Prior Authorization
Services for Which Prior Authorization is Recommended
- Bariatric Surgery
- Deep Brain Stimulation
- Drugs, including but not limited to:
- Alefacept (Amevive) and Efalizumab (Raptiva)
- Growth hormone
- Hemophilia Clotting Factors
- Intravenous immune globulin (IVIG)
- Omalizumab (Xolair)
- Durable medical equipment (PA must be completed by DME Provider)
- DME exceeding $500 (purchases)
- Custom wheelchairs, scooters
- High frequency chest wall oscillation devices (vest percussors)
- Hospital beds
- Seat lift mechanisms
- Home health (PA must be initiated by the Home Health Care Agency)
- Home Infusion
- Implantable ventricular assist systems and artificial hearts
- Lung volume reduction
- Prosthetics exceeding $1000
- Skilled nursing facility admissions
- Surgical treatment of obstructive sleep apnea
- Reconstructive procedures and potentially cosmetic procedures, such as:
- Blepharoplasty
- Panniculectomy
- Rhinoplasty
- Scar excision/revision
- Reduction mammoplasty, mastoplexy
- Routine care related to clinical trials (NCD eligible trials)
- Transplants
- Organ except cornea and kidney
- Bone marrow/stem cell
- Vagus nerve stimulation
Please write or fax Medical Management to communicate the prior authorization request to us.
Toll Free: 1-888-537-7702
TTY/TDD users: 1-651-662-1294
8:00 a.m. to 5:30 p.m., Monday – Friday, Central Time
Fax: 1-651-662-9478
Address: P.O. Box 64265, Route R418, St. Paul, MN 55164-0560
The above list not all-inclusive. The most complete, up-to-date list of services for which prior authorization is recommended can be accessed by calling Provider Services at 1-888-457-3009, 8:00 a.m. to 8:00 p.m., Central and Mountain Time.
MedicareBlue PPO Prior Authorization Request Forms
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Case & Disease Management