CurrentBlue Cross Blue Shield - OklahomaPolicy N/A

Blue Cross Medicare Advantage Prior Authorization Procedure Code List

Lists procedure codes that require prior authorization for Blue Cross Medicare Advantage members and describes medical review categories and required medical record documentation for providers.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyBlue Cross Medicare Advantage Prior Authorization Procedure Code List

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2019

Next Review DateN/A

Key ActionAttending physician must obtain prior authorization for the listed services (contact eviCore for specified codes).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2019-01-01effective date shown on list

20+procedure codes listed in this excerpt

phoneregional prior auth contact info

eviCoreexternal review vendor referenced

Coverage Criteria and Documentation Requirements

Prior Authorization and Documentation Requirements

Procedures are categorized and require submission of specified medical records for review; some are considered cosmetic and potentially excluded while others require medical necessity documentation.

Attending physician must obtain prior authorization for services listed, except in urgent situations.

Medical Review Categories

Medical Review Category = Medical Necessity: submit recent history & physical, plan of care, and documentation of medical necessity (including operative report when applicable).
Medical Review Category = Cosmetic - Potential Contract Exclusion: submit pre-operative evaluation, history and physical including functional impairment, and operative report; note that coverage may be excluded depending on contract.
When external review is indicated, contact eviCore for authorization/medical records review (phone 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs).

For codes routed to eviCore, providers must follow eviCore prior authorization and medical records submission instructions (phone/URL above).

Preauthorization and documentation criteria

Selected codes are subject to Medical Necessity review and require submission of specific documentation.

For craniofacial/maxillofacial osteotomy and related codes (e.g., 21198, 21199, 21206, 21208, 21209): Medical Review Category = Medical Necessity; submit chart notes including type of appliance, history of recurring TMJ, and copy of diagnostic sleep studies.

For graft and reconstructive facial codes (e.g., 21210, 21215, 21230, 21244): Medical Review Category = Medical Necessity; submit history and physical, and documentation of medical necessity including operative report.

For selected spine/vertebral augmentation codes (e.g., 22520, 22521, 22523): Medical Review Category = Medical Necessity; submit history and physical, documentation of medical necessity including operative report.

Medical necessity documentation requirements

Certain CPT codes are designated as requiring medical necessity review and specific documentation.

For procedures labeled 'Medical Necessity' (examples: 27279, 27445, 27557): submit pre-operative evaluation, history and physical including functional impairment, and operative report as part of the Medical Necessity review.

Authorization routing

Prior authorization routing

Providers are directed to eviCore for medical records requests and prior authorization routing: phone 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs.

Some entries note state-specific prior authorization requirements (e.g., Prior Auth required for MT Medicare Advantage Plan effective 4/1/2018); follow the per-code note where present.

Transplant documentation criteria

For codes designated Transplant:

If transplant approval is on record for the member: provide the Date of Transplant.

If no transplant approval is on record: submit history and physical, transplant evaluation, and date of transplant (when applicable) as part of the medical records request.

Examples

Transplant-designated codes include lung and heart transplant codes (e.g., 32850–32856) and liver/living donor hepatectomy codes (e.g., 47141–47147).
Per-code entries for transplant procedures explicitly list the same documentation requirements (history & physical, transplant evaluation, date of transplant).

Medical necessity and cosmetic documentation

For codes designated Medical Necessity or Cosmetic exclusion:

Provide pre-operative evaluation, history and physical including functional impairment, and operative report for procedures listed as Medical Necessity or Cosmetic - Potential Contract Exclusion.

Cosmetic - Potential Contract Exclusion codes may be excluded depending on contract; submission of the requested documentation does not guarantee coverage.

Per-code coverage criteria

For each listed CPT code, the document specifies a Medical Review Category and required medical records to establish medical necessity or other review outcomes.

Per-code entries indicate the Medical Review Category and list required documents; when Medical Review Category = Transplant, follow the transplant documentation rules (date of transplant if on record; otherwise history/physical, transplant evaluation, date).

