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. 
 
To request a specific medical policy guideline used in making prior authorization decisions, please contact Member and Provider Services at (608) 282-8900 or (800) 545-5015.

Acupuncture

Artificial Disc Replacement Surgery

Autism Intensive Therapy Services

Bariatric Outpatient Surgery

Bone Anchored Hearing Aid (BAHA)

Category III CPT Codes

Cosmetic Procedures, potential but not included to:

  • Benign skin lesions
  • Blepharoplasty
  • Botox Injections
  • Canthoplasty
  • Male Gynecomastia
  • Microtia
  • Reduction Mammoplasty
  • Rhinoplasty
  • Skin Tag Removal (ETF members only)
  • Varicosity Procedures

CT Endoscopy (Virtual CT)

Deep Brain Stimulation (DBS)

Durable Medical Equipment (DME)*

  • All DME purchase over $750
  • All DME rentals over $750/month
  • All DME replacement items
  • All CPAP machine purchases
  • Continuous glucose monitoring (CGM)
  • Mechanical stretching devices (contracture/joint stiffness)
  • Traction for Spinal Pain (Home Use)

Electroconvulsive Therapy 

Functional Electrical Stimulation

Gender Reassignment Surgery

Genetic Testing & Molecular Pathology

Home Care Services, Supplies & Therapies

 

 

Infusion Medications (See Pharmacy Medication Pre-authorization List

Inpatient Services, including but not limited to:

  • Acute Care Facility
  • Hospice Facility
  • Long Term Acute Care Facility
  • Rehabilitation Facility
  • Skilled Nursing Facility (includes therapy)
  • Subacute Facility

Intrathecal Pump Implantation 

Intratympanic Steroid Injection

Laser Treatment for Psoriasis 

Lumbar Discography

Non-emergent Patient Transport

Non-participating Providers: All Services

Oral/Orthognathic Surgery

Orthopedic/Neurosurgery Referrals (ETF Members Only)

Prophylactic Ovary/Breast Removal

Prostate Cryosurgery or Vaccine

Prosthetics, Limb - All Purchases

Radiofrequency Thermal Ablation for Barrett's Esophagus

Spinal Cord Stimulators

Stereotactic Radiosurgery

Stem Cell Storage (Non-transplant)

Temporomandibular - Op Surgery & Devices

Transcranial Magnetic Stimulation

Transplant Evaluations & Services

Vagus Nerve Stimulation

Virtual Colonoscopy


*Durable Medical Equipment (DME)

Definition: Plan defines Durable Medical Equipment (DME) as an item which can withstand repeated use and which, as determined by Plan, meets all of the following:

  • A) Primarily used to serve a medical purpose with respect to an illness or injury;
  • B) Generally not useful to a person in the absence of an illness or injury;
  • C) Appropriate for use in the member's home, but may not be limited to home use; and
  • D) Prescribed by a physician.

Non covered DME items require prior authorization if the cost is $750 or more. However that does not guarantee payment by Plan. Some DME items are considered over-the-counter items or are otherwise benefit exclusions. Other DME items have quantity limitations and are not payable by Plan once the Covered Person has received the maximum number of items for that benefit year.

In addition, all limb prosthetics require prior authorization regardless of the cost. Medical necessity guidelines will apply for any DME or prosthetic purchased.

All DME purchases and rentals are subject to Covered Person coinsurance amounts and deductibles.