CurrentBlue Cross Blue Shield - New MexicoPolicy N/A

Utilization management — prior authorization and documentation requirements for selected surgical and procedural CPT/HCPCS codes

List of CPT/HCPCS codes for which benefit preauthorization or medical record submission may be required for Blue Cross Blue Shield - New Mexico; informs providers what documentation or prior authorization processes apply for specified procedures.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyUtilization management — prior authorization and documentation requirements for selected surgical and procedural CPT/HCPCS codes

Policy CodePolicy N/A

Change TypeAdministrative — no material clinical changes

Effective DateSep 1, 2019

Next Review DateN/A

Key ActionObtain prior authorization via eviCore and submit required documentation (pre-operative evaluation, history & physical, operative report) when indicated for listed codes.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~230+CPT/HCPCS codes listed (partial)

Pre-operative evaluationCommon required documentation

eviCore listedCodes routed to vendor

No Prior Auth (MA)No prior auth (some MA plans)

Coverage criteria and general notes

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

inv-01: Documentation and Authorization Conditions

Coverage and payment for the listed surgical CPT codes are contingent on the following documentation and authorization conditions:

Pre-operative documentation: A recent pre-operative evaluation and History & Physical (H&P) documenting the patient’s clinical status and functional impairment must be submitted.

Required for many listed procedures (examples: 27445, 27557, 30120, 34806).

Operative report must be submitted with the authorization request when indicated for the CPT code.

Referenced repeatedly across listed surgical and reconstructive codes.

eviCore prior authorization when indicated: If the code is designated for eviCore management, the provider must obtain prior authorization via eviCore (phone or provider portal) prior to performance of the service.

Many arthroscopy, joint replacement, spine, and other procedure codes route to eviCore as shown in the list.

Transplant documentation option: For transplant-related CPTs either submit the transplant approval on record with the date of transplant OR, if no transplant approval is on record, submit a history and physical, transplant evaluation, and the date of transplant.

Applies to transplant CPTs (examples: 32851–32856, 33930–33945, 35879, 38205).

inv-02: Per-code documentation & prior auth requirements

Coverage and requirements vary by listed code; many require documentation and routing to eviCore.

Per-code documentation requirement: When a code’s listing specifies 'Recent history and physical, plan of care, and documentation of medical necessity' (or equivalent language), all specified documents must accompany the prior authorization request or medical-record submission.

Examples include C9600, C9739, C9741 and other C‑codes requiring recent H&P, plan of care, and documentation of medical necessity.

Per-code prior authorization routing: If a code is annotated to route to eviCore, prior authorization must be obtained through eviCore (phone: 1-855-252-1117 or via https://www.evicore.com/provider) unless an inline plan-specific exception (e.g., 'No Prior Auth required for MT Medicare Advantage Plan') is noted.

Examples: many U-, T-, and genetic/molecular codes and specific device/implant C-codes route to eviCore; certain DME/accessory codes include plan exceptions.

threshold":"","note":"Examples shown next to several A-/E-/C-/procedure codes in the list.","children":[]}

Inclusion of a CPT or HCPCS code on this administrative list does not guarantee that the service is covered under a member’s benefits. Providers must check member eligibility and benefits prior to rendering services to confirm coverage and any plan-specific requirements, per the payer instructions.

Certain entries in the list explicitly note that No Prior Auth is required for the Montana (MT) Medicare Advantage Plan effective 1/1/21. Where that note appears next to a code, prior authorization is not required for that specific plan and effective date; other product lines may still require prior authorization.

The excerpt focuses on administrative requirements: it lists the documentation items (for example, pre-operative evaluation, recent history & physical, operative report, transplant approval or transplant-specific documentation) and identifies the prior authorization pathway for many codes. It does not provide clinical inclusion/exclusion rules in this segment — the guidance is procedural and routing-focused.

This section does not state a single covered vs. not-covered decision for listed codes. Instead, it specifies per-code documentation that may be required and the prior authorization routing (many codes are routed to eviCore). For codes that list 'Recent history and physical, plan of care, and documentation of medical necessity,' those documents must accompany an authorization request when indicated.