When Medical Review Category = Medical Necessity (e.g., 36475), submit pre-operative evaluation, history and physical (including results of diagnostic studies when specified, e.g., Doppler), and operative report.

For codes listed as Obesity - Potential Contract Exclusion (e.g., 43644), required records include history and physical, nutritional and psychological evaluation, documentation of weight loss attempts and social supports as specified.

Per-code coverage criteria and documentation

Per-code review categories and required documentation as listed

Transplant codes (examples: 47141, 47143, 50300, 50360): if transplant approval is on record provide Date of Transplant; if not, submit history and physical, transplant evaluation, and date of transplant.

Medical Necessity examples (e.g., 47381, 62263): submit history and physical and relevant procedure/operative reports to support medical necessity.

Many procedure codes that lack an explicit Medical Review Category in the excerpt direct providers to eviCore for prior authorization/medical records submission (eviCore contact provided).

Certain per-code entries include state-specific prior auth notes (e.g., Prior Auth required for MT Medicare Advantage Plan effective 4/1/2018); follow the per-code annotation where present.

Coverage criteria and routing notes

Coverage and review approach shown in list entries:

If Medical Review Category = Medical Necessity, submission should include History & Physical and documentation of medical necessity including operative report.

Many codes require prior authorization and/or medical records submission via eviCore (phone 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs).

children":[]}]}

Preauthorization and documentation requirements

For listed procedure codes, providers must follow the indicated preauthorization or medical records submission instructions.

Contact eviCore for review and submit required clinical documentation (history & physical, operative reports, plan of care) when a code entry directs eviCore routing.

Some neuromodulation/nerve injection and nervous system codes include plan-specific prior authorization notes (e.g., 'Prior Auth required for MT Medicare Advantage Plan effective 4/1/2018' or 'No' where indicated); check the per-code note for the member's plan.

Per-code prior authorization / documentation requirements (examples)

Medical Review Category and medical records/prior authorization requirements are listed per code.

Advanced Imaging examples (e.g., 72291/72292): For prior authorization submit history & physical and results of previous diagnostic procedure reports as specified.

Imaging postprocessing and unlisted imaging codes (e.g., 76377, 76497): many entries direct providers to eviCore for prior authorization/medical records submission; follow eviCore instructions.

Prior authorization / medical records requirements (partial)

Procedure codes listed below include a note about medical records request/prior authorization via eviCore for MAPD members; many entries state 'Medical Records Request information required = eviCore... Prior Auth required for MT Medicare Advantage Plan effective 4/1/2018' or 'No.' where indicated.

Ultrasound and obstetric imaging codes: many entries list eviCore as contact for prior authorization and medical records request; several entries also include 'Prior Auth required for MT Medicare Advantage Plan effective 4/1/2018' or show 'No' where not required. Providers must follow per-code instructions.

Radiation therapy planning and delivery codes: entries direct providers to eviCore for prior authorization/medical records requests; submit documentation per eviCore instructions.

MAPD preauthorization criteria (excerpt)

Prior authorization stance for nuclear medicine (NM) codes in MAPD:

Certain nuclear medicine (NM) Medicare Advantage Plan services are explicitly marked 'No Prior Auth required' effective 11/1/2018 for the listed NM codes; follow the per-code 'No' flag where present.

When prior authorization/medical review is required for NM codes, contact eviCore at 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs as instructed in the per-code entry.

Preauthorization and medical records review note

Listed codes are subject to medical review via eviCore; some local plan exceptions (NM) noted.

Per-code entries in this segment direct medical records requests to eviCore; when a 'No Prior Auth' flag appears for NM Medicare Advantage Plan, the per-code exception applies (effective dates shown).

Preauthorization routing and code list

Preauthorization and medical records requests are to be directed to eviCore per listed instruction; individual code entries indicate molecular test type but no per-code coverage rules appear in this segment.

For genetic/molecular test codes in this range (e.g., 81242–81244, 81400–81402, etc.), many entries require contacting eviCore for prior authorization/medical records submission; follow eviCore instructions for documentation submission.

