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 

• Day Treatment
• Experimental and Investigational Treatments
• In Home Therapy
• Intensive Outpatient Program (IOP) 
• Partial Hospital Program (PHP)
• Transcranial Magnetic Stimulation (TMS)
• Vagus Nerve Stimulation

Diagnostic/Radiology Procedures 

• MRI 
• CT Scans 
• PET Scans 
• Nuclear Stress Tests 
• SPEC Scans

Durable Medical Equipment

• Airway Clearance Devices (including Vest therapy)
• Bone Growth Stimulators
• Braces/splints over $500
• Cardiac Cardioverter Defibrillator (Wearable)
• Continuous Glucose Monitors (CGM)
• Continuous Passive Motion Machines
• CPAP, BiPAP (rental and purchase)
• Dynamic Orthotic Cranioplasty (DOC) bands
• Electric Tumor Treatment Fields (TTF) Device (Optune®)
• Heart Failure Remote Monitoring (CardioMems™)
• Home Monitoring Devices
• Home Phototherapy (UVB) Light Devices
• Hospital Beds and Related Supplies
• Hospital Grade Electric Breast Pumps
• Insulin Pumps
• Life-Sustaining Nutritional Therapies
• Lymphedema Treatment Devices
• Mechanical Stretching Devices
• Patient Lift Equipment
• Pectus Carinatum Devices
• Prosthetics (including upper extremity, lower extremity, eye, face, etc.)
• Spinal Traction Devices
• Standing Frame / Stander
• TENS and Other e-Stim Devices
• Walk-aid Devices (electronic or e-Stim)
• Wheelchairs and Motorized Scooters

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)
• Psychiatric admissions
• Skilled nursing facility / swing bed

Other Services

• Biofeedback (only covered for spastic torticollis, headache or urinary incontinence)
• CAR T Cell Therapy
• Extended Cardiac Rhythm Monitoring (External and Implanted Cardiac Monitors/Loop Records)
• Experimental and Investigational Treatments
• Extracorporeal Shock Wave Therapy
• Fecal Bacteriotherapy
• 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
• Non-emergent/urgent Ambulance Services
• Prolotherapy
• Proton Beam Therapy
• Radioembolization with Yttrium 90 Microspheres (TheraSphere™/ SIR-Spheres®) Treatment
• Wound Therapy-Advanced (including Negative Pressure/Vac) Therapy, Noncontact Normothermic Wound Therapy (NNWT) and Bioengineered Skin Substitutes)

Out-of-Network Services or Supplies

Medication

Prior authorization is required for clinic-administered medications. Practitioners must submit a prior authorization request via My Quartz Tools or fax a Medication Prior Authorization Request Form to Quartz at (888) 450-4711.

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
• Corneal Crosslinking
• 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
• Orthopedic Procedures (Including Artificial Cervical and Lumbar Disc Surgery and OATS Procedures)
• POEM (per-oral endoscopic myotomy) Procedure
• POP (per-oral pyloromyotomy) Procedure
• Panniculectomy
• Prosthetic Urethral Lift (Urolift®)
• Removal of Port Wine Stains and Hemangiomas
• Rhinoplasty and Septorhinoplasty
• Robotic Assisted Procedures
• Scar Revision and Repair (cosmetic procedures are excluded)
• Surgical Treatment of Pectus Excavatum and Carinatum Syndrome
• Temporomandibular Joint Disease Surgical Treatment
• Transperineal Placement of Biodegradable Material (SpaceOAR™)
• Transplants Including Donor and Other Related Charges (excludes corneal except for artificial corneal transplants)
• Transcatheter Closure of Septal Defect
• Surgical Treatment of Obstructive Sleep Apnea
• Varicose Vein Procedures (including Sclerotherapy, Radiofrequency Ablation, Vein Stripping and Ligation)(including Sclerotherapy, Radiofrequency Ablation, Vein Stripping and Ligation)