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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 for 2009
Services Needing Preauthorization
- 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 Serices)
- Chiropractic Services (Deseret Choice / Deseret Select)
- Cochlear Implant
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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
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Transplants
Bone Marrow
Cornea
Heart
Intestine
Kidney
Liver
Lung
Pancreas/Kidney
Heart/Lung
- Ventricular Assist Devices (BIVAD, LVAD, RVAD)
- Wearable Cardioverter Defibrillator
Services Not Needing Preauthorization
- 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 of not Preauthorizing by Medical Plan
Deseret Choice and Deseret Select
| Plan Benefits |
Consequence of not Preauthorizing |
| 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 |
Consequence of not Preauthorizing |
| 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 |
Consequence of not Preauthorizing |
| 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.
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