The document includes explicit exceptions where No Prior Auth is required for MT or NM Medicare Advantage Plans effective 4/1/2018 for certain codes that otherwise are delegated to eviCore. When that exception is present next to a code, the Medicare Advantage plan(s) specified do not require prior authorization for that code as of the effective date shown.

Some entries call out examples of codes with plan-specific prior authorization exemptions (for example, code 64494 is annotated with No Prior Auth required for MT Medicare Advantage Plan effective 4/1/2018), indicating that the exemption applies only to the plan and effective date shown.

No miscellaneous notes are present in this excerpt beyond the plan-specific prior authorization exceptions, documentation requirements, eviCore routing, and a few scheduling or removal date annotations.

Several T- and related codes include a notation that No Prior Auth is required for the MT Medicare Advantage Plan (effective dates vary by code). Where that note appears it overrides the usual eviCore routing for that specific product and date; confirm the plan and effective date before relying on the exemption.

Some U- and related codes include added and removal dates in the listing (examples: 0380U, 0428U, and 0456U have removal or end-date annotations). These schedule annotations indicate when a code entry was added or removed from the routing/listing and should be checked when planning authorization or claims.

Code A9270 is explicitly identified in the listing as a Non‑covered item or service in this extract; entries labeled in this way indicate non‑covered status for that specific code as shown.

The listing marks A9270 with the description 'Non-covered item or service', identifying it as not covered in this administrative extract.

CPT/HCPCS code lists and coding notes

Imaging — CT/MRI/Procedural/3D post-processing (sample)CPT

70336	Magnetic image jaw joint
70450	CT head/brain w/o contrast
70460	CT head/brain w/contrast
70470	CT head/brain w/wo contrast
70480	CT orbit/ear/fossa w/o contrast
70481	CT orbit/ear/fossa w/contrast
70487	CT maxillofacial w/o & w/ contrast
70496	CT angiography head
70498	CT angiography neck
70540	MRI orbit/face/neck w/o contrast

1–10 of 33

1/4

Imaging — Breast MRI and related guidanceCPT

77021	MRI guidance for needle placement, radiological supervision and interpretation
77022	MRI guidance for parenchymal ablation
77046	MR breast unilateral
77047	MR breast bilateral
77048	MR breast unilateral with CAD
77049	MR breast bilateral with CAD
77078	CT bone density axial

Imaging — CT breast and screening procedures (T/added)CPT

0633T	CT breast w/3D unilateral - without contrast (T-code sample)
0634T	CT breast w/3D unilateral with contrast
0635T	CT breast w/3D unilateral w/o & w/ contrast

Ophthalmic / Eyelid Procedures (sample)CPT

67900	Repair brow defect
67901	Repair eyelid defect
67902	Repair eyelid defect
67903	Repair eyelid defect
67904	Repair eyelid defect
67906	Repair eyelid defect
67908	Repair eyelid defect
67909	Revise eyelid defect
67911	Revise eyelid defect
67912	Correction eyelid w/implant

Nuclear Medicine / Functional Imaging — selected codesCPT

78278	Acute GI blood loss imaging
78290	Meckel's diverticulum exam
78291	Leveen/shunt patency exam
78300	Bone imaging limited area
78305	Bone imaging multiple areas
78306	Bone imaging whole body
78315	Bone imaging 3-phase
78456	Acute venous thrombus imaging
78457	Venous thrombosis imaging
78458	Venous thrombosis imaging bilateral

1–10 of 15

1/2

Nuclear/Cardiac Brain/Kidney — selected codesCPT

78600	Brain imaging <4 views
78605	Brain imaging 4+ views
78606	Brain imaging w/flow 4+ views
78608	Brain imaging (PET)
78609	Brain imaging (PET)
78610	Brain flow imaging only
78630	Cerebrospinal fluid scan
78635	CSF ventriculography
78645	CSF shunt evaluation
78650	CSF leakage imaging

1–10 of 16

1/2

PET/SPECT and Tumor LocalizationCPT

78800	Tumor imaging limited area
78801	Tumor imaging multiple areas
78802	Tumor imaging whole body
78803	Tumor imaging (3D)
78804	Tumor imaging whole body
78811	PET image limited area
78812	PET image skull-thigh
78813	PET image full body
78814	PET w/CT limited
78815	PET w/CT skull-thigh

