General Prior Authorization List – Illinois

The following Prior Authorization List is not all-inclusive and will be updated periodically. Members are encouraged to review the Prior Authorization List frequently for changes. Please contact Quartz Customer Success at (800) 362-3310 with questions to determine if an item or service requires prior authorization.
Different prior authorization rules and criteria may apply if services are sought outside the Quartz service area. Contact Quartz Consumer Success at (800) 362-3310 to see if they apply to your situation.

Different prior authorization rules and criteria may apply if services are sought outside the Quartz service area. Contact Quartz Customer Success at (800) 897-1923 to see if it applies to your situation.

The services listed below require prior authorization. Prior authorization is not a guarantee of payment. Quartz will provide advance notice of changes to prior authorization requirements and will not apply a change in coverage or approval criteria for a previously authorized service sooner than the end of the plan year.

General Prior Authorization List

Behavioral Health Services
  • Experimental and Investigational Treatments
  • In-home Therapy
  • Partial Hospital Program (PHP)
  • Residential Treatment
  • Transcranial Magnetic Stimulation (TMS)
  • Vagus Nerve Stimulation
Durable Medical Equipment (DME)

See your Schedule of Benefits for prior authorization requirements on DME items.

Inpatient Admissions
  • Elective hospital admissions require prior authorization before admission and notification when admitted
  • Hospice/Palliative Care
  • Hospitals, Acute Inpatient Care
  • Inpatient Rehabilitation Facilities
  • Long-Term Acute Care Hospital (LTACH)
  • Psychiatric Admissions
  • Skilled Nursing Facility/Swing Bed
Surgical Procedures
  • Bariatric Surgery
  • Blepharoplasty
  • Bone Anchored Hearing Aids (BAHA)
  • Breast Surgery
  • Brow Lifts
  • Cochlear Implants
  • Deep Brain Stimulation
  • Endoscopic procedures for Reflux Management (LINX)
  • Gender Affirming Surgery
  • Implantable Nerve Stimulators
  • Laser resurfacing for non-cosmetic procedures (cosmetic procedures are excluded)
  • Laser Treatment of Actinic Keratosis or other benign skin lesions
  • Left Ventricular Assist Devices (LVAD) for the Treatment of Heart Failure
  • Orthognathic Procedures
  • Orthopedic Procedures (including Artificial Cervical and Lumbar Disc Surgery, OATS Procedures)
  • Panniculectomy
  • 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
  • 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)
Other Services
  • Ambulance Services (non-emergent/urgent)
  • Biofeedback (coverage limited to the treatment of Spastic Torticollis, headache, or Pediatric Urinary Incontinence)
  • CAR T-Cell Therapy
  • Custom Shoes and Custom-molded Orthotics (including orthopedic shoes)
  • Experimental and Investigational Treatments
  • Extracorporeal Shockwave Therapy
  • Genetic Testing
  • Home Health Care (including Home Infusion Services and Other In-Home Therapy Services)
  • Hyperbaric Oxygen Therapy
  • Infertility Treatment
  • Private Duty Nursing
  • Prolotherapy
  • Proton Beam Therapy
  • 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 and Bioengineered Skin Substitutes

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