ModifiedBlue Cross Blue Shield - OklahomaPolicy N/A

Medicare Advantage prior authorization list (services/CPT/HCPCS)

Governs prior authorization requirements for services and related CPT/HCPCS codes for Blue Cross Medicare Advantage plans in Oklahoma; applies to attending physicians requesting services for members (except urgent situations).

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyMedicare Advantage prior authorization list (services/CPT/HCPCS)

Policy CodePolicy N/A

Change TypeMaterial updates to radiation/proton therapy entries (removals and re-additions)

Effective DateJan 1, 2024

Next Review DateN/A

Key ActionAttending physicians must obtain prior authorization for services on the listed prior authorization list; submit required medical records to eviCore when requested.

SourceLink

POLICY UPDATE CHANGES

Multiple radiation therapy and related procedure codes (e.g., 77371-77373, 77385-77387, 77401, 77402, 77407, 77412, 77423-77425, 77520-77525, 77600-77610) were marked 'Removed' with end date 12/31/23 in prior-auth listings.

Proton therapy procedure codes 77520, 77522, 77523 and 77525 were added back to the prior authorization list with an Effective Date of 1/1/24 and require submission of history and physical and previous diagnostic procedure reports for prior authorization.

Many imaging procedure codes list eviCore contact (phone and URL) as the source for medical records request information.

Procedure codes 77520, 77522, 77523, and 77525 were added with an effective date of 1/1/24 and require history/physical and prior diagnostic reports for prior authorization.

Multiple procedure codes (e.g., 77520, 77522, 77523, 77525, 77600-77620, 77750-77778, 77761-77772, 77767-77768) were marked as removed with effective date 12/31/23 in prior listings.

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procedure codes listed in this segment

Mostcodes marked No Prior Auth for MT

Somecodes require documentation

eviCoreexternal UM vendor contact

1/1/24proton codes re-added effective

Coverage Criteria and Per‑Code Authorization Rules

Documentation requirements examples

Selected codes include required documentation items to support medical necessity determinations.

Code 11970: Pre-operative evaluation; history and physical including functional impairment; operative report.

Code 15271: Recent history and physical; plan of care; documentation of medical necessity.

Code 22510: Medical records requests handled by eviCore (1-855-252-1117 or https://www.evicore.com/healthplan/bcbs); note indicates 'No Prior Auth required for MT Medicare Advantage Plan effective 1/1/21.'

Partial coverage/authorization nodes

Procedure-specific prior authorization and documentation guidance (partial).

Code 22511: eviCore medical-records request contact (1-855-252-1117 or https://www.evicore.com/healthplan/bcbs); 'No Prior Auth required for MT Medicare Advantage Plan effective 1/1/21.'

Code 22800 (post-fusion): Submit history and physical, operative report, and documentation of conservative measures to support authorization.

Code 22860: Added 4/1/2023; medical records requests routed to eviCore (1-855-252-1117 or https://www.evicore.com/healthplan/bcbs).

Per-code authorization/documentation stance

Per-code notes indicate whether prior authorization is required for MT Medicare Advantage members and what documentation is requested.

Examples: Multiple procedure codes (e.g., hip/knee revision and many arthroplasty codes): 'No Prior Auth required for MT Medicare Advantage Plan effective 1/1/21.'

See per-code entries for exact codes and effective dates.

Selected procedures require pre-operative evaluation, history & physical including functional impairment, and operative report to support authorization/medical-record review.

Documentation criteria by code subset

Documentation required for prior authorization/medical-record requests varies by procedure code.

Codes 29889, 29914–29916: Contact eviCore for medical records; entries note 'No Prior Auth required for MT Medicare Advantage Plan effective 1/1/21' where stated.

Codes 30120, 30400–30462: Pre-operative evaluation; history and physical including functional impairment; operative report required for medical-record review.

Transplant-related codes (e.g., 32851–32856, 33930–33945): If transplant approval is on record, provide date of transplant; if not, submit history and physical, transplant evaluation, and date of transplant.

Per-code prior authorization/documentation requirements (partial)

Per-code documentation requirements for utilization management review (partial list):

Code 43887 / 43888: History and physical; nutritional evaluation; psychological evaluation; documentation of weight loss attempts; social supports.

Code 43999: If transplant approval on record provide date of transplant; otherwise submit history and physical, transplant evaluation, and date of transplant.

Code 47135: If transplant approval on record provide date of transplant; otherwise submit history and physical, transplant evaluation, and date of transplant.

Code 51585: Submit history and physical; documentation of medical necessity; operative report.

Code 52648: Recent history and physical; plan of care; documentation of medical necessity. Note: 52648 entry shows 'Removed 1/1/2023' in this document.

Prior authorization status and documentation instructions

For many listed procedure codes the MT Medicare Advantage Plan indicates whether prior authorization is required and specifies documentation contact or items to submit.

No Prior Auth examples: No prior authorization required for MT Medicare Advantage Plan for many listed codes (examples include 62326, 62327, 62350, 62351, 62360).

Check effective date per code.

When medical records are requested providers should contact eviCore (1-855-252-1117 or https://www.evicore.com/healthplan/bcbs) or submit history and physical, operative report, and documentation of medical necessity where specified.

Per-code prior authorization/documentation requirements

Procedure-specific prior authorization requirements and documentation requests.

Code 69930: Medical records required include pre-operative evaluation, operative report, prior hearing aid use, and level of hearing impairment.

Code 70450: Prior authorization and medical-record requests handled by eviCore (1-855-252-1117 or https://www.evicore.com/healthplan/bcbs).

Code 71271: Listed with Effective Date 4/1/2021; medical-record requests handled by eviCore.

Code 74712/74713: Note indicates 'No Prior Auth required for NM Medicare Advantage Plan effective 11/1/2018' as an exception; otherwise eviCore contact applies.

Radiation/proton therapy code actions

Coverage/authorization stance for radiation and proton therapy procedure codes in this segment

Multiple radiation delivery/related codes (e.g., 77371–77373, 77385–77387, 77401–77402, 77407, 77412, 77423–77425, 77600–77610) were marked 'Removed' effective 12/31/23 in prior listings.

