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2024 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: If you have an HMO plan and an Advocate Physician Partners (APP) primary care provider, APP will manage your prior authorizations.

The services and items listed below require prior authorization on all Devoted Health plans. If needed, you can review our coverage criteria here:

Internal coverage criteria for medical services

Internal coverage criteria for Part B drugs

For services managed by our partners, see the list below for links to coverage criteria.

Behavioral Health

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

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

Learn about Magellan Health's internal coverage criteria.

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

To get prior authorization on the services below for members on plans in Florida in Broward County, Miami-Dade County, Palm Beach County, Hillsborough County, or Pinellas County, call New Century Health at 1-888-999-7713. Learn about New Century Health’s internal coverage criteria.

For all other members, contact us directly.

  • 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

If your plan offers dental coverage through Delta Dental or Liberty Dental, you may need prior authorization for certain services related to:

  • Crowns
  • Root canals
  • Gum surgery
  • Deep cleanings
  • Dentures
  • Bridges
  • Extractions and oral surgery
  • Nitrous oxide (laughing gas)
  • Nightguards

See a detailed list of dental codes that require prior authorization

If your plan has a dental benefit card, dental and eyewear benefit card, or dental allowance, you do not need prior authorization.

Even when prior authorization isn’t required, we always recommend that you ask for a cost estimate before you get any dental care.

Diagnostic Imaging

  • MRA
  • MRI
  • PET Scan
  • SPECT

Durable Medical Equipment (DME)

To get prior authorization on the items below for members in Alabama, Hawaii, Illinois (if member’s PCP is not with Advocate Physician Partners), Pennsylvania, or Texas, call us directly at 1-800-338-6833 (TTY 711).

For members in all other states, call Integrated Home Care Services (our DME partner) at 1-844-215-4264. Note that when reviewing prior authorization requests, Integrated Home Care Services uses National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and other Medicare guidelines.

  • 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

To get prior authorization on the services below for members in Alabama, Hawaii, Illinois (if member’s PCP is not with Advocate Physician Partners), Pennsylvania, or Texas, call us directly at 1-800-338-6833 (TTY 711).

For members in all other states, call Integrated Home Care Services (our home healthcare partner) at 1-844-215-4264, fax: 1-844-215-4265.

  • Home health care
  • Home infusion

Inpatient Admissions

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

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

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

Learn about Magellan Health's internal coverage criteria.

Medicare Part B Drugs

2024 Prior authorization list for Medicare Part B drugs

You can also review our internal coverage criteria for part B drugs.

Observation

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

Oncology

To get prior authorization on the services below for members on plans in Florida in Broward County, Miami-Dade County, or Palm Beach County, call New Century Health at 1-888-999-7713. Learn about New Century Health's internal coverage criteria.

For all other members, call OncoHealth at 1-888-916-2616, extension 806. Learn about OncoHealth's internal coverage criteria.

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

Other Surgery

  • Cochlear and auditory brain stem 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

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

Prior authorization required
The following services require prior authorization:

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

Supplemental Naturopath, Supplemental Therapeutic Massage, and Acupuncture
The following services may require a review for medical necessity by American Specialty Health:

  • Supplemental Naturopath services on some plans in Arizona, Ohio, and Oregon
  • Supplemental Therapeutic Massage and Acupuncture services on some plans in Hawaii and Oregon

Check the plan’s Evidence of Coverage for requirements and benefit limits. To learn about American Specialty Health's coverage criteria, call 1-800-678-9133 (TTY 711).

Update requested
The following services don't require prior authorization but make sure to let us know about them:

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