CurrentBlue Cross Blue Shield - OklahomaPolicy N/A

Blue Cross Medicare Advantage Prior Authorization List

Governs prior authorization requirements for services and CPT/HCPCS codes for Blue Cross Medicare Advantage plans in Oklahoma; applies to attending physicians requesting services for enrolled members.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyBlue Cross Medicare Advantage Prior Authorization List

Policy CodePolicy N/A

Change TypeAdministrative update (no material clinical changes)

Effective DateEffective 1/1/2023

Next Review DateN/A

Key ActionAttending physician must obtain prior authorization for listed services; contact eviCore at 1-855-252-1117 or Customer Service at 1-877-774-8592 for requests.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Mon-Fri 8a-8p CTauthorization office hours

1-855-252-1117eviCore contact phone

1/1/21No Prior Auth date (many codes)

Prior to 9/1/2019 — 10/1/2022effective date range

~120+procedure codes listed

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Coverage criteria and per-code documentation requirements

Per-code documentation requirements

Per-code documentation and effective date requirements (examples):

11970 — Pre Operative Evaluation, History and Physical including functional impairment, and Operative report.Effective Date = Prior to 9/1/2019

15271 — Recent history and physical, plan of care, and documentation of medical necessity.Effective Date = Prior to 9/1/2019

17360 — Pre-operative evaluation, history and physical including functional impairment, and operative report.Effective Date = Prior to 9/1/2019

Authorization and documentation criteria

Prior authorization and documentation notes associated with listed procedure codes.

eviCore contact: For medical records requests and prior authorization, contact eviCore at 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs.

MT Medicare Advantage note: Many listed procedure codes are noted as 'No Prior Auth required for MT Medicare Advantage Plan effective 1/1/21' (examples in the spine and orthopedic code lists).

Documentation for fusion codes: For codes such as 22810, 22812 and similar spinal fusion entries: submit history and physical, operative report, and documentation of conservative measures or medical necessity.

Prior Auth / Documentation Rules

Prior authorization and documentation requirements (as stated):

Many listed procedure codes are noted as 'No Prior Auth required for MT Medicare Advantage Plan effective 1/1/21.'

Medical records requests for review should be directed to eviCore via phone 1-855-252-1117 or the eviCore web portal.

Certain codes require pre‑operative evaluation, history and physical (including functional impairment) and operative report to be submitted as supporting documentation.

Per-code documentation criteria

Documentation or prior authorization criteria by code

29889 — Medical records request routed to eviCore; noted 'No Prior Auth required for MT Medicare Advantage Plan effective 1/1/21.'

32855, 32856, 50300 and similar transplant-related codes — If transplant approval is on record: submit Date of Transplant; if no transplant approval: submit history and physical, transplant evaluation, and date of transplant.

33404 — Recent history and physical, plan of care, and documentation of medical necessity required.

43775 — For bariatric procedures provide history and physical, nutritional evaluation, psychological evaluation, weight loss attempts, and documentation of social supports as indicated.

33208 — Recent history and physical, plan of care, and documentation of medical necessity (note: removed 1/1/2023).

Documentation and authorization routing requirements

Documentation required for prior authorization varies by procedure; transplant-related codes require transplant approval date or transplant-specific documentation.

Transplant routing: If transplant approval on record, submit Date of Transplant; otherwise submit history and physical, transplant evaluation, and date of transplant.

Surgical procedures: many entries require history and physical, documentation of medical necessity, and operative report as part of the medical records submission.

Certain spine/epidural procedures are routed to eviCore for review (contact phone/URL provided); plan-specific notes may indicate No Prior Auth exemptions for some Medicare Advantage plans.

Coverage and documentation notes (excerpt)

For the procedure codes listed, the document states prior authorization requirements (often 'No Prior Auth required' for MT Medicare Advantage Plan) and specifies what medical records or documentation are requested.

Statement: Many listed CPT codes are noted as 'No Prior Auth required' for MT Medicare Advantage Plan (see multiple code entries across imaging, vascular, and surgical sections).

Documentation: Providers may be asked to submit history and physical, operative report, or pre-operative evaluation depending on the specific code.

Vendor contact: eviCore is referenced repeatedly as the vendor for medical records requests and utilization management (1-855-252-1117 or https://www.evicore.com/healthplan/bcbs).

Authorization and documentation criteria

Prior authorization routing and documentation requirements for listed codes:

Contact eviCore for prior authorization and medical records requests (1-855-252-1117 or https://www.evicore.com/healthplan/bcbs).

Provide specified medical records per code (examples include pre-operative evaluation, operative report, prior device use, and level of impairment where applicable).

