• WPS Medical Prior Authorization List Form

Prior Authorization List | Effective: Jan. 1, 2026 Page 1 of 16

Prior authorization is the process of obtaining approval from the health plan for services or products before they are received by the health plan customer. Prior authorization (PA) is required for many services including those listed below. At times, prior authorization is referred to as pre-service authorization, pre-authorization, or pre-certification. Prior authorization requests may be submitted by providers via iExchange (preferred) or fax to 608-226-4777. The Prior Authorization forms may be found online at wpshealth.com/resources/provider-resources/forms-documents.shtml. For more information about iExchange, please go to wpshealth.com/resources/provider-resources/iexchange/overview.shtml • Providers should verify customer eligibility and benefits through the WPS Provider Portal or by calling Customer Services at 800-765-4977. • Customers should review their health plan for specific authorization requirements, excluded services/treatments, and referral requirements. • Providers and/or customers can contact WPS with any questions regarding prior authorizations using the contact information found on the customer ID card. If the customer ID card is unavailable, please contact Customer Services at 800-765-4977. Disclaimer: These references are for informational purposes only and do not constitute medical advice, plan authorization, explanation of benefits, or a guarantee of payment. Benefit plans vary in coverage and some plans may not provide coverage for all services included on the list below. Note that some of the services or products listed may be considered non-covered. Note that some services or products considered non-covered may not be included on this list. Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and to applicable state and federal law. Some benefit plans administered by the organization may not utilize Medical Management medical policy in all of their coverage determinations. This list is not all-inclusive. Medical policies are based on constantly changing medical science. Our medical policies are reviewed annually and are subject to change. The organization uses tools developed by third parties, such as the evidence-based clinical guidelines developed by MCG Health and Hayes publications to assist in administering health benefits. Medical policies and MCG Health guidelines are intended to be used in conjunction with the independent professional medical judgment of a qualified health care provider. WPS Medical policies may be viewed online at wpshealth.com/resources/provider- resources/medical-policies.shtml. To obtain a referenced MCG guideline specific to your patient’s review, please call the number located on the back of the customer’s ID card. For general medical policy questions or concerns, please email medical.policies@wpsic.com. • Drug prior authorization, step therapy, and biosimilar information can be found at wpshealth.com/resources/files/drugpreauth.pdf • Radiation oncology services require prior authorization. Log onto evicore.com (preferred) or call: 800-475-1954. Fax: 800-540-2406 • High-Tech radiology services require prior authorization. Prior authorization requests may be submitted by providers via iExchange (preferred) or fax to 608-226-4777.

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Service/Procedure Notes Effective Date 3-D Conformal Radiation Log onto evicore.com (preferred) or call: 800-475-1954. Fax: 800-540-2406 01/01/18 3-D Imaging CT/MRI/US https://www.wpshealth.com/resources/files/3D-rendering-of-mri-ct-us.pdf 12/01/21 Acupuncture Verify customer health plan coverage. Often listed as an exclusion in health plans or with specific indications and limitations. 10/01/19 Alternative Communications Device/Speech Generating Device or Digitized Speech Verify customer health plan coverage. https://wpshealth.com/resources/files/Non-covered-services.pdf 10/01/15 Artificial Disc Replacement https://wpshealth.com/resources/files/artificial-disc-replacement.pdf https://wpshealth.com/resources/files/Non-covered-services.pdf 10/01/15 Artificial Pancreas https://wpshealth.com/resources/files/Non-covered-services.pdf 10/01/19 Autologous Chondrocyte Implantation (ACI), Matrix-induced Autologous Chondrocyte Implantation (MACI) May be allowed for knee only (if medical necessity criteria are met). https://www.wpshealth.com/resources/files/autologous-chondrocyte-implantation- and-maci.pdf 10/01/19 Bariatric Surgical Procedures and Weight- Related Services and Procedures Verify customer health plan coverage. Bariatric surgery and other weight loss services or procedures are often exclusions of customer health plans. https://wpshealth.com/resources/files/Non-covered-services.pdf 10/01/15 Behavioral Health Services: Inpatient, residential and therapeutic repetitive transcranial magnetic stimulation (TMS) treatment. Verify customer health plan coverage. For transcranial magnetic stimulation, utilize the Prior Authorization and Referral Request form which may be found at wpshealth.com/resources/provider-resources/forms-documents.shtml 10/01/15 Biofeedback Verify customer health plan coverage. This is often an exclusion of the customer health plan. 10/01/15 Bone Anchored Hearing Aids (BAHA) Verify customer health plan coverage. https://wpshealth.com/resources/files/Cochlear-Implants.pdf 10/01/15

