Which services typically require prior authorization in Medicare Advantage plans?

Prior authorization is a process used by Medicare Advantage plans to determine whether a particular service or procedure meets the necessary criteria for coverage. Typically, this process applies to high-cost procedures and specialized tests due to the significant financial implications involved. This requirement serves to ensure that the services provided are medically necessary, appropriate, and covered under the specific plan.

High-cost procedures can include surgeries, imaging tests such as MRIs or CT scans, and other specialized treatments that may not be considered routine or necessary in every case. These types of services are more closely monitored to prevent unnecessary costs and ensure that patient care is aligned with best practices.

In contrast, routine check-ups and vaccinations, emergency room visits, and office visits with primary care providers generally do not require prior authorization. These services are typically considered essential and standard components of healthcare, designed to promote ongoing health and are treated differently in terms of authorization to facilitate easier access for patients.