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Prior Authorizations


Providers: For the quickest turn-around on prior authorizations, submit your request through Availity.

Members: Usually, your provider handles prior authorization requests for you, but you can ask for one yourself. Learn how to ask for a prior authorization.

The services and items listed below require prior authorization.

Behavioral Health

Please contact our behavioral health partner, Carisk Behavioral Health (formerly Concordia Behavioral Health), about prior authorizations for:

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

Cardiac Devices

  • Cardiac resynchronization therapy
  • 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

  • Cardiac CT angiography (CCTA)
  • Electrophysiology study (EPS)
  • EPS with 3D mapping
  • Myocardial perfusion imaging SPECT
  • Nuclear stress test
  • Outpatient transthoracic echocardiogram (TTE)
  • Transesophageal echocardiogram (TEE)

Cardiac Procedures and Surgeries

  • Cardiac ablation
  • Cardiac catheterizations (elective)
  • 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

Diagnostic Imaging

  • MRA
  • MRI
  • PET Scan
  • SPECT

Durable Medical Equipment (DME)

  • Any DME that costs 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

Home Health Care

  • Home health care
  • Home infusion

Inpatient Admissions

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

Please contact our behavioral health partner, Carisk Behavioral Health (formerly Concordia Behavioral Health), about prior authorizations for:

  • Mental health hospitalizations
  • Partial hospital
  • Residential treatment
  • Substance use

Medicare Part B Drugs

Check this list to see which Medicare Part B drugs require prior authorization.

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

  • Gender dysphoria surgery
  • Mohs surgery
  • Obesity surgery, such as gastric bypass
  • Oral, orthognathic, temporomandibular joint surgeries
  • Orthopedic (hip, knee, shoulder arthroscopy)
  • Penile implants
  • 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
  • Spinal cord stimulator
  • Spinal decompression surgery
  • Spinal fusion
  • Vertebroplasty

Therapy and Rehab

No prior authorization needed for an initial evaluation. But before going ahead with treatment, providers must submit a Plan of Care for:

  • Physical therapy
  • Occupational therapy
  • Speech therapy

Other Services

  • Dental care — prior authorization needed only for dentures, extractions, and periodontics
  • 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.)
  • Vision care — prior authorization needed only for diagnostic testing and treatments

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

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