ModifiedBlue Cross Blue Shield - OklahomaPolicy N/A

Utilization management prior authorization for plastic/reconstructive surgery CPT/HCPCS codes

Lists CPT/HCPCS procedure codes for which benefit prior authorization may be required and specifies documentation to submit; applies to providers submitting claims to Blue Cross Blue Shield - Oklahoma.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyUtilization management prior authorization for plastic/reconstructive surgery CPT/HCPCS codes

Policy CodePolicy N/A

Change TypeCode additions and re-additions with updated documentation requirements

Effective DateSep 1, 2019

Next Review DateN/A

Key ActionObtain prior authorization through eviCore or submit required documentation (recent H&P, plan of care, and Letter of Medical Necessity) per line-item instructions before submitting claims.

SourceLink

POLICY UPDATE CHANGES

Several J-codes were added on various dates (examples: J0739 and J0741 added 10/1/2023; J1304 added 1/1/2024; multiple codes added 1/1/2025).

Some codes were removed effective 12/31/24 and then re-added with new documentation requirements effective 1/1/2025 (examples: J0584, J0881, J0885, J2796, J3262).

220+procedure codes listed (approximate count in this part of document)

eviCoreExternal review vendor referenced

ManyEntries requiring H&P/medical necessity

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MT Medicare AdvantageMT Medicare Advantage exceptions

Coverage and Authorization Criteria

Authorization and documentation conditions

Coverage and authorization stance varies by plan and code; many codes require documentation and/or eviCore review unless noted as 'No Prior Auth required' for MT Medicare Advantage Plan effective 1/1/21.

MT Medicare Advantage Plan exception: For numerous listed CPT/HCPCS codes the MT Medicare Advantage Plan does not require prior authorization effective 1/1/21 (see individual code lines).

Plan-specific 'No Prior Auth required' notes appear on multiple entries.

Prior authorization or eviCore review required: When no plan-specific exception applies, many listed codes require prior authorization or must be routed to eviCore for review (contact: 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs).

Document lines frequently reference eviCore as the authorization vendor.

Required clinical documentation: Submit pre-operative evaluation and a recent History & Physical documenting diagnosis and functional impairment, the operative/procedure report, and any additional code-specific supporting materials (e.g., Doppler results, pathology, photos, weight/height).

Specific required items vary by code and are listed on each code line.

Transplant procedure coverage criteria

Covered when required documentation is provided and prior-authorization conditions are met:

Transplant-related codes: If transplant approval is on record, provide the date of transplant; if no transplant approval on record, submit a recent history and physical, the transplant evaluation, and the date of transplant to support medical necessity and authorization.

Applies to donor/transplant codes such as 32851–32856, 33930–33935, 38204–38242, 47133–47147, 50300–50329, et al.

Vascular and venous procedure coverage criteria

Covered when required pre-operative and operative documentation is provided:

Vascular and venous procedures: Submit a pre-operative evaluation and recent History & Physical, diagnostic study results when applicable (e.g., Doppler), and the operative/procedure report; document functional impairment where specified.

Applies to venous/vascular codes such as 36468, 36470, 36479, 37241, 37500, 37700-series.

Cardiac/thoracic procedure coverage criteria

Covered when clinical documentation and plan of care supporting medical necessity are provided:

Cardiac and thoracic procedures: Provide a recent History & Physical, a plan of care, and documentation of medical necessity prior to authorization as indicated for the listed cardiac/thoracic procedures.

Applies to cardiac CPTs such as 33404–33415, 33471–33478, 33600–33622 and related entries.

Bariatric/gastrointestinal coverage criteria

Bariatric and gastrointestinal procedures require additional preoperative assessments when specified:

Bariatric/gastrointestinal procedures: When indicated, submit a History & Physical plus nutritional and psychological evaluations, documentation of prior weight-loss attempts, and social support information in addition to operative reports and standard pre-op documentation.

Examples include codes 43644–43645, 43770–43775, 43843–43848.

eviCore prior auth routing

Prior authorization and vendor routing

eviCore-managed codes: Many listed CPT/HCPCS/genetic and molecular test codes require prior authorization via eviCore; providers must contact eviCore by phone (1-855-252-1117) or via the eviCore BCBS web portal.

