Prior Authorization and Submission Instructions

Effective April 01, 2026 Prior Authorization is not a guarantee of benefits or payment at the time of service. Reimbursement of authorized services is dependent upon eligibility, benefit limitations / exclusions. There are services and procedures which are not covered by Baylor Scott & White Health Plan / FirstCare or its subsidiaries. These are NOT on the prior authorization list because they are never covered. Benefits vary between plans, so always verify benefits by consulting the member benefit booklet OR contacting a customer service representative to determine coverage for specific services or supplies. The current list of prior authorization codes, requirements for specific codes, AND online authorization submission is available on the Baylor Scott and White Health Plan Service Portal. Registered users of the secure provider portal website can log in and submit an electronic preauthorization request. Call the number listed on the member's ID card for more information about our secure provider website. Contact your Provider Relations Representative for additional assistance. We also request notification for certain other services so that we may assist providers and members with discharge planning, care coordination, and case management. All services must be medically necessary and appropriate and meet Texas Medicaid Provider Procedures Manual / BSWHP coverage criteria where applicable. Claims will be reviewed to determine member eligibility at the time of service, benefit availability, evidence of coverage provisions, and claims payment agreements. Benefits are determined by each member's plan. Newly published / assigned codes and new / emerging therapy services or technology not listed may require prior authorization to determine medical necessity. Check with Baylor Scott & White Health Plan before providing these types of services.

• Prior authorization required for services listed on the BSWHP Service Portal; authorization is not a guarantee of payment.
• Verify member benefits and eligibility prior to providing services; use the member ID card phone number or provider portal.
• Notification (not authorization) requested for certain services to enable discharge planning and care coordination.

Notification Requests and Medical Necessity

Notification or prior authorization requests will be reviewed for medical necessity against applicable coverage criteria. Submit sufficient documentation to demonstrate medical necessity. Lack of required documentation may result in delay or denial of authorization or claim payment.

• Include clinical history, prior conservative therapy, imaging and test results where applicable.
• For retrospective or urgent requests, indicate reason and provide supporting clinical evidence.

Coding list — provider billing reference

This policy includes extensive coding lists that providers should use for billing and for determining whether prior authorization is required. The coding lists are maintained with effective dates and crosswalks to help identify when newly published or revised CPT/HCPCS/other codes may require authorization. Always consult the latest coding list on the Service Portal before submitting an authorization or claim.

• Provider billing reference: consolidated code lists (CPT/HCPCS/ICD-10/Category III/T-codes and temporary codes) are available on the Service Portal and must be used for authorization and claims submission.
• Effective date for this policy: 2026-04-01 — verify code effective dates in the portal and crosswalks for any codes added after this effective date.
• Codes listed in the policy may have annotations (eg, effective dates, retired status, crosswalk mappings) — use those annotations when determining authorization requirements.

Spine arthrodesis codes (partial)

Spine arthrodesis and interbody device codes (examples shown in the coding list) may require prior authorization. Examples include codes 22612-22634 series and 22800-22862 series. Check the Service Portal for full code groupings and specific documentation requirements for fusion and interbody device procedures.

• 22612, 22614, 22630-22634 (lumbar arthrodesis series)
• 22800-22862 (spine instrumentation and interbody device codes)

Interbody device and disc arthroplasty codes (partial)

Interbody device and disc arthroplasty codes (examples) are included in the coding lists and may have specific prior authorization requirements, including documentation of failed conservative therapy and imaging. Examples: 22854, 22856-22860.

• 22854, 22856-22860 (interbody device / disc arthroplasty codes)

Orthopedic joint procedure codes (partial)

Orthopedic joint procedure codes across shoulder, hip, knee and related joints are included in the code list and may require authorization for primary and revision arthroplasty and certain joint reconstructions. Examples: 23465-23474 (shoulder), 27125-27138 (hip), 27412-27487 (knee). Refer to the Service Portal for full lists and any clinical criteria.

• 23465-23474 (shoulder arthroplasty and revision codes)
• 27125-27138 (hip arthroplasty and revision codes)
• 27412-27487 (knee arthroplasty and revision codes)

Arthroscopy procedure codes (partial)

Arthroscopy procedure codes for shoulder, hip, knee and other joints are listed and may require authorization depending on the procedure and clinical indication. Examples: 29805-29828 (shoulder arthroscopy), 29860-29883 (hip arthroscopy), 29866-29884 (crosswalked knee arthroscopy equivalents). See Service Portal for mapping and authorization rules.

• 29805-29828 (shoulder arthroscopy codes)
• 29860-29884 (hip and knee arthroscopy codes and mappings)

Arthroscopy code mappings

Some arthroscopy codes have mappings or equivalencies to other procedures — verify appropriate code selection and authorization requirements. When codes are mapped (eg, hip to knee equivalents), ensure documentation supports the billed procedure.

• Crosswalks between hip and knee arthroscopy codes are provided in the coding list.
• Use clinical documentation and operative reports to justify code selection when mappings exist.

Rhinoplasty and related procedures mappings

Certain rhinoplasty and nasal valve procedures are included in the coding lists with effective dates and mappings; authorization may be required for reconstructive or functional indications. Examples include codes in the 304xx series.

• 30410, 30420, 30435, 30450, 30460, 30468-30469 and related mappings

Cardiac/transplant code mappings

Cardiac and transplant-related procedure codes (including TAVR, valve implantation, heart and lung transplant, VAD insertion/replacement) are listed and generally require prior authorization. Examples: 33340, 33361-33366, 33418, 33927, 33935, 33945, 33975-33995 series. Consult transplantation/preauthorization teams for organ transplant procedures.

