CurrentBlue Cross Blue Shield - OklahomaPolicy N/A

MAPD Benefit Preauthorization Procedure Code List

Specifies procedure codes that require prior authorization for Blue Cross Medicare Advantage plans and lists the medical review category and required medical records for each code; applies to providers submitting PA requests for members of the listed BCBS Oklahoma Medicare Advantage organizations.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyMAPD Benefit Preauthorization Procedure Code List

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2019

Next Review DateN/A

Key ActionThe attending physician must obtain prior authorization for the services outlined in the Blue Cross Medicare Advantage Prior Authorization List.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

200+procedure codes listed

eviCore referralseviCore referrals

manymedical necessity category

frequentcosmetic category frequent

Coverage Criteria and Review Categories

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Per-code coverage review guidance

Per-code medical review categories and required documentation determine the coverage review pathway; some codes are flagged as Cosmetic (Potential Contract Exclusion) while others are Medical Necessity or routed to eviCore for external review.

Code 11043: Medical Review Category = Medical necessity; required documents = Recent history and physical, plan of care, and documentation of medical necessity.

Code 11970: Medical Review Category = Cosmetic - Potential Contract Exclusion; required documents = Pre-operative evaluation, history and physical including functional impairment, and operative report.

Code 15775/15776/15777/15783/etc.: Medical Review Category = Cosmetic - Potential Contract Exclusion; required documents = Pre-operative evaluation, history and physical including functional impairment, and operative report.

Code 20930: Medical Records Request information required = eviCore (1-855-252-1117 or https://www.evicore.com/healthplan/bcbs) — provider should refer to eviCore for review routing.

Preauthorization and documentation requirements

Procedures listed require medical review or prior authorization and submission of specified documentation; many codes are routed to eviCore for records requests or external review.

When Medical Necessity is indicated: submit history and physical, documentation of medical necessity, and operative report (as applicable).

For TMJ/maxillofacial codes (e.g., 21196, 21198, 21199, 21206): submit chart notes including type of appliance, history of recurrent TMJ, and copy of diagnostic sleep studies or H&P and operative report as specified.

For many spine and arthroplasty-related codes (see list): contact eviCore for preauthorization and medical records request (1-855-252-1117 or https://www.evicore.com/healthplan/bcbs).

When the Medical Records Request line lists eviCore: route prior authorization/records through eviCore per the contact information provided.

Documentation and submission criteria for Medical Necessity codes

When a procedure code in this list is labeled 'Medical Necessity', the preauthorization request must include the supporting clinical documentation below.

Submit a pre-operative evaluation and recent history and physical that documents functional impairment relevant to the requested procedure.

Include the operative report or procedure report when available; if procedure has not yet occurred, provide documentation that justifies medical necessity and plan of care.

If the code entry directs providers to eviCore for medical records request, follow eviCore submission instructions (1-855-252-1117 or https://www.evicore.com/healthplan/bcbs).

Coverage and documentation criteria (partial)

For listed procedure codes the policy specifies a Medical Review Category and the medical records or request information required for review.

ENT/Plastic surgery codes: Medical Review Category = Medical Necessity or Cosmetic - Potential Contract Exclusion; required documents include pre-operative evaluation, history and physical, operative report, and documentation of functional impairment.

Transplant codes: Medical Review Category = Transplant; if transplant approval on record: provide date of transplant; if not: submit history and physical, transplant evaluation, and date of transplant.

eviCore-managed codes: Medical Records Request information required = eviCore (1-855-252-1117 or https://www.evicore.com/healthplan/bcbs); follow eviCore routing for prior authorization/records.

Coverage criteria by review category

Coverage for procedures is conditional on the medical review category assigned and submission of the documentation specified for that category.

Transplant category: If transplant approval is on record provide date of transplant; if not, submit history and physical, transplant evaluation, and date of transplant.

Medical Necessity category: provide recent history and physical, plan of care, documentation of medical necessity, and operative report when applicable.

Obesity (Potential Contract Exclusion) category: provide history and physical, nutritional and psychological evaluations, documentation of prior weight loss attempts, and social supports.

Investigative category: submit specific diagnostic documentation (e.g., sleep study results, CPAP trial) as noted; some investigative codes reference eviCore for review (e.g., 41019).

Per-code criteria (partial)

Sample per-code review category and documentation requirements from the list (partial).

Code 44715 (Transplant): If transplant approval on record provide Date of Transplant; if not, submit history and physical, transplant evaluation, and date of transplant.

Code 47120 (Medical Necessity): Submit history and physical and procedure report to support medical necessity.

Code 49411 (eviCore routing): Medical Records Request information required = eviCore (1-855-252-1117 or https://www.evicore.com/healthplan/bcbs) — contact vendor for prior authorization guidance.

Preauthorization/Documentation criteria (excerpt)

Many listed CPT codes require submission of clinical records demonstrating medical necessity; some entries are noted as 'Potential Contract limits.'

For codes categorized as Medical Necessity: submit history and physical, documentation of medical necessity, and operative report as part of the preauthorization request.

For codes listed under Potential Contract limits: submit history and physical and documentation of medical necessity including operative report to support coverage determination.

Where the Medical Records Request line references eviCore, route prior authorization and records requests to eviCore per the contact information provided.