Where a specific line-item states 'No Prior Auth required' for a named plan that exception applies only to that plan member population.

Letters of Medical Necessity / H&P criteria

Documentation requirements for DME and wheelchairs

Letter of Medical Necessity and H&P: For many DME, seating, mobility and wheelchair items submit a Letter of Medical Necessity describing anticipated length of use, diagnosis, mobility status, functional abilities/limitations, duration of the condition, prior experience with similar equipment, and justification; include a History & Physical and any required evaluation findings (e.g., upper extremity strength for power seating accessories).

Examples: E0635, E0638, E0641–E0642, E1010–E1036, E1161, E1220–E1239, E2300–E2373 and related codes.

Recent H&P / Plan of Care requirements

Procedures/drugs requiring Recent H&P and plan of care

Recent H&P and plan of care required: Certain C-codes and other high-acuity services require a recent History & Physical, a plan of care, and documentation of medical necessity to support authorization (submit these with the prior authorization request).

Examples include C9076, C9600, C9739, C9741 which explicitly list Recent H&P and plan of care requirements.

Administrative coverage conditions

Coverage and prior authorization follow per-code administrative rules

Per-code administrative pathway: For each listed J-code follow the specific administrative instruction on the line: either route the request to eviCore for prior authorization OR submit the required documentation (e.g., History & Physical, chart notes from ordering physician, treatment plan and Letter of Medical Necessity) when that documentation pathway is specified.

Some J-codes were removed and re-added with new documentation requirements effective 1/1/2025; providers must follow the current line-item instruction.

Specified drug indication

Drug-specific indication example

Evenity (J3111) indication: Evenity (J3111) is indicated for treatment of osteoporosis in postmenopausal women at high risk for fracture (history of osteoporotic fracture or multiple risk factors) or for patients who have failed or are intolerant to other available osteoporosis therapy; prior authorization is routed to eviCore per the line-item.

Clinical indication and routing appear on the J3111 line.

The policy lists a plan-specific exception stating No Prior Auth required for MT Medicare Advantage Plan effective 1/1/21 for numerous CPT entries. Where this note appears on a code line, providers should not submit prior authorization for members enrolled in that MT Medicare Advantage plan, but must still confirm member eligibility and benefits prior to service.

Multiple code lines reiterate the MT Medicare Advantage Plan exception: No Prior Auth required for MT Medicare Advantage Plan effective 1/1/21. This effective date is applied on the line-level and represents a plan-specific authorization exemption rather than a clinical coverage determination.

In the provided excerpts there are no explicit clinical exclusions listed; the lines focus on administrative routing and documentation requirements rather than on statements that services are excluded from coverage.

Several spine and pain-management CPT lines note that No Prior Auth is required for MT or NM Medicare Advantage Plan for specified codes (with effective dates where shown). For non‑MT/NM members many of these same codes are routed to eviCore for prior authorization, so providers must check the member's plan and follow the line-level instruction.

The policy indicates that A9270 is a non‑covered / not payable item on the listed line. This HCPCS entry is flagged on the line and routed administratively to eviCore for review where indicated.

Many DME/accessory and airway-related HCPCS entries include explicit No Prior Auth notes for certain Medicare Advantage plans or otherwise specify administrative routing to eviCore. Examples in these excerpts show line-level notes such as No Prior Auth required for MT Medicare Advantage Plan effective 4/1/2018 alongside eviCore contact information for other members.

The PET imaging code G0219 is listed as “PET imaging whole body; melanoma for non‑covered indications” and the line refers requests to eviCore for determination; providers should use eviCore for prior‑authorization or medical review for indications not specified as covered.

Within the shown J‑code lines some entries were removed and re‑added with new documentation rules; otherwise these excerpts do not present explicit coverage denials — they focus on the administrative pathway (e.g., eviCore routing) and documentation required for re‑added codes.

Across the sampled cardiac and procedural code lines there are no explicit “not medically necessary” statements in these excerpts; instead the lines emphasize required clinical documentation (recent H&P, plan of care, operative report) to support medical necessity determinations.

