Blue Cross Blue Shield NM plastic/reconstructive Prior Auth

inv-01: General prior authorization guidance

Inclusion on the list indicates preauthorization may be required; providers must verify eligibility and submit required documentation prior to service delivery.

Prior authorization and benefit verification: Inclusion of a code on this list indicates benefit preauthorization may be required and providers must verify eligibility and benefits prior to rendering services.

The presence of a code does not guarantee coverage; consult the member benefit booklet or customer service.

inv-02: Transplant documentation criteria

Coverage and approval for transplant-related CPTs require documentation; approval is contingent on either an existing transplant authorization or submission of transplant-specific records.

Transplant-related CPT approval: If transplant approval is on record, provide the date of transplant; if no transplant approval is on record, submit a history and physical, transplant evaluation, and the date of transplant.

Applies to donor and recipient transplant CPTs listed (examples: 33930–33935, 33940–33945, 38205–38242).

inv-03: General documentation criteria

Surgical procedures listed require submission of standard clinical documentation to support medical necessity prior to authorization.

General surgical CPT documentation: Submit a recent history and physical and the operative/procedure report and documentation of medical necessity. Where specified for an individual CPT, also submit pre‑operative evaluations and relevant test results (e.g., Doppler studies, sleep study results, CPAP trial).

Referenced per individual CPT entry; failure to submit required documentation may result in denial.

inv-04: General eviCore prior authorization and documentation requirement

Covered when ALL of the following are met:

eviCore prior authorization and documentation: Prior authorization is obtained via eviCore (contact: 1-855-252-1117 or https://www.evicore.com/provider) and required clinical documentation (recent history & physical, chart notes from ordering clinician, and treatment plan/documentation of medical necessity) is submitted as specified for the J-code or other eviCore‑managed code.

Many J-codes and medication/injection codes in the list explicitly require eviCore routing and the documentation items above (see individual J-code lines for additional specifics).

The inclusion of a CPT/HCPCS code on this document does not by itself indicate that the service is covered under the member's benefits. Providers must verify eligibility and benefits for the individual member prior to delivering services by consulting the member benefit booklet or contacting customer service. The list is intended to flag services for which benefit preauthorization may be required rather than to establish coverage determinations.

Some entries include plan‑specific exceptions noting that No Prior Auth is required for the MT Medicare Advantage Plan effective 1/1/21 (examples appear in knee and arthroscopy code lines). Other T‑ or U‑code lines similarly document plan‑level exceptions (e.g., 0274T). Where such notes appear, they are limited to the named plan and effective date shown; providers should not assume the exception applies to other commercial or Medicare plans without verification.

This segment emphasizes the documentation requirements providers must submit for prior authorization review rather than listing explicit clinical exclusions. Typical items requested include a recent history and physical, pre‑operative evaluation, operative/procedure report, and any procedure‑specific test results (for example, Doppler studies for vascular procedures or transplant evaluation documentation for transplant codes). Failure to supply required documentation may lead to denial.

Certain code lines include notes that No Prior Auth is required for MT or NM Medicare Advantage Plan with specific effective dates (for example, several spine/pain and selected T/U codes reference a 4/1/2018 or 1/1/2021 exception). These exceptions are plan‑specific and appear inline with the individual code entries; verify applicability to the member's plan before assuming no authorization is needed.

Many entries are framed as utilization‑management actions (e.g., route to eviCore for prior authorization, or submission of specified documentation) rather than as explicit covered/not‑covered statements. The document serves as an operational routing and documentation guide: where a code line indicates prior authorization or eviCore management, providers must follow that process to obtain authorization and avoid potential claim denials.

Example legacy plan notation: several sleep study codes (including 95782, 95783, 95800, 95801, 95805, 95806, 95807, 95808, 95810, 95811) include a note that No Prior Auth was required for the MT Medicare Advantage Plan effective 4/1/2018. These dated entries reflect prior handling and should be confirmed against current plan rules.

Example of a plan‑specific exception tied to a single code: code 0274T includes an inline note indicating No Prior Auth required for MT Medicare Advantage Plan effective 4/1/2018 while also showing eviCore routing and effective/add dates for other plans. Treat such notes as code‑level, plan‑specific exceptions only.

Some code lines include historical timing markers such as Prior to 9/1/2019 or list specific add/remove dates for a code entry. These dates indicate legacy handling or when a code was added/removed from eviCore routing or documentation requirements; providers should confirm whether the date‑based note affects current authorization needs.

An example imaging entry identifies PET whole body for melanoma (60219) as routed to eviCore and flagged for a non‑covered indication in that line. This shows the list can include routing for cases where an indication is explicitly noted as non‑covered, and underscores the need to check the code line details and member benefits.