Preauthorization documentation and submission criteria

For codes listed with Medical Review Category = Medical Necessity, providers must submit clinical documentation to support the necessity of the procedure.

Requirement: Submit History and Physical and documentation of medical necessity including operative report for codes with Medical Review Category = Medical Necessity.

Instruction: If Medical Records Request information lists eviCore, contact eviCore (1-855-252-1117 or https://www.evicore.com/healthplan/bcbs) to submit records or initiate prior authorization.

Note: Some neurostimulator and related codes carry plan-specific prior authorization flags (e.g., 'Proir Auth required for MT Medicare Advantage Plan effective 4/1/2018') and inconsistent 'No' indicators for records request — follow eviCore and plan-specific instructions.

Prior authorization and documentation requirements (partial)

Listed procedures require prior authorization and/or medical review; specific documentation requirements are called out for certain codes.

Providers must contact eviCore (1-855-252-1117 or https://www.evicore.com/healthplan/bcbs) for medical records request and prior authorization for many listed CPT codes.

For vertebroplasty/vertebral augmentation (CPT 72291, 72292): for prior authorization submit history and physical and results of previous diagnostic procedure reports.

The CPT code ranges shown in this section (e.g., 70481–74185 in the partial list) are subject to the plan's preauthorization process as indicated in the list and may require eviCore routing.

Preauthorization and plan-specific notes

Plan-specific prior authorization status notes are included inline with codes and may modify prior authorization requirements for select plans.

Some nuclear medicine and cardiac MRI codes include an exemption note: 'No Prior Auth required for NM Medicare Advantage Plan effective 11/1/2018' (e.g., 74712, 74713, select cardiac MRI codes).

Several ultrasound and MT-plan entries include 'Proir Auth required for MT Medicare Advantage Plan effective 4/1/2018' or show 'No' for Medical Records Request in certain lines — follow plan-specific indicators.

Regardless of plan-specific flags, many codes still list eviCore contact for medical records/prior authorization requests; confirm routing with eviCore or plan resources.

Prior authorization requirement

For the Medicare Advantage Prescription Drug (MAPD) plan, many listed procedure codes require prior authorization; medical review and authorization processing are handled by eviCore.

Prior authorization is required for the listed CPT codes as indicated for the MAPD plan; providers should obtain prior authorization before scheduling non-urgent services.

Contact/Submission: route medical records requests and prior authorization submissions to eviCore (phone 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs) per code-specific instructions.

Authorization notes

Coverage and authorization notes are attached to specific codes; some imaging codes explicitly state exceptions to prior authorization.

Certain myocardial perfusion and related nuclear medicine CPT codes include an explicit note indicating 'No Prior Auth required for NM Medicare Advantage Plan effective 11/1/2018.'

Most listed CPT codes include instruction to contact eviCore for medical review/preauthorization via the vendor phone or website; follow the eviCore process for records submission and reviews.

Preauthorization requirement and routing

Procedure codes in imaging, PET, and molecular/genetic testing require preauthorization/medical review through eviCore; the excerpt provides routing but does not include detailed clinical coverage criteria.

Action: submit preauthorization and medical records requests to eviCore (1-855-252-1117 or https://www.evicore.com/healthplan/bcbs) for PET, nuclear medicine, and molecular/genetic procedure codes listed in this section.

Note: The excerpt lists procedure examples (e.g., 78800 series for radiopharmaceutical localization; 81161–81202 and 81295–81299 for molecular tests) that require eviCore medical review; refer to eviCore for submission instructions and clinical criteria where applicable.

Preauthorization routing and code listing

Provider action and routing for preauthorization and medical records requests for molecular and genetic testing codes are specified inline with each code.

Submit preauthorization and medical records requests for molecular/genetic procedure codes to eviCore (1-855-252-1117 or https://www.evicore.com/healthplan/bcbs).

The list includes molecular pathology procedure levels (81400–81405) and specific gene analyses (e.g., 81295–81299); descriptions and gene targets are provided, and eviCore is the contact for review processing.

Panel composition and review instructions

For genomic/exome and targeted panel CPT codes, the policy specifies panel composition requirements and reiterates eviCore as the contact for medical review processing.

Panel composition requirement: specific genomic panels must include minimum gene counts and named genes (examples: aortic panel 81410 must include sequencing of at least 9 genes including FBN1, TGFBR1, TGFBR2, COL3A1, MYH11, ACTA2, SLC2A10, SMAD3, MYLK; hearing loss panel 81430 must include at least 60 genes; mitochondrial/nuclear panel 81440 must include at least 100 genes).

Medical Records Request: for panel and molecular testing codes submit records and preauthorization requests to eviCore (1-855-252-1117 or https://www.evicore.com/healthplan/bcbs) as indicated in the code entries.

Procedure Codes and Groups

Advanced Imaging CPT (CT/MR) - Head/BrainCPTCovered

70551	Magnetic resonance imaging, brain (including brain stem); without contrast material.
70552	Magnetic resonance imaging, brain (including brain stem); with contrast material(s).
70553	Magnetic resonance imaging, brain (including brain stem); without contrast material, followed by contrast.
70554	Magnetic resonance imaging, brain, functional MRI; including test selection and administration of repetitive body part movement and/or visual stimulation, not requiring physician or psychologist administration.
70555	Magnetic resonance imaging, brain, functional MRI; requiring physician or psychologist administration of entire neurofunctional testing.

