Always check benefits through the Voice Response Unit (VRU) or My Insurance Manager^SM to determine if prior authorization is required.

Prior authorization is a process used to determine if a requested service is medically necessary. Currently, Medicare Advantage requires prior authorization for the following services:

Durable medical equipment $250 or more (including powered mobility)

All inpatient admissions

Note: Inpatient admissions also require review if a continued stay is necessary.

Dialysis treatment (initial)

Non-emergent transportation

Medications covered under Medicare Part B including, but not limited to visco-supplementation for knee osteoarthritis (hyaluronan), monoclonal antibody treatments and other biologicals for multiple sclerosis, rheumatoid arthritis, psoriasis, inflammatory bowel disease, or chronic migraines

Continuous glucose monitors

Facility-based polysomnography

Bariatric surgery

Inpatient level of care for non-emergency surgery

Behavioral health services

Note: Behavioral health services are managed by Companion Benefit Alternatives (CBA), a separate company that offers behavioral health benefits on behalf of BlueCross BlueShield of South Carolina.

Life Vest – external cardiac defibrillators

Trans-catheter aortic valve replacement

Testosterone replacement

Pneumatic compression devices

IV iron therapy

Spinal cord stimulators for chronic pain

Left atrial appendage closure devices

Electronic bone growth stimulators

As of July 1, 2022, the following service requires prior authorization:

• Recurring outpatient nerve stimulation treatments specifically including, but not limited to electrical nerve stimulation treatments carried out with or without injections of anesthetic agents and/or nutritional supplements or vitamins, like the RST Sanexas system

As of Aug. 1, 2022, the following services require prior authorization:

• Amniotic products for non-ophthalmic conditions

• Pelvic floor stimulation

• Transcutaneous electrical nerve stimulation (TENS) unit

You can review the medical policies for all the above-mentioned services for more information.

Radiology and Musculoskeletal Services

Coming soon, the following categories of services will require prior authorization through National Imaging Associates (NIA):

• Radiation oncology
• Musculoskeletal
• Radiology

Laboratory Services

On April 25, 2022, our Medicare Advantage plans began requiring prior authorization through Avalon Healthcare Solutions for certain services. On Jan. 23 2023, additional services were added to the prior authorization requirements.

View the list of procedure codes that require prior authorization through Avalon.

Methods for requesting prior authorization

Medical services

• My Insurance Manager℠
• Phone: 855-843-2325
• Fax: 803-264-6552

Behavioral health services

• Phone: 833-971-4075

Radiology and musculoskeletal services

• Online: www.RadMD.com
• Phone: 866-500-7664

Laboratory services

• PAS Portal – Avalon's prior authorization system (PAS). If you do not have an account, request one here.
• Phone: 844-227-5769
• Fax: 813-751-3760 – Submit the Preauthorization Request Form along with supporting documentation.

Avalon’s Laboratory Network

Avalon also manages a network of labs. Our members pay less out of pocket when you use network labs than for non-network labs. So, we urge you to use participating laboratories, when possible. 

Interested in enrolling in our lab network? Go to the Avalon website to get started. This link leads to a third party site. That company is solely responsible for the contents and privacy policies on its site.