Procedure, HCPCS, and Drug Codes

Authorization, Submission, and Denial Risk — Actions for Providers

Prior Authorization

Prior Authorization Required — eviCore Routing

Providers must obtain prior authorization for many procedures listed below. Numerous musculoskeletal, spinal, imaging, genetic, drug and device CPT/HCPCS codes are managed by eviCore — contact eviCore at 1-855-252-1117 or via https://www.evicore.com/healthplan/bcbs to request prior authorization. Check member eligibility and benefits before rendering services; failure to obtain required prior authorization or to submit requested documentation may result in claim denial or delay.

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

Prior Authorization

Spine & Instrumentation Prior Authorization

Spine procedures (fusion, instrumentation, artificial disc, disc removal, spinal implants and related imaging) require prior authorization via eviCore where indicated. Typical required documentation: recent history & physical (H&P), operative report, imaging (MRI/CT), and documentation of conservative treatment attempts. Certain codes have plan-specific exceptions (e.g., MT Medicare Advantage noted in list).

Common spine CPTs routed to eviCore: 22551, 22552, 22554, 22558, 22600, 22612, 22630, 22840–22870, 22853–22859, 22860, 22861–22865

Policy Background and Scope

This document is an administrative utilization management list that identifies CPT/HCPCS codes for which prior authorization or specific supporting documentation may be requested. Its primary purpose is to direct providers to the correct administrative pathway (including contacting eviCore where specified) and to list the documentation elements (e.g., recent history & physical, operative report, Letters of Medical Necessity) that must accompany authorization requests.

Definitions and Vendor Contacts

eviCore — external utilization management vendor contact and portal

eviCore contacteviCore prior-authorization phone: 1-855-252-1117; portal: https://www.evicore.com/healthplan/bcbs.

Services managed by eviCoreMany listed CPT/HCPCS/genetic and imaging codes require prior authorization or medical review routed through eviCore as noted per line-item.

Plan-specific exceptionsWhere a listing states 'No Prior Auth required for MT Medicare Advantage Plan' that plan-specific exception applies instead of eviCore routing.

MT Medicare Advantage Plan prior-authorization exception

MT Medicare Advantage exceptionMultiple entries state 'No Prior Auth required for MT Medicare Advantage Plan effective 1/1/21' (or other effective dates) — a plan-specific prior authorization exception.

Scope of exception

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyUtilization management prior authorization for plastic/reconstructive surgery CPT/HCPCS codes

Policy CodePolicy N/A

Change TypeCode additions and re-additions with updated documentation requirements

Effective DateSep 1, 2019

Next Review DateN/A

Key ActionObtain prior authorization through eviCore or submit required documentation (recent H&P, plan of care, and Letter of Medical Necessity) per line-item instructions before submitting claims.

SourceLink

On This Page

Artificial disc codes (e.g., 22860, 22864, 22865) — added dates noted where applicable (e.g., 22860 added 4/1/2023)

Documentation: recent H&P, plan of care, conservative treatment history, operative report, imaging studies

Prior Authorization

Instrumentation / Artificial Disc Prior Authorization

Instrumentation and artificial disc procedures require eviCore prior authorization when indicated. For artificial disc removal or revision, submit a recent history & physical, plan of care, and clear documentation of medical necessity. Some instrumented device insertions (e.g., 22840–22847, 22853–22859) are routed to eviCore; check code-level notes and effective dates.

Codes: 22840, 22841, 22845–22848, 22853–22859, 22861–22868
For removal/revision codes (22864, 22865): Recent H&P, plan of care, and medical necessity documentation required
Note: Some codes have MT Medicare Advantage exceptions effective 1/1/21

Prior Authorization

Cardiac / Thoracic Prior Authorization and Documentation

Cardiac and thoracic surgical procedures (including valve replacement/revision, conduit preparation, transplantation procedures) require prior authorization and submission of recent H&P, plan of care, and documentation of medical necessity. Failure to submit these materials may lead to denial.

