Preauthorization Guidelines

Preauthorization (sometimes referred to as precertification or prior authorization) is a process that requires either a provider or a covered individual to obtain approval from DMBA before receiving specific items and services. The medical and surgical services subject to preauthorization may vary by plan and/or employer group.

Please choose the appropriate product below to view DMBA’s product-specific Preauthorization List.

If Medicare A or B pays primary benefits for these services, you do not need to obtain authorization from DMBA.

SPECIALTY DRUG REQUESTS

Some specialty drugs require preauthorization through Magellan Rx Management. A complete list of these drugs can be found here. To request preauthorization, call Magellan Rx at 800-424-8269 or visit ih.magellanrx.com.

PREAUTHORIZATION PROCEDURES

Requests for preauthorization can be submitted using DMBA’s online Provider Authorization Request Tool. Upon successful submission, a provider will receive a nine-digit tracking number. The tracking number is verification that DMBA has received the request. THIS IS NOT AN AUTHORIZATION. Providers must not bill or perform a procedure(s) until DMBA has provided written approval.

Once approved, the authorization is valid for a certain length of time (usually 90 days) as outlined in DMBA’s written authorization. Services falling outside of the approved authorization period require the provider to submit a new request. If the request for services is not approved, the participant may choose to go forward with the procedure or service, but the plan will not cover it.

If preauthorization for a service is not obtained, it could result in payment denials for the healthcare provider or reduced benefits for the participant. Services or medications provided without preauthorization may be subject to retrospective review. Providers should verify benefits and authorization requirements with DMBA before providing services.

 

EMPLOYER PLAN PREAUTHORIZATION LIST

The following list provides categories of medical and surgical services for which preauthorization is required. This list is not all inclusive. Inclusion of a service on the preauthorization list does not guarantee coverage. Benefit coverage for any service is determined by the plan in which the participant is enrolled and any applicable medical criteria.

