2022 Prior Authorization List for Florida

Providers: For the quickest turnaround on prior authorizations, use Availity. You can find the login link and instructions in the "Using Availity" section of our Providers page.

Members: Your provider usually handles prior authorizations for you. If you need any help, call us at 1-800-338-6833, TTY 711.

The services and items listed below require prior authorization.

Behavioral Health

Contact our behavioral health partner, Magellan Healthcare (1-800-776-8684), about prior authorizations for:

• Electroconvulsive therapy (ECT)
• Transcranial magnetic stimulation (TMS)

Cardiac Devices

• Defibrillators (implantable)
• Left atrial appendage closure (LAAC) device, such as The Watchman
• Loop recorders
• Ventricular assist devices
• Wearable cardiac devices, such as Lifevest

Cardiac Diagnostic Testing

• Electrophysiology study (EPS)
• EPS with 3D mapping
• Myocardial perfusion imaging SPECT
• Nuclear stress test
• Transesophageal echocardiogram (TEE)

Cardiac Procedures and Surgeries

• Cardiac ablation
• Cardiac catheterizations (elective)
• Cardiac resynchronization therapy
• Outpatient coronary angioplasty/stent
• Transcatheter valve surgeries (TAVR)

Cosmetic and Plastic Surgery

• Abdominoplasty
• Blepharoplasty
• Breast procedures (except for mastectomy, reconstruction after mastectomy, and any cancer-related breast procedures)
• Gynecomastia surgery
• Panniculectomy and redundant skin tightening
• Rhinoplasty

Dental

In general, you don't need a prior authorization for dental care. We suggest that you always ask for a cost estimate before you receive dental services.

Diagnostic Imaging

• MRA
• MRI
• PET Scan
• SPECT

Durable Medical Equipment (DME)

Contact our DME partner, Integrated Home Care Services (1-844-215-4264), about prior authorizations for:

• Any DME that is not listed below and where the single purchase price or a rental over 13 months is more than $750
• Bariatric equipment (greater than 300 pounds)
• Bone growth stimulator
• Custom or specialized wheelchairs and scooters
• Neuromuscular stimulator
• Portable oxygen concentrator
• Prosthetic devices
• Specialty beds
• Ventilators covered by Medicare
• Wound vac

Home Healthcare

Contact our home healthcare partner, Integrated Home Care Services (1-844-215-4265), about prior authorizations for:

• Home healthcare
• Home infusion

Inpatient Admissions

• Acute hospital
• Acute rehab facility
• Long-term acute care (LTAC)
• Skilled nursing facility (SNF)

Please contact our behavioral health partner, Magellan Healthcare (1-800-776-8684), about prior authorizations for:

• Mental health/Substance abuse
• Partial hospitalization (PHP)

Medicare Part B Drugs

Prior authorization list for Medicare Part B drugs

Observation

No prior authorization needed, but make sure to let us know about it.

Oncology

• Chemotherapy, supportive drugs, and symptom management drugs
• Radiation therapy

Other Surgery

• Cochlear and auditory brainstem implants
• Gender dysphoria surgery
• Obesity surgery, such as gastric bypass
• Oral, orthognathic, temporomandibular joint surgeries
• Orthopedic (hip, knee, shoulder arthroscopy)
• Surgery for obstructive sleep apnea
• Transplant surgeries
• Varicose veins: surgical treatment and sclerotherapy

Outpatient Diagnostic Testing

• Facility-based sleep studies (PSG)
• Infertility testing and treatment
• Molecular diagnostic and genetic testing

Outpatient Therapy

• Hyperbaric therapy

Spine

• Epidural injections (outpatient)
• Facet injections
• Kyphoplasty
• Neurostimulators
• Spinal cord stimulator
• Spinal decompression surgery
• Spinal fusion
• Vertebroplasty

Vision care

• Ophthalmologic services

Wound Therapy

• Negative pressure wound therapy (NPWT)

Other Services

• Experimental procedures, services, or devices
• Non-emergency ambulance services
• Out-of-network services and care (In most cases, members need to see in-network providers. But for special cases, they can request a prior authorization to see if we'll cover out-of-network care.)

No prior authorization needed for the following services, but make sure to let us know about them:

• Clinical trials
• Out-of-area dialysis at a Medicare-certified facility