Prior Authorization

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

All equipment rentals and any purchased 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

Medication

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 receive prior authorization before they can be 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
• Orthognathic Surgery
• 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
• 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)