Note: Most codes in these sections list 'Effective Date = Prior to 9/1/2019'; individual codes may show alternate effective dates (e.g., 71271 = 4/1/2021).

Prior authorization and plan exceptions (as listed)

Coverage/prior authorization stance for listed codes and plan-specific exceptions where noted

Select ultrasound and imaging codes include plan-specific 'No Prior Auth required' exceptions for MT Medicare Advantage effective 4/1/2018 (examples: 76506, 76604, 76700, 76801 and related ultrasound codes).

Some fetal/maternal imaging codes have No Prior Auth exemptions for NM Medicare Advantage on specific effective dates (see per-code entries).

Per-code prior authorization/documentation requirements

Prior authorization / medical records request requirements by code and effective date.

Examples: 77525 (PROTON TREATMENT COMPLEX) — medical records request via eviCore; Effective Date = Prior to 9/1/2019.

Nuclear medicine codes (78830–78832, 78999) — medical records request via eviCore; Effective Dates include 9/1/2020 and Prior to 9/1/2019 as indicated per code.

Genetic testing and molecular codes (81162, etc.) — require medical records submission to eviCore with the Effective Date shown in each code entry.

Documentation and prior authorization notes

Documentation required and prior auth notes for selected procedures.

91111, 91112, 91132, 91133 — Recent history and physical, plan of care, and documentation of medical necessity required.

90870 (Electroconvulsive therapy) — History and physical, chart notes from ordering physician, and treatment plan required.

Vascular/TCD codes (93880, 93882, 93886, 93888, 93890, etc.) — eviCore contact required; some entries note 'No Prior Auth required' for MT and NM Medicare Advantage plans with specific effective dates.

Per-code prior auth notes

Per-code prior auth status and effective date notes

93926 — No Prior Auth required for MT Medicare Advantage Plan effective 4/1/2018; No Prior Auth required for NM Medicare Advantage Plan effective 11/1/2018. Medical records contact: eviCore (phone/URL).

93930 — No Prior Auth required for MT Medicare Advantage Plan effective 4/1/2018; No Prior Auth required for NM Medicare Advantage Plan effective 11/1/2018. Medical records contact: eviCore (phone/URL).

93975 — No Prior Auth required for MT Medicare Advantage Plan effective 4/1/2018; No Prior Auth required for NM Medicare Advantage Plan effective 11/1/2018. Medical records contact: eviCore (phone/URL).

Utilization management notes

Authorization / documentation notes tied to codes

For many listed codes, medical records requests must be submitted to eviCore (1-855-252-1117 or https://www.evicore.com/healthplan/bcbs).

Certain codes explicitly note 'No Prior Auth required for MT Medicare Advantage Plan' with effective dates provided (examples include some U/T/T and procedure-specific codes).

Code status changes: some codes are marked 'Removed' or show 'Added' with specific effective dates in the list (check individual code entries).

Submission and documentation requirements

Provider submission requirements and prior authorization notes associated with listed procedure codes

Providers must submit medical records/documentation to eviCore via phone 1-855-252-1117 or the eviCore web portal as specified for each code.

Selected DME/accessory codes (A70xx series) note 'No Prior Auth required for MT Medicare Advantage Plan effective 4/1/2018' — verify the code-specific entry for details.

Some codes (for example, cellular therapy, certain oncology codes, and select HCPCS entries) explicitly require recent history and physical, plan of care, and documentation of medical necessity.

Effective dates are provided per code and vary across the list (examples include 'Prior to 9/1/2019' and additions in 2022).

Documentation & prior auth criteria (excerpt)

Documentation and prior auth notes associated with listed HCPCS codes

E0635, E0638 and similar mobility/assistive device codes — require a Letter of Medical Necessity that includes anticipated length of need and description of the medical condition (including mobility status where applicable).

E0470, E0471 and other respiratory assist device codes — medical records requests processed via eviCore; some entries indicate 'No Prior Auth required' for MT Medicare Advantage Plan effective 4/1/2018 (see per-code notes).

Many HCPCS entries show Effective Date = Prior to 9/1/2019; some have later specific effective dates (e.g., codes added or updated in 2020–2022).