Advanced Imaging CPT (CT/MR) - Thorax/ChestCPTCovered

71250	Computed tomography, thorax; without contrast material.
71260	Computed tomography, thorax; with contrast material(s).
71270	Computed tomography, thorax; without contrast material, followed by contrast material(s) and further sections.
71275	Computed tomographic angiography, chest (noncoronary), with contrast material(s), including noncontrast images, if performed, and image postprocessing.
71550	Magnetic resonance imaging, chest; without contrast material(s).
71551	Magnetic resonance imaging, chest; with contrast material(s).
71552	Magnetic resonance imaging, chest; without contrast material(s), followed by contrast material(s) and further sequences.
71555	Magnetic resonance angiography, chest (excluding myocardium), with or without contrast material(s).

Maxillofacial / TMJ Related CPTCPTCovered

70486	Computed tomography, maxillofacial area; without contrast material.
70487	Computed tomography, maxillofacial area; with contrast material(s).
70488	Computed tomography, maxillofacial area; without contrast material, followed by contrast material(s) and further sections.

Vertebroplasty / Vertebral Augmentation CPTCPTCovered

22512	Percutaneous vertebroplasty, 1 vertebral body; includes imaging guidance.
22513	Percutaneous vertebral augmentation (eg, kyphoplasty), 1 vertebral body, inclusive of imaging.
22514	Percutaneous vertebral augmentation, additional descriptors per CPT.
22515	Percutaneous vertebral augmentation; each additional vertebral body (List separately).
22520	Percutaneous vertebroplasty, thoracic.
22521	Percutaneous vertebroplasty, lumbar.
22523	Percutaneous vertebral augmentation (eg, kyphoplasty); thoracic.
22524	Percutaneous vertebral augmentation (eg, kyphoplasty); lumbar.

Spine Arthrodesis / Instrumentation / Arthroplasty CPTCPTCovered

22533	Arthrodesis, lateral extracavitary technique; lumbar.
22534	Arthrodesis, lateral extracavitary technique; thoracic or lumbar, each additional segment.
22551	Arthrodesis, anterior interbody; cervical below C2.
22552	Arthrodesis, anterior interbody; cervical, each additional interspace.
22554	Arthrodesis, anterior interbody technique; cervical below C2.
22558	Arthrodesis, anterior interbody technique; lumbar.
22585	Arthrodesis, anterior interbody technique; each additional interspace.
22600	Arthrodesis, posterior or posterolateral technique, single level; cervical below C2.
22634	Arthrodesis, posterior interbody technique including laminectomy/discectomy; each additional interspace.
22800	Arthrodesis, posterior, for spinal deformity, up to 6 segments.

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Shoulder Procedure CPTCPTCovered

23120	Claviculectomy; partial.
23130	Acromioplasty or acromionectomy, partial, with or without coracoacromial ligament release.
23410	Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; acute.
23412	Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; chronic.
23415	Coracoacromial ligament release, with or without acromioplasty.
23420	Reconstruction of complete shoulder (rotator) cuff avulsion, chronic (includes acromioplasty).
23430	Tenodesis of long tendon of biceps.
23440	Resection or transplantation of long tendon of biceps.
23450	Capsulorrhaphy, anterior; Putti-Platt or Magnuson type.

Hip / Pelvic Procedures CPTCPTCovered

27125	Hemiarthroplasty, hip, partial (eg, femoral stem prosthesis, bipolar arthroplasty).
27130	Total hip arthroplasty.
27132	Conversion of previous hip surgery to total hip arthroplasty.
27134	Revision of total hip arthroplasty; both components.
27137	Revision of total hip arthroplasty; acetabular component only.
27138	Revision of total hip arthroplasty; femoral component only.
27279	Arthrodesis, sacroiliac joint, percutaneous or minimally invasive, with image guidance.

Arthroplasty / Arthrodesis Selected CodesCPTCovered

27445	Arthroplasty, knee, hinge prosthesis (eg, Walldius type).
27446	Arthroplasty, knee, condyle and plateau; medial OR lateral compartment.
27447	Arthroplasty, knee, condyle and plateau; medial AND lateral compartments (total knee arthroplasty).

Knee Arthroscopy CPTCPTCovered

29880	Arthroscopy, knee, surgical; with meniscal debridement/shaving (chondroplasty).
29881	Arthroscopy, knee, surgical; with meniscectomy (medial OR lateral).
29882	Arthroscopy, knee, surgical; with meniscus repair (medial OR lateral).
29883	Arthroscopy, knee, surgical; with meniscus repair (medial AND lateral).
29884	Arthroscopy, knee, surgical; with lysis of adhesions.
29885	Arthroscopy, knee, surgical; drilling for osteochondritis dissecans with bone grafting.

Nose / Rhinoplasty / Septoplasty CPTCPTCovered

30120	Excision or surgical planing of skin of nose for rhinophyma.
30400	Rhinoplasty, primary; lateral & alar cartilages and/or elevation, nasal tip.
30410	Rhinoplasty, primary; complete.
30420	Rhinoplasty, primary; with major septal repair.

Cardiac Surgery and Valve Procedure CPTCPTCovered

33225	(See policy) — documentation required: recent history and physical, plan of care.
33282	Implantation of patient-activated cardiac event recorder.
33404	Construction of apical-aortic conduit.
33405	Replacement, aortic valve, with prosthetic valve.

