Procedures that Require Prior Authorization


The procedures for which Rocky Mountain Health Plans requires prior authorization include the list below. If you have questions about whether a procedure requires prior authorization, contact a Rocky Mountain Customer Service Representative. Customer Service contact information.

Other items that require preauthorization are listed under DME and Prescription Drugs.

Procedure Prior Authorization Request Form  English | Español

Procedures that require Prior Authorization:

Ambulance transport that is not an emergency

Obtain authorization before you schedule ambulance transportation.  This does not apply to urgent or emergent transportation, but only when services are scheduled in advanced.


Behavioral Health Services

Medicaid Prime Members: Call the Behavioral Health Organization (BHO) – Colorado Health Partnerships at 800-804-5008. Follow process per Colorado State Department of Health Care Policy & Financing (HCPF).

All other Members: You do not need a referral or preauthorization to see RMHP participating behavioral healthcare providers. Certain procedures do require preauthorization.

Contact Value Options for all services at 855-886-2832.

Services to Preauthorize

  • Applied Behavioral Analysis (ABA) for treatment of Autism
  • Intensive outpatient treatment
  • Electric shock therapy
  • Psychological or neurological testing - No prior authorization is required for IMPACT test following a head injury
  • In-home outpatient services for a mental health diagnosis
  • Transcranial magnetic stimulation for depression/other neurologic disorders

Cardiovascular

  • External electrocardiographic recording for more than 48 hours up to 21 days by continuous rhythm recording and storage
  • Implantation of catheter-delivered prosthetic pulmonary valve, endovascular approach.
  • Insertion, removal, repositioning of SQ implantable defibrillator
  • Partial left ventriculectomy (e.g., Batista Procedure)
  • Photopheresis, extracorporeal
  • Programming device evaluation and/or adjustment
  • Therapeutic apheresis; with extracorporeal selective adsorption or selective filtration and plasma reinfusion
  • Transcatheter aortic valve replacement
  • Transcatheter insertion of stent of common carotid artery or innominate artery via percutaneous approach
  • Transcatheter mitral valve repair with prosthetic valve via percutaneous approach
  • Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when performed; initial prosthesis.
  • Transcatheter placement of extracranial vertebral or intrathoracic carotid artery stent(s).
  • Transcatheter placement of wireless physiologic sensor aneurysmal sac endovascular repair.

Dental and Orthodontic Related Services

All dental and orthodontic services, including surrounding services such as anesthesia, facility, or appliances.

Please refer to your Evidence of Coverage or contact Customer Service to determine if dental services are covered.

Dermatology

  • Photodynamic therapy for the treatment of skin lesions other than actinic keratosis or Bowen's Disease (e.g. Levualn Kerastick and Metvix CureLight):
  • Total Body Integumentary Photography, for monitoring of high risk patients with dysplastic nevus syndrome or a history of dysplastic nevi, or patients with a personal or familial history of melanoma.

Diagnostic Imaging

Breast Tomosynthesis - Submit request to RMHP

All other imaging procedures: Use this list when the procedure will be performed outside of Delta, or Montrose county and within Colorado.

Submit request to eviCore healthcare:

Phone: 800-792-8750

  • CT Scans
  • CT Angiography
  • CT Colonography
  • Magnetic Resonance Angiography (MRA)
  • Magnetic Resonance Imaging (MRI)
  • Magnetic Resonance Spectroscopy
  • Magnetic Source Imaging (MSI) somatosensory testing
  • 3D rendering of CT Scan, MRI, US or other tomographic modality
  • Nuclear Cardiology
  • Nuclear Medicine
  • PET Scans
  • Gastrointestinal Endoscopic Ultrasound

All other imaging procedures: Use this list when the procedure will be performed in Delta, or Montrose county or outside of Colorado

Submit request to RMHP:

Fax: 800-262-2567 or 970-255-5681

  • CT Angiography
  • CT Colonography
  • Electron Beam CT Scans
  • Functional MRI
  • PET Scans
  • SPECT Scan of the Brain

Ear, Nose, or Throat Procedures

  •  Osseointegrated hearing device, implantation or replacement
    • Commercial and CHP+ Members and RMHP Medicare Members only.
    • Medicaid Prime Members - Submit per HCPF direction.
  • Cochlear device implant
  • Rhinoplasty with or without septal repair - except for nasal deformity secondary to congenital cleft lip and/or palate.
  • Nasal/sinus endoscopy, with dilatation (balloon dilatation).
  • Surgeries and Procedures for snoring, obstructive sleep apnea syndrome, and upper airway resistance syndrome in adults
    • Partial glossectomy
    • Hemiglossectomy
    • Repose tongue suspension system
    • Submucosal ablation of tongue base, radiofrequency (radiofrequency assisted uvulopalatoplasty (RAUP); Submucosal radiofrequency uvulopalatoplasty (SRUP), Somnoplasty, Tongue reduction surgery)
    • Uvulectomy; Uvulopalatopharyngoplasty (UPPP)
Fetal Surgery

