Prior Authorization

Below are all the services requiring prior authorization. Each link provides services requirements, forms, and contact information to submit requests for prior authorization.

Durable Medical Equipment

• Bone Growth Stimulators
• Continuous Glucose Monitoring Policy
• Continuous Passive Motion Devices
• Cough Stimulating Devices
• Cranial Remolding Helmets
• High-Frequency Chest Wall Oscillation Device
• Low Air Loss Mattress / Pressure Reduction Therapy
• Lymphedema pumps
• Non-covered items < age 21 (EPSDT)
• Speech Generating Devices / Augmentative Communication Devices
• Wound Vacs

Home Health

• Extended Home Health Services / Private Duty Nursing

Inpatient Hospitalization

• Long Term Acute Care
• Medically Complex / Rehab < age 21
• Neonatal Intensive Care Units
• NICU transfers Out Of State
• Psychiatric Residential Treatment Facilities
• Psychiatric Units
• Rehabilitation Units

Nutrition

• Enteral Nutrition for > age 21
• EPSDT special requests < age 21
• Parenteral

Other Outpatient Services

• Botox
• Hydroxyprogesterone Caproate (Makena)
• Hyperbaric Oxygen Treatment
• Mental Health visits < age 2
• Mental Health visits over coverage limit
• Non-covered services < age 21 EPSDT (Vision, audiology, etc.)
• Synagis

Surgical Procedures

• Bariatric
• Breast Reconstruction
• Breast Reduction
• Cochlear implants
• Nerve stimulators
• Panniculectomy
• Questionably cosmetic
• Removal of excess skin
• Spinal
• Transplants

Other Procedures

These procedures do not require prior authorization, but they do have specific requirements including a specialized form.

• Hysterectomy
• Sterilization