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.
Update: The following procedures will require prior approval for dates of service effective Dec. 15, 2012 (Shoulder Arthrotomy and Arthroscopy will not be part of the December roll-out):
- Cochlear Implants
- Hemilaminectomy/Laminectomy (cervical, thoracic, lumbar)
Authorization requests for these procedures will be accepted beginning Dec. 1, 2012, for dates of service Dec. 15, 2012, and after. The new online utilization management tool will be available to complete all prior approval requests after Dec. 15, 2012.
After Feb. 4, 2013, prior approvals will no longer be accepted by fax.
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):
Abdominoplasty and Panniculectomy
Air Ambulance (non-emergency)
Allogeneic Hematopoietic Stem Cell Transplant
Autologous Hematopoietic Stem Cell Transplant
Bariatric Surgery for Morbid Obesity
Bone Growth Stimulation Devices
Cellular Immunotherapy for Prostate Cancer
Certolizumab Pegol (Cimzia®)
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
Hereditary Angioedema Therapies
Immune Globulin Therapy
Infertility Diagnosis and Treatment
Laminectomy/Hemi-laminectomy (cervical, thoracic and lumbar)
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
Pancreas (Including simultaneous pancreas-kidney, pancreas alone, and pancreas after kidney) Transplants
Rhinoplasty or Septorhinoplasty
Small Bowel Transplant
Small bowel/liver and multivisceral transplant
Surgical Management of Obstructive Sleep Apnea Syndrome
Total Hip Resurfacing