Services that require prior authorization

Infusions / injections administered in the physician’s office or facility — Note: Immunizations do NOT require authorization

  • includes chemotherapy and IVIG (intravenous immune globulin)

Orthotics (see DME)

Pain management services

  • Includes: epidural steroid injections, facet injections, SI joint injections (hip)

Prosthetics (see DME)

Services not available within the network

Skilled nursing facility (see inpatient admissions)

Sleep studies performed in a facility/clinic/office (home studies do not require authorization)

Substance abuse (see behavioral health)

Surgery and procedures, outpatient (listed below when performed in a hospital or ambulatory surgery center):

  • allografts
  • breast surgery
  • extracorporeal shockwave lithotripsy or therapy
  • hyperbaric oxygen therapy
  • intracathecal pump implantation
  • laser treatment for skin conditions (e.g. Psoriasis, Port-wine stain)
  • lumbar discography
  • radiofrequency hepatic tumor ablation
  • skin substitutes
  • spinal cord or dorsal column stimulation
  • stereotactic radiosurgery
  • total knee replacement
  • vagus nerve stimulation
  • vein disease treatment

Therapy: rehabilitative/habilitative (outpatient or in office)

  • speech therapy
  • physical therapy
  • occupational therapy — Note: the initial evaluation does NOT require authorization

Transplants

Tube feedings or enteral feedings

Weight loss surgery (bariatric surgery)

Weight loss programs (non-surgical)