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
• Partial hospitalization
• Intensive outpatient
• Residential services
• 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
• 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:
  • 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   
• 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

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.