Some medication/J‑code lines include lifecycle notes showing removal or end dates (for example, an entry records J2796 removed 12/31/24 in the list). These removal or end‑date annotations indicate the code's management status changed and should be confirmed for current routing and authorization requirements.

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Provider Responsibilities and Documentation Requirements

Prior Authorization

Prior Authorization May Be Required

Prior authorization may be required for many of the CPT/HCPCS/U/T/J codes listed in this document. Presence of a code on the list indicates that the payer or its vendor may require preauthorization or clinical documentation review before services are rendered. Always verify member eligibility and benefit coverage before scheduling services.

Check member benefits and eligibility prior to service.
Code presence on the list is not a guarantee of coverage.

Prior Authorization

Prior Authorization Routing to eviCore

Many codes in this file are managed by eviCore Healthcare. When a code is routed to eviCore, providers must contact eviCore for utilization management or prior authorization via the eviCore phone number or provider portal.

eviCore contact: 1-855-252-1117 or https://www.evicore.com/provider
When eviCore is listed for a code, prior authorization or clinical review is managed by eviCore.

Prior Authorization

eviCore Prior Authorization Requirement

For many spine, pain, imaging, genetic, molecular, drug and J-code services the prior authorization requirement is handled through eviCore. Providers should obtain prior authorization from eviCore where indicated and submit the required supporting documentation.

Examples: spine fusion, interventional pain injections, implantable neurodevices, select imaging and molecular/genetic panels.
Follow eviCore guidance for required clinical documents and prior-auth submission.

Documentation Required

Prior Authorization and Required Documentation for Listed CPTs

Certain surgical CPTs and other listed procedures explicitly require prior authorization and specific documentation at time of request. Submit requested records (H&P, operative/procedure reports, conservative treatment documentation) to support medical necessity.

Commonly requested documents: Pre-operative evaluation, recent History & Physical, operative report, imaging, and documentation of conservative measures tried.
Failure to supply required documentation may delay or prevent authorization.

Prior Authorization

eviCore Prior Authorization for Spine/Pain Codes

Many spine and interventional pain procedure codes listed are routed to eviCore for prior authorization. Providers must contact eviCore and include required clinical documentation (recent H&P, imaging, notes showing conservative care) when requesting authorization.

Examples: fusion CPTs (e.g., 22558, 22600, 228xx), implantable spine devices, neurostimulation and infusion pump implants.
Include documentation of prior conservative treatment and functional impairment where requested.

Documentation Required

Documentation and Prior-Auth Date Requirements for Genital/Gynecologic Codes

For genital and gynecologic procedures listed (e.g., hysterectomy-related and genital reconstructive codes), prior authorization often requires submission of a recent History & Physical and operative report and clear documentation of medical necessity.

Include documentation of functional impairment and prior conservative treatments when applicable.
Ensure prior-auth request dates correspond to the payer's stated effective/prior-to dates when required.

Prior Authorization

Prior Authorization Required Where Indicated

Obtain prior authorization where indicated on the code list. If a code entry specifies prior authorization or routes to eviCore, obtain authorization before performing the service to avoid denial.

When eviCore or 'Prior to' dates are shown, follow the routing and timing instructions in the list.
Verify plan-specific exceptions (see next callout) prior to requesting authorization.

Note

Plan-Specific Prior Authorization Exceptions

Some entries include plan-specific exceptions (for example, notes that no prior authorization is required for specific Medicare Advantage plans as of certain effective dates). Confirm applicable plan rules for the member's specific product before assuming an exception applies.

Example: 'No Prior Auth required for MT Medicare Advantage Plan effective 1/1/21' appears for selected codes; this is plan-specific and may not apply to all members.
If an exception applies, retain documentation of plan determination.

Prior Authorization

eviCore Prior Authorization for U-Codes and Specialized Tests

Many U-/T-/0012M-style codes and other molecular/genetic or specialized services are routed to eviCore for prior authorization and clinical review. Contact eviCore for these codes using the contact details in the list.

Examples: multiple U-codes and genetic panel codes (see list).
eviCore contact: 1-855-252-1117 or https://www.evicore.com/provider.

Documentation Required

Letter of Medical Necessity Required for DME and Speech Devices

Durable medical equipment (DME), speech devices, and wheelchair/accessory requests frequently require a Letter of Medical Necessity (LOMN) that includes clinical details to justify the need for the device.

LOMN should describe anticipated length of use, condition being treated, mobility/functional status, and device specifics.
Examples: wheelchair accessories (E1002–E1005, E2609–E2621), speech generating devices (E2504–E2510).