Transplant Surgical CodesCPTCovered

33933	Backbench standard preparation of cadaver donor heart/lung allograft prior to transplantation.
33935	Heart-lung transplant with recipient cardiectomy-pneumonectomy.
33940	Donor cardiectomy (including cold preservation).
33944	Backbench preparation of cadaver donor heart allograft prior to transplantation.

Bariatric / Obesity Surgery CPTCPTCovered

43645	Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and small intestine reconstruction.
43770	Laparoscopy, surgical gastric resective procedure; placement of adjustable gastric band.
43771	Revision of adjustable gastric band component only.

Investigative ENT Procedures CPTCPTExperimental

41512	Tongue base suspension, permanent suture technique (Investigative).
41530	Submucosal ablation of the tongue base, radiofrequency (Investigative).

Intestine Transplant Related CPTCPT

44715	Backbench standard preparation of cadaver or living donor intestine allograft.
44720	Backbench reconstruction of cadaver or living donor intestine allograft; venous anastomosis, each.
44721	Backbench reconstruction; arterial anastomosis, each.

Liver Transplant and Resection CPTCPTCovered

47120	Hepatectomy, resection of liver; partial lobectomy.
47122	Hepatectomy, trisegmentectomy.
47125	Hepatectomy, total left lobectomy.
47130	Hepatectomy, total right lobectomy.
47133	Donor hepatectomy, cadaver donor.
47135	Liver allotransplantation; orthotopic, partial/whole.

Pancreas and Radiation Guidance CPTCPTCovered

48551	(See policy) — backbench preparation prior to transplantation.
49411	Placement of interstitial device(s) for radiation therapy guidance (eg, fiducial markers), percutaneous.
49412	Placement of interstitial device(s) for radiation therapy guidance, open, including image guidance.

Sample Miscellaneous CPT CodesCPTCovered

57335	(Obstetric/Gynecologic) — documentation required.
58150	Hysterectomy procedures; documentation required.
62287	Percutaneous decompression of nucleus pulposus (needle-based), lumbar.

Spine Surgery Selected CPTCPTCovered

63050	Laminoplasty, cervical, with decompression, 2 or more vertebral segments.
63051	Laminoplasty with reconstruction of posterior bony elements.
63056	Transpedicular approach with decompression, single segment; lumbar.

Radiation and Neurostimulator CodesCPTCovered

63620	IMRT planning including dose-volume histograms.
63650	Percutaneous implantation of neurostimulator electrode array, epidural.
63655	Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural.
63685	Insertion or replacement of spinal neurostimulator pulse generator.

Large Imaging/MRI/CT Group (selected)CPTCovered

70481	CT, orbit/sella/posterior fossa; with contrast.
70482	CT, orbit/sella/posterior fossa; without then with contrast.
70486	CT, maxillofacial area; without contrast.
70487	CT, maxillofacial area; with contrast.
70540	MRI, orbit/face/neck; without contrast.
70542	MRI, orbit/face/neck; with contrast.
70543	MRI, orbit/face/neck; without then with contrast.
70544	MRA, head; without contrast.

Comprehensive CT/MR Abdomen/Pelvis and Vascular ImagingCPTCovered

73200	CT, upper extremity; without contrast.
73201	CT, upper extremity; with contrast.
73202	CT, upper extremity; without then with contrast.
73206	CTA, upper extremity, with contrast including noncontrast images if performed.
73218	MRI, upper extremity, other than joint; without contrast.
73219	MRI, upper extremity, other than joint; with contrast.
73220	MRI, upper extremity, other than joint; without then with contrast.
73221	MRI, any joint of upper extremity; without contrast.
73222	MRI, any joint of upper extremity; with contrast.
73223	MRI, any joint of upper extremity; without then with contrast.

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Prior Authorization, Contacts, and Submission Instructions

Prior Authorization

Prior authorization requirement and contacts

The attending physician must obtain prior authorization for services on the Blue Cross Medicare Advantage Prior Authorization List (effective 1/1/2019), except in an urgent situation. For prior authorization questions or to initiate a request, use the plan-specific customer service numbers below or route medical review/prior authorization requests to eviCore (external review vendor) as noted for many codes.

Tulsa area HMO members: Customer Service 1-866-796-5709
Oklahoma City area HMO and all PPO members: Customer Service 1-877-774-8592
eviCore (medical review / prior authorization vendor): 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs

Note

External review vendor (eviCore)

eviCore is the external medical review and prior authorization vendor used for many procedure categories in this list. Providers must contact eviCore for medical records requests and prior authorization determinations where the code entry directs them to eviCore.

eviCore phone: 1-855-252-1117
eviCore provider portal: https://www.evicore.com/healthplan/bcbs

Prior Authorization

Hip arthroplasty codes — prior authorization via eviCore

Hip arthroplasty and revision CPT codes (examples: 27125, 27130, 27132, 27134, 27137, 27138) require prior authorization via eviCore when indicated in the code list. Follow eviCore routing for submission and include required documentation.

Contact eviCore: 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs
Include history & physical, operative report, and documentation of medical necessity when requested

Documentation Required

Pelvic/meniscal/related codes — documentation requirements

Pelvic, meniscal, and related musculoskeletal procedures categorized as Medical Necessity require specific pre-operative documentation. Submit the listed pre-operative evaluation, history & physical (including functional impairment), and the operative report or procedure report as requested in the code entry.

