Services Requiring Prior Authorization

Please review the following listing of all services that require prior authorization.

Advanced Imaging

  • CT/CTA
  • MRI/MRA
  • SPECT
  • PET

Autism Spectrum Disorder Services

  • Diagnostic Evaluation
  • Outpatient Services

Cardiopulmonary Rehab

Durable Medical Equipment (Must Meet Medical Necessity)

Genetic Testing and Genetic Counseling

Home Care Services

  • Home Health
  • Home Infusion

Hospice

Inpatient Admissions

  • Hospitals, acute inpatient care
  • Inpatient Rehab Facilities
  • Long Term Acute Care (LTAC)
  • Psychiatric Admissions
  • Skilled Nursing Facility / swing bed

Mental Health Services

  • Neuropsychological Testing
  • Intensive Outpatient Program (IOP)
  • Partial Hospitalization Program (PHP)

Orthodontic Care

Out of Network Provider Services for HMO Members

Outpatient Surgery (See specific codes on CPT lookup)

PT/OT/ST/Vision Therapy

  • Prior Authorization is not required when provided by GHC-SCW PT/OT

Sleep Studies

Specialty Injectable Medications

Substance Use Disorder (SUD) Services

  • Residential Treatment
  • Intensive Outpatient Program (IOP)
  • Partial Hospitalization Program (PHP)

THESE SERVICES ARE NOT COVERED

  • Cosmetic Surgery for Cosmetic Purposes Only
  • Experimental and/or Investigational Services