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Surgical implantation of a cervical  intervertebral disc requires prior authorization. (MP9364) 

Electroretinogram or electroretinography (ERG) is considered medically necessary as an acceptable alternative useful for establishing loss of retinal function and distinguishing retinal from optic nerve lesions. Prior authorization is not required. (MP9542) 

Lumbar discography requires prior authorization  and is considered medically necessary when a Neurosurgeon or Orthopedist requests as a decision making aid for surgery.  (MP9427)

Therapeutic contact lenses may be considered medically necessary for the treatment of ocular surface diseases. Some examples include: keratoconus, aphakia, anterior corneal dystrophy or corneal ectasia. (MP9201)

Percutaneous Interspinous Spacer (VertiFlex®) (MP9544) requires prior authorization and is considered medically necessary for skeletally mature patients with impaired physical function with a diagnosis of degenerative lumbar stenosis. (MP9544)

Vertos Minimally Invasive Lumbar Decompression (MILD) requires prior authorization. It is considered medically necessary for patients with lumbar spinal stenosis secondary to ligamentum flavum hypertrophy when medical policy criteria is met.  (MP9551)

Dental services are limited to dental care as described in the policy, which are required for the direct treatment of a medical condition, trauma/accidental injury to teeth or oral surgery and temporomandibular disorder (TMD) as described in the Member’s Certificate. Prior authorization is required.

Hospice services require prior authorization. Hospice may be considered medically necessary with physician certification on terminal illness, no curative treatment and history of disease progression. (MP9299)

Admission to a skilled nursing facility requires prior authorization and is considered medically necessary when a member requires skilled rehabilitative and/or skilled nursing services. The skilled services must be medically necessary at a frequency and intensity that requires an inpatient skilled nursing facility level of care. Custodial care is considered not medically necessary. (MP9310)  (swing bed, SNF)

Habilitation services require prior authorization through the Health Services Division and assist individuals in acquiring, retaining, and improving the self-help, socialization, and adaptive skills necessary to reside successfully in home and community based settings. Habilitation services are distinct from rehabilitation services in that they help a person attain a particular function as opposed to restoring it. (MP9443)

A speech generating device requires prior authorization and may be considered medically necessary when a member has a severe speech disorder with an inability to communicate effectively using speech or the patient's medical condition is one resulting in a permanent severe expressive speech disability and they must be functionally able to use recommended devices. (MP9523)

Dental prosthesis and oncology services related to medically necessary head and neck radiation therapy require prior authorization. (MP9125)

Prothrombin time ( INR ) home monitoring devices do not require prior authorization. It may be considered medically necessary for patients that need anticoagulation therapy for 3 months or longer. (MP9263)