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Prior Approval

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. This procedure list is subject ot change, so please refer to this list each time a procedure is planned.

Airway Clearance Devices*
Allogeneic Hematopoietic Stem Cell Transplant*
Augmentative and Alternative Communication Systems*
Autologous Hematopoietic Stem Cell Transplant*
Bevacizumab*
Blepharoplasty*
Bone Growth Stimulation Devices*
Chemical Peels and Dermabrasion*
Clinical Trial Provision*
Cochlear Implants*
Computer Augmented Endoscopic Sinus Surgery*
Continuous and Intermittent Monitoring of Glucose in the Interstitial Fluid*
Corneal Remodeling*
Cosmetic/Reconstructive Services*
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 Replacement Therapy*
Infertility Diagnosis and Treatment*
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 Diagnosis*
Prophylactic Treatment for Respiratory Syncytial Virus (RSV)*
Pulmonary Vein Isolation for the Management of Atrial Fibrillation*
Reduction Mammoplasty*
Rhinoplasty or Septorhinoplasty*
Sleep Apnea and Upper Airway Resistance Syndrome*
Speech Therapy*
Surgery for Morbid Obesity*
Surgical Repair of Pectus Excavatum*
Total Ankle Replacement*
Total Hip Resurfacing*
Transcatheter Arterial Chemoembolization (TACE) of the Liver*
Transesophageal Therapies for Gastroesophageal Reflux Disease (GERD)*
Treatment of Hyperhidrosis*
Treatment of Vascular Birthmarks*

Submit a Prior Approval

Forms

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Iowa Prior Approval Form (pdf 18KB)
Iowa Referral Form (pdf 23KB)
South Dakota Prior Approval Form (pdf 32KB)

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

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