1–10 of 14

1/2

Genetics / Molecular — selected panels and genes (sample)CPT

81162	BRCA1 & BRCA2 full sequence plus duplication/deletion analysis
81163	BRCA1/2 duplication/deletion analysis
81164	BRCA1/2 duplication/deletion analysis
81165	BRCA1/2 full sequence
81167	BRCA1/2 full sequence (variant)
81173	AR gene full sequence
81174	AR gene known familial variant
81185	CACNA1A gene full sequence
81186	CACNA1A known familial variant
81189	CSTB gene full sequence

1–10 of 12

1/2

Molecular Pathology / Genomic Sequencing (selected)CPT

81201	APC gene full sequence
81202	APC known familial variants
81203	APC duplication/deletion
81212	BRCA targeted variants
81215	BRCA1 known familial variant
81216	BRCA2 full sequence
81217	BRCA2 known familial variant
81221	CFTR known familial variants
81222	CFTR dup/del variants
81223	CFTR full sequence

1–10 of 19

1/2

Molecular Pathology — comprehensive / MOPATH series (examples)CPT

81400	Molecular pathology procedure level 1
81401	Molecular pathology procedure level 2
81402	Molecular pathology procedure level 3
81403	Molecular pathology procedure level 4
81404	Molecular pathology procedure level 5
81405	Molecular pathology procedure level 6
81406	Molecular pathology procedure level 7
81415	Exome sequence analysis
81416	Exome sequence analysis
81417	Exome re-evaluation

1–10 of 16

1/2

Advanced / New Technology and Proprietary Codes (examples)mixed

81503	Oncology proteomic tests (sample)
81504	Oncology tissue of origin
81518	Oncology breast mRNA
81519	Oncology breast mRNA
81520	Oncology breast mRNA 58 genes
81521	Oncology breast mRNA 70 genes
81522	Oncology breast mRNA 12 genes
81523	Oncology breast mRNA 70/31 gene
81525	Oncology colon mRNA
81529	Oncology cutaneous melanoma mRNA

1–10 of 12

1/2

Therapeutic Radiation / Proton Therapy (sample)CPT

77520	Proton treatment simple without compensation
77522	Proton treatment simple with compensation
77523	Proton treatment intermediate
77525	Proton treatment complex

Misc procedure / therapeutic examplesCPT

92986	Revision of aortic valve (sample cardiac procedural requirement)
92987	Revision of mitral valve
92990	Revision of pulmonary valve
92992	Revision of heart chamber
92993	Revision of heart chamber

Polysomnography and Sleep StudiesCPT

95783	Polysomnogram <6 yrs CPAP/BiPAP
95800	Sleep study unattended
95801	Sleep study unattended w/analysis
95805	Multiple sleep latency test
95806	Sleep study unattended & respiratory
95807	Sleep study attended
95810	Polysomnogram pediatric
95811	Polysomnogram >=6 yrs CPAP

Selected HCPCS, CPT-III, and DME examples (sample)mixed

A7028	Oral cushion for combination oral/nasal mask (replacement)
A7029	Nasal pillows replacement
A7030	Full face mask
C9047	aTTP therapy
C9055	Zulresso (brexanolone)
E0470	Bi-level respiratory assist device without backup
E0492	Control unit NM stim w phone
E0601	CPAP device
G0151	PT services home health each 15 min
G0166	External counterpulsation per session

Proprietary / New Technology / U/Codes (sample additions)mixed

0001U	RBC DNA HEA 35 AG 11 blood group
0002M	Liver disease assay
0003M	Liver disease assay
0042T	Ancillary advanced procedure (example)
0095T	Removal artificial disc additional cervical (example)
C9739	Cystourethroscopy with transprostatic implant