Representative CPTs: 33404–33411, 33471, 33474–33478, 33600–33622, 33930–33945, 33940–33945
Required documentation: Recent history & physical, plan of care, documentation of medical necessity, operative report where applicable
Transplant-related cardiac/lung codes: if transplant approval is on record, provide date of transplant; otherwise submit full transplant evaluation and date of transplant

Prior Authorization

Transplant / Donor Prior Authorization and Required Dates

Transplant and donor procedures require prior authorization and special documentation. If transplant approval is already on record, provide the transplant date. If not, submit recent H&P, full transplant evaluation, and the planned transplant date. Missing transplant approval or documentation can result in denial.

Affected codes include donor and transplant CPTs (e.g., 32851–32856, 33930–33935, 33940–33945, 38204–38206, 38230, 38232, 38240–38242, 48550–48556, 50300–50380, 48554, 48556)
If approval on record: supply Date of Transplant
If no approval: submit history & physical, transplant evaluation, and date of transplant

Prior Authorization

Venous Procedure Authorization & Documentation

Venous procedures (sclerotherapy, endovenous laser, embolization, ligation/stripping, and other venous surgeries) require prior authorization and submission of pre-operative evaluation, H&P, operative report, and diagnostic study results (e.g., Doppler). Missing pre-op vascular documentation may trigger denial.

Representative CPTs: 36468, 36470, 36479, 37241, 37500, 37565, 37650, 37700, 37718, 37722, 37735, 37760–37761, 37780, 37785
Required docs: Pre-op evaluation, history & physical including Doppler results when indicated, operative report

Documentation Required

Prior Authorization — Documentation Requirements

Many listed procedures require prior authorization and specific documentation to support medical necessity: history & physical (H&P), recent pre-operative evaluation, operative report, plan of care, results of diagnostic studies, and letters of medical necessity for DME and select drugs. Submit all requested records with the authorization request to minimize denial risk.

Common required items: Recent H&P, pre-operative evaluation, operative report, plan of care, diagnostic imaging/study results, documentation of conservative treatment where noted
DME/accessory requests often require a Letter of Medical Necessity (LOMN) and H&P — see wheelchair and accessory codes (E1002, E1010, E2300, E2301, etc.)

Note

Effective Dates, Additions, and Plan-Specific Exceptions

Some codes have effective-date driven additions or removals and plan-specific exceptions (for example, additions on 1/1/2020, 4/1/2023, 1/1/2024, 1/1/2025; MT Medicare Advantage exceptions noted for many spine and other codes effective 1/1/21 or earlier). Verify the code list for updates and the member's plan to confirm whether an exception applies.

Examples of date changes: 22860 added 4/1/2023; multiple molecular/genomic codes added 1/1/2020–2025; imaging and device codes have various effective dates noted
MT Medicare Advantage Plan exceptions: many eviCore-managed CPTs show 'No Prior Auth required for MT Medicare Advantage Plan effective 1/1/21' — confirm for each code and plan

Documentation Required

Documentation Timing and Pre-Procedure Evidence

Always submit documentation dated prior to the procedure date as required (recent H&P, pre-op evaluation, operative report when available). For procedures added with specific effective dates, use the effective date shown for prior authorization requirements. Missing or untimely documentation is a frequent cause of denials.

Submit recent H&P and pre-operative evaluation prior to the procedure date
Operative report should be included for revisions or when specified
For some procedures (e.g., corneal transplant, cochlear implant, implantable hearing devices) include prior use of conservative measures or hearing aids and level of impairment

Denial Risk

Denial Risk — Authorization & Documentation Consequences

Failure to check eligibility, obtain required prior authorization, or submit complete documentation (H&P, operative report, imaging, LOMN, transplant approval/date, plan of care) increases the risk of claim denial or payment delay. For many codes eviCore pre-authorization is required — missing eviCore authorization is a common denial trigger.

