2020 Prior Authorization List for Texas

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

Please contact our behavioral health partner, Carisk 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

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)
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

CT/CTA (No prior authorization needed, but referral is required)
MRA
MRI
PET scan
SPECT

Durable Medical Equipment (DME)

Any DME that costs more than $250
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, about prior authorizations for:

Mental health hospitalizations
Partial hospital
Residential treatment
Substance use

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

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

Kyphoplasty
Spinal cord stimulator
Spinal decompression surgery
Spinal fusion
Vertebroplasty

Therapy and Rehab

For an initial evaluation, we require a referral. Before going ahead with treatment, providers must submit a Plan of Care and receive prior authorization for:

Physical therapy
Occupational therapy
Speech therapy

Other Services

Dental care — prior authorization needed only for dentures, extractions, and periodontics
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.)
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
In-network dialysis
Out-of-network dialysis at a Medicare-certified facility