Providers_forms_PA
The following is not an all-inclusive list. Updates are periodically made to the Prior Authorization list. Please contact Customer Service with specific code information to determine if an item or service requires prior authorization.

Durable Medical Equipment

  • Bone Growth Stimulators
  • Braces / splints over $500
  • Cardiac defibrillator (external only)
  • Continuous glucose monitors
  • Continuous passive motion machines
  • CPAP, BiPAP rental and purchase
  • Custom shoes and custom-molded foot orthotics (limited benefit) includes orthopedic shoes
  • Cystic Fibrosis vests
  • Dynamic Orthotic Cranioplasty (DOC) bands
  • Home monitoring devices
  • Hospital beds and related supplies
  • Insulin pumps
  • Life sustaining nutritional therapies
  • Light therapy (UVB) for in-home use
  • Mechanical stretching devices
  • Prosthetics, including upper extremity, lower extremity, eye, face, etc.
  • TENS and other eStim devices
  • Walk-aid devices (electronic or eStim)
  • Wheelchairs and motorized scooters
  • Wound therapy (Advanced), including vac therapy, wound warming devices and artificial skin

Experimental and Investigational Treatments

Genetic Testing including Pharmacogenetics Testing

 

Home Health Care including home infusion services and other in-home therapy services

 

Hospice Care

 

Other Services

  • Corneal Cross-linking
  • Day treatment
  • Intensive Outpatient Program (IOP)
  • Left Ventricular Assist Devices or LVAD’s for heart failure
  • Non-emergent Ambulance Services
  • Partial Hospital Program (PHP)
  • Residential treatment
  • Transcranial Magnetic Stimulation (TMS)
  • Vagus Nerve Stimulation
  • Wireless / remote heart failure monitoring devices (CardioMems)
  • ZIO Patch

Out-of-Network services or supllies

Pharmacy / Medications

Prior authorization is required for the clinic-administered injectible medications. Practitioners must fax a Medication Prior Authorization Request Form to Gundersen Health Plan Pharmacy at (608) 775-5790.
  • Abatacept IV (Orencia)
  • Abobotulinum toxin A (Dysport)
  • Alemtuzumab (Lemtrada)
  • Alglucosidase alfa (Lumizyme, Myozyme)
  • Alpha-1 proteinase inhibitors (Glassia, Aralast NP, Prolastin C, Zemaira)
  • Buprenorphine (Probuphine) implant
  • Cankinumab (Ilaris)
  • Carfilzomib (Kyprolis)
  • Daratumumab (Darzalex)
  • Denosumab (Prolia, Xgeva)
  • Eculizumab (Soliris)
  • Edaravone (Radicava)
  • Elotuzumab (Empliciti)
  • Eteplirsen (Exondys) not covered – experimental
  • Golimumab IV (Simponi)
  • GNRH agonist ( leuprolide, Lupron, Vantas, Supprelin LA) for use in gender dysphoria
  • HCG Injections (Novarel, Pregnyl)
  • HPV vaccine for ages outside of 9-26 years (Gardasil)
  • Hydroxyprogesterone caproate (Makena)
  • Incobotulinum (Xeomin)
  • Infliximab (Remicade, Inflectra)
  • Mepolizumab (Nucala)
  • Naltrexone Extended Release Injection (Vivitrol)
  • Natalizumab (Tysabri)
  • Nusinersen (Spinraza)
  • Omalizumab (Xolair)
  • Onabotulinum toxin A (Botox)
  • Palivizumab (Synagis)
  • Pegfilgrastim (Neulasta)
  • Renflexis (Infliximab-Abda)
  • Reslizumab (Cinqair)
  • Rilonacept (Arcalyst)
  • Rimabotulinum toxin B (Myobloc)
  • Romiplostim (Nplate)
  • Sebelipase alfa (Kanuma)
  • Testosterone Cypionate (Depo-Testosterone)
  • Testosterone Enanthate (Testosterone Enanthate)
  • Testosterone Implant (Testopel)
  • Testosterone Undecanoate (Aveed)
  • Tocilizumab (Actemra)
  • Ustekinumab (Stelara)
  • Vedolizumab (Entyvio)
  • Xofigo (Radium 223 Dichloride)
  • Zinplava (Bezlotoxumab)
  • Zoster vaccine for age <60 years (Zostavax)
  • Medications billed under miscellaneous codes (examples; J3490, J3590) with amount billed > $2,500

Skilled nursing facility / swing bed

Surgical Procedures

The following procedures must be prior authorized before they are scheduled.
  • Abortions including multi-fetal reductions
  • Bariatric Surgery
  • Blepharoplasty
  • Bone Anchored Hearing Aids (BAHA)
  • Breast Surgery
  • Brow lifts
  • Cochlear Implants
  • Implantable Nerve Stimulators
  • Laser re-surfacing for non-cosmetic procedures (cosmetic procedures are excluded)
  • Laser treatment of actinic keratosis or other benign skin lesions
  • Endoscopic procedures for Reflux Management
  • Orthopedic Procedures: Artificial cervical and lumbar disc surgery
  • Panniculectomy (tummy tuck)
  • Removal of port wine stains and hemangiomas
  • Rhinoplasty and septorhinoplasty
  • Robotic Assisted Procedures
  • Scar revision and other repair of scars
  • Surgical Treatment of Pectus Excavatum and Carinatum Syndrome
  • Temporomandibular Joint Disease surgical treatment
  • Transgender Surgery
  • Transplants including donor and other related charges (excludes corneal except for artificial corneal transplants)
  • Uvuloplasty, Uvulopalatoplasty, Somnoplasty, LAUP and other treatments for snoring or airway obstruction
  • Varicose vein or spider vein procedures including sclerotherapy, radiofrequency ablation, vein stripping and ligation

Therapies

  • Biofeedback (only covered for spastic torticollis or headache)
  • Hyperbaric Oxygen Therapy
  • Prolotherapy
  • TheraSphere / Sir-Spheres Treatment

High Tech Radiology

  • (ETF only) CT and CTA scans; MRI & MRA; PET scan; Nuclear stress test
If you have any questions about the prior authorization list or want to know if a service or supply requires prior authorization, please contact Customer Service at (800) 897-1923.