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

All DME related costs require PA (repair, buy, rent)

Review Medicare criteria:

  • If item is statutorily excluded by Medicare, notify member item is not covered by Senior Preferred; if member wants to purchase item, obtain signature on NDMC (available on website)
  • If item meets Medicare criteria, dispense and bill Health Plan
  • If item does not meet Medicare medical necessity criteria, submit PA to Health Plan for organizational determination

Refer to the DME Prior Authorization Process flowchart.

Experimental and Investigational Treatments

Genetic Testing including Pharmacogentics Testing

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

Hospice Care

  • Requires notification

Inpatient Admissions

  • Hospitals, acute inpatient care (All elective admissions require PA. All other admissions require notification)
  • Skilled nursing facility
  • Swing Bed

Other Services

  • Day treatment
  • Intensive Outpatient Program (IOP)
  • CardioMems (Implantable wireless Cardiovascular monitor system)
  • Corneal Cross-linking
  • Deep brain stimulator
  • Home sleep studies
  • Partial Hospital Program (PHP)
  • Residential treatment (contracted facilities only)
  • Transcranial Magnetic Stimulation (TMS)
  • Vagus Nerve Stimulation 
  • ZIO Patch (External Extended Elctrocardiographic recording)

Out-of-Network service or supplies

  • Requires PA unless urgent/emergent

Surgical Procedures

The following procedures must be prior authorized before they are scheduled.

  • Bariatric Surgery
  • Blepharoplasty
  • Bone Anchored Hearing Aids (BAHA)
  • Breast Surgery
  • Brow lifts
  • Cochlear Implants
  • Implantable Nerve Stimulators
  • Endoscopic procedures for Reflux Management
  • Orthopedic Procedures: Artificial lumbar disc surgery. Not for members > 60
  • Rhinoplasty and septorhinoplasty
  • Scar revision and other repair of scars
  • Surgical removal of redundant skin
  • Transplants including donor and other related charges (excludes corneal except for artificial corneal transplants)
  • Treatment of actinic keratosis or other benign skin lesions
  • 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 (limited therapy related to urinary incontinence
  • Hyperbaric Oxygen Therapy
  • TheraSphere / Sir-Spheres Treatment

Part B Therapies

  • PA required over Medicare Therapy Caps

IV Drugs - Outpatient Hospital and Clinic

  • Medications must meet applicable local coverage determination (LCD) guidelines required by the Medicare Administrative Contractor (MAC). The MAC for residents of WI and MN is National Government Services Inc. (NGS), and the MAC for residents of IA is Wisconsin Physicians Service Insurance Corporation (WPS). LCD guidelines can be found at www.cms.gov/medicare-coverage-database/indexes/icd-state-index.aspx

Gundersen Health Plan complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. 

Spanish – ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de ayuda con el idioma. Llame al (800) 897-1923, TTY 711 or toll free (800) 877-8973. 

Hmong – LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau (800) 897-1923, TTY 711 or toll free (800) 877-8973.