Provide pre-operative evaluation and history & physical including functional impairment
Include operative/procedure report and any imaging or diagnostic study results supporting medical necessity

Documentation Required

Knee/foot procedures — Medical Necessity documentation

Knee and foot procedures that are designated Medical Necessity require pre-operative evaluation and documentation of functional impairment. Submit history & physical, operative report, and any additional documentation specified (e.g., conservative care, imaging). Examples include arthroplasty, tendon transfers, and complex reconstructions.

Pre-operative evaluation, history & physical including functional impairment
Operative/procedure report and documentation of conservative management when requested

Prior Authorization

Arthroscopy codes — eviCore contact required

Arthroscopy codes for shoulder, hip, and knee frequently route prior authorization and medical records requests to eviCore. When the code entry lists eviCore, contact eviCore to obtain prior authorization or to submit medical records for review.

eviCore phone: 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs
Include relevant imaging, prior conservative treatment, H&P, and operative report as applicable

Prior Authorization

eviCore referral for arthroscopy and related codes

Multiple knee and hip arthroscopy/arthroplasty related codes explicitly instruct providers to contact eviCore for prior authorization and medical records requests. Follow eviCore submission instructions and include all requested documentation to avoid delays.

Use eviCore for prior authorization routing: 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs
Attach H&P, imaging, prior conservative management notes, and operative reports when requested

Documentation Required

ENT/craniofacial codes — pre-op documentation required

ENT and craniofacial procedures (for example, rhinoplasty, turbinate procedures, laryngoscopy entries) with Medical Review categories require pre-operative documentation. Submit pre-operative evaluation, history & physical including functional impairment, sleep study results or CPAP trial where specified, and the operative report.

Pre-operative evaluation and history & physical including functional impairment
Sleep study results, CPAP trial documentation when requested
Operative/procedure report

Prior Authorization

Transplant preauthorization and documentation

Transplant-category codes require special documentation. If a transplant approval is already on record, provide the date of transplant. If no prior transplant approval exists, submit history & physical, transplant evaluation documents, and the procedure report or operative note as indicated.

If prior transplant approval exists: include date of transplant
If no prior approval: submit H&P, transplant evaluation, and other requested transplant documentation

Documentation Required

Medical necessity — preauthorization documentation

When a procedure is listed under Medical Necessity, submit a recent history & physical, a clear plan of care, and documentation of medical necessity. Include operative/procedure reports when the service has been performed. These items support the clinical review and prior authorization decision.

Recent history & physical
Plan of care and documentation of medical necessity
Operative or procedure report when applicable

Documentation Required

Investigative procedures — documentation and vendor routing

Investigational or Investigative-category procedures require submission of history & physical and study results or operative reports for review. These procedures may route to eviCore for medical records requests and external review.

Submit history & physical and any relevant study results or operative reports
If code entry references eviCore, submit via eviCore: 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs

Documentation Required

Obesity-related procedures — preauthorization requirements

Obesity-related procedures (bariatric surgery codes) require comprehensive preauthorization documentation. Submit history & physical, nutritional and psychological evaluations, documentation of prior weight loss attempts, and social support information as specified.

History & physical
Nutritional evaluation and psychological evaluation
Documented weight loss attempts and social supports

Prior Authorization

eviCore prior authorization referral — general instruction

Certain codes across the list explicitly direct providers to eviCore for prior authorization or medical records requests. When a code entry includes the eviCore contact, providers must route the request and attach required documentation through eviCore.

eviCore contact: 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs
Attach H&P, imaging, prior conservative treatment documentation, and operative reports as requested

Note

Prior authorization flags — plan-specific inconsistencies

Several entries note plan-specific prior authorization flags that may be inconsistent (for example, 'Prior Auth required for MT Medicare Advantage Plan effective 4/1/2018' or 'No' for certain codes). Always verify the member's plan and payer routing before submitting a prior authorization request.

Confirm member plan (MAPD, MT, NM, HMO, PPO) before submitting PA
When in doubt, contact customer service or eviCore to confirm PA requirements

Prior Authorization

Spinal procedures — preauthorization instructions (eviCore)

Cervical and lumbar spinal procedures (including fusion, interbody, disc, and decompression codes) often require routing to eviCore for preauthorization and medical records review. Follow the eviCore submission process and include history & physical, operative reports, and documentation of conservative measures when requested.

Contact eviCore: 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs
Include H&P, operative report, and documentation of conservative care or failed conservative treatment where requested

Prior Authorization

Radiotherapy and neurostimulator procedures — PA and documentation

Radiotherapy planning, IMRT/SRS/SBRT delivery, proton therapy, hyperthermia, and related radiation oncology services listed in the code set require prior authorization and medical records requests via eviCore. Submit treatment plans, history & physical, and documentation of medical necessity.

eviCore contact for radiology/radiation: 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs
Include treatment planning documents, dose-volume histograms, H&P, and documentation supporting medical necessity

Documentation Required

Vertebroplasty/vertebral augmentation — documentation for PA

Vertebroplasty and vertebral augmentation codes require submission of history & physical and results of prior diagnostic testing (imaging, procedure reports) for prior authorization. Some vertebroplasty codes also route to eviCore for review.

