CurrentBlue Cross Blue Shield - OklahomaPolicy N/A

Blue Cross Medicare Advantage Prior Authorization List (partial)

List of CPT/HCPCS procedure codes that require prior authorization for Blue Cross Medicare Advantage plans in Oklahoma; includes documentation requirements and eviCore-managed codes.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyBlue Cross Medicare Advantage Prior Authorization List (partial)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2023

Next Review Date

Key ActionObtain prior authorization for listed services (except in urgent situations) and submit required documentation to eviCore at 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

100+procedure codes listed in this part (approximate)

~230procedure code entries in this part (approx.)

eviCoreprior auth / medical records request vendor

Someentries: require medical records to be submitted to eviCore

Mostentries: No Prior Auth required for MT Medicare Advantage

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Policy Snapshot

This document is the Blue Cross Medicare Advantage Prior Authorization List (Oklahoma) and identifies CPT/HCPCS procedure codes for which the attending physician must obtain prior authorization before providing the listed services (except in urgent situations). It applies to providers submitting requests for Medicare Advantage members and includes code‑specific instructions about the medical records to submit, the utilization management vendor contact, and plan‑specific exceptions; providers should verify member eligibility and benefits prior to scheduling. Effective date for this list is 2023-01-01.

Document metadata

PayerBlue Cross Blue Shield - Oklahoma

Policy typeAdministrative/Operational

Document typeother

StatusCURRENT

Effective date2023-01-01

Policy numberN/A

Subject / scopeList of CPT/HCPCS procedure codes that require prior authorization for Blue Cross Medicare Advantage plans (Oklahoma). Includes instructions for medical records required and eviCore-managed codes.

Code Groups and Billing Categories

Anesthesia for neuromonitoring/nerve-related spine proceduresCPTCovered

01939	Anes nulyt agt crv/thrc
01940	Anes nulyt agt lmbr/sac
01941	Anes neuromd/ntrvrt crv/thrc
01942	Anes neuromd/ntrvrt lmbr/sac

Plastic/reconstructive and cosmetic surgery (selected)CPTCovered

11970	Replace tissue expander
15775	Hair transplant 1-15 punch grafts
15776	Hair transplant >15 punch grafts
15777	Acellular derm matrix implant
15780	Dermabrasion total face
15781	Dermabrasion segmental face
15782	Dermabrasion other than face
15783	Dermabrasion superficial any site
15786	Abrasion lesion single
15787	Abrasion lesions add-on

1–10 of 38

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Dermatology/skin proceduresCPTCovered

17340	Cryotherapy of skin
17360	Skin peel therapy
17380	Hair removal by electrolysis

Breast surgery and reconstructionCPTCovered

19316	Suspension of breast
19318	Reduction of large breast
19324	Enlarge breast
19325	Enlarge breast with implant
19328	Removal of breast implant
19330	Removal of implant material
19340	Immediate breast prosthesis
19342	Delayed breast prosthesis
19350	Breast reconstruction
19355	Correct inverted nipple(s)

Bone grafts / electrical bone stimulationCPTCovered

20930	SP bone allograft morsel add-on
20931	SP bone allograft structural add-on
20936	SP bone allograft local add-on
20937	SP bone allograft morsel add-on (alt)
20938	SP bone allograft structural add-on (alt)
20974	Electrical bone stimulation
20975	Electrical bone stimulation (alt)

Maxillofacial / jaw reconstructionCPTCovered

21083	Prepare face/oral prosthesis
21085	Prepare face/oral prosthesis (alternative)
21120	Reconstruction of chin
21121	Reconstruction of chin (alt)
21122	Reconstruction of chin (alt2)
21123	Reconstruction of chin (alt3)
21125	Augmentation lower jaw bone
21127	Augmentation lower jaw bone (alt)
21138	Reduction of forehead
21141	LeFort I - 1 piece w/o graft

1–10 of 38

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Thoracic/sternal and other reconstructive proceduresCPTCovered

