To see if a member’s plan is subject to preauthorization, please check the member’s ID card, refer to member benefits using InTouch, or call our Customer Service Department at (888) 532-5332. 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.

This list is not a complete list of all services requiring preauthorization. Please use the search tool to check for preauthorization requirements for services with specific procedure codes (CPTs or HCPCS).

All Plans 

Excludes PacificSource Medicare, PacificSource Community Solutions, Legacy Employee Health Plan, and Billings Clinic Employee Health Plan.

Please note: This list was updated, effective January 22, 2018. We maintain a separate list for Medical Drugs & Diabetic Supplies: Diabetic Supply List.

  • Advanced diagnostic imaging (through AIM®). For more information, please read our Diagnostic Imaging Management FAQ.
  • Afirma Fine Needle Aspiration Thyroid Analysis
  • Ambulance transports (air or ground) between medical facilities, except in emergencies
  • Amniotic Membrane Transplantation
  • Anesthesia Care With Endoscopies – Not required for Inpatient or Emergency Room
  • 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 including allografts and autografts
  • 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 - While prior authorization is not required, certain criteria must be met for rental, purchase, replacement and repair. Replacement every 5 years.
  • Cymetra (Micronized Alloderm)
  • Cryoablation of renal cell carcinoma
  • CT Scans – See “Advanced diagnostic imaging.” 
  • Dental Services & Procedures – billed under the member's medical coverage
  • Dermoscopy (Total body photography, digital epiluminescence microscopy, mole mapping)
  • Drug testing – Preauthorization required after 12 units.
  • Durable medical equipment (DME) expense over $1000, including purchase, rental, repair, lease, or replacement, or rental for longer than three months, except preauthorization is not required for hospital beds, manual wheelchairs and initial purchase of CPAP/BiPAP equipment. 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
  • Genetic (DNA) testing, including fecal DNA and pharmacogenetics testing 
  • Hip Orthosis – (HCPCS L1600- L1690)
  • 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
  • Hospitalization for dental procedures when covered under this plan, including pediatric dental procedures
  • Hyperbaric Oxygen Therapy (HBOT) 
  • Hyperthermic Intraperitoneal Chemotherapy
  • Inhaled Nitric Oxide (iNO) for Neonatal Hypoxic Respiratory Failure
  • Impella 2.5 System with Percutaneous Coronary Intervention
  • Implantable Peripheral Nerve Stimulator 
  • Ingestible telemetric gastrointestinal capsule imaging system (wireless capsule enteroscopy) 
  • Intracranial Flow Diverting Stents 
  • Intraoperative Neurophysiologic Monitoring During Spinal Surgery
  • iStent Procedure
  • Knee Braces Functional or Rehabilitative and Unloading/Offloading – Preauthorization is required for purchase ≥ $800.
  • Kidney dialysis 
  • Laparoscopies of the female reproductive system, and hysterosalpingograms, hysteroscopies, and chromotubations for women younger than age 45. 
  • 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
  • MRIs – See “Advanced diagnostic imaging.”
  • Negative Pressure Wound Therapy
  • Neurostimulators – implantable 
  • Non-invasive Tests for Hepatic Fibrosis (FibroSURE and FIBROSpect II) 
  • Osteochondral Allografts and Autographs
  • Out-of-country medical services, except in emergencies  
  • Parenteral nutrition 
  • PET scans – See “Advanced diagnostic imaging.”
  • Prescription drugs – some require preauthorization 
  • Proton beam treatment delivery 
  • Radiofrequency procedures including radiofrequency neurotomy and ablations 
  • Rehabilitation admissions
  • Skin Substitutes (e.g., Apligraf, Dermagraft, or other) – External Applications Only
  • Somatostatin Receptor Scintigraphy
  • Surgical procedures and tongue retaining orthodontic appliances for sleep apnea and other sleeping disorders
  • Stereotactic radiosurgery 
  • 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 and related donor services. Preauthorization is not required for corneal transplants. 
  • Varicose vein procedures

Criteria for Preauthorization Decisions

Criteria may be requested by contacting our Health Services team. Criteria can be emailed, faxed, or mailed to you per your request. 



Oregon: (541) 684-5584, Toll free (888) 691-8209, ext. 2584
Idaho: (208) 333-1563, Toll free (800) 688-5008
Montana: (406) 442-6595, Toll free (877) 570-1563
TTY: (800) 735-2900 


Oregon: (541) 225-3625
Idaho: (208) 333-1597
Montana: (406) 441-3378 


PacificSource Health Plans, Attn: Health Services
PO Box 7068
Springfield, OR 97475-0068

InTouch for Members

Last updated 3/12/2018