Submit history & physical and prior diagnostic test results (relevant imaging)
If code references eviCore, contact 1-855-252-1117 or use https://www.evicore.com/healthplan/bcbs

Prior Authorization

Imaging codes — eviCore contact and submission instructions

Imaging codes (CT, MRI, advanced imaging, CT colonography, fetal MRI, pelvic imaging, and many others) listed direct providers to eviCore for medical records requests and prior authorization where indicated. Follow eviCore instructions and include prior imaging, H&P, and clinical indication.

eviCore contact: 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs
Attach clinical indication, prior imaging reports, and H&P as requested

Note

NM Medicare Advantage — prior authorization exemptions (example)

Certain fetal MRI codes had a New Mexico (NM) Medicare Advantage plan exemption noted in the source (No prior auth required for NM MAP effective 11/1/2018). Verify member plan location and benefit before submitting a prior authorization request.

Check member's plan and state-specific MAPD rules before submitting PA
If member is in NM MAP with exemption date, prior auth may not be required for specified fetal MRI codes

Note

MT Medicare Advantage — prior authorization notes

Some entries reference Montana (MT) Medicare Advantage plan-specific prior authorization requirements or 'No' flags effective 4/1/2018. Confirm the applicability to the member before relying on those flags.

Verify MT MAPD plan applicability for the member
When plan-specific notes conflict, contact customer service or eviCore for clarification

Prior Authorization

Ultrasound and related codes — prior authorization guidance

Ultrasound and related diagnostic ultrasound codes in the list may require prior authorization for MAPD plans and often route to eviCore. Some codes include plan-specific 'No' flags; always verify the member's plan and use eviCore when the entry requires it.

eviCore contact: 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs
Confirm plan-specific 'No' flags (e.g., MT plan) before submission

Prior Authorization

CT/MR and therapeutic radiology — prior authorization

CT, MR, and therapeutic radiology planning and imaging codes listed require prior authorization and routing to eviCore in many instances. Follow eviCore submission requirements and include clinical rationale and supporting imaging or reports.

Contact eviCore: 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs
Provide H&P, prior imaging, and treatment planning documentation as requested

Prior Authorization

Radiation therapy delivery — prior authorization required

Radiation therapy delivery services (IMRT, SRS/SBRT, stereotactic radiosurgery, fractionated treatments) and related delivery codes require prior authorization via eviCore per the code entries. Submit full treatment delivery details and supporting clinical documentation.

Use eviCore for PA: 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs
Include treatment prescriptions, fractionation, image guidance notes, and H&P

Prior Authorization

Proton therapy and hyperthermia — PA via eviCore

Proton therapy and hyperthermia procedure codes list eviCore as the contact for prior authorization. Providers must route requests through eviCore and include the required clinical documentation and treatment planning materials.

eviCore contact: 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs
Attach treatment plans, clinical justification, and H&P

Prior Authorization

Nuclear medicine and radiopharmaceutical localization — PA and records request

Nuclear medicine and radiopharmaceutical localization codes require medical review and routing to eviCore for prior authorization where noted. Submit clinical indication, prior studies, and H&P per eviCore instructions.

eviCore contact: 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs
Include H&P, prior imaging, and reason for test when submitting

Prior Authorization

PET imaging and PET/CT — eviCore review required

PET and PET/CT imaging codes require medical review and eviCore routing for prior authorization as specified. Providers should submit clinical indications, prior imaging results, and any other documentation requested by eviCore.

Contact eviCore: 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs
Attach prior imaging, H&P, and clinical rationale for PET/PET-CT

Documentation Required

Genetic and molecular testing — eviCore medical review

Molecular and genetic testing codes (example codes: 81161, 81200-81211, 81295-81299, 81400, 81404-81405, and many others) require medical records requests and prior authorization routing to eviCore where noted. Submit the patient's history, indication for testing, prior related test results, and any required consent or genetic counseling documentation.

eviCore contact: 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs
Provide H&P, clinical indication, prior test results, and genetic counseling/consent documentation when applicable

Definitions and Key Terms

Medical Review Category

DefinitionMedical Review Category = classification applied to each procedure code indicating the review rationale (e.g., Medical Necessity, Transplant, Cosmetic - Potential Contract Exclusion).

PurposeDetermines required documentation and the review pathway for each listed CPT/HCPCS code.

ExamplesEntries in the list show categories such as Medical Necessity, Transplant, Advanced Imaging, and Potential Contract limits.

Medical Records Request information required

Core documentsCommonly requested items include History & Physical (H&P), operative/procedure report, plan of care, and documentation of medical necessity.

Code-specific examplesFor TMJ-related entries submit chart notes including appliance type and diagnostic sleep studies; for many surgical codes submit operative report and H&P.

Vendor instructionSome code lines instruct providers to submit records to eviCore for review (phone/URL provided).

External utilization management vendor

Vendor name and contacteviCore: phone 1-855-252-1117; website https://www.evicore.com/healthplan/bcbs.

UsesDesignated external utilization management vendor for prior authorization routing and medical records requests for many listed codes.

Where listedeviCore contact appears on many code lines (spine, imaging, genetic testing, nuclear medicine, etc.).

Medical Necessity review

Medical Necessity review requirementWhen a code is designated 'Medical Necessity', submission of H&P, operative report, and documentation of conservative measures or other clinical documentation is required to determine coverage.