CPT / HCPCS code lists and examples

Examples of listed CPT codes and descriptionsCPT

01939-01942	Anesthesia/neuromonitoring related codes (examples shown)
11970, 15271, 15775-15793, 15819-15839, 15847, 15876-15879	Variety of plastic/reconstructive and dermatologic procedure codes

Spine injection/augmentation and IDET codesCPTCovered

22511	PERQ LUMBOSACRAL INJECTION
22512	VERTEBROPLASTY ADDL INJECT
22513	PERQ VERTEBRAL AUGMENTATION
22514	PERQ VERTEBRAL AUGMENTATION
22515	PERQ VERTEBRAL AUGMENTATION
22526	IDET SINGLE LEVEL

Spine fusion codesCPTCovered

22533	LAT LUMBAR SPINE FUSION
22534	LAT THOR/LUMB ADDL SEG
22551	NECK SPINE FUSE&REMOV BEL C2
22612	LUMBAR SPINE FUSION
22630	LUMBAR SPINE FUSION

Post-fusion and fixation device codesCPTCovered

22800	POST FUSION </6 VERT SEG
22802	POST FUSION 7-12 VERT SEG
22804	POST FUSION 13/> VERT SEG
22840	INSERT SPINE FIXATION DEVICE
22856	CERV ARTIFIC DISKECTOMY

Upper/lower extremity orthopedic procedure codesCPTCovered

23410	REPAIR ROTATOR CUFF ACUTE
23412	REPAIR ROTATOR CUFF CHRONIC
27096	INJECT SACROILIAC JOINT
27130	TOTAL HIP ARTHROPLASTY
27332	REMOVAL OF KNEE CARTILAGE

orthopedic and related surgical CPT codes (partial list from this chunk)CPT

27134	REVISE HIP JOINT REPLACEMENT
27137	REVISE HIP JOINT REPLACEMENT
27138	REVISE HIP JOINT REPLACEMENT
27279	ARTHRODESIS SACROILIAC JOINT
27280	FUSION OF SACROILIAC JOINT

additional CPT codes (partial list)CPT

29805	SHOULDER ARTHROSCOPY DX
29806	SHOULDER ARTHROSCOPY/SURGERY
29914	HIP ARTHRO W/FEMOROPLASTY
30120	REVISION OF NOSE
30400	RECONSTRUCTION OF NOSE

Orthopedic arthroscopy codesCPT

29889	KNEE ARTHROSCOPY/SURGERY
29914	HIP ARTHRO W/FEMOROPLASTY
29915	HIP ARTHRO ACETABULOPLASTY
29916	HIP ARTHRO W/LABRAL REPAIR

Cardiac surgery codesCPT

33404	PREPARE HEART-AORTA CONDUIT
33405	REPLACEMENT AORTIC VALVE OPN
33406	REPLACEMENT AORTIC VALVE OPN

Bariatric surgery codesCPT

43644	LAP GASTRIC BYPASS/ROUX-EN-Y
43775	LAP SLEEVE GASTRECTOMY
43846	GASTRIC BYPASS FOR OBESITY

Gastric/stomach procedures (partial)CPT

43887	REMOVE GASTRIC PORT OPEN
43888	CHANGE GASTRIC PORT OPEN
43999	STOMACH SURGERY PROCEDURE

Liver/transplant procedures (partial)CPT

47135	TRANSPLANTATION OF LIVER
47133	REMOVAL OF DONOR LIVER
47140	PARTIAL REMOVAL DONOR LIVER

Pancreas/kidney transplant procedures (partial)CPT

48550	DONOR PANCREATECTOMY
50365	TRANSPLANTATION OF KIDNEY
50300	REMOVE CADAVER DONOR KIDNEY

Genitourinary/sex transformation procedures (partial)CPT

54400	INSERT SEMI-RIGID PROSTHESIS
55970	SEX TRANSFORMATION M TO F
55980	SEX TRANSFORMATION F TO M

Spine/epidural procedures (partial)CPT

62263	EPIDURAL LYSIS MULT SESSIONS
62360	INSERT SPINE INFUSION DEVICE

Example early codes in excerptCPT

62326	Procedure code listed in Utilization Management Process excerpt
62327	NJX INTERLAMINAR LMBR/SAC (as labeled)
62350	IMPLANT SPINAL CANAL CATH.

Neuroelectrode and generator codesCPT

63650	IMPLANT NEUROELECTRODES
63655	IMPLANT NEUROELECTRODES
63685	INSRT/REDO SPINE N GENERATOR

Sample listed procedure codes (partial)CPT

69718	Procedure related to hearing (medical records required)
69930	Implant cochlear device
70336	Magnetic image jaw joint
70450	CT head/brain without dye
70460	CT head/brain with dye

Extremity imaging codes (partial)CPT

73200	CT upper extremity w/o dye
73201	CT upper extremity w/ dye
73700	CT lower extremity w/o dye
73718	MRI lower extremity w/o dye

