Preauthorization

The following are lists of services that require preauthorization for many plans. To see if a member's plan is subject to these lists, please check the member's ID card, refer to member benefits using InTouch, or call our Customer Service Department.  For pre-existing waiting period information, please contact our Customer Service Department.

If you have questions about preauthorization other than eligibility, please contact our Health Services Department at (800) 624-6052, ext. 2584. These lists do not imply that a plan provides benefits for these items, and they are subject to revision as new technologies and standards of medical practice are reviewed.

All plans (excluding PacificSource Medicare and PacificSource Community Solutions):

Please note: This list was updated, effective July 12, 2014.
View printable list. 

  • Advanced diagnostic imaging (through AIM®). Please note: AIM is not utilized by PacificSource Administrators, Inc. at this time. For more information, please read our Diagnostic Imaging Management FAQ
  • Afirma Fine Needle Aspiration Thyroid Analysis (Veracyte inc) – Effective 6/1/2014 MCG criteria ACG: A-0711 
  • Ambulance transports (air or ground) between medical facilities, except in emergencies
  • Anesthesia Care With Endoscopies – Effective 4/01/2014 PacificSource Criteria
  • Applied Behavior Analysis (ABA) Therapy
  • Artificial intervertebral disc replacement  
  • Back surgeries - instrumented (Recommended documentation for preauthorization)
  • Breast Brachytherapy (Accelerated Partial Breast Irradiation (PBI))
  • Breast reconstruction, including reduction and implants
  • Canaloplasty
  • Chelation therapy
  • Chondrocyte implants
  • Cochlear implants
  • Continuous Intraoperative Neurophysiologic Monitoring During Spinal Surgery
    Cosmetic and reconstructive procedures
    including skin peels, scar revisions, facial plastic procedures or reconstruction, and procedures to remove superficial varicosities or other superficial vascular lesions (Recommended documentation for Blepharoplasty preauthorization)
  • CPAP or BiPAP: While prior authorization is not required, certain criteria must be met for rental, purchase, and replacement. Replacement every 5 Years.
  • Cryoablation of renal cell carcinoma
    CT Scans
    – see “Advanced diagnostic imaging” 
  • Dermoscopy (total body photography, digital epiluminescence microscopy, mole mapping)
  • Durable medical equipment (DME) expense over $800, including purchase, rental, repair, lease, or replacement, or rental for longer than three months. Members will obtain their best benefit through use of participating DME providers. PacificSource does not consider mail order only or Internet/Web-based only providers as eligible DME providers. Preauthorization is not required for hospital beds or manual wheelchairs.
  • Dynamic elbow/knee/shoulder flexion devices
  • Elective medical admissions, such as preadmission, or admission to a hospital for diagnostic testing or procedures normally done in an outpatient setting, and transfers to nonparticipating facilities
  • Enteral nutrition and supplies  
  • Experimental or investigational procedures or surgeries 
  • Femoroacetabular Impingement (FAI) Hip Surgeries
  • Genetic (DNA) testing
  • High-resolution Anoscopy HLA Testing 81382 – Preauthorization required
  • HLA Testing 81382 – Preauthorization required
  • Home health nursing and social worker – preauthorization required for all visits
  • Home health rehabilitation (physical, occupational or speech therapy) – preauthorization required after initial 10 visits
  • Home Infusion and freestanding infusion centers
  • Hospice – Inpatient only
  • Hospitalization for dental procedures when covered under this plan, including pediatric dental procedures
  • Hyaluronic Acid Joint Lubricant Injections for Viscosupplementation (Hyalagan, Supartz, Euflexxa, Orhtrovisc, Synvisc or Synvisc-One or Gel-One) for joints other than knee
  • Hyperbaric oxygen  
  • Ingestible telemetric gastrointestinal capsule imaging system (wireless capsule enteroscopy)
  • iStent Procedure, effective 7/1/2014. Preauthorization is required.
  • Kidney dialysis  
  • Laparoscopies of the female reproductive system, and hysterosalpingograms, hysteroscopies, and chromotubations. Preauthorization not required for females age 45 and older.
  • Mental health and chemical dependency inpatient or residential treatment, partial hospitalization, including intensive outpatient mental health treatment
  • MRIs - see "Advanced diagnostic imaging"
  • Negative Pressure Wound Therapy – PacificSource Criteria effective 1/1/2014 – MCG criteria prior to 1/1/2014. Preauthorization is required.
  • Neurostimulators – implantable
  • Nonmedically Indicated (Elective) Induction of Labor Before 39 Weeks Gestational Age - effective 9/1/2014. Preauthorization is required.
  • Out-of-country medical services, except in emergencies 
  • Parenteral nutrition
  • PET scans - see "Advanced diagnostic imaging"  
  • Prescription drugs - some require preauthorization; view list (Recommended Documentation for Remicade (Infliximab) Preauthorization)
  • Proton beam treatment delivery
  • Radiofrequency Ablation for Renal Caner, effective 7/1/2014. Preauthorization is required.
  • Radiofrequency procedures including radiofrequency neurotomy
  • Rehabilitation or skilled nursing facility admissions
  • Skin Substitutes (e.g., Apligraf, Dermagraft, or other) - External Applications Only
  • Surgical procedures and tongue retaining orthodontic appliances for sleep apnea and other sleeping disorders
  • Stereotactic radiosurgery  
  • Surgeries or procedures in a hospital or ambulatory center during any exclusion period
  • Transcatheter occlusion or embolization with Yttrium-90 (TheraSpheres or SIRSpheres) 
  • Transplantation of organ, bone marrow, and stem cells, including evaluations, related donor services, and HLA tissue typing.  Preauthorization is not required for corneal transplants.
  • Varicose vein procedures  

   

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Request a Preauthorization

To request preauthorization, please complete and submit our medical preauthorization request form along with related chart notes and/or operative report to support the request. We will respond to the request within two business days of receipt. Questions? You're welcome to contact us.

Preauthorization Request Forms:

Last updated 7/30/2014