Medicare Advantage Prior Authorization List
The following is not an all-inclusive list. Updates are periodically made to the Prior Authorization List.
Please contact Customer Service with specific code information to determine if an item or service requires prior authorization.
Durable Medical Equipment
- All durable medical equipment (DME) costs of $500 or more require 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.
Experimental and Investigational Treatments
Genetic Testing including Pharmacogenetics Testing
Home Health Care, including home infusion services and other in-home therapy services
- Requires notification
- Skilled nursing facility requires prior authorization
- Swing Bed requires prior authorization
- Inpatient admissions requires notification only
- Day treatment
- Intensive Outpatient Program (IOP)
- CardioMems™ (implantable wireless cardiovascular monitor system)
- Corneal cross-linking
- Deep brain stimulator
- Partial Hospital Program (PHP)
- Transcranial Magnetic Stimulation (TMS)
- Vagus Nerve Stimulation
- Implantable Loop Recorders
Out-of-Network Service or Supplies
- Requires prior authorization unless urgent/emergent
The following procedures must receive prior authorization before they can be scheduled.
- Bariatric Surgery
- Bone Anchored Hearing Aids (BAHA)
- Breast Surgery
- Brow lifts
- Cochlear Implants
- Implantable Nerve Stimulators
- Endoscopic Procedures for Reflux Management
- Orthopedic Procedures: Artificial Lumbar Disc Surgery (not for members > 60)
- Rhinoplasty and Septorhinoplasty
- Scar Revision and Other Repair of Scars
- Surgical Removal of Redundant Skin
- Transplants including Donor and Other Related Charges (excludes corneal except for artificial corneal transplants)
- Treatment of Actinic Keratosis or Other Benign Skin Lesions
- Uvuloplasty, Uvulopalatoplasty, Somnoplasty, LAUP, and Other Treatments for Snoring or Airway Obstruction
- Varicose Vein or Spider Vein Procedures (including Sclerotherapy, Radiofrequency Ablation, Vein Stripping, and Ligation
- Biofeedback (limited therapy related to urinary incontinence)
- Hyperbaric Oxygen Therapy
Part B Therapies
- Prior authorization required over Medicare Therapy Caps
Clinic-Administered Medications – Outpatient Hospital and Clinic
Quartz Health Plan Corporation complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.
Spanish – ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de ayuda con el idioma. Llame al (800) 897-1923, TTY 711 or toll free (800) 877-8973.
Hmong – LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau (800) 897-1923, TTY 711 or toll free (800) 877-8973.