Gundersen Lutheran Administration System (GLAS) Prior Authorization

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. Prior authorization is not a guarantee of payment.

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

Any purchase items in excess of $500 in billed charges, and all equipment rental, 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 (LTACH)
• Skilled nursing facility / swing bed

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
• Palliative Care
• Prolotherapy
• Proton Beam Therapy
• Prostate Artery Embolization
• Robotic Assisted Procedures
• 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)

Out-of-Network Services or Supplies

Surgical Procedures

Note: 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
• Deep Brain Stimulation 
• Endoscopic procedures for Reflux Management
• 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
• Orthopedic Procedures (Including Artificial Cervical and Lumbar Disc Surgery and OATS Procedures)
• Panniculectomy
• POEM (per-oral endoscopic myotomy) Procedure
• POP (per-oral pyloromyotomy) Procedure
• Prostate Artery Embolization
• 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
• Transcatheter Closure of Septal Defect
• Transperineal Placement of Biodegradable Material (SpaceOAR™)
• 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)