Documentation Required

Medical Necessity Documentation

Requests for prior authorization must include documentation of medical necessity. Typical required documents include a recent History & Physical, plan of care, test results/imaging, and operative reports where applicable.

Recent History & Physical and plan of care are commonly required for cardiac, oncologic, transplant, and other major procedures.
Include prior conservative treatment, functional impairment, and diagnostic results when requested.

Denial Risk

Documentation-Related Denial Risk

Failure to obtain required prior authorization or to submit requested clinical documentation can result in claim denial or retrospective non-coverage determinations. Providers should follow routing instructions and retain prior-auth confirmations.

Denial risk is higher for fusion, implant, transplant, major cardiac, and eviCore-managed codes when documentation or authorization is missing.
Confirm prior authorization approval in writing and include authorization numbers on claims where required.

Documentation Required

Transplant-Specific Documentation

For transplant-related procedure codes, if transplant approval is already on record provide the date of transplant and approval; if not, submit a full transplant evaluation, History & Physical, and the transplant date when available.

Codes affected include donor/recipient procedures and transplant preparation codes (e.g., 32851–32856, 33930–33935, 38205–38240).
If transplant authorization exists, include approval reference to avoid redundant review.

Documentation Required

Additional Documentation for Jaw/Face and Device Procedures

When a code entry references additional device- or site-specific documentation (for example jaw/face procedures, TMJ-related services, or implant/device removals), include appliance details, TMJ history, diagnostic sleep study results and imaging as requested.

Examples: mandibular/maxillofacial codes (21123–21208) request appliance type, TMJ history, and diagnostic sleep study copies.
Artificial disc removal/revision codes require a recent H&P, plan of care, and documentation of medical necessity.

Documentation Required

Required Supporting Clinical Documentation

Required supporting clinical documentation varies by code but commonly includes pre-operative evaluation, History & Physical, operative/procedure report, imaging, and documentation of prior conservative measures or treatment trials.

Surgical examples: major joint, nasal, ophthalmologic, and reconstructive procedures often require H&P and operative reports.
Diagnostic prior auths (imaging, PET) require test results and prior diagnostic reports where indicated.

Documentation Required

Cardiac Procedure Documentation

Major cardiac and related procedures require a recent History & Physical, an explicit plan of care, and documentation of medical necessity when requesting prior authorization.

Examples: open valve replacement, conduit preparation, complex cardiac repairs (CPTs in the 33400–33600 range).
Include operative notes and relevant diagnostic testing supporting the need for surgery.

Documentation Required

Abortion-Related Documentation Requirements

For abortion-related CPTs and certain related procedures, submit a History & Physical and documentation of medical necessity including operative reports where requested when seeking prior authorization.

Codes such as 59856, 59857 and related entries specify H&P and operative documentation.
Ensure clinical justification and required consent/records are included in the submission.

Documentation Required

Documentation for Diagnostic Prior Authorization

Diagnostic imaging and certain advanced diagnostic prior authorizations require submission of a History & Physical and relevant test results or prior diagnostic reports as part of the prior authorization request.

Examples: discography (72291/72292), advanced MRI/CT studies, PET imaging routed to eviCore.
Provide the history, prior conservative management, and prior imaging reports when requested.

Documentation Required

Letter of Medical Necessity Content

When a code entry requests a Letter of Medical Necessity (LOMN), include specific content: anticipated length of use, description of the medical condition, mobility/functional status, and device specifications to support the request.

LOMN examples: power seating accessories, standing frames, pneumatic compressors, and other complex DME.
Attach H&P, chart notes, and treatment plan alongside the LOMN when required.

Documentation Required

History and Plan of Care Requirements

Many codes require recent History & Physical, a plan of care, and clear documentation of medical necessity as part of the prior authorization or clinical review — include these routinely to avoid delays.

This requirement applies broadly across surgical, infusion/drug, imaging, genetic, and DME code categories.
Chart notes and prior treatment details help demonstrate medical necessity.

Documentation Required

Conservative Treatment Documentation for Select Procedures

For certain elective or reconstructive procedures (for example reduction mammoplasty, major reconstructive stages) document conservative treatment attempts and include weight/height, pathology and specimen details where requested.

Example: reduction mammoplasty (19318) requests pre-operative evaluation, height/weight, prior conservative treatment, pathology and operative report.
Providing prior conservative-treatment documentation supports medical necessity determinations.

Definitions and Vendor Contacts

inv-152: eviCore-managed codes

DefinitionCodes highlighted as managed by eviCore healthcare indicate those services are managed through an external utilization management vendor for prior authorization.

Indicator in documentGreen highlighted codes are managed by eviCore healthcare (document header).