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Service/Procedure Notes Effective Date Bone Growth (Osteogenesis) Stimulators (BGS) https://www.wpshealth.com/resources/files/bone-growth-stimulators.pdf 10/01/15 Botulinum Toxin Injection (Botox) Requires prior authorization review by pharmacy. https://www.wpshealth.com/resources/files/drugpreauth.pdf 10/01/15 Brachytherapy Log into evicore.com (preferred) or call: 800-475-1954. Fax: 800-540-2406 01/01/18 Bronchial Thermoplasty https://wpshealth.com/resources/files/Non-covered-services.pdf 10/01/19 Capsule Endoscopy Verify customer health plan coverage. MCG used to review. https://wpshealth.com/resources/files/Non-covered-services.pdf 10/01/19 Cell-Free Fetal DNA testing Verify customer health plan coverage. MCG used to review. https://wpshealth.com/resources/files/Non-covered-services.pdf 01/01/18 Chemotherapy https://www.wpshealth.com/resources/files/drugpreauth.pdf 10/01/19 CPAP/BiPAP Machine Purchases https://wpshealth.com/resources/files/sleep_disorder_treatment.pdf https://www.wpshealth.com/resources/files/dme-pap-oral-devices-hypoglossal- nerve-med-policy.pdf
10/01/15 Updated 01/01/26 Clinical Trials Verify customer health plan coverage. 10/01/15 Cochlear Implants Verify customer health plan coverage. https://wpshealth.com/resources/files/Cochlear-Implants.pdf 10/01/15 Corneal Treatments and Specialized Contact Lenses https://wpshealth.com/resources/files/corneal-treatments-specialized-contact- lenses.pdf https://wpshealth.com/resources/files/Non-covered-services.pdf 01/01/18

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Service/Procedure Notes Effective Date Cosmetic and Plastic Surgery Procedures (and any procedure that may be considered cosmetic) Examples of potential cosmetic procedures include, but are not limited to: • Acne peels and other acne treatments • Blepharoplasty, canthoplasty, eyelid, or eyebrow surgery • Lipectomy • Panniculectomy • Pectus excavatum/carinatum and Poland Syndrome surgery • Port Wine Stain Laser Treatment • Reduction/augmentation mammoplasty/mastopexy and other breast-related procedures; verify customer health plan coverage; some health plans exclude coverage/do not cover reduction mammoplasty (breast reduction) for any reason; except when related to mastectomy for breast cancer. • Removal of redundant skin • Rhinoplasty • Temporomandibular Joint Disease (TMJ) treatments 10/01/15 Updated 01/01/26

