Information Regarding Services Requiring Preauthorization

Services Requiring Preauthorization

Services Requiring Preauthorization include, but are not limited to the following:

  • Behavioral Health Higher Levels of Care
    • Inpatient Services
    • Intensive Outpatient
    • Partial Hospitalizations
    • Residential Services
  • Dialysis (outpatient and home dialysis)
  • Durable Medical Equipment for the following items with a purchase OR rental price greater than $5,000
    • Electric Wheelchairs
    • Prosthetics
    • Zoll Vests
    • Compression Vests for Cystic Fibrosis
  • Genetic Testing
    • Exception: the following Genetic Testing Services DO NOT require Preauthorization:
      • CFTR/Cystic Fibrosis Transmembrane Conductance Regulator (81220)
      • 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)
      • Spinal Muscular Atrophy (SMA) Carrier Screening (81329)
  • Hyperbaric Oxygen Therapy
  • Inpatient admissions (elective/planned, including observation stays that extend beyond 48 hours)
  • Intensity-Modulated Radiation Therapy (IMRT).
  • Invasive Back Procedures (injections, radio frequency ablation)
  • Nutritional Support (Enteral Feedings)
  • Oncology Related Services:
    • All treatment regimens (including chemotherapy, radiation, services, procedures, etc. being requested for a member with a cancer diagnosis requires prior authorization. [Use this form when requesting authorization]
  • Orthognathic Surgery
  • Orthopedic Procedures such as, but not limited to:
    • Arthroscopic Procedures (knees, hips and shoulders)
    • Back Surgeries
    • Total Joint Replacements/Revisions/Repairs
  • Physical, Speech, and Occupational Therapy Services (excluding evaluations)
  • Proton Beam Therapy
  • 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
    • Septoplasty
    • Thighplasty
    • Treatment of Varicose Veins
  • Skilled Nursing Facilities
  • Skilled Rehabilitation Services
  • Sleep Studies - in a Facility (In-home sleep studies do not require preauthorization)
  • Specialty Drugs (See Prescription Drug Preauthorization list at the top of the page)
  • TMJ/TMD Devices/Oral Appliances
  • Transplant evaluations, services, and procedures

Decisions on preauthorization requests submitted with all necessary clinical information will be made within 15 calendar days of receipt of the request. It is highly recommended you not schedule services prior to receiving an approved authorization.

Please note that the preauthorization of any procedure does not guarantee benefits or payment. Approval is based on medical appropriateness and necessity as defined in the patient’s benefit plan or certificate.

All benefits are subject to the term, conditions and exclusions of the benefit plan or certificate.

 

Third-party Preauthorization

Magellan logo

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

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