Medicare 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
Continuous 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
Durable medical equipment (DME) purchases >$1,000 and rentals
E
Eating disorders
Experimental/investigational/unproven care
F
Fetal surgery
G
Gastroparesis testing and treatment
Genetic counseling, testing & screenings
H
Home health care
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 >$1,000
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