Predetermination Reviews
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Governs manual predetermination review process for specified services and notes precertification requirement for inpatient procedures; applies to providers submitting requests to Blue Cross and Blue Shield of Alabama.
No material clinical or coverage changes in this revision.
Predetermination Coverage Criteria
Predetermination Coverage Criteria
Predetermination reviews are provided only for specific services listed below. Precertification is required when the procedure is performed in an inpatient setting.
Services eligible for manual predetermination (ONE of)
- Automatic external defibrillator (HCPCS K0606)
- Durable medical equipment (DME) items with a per-line-item cost greater than $3,500$3,500
- Gender reassignment surgery
- Generic code used when no specific code is given
- Prosthesis items with a per-line-item cost greater than $3,500$3,500
Codes and Dollar Thresholds
| K0606 | Automatic external defibrillator |
| 33270 | Implantable defibrillator |
| 33271 | Implantable defibrillator |
| 33272 | Implantable defibrillator |
| 33273 | Implantable defibrillator |
| 33274 | Implantable defibrillator |
| 33275 | Implantable defibrillator |
| E0650 | Lymphedema pump |
| E0651 | Lymphedema pump |
| E0652 | Lymphedema pump |
Predetermination / Precertification Requirements and Provider Instructions
Predetermination Contact and Inpatient Precertification Requirement
Fax clinical information to 205-220-9560. Precertification is required if the procedure is performed in an inpatient setting.
Eligibility for Manual Predetermination and Handling of Non‑listed Requests
Blue Cross and Blue Shield of Alabama will only provide manual predetermination reviews for the services listed; predetermination requests for procedures not on the list will be declined with notification that predetermination is not offered for that service.
- Only the following services qualify for manual predetermination: K0606; DME > $3,500 per line item; gender reassignment surgery; generic code when no specific code is given; implantable defibrillator codes 33270–33275; lymphedema pumps E0650–E0652; MCOT codes 93228, 93229; prosthesis > $3,500 per line item; unlisted codes (examples 76499, 37799).
- If a provider submits a predetermination for a procedure not on the list, the payer will notify the provider that predetermination is not offered for that service.
Scope Definitions and Notes
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