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AHP – PRIOR AUTHORIZATION REQUIREMENTS
March 2026

PRIOR AUTHORIZATION REQUIREMENTS
The requesting provider is responsible for verifying the member’s eligibility and benefits on the date of service. Prior Authorization approval is subject to all plan limits and exclusions. Please note, Prior Authorization requirements apply to all in-network and out-of-network providers. Alliant Health Plans may need to assist in returning the Member to an in- network Provider when it is medically safe.

The below list of services which require Prior Authorization is not inclusive. For prior authorization requirements by specific code, you may use the Prior Authorization Verification Tool located in your Provider Portal or in the Provider section of AlliantPlans.com, or contact Client Services at (800) 811-4793.

ADVANCED IMAGING
• CT
• PET
• MRI
• MRA
•

• Magnetic Resonance Spectroscopy
• Myocardial Perfusion Imaging
• Magnetic Resonance Guidance
BEHAVIORAL HEALTH
• Inpatient
• Intensive Outpatient Treatment Program
• Partial Hospitalization Program (PHP)
• Residential Treatment Center services
CLINICAL TRIAL RELATED SERVICES
All covered services related to an approved clinical trial
DURABLE MEDICAL
EQUIPMENT (DME),
ORTHOTIC AND PROSTHETIC
(O&P), MEDICAL SUPPLY
DME:
• Ambulatory Assistive Devices (excluding crutches, canes and walkers)
• Custom DME
• Home Ventilators
• Hospital Beds and Accessories • Infusion Pumps
• Orthotics
• Prosthetics (excluding breast prosthetics)
• Wheelchairs and accessories

AHP – PRIOR AUTHORIZATION REQUIREMENTS
March 2026

PRIOR AUTHORIZATION REQUIREMENTS
HYPERBARIC OXYGEN THERAPY
All Hyperbaric Oxygen Therapy
INPATIENT ADMISSION
All inpatient admissions require Prior Authorization, including but not limited to:
• Neonatal Intensive Care Unit admissions Levels II, III, or IV (Revenue codes 0172, 0173, or 0174)

EXCEPTION: Maternity related inpatient admissions do not require Prior Authorization.
LABORATORY SERVICES
• Genetic
• Chromosomal
• DNA
• Molecular Pathology
OBSERVATION STAYS
All Observation stays require Prior Authorization, except observation admissions from the Emergency Room do not require Prior Authorization.
OUTPATIENT SERVICES

Including, but not limited to: • Abdominoplasty
• Arthroscopy
• Blepharoplasty
• Brachytherapy
• Breast Reduction
• Cardiac Surgery and Procedures
• Chemodenervation
• Cochlear Device
• Dental Related
• Esophagogastroduodenoscopy (EGD) • Excess Skin Removal
• Facial and Ear Revision/Augmentation/Reconstruction
• Hysterectomy and Related Procedures
• Implantable Devices
• Interdental Fixation
• Joint Repair/Reconstruction/Replacement
• Mastectomy
o EXCEPTION: Breast cancer diagnoses do not require Prior Authorization.

AHP – PRIOR AUTHORIZATION REQUIREMENTS
March 2026

PRIOR AUTHORIZATION REQUIREMENTS
OUTPATIENT SERVICES
(CONT’D)

• Mohs Surgery
• Orchiectomy
• Pain Management Invasive Procedures (including but not limited to Epidural Steroid, Facet and Botox injections)
• Panniculectomy
• Reconstructive Repair Pectus Excavatum
• Scrotoplasty
• Sinus and Nasal Surgery
• Skin Color Correction
• Sleep Studies
o EXCEPTION: Unattended sleep studies
• Spine Surgery
• Stomach/Colon Surgery
• Therapeutic Repetitive Transcranial Magnetic Stimulation (TMS)
• Transplant Related Services/Procedures
• Treatment of contour defects
• Pregnancy Reduction(s)
• Neurostimulator
• Unlisted Procedure Male Genital System
• Unlisted Procedure Nervous System
• Vaginal/Perineum Surgery
• Venous Surgery
• Vein Ligation
• Varicose Vein Treatment
• Vascular Embolization or Occlusion
OUTPATIENT THERAPIES

All Outpatient Therapies
EXCEPTIONS:
• Evaluations
• Physical Therapy
• Occupational Therapy
• Speech Therapy • Chiropractic therapeutic rehabilitation services

AHP – PRIOR AUTHORIZATION REQUIREMENTS
March 2026

PRIOR AUTHORIZATION REQUIREMENTS
PHARMACY
• For specialty or other pharmacy medications, a prior authorization may be required. Contact Prime Therapeutics, Alliant Health Plan’s Pharmacy Benefit Manager, at (844) 451-8288.
• For provider administered specialty pharmacy medications administered in an outpatient setting (ex. infusion center, outpatient hospital, office, home infusion) contact Prime Therapeutics Management, at (800) 424-1799 option 3, option 2, option 1 OR register as a provider on the Prime Therapeutics Management web portal at https://gatewaypa.com/.
• Further specific medication information is available on the formulary page of AlliantPlans.com.
RECONSTRUCTIVE SURGERY
Reconstructive Surgery, including, but not limited to breast reconstruction, is covered only to the extent Medically Necessary.
NOTE: Beautification Procedures are not covered. Refer to the Certificate of Coverage for Non-Covered Services.
TRANSPLANT SERVICES
All transplant procedures, including transplant evaluations must be Prior Authorized and be Medically Necessary and not Experimental or Investigational, according to criteria established by Alliant. Providers should contact Alliant Health Plans to verify participating facilities in the transplant network before referring Members for transplant evaluation or services, which could result in a transplant (e.g., high dose chemotherapy). It is critically important, to both the Provider and Member, that Alliant Health Plans Case Management Department be contacted as soon as the Member has completed the evaluation, and the Provider has deemed the Member as an appropriate candidate to be listed for transplant. To initiate a transplant authorization, call Alliant Health Plans at (800) 865-5922.
TRANSPORTATION
• Ambulance air transport: Non-emergent
NON-COVERED SERVICES AND PROCEDURES
Refer to the Certificate of Coverage for Non-Covered Services.

The information included on this list may change periodically. For updates to the listing, visit AlliantPlans.com, select Providers, and select Forms and Documents under the Main Menu. Select “Procedures Requiring Prior Authorization” under Medical Resources.

To obtain a Prior Authorization, please call (800) 865-5922 or fax a completed Prior Authorization form to (866) 370-5667.

AHP – PRIOR AUTHORIZATION REQUIREMENTS
March 2026

PRIOR AUTHORIZATION REQUIREMENTS
If you have additional questions, please contact Client Services at (800) 811-4793.