Member Prior Authorization Resources:
Southwest Health List

All equipment rental, and any purchase DME items in excess of $500 in billed charges require prior authorization. Exceptions are as follows (items below do NOT require prior authorization):

• Airway Clearance Device (except Vest Therapy)
• Cardiac Cardioverter Defibrillator (Wearable)
• Continuous Glucose Monitor
• Hospital Bends & Related Supplies
• Insulin Pumps
• Spinal Traction Devices
• Walk-aid Devices (electronic or e-Stim)

Note: Urgent/emergent hospital admissions require notification at the time of admission. Elective hospital admissions require prior authorization before admission and notification when admitted.

• Hospitals, inpatient care
• Inpatient rehabilitation facilities
• Long term acute care hospital (LTACH)
• Skilled nursing facility / swing bed facility

• Ambulance Services (non-emergent/urgent)
• Autism
• Bioengineered Skin Substitutes
• Biofeedback (only covered for spastic torticollis, headache or pediatric urinary incontinence)
• CAR T Cell Therapy
• Custom Shoes and Custom-molded Orthotics (limited benefit) Including Orthopedic Shoes
• Experimental and Investigational Treatments
• Fractional Flow Reserve Calculation after Coronary CT Angiography (FFR-CT)
• Genetic Testing
• Home Health Care (including home infusion services and other in-home therapy services)
• Hospice Care
• Hyperbaric Oxygen Therapy
• Life-Sustaining Nutritional Therapy
• Palliative Care
• Proton Beam Therapy
• Treatment of Urinary & Fecal Incontinence

A prior authorization is required for services outside of the Quartz network unless for urgent or emergency service.

Note: The following procedures must be prior authorized before they are scheduled.

• Abortions (including multi-fetal reductions)
• Artificial Iris
• Bariatric Surgery
• Basivertebral Nerve Ablation
• Gender Affirming Surgical Procedures
• Implantable Nerve Stimulators
• Laser Treatment Including Eximer, Pulsed Dye, Fractional and Other Lasers
• Left Ventricular Assist Devices (LVAD) for Treatment of Heart Failure
• Mandibular Osteotomy and Maxillomandibular Osteotomy and Advancement for Obstructive Sleep Apnea
• Orthognathic Surgery (Repair/Revision/Reconstruct procedures on head) (cosmetic procedures are excluded)
• Orthopedic Procedures (Including Artificial Cervical and Lumbar Disc Surgery, and OATS Procedures)
• Panniculectomy
• Reconstructive Surgery
• Removal of Port Wine Stains and Hemangiomas
• Rhinoplasty and Septorhinoplasty
• Scar Revision and Repair (cosmetic procedures are excluded)
• Surgical Treatment of Obstructive Sleep Apnea
• Temporomandibular Joint (TMJ) Disease Surgical Treatment
• Transplants Including Donor and Other Related Charges (excludes corneal except for artificial corneal transplants)
• Varicose Vein Procedures (including Sclerotherapy, Radiofrequency Ablation, Vein Stripping and Ligation)

Prior authorization is required for clinic-administered medications. Practitioners must submit a prior authorization request via My Quartz Tools or fax a Medication Prior Authorization Request Form to Quartz at (888) 450-4711.