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Prior Authorization List
Contact Quartz Customer Service with specific code information to determine if an item or service requires 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
- 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)