Preauthorization

PacificSource requires preauthorization for coverage of the following procedures and services. This list is subject to revision and updating as PacificSource reviews new technologies and standards of medical practice*.

• Ambulance transports (air or ground) between medical facilities, except in emergencies
• Artificial intervertebral disc replacement
• Breast reconstruction, including reduction and implants
• Chelation therapy
• Chondrocyte implants
• Cochlear implants
• 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

• Durable medical equipment expense over $800, including purchase, rental, repair, lease, or replacement, or rental for longer than three months, except for initial purchase of CPAP/BiPAP equipment which does not require preauthorization

• 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

• Enhanced external counterpulsation

• Excimer laser for psoriasis

• Experimental or investigational procedures or surgeries

• Extensions of previously authorized benefits, such as physical therapy, occupational therapy, mental health treatment, or chemical dependency treatment

• Genetic (DNA) testing

• Home health, outpatient and home IV infusion, and hospice services, and enteral nutrition supplies

• Hospitalization for dental procedures when covered under this plan, including pediatric dental procedures

• Hyperbaric oxygen

• Ingestible telemetric gastrointestinal capsule imaging system (wireless capsule enteroscopy)

• Intradiscal electrothermal therapy (IDET)

• Kidney dialysis

• Laparoscopies of the female reproductive system, and hysterosalpingograms, hysteroscopies, and chromotubations.
• Mental health and chemical dependency inpatient or residential treatment, including intensive outpatient mental health treatment
• MRIs during any exclusion period
• Multidisciplinary developmental pediatric evaluations
• Multidisciplinary pain management and rehabilitation evaluations and programs
• Neurostimulators – implantable
• Parenteral nutrition
• Percutaneous vertebroplasty and balloon-assisted vertebroplasty (kyphoplasty)
• PET scans
• Some prescription drugs require preauthorization; for more information, click here

• Proton beam treatment delivery

• Radiofrequency procedures including radiofrequency neurotomy
• Rehabilitation or skilled nursing facility admissions
• 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
• Transmyocardial revascularization (TMR)
• 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