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:
  • WEA will review all oncology related treatment plans for medical concordance [Use this form when requesting authorization]
• 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

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