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Service/Procedure Notes Effective Date • Orthognathic surgical services • Varicose vein treatments • Laser treatment for psoriasis or other skin conditions https://wpshealth.com/resources/files/varicose-vein-treatments.pdf https://wpshealth.com/resources/files/blepharoplasty-browlift.pdf https://wpshealth.com/resources/files/reduction-mammoplasty.pdf https://wpshealth.com/resources/files/Non-covered-services.pdf https://www.wpshealth.com/resources/files/panniculectomy-abdominoplasty-and- repair.pdf https://www.wpshealth.com/resources/files/pectus-excavatum-pectus-carinatum- and-poland-syndrome-treatment.pdf https://www.wpshealth.com/resources/files/septoplasty-and-rhinoplasty.pdf https://www.wpshealth.com/resources/files/dme-tmj-medical-policy.pdf
Cranial Orthotic (cranial banding, cranial remodeling, orthotic cranioplasty) Verify customer health plan coverage. Please note, this is often an exclusion of the customer health plan. MCG used to review. 10/01/15 Craniectomy or Craniotomy MCG Guideline used for review. 10/01/19 Deep Brain Stimulation (DBS) and Responsive Cortical Stimulation Verify customer health plan coverage. https://wpshealth.com/resources/files/Non-covered-services.pdf 10/01/15 Dialysis https://www.wpshealth.com/resources/files/34249-wps-kidney-resource-prior-auth- form.pdf 10/01/19 Drugs, Biosimilars, Chemotherapy, Immunotherapy Certain drugs require prior authorization, step therapy, or biosimilar use. https://www.wpshealth.com/resources/files/drugpreauth.pdf 10/01/19 Durable Medical Equipment (DME) and Orthotics Typically, DME or orthotics with rental prices above $750 per month or purchase prices above $1,000. Continuous glucose monitors review at $10,000; check pharmacy formulary if obtaining through pharmacy benefit. NOTE: Some customer health plans may have different price thresholds. Contact Customer Services to verify the price threshold. NOTE: Some orthotics always require prior authorization, regardless of prices. Examples of DME that always require prior authorization regardless of dollar threshold include: • Rentals and purchases of CPAP/BiPAP Machine Purchases 10/01/15 Updated 01/01/26

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Service/Procedure Notes Effective Date • Heated humidifier for use with positive airway pressure (PAP) devices • Home ventilators • Home negative pressure wound therapy (wound vac) • Home pneumatic compression devices • Wearable cardiac defibrillator vests • Tumor treatment fields (TTF), Electric tumor treatment fields (ETTF) devices (such as Optune®) https://wpshealth.com/resources/files/Non-covered-services.pdf https://wpshealth.com/resources/files/sleep_disorder_treatment.pdf https://www.wpshealth.com/resources/files/tumor-treating-fields.pdf https://www.wpshealth.com/resources/files/dme-afo-kafo-ko-foot-orthoses.pdf
https://www.wpshealth.com/resources/files/dme-spinal-orthoses.pdf
Gender Dysphoria Treatment https://wpshealth.com/resources/files/treatment-of-gender-dysphoria.pdf https://wpshealth.com/resources/files/Non-covered-services.pdf 10/01/19 Genetic Testing, Genetic Panels, Genome- wide Association Studies, Molecular Profiling, Pharmacogenetic Testing All types of genetic-related testing require prior authorization. Customers: Please ensure your health care provider gets a prior authorization for genetic- related testing before it is performed, as the test may be considered experimental, investigational, or unproven to affect health outcomes. Note: All genetic, genomic, pharmacogenetic, pharmacogenomics, molecular genetic, mRNA, DNA, chromosome, telomere, single nucleotide polymorphism (SNP), gene sequencing, gene expression profiles, and gene-related panels, tests, and analyses require prior authorization before the testing is completed. Verify customer health plan coverage.
https://www.wpshealth.com/resources/files/genetic-testing-medical-policy.pdf
Required documentation from the ordering provider or the genetic counselor associated with the ordering provider includes: • Diagnosis or symptoms being evaluated • Complete relevant family and personal history • Discussion of the calculated potential risks and benefits of the testing; role of heredity in the condition being confirmed diagnosed or treated • How the results of testing will change or influence the current treatment plan 10/01/15 Updated 01/01/26

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Glaucoma Surgical Treatments https://wpshealth.com/resources/files/glaucoma-surgical-treatments.pdf https://wpshealth.com/resources/files/Non-covered-services.pdf 10/01/19

