ModifiedBlue Cross Blue Shield - OklahomaPolicy N/A

Prior authorization list for plastic/reconstructive surgery and related procedures

This document lists CPT/HCPCS procedure codes for which benefit preauthorization or utilization management processes may be required for Blue Cross Blue Shield - Oklahoma members; it informs providers which codes may need prior authorization and what documentation is typically requested.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyPrior authorization list for plastic/reconstructive surgery and related procedures

Policy CodePolicy N/A

Change TypeAdded and removed codesvendor routing clarified

Effective Date

Next Review Date

Key ActionContact eviCore (1-855-252-1117 or https://www.evicore.com/healthplan/bcbs) to request prior authorization and submit required documentation.

SourceLink

POLICY UPDATE CHANGES

Multiple proton therapy, brachytherapy, and related codes (e.g., 77523, 77600, 77605, 77610, 77615, 77620, 77750, 77761-77772, 77778, 78012-78015, etc.) were added with an effective date of 1/1/24.

Several SRS/SBRT and related radiation delivery codes (e.g., 77371, 77373, 77385-77387, 77401-77412, 77423-77425, 77520, 77522-77525, etc.) were marked 'Removed 12/31/23'.

For many listed codes, the prior authorization vendor is eviCore with contact 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs.

Multiple temporary U/T/T-modifier HCPCS-like codes (e.g., 0333U–0475U, 0394T–0866T, A-codes) were added on various dates (examples: many 'Added 4/1/2023', 'Added 10/1/2023', 'Added 4/1/24').

Some temporary codes were removed on specified dates (examples: 0386U Removed 10/1/23; several T-codes removed 12/31/23).

Most listed codes route prior authorization or clinical review to eviCore with contact information (1-855-252-1117 and URL).

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procedure codes listed (approximate, multiple pages)

eviCoreuses external UM manager for some codes

Pre-op H&Pcommon requested documentation

Prior to 9/1/2019entries with prior-to/effective notes

Added 4/1/2023explicit add note example

Coverage Criteria and Scope

This document is a utilization management code list and is not a guarantee of coverage. The presence of codes on this list does not necessarily indicate coverage under a member's benefits contract; coverage depends on the member's specific plan, eligibility, and benefit design. Providers must check eligibility and benefits prior to rendering services and consult the member benefit booklet or customer service to determine coverage for a specific medical service or supply.

Certain entries include plan-specific exceptions stating No Prior Auth required for MT Medicare Advantage Plan effective 1/1/21. These exceptions appear inline for multiple CPTs (examples in the knee and shoulder sections) and indicate that prior authorization requirements may vary by plan; always verify the member's plan variant before relying on an in-line exception.

Example of a removed code entry: 37225 includes the historical note indicating it was Removed 1/1/2023, meaning that as of that date the prior-authorization entry for this code no longer applies on this list.

Several procedure entries include a No Prior Auth required for MT Medicare Advantage Plan effective 4/1/2018 statement (for example, multiple spine and epidural/discography-related codes), reflecting plan-level variation in prior authorization requirements.

Medicare Advantage plan notes in the list indicate that select vascular and Doppler codes (and some intracranial transcranial Doppler entries) have No Prior Auth required for MT Medicare Advantage Plan effective 4/1/2018, demonstrating that prior authorization routing can differ by Medicare Advantage product.

The document includes multiple codes annotated as Removed with dates (for example, several imaging/radiation therapy CPTs are indicated as Removed 12/31/23 and some ultrasound/echo entries show Removed 7/1/2023), signifying those entries no longer apply for prior authorization routing as of the listed removal date.

A number of radiation therapy and SRS/SBRT related codes are explicitly noted as Removed 12/31/23 in this segment of the list, indicating they were taken off the prior-authorization routing effective that date.

The list shows examples of codes that were removed from prior authorization requirements on specified dates — for instance, 90870 (ECT) is marked Removed 12/31/23 and several Doppler/transcranial Doppler entries show removal effective 7/1/2023 in the historical notes.