• 33340 (LAA closure), 33361-33366 (TAVR approaches)
• 33418 (transcatheter mitral repair), 33927-33945 (heart/organ transplant codes)
• 33975-33995 (ventricular assist device codes)

Venous procedure code mappings

Venous procedure codes for endovenous ablation, sclerotherapy, and percutaneous venous interventions are listed and may require prior authorization depending on the procedure. Examples include 36473-36483, 36836-36837, and related CPTs.

• 36473-36483 (sclerotherapy and endovenous ablation series)
• 36836-36837 (percutaneous AV fistula creation)

Transplant/bariatric code mappings

Transplant preparation and bariatric procedure codes (including hematopoietic progenitor cell prep and bariatric laparoscopy codes) are included and often require authorization. Examples: 38208-38215, 38240-38241, 43290-43291, 43644-43775, 43845-43847.

• 38208-38215, 38240-38241 (HPC/transplant prep)
• 43290-43291, 43644-43775, 43845-43847 (bariatric and endoscopic bariatric procedures)

CPT equivalencies (partial)

Some CPT equivalencies, temporary T-codes, and other code replacements are provided in the coding lists to aid in billing transitions. Use the Service Portal crosswalks for guidance on equivalent codes and retirement dates.

• Temporary entries and CPT equivalencies are annotated with effective/retire dates in the coding list.

Implantation/revision device codes

Device implantation and revision codes (eg, intrathecal pump, neurostimulator, spinal cord stimulators, ventricular assist devices) appear in the coding lists and typically require prior authorization with device-specific documentation.

• 62351, 62360-62362 (intrathecal/epidural catheter and pump devices)
• 33975-33995 (ventricular assist device implantation/revision)

Procedure code list — no explicit authorization instructions

A broad procedure code list is provided in the policy for provider reference; not every code has explicit authorization instructions within the policy text — check the Service Portal for code-specific requirements and any plan-level exceptions.

• Extensive code lists (orthopedics, spine, cardiac, transplant, oncology, genetics, molecular assays, radiology, etc.) are included in the policy content.
• When no explicit instruction is listed for a code in this document, consult the Service Portal or Provider Relations for authorization guidance.

Coding crosswalks — no authorization actions specified

Coding crosswalks and mappings are included throughout the policy to help identify code equivalencies and replacements; these are informational but critical for correct billing and authorization submission. Always use the most current crosswalks on the Service Portal.

• Crosswalks for arthroscopy, rhinoplasty, genetic tests, and temporary codes exist within the coding lists.
• Mappings note effective dates and retired code replacements.

CPT code list and effective dates

A CPT code list with effective dates is maintained; when submitting authorizations or claims, ensure the CPT code effective date aligns with the date of service and that any recently added codes are checked for authorization requirements.

• CPT and HCPCS codes in this policy include effective dates and annotations; verify before submission.

Genomic/molecular CPT code mappings

Genomic and molecular CPT code mappings and panels are listed with required panel composition or test description where applicable. Prior authorization may be required for certain molecular and genomic tests — refer to the genetic testing criteria and preauthorization pathways on the Service Portal.

• Examples: BRCA gene panels (81162-81167), various genomic panels (81410-81443 series), oncology expression assays (81529-81595 series).
• Panel descriptions include required genes or panel sizes where applicable.

Genomic panel descriptions and requirements

When genomic panels or molecular tests are listed, required documentation and specific panel descriptions (eg, minimum gene list, sequencing or duplication analysis requirements) are included in the coding list. Ensure test reports include required elements to support medical necessity.

• Panel descriptions and requirements (eg, minimum gene content) are provided for selected codes.
• Attach laboratory reports and clinical rationale when submitting authorizations for genomic testing.

Oncology molecular tests

Oncology molecular tests and tumor profiling codes are included with effective dates and may require prior authorization; provide pathology, staging, prior therapies, and intended clinical use when requesting authorization.

• Examples: 81535, 81539, 81541, 81546, 81551, 81554, 81560, 81595 and related oncology assay codes.

Unlisted and cardiovascular procedure codes

Unlisted procedure and cardiovascular codes are presented with mappings to related listed procedures where available; unlisted codes often require additional documentation (operative report, rationale) to support medical necessity and appropriate reimbursement.

• Unlisted and cardiovascular procedure examples: various 4xxxx–9xxxx unlisted codes and mappings included in the coding list.

Code listings and descriptors

Extensive code listings and descriptors are included for provider billing reference; these lists do not replace plan benefits — verify member coverage and network constraints before performing services.

• Use the coding lists to prepare accurate authorization requests and claims.
• Coverage determination remains subject to member benefits and eligibility.

Continued code listings

Continue to consult the Service Portal for the most current code listings, mappings, effective dates, and any policy updates that affect prior authorization requirements. For codes added after this document's effective date (2026-04-01), check the portal before rendering services.

• Codes added or revised after 2026-04-01 may require authorization — always verify on the Service Portal.

Coding list — provider billing reference

Provider billing reference: the included coding lists serve as the authoritative guide for which procedures may require prior authorization and the documentation expected for review. When in doubt, submit a preauthorization request with complete documentation or contact Provider Relations.

• Submit authorizations via the secure provider portal; phone/contact info listed on member ID cards for assistance.
• Incomplete or missing documentation may result in denial or payment delay.