Prior Approval
Before you provide any of the treatments, procedures, services or supplies listed below, Wellmark recommends getting a prior approval to determine medical necessity. Prior approvals are valid for a specific length of time, as long as a patient's benefits stay the same between the approval date and date of service.
View the medical policies associated with the procedures listed below by clicking on the procedure name.
Refer to this list any time a procedure is planned.
Abatacept*
Abdominoplasty and Panniculectomy*
Allogeneic Hematopoietic Stem Cell Transplant*
Autologous Hematopoietic Stem Cell Transplant*
Bariatric Surgery for Morbid Obesity*
Bevacizumab (Avastin®)*
Blepharoplasty*
Bone Growth Stimulation Devices*
Botulinum Toxin*
Cellular Immunotherapy for Prostate Cancer*
Certolizumab Pegol (Cimzia®)*
Cetuximab*
Chromosomal Microarray (CMA) Analysis for the Genetic Evaluation of Patients with Developmental Delay/Intellectual Disability or Autism Spectrum Disorder*
Diagnosis and Treatment of Speech and Language Disorders*
Facet Joint Denervation for Chronic Back and Neck Pain*
Genetic Assays of Tumor Tissue to Predict Prognosis of Breast Cancer*
Genetic Molecular Testing for Miscellaneous Indications*
Genetic Molecular Testing for Oncologic Indications*
Heart Transplant*
Heart/Lung Transplant*
Immune Globulin Therapy*
Infertility Diagnosis and Treatment*
Infliximab*
Knee Arthroplasty*
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®)*
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)*
Total Hip Resurfacing*
Trastuzumab*
Ustekinumab (STELARA™)*
An asterisk (*) indicates that prior approval is recommended for this medical policy.
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