Some entries carry historical annotations such as 'Prior to 9/1/2019 Removed 7/1/2023', indicating the code was subject to prior-auth routing before 9/1/2019 and was later removed from the list effective 7/1/2023 for those specific entries.

The list includes explicit statements that No Prior Authorization is required for MT Medicare Advantage Plan effective 1/1/21 for certain temporary or procedural codes (examples shown in the U/T/T-code segments such as 0163T/0164T/0165T), demonstrating plan-level exceptions embedded in the code list.

Specific temporary and proprietary codes are annotated with addition and removal notes; for example, 0386U is shown as Added 7/1/2023 and then Removed 10/1/23 in the running log, illustrating that some U-/T-codes were later removed from routing or prior-authorization requirements on the listed dates.

Multiple HCPCS and miscellaneous codes are marked with removal notes such as Removed 12/31/23 (for example, select A-/C-/drug-related codes in this excerpt), indicating those entries were removed from prior authorization routing or the list as of that date.

Some imaging/PET codes include explicit non-coverage language for specified uses; for example, 60219 lists 'whole body; melanoma for non-covered indications', which identifies a non-covered indication called out in the listing.

Listed CPT / HCPCS / Proprietary Codes

Listed CPT Codes - Surgical / Cardiac / TransplantCPT

29914	HIP ARTHRO W/FEMOROPLASTY
29915	HIP ARTHRO ACETABULOPLASTY
29916	HIP ARTHRO W/LABRAL REPAIR
30120	REVISION OF NOSE
30400	RECONSTRUCTION OF NOSE
30410	RECONSTRUCTION OF NOSE
30420	RECONSTRUCTION OF NOSE
30430	REVISION OF NOSE
30435	REVISION OF NOSE
30450	REVISION OF NOSE

1–10 of 55

1/6

Imaging / Nuclear Medicine / PET / SPECTCPT

78814	PET IMAGE (listed)
78815	PET IMAGE (listed)
78816	PET IMAGE (listed)
78830	RP LOCLZJ TUM SPECT W/CT 1
78831	RP LOCLZJ TUM SPECT 2 AREAS
78832	RP LOCLZJ TUM SPECT W/CT 2
78999	NUCLEAR DIAGNOSTIC EXAM
79005	NUCLEAR RX ORAL ADMIN
79101	NUCLEAR RX IV ADMIN
79403	HEMATOPOIETIC NUCLEAR TX

Genetic / Molecular / Proprietary Codes - Sequencing & Panelsmixed

81162	BRCA1&2 GEN FULL SEQ DUP/DEL
81164	(Listed)
81165	(Listed)
81166	(Listed)
81167	(Listed)
81173	(Listed)
81174	(Listed)
81185	(Listed)
81186	(Listed)
81189	(Listed)

1–10 of 84

1/9

Molecular / Oncology Panels and Sequencing (HCPCS / Proprietary U-codes/T-codes)mixed

81400	MOPATH PROCEDURE LEVEL 1
81401	(Listed)
81402	MOPATH PROCEDURE LEVEL 3
81403	MOPATH PROCEDURE LEVEL 4
81404	MOPATH PROCEDURE LEVEL 5
81405	MOPATH PROCEDURE LEVEL 6
81406	MOPATH PROCEDURE LEVEL 7
81407	MOPATH PROCEDURE LEVEL 8
81408	MOPATH PROCEDURE LEVEL 9
81410	AORTIC DYSFUNCTION/DILATION

1–10 of 28

1/3

Selected Vascular / Doppler / Peripheral Vascular CodesCPT

92987	(Listed)
93880	(Listed)
93882	(Listed)
93888	(Listed)
93890	(Listed)
93893	(Listed)
93922	(Listed)
93923	(Listed)
93925	(Listed)
93926	(Listed)

1–10 of 21

1/3

Prior Authorization, Documentation & Provider Responsibilities

Prior Authorization

Prior Authorization Required

Prior authorization is required for the CPT/HCPCS codes listed in this section. Before scheduling or performing services, providers must check member eligibility and benefits and obtain any required authorization to avoid denials or retrospective reviews.