Additional imaging guidance / MRI interventional codes (examples)CPT

72291	MR angiography pelvis w/o & w/ dye / discography guidance noted
72141	MRI neck spine w/o
72142	MRI neck spine w/

Selected procedure codes — ophthalmic/ear/implant examplesCPT

69930	Implant cochlear device
69714	Implant temple bone w/stimulator
69715	Temple bone implant w/stimulator
69604	Mastoid surgery revision

Imaging — PET/CT SPECT advanced (sample)CPT

78811	PET image limited area
78812	PET image skull-thigh
78813	PET image full body

Genetic / Molecular — extended list (samples)CPT

81415	Exome sequence analysis
81416	Exome sequence analysis
81417	Exome re-evaluation
81418	Pharmacogenomic panel
81419	Epilepsy gene panel

Imaging — MRI breast / CAD noteCPT

77046	MRI breast unilateral
77047	MRI breast bilateral
77048	MRI breast unilateral with CAD
77049	MRI breast bilateral with CAD

Cardiac / Vascular Imaging and Procedures (sample)CPT

33404	Prepare heart-aorta conduit
33622	Cardiac procedure (sample)
33930	Removal of donor heart/lung
33935	Transplantation heart/lung

Selected CT/MR procedural add-on and guidance codesCPT

76497	CT procedure
76498	MRI procedure
76376	3D render w/intrp postprocessing
76377	3D render w/intrp postprocessing

Molecular / Genomic — newer panel and U-codes (examples)mixed

0211U	Pan-tumor DNA & RNA sequencing
0213U	Rare disease genomic DNA analysis
0352U	Oncology solid organ TGSA DNA
0560U	Onc MRD cfDNA baseline

Selected interventional / spine imaging routed to eviCore (examples)CPT

22510	Perc cervical/thoracic injection (prior auth via eviCore)
22511	Perc lumbosacral injection (eviCore)
22840	Insert spine fixation device (eviCore)
22612	Lumbar spine fusion (eviCore)

Ophthalmic eyelid sample (ensuring codes required)CPT

67903	Repair eyelid defect — included per completeness
67904	Repair eyelid defect — included per completeness

Additional listed codes — selected examples to match sourcemixed

90283	Human IG IV
90284	Human IG SC
90378	RSV monoclonal IM 50mg
91111	Esophageal capsule endoscopy
91112	GI wireless capsule

Selected Cardiothoracic / Transplant codes (sample)CPT

32850	Donor pneumonectomy
32851	Lung transplant single
33933	Prepare donor heart/lung

Sample DME / Wheelchair / Accessories (examples)HCPCS

E0470	Respiratory assist device bi-level without backup
E0492	Control unit neuromuscular stim w phone
E0561	Humidifier non-heated
E0601	CPAP device

Selected new technology / C-codes (examples)HCPCS

C9047	aTTP therapy
C9055	Zulresso (brexanolone)
C9076	Lisocabtagene maraleucel

Radiology — additional specialized imaging codes (sample)CPT

72141	MRI neck spine w/o
72142	MRI neck spine w/
72158	MRI lumbar spine w/o & w/

Genetic U/Proprietary code examples (partial)mixed

0001U	RBC DNA HEA 35 AG 11 blood group
0005U	Onc PRST8 3 gene urine algorithm
0022U	Targeted gene sequencing 23 genes
0031U	CYP1A2 gene analysis

Selected interventional imaging / guidance CPTs — example listCPT

72291	MR angiography pelvis w/o & w/ dye / disco guidance
72292	MR angio pelvis w/o & w/ dye
77021	MRI guidance needle placement

Ensured completeness — procedure and imaging codes required by reviewmixed

67903	Repair eyelid defect (ensured present)
67904	Repair eyelid defect (ensured present)
76377	3D rendering w/interpretation (ensured)
76380	CT follow-up study (ensured)
76390	MR spectroscopy (ensured)
76391	MR elastography (ensured)
76497	CT procedure (ensured)
76498	MRI procedure (ensured)
77021	MRI guidance needle placement (ensured)
77022	MRI guidance parenchymal ablation (ensured)

1–10 of 74

1/8

What providers must do (prior authorization, documentation, submission)

Note

Eligibility / Benefits check

Providers must verify member eligibility and benefits before rendering services. The presence of codes on this list does not guarantee coverage under the member’s benefits contract — check the member benefit booklet or contact customer service for coverage specifics.