Preauthorization requirement

Preauthorization / medical records request requirement

Molecular pathology and panel codes (e.g., 81401–81415, 81430–81436) list eviCore as the contact for medical records/prior authorization; follow the per-code documentation instructions and eviCore routing.

Medical Necessity documentation requirements

Codes designated as 'Medical Necessity' require documentation to support the request.

Provide recent history and physical, plan of care, and documentation of medical necessity (including operative report when applicable) for codes labeled Medical Necessity (examples include 90867–90870, 91110–91112, 92145).

Prior authorization notes for speech/swallowing services

Some speech/language and swallowing services note prior authorization requirements for a specific state MAPD plan (MT) and effective date.

Certain speech/language and swallowing codes (examples: 92507, 92508, 92511, 92520, 92521, 92522, 92523, 92524, 92526, and 92611) include per-code notes indicating 'Prior Auth required for MT Medicare Advantage Plan effective 4/1/2018' or show 'No' where not required; verify member plan specifics and follow per-code instructions (contact eviCore when directed).

Procedure Codes and Grouped Code Listings

Sample listed procedure codes (partial)CPT

11043	Debridement, muscle and/or fascia; first 20 sq cm or less
11970	Replacement of tissue expander with permanent prosthesis
15271	Application of skin substitute graft to trunk, arms, legs; first 25 sq cm or less

Additional listed codes (partial)CPT

19296	Placement of radiotherapy afterloading expandable catheter into the breast; eviCore
20930	Allograft, morselized, placement of osteopromotive material for spine surgery
21270	Malar augmentation, prosthetic material

Craniofacial/maxillofacial proceduresCPT

21198	Osteotomy, mandible, segmental
21199	Osteotomy, mandible, segmental; with genioglossus advancement
21206	Osteotomy, maxilla, segmental
21208	Osteoplasty, facial bones; augmentation
21209	Osteoplasty, facial bones; reduction
21210	Graft, Bone; Nasal, Maxillary/Malar Areas

Spine vertebroplasty/arthrodesis proceduresCPT

22510	Percutaneous vertebroplasty; cervicothoracic
22511	Percutaneous vertebroplasty; lumbosacral
22513	Percutaneous vertebral augmentation (kyphoplasty); 1 vertebral body
22800	Arthrodesis, posterior, for spinal deformity, up to 6 vertebral segments
22808	Arthrodesis, anterior, for spinal deformity, 2 to 3 vertebral segments

Major joint and disc arthroplastyCPT

22856	Total disc arthroplasty, cervical
22857	Total disc arthroplasty, lumbar
22864	Removal of total disc arthroplasty; cervical
27130	Total hip arthroplasty

Orthopedic procedures (sample)CPT

23474	Revision of total shoulder arthroplasty, including allograft when performed; humeral and glenoid component.
27096	Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed.

Arthroscopy procedures (sample)CPT

29805	Arthroscopy, shoulder, diagnostic, with or without synovial biopsy (separate procedure).
29827	Arthroscopy, shoulder, surgical; with rotator cuff repair.

Knee arthroscopy groupCPT

29880-29889

Knee arthroscopy and ligament repair/ reconstruction codes

Rhinoplasty/SeptoplastyCPT

30400-30462

Rhinoplasty and septoplasty codes

Transplant proceduresCPT

32850-32856,33930-33945

Lung and heart transplant donor/recipient procedure codes

Selected transplant and vascular procedure codesCPT

33945	Heart Transplant, W/Wo Recipient Cardiectomy
36475	Endovenous ablation therapy, first vein treated
47135	Liver Allotransplantation; Orthotopic

Bariatric/obesity-related procedure codesCPT

43644	Laparoscopy, Gastric Restrictive Procedure; Roux-En-Y
43770	Placement of adjustable gastric band

Unlisted procedure codesCPT

37799	Unlisted procedure, vascular surgery
43999	Unlisted procedure, stomach

Liver/transplant procedure codes (sample)CPTCovered

47141	Donor Hepatectomy, total left lobectomy
47142	Donor Hepatectomy, total right lobectomy
47143	Backbench standard preparation of cadaver donor whole liver graft
47144	Split backbench preparation with trisegment split
47145	Backbench preparation with lobe split