This list is not exhaustive — presence of a code does not guarantee coverage. Always verify member benefits prior to services.

Prior Authorization

eviCore Prior Authorization Required

eviCore (vendor) prior authorization is required for many imaging, interventional, genetic and specialty therapy CPT/HCPCS codes in this list. Providers should contact eviCore to request authorization via phone or web.

eviCore phone: 1-855-252-1117
eviCore web: https://www.evicore.com/healthplan/bcbs
Applicable to many CPT/HCPCS and temporary U/T/A codes listed throughout this section.

Background and Purpose

Background: this file is a utilization management code list and does not provide full clinical coverage criteria. It indicates procedures commonly routed for utilization management or prior authorization and the typical supporting documentation requested, but coverage and medical necessity decisions require checking member benefits and the applicable clinical policy.

Key Definitions and Contacts

eviCore-managed highlight — codes in green managed by eviCore requiring contact for preauthorization

Definition: eviCore-managed (green-highlight)Codes highlighted in green are managed by eviCore Healthcare and require contacting eviCore for preauthorization/medical records submission

eviCore contact methodeviCore is the external utilization management vendor listed for many codes; providers must follow eviCore routing instructions

ImplicationPresence of a green highlight means prior authorization decisions and clinical review are handled by eviCore

eviCore vendor contact reference (phone and website)

eviCore phone numberContact eviCore at 1-855-252-1117 for prior authorization or clinical review

eviCore web portal

Policy Update Changes

2024-01-01added_codesLatest

Multiple proton therapy and related codes (examples: 77523, 77600–77620, 77750, 77761–77778 and others) were added to the prior authorization list with effective date 1/1/24 and require history and physical and prior diagnostic reports for prior authorization via eviCore.

2023-12-31removed_codes

Several SRS/SBRT and related radiation delivery codes (examples: 77371, 77373, 77385–77387, 77401–77412, 77423–77425, 77520, 77522–77525) were marked 'Removed 12/31/23' and therefore are no longer routed/managed under this prior authorization list as of that date.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyPrior authorization list for plastic/reconstructive surgery and related procedures

Policy CodePolicy N/A

Change TypeAdded and removed codesvendor routing clarified

Effective Date

Next Review Date

Key ActionContact eviCore (1-855-252-1117 or https://www.evicore.com/healthplan/bcbs) to request prior authorization and submit required documentation.

SourceLink

On This Page

Documentation Required

Prior Authorization and Documentation Required

Certain procedures require both prior authorization and specific supporting documentation. When requesting authorization, submit the required records to demonstrate medical necessity.

Common required documents: recent History & Physical (H&P), operative report, plan of care, and documentation of prior conservative measures where applicable.
Failure to submit required documentation may result in denial or delayed authorization.

Prior Authorization

Prior Authorization — Hematopoietic & Craniofacial/Transplant Procedures

For hematopoietic cell transplant and related procedures (e.g., bone marrow harvest, stem cell harvest), and for craniofacial/cleft reconstructive procedures, prior authorization and transplant-specific documentation are required.

If transplant approval is on record: include date of transplant.
If no transplant approval is on record: submit H&P, transplant evaluation, and date of transplant.
For craniofacial/cleft repairs submit H&P and operative report.

Note

Plan-Specific Exceptions

Some codes in the list are plan-specific exceptions (no prior authorization required). Providers must confirm plan type and follow routing instructions accordingly.

Example exceptions: MT Medicare Advantage and NM Medicare Advantage plans have specific codes noted as No Prior Auth effective on the dates shown in the list.
When a plan-specific No Prior Auth is indicated, follow the member’s plan rules but still verify eligibility and coverage.