Denial risks: missing prior authorization, missing required H&P or operative report, absent transplant approval/date, absent diagnostic study results (e.g., Doppler for venous cases)
Action: Verify member eligibility and benefits, route priors to eviCore when indicated, and attach all requested clinical documentation

Prior Authorization

How to Request Authorization — Contact & Portal

How to request authorization: Contact eviCore by phone at 1-855-252-1117 or submit requests through the eviCore web portal at https://www.evicore.com/healthplan/bcbs. For procedures not routed to eviCore or when plan notes indicate 'No Prior Auth required' for specific Medicare Advantage plans, follow payer portal instructions and include required documentation.

eviCore phone: 1-855-252-1117
eviCore portal: https://www.evicore.com/healthplan/bcbs
If MT Medicare Advantage exception applies, no prior auth may be required for listed codes — verify prior to submission

Documentation Required

Service-specific Documentation Expectations

Additional documentation requirements by service type: for fusion procedures provide H&P, imaging, and documentation of prior conservative treatment; for artificial disc removal provide recent H&P, plan of care and medical necessity; for bariatric procedures include H&P, nutritional and psychological evaluations; DME and wheelchair/accessory requests require H&P and a Letter of Medical Necessity with device-specific details.

Fusion procedures (e.g., 22800–22812, 22840 series): H&P, operative report, conservative treatment documentation
Artificial disc removal (22864, 22865): Recent H&P, plan of care, medical necessity
Bariatric (43644–43645, 43770–43775): H&P, nutritional and psychological evaluations, documentation of weight loss attempts and supports
Wheelchair/accessories (E1161, E1002, E2300, E2301): detailed H&P describing abilities, duration, prior equipment experience, and LOMN

Applies only to the MT Medicare Advantage Plan and only for the codes explicitly labeled with the 'No Prior Auth required' note.

Check member benefitsProviders must verify member's plan and effective dates as the exception is plan-specific and time-limited.

Transplant approval on record — definition and required documentation

Definition: transplant approval on recordIf transplant approval is on record with the payer, providers should supply the date of transplant rather than the full transplant evaluation packet.

If not on recordIf no transplant approval on record, submit history and physical, transplant evaluation, and date of transplant to support prior authorization.

Applies to specific codesThis requirement applies to transplant-related CPTs (examples: 33930, 33933, 33935, 38204–38242, 47133–47146, 50300–50329).

Pre-operative evaluation — definition and typical components

Pre-operative evaluation definitionA clinical assessment including history and physical examination and, when applicable, diagnostic studies documenting the indication and functional impairment for the procedure.

Typical componentsMay include H&P, diagnostic test results (e.g., Doppler for venous procedures), documentation of conservative measures, and operative plan.

When requiredRequired prior to authorization for many surgical entries and specifically called out for vascular/venous and other procedures in the listing.

eviCore — imaging prior authorization vendor (definition)

eviCore vendor roleExternal prior-authorization vendor contracted to manage reviews for many imaging, molecular/genetic, and procedure codes listed in this policy.

Contact detailsPhone: 1-855-252-1117; Web portal: https://www.evicore.com/healthplan/bcbs.

Per-code routingMany line-items indicate eviCore review; follow the code-specific instruction (eviCore vs. plan-specific exception).

eviCore — named utilization management/prior authorization vendor

Named vendor and contacteviCore — contact 1-855-252-1117; portal https://www.evicore.com/healthplan/bcbs.

Applies to many codesListed HCPCS/CPT/drug/genetic codes reference eviCore as the prior-authorization reviewer; follow per-line instructions.

Exception handlingIf a line explicitly notes 'No Prior Auth required for MT Medicare Advantage Plan', that exception supersedes eviCore routing for that plan member.

History and physical — expected contents when requested

History and physical expected contentsShould include diagnosis, abilities and limitations related to the requested equipment, duration of condition, prior experience with similar equipment, and relevant exam findings (e.g., upper extremity strength for power seating/standing accessories).

DME-specific detailsFor wheelchairs and accessories, include justification of mobility limitations, anticipated duration of use, and brand/model details when requested.

Use with Letter of Medical NecessityH&P often accompanies a Letter of Medical Necessity for DME requests as specified per code lines.

Evenity (J3111) — indication and summary

Evenity (J3111) indication summaryEvenity is indicated for treatment of osteoporosis in postmenopausal women at high risk for fracture (history of osteoporotic fracture or multiple fracture risk factors) or patients who have failed or are intolerant to other osteoporosis therapies.

Prior authorization routingeviCore referenced as reviewer for J3111 (contact and portal provided).

Effective date noteListing shows effective/prior-auth date of 1/1/2021 for J3111.