  • Fetal umbilical cord occlusion
  • Fetal fluid drainage (eg, vesicocentesis, thoracocentesis, paracentesis)
  • Fetal shunt placement
  • Unlisted fetal invasive procedure
  • Other fetal surgeries may be considered to be experimental.  Refer to the experimental procedure secton

Gastroenterology/General Surgery

  •  Abdominoplasty, Lipectomy, Panniculectomy
  • Breast related procedures: Reconstruction, Reduction, Augmentation, Breast Implant or Removal, Removal or Replacement of tissue expander (No prior authorization required if Member has had a medically necessary mastectomy)
  • Gastric Electrical Stimulation:
    • Implantation, replacement, or removal or gastric neurostimulator electrodes, antrum; laparscopic or open. 
    • Insertion, replacement, or removal of peripheral or gastric neurostimulator pulse generator or receiver
    • Electronic analysis of gastric neurostimulator pulse generator/transmitter system.
  • Gastrointestinal transit and pressure measurement, stomach through colon, wireless capsule, with interpretation and report.
  • Obesity related surgeries: All surgeries related to obesity, including but not limited to bariatric 
    surgeries, lipectomy, or excision of skin due to weight loss
  • Optical endomicorscopy
  • Repair of anorectal fistula with plug (e.g., porcine small intestine submucosa (SIS))
  • Transesophageal endoscopic therapies for gastroesophageal reflux disease (Stretta procedure, Gatekeeper device and EndoCinch device)
  • Treatment of varicose veins, including but not limited to, radiofrequency ablation, sclerotherapy, stripping and ligation, endolaser therapy.

Genetic Testing

Contact eviCore healthCare at 800-792-8750 for genetic testing services listed here -
Specific tests that require prior authorization.


To help ensure that you are receiving the most clinically appropriate care, we have partnered with eviCore healthCare to review certain outpatient Molecular and Genomic tests.  You or your doctor must contact eviCore for prior authorization of the Molecular and Genomic tests associated with the CPT codes that are listed, or your claims will be denied.

Other Laboratory Tests: Submit requests to RMHP
  • Apolipoprotein
  • Lipoprotein (a) enzyme immunoassay (LP(a))
  • FIBROSpect II®, HCV, ASH, or NASH FibroSURETM except when used for evaluation of Hepatitis C


GenitoUrinary (Reproductive system, Kidneys, Urinary system)

  • Biopsies, prostate, needle,transperineal, stereotactic template guided saturation sampling, including imaging guidance
  • Insertion or replacement of penile prosthesis
  • Implant of neurostimulator electrodes; sacral nerve; Insertion, replacement, or revision of peripheral neurostimulator pulse generator or receiver
  • Penile revascularization for impotence
  • Penile venous occlusion surgery
  • Percutaneous posterior tibial nerve stimulation
  • Temporary prostatic stent (e.g., Spanner stent)
​Gynecology (GYN)

  • Laparoscopy, surgical, ablation of uterine fibroid(s)

Hearing Aids or Repairs

  • Hearing Aids or Repairs of Hearing Aids for Children less than 18 years of age
    • Commercial and CHP+ Members under 18 years of age.
    • Medicaid members - submit per HCPF direction.

Interventional Cancer Treatment

  • Cytoreduction, hyperthermic intraperitoneal chemotherapy (HIPEC)
  • Cryosurgical ablation of tumors

    • Cryosurgical ablation of tumors other than liver, kidney (50250, 50593) or prostate
    • Percutaneous cryoablation of tumor of bone without imaging guidance 
  • Radiation Oncology

    • Proton Beam Therapy for uveal melanomas
    • Stereotactic body radiation therapy
    • Thoracic target(s) delineation for stereotactic body radiation therapy
    • High dose rate electronic brachytherapy, skin surface application
    • High dose rate electronic brachytherapy, interstitial or intracavitary treatment 
  • Radioembolization with Yttrium-90 Microspheres (e.g. SIR-spheres, TheraSpheres) except for unresectable primary hepatocellular carcinoma (HCC) or unresectable metastatic liver tumors

Neurosurgery (Brain or Spine)

  • Bone or Soft Tissue Healing and Fusion Enhancement Products
  • Intracranial angioplasty/stenting (Neurolink System, Wingspan TM Stent System)
  • Laminectomy, cervical or lumbar
  • Magnetoencephalography (MEG)/Magnetic Source Imaging (MSI) (Preauthorization required prior to 10/1/2016)
  • Percutaneous lumbar discectomy
  • Spinal arthrodesis, lumbar and cervical, except when done to treat scoliosis.
  • Total disc arthroplasty (artificial disc) including revision, removal
  • Spinal cord stimulation
  • Vagus nerve stimulation