Documentation Required

Documentation Requirement for Discography

Discography (e.g., 72291, 72292) requires specific documentation for prior authorization requests.

Required for discography prior authorization: history and physical, and results/reports of previous diagnostic procedures.
Include operative reports or imaging reports when applicable.

Documentation Required

Transplant & Complex Cardiac/Vascular Documentation and Authorization

Transplant, complex cardiac and vascular procedures require prior authorization and detailed documentation. If transplant approval is not on record, submit transplant evaluation and related documents.

If transplant approval on record: include date of transplant.
If no approval: submit H&P, transplant evaluation, and date of transplant.
Include recent H&P, plan of care, operative report, and documentation of medical necessity for complex cardiac/vascular procedures.

Documentation Required

A-code and DME Documentation / Prior Authorization

A-codes (ambulance and many DME/accessory codes) require documentation and, in many cases, prior authorization routed to eviCore. Failure to provide requested clinical records or a Letter of Medical Necessity (LOMN) may result in denial.

Ambulance (A0430, A0435): submit physician order and progress notes for the 24 hours prior to transport.
DME and accessories (E/C codes, E2504–E2510, E1002–E1235, etc.): Letter of Medical Necessity required where noted; include anticipated length of need, functional status, and clinical rationale.
Many A- and E-/C-codes list eviCore contact for prior authorization routing.

Prior Authorization

eviCore Routing for C8900-series and Select C-codes

Some C8900-series and other C-codes (imaging and drug/biologic HCPCS) were historically routed to eviCore for prior authorization. Providers should follow current routing and contact eviCore when indicated.

C8900–C8905 and related MRI/MRA codes list eviCore routing.
Confirm date-based changes noted in the list (historical routing prior to 9/1/2019 or removal dates) and verify current authorization requirements.

Denial Risk

Denial Risk and Routing Compliance

Providers who do not obtain required prior authorization, or who fail to check benefits, risk claim denial or retrospective review. Follow eviCore routing and submit complete documentation with authorization requests.

Denial risk if prior authorization or benefit check is not completed before services.
Failure to follow eviCore prior authorization routing may result in utilization management denial.
Codes removed or with changed routing (see 'Removed' or effective dates in the list) may affect current authorization requirements — confirm status before services.

Denial Risk

Missing Documentation Risk

Missing or incomplete supporting documentation (H&P, operative report, plan of care, conservative care documentation, LOMN, prior diagnostic reports) will increase risk of denial or delay. Ensure all required documents listed per code are submitted with the authorization request.

Examples of commonly required supporting documentation: recent History & Physical, operative report, documentation of conservative measures, results of prior diagnostics, plan of care, and Letters of Medical Necessity when required.
Documentation-linked denial risk exists even for codes removed from prior auth lists — medical necessity still applies.

Prior Authorization

Specialty Therapy & Genetic Testing Authorization Requirements

For selected specialty therapy and advanced testing codes (proton therapy, radiation SRS, genetic/genomic tests, MOPATH/814xx series), prior authorization via eviCore is required and specific supporting documentation must be provided.

Radiation/proton therapy codes (77520–77525, 77600–77620, 77750, etc.): submit H&P and results of previous diagnostic procedures.
Genetic testing / molecular pathology (81402–81408, 81410–81436, etc.): contact eviCore for prior authorization and provide relevant clinical history and test-specific documentation.

Documentation Required

Required Pre-operative and Surgical Documentation

Providers must submit recent History & Physical, operative reports, and documentation of medical necessity for many surgical, reconstructive, spinal and implant procedures. Pre-operative documentation requirements are specified by code.

Pre-op H&P including functional impairment, operative report, and documentation of prior conservative care where applicable.
Spine and implant procedures often require conservative care documentation in addition to H&P and operative report.
Bariatric procedures require H&P, nutritional and psychological evaluations, and documentation of weight-loss attempts and supports.