Mixed procedural codes (sample)CPT

47381	Ablation, open, of 1 or more liver tumor(s); cryosurgical
47383	Ablation, percutaneous, cryoablation
49411	Placement of interstitial device(s) for radiation therapy guidance (intra-abdominal)
49412	Placement of interstitial device(s) for radiation therapy guidance, open intra-abdominal
50300	Donor nephrectomy, cadaver
50320	Donor nephrectomy, living donor, open
50360	Renal allotransplantation, implantation of graft
54401	Insertion of penile prosthesis; inflatable
62263	Percutaneous lysis of epidural adhesions, multiple sessions
62264	Percutaneous lysis of epidural adhesions, single day

1–10 of 11

1/2

Selected procedure codes in excerptCPT

61798	Basic radiation dosimetry calculation
62263	Percutaneous lysis of epidural adhesions, multiple sessions
62380	Endoscopic decompression of spinal cord, nerve root(s)
63620	Intensity modulated radiotherapy plan
63650	Percutaneous implantation of neurostimulator electrode array, epidural
64479	Transforaminal epidural injection with imaging guidance
64530	Celiac plexus injection
64633	Destruction by neurolytic agent, paravertebral facet joint nerve(s)

Ophthalmology corneal transplant codesCPT

65710	Keratoplasty (corneal transplant); anterior lamellar
65730	Keratoplasty; penetrating

Hearing implant codesCPT

69930	Cochlear Device Implantation, w/wo Mastoidectomy
69714	Implantation, osseointegrated implant, temporal bone

Thorax CT codesCPT

71250	CT thorax without contrast
71260	CT thorax with contrast

Imaging procedure codes (sample from partial list)CPT | mixedCovered

72133	Computed tomography, lumbar spine; without contrast followed by contrast
72141	MRI spinal canal and contents, cervical; without contrast
73200	Computed tomography, upper extremity; without contrast
74150	Computed tomography, abdomen; without contrast

Selected ultrasound obstetric and transplant codesCPTCovered

76776	Ultrasound, transplanted kidney, real time and duplex Doppler with image documentation
76800	Ultrasound, spinal canal and contents
76801	Ultrasound, pregnant uterus, first trimester, transabdominal; single or first gestation
76802	Ultrasound, pregnant uterus, each additional gestation (add-on)

Imaging guidance and MRI codesCPTCovered

77014	Computed tomography guidance for placement of radiation therapy fields
77021	Magnetic resonance guidance for needle placement
77058	MRI, breast, unilateral

Radiation therapy and treatment planning codesCPTCovered

77261	Therapeutic radiology treatment planning; simple
77373	Stereotactic body radiation therapy, per fraction
77470	Special treatment procedure (eg, total body irradiation)
77520	Proton treatment delivery; simple

Radiation therapy and related codes (sample)CPT

77469	Intraoperative radiation treatment management
77470	Special treatment procedure (eg, total body irradiation, hemibody radiation, per oral or endocavitary irradiation)
77520	Proton treatment delivery; simple, without compensation

Brachytherapy codes (sample)CPT

77767	Remote afterloading high dose rate radionuclide skin surface brachytherapy; lesion diameter up to 2.0 cm or 1 channel
77768	Remote afterloading high dose rate radionuclide skin surface brachytherapy; lesion diameter over 2.0 cm and 2 or more channels
77770	Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy; 1 channel

Nuclear medicine imaging codes (sample)CPT

78226	Hepatobiliary system imaging, including gallbladder when present
78227	Hepatobiliary system imaging; with pharmacologic intervention
78300	Bone and/or joint imaging; limited area

Cardiac nuclear imaging codes (sample)CPT

78451	Myocardial perfusion imaging, tomographic (SPECT); single study
78452	Myocardial perfusion imaging, tomographic (SPECT); multiple studies
78453	Myocardial perfusion imaging, planar; single study