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Service/Procedure Notes Effective Date High-Tech Radiology Contact Customer Service at 800-765-4977 to verify requirements Please Contact Customer Services (refer to customer ID card) to verify requirements. Prior authorization is required for all Magnetic Resonance (MRA, MRI, MRS, MRV), Computed Tomography Angiography (CTA), Computed Tomography (CT), Positron emission tomography (PET), and MR Cholangiopancreatography (MRCP).
https://www.wpshealth.com/resources/files/mri-abdomen.pdf https://www.wpshealth.com/resources/files/mri-breast.pdf https://www.wpshealth.com/resources/files/mri-cardiac.pdf https://www.wpshealth.com/resources/files/mri-chest.pdf https://www.wpshealth.com/resources/files/mri-brain.pdf https://www.wpshealth.com/resources/files/mri-neck-face-orbit.pdf https://www.wpshealth.com/resources/files/mri-pelvis.pdf https://www.wpshealth.com/resources/files/mri-spine.pdf https://www.wpshealth.com/resources/files/mri-upper-and-lower-extremities.pdf https://www.wpshealth.com/resources/files/pet-scan.pdf MCG Guidelines are used to review CT scans.
10/01/15 Updated 01/01/26 Hip Arthroplasty, Hemi-Arthroplasty, Resurfacing, Revision or Replacement (Hip Replacement) https://wpshealth.com/resources/files/hip-replacement-surgery.pdf 10/01/19 Home UVB Light Treatment for Skin Conditions Verify customer health plan coverage. 10/01/15 Hospice Services (Home and Inpatient) Verify customer health plan coverage and benefit limits. 10/01/15 Hospital Bed Verify customer health plan coverage. 10/01/15 Hyperbaric Oxygen Therapy Prior authorization is required for non-emergency use (Example: wound treatment). https://wpshealth.com/resources/files/Hyperbaric-Oxygen.pdf 10/01/15 Infertility and Recurrent Pregnancy Loss Testing and Treatment Verify customer health plan coverage. Many health plans have exclusions or limitations related to infertility. Also includes cryopreservation. https://wpshealth.com/resources/files/Infertility.pdf 10/01/19 Infusion Services (Outpatient and Home Infusions) Customer health plans require prior authorization for infusion (IV) administration and the drug(s) being infused. Some drugs may require a separate review through specialty pharmacy if they are on the specialty drug prior authorization list. 10/01/19

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Service/Procedure Notes Effective Date Documentation should include the diagnosis, name of the drug(s), dose infused, and duration of treatment. https://www.wpshealth.com/resources/files/drugpreauth.pdf Immune Globulin (IVIG) https://www.wpshealth.com/resources/files/drugpreauth.pdf 10/01/19 Inpatient Admission: Planned (elective/scheduled) Includes Hospital, Behavioral Health, Skilled Nursing Facility (SNF), Long-term Acute Care (LTAC), Inpatient Rehabilitation, and Inpatient Hospice • Notification/prior authorization request to the health plan must be made a minimum of three days prior to date of planned admission. • Notification to the health plan of urgent/emergent admissions must be made within two days of the admission (sooner if possible). 10/01/15 Intensity Modulated Radiation Therapy (IMRT) Log into: evicore.com (preferred) or call: 800-475-1954. Fax: 800-540-2406 10/01/15 Joint Replacement Surgery (Ankle, Elbow, Hip, Knee, Shoulder, Wrist) https://www.wpshealth.com/resources/files/Ankle-Arthroplasty.pdf https://www.wpshealth.com/resources/files/hip-replacement-surgery.pdf https://www.wpshealth.com/resources/files/knee-replacement-surgery.pdf https://www.wpshealth.com/resources/files/shoulder-replacement- surgery.pdf MCG guidelines used to review Elbow and Wrist Arthroplasty 10/01/19 Updated 01/01/26 Knee Arthroplasty (Knee Replacement) https://wpshealth.com/resources/files/knee-replacement-surgery.pdf 10/01/19 Meniscal Allograft Transplantation https://www.wpshealth.com/resources/files/meniscal-allograft-transplant.pdf 10/01/19 Multiplex Polymerase Chain Reaction (mPCR) or Nucleic acid Pathogen Testing for Infectious Disease Prior authorization is required for testing of more than five gastrointestinal, central nervous system, respiratory, and vaginal pathogens. For testing of greater than 5 pathogens, there must be documentation by the ordering provider of the need for rapid result and the need to test for each of the pathogens identified on the panel. https://www.wpshealth.com/resources/files/multiplex-pathogen-testing-for- infectious-disease.pdf 10/01/19 Neuropsychological Testing Verify customer health plan coverage, initial visit to determine need for testing does not require prior authorization. https://www.wpshealth.com/resources/files/neuropsych-testing.pdf 10/01/15