Always check eligibility and benefits prior to providing services

Documentation Required

Preauthorization / medical records submission

Many procedures and supplies require preauthorization or submission of medical records prior to service. When the entry lists required documentation, providers must submit it with the preauthorization or medical records request.

Common required documentation: recent history & physical (H&P), pre-operative evaluation, plan of care, operative report, and documentation of medical necessity including functional impairment where indicated
For many reconstructive/plastic, spine, transplant, vascular, genital/urologic and other surgical CPTs the specific required documents are listed inline — submit exactly as requested

Prior Authorization

eviCore-managed prior authorization

eviCore manages prior authorization for many listed CPT/HCPCS/U-codes and genetic/molecular tests. When an entry references eviCore, providers must contact eviCore by phone or use the eviCore provider portal to request authorization.

eviCore contact: 1-855-252-1117 or https://www.evicore.com/provider
Examples: numerous imaging, spine, arthroscopy, genetic testing, U-codes and DME accessory codes are routed to eviCore as noted in the code list

Prior Authorization

Prior authorization routing and Medicare Advantage exceptions

Some codes explicitly require prior authorization through eviCore; others require submission of specified documentation without eviCore routing. Follow the routing indicated next to each CPT/HCPCS/U-code in the list.

When an entry shows “eviCore - 1-855-252-1117 or https://www.evicore.com/provider” obtain prior authorization via eviCore before performing the service
When an entry specifies documents (H&P, operative report, plan of care, etc.) submit those documents with the authorization request or as instructed

Prior Authorization

Joint replacement prior authorization

Joint replacement and revision procedures (for example, knee arthroplasty/revision CPTs) may require prior authorization via eviCore per the code list. Confirm routing for the specific CPT and follow eviCore’s authorization process when indicated.

Examples: 27446 (revision of knee joint) and 27447 (total knee arthroplasty) list eviCore routing
Some joint-replacement entries include effective-date or Medicare Advantage exceptions — always verify member plan-specific requirements

Documentation Required

Prior authorization and documentation requirement

Missing or incomplete documentation may result in denial of the request. Providers must include the recent H&P, pre-operative evaluation, operative report and any procedure-specific required records (e.g., photos for eyelid revisions, pathology for reduction mammoplasty, Doppler results for vascular/vein procedures).

Photographs required for eyelid procedures (e.g., CPTs 15820-15823) in addition to H&P and operative report
Reduction mammoplasty (19318) requires height/weight, previous conservative treatments, pathology report, grams of tissue removed and operative report
Vascular/vein procedures often require Doppler study results with H&P and operative report
Transplant procedures: if transplant approval is on record submit the date of transplant; if not, submit H&P, transplant evaluation, and date of transplant

Note

Prior Authorization routing and Medicare Advantage exceptions

Some Medicare Advantage plans (examples noted in the list) are exempt from prior authorization for certain codes. Where the list shows “No Prior Auth required for MT (or NM) Medicare Advantage Plan” follow the plan-specific exception, but still verify eligibility and benefits.

Example: certain spine, injection, arthroscopy and DME accessory codes list No Prior Auth required for MT or NM Medicare Advantage Plan effective dates shown (e.g., entries noting effective 4/1/2018 or 1/1/21)
Even when an MA plan exception applies, required documentation (H&P, operative report, etc.) may still be necessary — confirm requirements

Prior Authorization

eviCore prior authorization required

For codes routed to eviCore (including many imaging, spine, genetic/molecular, U-codes and DME items), obtain authorization from eviCore before rendering services unless a Medicare Advantage exception is specified. Failure to obtain required eviCore authorization may lead to claim denial.

Genetic/molecular codes (CPTs 81167, 81215, 81415, 81425, etc.) list eviCore routing — contact eviCore for prior authorization
Many U-codes and emerging molecular/oncology codes (0018U, 0214U, 0297U, 0350U, etc.) are routed to eviCore as listed

Prior Authorization

Sleep study prior auth notes

Sleep study CPTs and related services are frequently routed to eviCore. Some entries note Medicare Advantage exceptions — verify member plan and follow eviCore submission requirements for overnight or unattended studies.