Note

Authorization Contact & eviCore Routing Guidance

Authorization contact information and routing reminders: when a code lists eviCore, providers should contact eviCore at the phone number or web address shown in the list. Follow plan-specific notes where included.

eviCore phone: 1-855-252-1117
eviCore web: https://www.evicore.com/healthplan/bcbs
Confirm plan exceptions (e.g., MT or NM Medicare Advantage No Prior Auth effective dates) before acting.

Documentation Required

Documentation Requirements for T-/U-/Temporary Codes

Certain T-codes, U-codes and temporary codes require documentation similar to other advanced services (recent H&P, plan of care, and medical necessity). Submit those items with prior authorization requests routed to eviCore when listed.

T-/U-code examples in the list include documentation requirements and eviCore routing; check each code row for details.
Some temporary codes have added or removed effective dates — verify current requirements prior to submission.

Documentation Required

Home Health / Hospice and Speech Device Documentation

Home health and hospice services, and speech-generating devices, require clinical documentation including History & Physical, chart notes, treatment plan, and a Letter of Medical Necessity when noted. Missing clinical documentation may lead to denial.

Home health/hospice services: H&P, chart notes from ordering physician, treatment plan and LOMN.
Speech devices (E2504–E2510) require a Letter of Medical Necessity describing anticipated duration of need, functional status, and condition.
Failure to submit required home health/hospice documentation may result in claim denial.

Documentation Required

Letter of Medical Necessity — Content Requirements

Letter of Medical Necessity (LOMN) content expectations for DME, standing/lift devices, wheelchairs and accessories: include anticipated length of need, clinical rationale, functional status, prior interventions tried, and how the device meets the patient’s needs.

LOMN should describe anticipated duration of use, mobility/functional limitations, prior conservative interventions and their outcomes, and specific rationale for the requested device or accessory.
Incomplete or absent LOMN can cause denial for DME and wheelchair accessory claims.

Note

Removed/Effective Date Risk — Verify Current Status

Codes removed or with effective/removed dates are noted in the list. Providers must confirm the current status of a code (added/removed/changed routing) before submitting an authorization or performing services to avoid erroneous submissions.

Examples: codes removed 12/31/23 or with other removal dates are indicated in the list; verify whether a code remains subject to prior authorization.
Changed routing (historical eviCore routing prior to specific dates) may not reflect current requirements — always confirm.

Or use https://www.evicore.com/healthplan/bcbs to submit requests and supporting documentation

When to contactContact eviCore when a code line indicates routing to eviCore or when required documentation is listed

Transplant approval on record definition and implications for documentation

Transplant approval on record — definitionIf transplant approval is on record, include the date of transplant with the claim; if not, submit history and physical, transplant evaluation, and date of transplant

Implication for documentationFor transplant-related CPTs (e.g., 32851–32856, 33930–33935, 50323–50329), lack of approval on record requires full transplant evaluation documentation

Provider actionConfirm transplant approval status before submitting claims; include transplant date when approval exists

Transplant approval note (definition restated)

Transplant approval noteWhen transplant approval is present, include the date of transplant; when not present, provide history and physical, transplant evaluation, and date of transplant

Applies toApplies to multiple donor and transplant procedures listed throughout the document (heart, lung, liver, renal, intestinal)

ReasonDocumentation ensures appropriate authorization routing and supports medical necessity determinations

eviCore definition (vendor referenced for spine and pain-related codes)

eviCore — definition and roleeviCore is an external utilization management vendor contracted to manage prior authorization and clinical review for many listed codes

Contact details in policyeviCore contact is provided throughout the code list (phone and web portal) and should be used when code lines route to eviCore

ScopeeviCore routing appears for imaging, genetic/molecular tests, spine/pain, and many novel temporary codes

eviCore definition (vendor contracted for imaging and therapy codes)

eviCore contracted roleeviCore is the third-party utilization management vendor contracted to manage prior authorization for many imaging, genetic, and therapy codes listed

