Preauthorization Guidelines

To help you minimize your costs, we recommend you preauthorize medical care when necessary according to these guidelines. If you're enrolled in a contracted HMO, check with your plan representative for information about preathorization guidelines.

General Guidelines

Services that must be preauthorized

• Allomap
• Artificial Intervertebral Discs
• Auditory Brain Stem Implant
• Aural Rehabilitation
• Biofeedback
• Bone Anchored Hearing Assistive Device
• Bone Morphogenic Protein Bone Graft Substitute
• Breast Reconstruction Surgery following Breast Cancer
• Chemical Dependency (Inpatient Services and Outpatient Services)
• Chiropractic Services (Deseret Choice and Deseret Select)
• Dialysis
• Durable Medical Equipment (DME) such as:

  Apnea Monitors
  BIPAP Machines / CPAP Machines
  Bone Growth Stimulators
  Breast Pumps
  Communication Devices
  Hospital Beds
  Insulin Pumps
  Knee Walker
  Liquid Oxygen
  Lymphedema Pumps
  Oxygen Concentrators
  Oximeters
  Pain Pumps
  Prosthetics
  Respirators / Ventilators
  Sacral Nerve Stimulator for Urinary Voiding Dysfunction
  Scooters
  Seasonal Affective Disorder Lights
  Spinal Cord Stimulators for Treatment of Pain
  Suction Machines
  ThAIRpy Vests for Cystic Fibrosis
  Wheelchairs
  Wound Vacs
  

• Enteral Therapy
• Fetoscopic Laser Ablation
• Genetic Testing
• Hip Resurfacing (Partial / Total)
• Home Health Nursing
• Home Intravenous Infusion Therapy
• Hormonal Therapy
• Hospital Inpatient Admissions
• Hospice
• Hyperbaric Oxygen Therapy
• Hyperhydrosis Treatment with Botox / Endoscopic Thoracic Sympathectomy (ETS)
• Maternity Hospitalization (Extended Stay)
• Mental Health: Alternative Care
• Mental Health: Family Psychotherapy with Patient present
• Mental Health: Inpatient Hospital Services
• Mental Health: Outpatient Therapy
• Mental Health: Psychological /Neuropsychological Testing
• Obesity Surgery (Inpatient and Outpatient)
• Oral Appliances
• Pain Clinic (Inpatient)
• Rehab Inpatient Admissions
• Radiology (PET scans, PET-CT, MEG, MRAs,proton beam therapy, brachytherapy, new radiology technologies, etc.)
• Robotic Assisted Surgery
• Skilled Nursing Facility Admissions
• Speech Therapy (Outpatient)
• Stereotactic Radiosurgery for Neurosurgical Conditions
• Tocolytic Therapy / Uterine Fetal Monitoring in the Home
• Transportation
• Transplants

  Bone Marrow
  Cornea
  Heart
  Intestine
  Kidney
  Liver
  Lung
  Pancreas/Kidney
  Heart/Lung
  

• Ventricular Assist Devices (BIVAD, LVAD, RVAD)
• Wearable Cardioverter Defibrillator

Services that do not need to be preauthorized

• Most Outpatient Procedures
• Most Outpatient Surgeries

Questionable Services

Providers and Members are encouraged to call to verify coverage for procedures that may be:

• Cosmetic in nature (not to be considered all inclusive)
  

  Breast Surgeries (i.e. reduction mamoplasty, gynecomastia excision, etc.)
  Nasal Surgeries (i.e. rhinoplasties, septorhinoplasties, etc.)
  Congenital defects such as missing ear, extra finger, or some facial disfigurements)
  Ear Surgery (i.e. otoplasty, to correct certain defects or deformities)
  Eyelid Surgery such as Blepharoplasty
  Jaw Surgery (maxillary and mandibular osteotomies)
  Scar revisions
  Varicose Veins
  

• New Technology
• Experimental Technology
• Exclusion to the Plan
• Clinical Trials

Consequences if you do not preauthorize:

Deseret Choice and Deseret Select

Plan Benefits	If you do not preauthorize you pay
Certain Medical Equipment	$200 per year
Chemical Dependency	$200 per day
Chiropractic Therapy	Must be done through CHP
High-cost Radiology Services	$200 per service
Home Health	$200 per day
Inpatient Hospitalization	$200 per admission
Maternity Hospitalization: Extended	$200 per admission
Mental Health Alternative Care	All Charges (No benefit)
Mental Health Inpatient Hospitalization	$200 per day
Mental Health Outpatient Therapy	$200 per year
Mental Health Testing	$200 per day
Pain Clinics: Inpatient and Outpatient	$200 per day
Speech Therapy	$200 per year
Transportation	$200 per year

Deseret Premier

Plan Benefits	If you do not preauthorize you pay
Certain Medical Equipment	$200 per year
Chemical Dependency	$200 per day
High-cost Radiology Services	$200 per service
Home Health	$200 per day
Inpatient Hospitalization	$200 per admission
Maternity Hospitalization: Extended	$200 per admission
Mental Health Alternative Care	All Charges (No benefit)
Mental Health Inpatient Hospitalization	$200 per day
Mental Health Outpatient Therapy	$200 per year
Mental Health Testing	$200 per day
Pain Clinics: Inpatient and Outpatient	$200 per day
Speech Therapy	$200 per year
Transportation	$200 per year

Deseret Value

Plan Benefits	If you do not preauthorize you pay
Certain Medical Equipment	$200 per year
High-cost Radiology Services	$200 per service
Home Health	$200 per day
Inpatient Hospitalization	$200 per admission
Maternity Hospitalization: Extended	$200 per admission
Mental Health Alternative Care	All Charges (No benefit)
Mental Health Inpatient Hospitalization	$200 per day
Mental Health Outpatient Therapy	$200 per year
Mental Health Testing	$200 per day

For more information about your benefits, please see your Benefits Handbook.

If you have any questions, please contact Deseret Mutual.