Prior Authorization List for Medical Services

Prior authorization does not guarantee payment. Coverage of services is based on member eligibility and member’s benefits per the medical certificate of coverage at the time services are rendered.

Providers are encouraged to review the Prior Authorization List frequently for changes.

Services Requiring Prior Authorization (Effective as of January 1, 2018)

The following list of services require prior authorization from Plan before rendering services:

Durable Medical Equipment

  • Airway Clearance Devices
  • Bone Growth Stimulators
  • Braces / splints over $500
  • Cardiac defibrillator (external only)
  • Continuous glucose monitors
  • Continuous passive motion machines
  • CPAP, BiPAP (rental and purchase)
  • Custom shoes and custom-molded foot orthotics (limited benefit) includes orthopedic shoes
  • Cystic Fibrosis vests
  • Dynamic Orthotic Cranioplasty (DOC) bands
  • Electric Tumor Treatment Fields (TTF) Device (Optune®) ​
  • Home monitoring devices
  • Home Phototherapy (UVB) Light Devices for Treatment of Psoriasis​
  • Hospital beds and related supplies
  • Insulin pumps
  • Life sustaining nutritional therapies
  • Mechanical stretching devices
  • Patient​ lift ​equipment
  • Prosthetics, including upper extremity, lower extremity, eye, face, etc.
  • Spinal Traction Devices
  • Standing Frame / Stander
  • TENS and other e-Stim devices
  • Walk-aid devices (electronic or e-Stim)
  • Wheelchairs and motorized scooters

  • Wound Therapy (Advanced), including Negative Pressure (Vac) Therapy, Noncontact Normothermic Wound Therapy (NNWT) and Bioengineered Skin Substitutes
  • Experimental and Investigational Treatments
  • Genetic Testing including Pharmacogenetics Testing
  • Home Health Care including home infusion services and other in-home therapy services
  • Hospice Care

Inpatient Admissions

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, Acute Inpatient Care
  • Inpatient Rehabilitation Facilities
  • Long Term Acute Care (LTACH)
  • Psychiatric ​Admissions
  • Skilled ​Nursing ​Facility / ​Swing ​Bed

Other Services

  • CAR T Cell therapy
  • Day treatment
  • Extended Cardiac Rhythm Monitoring (External and Implanted Cardiac Monitors/Loop Records)
  • Fecal Bacteriotherapy ​
  • Outpatient High Tech Radiology Services (ETF Only)*
    • Cardiac Nuclear Stress Tests
    • CT and CTA
    • MRI and MRA
    • PET Scan
  • Intensive Outpatient Program (IOP)
  • Non-emergent Ambulance Services
  • Partial Hospital Program (PHP)
  • Platelet-Rich Plasma (PRP) Injections​
  • Residential treatment
  • Steroid Releasing Sinus Implants
  • TheraSphere / Sir-spheres Treatment ​
  • Transcranial Magnetic Stimulation (TMS)
  • Vagus Nerve Stimulation
  • Wireless / remote heart failure monitoring devices (CardioMems™)

*UW Health and UnityPoint Health – Meriter Clinics are exempt from prior authorization for High Tech Radiology Services


Out-of-Network Services or Supplies


Surgical Procedures

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

  • Abortions including multi-fetal reductions
  • Bariatric Surgery
  • Blepharoplasty
  • Bone Anchored Hearing Aids (BAHA)
  • Breast Surgery
  • Brow lifts
  • Cochlear Implants
  • Corneal Cross-linking
  • Endoscopic procedures for Reflux Management ​
  • Implantable Nerve Stimulators
  • Laser re-surfacing for non-cosmetic procedures (cosmetic procedures are excluded)
  • Laser treatment of actinic keratosis or other benign skin lesions
  • Left Ventricular Assist Devices (LVAD) for Treatment of Heart Failure ​
  • Orthopedic Procedures Including Artificial Cervical and Lumbar Disc Surgery, OATS Procedures and Hip Resurfacing
  • POEM Procedure
  • Panniculectomy
  • Prosthetic Urethral Lift (Urolift®) ​
  • Removal of port wine stains and hemangiomas
  • Rhinoplasty and septorhinoplasty
  • Robotic Assisted Procedures
  • Scar revision and repair
  • Surgical Treatment of Pectus Excavatum and Carinatum Syndrome
  • Temporomandibular Joint Disease surgical treatment
  • Transgender Surgery
  • Transplants including donor and other related charges (excludes corneal except for artificial corneal transplants)
  • Transcatheter Closure of  Septal Defect
  • Surgical Treatment of Obstructive Sleep Apnea
  • Varicose Vein or Spider Vein Procedures including Sclerotherapy, Radiofrequency Ablation, Vein Stripping and Ligatio

Therapies

  • Biofeedback (only covered for spastic torticollis, headache or pediatric urinary incontinence)
  • ​Extracorporeal Shockwave Therapy
  • Hyperbaric Oxygen Therapy
  • Prolotherapy

This health plan is underwritten by Physicians Plus Insurance, Inc.