Proton therapy codes 77520, 77522, 77523, 77525 were re-added effective 1/1/24 and require prior authorization with specific documentation requirements (history and physical; results of previous diagnostic procedure reports).

Coverage criteria and documentation requirements

Documentation and authorization stance for specific codes in this segment

Codes 77520, 77522, 77523, 77525: Prior authorization required; documentation required for prior authorization includes history and physical and results of previous diagnostic procedure reports; eviCore contact referenced for submissions.

Code 78445: Noted 'No Prior Auth required for NM Medicare Advantage Plan effective 11/1/2018' (plan-specific exception).

Utilization management routing and effective-date notes

Listed CPT codes require utilization management review and medical records requests be submitted to eviCore.

Submit prior authorization requests and supporting medical records to eviCore at 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs for the CPT codes listed in this section (e.g., PET/PET-CT and other nuclear imaging codes).

Verify code-specific effective/removal dates before submission.

Genetic and molecular testing CPT codes (e.g., BRCA series and MOPATH CPTs 81162–81407) require eviCore review and medical-records submission where indicated.

Prior authorization / medical records-required codes

Codes in this section require prior authorization or medical-records-based review via eviCore unless otherwise noted.

Codes including (but not limited to) 81364, 81400–81407, 81518–81522, 81162–81167, and multiple other molecular/genetic and select procedural CPTs: prior authorization or medical-records request via eviCore is required; contact eviCore (1-855-252-1117 or https://www.evicore.com/healthplan/bcbs).

PA-exempt codes (plan-specific)

For many listed codes the document states prior authorization is not required for specific Medicare Advantage plans and provides eviCore contact for medical records.

Code 93882: No Prior Auth required for MT and NM Medicare Advantage Plans; medical-records requests are routed to eviCore; note indicates removal effective 7/1/2023 in some entries.

Code 93922: No Prior Auth required for MT and NM Medicare Advantage Plans; medical-records requests via eviCore; some vascular/TCD codes show removal effective 7/1/2023—verify current status.

Code 95782: No Prior Auth required for MT Medicare Advantage Plan effective 4/1/2018 (plan-specific exemption); check effective date per code.

Codes with removal/effective date notes

Some codes include removal/effective date annotations indicating prior internal updates.

Code 0053U: Marked 'Removed 10/1/2023' in this listing; verify current code status before submission.

Code 0056U: Marked 'Removed 4/1/2023' (see code-specific entry).

Codes 79005, 79101, 79403: Noted 'Removed 12/31/23' in this document segment; confirm current applicability.

Per-code authorization and documentation notes

Per-code notes and documentation requirements

Code 0163T: 'No Prior Auth required for MT Medicare Advantage Plan effective 1/1/21' (plan-specific exemption as listed).

Code 0178T: Requires recent history and physical; plan of care; documentation of medical necessity for medical-record requests.

Code 0208U: Marked 'Removed effective 7/1/2022' (verify current status).

Per-code coverage/authorization criteria

Per-code prior authorization and documentation expectations (examples):

Code 0540T: Submit recent history and physical; plan of care; documentation of medical necessity for authorization/medical-record review.

Code 0629T: Contact eviCore (1-855-252-1117 or https://www.evicore.com/healthplan/bcbs) and provide requested medical records as directed.

Notes: Code 0745T/0746T: Entries were Added 4/1/2023 and then marked 'Removed 12/31/23' in this listing — confirm current effective status before submitting requests.

Code A7037: No Prior Auth required for MT Medicare Advantage Plan effective 4/1/2018 (DME/accessory exemption).

Code 0865T: Prior authorization required via eviCore; Effective Date noted as 4/1/2024 in the listing — follow eviCore submission process.

CPT/HCPCS Codes and Status

sample CPT procedure codes and descriptions (partial list)CPT

01939	Anes nulyt agt crv/thrc
11970	REPLACE TISSUE EXPANDER
15775	HAIR TRNSPL 1-15 PUNCH GRFTS

bone graft / stimulation codes (partial)CPT

20930	SP BONE ALGRFT MORSEL ADD-ON
20974	ELECTRICAL BONE STIMULATION

spine/interventional procedures (partial list)CPT

22511	PERQ LUMBOSACRAL INJECTION
22512	VERTEBROPLASTY ADDL INJECT
22513	PERQ VERTEBRAL AUGMENTATION
22514	PERQ VERTEBRAL AUGMENTATION
22515	PERQ VERTEBRAL AUGMENTATION
22526	IDET SINGLE LEVEL
22527	IDET 1 OR MORE LEVELS
22533	LAT LUMBAR SPINE FUSION
22534	LAT THOR/LUMB ADDL SEG

shoulder procedures (partial list)CPT

23000	REMOVAL OF CALCIUM DEPOSITS
23020	RELEASE SHOULDER JOINT
23410	REPAIR ROTATOR CUFF ACUTE
23412	REPAIR ROTATOR CUFF CHRONIC
23430	REPAIR BICEPS TENDON

hip arthroscopy codesCPT

29860	HIP ARTHROSCOPY DX
29861	HIP ARTHRO W/FB REMOVAL
29862	HIP ARTHR0 W/DEBRIDEMENT
29863	HIP ARTHR0 W/SYNOVECTOMY

rhinoplasty/revision codesCPT

30120	REVISION OF NOSE
30400	RECONSTRUCTION OF NOSE
30410	RECONSTRUCTION OF NOSE
30420	RECONSTRUCTION OF NOSE

Sample procedure code group from fragmentCPT

29889	KNEE ARTHROSCOPY/SURGERY
29914	HIP ARTHRO W/FEMOROPLASTY
29915	HIP ARTHRO ACETABULOPLASTY
29916	HIP ARTHRO W/LABRAL REPAIR
30120	REVISION OF NOSE
30400	RECONSTRUCTION OF NOSE