Operational impactServices routed to eviCore require prior authorization via eviCore phone or provider portal as specified per code line.

inv-153: eviCore

Vendor name & contacteviCore — contact 1-855-252-1117 or https://www.evicore.com/provider for prior authorization routing.

ScopeMany CPT, imaging, genetic and J-code entries are routed to eviCore for utilization management.

Plan exceptionsSome entries note plan-specific exceptions (e.g., 'No Prior Auth required for MT Medicare Advantage Plan effective 1/1/21').

inv-154: Transplant approval documentation

When transplant approval is on recordProvide the date of transplant to satisfy transplant-related documentation requirements.

If transplant approval not on recordSubmit history and physical, transplant evaluation, and date of transplant for donor/recipient transplant CPTs.

Applies toDonor and recipient transplant CPTs such as 33930–33945, 38205–38242, and other listed transplant codes.

inv-155: Transplant approval

Transplant approval definitionAn authorization on record indicating the transplant has been approved; when present provide the date of transplant to satisfy documentation requirements.

Alternate documentationIf no transplant approval exists, submit H&P, transplant evaluation, and date of transplant.

Relevant codesApplies to listed transplant CPTs (examples: 33930–33945, 38205, 38206).

inv-156: Required documentation

Typical required documentsHistory and physical, pre-operative evaluation, operative/procedure report, and documentation of medical necessity.

Additional possible itemsStudy results where noted (e.g., Doppler, sleep study, CPAP trial), photographs, pathology reports, height/weight for breast reduction.

Submission adviceInclude all specified items with the prior authorization request to reduce risk of denial or delay.

inv-157: eviCore

Designated UM vendoreviCore is the designated utilization management vendor for many molecular/genetic and specialty procedure codes listed in the document.

Provider contactContact eviCore at 1-855-252-1117 or via https://www.evicore.com/provider for authorization and review of these codes.

ExamplesMultiple 81xxx and 814xx molecular/genetic CPT entries reference eviCore routing in the code lines.

inv-158: eviCore

J-code prior auth vendoreviCore is the third-party utilization management vendor referenced for prior authorization and medical necessity review of listed J-codes.

Contact detailsProviders must contact eviCore at 1-855-252-1117 or https://www.evicore.com/provider for J-code authorizations.

Examples of managed J-codesJ1428, J1551, J2350, J2777 and many others in the J-code lists indicate eviCore routing and documentation requirements.

73706	Magnetic resonance, lower extremity; without contrast
73718	Magnetic resonance, lower extremity joint; without contrast, followed by with contrast
73720	Magnetic resonance, lower extremity, other protocols
73721	Magnetic resonance, lower extremity, other protocols with contrast
73722	Magnetic resonance, lower extremity, other protocols MRI arthrography
73723	Magnetic resonance, lower extremity, add-on sequences
73725	Magnetic resonance, lower extremity, 3D sequences
74150	Computed tomography, abdomen; without contrast
74160	Computed tomography, abdomen; with contrast
74170	Computed tomography, abdomen; without and with contrast

73200	CT upper extremity without contrast
73201	CT upper extremity with contrast
73202	CT upper extremity without and with contrast
73206	CT angiography upper extremity
73218	MRI upper extremity without contrast
73219	MRI upper extremity with contrast
73220	MRI upper extremity without and with contrast
73221	MRI joint upper extremity without contrast
73222	MRI joint upper extremity with contrast
73223	MRI joint upper extremity without and with contrast

OO02M	Proprietary oncology/genetic assay - liver disease labeling
0003M	Proprietary assay - liver disease
OO04M	SCO 53 SNPs panel
OO06M	Oncology gene risk classifier
OO11M	Oncology mRNA panel (proprietary)
0012M	Oncology mRNA 5 gene panel
0013M	Oncology mRNA 5 gene recurrent panel
0016M	Oncology bladder mRNA 209 gene algorithm
0018U	Oncology microRNA assay
0019U	Oncology RNA tissue predictive algorithm

A0430	Ambulance service, conventional air one way
A0435	Fixed wing air mileage
A4604	Tubing with integrated heating element for PAP device
A7027	Combination oral/nasal mask
A7028	Oral cushion replacement
A7029	Nasal pillows replacement
A7030	Full face mask
A7031	Face mask interface replacement
E0470	Respiratory assist device, bi-level
E0471	Respiratory assist device with backup

OpenPayer

Preauthorization requirements for plastic/reconstructive surgery CPT/HCPCS codes

Coverage and Authorization Criteria

CPT / HCPCS Code Listings

Provider Responsibilities and Documentation Requirements

Background

Definitions and Vendor Contacts