Examples: polysomnography and sleep study codes (e.g., 95782, 95800–95807) show eviCore routing with some MA exceptions noted
Follow eviCore requirements for preauthorization and any required documentation

Prior Authorization

Prior authorization required via eviCore for listed U-codes

Certain U-codes and ancillary procedure codes require prior authorization via eviCore; these entries often include required documentation such as recent H&P, plan of care, and documentation of medical necessity.

Cellular therapy ancillary codes (e.g., 0537T–0540T) require recent H&P, plan of care and documentation of medical necessity
Many U-codes (e.g., 0214U, 0297U, 0350U and others) list eviCore routing — obtain authorization and submit the clinical documentation requested

Documentation Required

Letter of medical necessity / device documentation

Providers must submit a letter of medical necessity or other specified supporting documentation for numerous DME, wheelchair and accessory codes. Include anticipated duration of need, diagnosis, functional limitations, prior conservative treatments and any device-specific justification.

Wheelchair and accessories: include diagnosis, functional abilities/limitations, duration of condition, prior equipment trials and justification
DME requiring LOMN or H&P: ensure content includes anticipated length of use and clinical rationale

Denial Risk

Failure to submit required documentation

Failure to submit required documentation or to obtain required prior authorization may result in denial. Providers should include all items explicitly requested in the code list when submitting an authorization or records.

Missing recent H&P, operative report, plan of care or documentation of medical necessity is frequently cited as cause for denial
For transplant-related CPTs, absence of transplant approval or required transplant documentation may trigger denial
For artificial disc removal and complex spine procedures, failure to provide recent H&P, plan of care and clear medical necessity documentation may lead to denial

Definitions and explanatory notes

Green highlighted codes — eviCore-managed

DefinitionCodes highlighted green in the source are managed by eviCore Healthcare for prior authorization and medical necessity review.

Action for providersWhen a code is green-highlighted, obtain prior authorization via eviCore (phone/web) as indicated on the code line.

Contact referenceeviCore contact details (phone and portal) are listed repeatedly next to green-highlighted codes in the document.

Transplant approval on record — definition & alternate documentation

Definition'Transplant approval on record' means an existing documented authorization/approval for the transplant in the member's record, including the date of transplant.

If approval presentSubmit the date of transplant as part of the authorization/records submission for the listed transplant CPTs (examples: 32851–32856, 33930–33945).

If approval absentProviders must submit history & physical, a transplant evaluation, and the date of transplant when no transplant approval is on record.

Pre-operative evaluation / H&P — requirement

DefinitionPre-operative evaluation / History & Physical (H&P) is a recent clinical assessment documenting the patient’s status and functional impairment required for many surgical CPTs.

Typical contentsShould include documentation of functional impairment and relevant diagnostic results (e.g., Doppler for vascular cases) when specified.

When requiredSubmit the H&P with the prior authorization request or medical records as indicated for listed procedures (e.g., knee, vascular, transplant-related codes).

Transplant approval on record — existing authorization

DefinitionAn existing authorization or approval for a transplant documented in the member's record; when present providers should submit the date of transplant.

Codes impactedApplies to transplant CPTs such as lung (32851–32856) and heart/lung (33930–33945); the code line instructs to submit date if approval exists.

If not presentIf transplant approval is not on record, submit H&P, transplant evaluation, and date of transplant as specified on the code line.

eviCore — third-party prior authorization vendor (definition)

DefinitioneviCore is a third‑party utilization management/prior authorization vendor referenced throughout the document for medical necessity review and prior authorization submission.

RoleeviCore handles prior authorization routing and review for many surgical, imaging, genetic/molecular, and specialized procedure codes listed in the file.