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Service/Procedure Notes Effective Date Negative Pressure Wound Therapy https://www.wpshealth.com/resources/files/negative-pressure-wound-therapy.pdf 10/01/19 Neurostimulation Including, but not limited to, deep brain, posterior tibial, hypoglossal, percutaneous, functional stimulation; neurostimulators for pain management, central sleep apnea, and obstructive sleep apnea. https://wpshealth.com/resources/files/sleep-disorder-testing.pdf https://wpshealth.com/resources/files/sleep_disorder_treatment.pdf https://wpshealth.com/resources/files/Non-covered-services.pdf https://wpshealth.com/resources/files/back-pain-sacroiliac-joint-and-coccydinia- treatments.pdf https://wpshealth.com/resources/files/back-and-nerve-pain-procedures- radiofrequency-ablation-facet-joint-and-other-injections.pdf https://wpshealth.com/resources/files/back-pain-procedures-epidural-injections.pdf https://www.wpshealth.com/resources/files/spinal-cord-and-peripheral-nerve- stimulators.pdf 10/01/15 Updated 01/01/26 New or Unproven Technology: Medical, Surgical, or Biomedical Services that Might be Considered Experimental, Investigational, or Unproven • Examples: Bronchial thermoplasty, certain corneal treatments and specialty contact lenses; multianalyte laboratory assays and analyses (MAAA); and proprietary laboratory analyses (PLA) tests. • Prior authorization required if not addressed in the Non-covered Services and Procedures Medical Policy. • All genetic-related testing requires prior authorization. • Category III coded procedures/services, also known as “T” codes. https://wpshealth.com/resources/files/Non-covered-services.pdf https://www.wpshealth.com/resources/files/genetic-testing- medical-policy.pdf
10/01/15 Updated 01/01/26 Orthotics All orthotics at or above $750 require prior authorization. Note: Many health plans have exclusions related to foot orthotics. Some orthotics may always require prior authorization, regardless of price. Verify customer health plan coverage and benefits. https://www.wpshealth.com/resources/files/dme-afo-kafo-ko-foot-orthoses.pdf
https://www.wpshealth.com/resources/files/dme-spinal-orthoses.pdf
10/01/19 Updated 01/01/26

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Osteoarticular Transfer System (OATS) Procedure and Mosaicplasty (Cartilage Transfer Procedures) May be allowed for knee only (if medical necessity criteria are met). https://www.wpshealth.com/resources/files/cartilage-transfer-procedures- oats-and-mosaicplasty.pdf 10/01/19