ExamplesKnee and pelvic procedures labeled Medical Necessity require pre-op evaluation, H&P including functional impairment, and operative report.

RoutingSome Medical Necessity entries also list eviCore as the contact for records submission or prior authorization processing.

Medical Necessity

Required documentationMedical Necessity category requires pre-operative evaluation, history & physical including functional status, plan of care, and operative report when applicable.

Submission guidanceProviders should submit these documents with the prior authorization request; some codes explicitly direct providers to eviCore for processing.

ExamplesKnee arthroplasty, vertebroplasty (where Medical Necessity is specified) list these documentation requirements on the code lines.

eviCore

Vendor roleeviCore is the third-party medical review vendor for submitting medical records requests and prior authorization processing for many listed procedures.

Contact detailsPhone: 1-855-252-1117; URL: https://www.evicore.com/healthplan/bcbs (listed repeatedly on code lines).

Common applicationReferenced for spine, imaging, radiation, genetic testing, and other procedure groups in the list.

Transplant

DefinitionTransplant review category = codes related to transplant procedures that require transplant-specific documentation such as date of transplant or transplant evaluation and H&P.

Documentation specificsIf transplant approval is on record: supply date of transplant; if not: submit history and physical, transplant evaluation, and date of transplant.

ExamplesCodes such as 33933, 33935, 33940, 44715, 47135 are listed under Transplant and include the specified documentation instructions.

Medical Necessity (repeated)

Medical Necessity labelUsed repeatedly across the list to indicate the review rationale requiring clinical documentation to support coverage decisions.

ImplicationCodes labeled 'Medical Necessity' trigger requests for H&P, operative reports, and functional status documentation.

ExamplesMultiple surgical codes (e.g., 27445 knee arthroplasty) show Medical Necessity and list required documents.

Cosmetic - Potential Contract Exclusion

DefinitionCosmetic - Potential Contract Exclusion = category applied to procedures that are likely cosmetic and may be contract exclusions; documentation such as pre-op evaluation, H&P including functional impairment, and operative report is required when submitted.

ExamplesCodes like 11970, 15775, 19328, 30120, 36469 are flagged as Cosmetic - Potential Contract Exclusion in the list.

Provider actionWhen listed, providers should include pre-operative evaluation and H&P with functional impairment documentation if seeking coverage consideration.

Transplant (repeated)

Transplant (duplicate)Transplant category reiterated across the list with the same documentation expectations (date of transplant or H&P and transplant evaluation).

Common codesReappears on codes such as 33933, 47135, 44715 indicating consistent review approach.

Submission noteTransplant entries may still reference eviCore for routing of records/authorizations.

Medical Necessity (repeated)

Medical Necessity (repeated)Repeated label across code lines indicating requirement for documentation to demonstrate necessity; see many surgical and interventional CPT entries.

Documentation requiredHistory & Physical, operative report, and documentation of medical necessity are commonly specified.

RoutingSome Medical Necessity entries instruct providers to contact eviCore for review processing.

Cosmetic - Potential Contract Exclusion (repeated)

Cosmetic category (repeated)Cosmetic - Potential Contract Exclusion appears multiple times in the list with the same documentation expectations (pre-op evaluation, H&P, operative report).

ImplicationCodes flagged cosmetic may be denied as contract exclusions unless clinical justification is provided.

ExamplesA large set of reconstructive/cosmetic CPTs across chunks 1–12 are marked with this category.

Transplant (repeated)

Transplant (again)Transplant classification repeated across sections to denote consistent review rationale and documentation requirements.

Documentation reminderIf transplant approval exists, provide date; otherwise provide H&P and transplant evaluation.

ExamplesAppears on donor preparation and transplant procedure CPTs (e.g., 33933, 44715, 47135).

Medical Necessity (repeated)

Medical Necessity (consistent)Label used as Medical Review Category where additional documentation (pre-op evaluation, H&P including functional impairment, operative report) is required to support authorization.

Operational impactTriggers submission of clinical records with PA requests; may route to eviCore for review.

ExamplesUsed for procedures across specialties including orthopedics, general surgery, and others.

Medical Review Category = Medical Necessity

Equivalent definitionMedical Review Category = Medical Necessity indicates the requirement for documented clinical justification (H&P, operative report) to determine coverage.

Where appliedApplied to many CPT codes in the list that require clinical documentation for prior authorization.

Provider actionSubmit the required clinical records with the authorization request as specified on the code line.

Potential Contract limits

DefinitionPotential Contract limits = Medical Review Category indicating procedures that may be subject to contract limitations; documentation such as H&P and operative report required.

DocumentationCodes under this category require history & physical and documentation of medical necessity including operative report.

ExamplesSeveral obstetric/abortion-related CPTs (e.g., 59841–59856) are listed under Potential Contract limits.

Medical Records Request instruction

eviCore contact for records/PAMedical Records Request/PA submissions: eviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs (listed on many code lines).

Use casesUsed for medical records requests, prior authorization routing, and external review processing across multiple procedure groups.

Provider instructionContact eviCore per the code line instructions to submit records or request prior authorization.

Medical Review Category: Medical Necessity

Medical Necessity (per-code)Medical Review Category: Medical Necessity indicates submission of H&P and documentation of medical necessity including operative report with PA request.

Example codesHepatectomy and other major surgical CPTs (e.g., 47120, 47122) list Medical Necessity with required documents.