Transplant-related CPT codesCPT

32851	LUNG TRANSPLANT SINGLE
33935	TRANSPLANTATION HEART/LUNG

bariatric/intestinal/transplant-relatedCPT

43887	REMOVE GASTRIC PORT OPEN
43888	CHANGE GASTRIC PORT OPEN
43999	STOMACH SURGERY PROCEDURE
44132	ENTERECTOMY CADAVER DONOR
44133	ENTERECTOMY LIVE DONOR

liver/pancreas transplant-relatedCPT

47133	REMOVAL OF DONOR LIVER
47135	TRANSPLANTATION OF LIVER
48550	DONOR PANCREATECTOMY
48554	TRANSPL ALLOGRAFT PANCREAS

spinal/interventional pain procedures (eviCore referenced)CPT

62263	EPIDURAL LYSIS MULT SESSIONS
62264	EPIDURAL LYSIS ON SINGLE DAY
62320	NJX INTERLAMINAR CRV/THRC
62350	IMPLANT SPINAL CANAL CATH
62360	INSERT SPINE INFUSION DEVICE

Spine injection/implant codesCPT

62326	Injection/nerve-related spine procedure (per list)
62327	Interlaminar lumbar/sacral injection (listed as NJX INTERLAMINAR LMBR/SAC)
62350	Implant spinal canal catheter

Injection/nerve block codesCPT

64451	Nerve block/standard nerve procedure (listed)
64479	Injection, foramen epidural C/T
64480	Injection foramen epidural add-on

Corneal/ocular transplant codesCPT

65710	Corneal transplant
65730	Corneal transplant

Selected CT codesCPT

71271	CT THORAX LUNG CANCER (Effective Date = 4/1/2021)
72131	CT LUMBAR SPINE W/O DYE
74150	CT ABDOMEN W/O DYE

Selected MRI codesCPT

70540	MRI ORBIT/FACE/NECK W/O DYE
72141	MRI NECK SPINE W/O DYE
72148	MRI LUMBAR SPINE W/O DYE

CT colonography codesCPT

74261	CT COLONOGRAPHY DX
74262	CT COLONOGRAPHY DX W/DYE
74263	CT COLONOGRAPHY SCREENING

Proton therapy codes (re-added)CPTCovered

77520	PROTON TRMT SIMPLE W/O COMP
77522	PROTON TRMT SIMPLE W/COMP
77523	PROTON TRMT INTERMEDIATE
77525	PROTON TREATMENT COMPLEX

Listed CPT procedure codes (sample from this segment)CPTCovered

77520	PROTON TRMT SIMPLE W/O COMP
77522	PROTON TRMT SIMPLE W/COMP
77523	PROTON TRMT INTERMEDIATE
77525	PROTON TREATMENT COMPLEX
77600	HYPERTHERMIA TREATMENT
77750	INFUSE RADIOACTIVE MATERIALS
78012	THYROID UPTAKE MEASUREMENT
78300	BONE IMAGING LIMITED AREA
78813	PET IMAGE FULL BODY
78999	NUCLEAR DIAGNOSTIC EXAM

PET/PET-CT procedure codesCPTCovered

78811	Procedure code listed (PET/other) with eviCore review
78812	PET IMAGE SKULL-THIGH
78813	PET IMAGE FULL BODY
78814	PET IMAGE W/CT LMTD
78815	PET IMAGE W/CT SKULL-THIGH
78816	PET IMAGE W/CT FULL BODY

Genetic testing codes (examples)CPTCovered

81162-81167	BRCA1/2 full sequencing and duplication/deletion analysis codes
81201-81203	APC gene sequencing/variants codes

Pharmacogenomic and cytogenetic codesCPTCovered

81221-81231

CFTR and various CYP and cytogenetic microarray codes

Exome/genomic sequencing codesCPT

81415	EXOME SEQUENCE ANALYSIS
81416	EXOME SEQUENCE ANALYSIS
81417	EXOME RE-EVALUATION
81418	Rx metab gen seq alys pnl 6

Oncology mRNA panelsCPT

81518	ONCOLOGY BREAST MRNA
81519	ONCOLOGY BREAST MRNA
81520	ONC BREAST MRNA 58 GENES
81522	ONC BREAST MRNA 12 GENES

Examples from vascular/TCD/ultrasound groupCPT

93882	EXTRACRANIAL UNI/LTD STUDY
93886	INTRACRANIAL COMPLETE STUDY
93922	UPR/L XTREMITY ART 2 LEVELS

Genomic/molecular temporary codes (U/M/T codes)HCPCS

0001U	RBC DNA HEA 35 AG 11 BLD GRP
0018U	ONC THYR 10 MICRORNA SEQ ALG
0094U	GENOME RAPID SEQUENCE ALYS

Genetic and genomic testing codesmixed

0084U	RBC DNA GNOTYP 10 BLD GROUPS
0094U	GENOME RAPID SEQUENCE ALYS
0138U	BRCA1 BRCA2 MRNA SEQ ALYS

Large-panel oncology sequencingmixed

0239U	TRGT GEN SEQ ALYS PNL 311+
0244U	ONC SOLID ORGN DNA 257 GENES

sample listed codes and descriptionsmixed

0268U	HEM AUT DM CGEN TRMBCTPNA 14
0274T	PERQ LAMOT/LAM CRV/THRC (note: No Prior Auth required for MT Medicare Advantage Plan effective 4/1/2018)
0326U	TRGT GEN SEQ ALYS PNL 83+
0332U	Onc pan tum gen prflg 8 dna

additional added codesmixed

0346U	Beta amyl ab40&ab42 lc-ms/ms
0355U	APOL1 RISK VARIANTS
0426U	GENOME ULTRA-RAPID SEQ ALYS

Selected procedure codes from listCPT

0539T	Cellular therapy procedures (example entry listed)
0540T	Cellular Therapy Procedures Ancillary Code
0627T	Perq njx algc fluor lmbr 1st (example)
0633T	CT breast w/3D unilateral category

DME/accessories with MT Medicare Advantage exemptionsHCPCSCovered

A4604	Tubing with integrated heating element for PAP device; No Prior Auth for MT Medicare Advantage effective 4/1/2018
A7027	Combination oral/nasal mask for CPAP; No Prior Auth for MT Medicare Advantage effective 4/1/2018
A7037	Tubing used with positive airway pressure device; No Prior Auth for MT Medicare Advantage effective 4/1/2018

eviCore contact required

Primary contact for medical-records/prior authorization requests

What Providers Must Do (Prior Authorization & Documentation)

Prior Authorization

Prior Authorization Required

The attending physician must obtain prior authorization for services listed below except in urgent situations. For prior authorization and medical records submission, contact eviCore Healthcare: 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs. For general Customer Service inquiries call 1-877-774-8592 (Mon–Fri 8 a.m.–8 p.m. CT).

