Prior Authorization Requirements

TRS-Care Standard requires advance approval by Blue Cross and Blue Shield of Texas for certain services. This is called prior authorization. It establishes, in advance or within 48 hours of an emergency hospital admission, the medical necessity of certain covered care and services. Prior authorization is required for medical and behavioral health inpatient services including acute care, skilled nursing facility care, hospice, long-term acute care, rehabilitation, residential and Partial Hospital Programs (PHP) and certain outpatient behavioral health services.

Prior authorization is also required for certain medical services and procedures, including:

• Ear, nose and throat treatments such as cochlear implants and sinus surgery
• Surgical procedures such as facial reconstruction, face lifts and breast reduction
• Gastric electrical stimulation (GES)
• Neurological procedures including deep brain stimulation
• Hyperbaric oxygen (HBO2) therapy for wound care
• Lipid apheresis
• Non-emergency fixed-wing ambulance transportation
• Coordinated home care program services, such as hemodialysis, home hospice and private duty nursing
• Advanced imaging including computerized tomography (CT) scans, magnetic resonance imaging (MRI) and position emission tomography (PET) scans
• Cardiology services including stress testing, cardiac CT and MRI and nuclear medicine/myocardial perfusion imaging (MPI)
• Sleep medicine services including sleep studies
• Joint and spine surgery including shoulder, knee and hip surgeries and spinal decompression and fusion
• Pain management including epidural and facet joint injections
• Genetic testing
• Radiation therapy