Prior Authorization List - Southwest Health

Prior Authorization List for Medical Services

The following is not an all-inclusive list. Updates are periodically made to the Prior Authorization list. Providers are encouraged to review the Prior Authorization List frequently for changes.

Please contact Quartz Customer Service at (800) 805-0693 with specific code information to determine if an item or service requires prior authorization. Prior Authorization is not a guarantee of payment.

Durable Medical Equipment

  • Airway Clearance Devices
  • Bone Growth Stimulators
  • Braces / splints over $500
  • Cardiac Cardioverter 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 threapy
  • Day treatment
  • Extended Cardiac Rhythm Monitoring (External and Implanted Cardiac Monitors / Loop Recorders)
  • Fecal Bacteriotherapy
  • 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™)

Out-of-Network Services or Supplies

Medication

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

Medication Prior Authorization List

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 Resurfacting
  • Panniculectomy
  • POEM Procedure
  • Prosthetic Urethral Lift (Urolift®)
  • Removal of port wine stains and hemangiomas
  • Rhinoplasty and septorhinoplasty
  • Robotic Assisted Procedures
  • Scar revision and repair
  • Surgical Treatment of Obstructive Sleep Apnea
  • Surgical Treatment of Pectus Excavatum and Carinatum Syndrome
  • Temporomandibular Joint Disease surgical management
  • Transcatheter Closure of Septal Defect
  • Transgender Surgery
  • Transplants including donor and other related charges (excludes corneal except for artificial corneal transplants)
  • Varicose vein or spider vein procedures including sclerotherapy, radiofrequency ablation, vein stripping and ligation

Therapies

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

Southwest Health Additional Requirements

  • Autism