Prior authorization required unless noted otherwise for specific codes or plan exceptions.
eviCore manages clinical review for many procedure, radiology, nuclear medicine and genetic testing codes.
Include requested documentation at time of prior authorization: history & physical, operative report, diagnostic test reports, plan of care, and documentation of conservative measures when applicable.

Note

Documentation & External Review Vendor

eviCore is the external review/vendor for clinical prior authorization and medical record requests for managed codes. Use eviCore for authorization decisions and to submit clinical records.

Key Terms and Contacts

Codes highlighted in green on the list that are managed by eviCore healthcare

Definition — eviCore-managed codesCodes highlighted in green on the list are managed by eviCore Healthcare; eviCore handles medical-record requests and prior authorization review for those entries (phone 1-855-252-1117; https://www.evicore.com/healthplan/bcbs).

ImplicationWhen a code is marked as eviCore-managed, follow the code line routing and contact eviCore for prior authorization/records submission.

Not coverage guaranteeInclusion on the list (even if eviCore-managed) does not guarantee coverage — check member benefits first.

Approval that the attending physician must obtain before rendering listed services (except in urgent situations)

Definition — Prior authorizationApproval that the attending physician must obtain before rendering listed services, except in urgent situations (per opening statement).

Document Changes and Effective Dates

2023-12-31removal

Multiple radiation delivery and related procedure codes were marked Removed effective 12/31/2023.

2024-01-01additionLatest

Proton therapy procedure codes 77520, 77522, 77523, and 77525 were added back to the prior authorization list effective 1/1/2024 with required submission of history and physical and prior diagnostic procedure reports for prior authorization.

2022-01-01

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyMedicare Advantage prior authorization list (services/CPT/HCPCS)

Policy CodePolicy N/A

Change TypeMaterial updates to radiation/proton therapy entries (removals and re-additions)

Effective DateJan 1, 2024

Next Review DateN/A

Key ActionAttending physicians must obtain prior authorization for services on the listed prior authorization list; submit required medical records to eviCore when requested.

SourceLink

On This Page

Code range 62263–62380 (selected spinal/interventional codes): Refer to eviCore (1-855-252-1117 or https://www.evicore.com/healthplan/bcbs); some entries note 'No Prior Auth required for MT Medicare Advantage Plan effective 4/1/2018.'

Code C9076: Submit recent history and physical; plan of care; documentation of medical necessity for authorization review.

eviCore Healthcare — phone 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs

When requiredFor many listed CPT/HCPCS codes providers must submit medical records or prior authorization requests to eviCore as indicated on the code line items.

Exception notePresence on the list does not guarantee coverage; check member benefits and eligibility before proceeding.

eviCore routing effective date note

MT Medicare Advantage routing noteSeveral spinal and related codes are marked 'No Prior Auth required for MT Medicare Advantage Plan effective 4/1/2018' but still show eviCore as the medical-records contact where records are requested.

Provider actionIf medical records are requested for codes with this note, submit them to eviCore (phone/URL) even when 'No Prior Auth required' for MT plan entries.

Verify effective datesCheck the code-specific Effective Date on each line prior to submission (entries vary by code).

required documentation for proton therapy prior auth

Required documents for proton therapy prior authorizationHistory and physical, and results of previous diagnostic procedure reports (required for CPT codes 77520, 77522, 77523, 77525).

Routing for records/prior authSubmit prior authorization request and supporting records to eviCore (1-855-252-1117 or https://www.evicore.com/healthplan/bcbs).

Effective date for re-additionProton therapy codes were added back with an Effective Date = Added 1/1/24 and include the documentation requirement above.

No prior auth exception

Example of a plan-specific No Prior Auth exceptionCPT 78445 — No Prior Auth required for NM Medicare Advantage Plan effective 11/1/2018 (as noted on the code line).

Action when exception appliesWhen a code line indicates a plan-specific No Prior Auth exception, providers should still follow medical-records submission instructions if records are requested (eviCore contact shown).

Confirm applicabilityVerify the member's plan (e.g., NM Medicare Advantage) and the stated effective date before assuming an exception applies.

Added codes effective date

Sample added-code effective dateCPT 81349 — Effective Date = added 4/1/2022.

General practiceSome molecular/pathology codes list specific added Effective Dates (verify per-code line item before submission).

RoutingRecords/prior authorization requests for newly added codes are handled via eviCore (phone/URL on code line).

Removed codes

Example removed codes and removal dateCPT 79005, 79101, 79403 — noted 'Removed 12/31/23' on their code lines.

Provider actionDo not submit prior authorization for codes marked 'Removed' without confirming current list status; verify with Customer Service or eviCore.

Record routingIf documentation is needed historically, eviCore contact remains the listed route for records questions.

panel size example

Panel size example (large oncology panel)Code 0239U — described as 'TRGT GEN SEQ ALYS PNL 311+' (311+ genes).

InterpretationLarge-panel genomic tests may be identified by gene count on the code line; documentation requirements and eviCore routing apply.

ActionConfirm panel size and provide requested medical records when submitting to eviCore for review.

Effective dates and removals

General effective-date/removal observationSome codes show specific Effective Dates or are marked 'Removed' (several entries removed 12/31/2023; others removed 7/1/2023 or earlier).

Provider recommendationVerify the current status and effective date on the code line prior to submitting authorization or scheduling services.