Pulmonary and brain NM codes (sample)CPT

78580	Pulmonary perfusion imaging (eg, particulate)
78600	Brain imaging, less than 4 static views

Selected nuclear cardiopulmonary procedure codesCPT

78494	Cardiac blood pool imaging, gated equilibrium, SPECT, at rest, wall motion study plus ejection fraction
78496	Cardiac blood pool imaging, gated equilibrium, single study, at rest, with right ventricular ejection fraction by first pass technique
78499	Unlisted cardiovascular procedure, diagnostic nuclear medicine
78579	Pulmonary ventilation imaging (eg, aerosol or gas)

Selected PET/genetic/cytogenomic procedure codesmixed

78580	Pulmonary perfusion imaging (eg, particulate).
78600	Brain imaging, less than 4 static views.
78607	Brain imaging, tomographic (SPECT).
78700	Kidney imaging morphology.
78811	Positron emission tomography (PET) imaging; limited area
78816	Positron emission tomography (PET) with CT; whole body
81161	DMD (dystrophin) deletion and duplication analysis.
81211	BRCA1/BRCA2 full sequence analysis and common duplication/deletion variants.
81225	CYP2C19 gene analysis, common variants.
81226	CYP2D6 gene analysis, common variants.

1–10 of 13

1/2

Genetic/molecular procedure codes in listed rangeCPT | mixedCovered

81242	FMR1 related / genetic test (listed in segment)
81243	FMR1 gene analysis; detect abnormal (expanded) alleles
81244	FMR1 characterization (expanded size and methylation status)
81248	G6PD gene analysis familial variants
81249	G6PD full gene sequence
81250	G6PC common variants
81251	GBA common variants
81252	GJB2 full gene sequence
81253	GJB2 known familial variants
81254	GJB6 common variants (309kb and 232kb deletions)

1–10 of 62

1/7

Molecular pathology levels 4-7CPT

81403	Molecular pathology procedure, Level 4
81404	Molecular pathology procedure, Level 5
81406	Molecular pathology procedure, Level 7

Higher complexity molecular and panel codesCPT

81407	Molecular pathology procedure, Level 8
81408	Molecular pathology procedure, Level 9
81410	Aortic dysfunction/dilation genomic sequence analysis panel

Panels, exome, genome, fetal and specialty panelsCPT

81413	Cardiac ion channelopathies genomic sequence analysis panel
81415	Exome sequence analysis
81420	Fetal chromosomal aneuploidy cfDNA panel (chromosomes 13,18,21)
81430	Hearing loss genomic sequence analysis panel (must include at least 60 genes)
81432	Hereditary breast cancer-related genomic sequence analysis panel (must include at least 14 genes)

Genetic/molecular panels (selected)CPT

81427	Genomic sequence analysis (various indications) with eviCore contact
81430	Hearing loss genomic sequence analysis panel (≥60 genes)
81431	Hearing loss duplication/deletion analysis panel
81432	Hereditary breast cancer genomic sequence analysis panel (≥14 genes)
81433	Hereditary breast cancer duplication/deletion analysis panel
81434	Hereditary retinal disorders genomic sequence analysis panel (≥15 genes)
81435	Hereditary colon cancer genomic sequence analysis panel (≥10 genes)
81436	Hereditary colon cancer duplication/deletion analysis panel (≥5 genes)

Oncology/multianalyte assay codesCPT

81519	Oncology (breast) mRNA gene expression profiling (21 genes)
81520	Oncology (breast) mRNA gene expression profiling (58 genes)
81521	Oncology (breast) microarray gene expression profiling (70 content genes)
81504	Oncology (tissue of origin), microarray >2000 genes
81500	Oncology (ovarian), biochemical assays of two proteins (CA-125 and HE4)

Other therapy/diagnostic codesCPT

90281	Immune globulin (IM)
90283	Immune globulin (IV)
90284	Immune globulin (SCIg)
90867	Therapeutic rTMS planning (Medical Necessity)
90868	Therapeutic rTMS delivery (Medical Necessity)
90870	Electroconvulsive therapy (with monitoring) (Medical Necessity)
92507	Treatment of speech, individual
92610	Evaluation of oral and pharyngeal swallowing function

Documentation — Submit history and physical, operative report, documentation of conservative measures

Required clinical recordsSubmit recent history & physical and operative report to support requests for codes assigned Medical Necessity or when requested for review

Conservative care documentationInclude documentation of conservative measures (eg, prior non-surgical treatments) for spine arthrodesis codes

Plan of careProvide plan of care when specified (eg, for wound debridement and grafting codes) to demonstrate medical necessity

TMJ/sleep study requirement — For certain craniofacial codes submit chart notes including type of appliance, history of recurring TMJ, and copy of diagnostic sleep stu...

