Document Library
Need a prior authorization form?
285 results found.
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Artificial Intervertebral Discs 9364pdf|Surgical implantation of a cervical intervertebral disc requires prior authorization. (MP9364)
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Hearing Aids 9445pdf|
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Hospice Services 9299pdf|
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Laboratory Testing 9539pdf|
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Lumbar Discography 9427pdf|Lumbar discography requires prior authorization and is considered medically necessary when a Neurosurgeon or Orthopedist requests as a decision making aid for surgery. (MP9427)
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Actigraphy 9559pdf|
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Microprocessor Controlled Knee Prostheses, With or Without Polycentric 9638pdf|Microprocessor Controlled Knee Prostheses, With or Without Polycentric, Three-Dimensional Endoskeletal Hip Joint System MP9638
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Home Use of Bilevel Positive Airway Pressure (BiPAP) for Conditions Other Than Obstructive Sleep Apnea (OSA) 9658pdf|Home Use of Bilevel Positive Airway Pressure (BiPAP) for Conditions Other Than Obstructive Sleep Apnea (OSA) MP 9658
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Foot Care 9656pdf|
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Telehealth 9662pdf|
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Fecal Calprotectin 9665pdf|
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Trigger Point Dry Needling 9672pdf|Effective 01/01/2024