Where to confirmConfirm via the code line notes, Customer Service, or eviCore contact if status is unclear.

eviCore phone: 1-855-252-1117
eviCore portal: https://www.evicore.com/healthplan/bcbs
Green-highlighted codes in this list indicate eviCore-managed codes.

Prior Authorization

Procedure Codes & Prior Authorization Status (Selected)

The CPT/HCPCS procedure codes below show the required prior authorization or note exceptions where no prior authorization is required for select Medicare Advantage plans. Always verify member-specific benefit and plan exceptions.

Examples (partial list): 22511,22512,22513,22514,22515 — eviCore (some noted No Prior Auth for MT Medicare Advantage effective 1/1/21).
22860,22861,22862,22864,22865,22867,22868 — eviCore; some codes added 4/1/2023 or have plan-specific No Prior Auth notes.
27134,27137,27138,27279,27280 — eviCore; many have No Prior Auth noted for MT Medicare Advantage Plan effective 1/1/21.
29805–29826 (shoulder arthroscopy codes) and 29889 (knee arthroscopy) — eviCore-managed; some have No Prior Auth for MT Medicare Advantage Plan effective 1/1/21.
30120,30400–30462 (rhinoplasty/reconstruction/revision) — require pre-op evaluation, H&P, operative report; effective prior to 9/1/2019.
77520,77522,77523,77525 (proton treatment codes) — added 1/1/24; Prior Authorization requires history & physical and prior diagnostic procedure reports.

Documentation Required

Documentation Requirements for Fusion Procedures

For spinal fusion and related fusion procedures, submit history & physical, operative report, and documentation of conservative measures (e.g., prior conservative treatments, duration, and outcomes).

Codes include 22800,22802,22804,22808 and related fusion codes.
Ensure documentation shows failure of nonoperative care and objective findings supporting fusion level selection.

Documentation Required

Additional Documentation & Effective Date Notes

Additional documentation requirements and effective date notes: include recent history & physical, plan of care, operative reports, diagnostic imaging reports (e.g., Doppler for vascular), and transplant evaluation materials when applicable. Effective dates or removal dates for codes are included in the code list — confirm the effective date for each code before submission.

Vascular codes (e.g., 34806,37225) require Doppler results and operative report; note some vascular codes were removed 1/1/2023.
Radiation therapy and certain SBRT/SRS codes have removal dates (many removed 12/31/2023); proton codes were re-added/updated effective 1/1/24.
When code removal or plan-specific No Prior Auth exceptions exist, follow the most recent effective date notes in this list.

Documentation Required

Prior Authorization / Medical Records Instructions (Sample)

Sample prior authorization / medical records instructions — submit clinical documentation at time of request to minimize delays. Required documents commonly requested include history and physical, consultation notes, operative report, prior imaging and diagnostic reports, treatment plans, and documentation of prior conservative therapies.

For transplant-related procedures (e.g., 32850–32854,33930–33945,47133–47147): if transplant approval is on record provide the date of transplant; if not, submit H&P, transplant evaluation and date of transplant.
For rhinoplasty/reconstruction (30120,30400–30462): include pre-op evaluation, H&P with functional impairment and operative report.
For cellular therapy ancillary codes (0537T–0540T): include recent H&P, plan of care and documentation of medical necessity.
For radiology/nuclear and genetic testing codes, route requests through eviCore with supporting diagnostic reports and reason for study/test.

Documentation Required

Documentation Requirements for Selected Procedures

Selected procedures require code-specific documentation; failure to include the listed documentation increases risk of denial. Follow the code-specific notes in the list when preparing authorizations or responding to medical record requests.

Orthopedic arthroscopy (e.g., 29805–29826, 29889, 29914–29916): many are eviCore-managed; include H&P, operative report and documentation of functional impairment — some codes have No Prior Auth for MT Medicare Advantage effective 1/1/21.
Rhinoplasty/reconstruction (30120,30400–30462): pre-operative evaluation, H&P including functional impairment, operative report required.
Transplant (multiple codes across sections): if prior transplant approval exists submit date of transplant; otherwise submit H&P, transplant evaluation, and transplant date.
Cardiac and vascular surgery (33406–33476, 34806, 37225): recent H&P, plan of care, Doppler or vascular studies where noted, and operative report.

Prior Authorization

Orthopedic Arthroscopy Codes & Prior Authorization Contact

Orthopedic arthroscopy and related joint surgery codes are frequently managed by eviCore. For authorization or records requests contact eviCore and include operative reports and prior conservative care documentation.

Shoulder arthroscopy codes: 29805–29826 — eviCore review; many have No Prior Auth for MT Medicare Advantage Plan effective 1/1/21.
Knee arthroscopy: 29889 — eviCore-managed; include H&P and operative report.
Hip arthroscopy: 29914–29916 — eviCore-managed; include documentation of clinical findings and prior conservative management.

Documentation Required

Rhinoplasty / Reconstruction Documentation Requirements

Rhinoplasty and nasal reconstruction codes require documentation demonstrating medical necessity (functional impairment) rather than cosmetic indication. Provide pre-operative evaluation, history & physical, and operative report.

Codes: 30120, 30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462.
Document symptoms (e.g., nasal obstruction), prior treatments, and objective findings to support medical necessity.

Documentation Required

Vascular Procedure Codes & Removal Note

Vascular procedure codes require appropriate vascular studies and documentation of medical necessity; some vascular codes were removed effective 1/1/2023 — verify code status before submission.

Examples: 34806 (open axillary/subclavian exposure) — include Doppler studies and operative report.
37225 (femoral/popliteal revascularization) — noted as removed 1/1/2023 in this list; do not use removed codes without confirmation.
Endovenous and sclerotherapy codes (36468,36470,36479) — include H&P and operative report as applicable.

Documentation Required

Prior Authorization Documentation for Select Procedures

Prior authorization documentation for select procedures: include plan of care, documentation of conservative measures (physical therapy, injections, medications), prior diagnostic testing, and clear rationale for the requested intervention to reduce denial risk.

