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 April 24, 2015. We maintain a separate list for Medical Drugs & Diabetic Supplies: Medical Drug and Diabetic Supplies Formulary.

View printable Preauthorization 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
  • Amniotic Membrane Transplantation
  • Anesthesia Care With Endoscopies – Effective 4/01/2014 PacificSource Criteria
  • Anesthesia or Sedation for Dental Procedures – when covered under the members plan, including pediatric dental procedures 
  • Applied Behavior Analysis (ABA) Therapy
  • Artificial intervertebral disc replacement  
  • Back surgeries - instrumented
  • Breast Brachytherapy (Accelerated Partial Breast Irradiation (PBI))
  • Breast reconstruction, including reduction and implants
  • Canaloplasty
  • Cerebral Perfusion Analysis Effective - 8/11/2015 PacificSource Criteria  
  • Cervical Artificial Intervertebral Disc Replacement
  • Chelation therapy
  • Chondrocyte implants
  • Clopidogrel (Plavix) Pharmogenetics – Effective 4/22/2015, preauthorization is required.
  • 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 
  • CPAP or BiPAP: Prior authorization is required for purchase of replacement machine and initial rental extension and must meet certain criteria. Initial rental and convert to purchase* does not require prior authorization.
    *PacificSource does not consider mail order only or Internet/Web-based only providers, as eligible DME providers.
  • Cryoablation of renal cell carcinoma
    CT Scans
    – see “Advanced diagnostic imaging” 
  • Dental Procedures – billed under the member’s medical coverage
  • 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 
  • Fecal DNA testing – Effective 4/24/2015 Preauthorization required. 
  • Femoroacetabular Impingement (FAI) Hip Surgeries
  • Genetic (DNA) testing
  • Hip Orthosis – L1600-L1686 - 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
  • Hyperbaric Oxygen Therapy (HBOT)  
  • Inhaled Nitric Oxide (iNO) for Neonatal Hypoxic Respiratory Failure Effective 4/22/2015. Preauthorization is required.
  • Implantable Peripheral Nerve Stimulators
  • Ingestible telemetric gastrointestinal capsule imaging system (wireless capsule enteroscopy)
  • Intracranial Flow Diverting Stents – Effective 7/17/2015 PacificSource Criteria 
  • 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.
  • Liver Cancer Treatment: Preauthorization is required for cryosurgical, percutaneous ethanol injection [PEI], microwave or radiofrequency ablation – PacificSource Criteria
  • Mental health and chemical dependency inpatient or residential treatment, partial hospitalization, including intensive outpatient mental health treatment
  • MiniMed 530G with Enlite Next Generation Continuous Glucose System Effective 4/22/2015. Preauthorization is required.
  • 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"  
  • Proton beam treatment delivery
  • Radiofrequency Ablation of Ilioinguinal Nerve Effective 4/22/2015 Preauthorization is required.
  • Radiofrequency Ablation for Renal Cancer, 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
  • Somatostatin Receptor Scintgraphy – Effective 8/11/2015 Preauthorization is required. 
  • 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) 
  • Transcatheter Valve Repair or Implantation – Effective 4/22/2015 Preauthorization is required.
  • 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

Medical preauthorization requests may be submitted online through InTouch. Or, complete a paper form and fax or mail it along with related chart notes and/or operative report. We will respond within two business days of receipt.

Preauthorization Request Forms:

Preauthorization Checklists:


Last updated 8/13/2015