procedures 
• Treatment of temporomandibular disorders (TMD)
• UAS Therapy 
• Whole Body Imaging

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.