Spine procedures and fusion codes: document conservative therapy timeline and objective imaging.
Joint revision/replacement codes (e.g., 27134,27441–27447): include H&P, operative report, and documentation of implant failure or functional impairment.
Pain procedures: include prior conservative measures, pain scores, and imaging when applicable.

Prior Authorization

Transplant Procedure Prior Authorization Requirements

Transplant procedures require prior transplant approval. If approval is documented, submit the transplant date; if not, provide history & physical, transplant evaluation, and the scheduled transplant date.

Lung transplant codes: 32850–32854 — if transplant approval on record, supply date of transplant; otherwise submit H&P, transplant evaluation and transplant date.
Heart/lung and heart transplant codes: 33930–33945 — same requirements as above.
Liver/intestine transplant codes: 47133–47147,44132–44137 — include transplant evaluation and dates if no prior approval on record.

Note

Prior Authorization / Medical Records Contact

For prior authorization and medical records submission contact eviCore. For general plan eligibility or benefit questions contact Blue Cross Blue Shield of Oklahoma Customer Service.

eviCore phone: 1-855-252-1117; portal: https://www.evicore.com/healthplan/bcbs
BCBSOK Customer Service: 1-877-774-8592 (Mon–Fri 8 a.m.–8 p.m. CT).

Prior Authorization

Pain Procedures — Prior Authorization

Pain management and interventional pain procedure codes are managed per the list; many codes are routed to eviCore and some have plan-specific No Prior Auth exceptions. Include prior conservative management documentation and pain assessment.

Examples: 62263–62327,62350–62362,62380 — many are eviCore-managed; note No Prior Auth exceptions for MT Medicare Advantage effective dates where listed.
Provide history of treatments (PT, meds, injections), pain scores, and diagnostic imaging when applicable.

Note

Code-Specific Exception Notes

Code-specific exceptions and notes are included throughout the code list. Pay attention to plan-specific No Prior Auth exemptions and removal effective dates to avoid inappropriate denials.

Many codes include annotations such as 'No Prior Auth required for MT Medicare Advantage Plan effective 1/1/21' — check member plan before requesting authorization.
Several radiation and nuclear codes were removed 12/31/23 — updated proton codes were added 1/1/24.
Certain vascular and vascular ultrasound codes show removal effective 7/1/2023 — verify current code status.

Prior Authorization

Proton Treatment Codes — Prior Authorization Requirements

Proton treatment codes (77520,77522,77523,77525) require prior authorization effective 1/1/2024. For authorization submit history & physical and results of prior diagnostic procedure reports; route requests to eviCore.

77520 — Proton treatment simple w/o comp; added 1/1/24; prior auth requires H&P and diagnostics.
77522,77523,77525 — similarly added 1/1/24 with the same documentation requirements.
Older entries showing these codes removed through 12/31/23 have been superseded by additions effective 1/1/24.

Note

eviCore Contact for Authorization / Records (Radiology, Nuclear, Genetic)

eviCore is the primary contact for authorization and medical records for radiology, nuclear medicine and many genetic/pathology codes. Use eviCore portal or phone to submit requests and records to avoid processing delays.

Radiology MRI/CT/Angio codes (e.g., 70450–70480,74183,74261,74262) — route to eviCore.
Nuclear/PET codes (78811–78816,78830–78832,78999) — route to eviCore; some codes have specific effective dates (e.g., 78830–78832 effective 9/1/2020).
Genetic testing codes (BRCA series 81162–81167 and many others 81201–81203,81361–81364, etc.) — eviCore-managed; include test indication and prior genetic history as requested.

Prior Authorization

Radiology / Nuclear Codes Requiring eviCore Review

Radiology and nuclear medicine codes in this list often require eviCore review; some were removed or had effective date changes — verify code status and plan-specific exceptions before submission.

Codes removed 12/31/23 include many radiation delivery and SBRT/SRS procedure codes — check current list for replacements or re-added codes.
CT colonography (74261–74263), MRI fetal (74712–74713) and multiple angiography/MRI angio codes are eviCore-managed.
PET and nuclear imaging codes (78812–78816,78830–78832) are managed by eviCore; note the effective dates noted in the listing.

Documentation Required

Additional Nuclear / Radiology Codes & Removal Notes

Additional nuclear/radiology codes and removal notes: several vascular duplex and transcranial Doppler codes were removed effective 7/1/2023 or have plan-specific No Prior Auth exceptions — always confirm current code applicability.

Examples of removed/changed codes: 93922–93926 and related vascular study codes — removed 7/1/2023 in this list; confirm current coding guidance.
Transcranial Doppler and extracranial/intracranial study codes (93880–93892) include No Prior Auth plan exceptions in some regions and removal notes; verify before submission.

Documentation Required

Documentation Requirements & Removal Notes

Documentation requirements and removal notes: when a code shows 'Removed' with an effective removal date, do not submit prior authorizations for that code without confirming an updated replacement. For codes still effective, include the code-specific documentation listed (H&P, operative report, diagnostics).

Radiation therapy codes removed 12/31/23 should not be used; proton codes were re-added effective 1/1/24 with specific PA documentation requirements.
Genetic and molecular testing codes often require clinical indication, prior testing history, and eviCore routing.
When code-specific notes call for diagnostic study results (e.g., Doppler), include those reports in the submission.

Note

Medical Record Requests & PA Exemptions

Medical record requests will be issued for many codes; some codes or situations are noted as PA-exempt for specific Medicare Advantage plans — verify member plan and the note in the code entry to determine if PA or medical records are required.

Examples of PA exemptions: numerous orthopedic and spine codes show 'No Prior Auth required for MT Medicare Advantage Plan effective 1/1/21' or similar regional plan notes.
If a PA exemption exists for a plan, records may still be requested for retrospective review — retain full documentation.
When in doubt, contact BCBSOK Customer Service or eviCore to confirm current PA requirements for the member.

Prior Authorization

Genetic / Diagnostic Procedure Codes (Sample)

Selected genetic and diagnostic procedure codes require eviCore review and specific documentation (test indication, prior genetic history, relevant family history, and prior test results).