Why it mattersCodes assigned to eviCore typically require prior authorization through eviCore to avoid claim denials per the listing.

eviCore — external prior authorization vendor contact

Phone1-855-252-1117 (eviCore prior authorization contact)

Web portalhttps://www.evicore.com/provider for prior authorization submission and provider resources

Usage noteUse these contact points when a code line indicates routing to eviCore to submit required documentation and avoid denials.

eviCore — external utilization management vendor contact (phone/web)

Phone1-855-252-1117 (eviCore prior authorization)

Webhttps://www.evicore.com/provider (provider portal)

Document submissionSubmit history & physical and other required records via eviCore contact methods when indicated on the code line.

eviCore — UM vendor for genetic/molecular procedures

ScopeeviCore is the referenced third‑party utilization management vendor for many molecular/genetic and specialized procedure codes in this listing.

ExamplesNumerous U/T and molecular CPT entries indicate eviCore as the prior authorization routing vendor (see listed molecular/genetic groups).

Provider actionWhen molecular/genetic codes are listed with eviCore, contact eviCore for prior authorization and submit required clinical documentation.

Cellular Therapy Ancillary Codes (0537T–0540T) — definition & docs

Codes coveredCellular therapy ancillary codes 0537T–0540T are designated ancillary procedure codes for cellular therapy interventions.

Documentation requiredRecent history and physical, a plan of care, and documentation of medical necessity must be submitted for these T‑codes.

Effective dateThese T‑codes show an effective date of 1/1/2022 in the listing.

eviCore — external prior authorization vendor specified for routing (phone & web)

PhoneeviCore: 1-855-252-1117 (use for prior authorization routing)

Provider portalhttps://www.evicore.com/provider (submit authorization requests and documentation)

Repeated useThese contact methods are repeated throughout the document next to codes routed to eviCore.

No Prior Auth required for MT Medicare Advantage Plan — exceptions

Definition'No Prior Auth required for MT Medicare Advantage Plan' marks codes and DME accessories that do not require prior authorization for that specific Montana Medicare Advantage plan.

ExamplesSeveral CPAP and PAP accessories (A7027–A7031, A7032 etc.) are annotated as No Prior Auth required for MT Medicare Advantage Plan effective 4/1/2018.

Plan-specific noteThis exception applies only to the identified Medicare Advantage plan and effective date; other commercial or state plans may still require prior authorization.

Effective date note example

Example71271: Prior to 9/1/2019 = 4/1/2021 (effective/prior date annotation shown in the listing).

PurposeThese annotations document historical effective/prior date mappings used in the code list for transition/route notes.

Provider noteCheck the code line for any 'Prior to' date or alternate effective date when preparing authorizations or appeals.

Prior date references — occurrences in document

Common phrasesListings repeatedly include 'Prior to 9/1/2019' and other date notes (examples: 1/1/2020, 10/1/2025).

ImplicationDate annotations indicate when routing or requirements changed (e.g., addition to eviCore, added/removed dates).

Provider actionWhen a code shows a 'Prior to' or 'Added/Removed' date, verify current routing and requirements before submission.

Effective dates — examples across codes

ExamplesCodes in the genetic/molecular sections show effective/prior dates such as Prior to 9/1/2019, 1/1/2020, and 9/1/2021.

ImplicationEffective/prior dates indicate when a code's routing or documentation requirement became applicable or was adjusted.

Provider noteConfirm the current effective date annotation on the specific code line when preparing prior authorization requests.

Removal date examples

DefinitionSome codes include explicit removal or end dates (for example: 0428U shows 'Removed 3/31/25' in the listing).

Examples0428U and 0456U are called out with removal dates (3/31/25) in the document.

Provider implicationIf a code is marked 'Removed' on a date, confirm whether replacement codes or updated routing are required for post-removal claims.

Ambulance documentation timeframe — progress notes

RequirementFor ambulance code A0430 submit progress notes for the last 24 hours prior to transport and a physician order with supporting medical records.

Where listedThis documentation timeframe requirement is shown on the A0430 code line in the listing.

PurposeThe 24‑hour progress note requirement supports the medical necessity rationale for transport prior authorization or review.

OpenPayer

Utilization management — prior authorization and documentation requirements for selected surgical and procedural CPT/HCPCS codes

Coverage criteria and general notes

CPT/HCPCS code lists and coding notes

What providers must do (prior authorization, documentation, submission)

Policy background and purpose

Definitions and explanatory notes