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 September 1, 2016. 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)   
  • Ambulance transports (air or ground) between medical facilities, except in emergencies
  • Amniotic Membrane Transplantation
  • Anesthesia Care With Endoscopies
  • 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   
  • Cervical Artificial Intervertebral Disc Replacement
  • Chelation therapy
  • Chondrocyte implants
  • Cochlear implants
  • Coil Embolization of Scrotal Varices
  • 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” 
  • Cymetra (Micronized Alloderm)  
  • Dental Procedures – billed under the member’s medical coverage
  • Dermoscopy (total body photography, digital epiluminescence microscopy, mole mapping)
  • Drug testing – PA required after 12 units. 
  • 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. See “CPAP or BiPAP.”
  • 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 – including fecal DNA and pharmacogenetics testing
  • Hip Orthosis – (HCPCS L1600-L1690)
  • HLA Testing (CPT 81382 only)
  • 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)  
  • Hyperthermic Intraperitoneal Chemotherapy for Peritoneal Cancer
  • Impella 2.5 System with Precutaneous Coronary Intervention
  • Implantable Peripheral Nerve Stimulators
  • Ingestible telemetric gastrointestinal capsule imaging system (wireless capsule enteroscopy)
  • Inhaled Nitric Oxide (iNO) for Neonatal Hypoxic Respiratory Failure
  • Intracranial Flow Diverting Stents 
  • Intraoperative Neurophysiologic Monitoring During Spinal Surgery
  • iStent Procedure 
  • 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, chemoablation
  • Liver Elastography  
  • Liver Embolization including Portal Vein Embolization, Radioembolization 
  • Mental health and chemical dependency residential detox and residential treatment, partial hospitalization, including intensive outpatient mental health treatment and intensive chemical dependency treatment
  • MiniMed 530G with Enlite Next Generation Continuous Glucose System
  • MRIs - see "Advanced diagnostic imaging"
  • Negative Pressure Wound Therapy
  • Neurostimulators – implantable
  • Non-invasive Tests for Hepatic Fibrosis (FibroSURE and FIBROSpect II) 
  • Nonmedically Indicated (Elective) Induction of Labor Before 39 Weeks Gestational Age 
  • Osteochondral Allografts and Autographs
  • Out-of-country medical services, except in emergencies 
  • Parenteral nutrition
  • PET scans - see "Advanced diagnostic imaging"  
  • Proton beam treatment delivery
  • Radiofrequency procedures including radiofrequency neurotomy and ablations
  • Rehabilitation or skilled nursing facility admissions
  • Skin Substitutes (e.g., Apligraf, Dermagraft, or other) - External Applications Only
  • Somatostatin Receptor Scintgraphy  
  • 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
  • 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 9/1/2016