Services That Require Prior Authorization
This page lists all Medicare-covered services that require prior authorization under your Elderplan Select (HMO-POS I-SNP/IE-SNP) plan. Your provider should contact us before scheduling any service on this list. If you are unsure.
All planned inpatient and facility admissions require prior authorization. Your hospital or facility will typically submit the request on your behalf.
| Service | What you should know |
|---|---|
| Inpatient hospital care | Includes acute care, rehabilitation hospitals, and long-term care hospitals. Authorization is required for all planned admissions. Emergency admissions do not require prior authorization. |
| Skilled nursing facility (SNF) care | Authorization is required. The plan covers up to 100 days per benefit period, and a 3-day prior inpatient hospital stay is NOT required. |
Authorization is required for the outpatient services below. Your provider’s office or the facility usually submits the request before your first visit or procedure.
| Service | What you should know |
|---|---|
| Physical therapy | Authorization is required in all outpatient settings — including hospital outpatient departments, independent therapy offices, Comprehensive Outpatient Rehabilitation Facilities (CORFs), and other outpatient settings. |
| Speech/Language Pathology Services | Authorization is required in all outpatient settings. |
| Occupational therapy | Authorization is required in all outpatient settings. |
| Home health agency care | Authorization is required. A doctor must certify that you need home health services and that you are homebound before services begin. |
| Partial hospitalization services | Authorization is required for partial hospitalization behavioral health programs. |
| Intensive outpatient services (IOP) | Authorization is required for intensive outpatient behavioral health programs. |
| Outpatient mental health specialty services | Authorization is required for individual and group mental health specialty sessions. |
| Cardiac rehabilitation | Authorization is required and covered for members who meet Medicare coverage criteria with a doctor’s order. |
| Intensive cardiac rehabilitation | Authorization is required. Typically, more rigorous or intense than standard cardiac rehabilitation. |
| Pulmonary rehabilitation | Authorization is required and covered for members with moderate to very severe COPD and a doctor’s order. |
| Supervised Exercise Therapy (SET) for peripheral artery disease (PAD) | Authorization is required. Covered for up to 36 sessions over 12 weeks for members with symptomatic PAD who meet Medicare criteria. May be extended for an additional 36 sessions if medically necessary. |
| Outpatient diagnostic radiological services (selected) | Authorization is required ONLY for Positron Emission Tomography (PET), Magnetic Resonance Imaging (MRI), Magnetic Resonance Angiography (MRA), and Computed Axial Tomography (CT). Standard X-rays and other diagnostic imaging may not require authorization, but your provider should confirm before scheduling. |
Equipment, Devices & Supplies
Authorization requirements for equipment and supplies vary by item. Always confirm with your provider or call Member Services before ordering any equipment or supplies to verify whether authorization is needed for your specific item.
| Service | What you should know |
|---|---|
| Durable Medical Equipment (DME) — certain items only | Authorization is required for certain equipment or items. Not all DME requires authorization. Examples that typically require authorization include power wheelchairs, custom orthotics, and home oxygen equipment. Ask your provider or call Member Services to confirm before ordering. You pay 20% coinsurance for Medicare-covered DME. |
| Continuous Glucose Monitors (CGM) — including FreeStyle Libre | Authorization may be required. CGM devices (FreeStyle Libre) and related supplies are covered with a [$0] copayment at participating pharmacies. Contact Member Services or ask your provider to confirm whether authorization is needed before you proceed. |
| Medical supplies | Authorization is required. You pay 20% coinsurance for Medicare-covered medical supplies. |
| Prosthetic and orthotic devices | Authorization is required for prosthetics (such as artificial limbs) and orthotics (such as braces). Includes replacement and repairs due to breakage, wear, or changes in your physical condition. You pay 20% coinsurance. |
| Home infusion therapy — medical supplies | Authorization is required for medical supplies used in home infusion therapy. You pay 20% coinsurance. |
| Home infusion therapy — DME | Authorization is required for certain DME items used in home infusion, including high-dollar, motorized, and custom equipment. Not all home infusion DME requires authorization. |
| Home infusion therapy — Medicare Part B drugs | Authorization may be required for certain Medicare Part B drugs administered through home infusion. Confirm with your provider or call Member Services for your specific medication. |
Medicare Part B Prescription Drugs
| Service | What you should know |
|---|---|
| Medicare Part B prescription drugs | Authorization may be required for certain Part B drugs — including specialty injectables, infused medications, and certain drugs administered through DME. You pay 20% coinsurance. Your insulin cost is capped at [$35] per one-month supply, even when covered under Part B (for example, insulin pumps). |
Ambulance Services
| Service | What you should know |
|---|---|
| Non-emergency ambulance transport | Authorization is required. The member’s medical condition must be documented as requiring ambulance transport (i.e., the member cannot be safely transported by other means). |
| Emergency ambulance transport | Authorization is NOT required. Emergency ambulance is always covered without prior approval. |
This is not a complete list of all covered services — only those requiring authorization. Your provider should confirm with us if there is any question about whether authorization is needed before scheduling.
How to Get Prior Authorization
In most cases, your doctor or specialist submits the authorization request on your behalf — generally through your Primary Care Provider or directly through our Prior Authorization Department. You do not need to handle this yourself. For more information on how the process works, including timeframes and your appeal rights, learn how to get approval for care.