TMJ/appliance notesSubmit chart notes including type of appliance and history of recurring TMJ for listed craniofacial/maxillofacial procedures (eg, 21198–21210)

Diagnostic sleep studyProvide a copy of diagnostic sleep study results when indicated in the code entry

History & physical for related codesAlso submit history and physical and operative report where the code entry specifies Medical Necessity (eg, 21210)

Molecular pathology levels — Level 1: single variant; Level 2: 2-10 variants; Level 3: >10 variants (as described)

Level 1Molecular pathology Level 1 = identification of a single germline variant (eg, SNP) by targeted techniques

Level 2Molecular pathology Level 2 = analysis of 2–10 variants (eg, 2–10 SNPs or similar) as described under 81401/81402 definitions

Level 3Molecular pathology Level 3 = >10 variants (eg, >10 SNPs, multiple analyses such as immunoglobulin/T-cell receptor rearrangements) as described in the Level 3 definition

Minimum genes required for specified panels — Examples: 9 genes (81410/81412), 10 genes (81413), 14 genes (81432), 60 genes (81430)

81410 / 81412Panels such as 81410 and 81412 must include sequencing of at least 9 specified genes (examples: FBN1, TGFBR1, TGFBR2, COL3A1, MYH11, ACTA2, SLC2A10, SMAD3, MYLK)

8141381413 (cardiac ion channelopathies panel) must include sequencing of at least 10 specified genes (eg, ANK2, CASQ2, CAV3, KCNE1, KCNE2, KCNH2, KCNJ2, KCNQ1, RYR2, SCN5A)

8143281432 (hereditary breast cancer panel) must include sequencing of at least 14 genes (eg, ATM, BRCA1, BRCA2, BRIP1, CDH1, MLH1, MSH2, MSH6, NBN, PALB2, PTEN, RAD51C, ...)

8143081430 (hearing loss panel) must include sequencing of at least 60 genes (eg, CDH23, CLRN1, GJB2, GPR98, MTRNR1, MYO7A, MYO15A, PCDH15, OTOF, SLC26A4, ...)

Minimum gene count requirements — Several panels specify minimum number of genes (examples: ≥60, ≥14, ≥15, ≥10, ≥100)

Examples of minimum gene countsSeveral panels require a minimum gene count: hearing loss panels ≥60 genes (81430); hereditary breast cancer panels ≥14 genes (81432); retinal disorder panels ≥15 genes (81434); colon cancer panels ≥10 genes (81435)

Other panel minimaSome panels specify smaller minima (eg, certain duplication/deletion panels require ≥5 genes per entry for 81436)

Exome/genome notesExome sequencing (81415) and related genomic analyses are listed separately and routed to eviCore for records/prior auth per entries

Prior Authorization and Medical Records Submission — Actions for Providers

Prior Authorization

Prior Authorization and Medical Records Submission — Actions for Providers

The attending physician must obtain prior authorization for services listed on the Blue Cross Medicare Advantage Prior Authorization List. For many codes listed below, medical review, preauthorization routing, and medical records requests are handled by eviCore. Contact eviCore at 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs for authorization, medical records submission, and external medical review.