Nutritional Products

  • Medical foods
  • Enteral nutrition
  • Home parenteral nutrition (TPN); Lipids
  • Inpatient pediatric feeding programs

Ophthalmology

  • Electro-oculography with interpretation and report (Preauthorization required prior to 10/1/2016)
  • Implantation of intrastromal corneal ring segments
  • Insertion of anterior segment aqueous drainage device, without extraocular reservoir
  • Keratoprosthesis for refractive error
  • Oculoplastic Surgery:  Blepharoplasty, Eyebrow Ptosis Repair
  • Probing Nasolacrimal Duct with transluminal ballon catheter dilatation.  Applies only when Member is 10 years of age or older. 
  • Transpupillary thermoplasty

Orthopedic

  • Arthrodesis, sacroiliac joint, percutaneous or minimally invasive
  • Arthroplasty, ankle; with implant (total ankle replacement)
  • Arthroplasty, hip or hip resurfacing (hip replacement/resurfacing)
  • Arthroplasty, knee (knee replacement)
  • Arthroplasty, shoulder (shoulder replacement)
  • Autologous chondrocyte implant, including harvesting of chondrocytes
  • Arthroscopy, knee, surgical; Meniscal transplantation, medical or lateral
  • Bone or Soft Tissue Healing and Fusion Enhancement Products
  • Core hip decompression
  • Insertion of posterior spinous process distraction device (Xstop)
  • Intradiscal electrothermal therapy (IDET)
  • Laminectomy, cervical or lumbar
  • Low-intensity ultrasound stimulation to aid bone healing, non-invasive (nonoperative)
  • Open osteochondral autograft, talus
  • Percutaneous Intradiscal Radiofrequency Thermocoagulation (PIRFT)
  • Percutaneous lumbar disectomy
  • Spinal arthrodesis, lumbar and cervical, except when done to treat scoliosis, and related instrumentation
  • Total disc arthroplasty (artificial disc), including revision/removal.

Outpatient Services

  • Allergy immunotherapy; sublingual, oral 
  • Bone Growth Stimulation for bone healing:  Electrical or Low intensity US stimulation
  • Brachytherapy to reduce risk of a de novo restenosis in conjunction with a PTCA, with or without stent placement
  • Bronchoscopy, rigid or flexible, with:
    • balloon occlusion, when performed, assessment of air leak, airway sizing, and insertion
    • removal of bronchial valve(s)
    • bronchial thermoplasty
  • Chelation therapy except when used to treat poisoning or toxicity from heavy metals, e.g. lead, arsenic, mercury
  • Cineradiography/videography
  • Hyperbaric Oxygen Therapy, including topical O2 for wound care
  • Ocular Photoscreening (e.g. Photoscreener), except 12 months through 36 months of age.
  • Orthoptics (eye exercises) for learning disabilities and traumatic brain injury
  • Sleep studies: Home sleep study, unattended, Polysomnography, Acoustic pharyngometer (SNAP) testing. (Preauthorization required prior to 10/1/2016)
  • Therapy - RMHP PRIME Members only.
    • Habilitative: Physical, Occupational, or Speech - Habilitative services will help a person retain, learn, or improve skills and functions for daily living.
      • Habilitative Speech Therapy - Preauthorization needed for adults age 21 or older
      • Habilitative Physical and Occupational Therapy - All habilitative PT/OT services require preauthorization.
    • Rehabilitative: Physical or Occupational - Rehabilitative Services will help restore functional ability that has been lost due to injury or illness.
      • Preauthorization needed for Members UNDER age 21 when exceeding 48 units of any combination of PT/OT per 12 month period – habilitative, rehabilitative, or combination. DO NOT SUBMIT REQUESTS FOR ADULTS 21 OR OVER. BENEFIT LIMITS APPLY.
  • Sensory Integration Therapy – CHP+, Commercial, and Medicare Members only

  • Vision therapy for the treatment of learning disabilities and mild traumatic brain injury


Pain Management - Spinal Pain

  • Destruction by neurolytic agent, paravertebral facet joint nerve(s)
  • Injection(s), paravertebral facet joint or nerves innervating the joint
  • Percutaneous lysis of epidural adhesions using solution injection or mechanical means (eg, catheter) including radiologic localization, multiple adhesiolysis sessions
  • Spinal manipulation under anesthesia

