Documentation requirements by code (partial). The following codes require the listed medical records or documentation to support prior authorization or claims processing. Where eviCore routing is noted, contact eviCore at 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs for clinical review and submission instructions.
E0749 — Osteogenesis stimulator, electrical, surgically implanted: eviCore routing for clinical review; No Prior Auth required for MT Medicare Advantage Plan effective 1/1/21. Medical records requested: clinical history and documentation of medical necessity.
E0760 — Osteogenesis stimulator, low intensity ultrasound, non-invasive: Letter of medical necessity containing anticipated length of use and description of medical condition including mobility status.
E0762 — Transcutaneous electrical joint stimulation device system: History and physical or clinical notes, including anticipated length of use.
E0764 — Functional neuromuscular stimulation system for ambulation: Letter of medical necessity with anticipated length of use and description of medical condition including mobility status.
E0766 — Electrical stimulation device used for cancer treatment: Letter of medical necessity with anticipated length of time patient will require equipment and description of medical condition including mobility status.
E0769 — Electrical stimulation or electromagnetic wound treatment device, not otherwise classified: Letter of medical necessity with anticipated length of use and description of medical condition including mobility status.
E0770 — Functional electrical stimulator, transcutaneous: Letter of medical necessity with anticipated length of use and description of medical condition including mobility status.
E0782 — Infusion pump, implantable, non-programmable: Letter of medical necessity including anticipated length of use and description of medical condition requiring device.
E0783 — Infusion pump system, implantable, programmable: Letter of medical necessity including anticipated length of use and description of medical condition requiring device.
E1004 / E1005 / E1006 / E1007 / E1008 — Wheelchair accessories (power seating systems variants): Letter of medical necessity supporting need for the wheelchair accessory.
E1010 / E1012 — Wheelchair accessory additions (power leg elevation, center mount power elevating leg rest): Letter of medical necessity supporting need for the wheelchair accessory.
E2300 — Wheelchair accessory, power seat elevation system: History and physical to include diagnosis; abilities and limitations related to equipment (degree of independence/dependence, frequency and nature of activities), duration of medical condition, past experience with similar equipment (if any), and evaluation of upper extremity strength.
E2301 — Wheelchair accessory, power standing system: History and physical to include diagnosis; abilities and limitations related to equipment (degree of independence/dependence, frequency and nature of activities), duration of medical condition, past experience with similar equipment (if any), and evaluation of upper extremity strength.