BRCA full gene and duplication/deletion series (81162–81167) — eviCore-managed; include clinical indication and family history.
APC, CFTR, CYP and other gene-specific codes (81201–81203,81221–81231,81361–81364,81349,81350 etc.) — submit clinical rationale and prior testing.
Large panel and oncology panels (0050U,0171U,0053U etc.) — include tumor pathology report or clinical synopsis as applicable.

Documentation Required

Documentation Requirements (Examples)

Documentation examples to include with prior authorization requests to reduce denials: recent H&P, consultation notes, imaging and diagnostic reports, operative reports, treatment plans, prior conservative care documentation, transplant evaluations, and test-specific supporting documents (e.g., Doppler, pathology, family history).

For surgeries: H&P, operative report, plan of care, documentation of functional impairment.
For imaging: diagnostic test reports, prior imaging comparisons, and ordering clinician notes.
For genetic tests: indication, family history, and prior test results; for panels include phenotype or tumor report.

Denial Risk

Denial Risk & Prior Authorization Exemptions

Failure to obtain required prior authorization or to submit adequate documentation may result in denial of payment. Always confirm member eligibility, plan-specific PA exemptions, and current code effective/removal dates before rendering services.

Confirm member benefits and PA requirements before scheduling procedures.
When codes show plan-specific 'No Prior Auth' notes, validate those notes against the member's plan and the effective date.
Retain and submit all requested clinical documentation to reduce retrospective denials.

Note

Medical Records / Prior Authorization Contact

For all prior authorization requests, medical records submissions, or questions about code-specific requirements use the contacts below. Submissions to eviCore via phone or portal are the preferred route for managed codes; for eligibility/benefit verification contact BCBSOK Customer Service.

eviCore (authorization and medical records): 1-855-252-1117; portal: https://www.evicore.com/healthplan/bcbs
Blue Cross and Blue Shield of Oklahoma Customer Service: 1-877-774-8592 (Mon–Fri 8 a.m.–8 p.m. CT)

For prior authorization information contact Customer Service at 1-877-774-8592 or the Oklahoma Medicare Advantage Network as listed.

Business hoursCustomer Service hours: Monday–Friday, 8 a.m. to 8 p.m. Central time.

eviCore - external utilization management/vendor for medical records and prior auth handling (phone and web link provided)

eviCore contact infoeviCore Healthcare — phone 1-855-252-1117; URL https://www.evicore.com/healthplan/bcbs

RoleThird‑party utilization management/vendor for medical records review and prior authorization handling for many codes listed in this document.

Use whenSubmit medical records or prior authorization requests per code line instructions directing providers to eviCore.

History and physical, operative report, plan of care, and documentation of conservative measures as requested for certain procedures

Common documentation requestedHistory and physical; operative report; plan of care; documentation of conservative measures — requested for many surgical and fusion procedures.

When transplant-relatedIf transplant approval is on record, the date of transplant may suffice; otherwise provide history & physical and transplant evaluation.

Provider actionInclude functional impairment details and operative/pathology reports where specified to support medical necessity determinations.

eviCore (utilization management vendor/contact for medical records and prior authorization)

eviCore — vendor for prior authorization and recordseviCore is the contracted utilization management vendor; contact 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs for prior authorization and medical records requests.

Where listedMany per-code entries explicitly direct providers to eviCore for submission of records or prior-authorizations (see code line items).

Alternate contactFor general prior authorization questions also contact Blue Cross Customer Service (1-877-774-8592) as appropriate.

eviCore - third-party medical review contact for some procedure code documentation requests

Third‑party review contacteviCore — phone 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs is the contact for clinical review/medical-record requests for many procedure codes.

ScopeUsed for nuclear medicine, radiology, genetic, molecular, and many surgical procedure code reviews as indicated on code lines.

Provider stepFollow code-specific instructions and include requested documentation when contacting eviCore.

If transplant approval is on record the date of transplant suffices; otherwise additional transplant evaluation documentation is required

Transplant approval on recordIf transplant approval is on record, the date of transplant may be sufficient documentation for transplant-related codes (per transplant code lines).

If no approval on recordProvide history & physical, transplant evaluation, and date of transplant when prior approval is not on record.

RoutingSubmit records to eviCore where the code line directs or follow Blue Cross prior authorization instructions.

Transplant documentation requirement

Transplant documentation — summarized requirementIf transplant approval is on record: Date of Transplant. If no transplant approval: history and physical, transplant evaluation, and date of transplant are required.

Codes affectedApplies to numerous transplant-related CPT codes (e.g., 32851–32854, 33930–33935, 44132–44135, 47133–47135).

Provider actionInclude transplant-specific evaluations and dates in submissions to support authorization determinations.

eviCore routing / contact

eviCore routing/contact (short)eviCore — 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs.

When to useUse this routing for medical-records requests and prior authorization submissions where code lines indicate eviCore handling.

NotesSome codes may still be marked 'No Prior Auth required' for specific Medicare Advantage plans even when eviCore is listed for records requests.

Utilization management vendor and contact for medical records and prior authorization

UM vendor / contact for auth and recordseviCore — 1-855-252-1117; https://www.evicore.com/healthplan/bcbs

RoleHandles external utilization management, prior authorization reviews, and medical-record requests for many listed services.

Provider instructionFollow per-code instructions and include required record types when submitting to eviCore.

Documentation items requested for certain surgical procedures

Documentation items commonly requestedPre-operative evaluation, history & physical, operative report (and where applicable prior conservative measures or functional impairment details).

When requiredRequested for many surgical, ophthalmologic, and fusion procedures to assess medical necessity.

Provider tipInclude objective findings and prior-conservative-therapy details to support authorization requests.

External prior authorization vendor/clinical review vendor (contact phone 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs)

eviCore contact for external prior authorization/clinical reviewPhone 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs

ScopeDesignated external prior authorization and clinical review vendor for many codes (imaging, molecular, surgical) listed in the document.

Provider actionUse the eviCore contact shown on the code line when submitting records or initiating prior authorization for those entries.

eviCore

eviCore (term) — conciseThird‑party utilization management/vendor (eviCore) responsible for handling prior authorization and medical-records review for many listed procedures.