Widespread routingMultiple code groups explicitly instruct providers to contact eviCore for authorization or clinical review

Provider implicationFollow eviCore submission requirements and include specified supporting documentation when routing to eviCore

eviCore full contact reference (1-855-252-1117 or https://www.evicore.com/healthplan/bcbs)

Full eviCore contactFor prior authorization or clinical review contact eviCore at 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs

Use for many code typesThis contact is referenced repeatedly for imaging, genetic tests, specialty procedures, and DME routing

When uncertainIf a code line references eviCore or green highlight, use this phone/URL to initiate preauthorization or submit records

eviCore vendor reference (alternate chunk)

Alternate vendor reference in code linesSeveral code entries repeat eviCore contact information in adjacent chunks; providers should use the main eviCore contact when routing is indicated

Redundant referencesThe document includes multiple repeated eviCore lines to ensure visibility across code groups

Practical tipCite the code-level line item and call the provided eviCore number or use the web portal for submission

eviCore vendor designation repeated (contact info across document)

Vendor designation repeatedeviCore is repeatedly designated as the utilization management vendor; follow eviCore routing where specified

Codes coveredRouting includes spine, imaging, genetic, vascular, sleep studies, and many temporary U/T codes

Ensure accurate submissionProvide the required H&P, operative report, plan of care or LOMN as specified on the code line when contacting eviCore

eviCore vendor reference for A-code area

eviCore for A-code areaMany A-codes (A46xx–A70xx range) list eviCore contact for prior authorization and note plan-specific No Prior Auth exceptions; contact eviCore when routing is indicated

ExamplesA4604, A7027–A7034 lines include eviCore contact and MT MA No Prior Auth notes

Documentation noteFollow A-code-specific documentation instructions (e.g., for A0430/A0435 ambulance progress notes) when submitting to eviCore

Letter of medical necessity definition and required elements

Letter of medical necessity — required elementsA Letter of Medical Necessity must include anticipated length of time patient will require the equipment, description of the medical condition requiring the equipment, and mobility/functional status (where applicable)

When requiredRequired for many DME items (E0635, E0638, E0641, E0642, E1012, E1035/E1036, wheelchair codes) per the code line entries

Use in submissionsInclude LOMN with clinical notes and H&P when requesting prior authorization or submitting to eviCore for DME codes

History and physical definition

History and physical — definitionHistory and physical is the clinical document including diagnosis, functional abilities/limitations related to equipment or procedure, duration of condition, and prior relevant interventions (used to support prior authorization)

Where requiredH&P is requested for many surgical, transplant, and DME code lines (e.g., transplant prep codes, reconstructive surgery, bariatric and wheelchair requests)

Submission guidanceAttach the most recent H&P and relevant operative/procedure reports when submitting prior authorization to eviCore

added_and_removed_temp_codes

Many temporary U-/T-/U-like codes were added on various dates and some entries (eg, 0386U) show add/remove activity including 'Added 7/1/2023' and removal notes such as '0386U Removed 10/1/23'.

2023-07-01added_codes

Multiple proprietary and molecular test codes (examples: 0346U, 0379U, 0380U) were recorded as added on 7/1/2023 with eviCore routing indicated.

2023-04-01added_codes

Numerous genomic and multi‑omic codes (examples: 0334U, 0335U, 0336U, 0341U, 0343U, 0345U, 0347U–0350U, 0355U–0356U) were added effective 4/1/2023 and route prior authorization to eviCore.

2022-10-01effective_date_recorded

Select advanced imaging and procedure T-codes and other newly listed services show effective or added dates (examples: several codes with '4/1/2022' and '10/1/2022' noted in the running log).

The list includes effective add and removal dates throughout the document. Providers must observe the per-code add/remove effective dates when submitting authorization requests because routing and prior-authorization requirements change based on those dates.