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.
ACTH Gel (Adrenocorticotropic Hormone)*
Abdominoplasty and Panniculectomy*
Adalimumab*
Alefacept (Amevive®)*
Allogeneic Hematopoietic Stem Cell Transplant*
Autologous Hematopoietic Stem Cell Transplant*
Bariatric Surgery for Morbid Obesity*
Beta Interferons and Copaxone for Multiple Sclerosis*
Bevacizumab*
Blepharoplasty*
Bone Growth Stimulation Devices*
Botulinum Toxin*
Certolizumab Pegol (Cimzia®)*
Cetuximab*
Chemical Peels and Dermabrasion*
Clinical Trial Provision*
Continuous or Intermittent Monitoring of Glucose in Interstitial Fluid*
Cosmetic/Reconstructive Services*
Diagnosis and Treatment of Speech and Language Disorders*
Etanercept*
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*
Growth Hormone Therapy*
Heart Transplant*
Heart/Lung Transplant*
Humanitarian Use Devices*
Immune Globulin Therapy*
Infertility Diagnosis and Treatment*
Infliximab*
Interferons for Hepatitis C*
Knee Arthroplasty*
Liver Transplant*
Lung and Lobar Lung Transplant*
Mastectomy for Gynecomastia*
Meniscal Allograft Transplant*
Microprocessor-Controlled Prostheses for the Lower Limb*
Motorized Wheelchairs and Other Power-Operated Vehicles*
Natalizumab*
Omalizumab for Allergy Related Asthma*
Palivizumab (Synagis®)*
Pancreatic Islet Cell Transplant*
Panitumumab (VectibixTM)*
Percutaneous Vertebroplasty and Kyphoplasty*
Preimplantation Genetic Testing*
Reduction Mammoplasty*
Rhinoplasty or Septorhinoplasty*
Rituximab*
Small Bowel Transplant*
Small bowel/liver and multivisceral transplant*
Spinal Fusion*
Surgical Management of Obstructive Sleep Apnea Syndrome*
Surgical Repair of Pectus Excavatum*
Total Ankle Replacement*
Trastuzumab*
Vacuum-Assisted Wound Closure*
Forms
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An asterisk (*) indicates that prior approval is recommended for this medical policy.
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