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Service/Procedure Notes Effective Date Pain Management Procedures (Customer Health Plan and Medical Policy Limitations May Apply) All spinal surgeries require prior authorization. Other examples include, but are not limited to: • Automated percutaneous lumbar discectomy • Epidural steroid injections • Facet joint injections (Includes facet, MBB, zygapophysial joint, paravertebral facet joint, and dorsal/posterior ramus injections) • Intrathecal pump implantation • Lumbar discography • Microwave ablation • Occipital nerve block • Peripheral nerve blocks or ablation • Piriformis injections • Radiofrequency ablation • Spinal cord/dorsal column stimulation • Sacroiliac (SI) joint fusion • Sacroiliac (SI) joint injections and treatment • Sympathetic Nerve Injection https://wpshealth.com/resources/files/back-pain-procedures-epidural-injections.pdf https://wpshealth.com/resources/files/back-and-nerve-pain-procedures- radiofrequency-ablation-facet-joint-and-other-injections.pdf https://wpshealth.com/resources/files/back-pain-sacroiliac-joint-and-coccydinia- treatments.pdf https://wpshealth.com/resources/files/Non-covered-services.pdf https://www.wpshealth.com/resources/files/spinal-cord-and-peripheral-nerve- stimulators.pdf 10/01/15 Pectus Excavatum/Carinatum Surgery (Sunken Chest Surgery; “Pigeon Chest” Surgery) https://www.wpshealth.com/resources/files/pectus-excavatum-pectus-carinatum- and-poland-syndrome-treatment.pdf 10/01/15 Pharmacogenetic Testing https://wpshealth.com/resources/files/Non-covered-services.pdf https://www.wpshealth.com/resources/files/genetic-testing-medical-policy.pdf
FDA Table of Pharmacogenomic Biomarkers in Drug Labeling is found at: https://www.fda.gov/media/124784/download 10/01/19 Updated 01/01/26

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Service/Procedure Notes Effective Date Physical Therapy (PT), Occupational Therapy (OT), and Speech Therapy (ST) Benefit coverage varies by group and should be verified prior to services rendered.
Medical necessity review after 10 visits for PT, after 8 visits for all other therapies. Authorization requests should be faxed to 608-226-4777. For Speech Therapy MCG is used for review. https://www.wpshealth.com/resources/files/physical-and-occupational-therapy.pdf 10/01/15 Updated 01/01/26 Pneumatic Compression Devices for Home Use https://www.wpshealth.com/resources/files/pneumatic-compression-devices.pdf Note: Pneumatic compression devices are often listed as an exclusion of the health plan. Verify customer health plan coverage. 10/01/19 Prosthetics Prior authorization is required for prosthetics over $5,000 NOTE: Some customer health plans may have lower dollar threshold requirement for prior authorization; Contact Customer Service to verify cost threshold. Microprocessor and myoelectric-controlled prosthetics require prior authorization regardless of cost.
https://www.wpshealth.com/resources/files/dme-upper-and-lower-ext- prostheses.pdf
10/01/19 Updated 01/01/26 Proton Beam Radiotherapy Log into evicore.com (preferred) or call: 800-475-1954. Fax: 800-540-2406 10/01/15 Radiation Oncology (Cancer) Treatments Log into evicore.com (preferred) or call: 800-475-1954. Fax: 800-540-2406 01/01/18 Radiation Therapies/Radiation Treatments Log into evicore.com (preferred) or call: 800-475-1954. Fax: 800-540-2406 01/01/18 Radiopharmaceutical Therapy Log into evicore.com (preferred) or call: 800-475-1954. Fax: 800-540-2406 01/01/18 Referrals for Out-of-Network Providers Verify customer health plan coverage. Some plans do not allow out-of-network referrals. https://www.wpshealth.com/resources/files/30652-wps-prior-auth-referral.pdf 10/01/19 Selective Internal Radiation Therapy (SIRT) Log into evicore.com (preferred) or call: 800-475-1954. Fax: 800-540-2406 01/01/18 Skilled Nursing Facility Prior authorization required for customer admission and extensions of stay. 10/01/15

