HMO/EPO plans: List of services that require pre-approval

Find which services require pre-approval from Priority Health under your plan.

Remember:

  • This is a comprehensive list for all Medicare plans, and this information does NOT indicate if the service is a covered benefit of your plan. See the prior authorization reference chart in chapter 4 of your EOC for a complete list of services requiring pre-approval.
  • Self-funded plans may not cover the services listed here.
  • Priority Health does not require a referral from your primary care physician for you to see a specialist.
  • Talk to your doctor about the pre-approval process for any of the services listed here.

A | B | C | D | E | F | G | H | I | J | K | L | M | N | O | P | Q | R | S | T | U | V | W | X | Y | Z

 

A

Abdominoplasty/pannieculectomy

Adenotonsillectomy, pediatric (applies to members under 18 only)

Ambulance services, air/fixed wing

Ambulance services, non-emergent

Artificial intervertebral discs

Autism spectrum disorders: Treatment services - including psychiatric, psychological and therapeutic care (i.e., evidence-based speech therapy, physical therapy, occupational therapy and ABA therapy)

Autologous chondrocyte implant/meniscal allograft/osteochondral

AxiaLIFTM lumbar interbody fusion

B

BAHA device or cochlear implant

Behavioral health & substance abuse therapies, inpatient

Bone marrow/stem cell transplantation

Breast MRI

Bronchial thermoplasty

C

Cardioverter defibrillators (ICDs)/Biventricular Pacemaker Insertion + ICD

Catheter ablation for cardiac arrhythmias

Chemosensitivity assays (see your policy document for specific prior authorization requirements)

Clinical trials

Clinical trials for cancer care

Computed tomography scanning for lung cancer screening

Contnuous passive motion (CPM)

CPAP & other equipment to treat sleep apnea (i.e. ASV, APAP, BiPAP, oral appliances)

Cranial helmets

D

Detoxification

Developmental disorders, pervasive

Dialysis access, permanent

Dialysis for end-stage renal disease

Drugs, injectable

Durable medical equipment (DME) purchases >$1000 and rentals

E

Eating disorders

Enteral nutrition therapy

Experimental/investigational/unproven care

F

Feeding disorders

Fetal surgery

G

Gastroparesis teseting and treatment

Genetic counseling, testing & screenings

H

Home health care

Hospice care, inpatient

Hyperhidrosis

I

Implantable heart failure monitors

Infertility and assisted reproduction

Infusion services & equipment

Inpatient care services: all admissions including behavioral health and substance abuse

Intraoperative radiation therapy

K

Kyphoplasty/vertebroplasty

M

Multi-marker tumor panels

N

Non-acute inpatient services

O

Obesity-related services - surgical treatment

Observation

Observations exceeding 48 hours

Orthotics: shoe inserts, orthopedic shoes

P

Palliative care

Parenteral nutrition therapy

Percutaneous Left Atrial Appendage Closure

Pharmacogenomic testing

Power vehicles

Prophylactic cancer risk-reduction surgery

Prosthetics, purchased for >$1000

Pulse oximetry for home use

Pumps, implantable & external infusion

R

Radical prostatectomy

Radiofrequency ablation for back pain

Radiology: All non-emergent outpatient diagnostic services (MRA, MRI, CT, CTA, PET scans and nuclear cardiology)

Radio surgery, stereotactic, and proton and neutron beam therapies

Reconstructive/cosmetic surgery

S

Septoplasty/rhinoplasty

Sleep studies - in-center only

Stimulation therapy and devices

Substance abuse/behavioral health therapies, inpatient

Surgery, spinal

T

Titanium rib

Tonsillectomy, pediatric

Transcatheter closure of septal defects

Transcatheter heart valves

Transcranial magnetic stimulation therapy for depression

Transplantation of solid organs

Tumor markers

V

Ventilator, outpatient

Ventricular assist devices (VADs) and artificial hearts

Virtual colonoscopy