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2023 Prior Authorization List

Providers: For the quickest turnaround on prior authorizations, use Availity. Follow the steps in the CPT authorization verification tool video or the How to submit prior authorizations and referrals guide located in our Provider Portal Training Library.

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

Note: For members with an HMO plan and an Advocate Physician Partners (APP) PCP, APP will manage referrals and authorizations.

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

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)
  • Cardiac Resynchronization Therapy

Cosmetic and Plastic Surgery

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

Dental

No prior authorization needed 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)

If you're on a plan in Arizona, Colorado, Florida, Hawaii, North Carolina, Ohio, Oregon, Pennsylvania, South Carolina, or Tennessee:

Contact our DME partner, Integrated Home Care Services (1-844-215-4264), about prior authorizations for the items listed below.

If you're on a plan in Alabama, Illinois, or Texas:

Call us directly at 1-800-338-6833 (TTY 711) if you need any of the items below.

The following items require prior authorization:

  • Any DME (not listed below) that costs more than $750 based on Medicare allowable amount
  • Bariatric equipment (greater than 300 pounds)
  • Bone growth stimulator
  • Custom or specialized wheelchairs and scooters
  • Neuromuscular stimulator
  • Portable oxygen concentrator
  • Prosthetics
  • Specialty beds
  • Ventilators covered by Medicare
  • Wound vac

Home Healthcare

If you're on a plan in Alabama, Arizona, Colorado, Florida, Hawaii, North Carolina, Ohio, Oregon, Pennsylvania, South Carolina, or Tennessee:

Contact our home healthcare partner, Integrated Home Care Services at 1-844-215-4264 (fax: 1-844-215-4265), about prior authorizations for the services listed below.

If you're on a plan in Illinois or Texas:

Call us directly at 1-800-338-6833 (TTY 711) if you need any of the services listed below:

The following services require prior authorization:

  • 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, Magellan Healthcare (1-800-776-8684), about prior authorizations for:

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

Medicare Part B Drugs

2023 Prior authorization list for Medicare Part B drugs

Observation

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

Oncology

For most plans: Please call OncoHealth (1-888-916-2616 ext. 806) if you need any of the services listed below.

If you're on a plan in Miami-Dade, Broward, or Palm Beach County: Please call New Century Health (1-888-999-7713) if you need any of the services listed below.

  • 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)
  • Orthopedic total joint replacement
  • 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

Wound Therapy

  • Negative pressure wound therapy (NPWT)

Other Services

  • Non-emergency ambulance services
  • Vision care (some ophthalmologic services only)
  • Experimental Procedures (category III CPTs)

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