Contact details1-855-252-1117; https://www.evicore.com/healthplan/bcbs

Implication for providersFollow the per-code routing to eviCore when submitting required documentation.

eviCore

eviCore (reiteration)eviCore — utilization management vendor/contact for prior authorization and medical records requests (1-855-252-1117; https://www.evicore.com/healthplan/bcbs).

Used forGenetic, molecular, imaging, nuclear, and many surgical code reviews per the code lines.

Provider noteConfirm code-specific documentation requirements when contacting eviCore.

MOPATH PROCEDURE LEVEL 1-8

MOPATH Procedure LevelsMOPATH PROCEDURE LEVEL 1–8 correspond to CPT codes 81400–81407 and are listed as requiring utilization management review.

RoutingSubmit medical-records requests/prior authorization for MOPATH codes to eviCore as directed on the code line.

Verify effective datesCheck per-code Effective Date before submission (code lines list dates where applicable).

eviCore utilization management vendor/contact for prior authorization and medical records requests

eviCore for prior auth/medical records requestsMany molecular/genetic procedure codes require a medical records request or prior authorization via eviCore (1-855-252-1117; https://www.evicore.com/healthplan/bcbs).

Codes includedIncludes numerous CPT codes in the 813xx–814xx range and related genetic/molecular codes as listed per code line entries.

Provider instructionProvide requested documentation (history/physical, plan of care, etc.) when submitting to eviCore for these codes.

Examples include recent history and physical, plan of care, and documentation of medical necessity

Examples of required recordsRecent history and physical; plan of care; documentation of medical necessity — commonly requested examples across multiple code groups.

When usedRequested for surgical, transplant, cardiac, and other procedures to support medical necessity determinations.

Provider tipInclude all specified elements (e.g., nutritional or psychological evaluations for bariatric codes) to avoid delays.

eviCore - utilization management vendor for medical record requests (phone 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs)

eviCore contact for medical-records requestsPhone 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs — submit records or request prior authorization as directed on code lines.

When to contactWhen a code line explicitly lists eviCore as the medical-records/prior-auth contact or for codes managed by eviCore (green-highlighted).

Alternate verificationIf uncertain about routing, confirm via Blue Cross Customer Service (1-877-774-8592).

Medical Records Request information

Medical records request instructionWhen medical-records requests are listed, include the specific records requested on the code line (examples: H&P, plan of care, documentation of medical necessity).

Where to sendSend records per code-line instructions — often routed to eviCore (1-855-252-1117 or https://www.evicore.com/healthplan/bcbs).

Examples of codes with record instructionsExamples include 90284, 90870 (history & physical, chart notes, treatment plan), and others listed with specific documentation requirements.

Removed effective

Removed effective — definitionIndicates the code was removed from the list as of the stated removal date (example: multiple radiation and nuclear codes removed 12/31/2023; 0208U removed effective 7/1/2022).

Provider actionDo not rely on removed codes for current prior-auth processes without confirming updated list status — contact Customer Service or eviCore to verify.

ExamplesCPT/HCPCS examples include codes removed 12/31/2023 (several nuclear/radiation codes) and 7/1/2023 (selected ultrasound/TCD codes).

eviCore

eviCore — concise contacteviCore — phone 1-855-252-1117; https://www.evicore.com/healthplan/bcbs

Role summaryeviCore is the external utilization management vendor for many code reviews and medical-records requests listed in this document.

Use caseUse the eviCore contact listed on the code line when a code requires prior authorization or medical-record submission.

eviCore (vendor)

eviCore (vendor) — shorteviCore — third‑party utilization management vendor for prior authorization and medical-records review (1-855-252-1117; https://www.evicore.com/healthplan/bcbs).

Provider instructionFollow per-code instructions to submit records or requests to eviCore where indicated.

NoteSome codes remain marked 'No Prior Auth required' for specific Medicare Advantage plans despite eviCore being the records contact.

MT Medicare Advantage exemption

MT Medicare Advantage exemption (definition)'No Prior Auth required for MT Medicare Advantage Plan' — a plan-specific exemption noted on many code lines (example effective dates include 4/1/2018 or 1/1/2021 depending on code).

ImplicationWhen the MT exemption applies, prior authorization is not required for that plan — but medical-records requests may still be routed to eviCore if listed.

Provider stepVerify member is in the MT Medicare Advantage plan and confirm the effective date shown on the code line before assuming exemption.

Codes 0648T and 0649T were assigned an effective date of 1/1/2022.

2022-10-01effective_date

Codes 0697T, 0698T, 0711T, 0712T, and 0713T were assigned effective dates of 10/1/2022.

2023-07-01removal

Selected cerebrovascular/vascular procedure codes (examples noted in the document) were removed effective 7/1/2023.

2023-10-01removal

Code 0053U was removed effective 10/1/2023.

2024-04-01effective_date

Code C9791 (MRI hyperpolarized xenon129) was assigned an effective date of 4/1/2024.

Denial Risk

Notable radiation code removals effective 12/31/23

The radiation/nuclear code entries include notable removals effective 12/31/23 (see codes in the 77371–77778, 77600–77620 ranges); providers should verify whether a code was removed or subsequently re-added before submission.

Several codes in the radiation delivery and brachytherapy ranges are annotated 'Removed 12/31/23'.

Prior Authorization

Proton therapy codes re-added effective 1/1/24 with H&P and diagnostic-report requirements

Proton therapy procedure codes 77520, 77522, 77523, and 77525 were re-added to the prior authorization list with an Effective Date of 1/1/24 and require submission of a history and physical and results of previous diagnostic procedure reports for prior authorization.

Codes re-added Effective Date = 1/1/24; required records: H&P and prior diagnostic procedure reports.

Note

Confirm code additions and effective dates (example: 81349 added 4/1/2022)

Some codes were added with specific effective dates (example: 81349 added 4/1/2022); verify the code's effective date in the listing before submitting prior authorization or medical records.

Example addition: 81349 (added 4/1/2022).