Prior Authorization
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General Prior Authorization Forms
Request for Preservice Review
Services Requiring Prior Authorization
Forms for Specific Procedures/Items
Request for Authorization for Synagis
17-P Universal Authorization Form
Services Requiring Prior Authorization
Allergy Testing
Brachytherapy for Oncologic Indications
Cochlear and Auditory Brainstem Implants
Continuous Passive Motion Devices
Custom-made Knee Braces
Electrical Bone Growth Stimulator
External Insulin Infusion Pump
Glucose Monitoring and Related Supplies
Home Oxygen Therapy
Hyperbaric Oxygen Therapy
Implantable Infusion Pumps
Ultraviolet Light, including Laser Therapy, for the Treatment of Skin Disorders
Lower Limb Prosthesis
Mastectomy for Gynecomastia
Power Wheeled Mobility Assist Device
Prefabricated and Prophylactic Knee Braces
Prophylactic Mastectomy
Prothrombin Time Self-Monitoring Devices
Single Photo Emission Computed Tomography Scans (SPECT) and Scintimammography
Spinal Orthoses: Thoracic-Lumbar-Sacral (TLSO), Lumbar-Sacral (LSO) and Lumbar
Treatment of Obstructive Sleep Apnea in Adults
Treatment of Varicose Vein (lower extremities)
Vacuum-Assisted Wound Therapy