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General Prior Authorization List for Medical Services

The following Prior Authorization List is not an all-inclusive list and will be updated on a periodic basis. Providers are encouraged to review the Prior Authorization List frequently for changes.

Please contact Quartz Customer Service at (800) 362-3310 with specific code information to determine if an item or service requires prior authorization. Prior authorization is not a guarantee of payment.

Behavioral Health Services

  • Experimental and Investigational Treatments
  • In-home Therapy
  • Intensive Outpatient Program (IOP)
  • Partial Hospital Program (PHP)
  • Residential Treatment
  • Transcranial Magnetic Stimulation (TMS)
  • Vagus Nerve Stimulation

Durable Medical Equipment

All equipment rental and any purchase items in excess of $500 in billed charges require prior authorization.

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 Hospital (LTACH)
  • Psychiatric ​Admissions
  • Skilled ​Nursing ​Facility/Swing ​Bed


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

Medication Prior Authorization List

Other Services

  • Ambulance Services (non-emergent/urgent) 
  • Biofeedback (only covered for spastic torticollis, headache, or pediatric urinary incontinence) 
  • CAR T Cell Therapy 
  • Custom Shoes and Custom-molded Orthotics Including Orthopedic Shoes 
  • Experimental and Investigational Treatments 
  • Extended Cardiac Rhythm Monitoring (External and Implanted Cardiac Monitors/Loop Records) 
  • Extracorporeal Shock Wave Therapy 
  • Fractional Flow Reserve Calculation after Coronary CT Angiography (FFR-CT). 
  • Genetic Testing (including Cell-free DNA Testing for Fetal Aneuploidy, Pharmacogenetic, Tumor Marker, Whole Exome and Whole Genome Sequencing Testing) 
  • Home Health Care (including home infusion services and other in-home therapy services)
  • Hospice Care 
  • Hyperbaric Oxygen Therapy 
  • Outpatient High Tech Radiology Services (ETF Only)*
    • Cardiac Nuclear Stress Tests
    • CT and CTA
    • MRI and MRA
    • PET Scan
  • Palliative Care
  • Prolotherapy
  • Proton Beam Therapy
  • Prostate Artery Embolization
  • Radioembolization with Yttrium 90 Microspheres (TheraSphere™/SIR-Spheres®) Treatment
  • Treatment of Urinary and Fecal Incontinence
  • Vagus Nerve Stimulation
  • Wound Therapy-Advanced (including Negative Pressure/Vac) Therapy, Noncontact Normothermic Wound Therapy (NNWT) and Bioengineered Skin Substitutes) 
*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

Note: 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
  • Deep Brain Stimulation
  • Endoscopic Procedures for Reflux Management (LINX®)
  • Gender Reassignment Surgical Procedures
  • 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 Atrial Appendage Closure (Watchman™)
  • Left Ventricular Assist Devices (LVAD) for Treatment of Heart Failure
  • Orthopedic Procedures (Including Artificial Cervical and Lumbar Disc Surgery and OATS Procedures)
  • Panniculectomy
  • POEM (per-oral endoscopic myotomy) Procedure
  • POP (per-oral pyloromyotomy) Procedure
  • Removal of Port Wine Stains and Hemangiomas
  • Rhinoplasty and Septorhinoplasty
  • Robotic Assisted Procedures
  • Scar Revision and Repair (cosmetic procedures are excluded)
  • Surgical Treatment of Obstructive Sleep Apnea
  • Temporomandibular Joint Disease Surgical Treatment
  • Transcatheter Closure of Septal Defect
  • Transperineal Placement of Biodegradable Material (SpaceOAR™)
  • 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)


If you have any questions about the prior authorization list or want to know if a service or supply requires prior authorization, please contact Customer Service through the message center within My Quartz Tools for providers or MyChart for members or call (800) 362-3310.