Selected imaging codes listed in these chunksCPT

74183	MRI ANGIO ABDOM W OR W/O DYE
74185	MRI ANGIO ABDOM W ORW/O DYE
74261	CT COLONOGRAPHY DX
74262	CT COLONOGRAPHY DX W/DYE
74263	CT COLONOGRAPHY SCREENING
74712	MRI FETAL SNGL/1ST GESTATION
74713	MRI FETAL EA ADDL GESTATION

Obstetric ultrasound codesCPT

76801	OB US < 14 WKS SINGLE FETUS
76802	OB US < 14 WKS ADDL FETUS
76805	OB US >= 14 WKS SNGL FETUS
76810	OB US >= 14 WKS ADDL FETUS
76811	OB US DETAILED SNGL FETUS
76812	OB US DETAILED ADDL FETUS

MRI breast and radiation therapy codesCPT

77021	MRI GUIDANCE NDL PLMT RS&I
77022	MRI GDN PARNCHYMA TISS ABLTJ
77046	MRI BREAST C- UNILATERAL
77047	MRI BREAST C- BILATERAL
77048	MRI BREAST C-+ W/CAD UNI
77049	MRI BREAST C-+ W/CAD BI
77371	SRS MULTISOURCE
77372	SRS LINEAR BASED
77373	SBRT DELIVERY

Radiation therapy / Proton therapyCPTCovered

77525

PROTON TREATMENT COMPLEX

Hyperthermia treatmentsCPTCovered

77600	HYPERTHERMIA TREATMENT
77605	HYPERTHERMIA TREATMENT
77610	HYPERTHERMIA TREATMENT

Genetic testing (BRCA)CPTCovered

81162	BRCA1&2 GEN FULL SEQ DUP/DEL
81163	BRCA1&2 GEN FULL SEQ DUP/DEL

sample nuclear medicine codes and descriptionsCPT

78830	RP LOCLZJ TUM SPECT W/CT 1
78831	RP LOCLZJ TUM SPECT 2 AREAS
78832	RP LOCLZJ TUM SPECT W/CT 2
78999	NUCLEAR DIAGNOSTIC EXAM
79005	NUCLEAR RX ORAL ADMIN
79101	NUCLEAR RX IV ADMIN

genetic testing codes (BRCA and others)CPT

81162	BRCA1&2 GEN FULL SEQ DUP/DEL
81163	BRCA1&2 GEN FULL SEQ DUP/DEL
81164	BRCA1&2 GEN FULL SEQ DUP/DEL
81165	BRCA1&2 GEN FULL SEQ DUP/DEL
81166	BRCA1&2 GEN FULL SEQ DUP/DEL
81167	BRCA1&2 GEN FULL SEQ DUP/DEL
81173	AR GENE FULL GENE SEQUENCE

additional genetic testing codesCPT

81201	APC GENE FULL SEQUENCE
81202	APC GENE KNOWN FAM VARIANTS
81203	APC GENE DUP/DELET VARIANTS
81212	BRCA1&2 185&5385&6174 VRNT
81215	BRCA1 GENE KNOWN FAMIL VRNT

recently added/annotated genetic and molecular codesCPT

81307	PALB2 GENE FULL GENE SEQ
81308	PALB2 GENE KNOWN FAMIL VRNT
81313	PCA3/KLK3 ANTIGEN
81349	Short description not available at time of distribution (added 4/1/2022)
81415	EXOME SEQUENCE ANALYSIS

Examples of listed procedure codesCPT | HCPCS

81404	MOPATH PROCEDURE LEVEL 5
81415	EXOME SEQUENCE ANALYSIS
81425	GENOME SEQUENCE ANALYSIS
81518	ONCOLOGY BREAST MRNA (effective 1/1/2020)
93880	EXTRACRANIAL BILAT STUDY

Vascular/Extremity ultrasound codesCPT

93926	LOWER EXTREMITY STUDY
93930	UPPER EXTREMITY STUDY
93931	UPPER EXTREMITY STUDY
93970	EXTREMITY STUDY
93971	EXTREMITY STUDY
93975	VASCULAR STUDY
93976	VASCULAR STUDY
93978	VASCULAR STUDY
93979	VASCULAR STUDY
93980	PENILE VASCULAR STUDY

1–10 of 11

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Genomic/molecular codes (sample)CPT | HCPCS

