| These services require Pre-Authorization. | Click to View Medical Policy |
| Abortions |
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| Botox |
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| Cancer Prevention Surgery |
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| Cartilage Transplants, Lower Extremities |
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| Dental Anesthesia |
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| Dorsal Column Stimulator |
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| Eyelid Surgery |
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| Hip Resurfacing Arthroplasty |
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| Intervertebral Disk Prosthesis |
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| Liver Neoplasms Treatment |
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| Neurostimulator - Implantable Electrodes |
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| Penetrating Keratoplasty other than Corneal Transplant. |
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| Penile Implants |
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| Percutaneous Kyphoplasty |
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| Percutaneous Transluminal Sep0tal Myocardial Ablation |
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| Percutaneous Vertebroplasty |
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| Peripheral Atherectomy |
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| Prophylactic or Preventive Surgery |
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| Proton Beam Radiotherapy |
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| Radiofrequency Ablation of Lesions |
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| Reconstruction of the intact breast after contralateral mastectomy for cancer. |
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| Reconstructive surgery and all potentially cosmetic surgery. |
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| Stereotactic Radiosurgery (eg: Gamma Knife) |
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| Strabismus Surgery over 6 years of age. |
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| TMJ, services for the diagnosis or treatment. |
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| Total Disk Arthroplasty--Cervical or Lumbar |
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| Transcatheter Pulmonary Valve Implantation (TPVI) |
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| Urinary incontinence treatment with devices and artificial sphincter. |
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| Varicose Vein Surgery |
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