21685	Hyoid myotomy & suspension
21740	Reconstruction of sternum
21742	Repair sternum/Nuss w/o scope
21743	Repair sternum/Nuss w/ scope

Spine procedures and injectionsCPTCovered

22505	Manipulation of spine
22510	Perc cervical-thoracic injection
22511	Perc lumbosacral injection
22512	Vertebroplasty additional inject
22513	Perc vertebral augmentation
22514	Perc vertebral augmentation (alt)
22515	Perc vertebral augmentation (alt2)
22526	IDET single level
22527	IDET 1 or more levels
22533	Lateral lumbar spine fusion

1–10 of 38

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Procedure codes and descriptions (excerpted from document part)CPT

22842	INSERT SPINE FIXATION DEVICE
22843	INSERT SPINE FIXATION DEVICE
22844	INSERT SPINE FIXATION DEVICE
22845	INSERT SPINE FIXATION DEVICE
22846	INSERT SPINE FIXATION DEVICE
22847	INSERT SPINE FIXATION DEVICE
22848	INSERT PELVIC FIXATION DEVICE
22853	INSERT BIOMECHANICAL DEVICE (INSJ BIOMECHANICAL DEVICE)
22854	INSERT BIOMECHANICAL DEVICE (INSJ BIOMECHANICAL DEVICE)
22856	CERVICAL ARTIFIC DISCECTOMY

1–10 of 123

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What Providers Must Do

Prior Authorization

Prior authorization required

Attending physician must obtain prior authorization for the services on this list (except in urgent situations). Some codes are managed by eviCore; contact eviCore at 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs for those codes.

For eviCore-managed codes contact: 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs

Prior Authorization

eviCore contact for utilization management / medical records requests

Medical records and prior authorization handling for listed procedure codes is managed via eviCore. Use eviCore’s phone or portal to submit requests and documentation.

Phone: 1-855-252-1117
Portal: https://www.evicore.com/healthplan/bcbs

Medical Records & Documentation Requirements

Providers should be prepared to submit medical records to support prior authorization requests. Typical required documents include a recent History & Physical, pre‑operative evaluation or procedure report, operative note when applicable, the plan of care, and explicit documentation of medical necessity. For many device and DME requests a Letter of Medical Necessity and functional status evaluation are requested. When codes are managed by eviCore, submit records or initiate authorization via eviCore at 1‑855‑252‑1117 or https://www.evicore.com/healthplan/bcbs; the list highlights eviCore‑managed codes and identifies code‑level record requirements (for example, pre‑op evaluation, H&P including functional impairment, operative report, doppler results, or transplant evaluation/date where noted).

Documentation Required

Codes requiring H&P, operative note, plan of care

Certain codes explicitly require submission of H&P, operative note, and plan of care (or pre-operative evaluation/H&P including functional impairment) with the authorization request; these must be included for those codes.

These codes explicitly require H&P, operative note, plan of care: 22864, 22865, 22999, 27445, 27557, 27558, 27690, 27691, 27692, 28446, 28890

Defined Terms

Definitions / key terms

eviCoreThird-party utilization management vendor contracted by Blue Cross Blue Shield - Oklahoma to manage prior authorization and medical records review; contact: 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs.

Prior authorizationRequirement that the attending physician obtain approval from the plan (or delegated manager) before performing the listed service, except in urgent situations.

Medical Records Request information requiredTypical documentation requested: recent history & physical, pre-operative evaluation, plan of care, operative report, documentation of medical necessity, functional status evaluation, and Letters of Medical Necessity when applicable.

MT Medicare AdvantageMedicare Advantage plan designation referenced where some codes have 'No Prior Auth required' exceptions (examples and effective dates noted in code entries).

Letter of Medical NecessityProvider-authored letter documenting clinical need, functional status, anticipated length of need and medical rationale; frequently required for DME, mobility and prosthetic codes.

OpenPayer

Blue Cross Medicare Advantage Prior Authorization List (partial)

Policy Snapshot

Code Groups and Billing Categories

What Providers Must Do

Medical Records & Documentation Requirements

Defined Terms

Revision History