0001U	RBC DNA HEA 35 AG 11 BLD GRP
0002M	Liver disease
0003M	Liver disease
0004M	SCO 53 SNPS

sample listed U/T/T procedure codesmixed

0118U	Medical Records Request information required; eviCore contact; Effective Date 1/1/2020
0163T	LUMB ARTIF DISKECTOMY ADDL; No Prior Auth required for MT Medicare Advantage Plan effective 1/1/21; Effective Date 9/1/2020
0285U	ONC RSPS RADJ CLL FR DNA TOX; Effective Date added 4/1/2022
0329U	ONC NEO XOME&TRNS SEQ ALYS; Effective Date added 7/1/2022

Selected oncology/genomic temporary codesCPT

0294U	LNGVTY&MRTLTY RSK MRNA 18GEN
0296U	ONC ORL&/OROP CA 20 MLC FEAT
0297U	ONC PAN TUM WHL GEN SEQ DNA
0298U	ONC PAN TUM WHL TRNS SEQ RNA
0299U	ONC PAN TUM WHL GEN OPT MAPG
0300U	ONC PAN TUM WHL GEN SEQ&OPT

Therapy, transport, and DME codesHCPCS

0537T	Cellular Therapy Procedures Ancillary Code
0538T	Cellular Therapy Procedures Ancillary Code
0539T	Cellular Therapy Procedures Ancillary Code
0540T	Cellular Therapy Procedures Ancillary Code
0394T	HDR ELCTRNC SKN SURF BRCHYTX
A0430	AMBULANCE SERVICE, CONVENTIONAL AIR SERVICES, TRANSPORT, ONE WAY (FIXED WING)
A0435	FIXED WING AIR MILEAGE, PER STATUTE MILE
A4604	Tubing with integrated heating element for use with positive airway pressure device

Drug, biologic, and procedure codesHCPCS

A9513	Lutetium Lu 177, dotatate, therapeutic
C9066	Sacituzumab govitecan-hziy OR Trodelvy
C9076	Lisocabtagene maraleucel
C9600	Percutaneous transcatheter placement of drug eluting intracoronary stent(s)

Selected C and E codes (continued list)HCPCS

C9741	Right heart catheterization with implantation of wireless pressure sensor in the pulmonary artery
C9757	Laminotomy with decompression and implantation of bone anchored annular closure device, lumbar
E0470	Respiratory assist device, bi-level pressure capability, without backup rate feature
E0471	Respiratory assist device, bi-level pressure capability, with backup rate feature

Provider responsibilities, contacts, and submission requirements

Prior Authorization

eviCore-managed authorization and documentation requirements

The attending physician must obtain prior authorization for services managed by eviCore. For many procedure and imaging codes listed below, eviCore handles authorization and medical-records review. Submit required documentation to eviCore for review prior to services when indicated.

eviCore contact for prior authorization and medical records: 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs
Green-highlighted codes in the full list indicate eviCore-managed services

Documentation Required

Documentation requirements for select codes

Certain codes require specific supporting documentation at time of prior authorization or medical-records request. Providers should include the items listed below when submitting to eviCore to avoid delays.

History and physical (recent)

Key terms and vendor contacts

eviCore-managed

eviCore-managed (green-highlighted) codesCodes marked in the list as managed by eviCore (green highlight) — providers should route medical records/authorization requests to eviCore

Representative sectionsMany entries across the document (e.g., chunks 36, 54, 144) state 'Medical Records Request information required = eviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs'

ImplicationeviCore is the external utilization management vendor for prior authorization and medical records review for these codes

eviCore (third-party utilization management vendor)

eviCore (third‑party UM vendor)eviCore is the designated external utilization management vendor referenced throughout the list for prior authorization and medical records requests

Where stated

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyBlue Cross Medicare Advantage Prior Authorization List

Policy CodePolicy N/A

Change TypeAdministrative update (no material clinical changes)

Effective DateEffective 1/1/2023

Next Review DateN/A

Key ActionAttending physician must obtain prior authorization for listed services; contact eviCore at 1-855-252-1117 or Customer Service at 1-877-774-8592 for requests.

SourceLink

On This Page

No Prior Auth effective date for MT Medicare Advantage Plan

No Prior Auth effective date (MT Medicare Advantage Plan)1/1/2021 (Many listed procedure codes are noted 'No Prior Auth required for MT Medicare Advantage Plan effective 1/1/21')

Example codes with MT MA exemption27134, 27137, 27138, 27279, 27280, 27332 — all note 'No Prior Auth required for MT Medicare Advantage Plan effective 1/1/21'

Reference for providersMedical records requests for these codes direct providers to eviCore (1-855-252-1117 or https://www.evicore.com/healthplan/bcbs)

eviCore handling effective date

eviCore routing notes and effective datesCertain spine/epidural and related procedures routed to eviCore; notes specify plan-specific effective dates (e.g., No Prior Auth for MT MA effective 4/1/2018 for some spine entries)