Plastic, Reconstructive, and/or Cosmetic Procedures

  • Oculoplastic Surgery:  Blepharoplasty/Eyebrow Ptosis Repair
  • Breast related procedures:  Reconstruction, Reduction, Augmentation, Breast Implant or Removal, Removal or Replacement of tissue expander (No prior authorization required if Member has had a medically necessary mastectomy).
  • Abdominoplasty, Lipectomy, Panniculectomy
  • Laser treatment for inflammatory skin disease, except for diagnosis of psoriasis
  • Rhinoplasty with/without septal repair - except for nasal deformity secondary to congenital cleft lip and/or palate
  • Treatment of varicose veins, including but not limited to, radiofrequency ablation, sclerotherapy, stripping and ligation, endolaser therapy.
Transplant related services, including initial consult and evaluations

All transplant services, including artificial heart, beginning with initial physician consultation, transplant evaluation, including testing and transplant procedures (except corneal transplants)

Wound Care Clinic

  • Services provided in a Wound Care Clinic, including but not limited to:
    • Debridement
    • Negative Pressure Wound Therapy
    • Low frequency, non-contact, non-thermal ultrasound

 

Wound Care Products
Bioengineered Skin Products, including but not limited to:

Affinity, per square centimeter
• Alloderm
• Allopatch HD; Flex HD 
• Alloskin 
• Alloskin AC, per sq cm
• Alloskin RT, per sq cm 
• Allowrap ds or dry, per square centimeter
• Amnioband or guardian, per square centimeter
• Amnioexcel or Biodexcel, per sq cm
• Amniopro, bioskin, biorenew, woundex, amniogen-45, amniogen-200, per square centimeter
• Apligraf
• Architect extracellular matrix, per sq cm
• Artiss
• BioBrane Biosynthetic Dressing
• BioDfence, per sq cm
• Biovance, per square centimeter
• DermACELL, per sq cm
• Dermagraft
• Dermapure, per square centimeter
• DermaSpan 
• Dermavest, per square centimeter
• Epicel
• EZderm, per sq cm
• GammaGraft, per sq cm
• Grafix core, per sq cm
• Grafix prime, per sq cm
• GRAFTJACKET; GRAFTJACKET Regenerative Tissue Matrix
• Helicoll, per square centimeter
• hMatrix, per sq cm 
• Hyalomatirx 
• Integra Bilayer Matrix Wound Dressing 
• Integra Dermal Regeneration Template(collagen-glycosaminoglycan copolymer 
• Integra matrix, per sq cm 
• Integra Meshed Bilayer Wound Matrix 
• Keramatrix, per square centimeter 
• Marigen, per square centimeter 
• Matristem burn matrix 
• Matristem micromatrix 
• Matrixtem wound matrix 
• Mediskin, per sq cm 
• Memoderm/derma/tranz/integup 
• Neox 100, per square centimeter 
• Neox 1k, per sq cm 
• Neoxflo or clarixflo, 1 mg
• Nushield, per square centimeter
• Oasis burn matrix, per sq cm 
• Oasis tri-layer wound matrix 
• Oasis Wound Matrix
• Orcel (bilayered cellular matrix)
• Primatrix
• Regranex 
• Revitalon, per square centimeter 
• Skin substitute, NOS 
• Talymed 
• Tensix, per sq cm 
• Theraskin 
• TissueMend, per sq cm
• TransCyte (allogeneic human dermal fibroblasts)
• Unite biomatrix 

Refer to the Potentially Experimental List for additional products

 

Potentially Cosmetic Procedures

Link to Potentially Cosmetic Section of the Prior Authorization List

Surgical procedures often are done to correct a functional defect resulting from an injury, sickness, or surgery, or to correct cleft lip or palate.  In many cases, the same procedures might be performed for cosmetic reasons.

Procedures that are done for cosmetic reasons are not covered.  This includes:

  • Cosmetic surgery, services or supplies, except to the extent such surgery, services or supplies are provided as a benefit in your Evidence of Coverage.
  • Reconstructive surgery primarily for improving or correcting a psychological or other non-physical condition.
  • Surgical treatment for obesity or conditions related to obesity.  Refer to the prior authorization section.

The Potentially Cosmetic Section of the Prior Authorization List labels the most commonly performed potentially cosmetic procedures so that you will know if the procedures is not covered, requires prior authorization, or will be covered without prior authorization.

This is not a complete listing of every procedure that could be cosmetic.

Procedures that RMHP considers to be experimental

Link to Experimental Section of the Prior Authorization List

Prior authorization is required for all potentially experimental or investigational procedures.

Experimental and/or investigational procedures, items and treatments, including participation in Clinical research studies are generally excluded, but may be covered when mandated by the state or federal law.

Treatment and services for complications which are "related to" having received an uncovered experimental or investigational procedure are not covered.  "Related to" includes services and supplies that are a part of, made necessary by, or support, the uncovered service or benefit.

Rocky Mountain Health Plans reserves the right to change this list at any time without notice.  Rocky Mountain Health Plans does not guarantee that this list is complete or current.