The following are services that require prior authorization (sorted in alphabetical order). Please note that this list is subject to change. Please contact the Utilization Management Department at 1-800-805-7938 or (605)328-6807 for the most current information or for any other questions related to the prior authorization process.
- Airway Clearance Device
- Ambulance services for non-emergency situations
- Autonomic Testing
- Bariatric Surgery
- Blepharoplasty
- Bone Growth Stimulator (external)
- Botulinum Toxin (Botox)
- Brachytherapy
- Breast Implant Removal, Revision or Reimplantation
- Breast Reconstructive Surgery & Mastectomy
- Breast Reduction Mammoplasty
- Clinical Trials
- Cochlear Implants
- Cranial Molding
- Deep Brain Stimulation
- Dental anesthesia for children under 5 and for those with a developmental disability
- Durable Medical Equipment (consult plan for details) (Note: CPAP, Apnea Monitors, BIPAP, CPM, and non –small volume Nebulizers do not require prior authorization)
- Endoscopic Ultrasonography (EUS)
- Enteral/Parenteral Nutritional Therapy
- Growth Hormone
- Home Health and home IV therapy services
- Hospice
- Hyperbaric Oxygen Therapy
- Inpatient hospital admission including admission for medical, surgical, obstetric, neonatal intensive care nursery, rehabilitation, mental health and chemical dependency services
- Lithotripsy
- Neuromuscular Electrical Stimulation
- One on One Water Therapy
- Ossatron (ESWT)
- Pain Control Program
- Partial Hospital Program (PHP)/Day Treatment for mental health
- Perception Sensory Threshold Test
- Photodynamic Therapy for Cancer
- Phototherapy (UVB Light Treatment)
- Prosthetic Limb
- Referrals to non-participating providers which are recommended by participating providers
- Selected injectable medications
- Selected outpatient surgeries
- Skilled nursing, hospice, swing bed and sub-acute
- Spinal Cord Stimulator
- STEPPS Program
- Testosterone
- Transplants
- Vagus Nerve Stimulation
- Varicose Vein Treatment
- Vitamin B-12 Injections
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