Vendor routing instructionContact eviCore at 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs for medical records and prior authorization handling

Example codes with eviCore handling62263, 62264, 62280, 62281, 62282 — all list eviCore contact and include effective date annotations

Required documentation before authorization

Required documentation before authorizationPre-operative evaluation; history and physical including functional impairment; operative report (commonly requested)

Procedure-specific examplesCochlear/hearing (69718, 69930): previous use of hearing aids and level of hearing impairment also requested

Surgical examplesMany orthopedic and plastic surgery codes require history & physical plus operative report; transplant codes may require transplant evaluation and dates

Effective date examples

Common effective-date patternMany codes show 'Effective Date = Prior to 9/1/2019'

Examples of later effective datesE0485/E0486 Effective Date = 9/1/2020; select nuclear medicine codes (78830–78832, 78999) show 9/1/2020; some U/T codes added 2020–2022

Newly added codes with add dates0294U–0300U entries show 'Effective Date = added 4/1/2022' and others 'added 7/1/2022'

Operative report when applicable

Documentation of medical necessity and plan of care

Documentation of conservative measures (where noted)

Pre-operative evaluation and evidence of functional impairment (for reconstructive/ENT procedures)

Nutritional and psychological evaluations, weight-loss attempts, and social supports (for bariatric-related codes)

Previous diagnostic procedure reports or results (e.g., for discography)

Prior hearing-aid use and level of hearing impairment (for cochlear/hearing device codes)

Transplant evaluation and Date of Transplant when transplant-related

Letters of medical necessity for select DME or device codes

Note

Code removal notice

Some entries in the code list have been removed effective 1/1/2023. Providers should rely on the current published list and eviCore guidance for up-to-date prior authorization routing.

Example: CPT 33208 (INSRT HEART PM ATRIAL & VENT) marked as Removed 1/1/2023

Documentation Required

Medical records required for prior authorization (examples)

Examples of common medical records and supporting documentation routinely requested for prior authorization by eviCore are listed below. Include these as applicable to the service to support timely review.

History and physical
Operative report
Pre-operative evaluation
Functional impairment documentation
Nutritional evaluation and psychological evaluation (for bariatric procedures)
Weight loss attempt documentation and social supports (for bariatric procedures)
Results of previous diagnostic procedures (e.g., imaging, discography)
Transplant evaluation and Date of Transplant (if transplant-related)
Plan of care and documentation of conservative measures (for spine/orthopedic procedures)

Prior Authorization

eviCore authorization routing and Medicare Advantage note

For many spine, epidural, and similar procedures, prior authorization requests and medical records must be routed to eviCore. Note that some Medicare Advantage plans have specific 'No Prior Auth' exceptions — check the member's plan and effective dates.

eviCore routing: 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs
MT Medicare Advantage plan exceptions (examples): several spine/epidural codes list 'No Prior Auth required for MT Medicare Advantage Plan' with varying effective dates (e.g., 4/1/2018, 1/1/2021)
Always verify the member's plan and effective date before submitting an authorization request to eviCore

Documentation Required

Cochlear and hearing-related procedures

Cochlear implant and other hearing-related procedures require additional audiologic and surgical documentation when submitted for prior authorization. Include both clinical evaluation and prior-use history to demonstrate medical necessity.

Required: Pre-operative evaluation and operative report
Required: Documentation of prior hearing aid use and audiologic test results
Required: Clear statement of level of hearing impairment and functional impact

Note

MT Medicare Advantage prior auth exemption note

Certain ultrasound and related imaging codes are exempt from prior authorization for Montana (MT) Medicare Advantage plans. Providers should confirm member plan before requesting authorization.

MT Medicare Advantage prior auth exemption examples: multiple ultrasound and related codes noted as 'No Prior Auth required for MT Medicare Advantage Plan' effective 4/1/2018 and other dates (see detailed list)
Always verify eligibility and plan-specific rules prior to ordering

Note

NM Medicare Advantage prior auth exemption note

Certain fetal MRI codes are noted as exempt from prior authorization for New Mexico (NM) Medicare Advantage plans. Confirm member plan and effective dates before ordering.

Example NM MA exemption: CPT 74712 and 74713 marked 'No Prior Auth required for NM Medicare Advantage Plan effective 11/1/2018'
Verify member plan before submitting or obtaining prior authorization

Prior Authorization

78456-78458

Acute venous thrombosis and related nuclear medicine imaging codes require eviCore routing for prior authorization and records review.

