Prior Authorization Required

The following services require notification or preauthorization. Services that require preauthorization will be denied if preauthorization is not obtained. This list does not include services that may be reviewed post-service for medical necessity upon receipt of the claim; claims reviewed for medical necessity may result in a denial. Kaiser Permanente Washington members and providers can check prior authorization requirements and current lists by signing in to kp.org or contacting Member Services.

• Preauthorization required services will be denied if preauthorization is not obtained.
• Some services may be reviewed after the claim is submitted for medical necessity and can be denied.
• Check kp.org or contact Member Services for plan-specific requirements and current authorization lists.

Notification Required

Notification is required for the following admissions and services. Providers must notify the health plan per the plan's notification procedures for all inpatient and specified settings.

• All inpatient admissions, including emergency admissions, planned admissions, mental health, and withdrawal management.
• Home health care, including home infusion and home dialysis.
• Hospice.
• Long-term acute care admission.
• Skilled nursing facility admissions.
• Substance use disorder residential admissions.

DME, Prosthetics, and Supplies — Prior Authorization Required

Durable medical equipment (DME), prosthetics, and certain supplies require prior authorization. Obtain authorization before providing these items to avoid denial. Concurrent care review may be required and visit limits may vary by plan.

• Bone growth stimulators (electrical and ultrasonic).
• Electrical stimulation devices.
• Home oxygen.
• Mobility assist devices, including wheelchairs and other high-end mobility equipment.
• Negative pressure wound therapy pumps.
• Oscillatory chest compression devices.
• Prosthetic limbs.
• Speech generating devices.
• Tumor treating fields therapy.
• Concurrent care review required; visit limits may be higher depending on plan.

Other Services — Prior Authorization Required

A range of other services require prior authorization. Providers should verify authorization requirements for specific services and plan benefits; some items (e.g., genetic testing, clinical trials, fertility services, experimental services) may have additional documentation or coverage criteria.

• Acupuncture (after 8 visits*).
• Advanced care at home.
• Advanced imaging.
• Applied behavioral analysis (ABA) therapy.
• Capsule endoscopy.
• Cardiac telemetry.
• Charged particle radiation therapy.
• Clinical trials.
• Craniofacial dental procedures.
• Elective air transport.
• Electroconvulsive therapy.
• Experimental and investigational services, including new technologies.
• Fertility services.
• Genetic testing and panels (e.g., cell-free fetal DNA testing, BRCA, Lynch).
• Hyperbaric oxygen therapy.
• Inpatient rehabilitation.
• Level of Care reviews/policies.
• Manipulative therapy (after 8 visits*).
• Neuropsychological testing.
• Partial hospitalization (mental health and chemical dependency).
• Platelet rich plasma (PRP).
• Repetitive transcranial magnetic stimulation (rTMS).
• Transgender services (when benefit is available).
• Ventricular assist devices (VAD).
• Virtual colonoscopy.

Surgery — Prior Authorization and Site-of-Care Guidance

Surgical procedures require prior authorization. Providers must consult the current surgical authorization rules and site-of-care guidance posted on kp.org. Follow the Ambulatory Surgery Center (ASC) Site of Care Policy and the Clinical Review Criteria available on the provider site for up-to-date lists and any site-of-care restrictions.

• See kp.org/walprovider → Authorization & Clinical Review → Clinical Review Criteria → A → Ambulatory Surgery Center (ASC) Site of Care Policy for the current surgery authorization list and site-of-care guidance.
• Examples of surgeries that require prior authorization include (but are not limited to): autologous chondrocyte implantation and other cell-based cartilage treatments; bariatric surgery (reflux and obesity surgery when benefit available); blepharoplasty and brow ptosis repair; bone lengthening; cardiac defibrillators; cochlear implants; deep brain stimulation; facet neurotomy; gastric electrical stimulation; hip procedures for femoroacetabular impingement criteria; implantable hearing aids; keratoprosthesis; meniscal allografts; orthognathic surgery; pacemakers; panniculectomy; peroral endoscopic myotomy (POEM); plugs for fistula repair; reconstructive breast surgery and related breast implant management; reduction mammoplasty; rhinoplasty; sacral nerve modulation; sling procedures for urinary incontinence; spinal surgeries (cervical fusion, lumbar fusion, minimally invasive procedures); vertebroplasty and vertebral augmentation; stereotactic radiosurgery and stereotactic body radiation therapy; transcatheter valve procedures (TAVR/Mitra-clip); transplants; vagus nerve stimulation; varicose vein treatment.
• Follow site-of-care directions (e.g., ASC vs hospital-based) as specified in the ASC Site of Care Policy to ensure appropriate authorization and avoid denials.

Office-Administered Injectable Drugs — Prior Authorization Required

Office-administered injectable drugs require prior authorization per the maintained pharmacy list. Providers must check the current injectable drug prior-authorization list on the provider website before administration.

• See kp.org/walprovider → Pharmacy → Pharmacy Overview → Injectable Drugs Requiring Prior Authorization for the current list.
• Obtain prior authorization before administering office-administered injectable drugs to avoid claim denial.