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Prior Approvals - Recommended (Wellmark and FEP Members)

Prior approval is the process for obtaining a medical necessity determination before a treatment, procedure, service or supply has been provided. Prior approvals are recommended for all of the treatments, procedures, services, or supplies listed in the prior approval table. Prior approvals are valid for a specific length of time – usually 6 months, but occasionally longer or shorter – as long as the patient’s benefits do not change between the date the approval is given and the date the service is provided.

Prior Approval is a review for medical necessity and is recommended for each of the procedures listed below. Our medical policy for each of these procedures can be obtained by clicking on the procedure name below. This procedure list is subject to change, so please refer to this list each time a procedure is planned.

For services below that are a drug-related service, complete the service’s unique Treatment Request. We have added links to specific Treatment Requests within each of these medical policies (Abatacept is one example).

For all other services, complete and submit the online Prior Approval request, or complete and fax the interactive PDF. Links to these forms follow the list.

Wellmark responds to prior approval requests in writing, typically within 15 calendar days of receipt of the request. To avoid review delays, complete the proper form and include applicable diagnoses, procedure codes, and medical information. We return incomplete forms for missing information, and cannot start the authorization process until we receive all information.

In addition to the Prior Approvals recommended by Wellmark, the Federal Employee Program (FEP) Standard and Basic Option plans require a Prior Approval for certain procedures.

ACTH Gel (Adrenocorticotropic Hormone)*
Abatacept*
Abdominoplasty and Panniculectomy*
Adalimumab*
Airway Clearance Devices*
Allogeneic Hematopoietic Stem Cell Transplant*
Augmentative and Alternative Communication Systems*
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*
Cetuximab*
Chemical Peels and Dermabrasion*
Clinical Trial Provision*
Cochlear Implants*
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*
Humanitarian Use Devices*
Immune Globulin Therapy*
Infertility Diagnosis and Treatment*
Infliximab*
Interferons for Hepatitis C*
Mastectomy for Gynecomastia*
Meniscal Allograft Transplant*
Microprocessor Controlled Prosthetic Knee*
Motorized Wheelchairs and Other Power-Operated Vehicles*
Natalizumab*
Omalizumab for Allergy Related Asthma*
Pancreatic Islet Cell Transplant*
Panitumumab (Vectibix^TM)*
Percutaneous Vertebroplasty and Kyphoplasty*
Preimplantation Genetic Testing*
Prophylactic Treatment for Respiratory Syncytial Virus (RSV)*
Reduction Mammoplasty*
Rhinoplasty or Septorhinoplasty*
Rituximab*
Surgical Management of Obstructive Sleep Apnea Syndrome*
Surgical Repair of Pectus Excavatum*
Total Ankle Replacement*
Total Hip Resurfacing*
Trastuzumab*
Treatment of Vascular Birthmarks*

Submit a Prior Approval

Forms

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Iowa Prior Approval Form (pdf 18KB)
South Dakota Prior Approval Form (pdf 32KB)
Federal Employee Program Prior Approval Form
Treatment Requests

An asterisk (*) indicates that prior approval is recommended for this medical policy.

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