RoutingSome entries also direct providers to eviCore for records submission when indicated.

Advanced Imaging

Advanced Imaging definitionAdvanced Imaging = Medical Review Category indicating elevated review/documentation requirements for specific imaging/interventional procedures (e.g., vertebroplasty CPT 72291 listed as Advanced Imaging).

Documentation exampleFor CPT 72291 submit history and physical and results of previous diagnostic procedure report for prior authorization.

RoutingAdvanced Imaging entries often reference eviCore for records/authorization handling.

eviCore (medical review vendor/contact)

eviCore contact (definition)eviCore (medical review vendor) contact: 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs — used for medical records and prior authorization requests.

Repetition across listeviCore appears repeatedly as the designated vendor for many procedure categories (imaging, spine, genetic testing, radiation).

Action for providersCall or use the eviCore website per code line instructions to initiate PA or submit records.

Designated medical review/authorization vendor

Designated vendoreviCore is the designated medical review/authorization vendor for many listed CPT codes (contact info on code lines).

Contact infoPhone: 1-855-252-1117; URL: https://www.evicore.com/healthplan/bcbs — listed repeatedly in the source.

Provider instructionUse eviCore for submission of medical records and prior authorization requests as indicated by each code line.

Indicates that prior authorization is required for the Medicare Advantage plan

Prior auth indicator (MT)'Proir Auth required for MT Medicare Advantage Plan effective 4/1/2018' appears on multiple code lines indicating plan-specific prior authorization requirement (source text contains typographical errors).

InterpretationIndicates prior authorization is required for the MT Medicare Advantage plan for affected codes; providers should follow eviCore/plan guidance.

Note on sourceText includes typographical errors (e.g., 'Proir Auth') in the original document but conveys the plan-specific prior auth requirement.

Medical review / preauthorization vendor

Vendor repeatedeviCore listed repeatedly as the medical review / preauthorization vendor with phone and URL for provider use.

Where usedReferenced across imaging, nuclear medicine, radiation therapy, genetic testing, and surgical procedure entries.

ActionContact eviCore for PA initiation or records submission per code line instructions.

No Prior Auth note

NM No Prior Auth note'No Prior Auth required for NM Medicare Advantage Plan effective 11/1/2018' is explicitly noted on several myocardial perfusion and related nuclear medicine CPT lines.

ImplicationThese NM MAPD exemptions apply to specific cardiac/nuclear medicine CPTs as annotated on the code lines.

Provider checkProviders should verify plan-specific exemptions despite general eviCore routing instructions on other lines.

Medical Records Request / Medical Review

Medical records request routingMedical records request and medical review entries repeatedly instruct providers to contact eviCore (1-855-252-1117 or https://www.evicore.com/healthplan/bcbs).

ApplicationApplies to many procedure groups including radiopharmaceutical localization, PET, genetic/molecular testing, and molecular pathology levels.

Provider actionUse eviCore contact information on the code line to submit records or initiate PA processing.

Molecular pathology procedure levels

Molecular pathology levelsMolecular pathology procedure levels 1–6 are listed (CPT 81400–81405) with descriptions in the document.

ExamplesLevel descriptors include single-variant identification (Level 1) through targeted exon/array analyses (Level 6).

RoutingMedical Records Request information for molecular pathology levels directs providers to eviCore for review/PA processing.

Genomic sequence analysis panel

DefinitionGenomic sequence analysis panel = targeted multi-gene sequencing panels described in the list (e.g., aortic panel CPT 81410).

Panel requirementsPanels specify minimum gene counts and named genes that must be included (see per-code entries such as CPT 81410).

Medical review contacteviCore contact is provided for panel-related PA/records requests.

Exome

Exome definitionExome sequence analysis (CPT 81415/81416/81417) refers to sequence analysis of the exome and related re-evaluation/re-analysis procedures listed in the document.

Use casesIncluded for unexplained constitutional or heritable disorders; re-evaluation and comparator exomes are separately coded.

RoutingMedical Records Request information for exome codes directs providers to eviCore for review/PA processing.

Whole mitochondrial genome

Whole mitochondrial genomeCPT 81460 and related entries reference whole mitochondrial genome sequence analysis with heteroplasmy detection (used for mitochondrial disorders).

Related panel distinctionSeparate CPT 81440 describes nuclear-encoded mitochondrial gene panels (>=100 genes) distinct from whole mitochondrial genome analysis.

Medical review contacteviCore is listed for records/PA submission for mitochondrial genome and related analyses.

Policy Dates and History

2019-01-01policy_effectiveLatest

Blue Cross Medicare Advantage Prior Authorization List became effective for MAPD plans; attending physician must obtain prior authorization for services listed.

2018-11-01plan_specific_exemption

No prior authorization required for certain nuclear medicine (NM) Medicare Advantage plan procedures effective 11/1/2018 as noted inline with specific codes.

2018-04-01plan_specific_note

Prior authorization required status for MT Medicare Advantage Plan noted effective 4/1/2018 for multiple ultrasound-related codes (some entries also indicate 'No' for records request).

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyMAPD Benefit Preauthorization Procedure Code List

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2019

Next Review DateN/A

Key ActionThe attending physician must obtain prior authorization for the services outlined in the Blue Cross Medicare Advantage Prior Authorization List.

SourceLink

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