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Prior Approval

Before you provide any of the treatments, procedures, or services designated, Wellmark requires a prior approval to determine medical necessity. View the Authorization Table for details on which procedures require pre-service review, and refer to the table any time a procedure is planned.

 

Wellmark is licensed to use InterQual® criteria to guide medical necessity determinations. For services that are not addressed by InterQual criteria, detailed clinical criteria is included in the associated medical policy(s), which will be applied during the medical necessity determination process.

 

Contracting practitioners can view the InterQual criteria via SmartSheets . DME providers and out-of-state providers can receive the SmartSheets via fax by calling 800-552-3993.

 

Prior approvals are valid for a specific length of time. If there is a date of service change, it is not necessary to update or complete a new prior approval if the new date of service remains within the defined authorization period. If there is a change in the patient's benefit plan, a new prior approval submission is required.

 

Below is a list of prior approval procedures and services (more details are included in the Authorization Table):
Abatacept
Abdominoplasty and Panniculectomy
Air Ambulance (non-emergency)
Allogeneic Hematopoietic Stem Cell Transplant
Autologous Hematopoietic Stem Cell Transplant
Bariatric Surgery for Morbid Obesity
Bevacizumab (Avastin®)
Blepharoplasty
Bone Growth Stimulation Devices
Botulinum Toxin
Capsule Endoscopy
Certolizumab Pegol (Cimzia®)
Cetuximab
Cochlear Implants
Diagnosis and Treatment of Speech and Language Disorders
Facet Joint Denervation for Chronic Back and Neck Pain
Heart Transplant
Heart/Lung Transplant
Hereditary Angioedema Therapies

Hysterectomy
Immune Globulin Therapy
Infertility Diagnosis and Treatment
Infliximab
Knee Arthroplasty

Laminectomy/Hemi-laminectomy (cervical, thoracic and lumbar)

Liver Transplant
Lung and Lobar Lung Transplant
Mastectomy for Gynecomastia
Microprocessor-Controlled Prostheses for the Lower Limb
Motorized Wheelchairs and Other Power-Operated Vehicles
Myoelectric Prostheses for the Upper Limb
Negative-pressure Wound Therapy
Omalizumab for Allergy Related Asthma
Palivizumab (Synagis®)
Pancreas (Including simultaneous pancreas-kidney, pancreas alone, and pancreas after kidney) Transplants
Panitumumab (VectibixTM)
Reduction Mammoplasty
Rhinoplasty or Septorhinoplasty
Rituximab

Small Bowel Transplant
Small bowel/liver and multivisceral transplant
Spinal Fusion
Surgical Management of Obstructive Sleep Apnea Syndrome
Tocilizumab (Actemra)
Ustekinumab (STELARA&trade)


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