Provider Prior Authorization Resources:
Gundersen Lutheran Administration System (GLAS)

• Experimental and Investigational Treatments 
• Inpatient Care (elective/non-emergent)
• In-home Therapy
• Partial Hospital Program (PHP)
• Residential Treatment
• Transcranial Magnetic Stimulation (TMS)
• Vagus Nerve Stimulation

All equipment rental, and any purchase DME items in excess of $500 in billed charges require prior authorization. Exceptions are as follows (items below do NOT require prior authorization):

• Airway Clearance Device (except Vest Therapy)
• Cardiac Cardioverter Defibrillator (Wearable)
• Continuous Glucose Monitor
• Hospital Bends & Related Supplies
• Insulin Pumps
• Spinal Traction Devices
• Walk-aid Devices (electronic or e-Stim)

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

Prior authorization is required for the clinic-administered medications listed below:

• View the clinic administration medication list
• View the medical benefit PA criteria library
• View additional resources for medical benefit medications

For patients that have pharmacy coverage through Quartz, prior authorization is required for the prescription medications listed in the prescription benefit PA criteria library.

Quartz pharmacy criteria – Large Group

Note: The following procedures must be prior authorized before they are scheduled.

• Abortions (including multi-fetal reductions)
• Artificial Iris
• Basivertebral Nerve Ablation
• Gender Affirming  Surgical Procedures
• Implantable Nerve Stimulators
• Laser Treatment Including Eximer, Pulsed Dye, Fractional and Other Lasers
• Left Ventricular Assist Devices (LVAD) for Treatment of Heart Failure
• Mandibular Osteotomy and Maxillomandibular Osteotomy and Advancement for Obstructive Sleep Apnea
• Orthognathic Surgery (repair/revision/reconstruct procedures on head) (cosmetic procedure are excluded)
• Orthopedic Procedures (Including Artificial Cervical and Lumbar Disc Surgery and OATS Procedures)
• Panniculectomy
• Reconstructive Surgery
• Removal of Port Wine Stains and Hemangiomas
• Rhinoplasty and Septorhinoplasty
• Scar Revision and Repair (cosmetic procedures are excluded)
• Surgical Treatment of Obstructive Sleep Apnea
• Temporomandibular Joint (TMJ) 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)

Out-of-Network Services or Supplies

A prior authorization is required for services outside of the Quartz network unless for urgent or emergency services.

• Ambulance Services (non-emergent/urgent)
• Autism
• Bioengineered Skin Substitutes
• 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
• Fractional Flow Reserve Calculation after Coronary CT Angiography (FFR-CT).
• Genetic Testing 
• Home Health Care (including home infusion services and other in-home therapy services)
• Hospice Care
• Hyperbaric Oxygen Therapy
• Life-Sustaining Nutritional Therapy
• Palliative Care
• Proton Beam Therapy
• Treatment of Urinary and Fecal Incontinence