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Before you provide any of the treatments, procedures, services or supplies listed below, Wellmark recommends getting a prior approval to determine medical necessity. Wellmark is licensed to use InterQual® Criteria to guide medical necessity determinations. For services that are not addressed by InterQual Criteria, detailed clinical criteria included in associated medical policies may be applied. 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.
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®)
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)
Total Hip Resurfacing
Trastuzumab
Ustekinumab (STELARA™)
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