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*.

• Advanced diagnostic imaging (through AIM®) for services on or after November 1, 2010. AIM contact information will be available in mid-October. Please note that AIM is not utilized by PacificSource Administrators, Inc. at this time.
• Ambulance transports (air or ground) between medical facilities, except in emergencies
(air or ground) between medical facilities, except in emergencies
• Artificial intervertebral disc replacement
• Breast Brachytherapy (Accelerated Partial Breast Irradiation (PBI)
• 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
• Mobile Cardiac Outpatient Telemetry (MCOT) e.g., CardioNet Ambulatory ECG or HEARTlink Telemetry
• 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
• Prescription drugs - some require preauthorization; view list
• Proton beam treatment delivery
• Radiofrequency procedures including radiofrequency neurotomy
• Rehabilitation or skilled nursing facility admissions
• Skin Substitutes (e.g., Apligraf, Dermagraft, or other)
• 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