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Service/Procedure Notes Effective Date Sleep Study Evaluation and Treatment of Sleep Disorder (Sleep Apnea Testing and Treatment) • Polysomnograms (Sleep study: home and in-lab) • Purchases of CPAP/BiPAP and other positive airway pressure devices and heated humidifiers • Oral appliances • Hypoglossal nerve stimulation • Surgical procedures (such as UPPP, Inspire system, remedē® System)

https://www.wpshealth.com/resources/files/dme-pap-oral-devices- hypoglossal-nerve-med-policy.pdf
https://wpshealth.com/resources/files/sleep-disorder-testing.pdf
https://wpshealth.com/resources/files/Non-covered-services.pdf 10/01/15 Updated 01/01/26 Spinal Cord Stimulators and Peripheral Nerve Stimulation https://www.wpshealth.com/resources/files/spinal-cord-and-peripheral-nerve- stimulators.pdf 10/01/15 Spine Surgery Examples of spinal surgeries that require prior authorization may include, but are not limited to: • Artificial Intervertebral Discs • Arthrodesis • Fusions (including SI joint treatments) • Laminectomy and facetectomy Note: For sacroplasty see the Non-Covered Services and Procedures Medical Policy. Some procedures may be reviewed using MCG Guidelines. https://wpshealth.com/resources/files/artificial-disc- replacement.pdf https://wpshealth.com/resources/files/back-pain-sacroiliac- joint-and-coccydinia-treatments.pdf https://wpshealth.com/resources/files/Non-covered-services.pdf 10/01/15 Stereotactic radiosurgery/radiotherapy Log into evicore.com (preferred) or call: 800-475-1954. Fax: 800-540-2406 10/01/15 Temporomandibular Joint (TMJ) Treatments Verify customer health plan coverage.
https://www.wpshealth.com/resources/files/dme-tmj-medical-policy.pdf
01/01/26 Therapeutic contact lenses Verify customer health plan coverage. 10/01/15 Total Ankle Arthroplasty (Ankle Replacement) https://wpshealth.com/resources/files/Total-Ankle-Arthroplasty.pdf 10/01/15

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Total Elbow Arthroplasty, Hemi-Arthroplasty, Revision or Replacement (Elbow Replacement) MCG Guidelines used to review. 01/01/26 Total Shoulder Arthroplasty, Hemi- Arthroplasty, Reverse Shoulder Arthroplasty, Revision or Replacement (Shoulder Replacement) https://www.wpshealth.com/resources/files/shoulder-replacement-surgery.pdf 10/01/15 Total Wrist Arthroplasty, Hemi-Arthroplasty, Revision or Replacement (Wrist Replacement) MCG Guidelines used to review.
01/01/26

Prior Authorization List | Effective: Jan. 1, 2026 Page 16 of 16 Service/Procedure Notes Effective Date Transplants (Solid Organ, Bone Marrow, Stem Cell, Fecal, Eye-Related, and Cartilage- Related) Verify customer health plan coverage. https://wpshealth.com/resources/files/Non-covered-services.pdf 10/01/15 Transport of Patients: Non-Emergency (MediVan, Ground Ambulance, or Air Ambulance) Prior authorization required for non-emergency transport. 10/01/15 Tumor Treatment Fields Therapy (TTF) a.k.a. Alternating Electric Field Therapy (Example: Optune®) https://www.wpshealth.com/resources/files/tumor-treating-fields.pdf 10/01/19 Updated 12/01/25 Varicose Vein Treatments https://wpshealth.com/resources/files/varicose-vein-treatments.pdf https://wpshealth.com/resources/files/Non-covered-services.pdf 10/01/15 Ventricular Assist Device and Related Services and Procedures MCG Guideline used to review. 10/01/19 Ventilator Prior authorization required for home use. 10/01/19 Wearable Cardiac Defibrillator (LifeVest®) MCG Guideline used to review. 10/01/15 Wheelchairs (Power Wheelchairs, Custom Wheelchairs, Scooters) Also, includes any with a rental price greater than $750 per month or purchase price greater than $1,000. 10/01/15 Revisions Approved: 10/16/2025 ©2025 Wisconsin Physicians Service Insurance Corporation. All rights reserved. JO27938 32345-100-2511