Services requiring preauthorization

Medical services requiring preauthorization in 2017

You or your provider must request preauthorization for the following services before they are performed. Services not approved may not be covered by the plan. Requesting preauthorization does not guarantee coverage. Visit the PEB Forms and publications page to find preauthorization requirements for UMP plans.

Some services require both preauthorization and notification. For example, the plan may approve surgery, but your doctor must still notify the plan of an inpatient admission.

The list of services requiring preauthorization is subject to change during the plan year.

Applied Behavior Analysis (ABA) Therapy.
Artificial hearts, total (see also "Transplants" below).
Artificial intervertebral disc surgery.
Atrial fibrillation, thoracoscopic treatment approaches (maze and related procedures).
Autologous fat grafting to the breast and adipose-derived stem cells.
Bariatric surgery.
Biofeedback (covered for migraine or tension headaches per coverage criteria without preauthorization).
Bone growth (osteogenic) stimulators.
Breast reduction (reduction mammoplasty).
Cardioverter defibrillator device, wearable.
Cardiac stenting.
Carotid artery stenting.
Catheter ablation for procedures for supraventricular tachyarrhythmia (SVTA) including atrial flutter/fibrillation.
Certain injectable drugs when obtained through a retail pharmacy or a network mail-order pharmacy. (These drugs are indicated on the UMP Preferred Drug List.)
Cervical fusion surgery.
Charged-particle (proton or helium ion) radiation therapy.
Chemical dependency treatment in residential treatment facilities. See related services that require plan notification.
Clinical trial, coverage of treatment provided.
Cochlear implants.
Computed Tomographic Angiography (CTA).
Computed tomography to detect coronary artery calcification.
Confocal laser endomicroscopy.
Cosmetic and reconstructive surgery.
Cryosurgical ablation of miscellaneous organ and breast tumors.
Deep brain stimulation.
Discography.
Drugs covered under the medical benefit may require preauthorization; call Customer Service at 1-888-849-3681.
Endometrial ablation.
Endovascular angioplasty and/or stenting for intracranial arterial disease (atherosclerosis and aneurysms).
Experimental or investigational services: Services that are considered potentially experimental or investigational, but may be medically necessary for certain diagnoses.
Extracorporeal Circulation Membrane Oxygenation (ECMO) for the treatment of respiratory failure in adults.
Facet neurotomy.
Fetal surgery for prenatally diagnosed malformations.
Fixed-wing air ambulance transport (elective transports only).
Gait analysis.
Gastric electrical stimulation.
Genetic testing.
Glucose monitors.
Hyperbaric oxygen therapy.
Hysterectomy.
Implantable bone conduction and bone-anchored hearing aids (BAHA).
Implantable cardiac defibrillators.
Implantable infusion pumps.
Inpatient admissions, elective.
Inpatient rehabilitation.
Intensity Modulated Radiation Therapy (IMRT).
In vivo analysis of colorectal polyps.
Laboratory and genetic testing for use of 5-fluorouracil (5-FU) in patients with cancer.
Long-term acute care (LTAC) admissions.
Lumbar fusion. (see "Spinal surgery").
Magnetoencephalography/Magnetic Source Imaging (MSI).
Manipulation under anesthesia.
Mechanical embolectomy for treatment of acute stroke.
Mental health treatment in residential treatment facilities. See related services that require plan notification.
Myoelectric prosthetic components for the upper limb.
Microwave tumor ablation.
Orthognathic surgery.
Oscillatory chest compression devices.
Ovarian and internal iliac vein embolization as a treatment of pelvic congestion syndrome.
Percutaneous angioplasty and stenting of veins.
Percutaneous Neuromodulation Therapy (PNT).
Posterior tibial nerve stimulation for voiding dysfunction.
Proton beam therapy.
Radio-embolization for primary and metastatic tumor of the liver.
Radiofrequency ablation (RFA) of tumors.
Reconstructive breast surgery/Mastopexy and management of breast implants (except following a mastectomy for breast cancer).
Sacral nerve modulation/stimulation for pelvic floor dysfunction.
Sacroiliac joint fusion.
Skilled nursing facility admissions.
Sleep apnea (see "Surgery for" below).
SPECT (single-photon emission computed tomography) for ADD/ADHD, dementia, and other psychiatric conditions.
Spinal cord stimulation.
Spinal injections.
Spinal surgery (see also "Artificial intervertebral disc surgery" above):
- Cervical fusion
- Cervical fusion for degenerative disc disease.
- Lumbar.
Stents, drug coated or drug-eluting (DES).
Stereotactic radiosurgery and stereotactic body radiation therapy.
Surgical treatments for hyperhidrosis.
Surgery for:
- Obstructive sleep apnea syndrome.
- Snoring.
- Upper airway resistance syndrome.
Temporomandibular joint (TMJ) surgical interventions.
Transanal endoscopic microsurgery.
Transgender services.
Transplants (preauthorization not required for cornea and kidney).
- Heart.
- Heart/lung.
- Islet transplantation
- Isolated small bowel.
- Liver.
- Lung and lobular lung.
- Pancreas.
- Small bowel/liver and multivisceral.
- Stem cell.
- Ventricular assist devices and total artificial hearts.
Vagus/vagal nerve stimulation.
Varicose veins treatment.
Ventricular assist devices and total artificial hearts.
Virtual Colonoscopy, CT Colonography.