Prior Authorization List

Prior authorization does not guarantee payment. Coverage of services is based on member eligibility and member’s benefits per the medical certificate of coverage at the time services are rendered.

Services Requiring Prior Authorization(Effective as of January 1, 2018)

The following list of services require prior authorization from Plan before rendering services:


Durable Medical Equipment (DME)

  • Bone Growth Stimulators
  • Braces/splints over $750
  • Cardiac Cardioverter Defibrillator (external only)
  • Continuous Passive Motion Machines
  • Spinal Traction Devices
  • Continuous Glucose Monitors
  • CPAP, BIPAP (rental and purchase)
  • Custom Shoes and Custom-Molded Foot Orthotics (limited benefit), includes orthopedic shoes
  • Airway Clearance Device
  • Dynamic Orthotic Cranioplasty (DOC) Bands
  • Electric Tumor Treatment Fields (TTF) Device (Optune®)
  • Home Phototherapy (UVB) light devices for treatment of Psoriasis
  • Hospital Beds and Related Supplies
  • Insulin Pumps
  • Mechanical Stretching Devices
  • Prosthetics, including upper extremity, lower extremity, eye, face, etc.
  • Standing Frame/Stander
  • TENS and Other e-stim Devices
  • Walk-aid Devices (electronic or e-stim)
  • Wheelchairs and Motorized Scooters
• Wound Therapy (Advanced), including Negative Pressure (Vac) Therapy, Noncontact Normothermic Wound Therapy (NNWT) and Bioengineered Skin Substitutes

• Experimental and Investigational Treatments

• Genetic Testing, including Pharmacogenetic Testing

• Home Health Care, including Home Infusion Services and Other In-Home Therapy Services

• Hospice care

Inpatient Admissions

Note: Urgent/emergent hospital admissions require notification at the time of admission. Elective hospital admission requires prior authorization before admission and notification when admitted.
  • Hospital, Acute Inpatient Care
  • Inpatient Rehabilitation Facilities
  • Long Term Acute Care (LTACH)
  • Psychiatric Admissions
  • Skilled Nursing Facility/Swing Bed

Other Services

  • Day Treatment
  • Extended Cardiac Rhythm Monitoring (External and Implanted Cardiac Monitors/Loop Records)
  • Fecal Bacteriotherapy
  • Intensive Outpatient Program (IOP)
  • Non-emergent Ambulance Services
  • Partial Hospital Program (PHP)
  • Platelet-Rich Plasma (PRP) Injections
  • Residential Treatment
  • Steroid Releasing Sinus Implants
  • TheraSphere/Sir-spheres Treatment
  • Transcranial Magnetic Stimulation (TMS)
  • Vagus Nerve Stimulation
  • Wireless/Remote Heart Failure Monitoring Devices (CardioMems™)

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 **For Federal Plan and Badger Care only. All other plans this is an exclusion**
  • Blepharoplasty
  • Bone Anchored Hearing Aids (BAHA)
  • Breast Surgery
  • Brow Lifts
  • Cochlear Implants
  • Corneal Cross-linking
  • Inplantable Nerve Stimulators
  • Laser Resurfacing for Non-Cosmetic Procedures (cosmetic procedures are excluded)
  • Laser Treatment of Actinic Keratosis or Other Benign Skin Lesions
  • Left Ventricular Assist Devices (LVAD) for Treatment of Heart Failure
  • Endoscopic Procedures for Reflux Management
  • POEM Procedure
  • Orthopedic Procedures including Artificial Cervical and Lumbar Disc Surgery, OATS Procedures and Hip Resurfacing
  • Prosthetic Urethral Lift (Urolift®)
  • Removal of Port Wine Stains and Hemangiomas
  • Rhinoplasty and Septorhinoplasty
  • Robotic Assisted Procedures
  • Scar Revision and Repair
  • Surgical Treatment of Pectus Excavatum and Carniatum Syndrome
  • Temporomandibular Joint Disease Surgical Management
  • Transgender Surgery
  • 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 or Spider Vein Procedures including Sclerotherapy, Radiofrequency Ablation, Vein Stripping and Ligation

Therapies

  • Acupuncture
  • Biofeedback (only covered for spastic torticollis, headache or pediatric urinary incontinence)
  • Extracorporeal Shockwave Therapy
  • Hyperbaric Oxygen Therapy