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.


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


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 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

Questions

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 MyPlanTools for providers or MyChart for members or call (800) 362-3310.