CPT 78456 — Acute venous thrombus imaging (eviCore review; Effective 1/1/2020)
CPT 78457 — Venous thrombosis imaging (eviCore review; Effective 1/1/2020)
CPT 78458 — Venous thrombosis images bilateral (eviCore review; Effective 1/1/2020)

Prior Authorization

Selected nuclear medicine codes

Selected nuclear medicine and radiopharmaceutical procedure codes are managed by eviCore and require submission of medical records for utilization review.

CPT 78830-78832 — RP localization tumor SPECT (eviCore review; Effective 9/1/2020)
CPT 78999 — Nuclear diagnostic exam (eviCore review; Effective 9/1/2020)
CPT 79005, 79101 — Nuclear Rx oral/IV administration (eviCore review)
CPTs 78579–78582, 78597–78598 — Lung ventilation/perfusion imaging (eviCore review)

Prior Authorization

Genetic/Molecular procedure codes and contact

Genetic and molecular testing codes are routed to eviCore for prior authorization and require detailed supporting documentation. Many molecular oncology, hereditary cancer panels, and other genetic assay codes are included.

Examples include: CPT 81162 (BRCA1/2 full seq), CPTs 81404–81408 (molecular pathology levels), CPTs 0118U–0138U and multiple U-codes and T-codes added in 2020–2022
Medical records request: submit clinical indication, relevant family/personal history, prior testing, and any pathology or diagnostic reports

Prior Authorization

Prior authorization / medical records request notes

For all prior authorization and medical-records submissions, use eviCore as the utilization management vendor. Confirm plan-specific exceptions (e.g., MT or NM Medicare Advantage 'No Prior Auth' listings) and include required documentation to support medical necessity.

eviCore contact: 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs
Before submission, verify member eligibility and whether a plan-specific 'No Prior Auth' exception applies (dates and codes vary by plan)
Failure to include requested documentation may delay authorization or result in denial

Prior Authorization

eviCore contact and prior auth exceptions

eviCore is the primary contact for authorization and records requests for the codes noted in this list. Several codes also include plan-specific prior authorization exceptions — review the member's Medicare Advantage plan and effective dates before ordering.

eviCore contact: 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs
Common MA plan exceptions called out in the list: MT Medicare Advantage and NM Medicare Advantage have multiple 'No Prior Auth required' entries with effective dates (see detailed list)
Providers must check eligibility/benefits and follow eviCore submission instructions

Document repeatedly directs providers to eviCore for medical records requests and prior auth processing across imaging, surgical and DME sections

Relation to plan contactsBlue Cross still requires prior authorization per the list; eviCore handles medical record submission/clinical review for many codes

eviCore contact information

eviCore contact for medical records requestsPhone: 1-855-252-1117; Web: https://www.evicore.com/healthplan/bcbs

Use caseProviders directed to this contact for submission of required documentation and prior authorization inquiries for eviCore-managed codes

Document evidenceContact appears repeatedly alongside code entries (e.g., chunks 36, 126, 234) as the medical records/UM contact

Required documentation examples

Pre-operative evaluationOften required as part of medical records request prior to authorization

History and physical including functional impairmentFrequently requested to demonstrate medical necessity for surgical procedures

Operative reportCommonly requested post-procedure documentation or to support prior authorization for revision/repair codes

Medical records/documentation

Medical records submission requirementMedical Records Request information required; many HCPCS entries direct providers to submit records to eviCore for review

Typical documentation requestedRecent history and physical and documentation of medical necessity (example: C9741) or letter of medical necessity for DME (E0635, E0638)

Where listedSee HCPCS and device sections (chunks 252, 258, 254) for code‑specific documentation instructions

eviCore

eviCore designated contact repeatedeviCore (1-855-252-1117; https://www.evicore.com/healthplan/bcbs) is listed as the contact for medical records requests and prior authorization processing for many codes

RoleHandles clinical review/medical records intake for Blue Cross Medicare Advantage prior authorization list

Applicable areasImaging, surgical, DME, genetic/molecular and specialty procedure sections reference eviCore

Medical records required

Examples of medical records required (HCPCS/DME)E0635/E0638: Letter of medical necessity with anticipated length of need and condition details; E0762: history and physical or clinical notes including anticipated length of use

Submission pathRecords and letters of medical necessity are to be submitted to eviCore per the listed contact

Effective dates notedThese DME/HCPCS entries often show 'Effective Date = Prior to 9/1/2019' or newer specific dates where applicable

External utilization management vendor for certain spine/epidural authorizations

eviCore is external UM vendor for spine/epidural authorizationsEntries for epidural/ spine procedures instruct providers to contact eviCore for medical records and prior auth handling

