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)

• NON-COVERED DME ITEMS

Genetic Testing and Genetic Counseling

• ​Genetic Testing Laboratory ​Request Form 
  

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

• Specialty Injectable Medications List
• GHC-SCW Medical Pharmacy Program Webinar

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