  • Ambulance transport (air or ground)—non-emergent
    • Transport related to immediate care of a medical emergency or accidental injury does not require preauthorization.
  • Amniotic membrane transplantation
  • Ambulatory and video EEG
  • Anesthesia services for dental procedures under medical plans
  • Applied behavior analysis (ABA)
    • For an autism spectrum disorder, including evaluations and treatments. Please submit clinical records that include notes from the session(s) in which the diagnosis of an autism spectrum disorder was determined, a copy of the functional behavioral assessment if available, and the treatment plan. THE INITIAL ASSESSMENT DOES NOT REQUIRE PREAUTHORIZATION (CPT 97151).
  • Behavioral health services
    • Inpatient hospital services
    • Alternative care (includes chemical dependency/substance abuse):
      • Residential treatment
      • Partial hospitalization
      • Intensive outpatient program
    • Psychological and neuropsychological testing
    • Electroconvulsive therapy (ECT) — inpatient and outpatient
    • Biofeedback
  • BRCA testing and testing for large genomic rearrangements in the BRCA1 and BRCA2 genes
    • Required for both preventive and diagnostic testing
  • Cardiac Devices
    • Implantable cardiac event monitors (loop recorders)
    • Mobile cardiac outpatient telemetry (MCOT)
    • Wearable cardiac devices (e.g., LifeVest®)
  • Chelation therapy
  • Dental
    • Dental accidents
    • Anesthesia services for dental procedures under medical plans
    • Special medical dental
  • Depo-Provera
  • Diagnostic imaging
    • Magnetoencephalography (MEG)
    • Magnetic resonance angiogram (MRA)
    • Myocardial perfusion imaging
    • Nuclear stress test (nuclear cardiology)
    • Positron emission tomography (PET) scan
  • Durable medical equipment (DME)
    • Airway clearance devices
    • Apnea monitors (beyond seven days)
    • Bone growth stimulators
    • Breast pumps (hospital grade)
    • Communication devices
    • Continuous glucose monitoring system (CGM)
    • Continuous passive motion devices (CPM)
    • Continuous positive airway pressure (CPAP) devices; Bilevel (BPAP) devices
    • Dynamic low-load prolonged-duration stretch devices (excludes CPMs)
    • External cardiac defibrillator and associated accessories (e.g., LifeVest®)
    • Gait trainers
    • High frequency chest wall oscillation devices
    • Home oxygen
    • Home ventilators
    • Hospital beds and accessories
    • Insulin pumps
    • Lift systems (Hoyer, etc.)
    • Lymphedema pumps
    • Negative pressure wound therapy pumps (wound VACs)
    • Neuromuscular stimulators
    • Oximeters (Overnight oximeters do not require preauthorization.)
    • Pain pumps
    • Pressure reducing support surfaces including:
      • Air fluidized bed
      • Non-powered advanced pressure reducing mattress
      • Powered air flotation bed (low air loss therapy)
      • Powered pressure reducing mattress
    • Sacral nerve stimulator
    • Seasonal affective disorder (SAD) lights
    • Spinal cord stimulators
    • Speech generating devices
    • Tumor treatment fields (TTF) therapy
    • Ventricular assist devices (BIVAD, LVAD, RVAD)
    • Wheelchairs/scooters/power-operated vehicles (POV)
  • Enteral nutrition
  • Gene therapy and cellular immunotherapy, for example CAR-T and T-Cell receptor therapy
    • Preauthorization through Magellan Rx Management for:
      • Provenge (Sipuleucel-T)
      • Kymriah (Tisagenlecleucel)
      • Yescarta (Axicabtagene Ciloleucel)
      All others are excluded.
  • Home-care services (including infusion therapy in the home)
    • Certain drugs require separate preauthorization. Refer to Medications for additional information.
  • Hospice care
    • Includes home hospice, continuous home hospice, or inpatient hospice care services
  • Hospitalization (Inpatient)
    • All elective, urgent, and emergent inpatient care
    • Acute rehabilitation admissions
    • Inpatient hospice admissions (see hospice above)
    • Long-term acute care (LTAC) facility admissions
    • Skilled nursing facility (SNF) admissions
  • Hyperbaric oxygen therapy
  • Intraoperative neurophysiologic monitoring
  • Intrauterine device (IUD)
    • Mirena IUD only. All other IUDs are excluded.
  • In vitro fertilization
  • Medications
    • Current list of medications that require preauthorization through Magellan Rx Management can be found here.
    • Current list of medications that require preauthorization through DMBA:
      • Depo-provera
      • MIRENA IUD
      • VISUDYNE (Verteporfin)
      • Papaverine
      • XIAFLEX (Collagenase, clostridium histolyticum)
      • XOFIGO (Radium Ra-223 dichloride)
      • ZEVALIN (Yttrium Y-90 ibritumomab tiuxetan)
  • Molecular diagnostic/genetic testing
    • Not an all-inclusive list:
      • Hereditary cancer syndromes
      • Hereditary heart diseases
      • Other full gene analysis testing
      • Specialty oncology tests
      • Pharmacogenomic tests
      • Other specialty tests
      • Genome-wide tests
      • ANY genetic test for more than one gene or condition (often includes words like “panel” or “comprehensive” in the name)
  • Photodynamic therapy (PDT)
    • Including related medications
  • Prosthetic and orthotic devices
    • Bone-anchored hearing aid (BAHA)
    • Cochlear implant
    • Cranial remolding devices (helmets)
    • Oral appliances
    • Lower limb prostheses
    • Upper limb prostheses
  • Reconstructive procedures and potentially cosmetic procedures
    • Breast:
      • Reconstruction following medically necessary mastectomies for breast cancer
      • Simple mastectomy and gynecomastia surgery (excludes radical and modified)
      • Prophylactic procedures associated with hereditary breast and ovarian cancer syndrome
    • Congenital defects (e.g., missing ear, extra finger, or some facial disfigurements)
    • Excision of excessive skin (panniculectomy)
    • Eye: Blepharoplasty/ptosis repair/canthopexy/canthoplasty
    • Nasal surgeries (e.g., rhinoplasties, septorhinoplasties, etc. to repair defect caused by trauma or disease)
    • Orthognathic surgery procedures, bone grafts, osteotomies and surgical management temporomandibular joint (TMJ)
    • Pectus excavatum
    • Scar revisions (to regain function)
    • Varicose veins including perforators and sclerotherapy
  • Skin (bioengineered) and soft tissue substitutes
  • Speech therapy
    • Outpatient only. Limited to 25 visits per calendar year.
  • Sterilization procedures
    • Tubal ligation
    • Vasectomy
  • Surgery
    • All inpatient procedures
    • Artificial intervertebral discs
    • Bariatric surgery/obesity surgery (inpatient and outpatient) Benefits may be available only for the following procedures: Roux-en-Y gastric bypass, sleeve gastrectomy, biliopancreatic diversion with duodenal switch.
    • Bone graft substitutes and bone morphogenetic proteins (BMP)
    • Cervical decompression with or without fusion cervical disc arthroplasty
    • Fetoscopic laser ablation
    • Hip arthroplasty
    • Hip arthroscopy and open procedures
    • Hip resurfacing (partial/total)
    • Intrastromal corneal ring segment (ICRS)
    • Knee arthroplasty
    • Lumbar disc arthroplasty
    • Lumbar discectomy, foraminotomy, and laminotomy
    • Lumbar fusion and treatment of spinal deformity (including scoliosis and kyphosis)
    • Lumbar laminectomy
    • Obstructive sleep apnea surgery, including uvulopalatoplasty/uvuloplasty, or any other surgery for snoring
    • Percutaneous tibial neurostimulation
    • Stereotactic radiosurgery
    • Vertebroplasty/ kyphoplasty
  • Therapeutic radiation
    • Brachytherapy
    • External beam intraoperative radiation therapy
    • Image-guided radiation therapy (IGRT) with external beam radiation therapy (EBRT)
    • Intensity-modulated radiation therapy (IMRT)
    • Neutron beam radiotherapy
    • Proton beam radiation therapy (PBT)
    • Radioimmunotherapy and somatostatin receptor-targeted radiotherapy
    • Selective internal radiation therapy (SIRT)
    • Special radiation physics consult and treatment procedure
    • Stereotactic radiosurgery (SRS) and stereotactic body radiotherapy (SBRT)
    • Radium Ra 223 dichloride (XOFIGO®)
  • Transplants
    • Blood or marrow stem cell transplants
    • Organ/tissue transplants
      • Heart
      • Intestine
      • Kidney
      • Liver
      • Lung
      • Pancreas/kidney
      • Heart/lung
      Preauthorization is not required for transplants of corneal tissue.
  • Travel Reimbursement
 

STUDENT PLAN PREAUTHORIZATION LIST

BYU-Provo/LDSBC

ALL services received outside of the student health center (SHC) require preauthorization, except emergency room visits.

  • For outpatient services performed in Utah, call the SHC authorization line at 801-422-2771, then choose option 5.
  • For all other services (inpatient hospital in Utah or all services outside of Utah), preauthorization requests can be submitted using DMBA’s online Provider Authorization Request Tool.

BYU-Idaho

ALL services received outside of the student health center (SHC) require preauthorization, except emergency room visits and well-baby care.

BYU-Hawaii

ALL services received outside of the student health center (SHC) require preauthorization, except emergency room visits, physical therapy (when done in Hawaii), and one routine eye exam per benefit year.

  • For services received outside of the SHC, providers should contact DMBA at 808-675-4873.