Example codes62263, 62264, 62326, 62327 — all reference eviCore contact and plan‑specific No Prior Auth notes in some cases

Provider actionUse eviCore phone/portal for records and authorization routing as specified in the list

eviCore — contact for medical records requests and utilization management

eviCore contact repeated for records and UM1-855-252-1117; https://www.evicore.com/healthplan/bcbs — referenced consistently as the vendor contact for prior authorization and medical records requests

Sections referencing contactImaging, genetic/molecular, oncology temporary codes and many others include this eviCore contact instruction

Provider instructionProviders should direct medical records and prior auth inquiries for listed codes to the eviCore contact provided

Medical Records Request (pre-op)

Pre-operative evaluation, history & physical, operative report (pre-op) — common requestFrequently required for corneal/ocular, orthopedic and other surgical procedures as part of medical records prior to authorization

Use in ocular proceduresCorneal and ocular procedure entries (e.g., 65730, 65750) explicitly list pre-operative evaluation, history and physical, and operative report

Provider evidence submissionSubmit these documents to eviCore per the contact information when requested for prior authorization review

eviCore — designated prior authorization/vendor contact for imaging

eviCore imaging prior authorization contactDesignated prior authorization/vendor contact for imaging: call 1-855-252-1117 or use https://www.evicore.com/healthplan/bcbs

Imaging examplesCT/MRI/MRA entries across head/neck/chest/abdomen sections instruct providers to use the eviCore contact for records and authorization

Effective date notesSome imaging codes include specific effective dates (e.g., 78830–78832 effective 9/1/2020) alongside the eviCore routing instruction

eviCore — utilization management vendor and contact

eviCore as UM vendor and contacteviCore is listed repeatedly as the utilization management vendor and contact for medical records requests and prior authorization processing

Where to send recordsPhone 1-855-252-1117 or web portal https://www.evicore.com/healthplan/bcbs

Applies toMultiple sections including surgical, imaging, DME, genetic/molecular, and specialty procedures

eviCore — external utilization management vendor for prior authorization and medical records requests

eviCore — external UM and medical records contact (repeated)Contact: 1-855-252-1117; https://www.evicore.com/healthplan/bcbs — cited across many code entries as the submission route for medical records and prior auth reviews

Document sectionsRadiation therapy, genetic testing, oncology, imaging, and DME sections all include this eviCore contact instruction

Provider expectationProviders should use the eviCore contact when the code entry requests 'Medical Records Request information'

eviCore contact — medical review and prior authorization

eviCore contact and URL referencedeviCore phone 1-855-252-1117 and portal https://www.evicore.com/healthplan/bcbs appear as the central contact for medical records requests and prior auth handling

Examples of useGenomic/molecular and U/T/T code entries (chunks 216, 234) instruct providers to contact eviCore for records and authorization

Practical noteUse the eviCore contact for both submission of supporting documentation and to initiate prior authorization where indicated

Medical records / documentation

Medical records / documentation requirement (general)Many entries state 'Medical Records Request information required' and direct providers to eviCore for submission of those records

ExamplesHCPCS and DME codes (E0561, E0635, E0748) include specific documentation requirements such as letters of medical necessity or history & physical

Provider actionFollow code‑specific instructions and submit requested documentation to eviCore for review

eviCore (vendor) — contact for medical review and prior authorization

eviCore contact for medical review and prior authorization determinationseviCore (1-855-252-1117; https://www.evicore.com/healthplan/bcbs) is the vendor contact listed for medical records intake and prior authorization decisions for many codes

Spine and epidural examplesSeveral spine/epidural code entries direct providers to eviCore and note plan‑specific No Prior Auth exceptions in some instances

Consistent instructionThe same eviCore contact appears throughout the document for uniform submission and review processing

Medical records request instruction

Medical Records Request instruction (general)Entries commonly state: 'Medical Records Request information required = eviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs'

Vascular/ultrasound exampleCodes 93926/93930/93931/93970 etc. include that instruction and note No Prior Auth exceptions for MT and NM Medicare Advantage plans

Action for providersWhen requested, submit the specified records to eviCore using the provided phone or web portal

MT Medicare Advantage prior auth exception

MT Medicare Advantage prior auth exception (example)No Prior Auth required for MT Medicare Advantage Plan effective 4/1/2018 (noted for multiple DME/accessory and some procedural codes) — providers must still follow code-specific instructions

Where notedExamples appear in respiratory device and DME sections (e.g., E0470, E0471, A7027–A7032) and in spine/epidural sections

Provider cautionEven if 'No Prior Auth' is noted for MT MA on a given effective date, follow any documentation submission instructions if requested for medical review