Member Prior Authorization Resources:
Medicare Advantage and DNSP

• Experimental and Investigational Treatments
• In-home Therapy
• Partial Hospital Program (PHP)
• Transcranial Magnetic Stimulation (TMS)
• Intensive Outpatient Program (IOP)
• Day Treatment
• Inpatient Psychiatric Admissions (requires notification only)

All durable medical equipment (DME) costs of $500 or more requires prior authorization. DME costs of less than $500 do not need a prior authorization if the KX modifier is used on the claim. DME costs include repair, purchase, or equipment rental. (excluding CGM, insulin pump, hospital bed, and walking aids)

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 (see above explanation)
• Hospital Observation Care (out-of-network requires immediate notification, in-network after 24 hours)
• Inpatient Rehabilitation Facilities (Requires prior authorization)
• Long-Term Acute Care Hospital (LTACH) (requires prior authorization)
• Skilled ​Nursing ​Facility/Swing ​Bed for Part A stay (requires prior authorization)

• Self-Administered medications (patient picks up at pharmacy)
• Clinic-Administered medications (clinic and outpatient hospital)

Prior authorization is required for Part B therapies over Medicare Therapy Caps (30 visits for Physical/Speech Therapies combined and 30 visits for Occupational Therapy)

Note: The following procedures must receive prior authorization before they can be scheduled.

• Bariatric Surgery
• Blepharoplasty/Brow Lifts/Blepharoptosis/Brow ptosis
• Breast Surgery (not including Mammoplasty or Reconstruction Post Mastectomy)
• Cochlear Implants
• Gender Reassignment Surgical Procedures
• Implantable Nerve Stimulators
• Laser Treatment of Benign Skin Lesions (not including for diagnosis of Actinic Keratosis)
• Orthopedic Procedures: Artificial Lumbar Disc Surgery (including artificial cervical and Lumbar disc surgery and OATS procedures)
• Rhinoplasty and Septoplasty
• Scar Revision and Other Repair of Scars
• Panniculectomy
• Transplants including Donor and Other Related Charges (excludes corneal except for artificial corneal transplants)
• Surgical Treatment of Obstructive Sleep Apnea
• Varicose Vein or Spider Vein Procedures (including Sclerotherapy, Radiofrequency Ablation, Vein Stripping, and Ligation)
• Cosmetic Procedures/Surgeries (excludes skin cancer removal)

• Experimental and Investigational Treatments
• Genetic Testing including Pharmacogenetics Testing
• Home Health Care, including home infusion services and other in-home therapy services.
• Bioengineered Skin Substitutes
• Hospice Care (requires notification only)
• Hyperbaric Oxygen Therapy 
• Palliative Care (no prior authorization required for in clinic, 6 visits per lifetime for in-home)