External medical review / authorization contact: eviCore — 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs (used for routing authorizations and medical records requests for many listed codes).
Knee arthroscopy codes (e.g., 29880–29887) require eviCore routing for prior authorization and medical records requests.
Hip and related arthroscopy/ligament procedure codes (e.g., 29914–29916, 29888–29889) require eviCore contact for preauthorization and medical records submission.
ENT and rhinoplasty/turbinate codes (e.g., 30120, 30400, 30462, 30520, 30801) are categorized as Medical Necessity or Cosmetic - Potential Contract Exclusion; documentation requirements include pre-operative evaluation, history & physical including functional impairment, and operative report. Some cosmetic-category codes may be potential contract exclusions and require additional justification.
Special routing: Certain imaging, transplant, neuromodulation, and genetic/molecular pathology codes explicitly require eviCore routing or transplant-approval-on-record. When a code is designated 'Transplant', submit transplant approval date if on record; if no approval, submit history & physical and transplant evaluation documentation.
Selected procedures (e.g., brachytherapy catheter placement codes 19296–19298; graft/allograft codes 20930–20938; many imaging codes 70450–70491, 72133–72149, etc.; and many nuclear medicine codes) reference eviCore for authorization and records submission.
Prior authorization / medical records request general contact: eviCore — 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs.
81402 (Molecular pathology procedure, Level 3): Medical Records Request information required = eviCore — 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs.
Medical Necessity review and documentation requirements (applies when Medical Review Category = Medical Necessity): submit History & Physical, documentation of medical necessity (including prior conservative treatment when applicable), operative report, plan of care, relevant test results (eg, imaging, sleep study, CPAP trial), pathology reports, and other supporting records as specified per code.
Speech/audiology and rehabilitation prior auth notes: Some speech/language and audiology codes (e.g., 92507, 92508, 92511, 92520, 92521, 92522) list eviCore as the contact for medical records/authorization and note 'Prior Auth required for MT Medicare Advantage Plan' where specified — confirm plan-specific prior auth requirements and submit requested documentation or contact eviCore.

Key Definitions and Review Categories

Medical Review Category — Medical Review Category indicates whether a procedure is reviewed for medical necessity, cosmetic/contract exclusion potential, or requires external review (eviCore).

DefinitionMedical Review Category indicates whether a procedure is reviewed for medical necessity, cosmetic/contract exclusion potential, or requires external review (eg, eviCore)

PurposeUsed to determine required documentation and routing for prior authorization or medical records requests

ExamplesCommon categories include Medical Necessity, Transplant, Cosmetic - Potential Contract Exclusion, Investigative, Unlisted Code

Medical Necessity — Medical Review Category = Medical Necessity

Medical Necessity categoryWhen Medical Review Category = Medical Necessity, submit History & Physical and documentation of medical necessity including operative report (as specified)

Use caseApplies to multiple listed surgical and therapeutic procedures (eg, debridement, arthrodesis, neuromodulation) requiring justification

Routing implicationThese cases may require prior authorization or medical record review via eviCore per code entry

eviCore — eviCore is the external utilization management vendor to contact for certain procedures

Vendor identityeviCore is the external utilization management vendor designated for prior authorization and medical records requests for many listed codes

Contact infoPhone: 1-855-252-1117; Web: https://www.evicore.com/healthplan/bcbs (use for routing prior auth and medical records requests)

ScopeeviCore routing is referenced across imaging, molecular/genetic, spine, and other procedural code entries

Level 1/2/3 molecular pathology — Molecular pathology procedure Level 1/2/3

Level 1/2/3 referenceMolecular pathology Level 1/2/3 definitions are listed (Level 1 = single variant; Level 2 = 2–10 variants; Level 3 = >10 variants) and mapped to CPT 81400–81402 entries

Related CPTsSee CPT 81400 (Level 1), 81401 (Level 2), 81402 (Level 3) for procedure-level definitions and examples

RoutingMedical Records Request for these CPTs routed to eviCore as indicated in entries

eviCore — eviCore is the designated medical review/records request contact for preauthorization

eviCore contact for prior auth/recordsFor prior authorization or medical records requests related to molecular/genetic testing and many other codes, contact eviCore at 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs

Applies to CPT rangesEntries referencing eviCore include molecular/genetic CPTs (eg, 81242–81435), imaging, and other procedural codes

81402 exampleCPT 81402 (Level 3 molecular pathology) shows eviCore routing in its Medical Records Request field