Prior authorization requirements for surgical and related procedure codes
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This document lists CPT/HCPCS procedure codes for which prior authorization may be required for Blue Cross Blue Shield - Oklahoma members and specifies the medical record documentation needed when requesting authorization.
Multiple CPT codes and several 'Unlisted' codes were added with effective dates of 1/1/2026 and 4/1/2026.
Some codes were noted as being insourced from EviCore with an effective date of 1/1/2026.
Specific transplant and donor procedure codes require transplant approval on record or additional transplant documentation.
Several codes were marked as 'replacement code 4/1/2026' where short descriptions were not yet available (e.g., 37254–37261, 37262–37299 series).
Multiple unlisted and specialty procedure codes were added with Effective Date 1/1/2026 (e.g., 37254–37299 series, 38129, 38589, 38999, 39499, 39599, 41512, 41874, 41899, 43289, 43497).
Multiple HCPCS/CPT/HCPCS-level codes were added with associated medical records requirements and effective dates (examples: A2029, A9543, C1762, C9257, C9363, C9487, E0635, E0732–E0739, E0767, E1390, G0277, G0379, G0410, G0411, J0174).
Multiple J- and K- procedure codes were added (effective dates mostly 4/1/2026 and several earlier dates).
Several codes were insourced from Evicore with effective/insource notes (e.g., J9332, J9333, J9334, J9376).
Medical records request requirements for each listed code specify history and physical, chart notes from ordering physician, and treatment plan including condition being treated.
Multiple HCPCS codes (e.g., L5984, L6700, Q2017, Q2043, Q2050, Q2055, Q4101–Q4217 and others) were added to the Utilization Management Process list with specified effective dates.
Coverage and Documentation Conditions
Authorization and documentation criteria
Prior authorization applicability and required supporting documentation (as listed) govern coverage determination for the following procedure groups.
Applies to codes listed in this partial extract.
See code-specific entries for exact documentation items.
Coverage conditioned on documentation and medical necessity
Covered when required documentation is submitted and prior authorization/medical necessity is established
Applies per-code as listed in the document.
Documentation-based coverage adjudication
Coverage for listed DME/prosthetic items is contingent on submission of required documentation.
If documentation is not provided, claim may be denied or medical records requested.
Documentation-based coverage condition
Covered when ALL of the following are provided
These three items are required for review/coverage of listed Q- and many other procedure codes; T1000–T1002 additionally require chart notes for each home visit and notes for each discipline when benefit applies to select groups.
The presence of a CPT or HCPCS code on this utilization management list does not necessarily indicate coverage under a member's benefits contract. Member benefits and eligibility vary by policy; providers must check eligibility and benefits first before rendering services to confirm whether a given service is covered or requires additional authorization. Unless an alternate effective date is shown, prior authorization requirements on this list are effective Jan. 1, 2026.
The extracted sections primarily enumerate per-code medical records request information (for example: history & physical, statement of medical necessity, chart notes, operative reports) but do not contain an explicit coverage determination for each code within these chunks. Providers should treat the entries here as documentation requirements to support any authorization or medical necessity review rather than as standalone coverage approvals.
Within this extraction window the content is limited to documentation requirements and effective date annotations for listed codes (for example: pre-operative evaluation, H&P, operative report, and the Effective Date field). There are no detailed clinical coverage criteria included in these chunks; follow the per-code documentation guidance when preparing prior authorization requests.
No explicit exclusions are stated in the extracted segments provided here. The material lists required records and effective dates for many codes (including transplant- and device-related entries), but it does not enumerate clinical or benefit exclusions in this portion of the document.
This segment does not list specific clinical exclusions. Instead, it specifies the documentation required to support medical necessity for DME, prosthetic, and other codes (e.g., recent history & physical, plan of care, Letter of Medical Necessity) and notes that benefit determination depends on submitted records and member coverage.
The T-code entries (for example, T1000–T1002) indicate that these home nursing/RN assessment/service codes are a benefit for select groups only. Chart notes for each home visit and discipline are required when requesting authorization or submitting medical records for these codes.
Checking eligibility and/or obtaining prior authorization is not a guarantee of payment. Final payment is determined when the claim is received and is subject to the member’s eligibility and the terms of the certificate of coverage, including any exclusions or limitations. Contact the phone number on the member ID card with questions about individual coverage.
In this extraction window there are no explicit 'not medically necessary' statements. The document focuses on what documentation must be submitted to support medical necessity determinations rather than listing conditions that are categorically not medically necessary.
Adjudication for the listed codes relies on the submitted documentation to establish medical necessity. For many entries the required set includes a recent history & physical, the plan of care, and documentation of medical necessity (or a Letter of Medical Necessity for some DME/L-codes). If the requested records are not provided, the payer may deny the request or issue a medical records request; the extracted segments do not list enumerated clinical exclusions in this window.
Listed CPT/HCPCS Procedure and Supply Codes
| 67909 | REVISE EYELID DEFECT |
| 67911 | REVISE EYELID DEFECT |
| 67999 | Unlisted procedures related to the eyelids |
| 69714 | IMPLANT TEMPLE BONE W/STIMUL |
| 69717 | TEMPLE BONE IMPLANT REVISION |
| 69930 | IMPLANT COCHLEAR DEVICE |
| 76497 | CT PROCEDURE |
| 76498 | MRI PROCEDURE |
| 77399 | Unlisted procedure, medical radiation physics/dosimetry/treatment devices |
| 77499 | Unlisted procedure, therapeutic radiology treatment management |
| A0430 | AMBULANCE SERVICE, CONVENTIONAL AIR, TRANSPORT, ONE WAY (FIXED WING) |
| A0431 | Rotary wing air transport |
| A0435 | FIXED WING AIR MILEAGE, PER STATUTE MILE |
| A0999 | Unlisted ambulance service |
| A2001 | Innovamatrix ac per square centimeter |
| A2002 | Mirragen advanced wound matrix per square centimeter |
| A2005 | Microlyte matrix per square centimeter |
| A2006 | Novosorb synpath dermal matrix per square centimeter |
| A2007 | Restrata per square centimeter |
| A2008 | Theragenesis per square centimeter |
| C1821 | INTERSPINOUS PROCESS DISTRACTION DEVICE (IMPLANTABLE) |
| C1826 | Generator neurostimulator (implantable), rechargeable |
| C1827 | Generator neurostimulator (implantable), non-rechargeable |
| C1849 | Skin substitute, synthetic |
| C8902 | Magnetic resonance angiography w/o then w/ contrast, abdomen |
| C9363 | Skin substitute Integra Meshed Bilayer Wound Matrix per sq cm |
| C9399 | Unclassified drugs or biologicals, Non Oncology |
| C9757 | Laminotomy with annular closure device implantation |
| E0468 | Home ventilator, dual-function respiratory device |
| E0530 | Electronic positional OSA treatment with sensor |
| E0616 | Implantable cardiac event recorder with memory |
| E1002 | WHEELCHAIR ACCESSORY, POWER SEATING SYSTEM, TILT ONLY |
| E1004 | Wheelchair accessory, recline only |
| E1161 | MANUAL ADULT SIZE WHEELCHAIR, INCLUDES TILT IN SPACE |
| E2298 | Complex rehabilitative power wheelchair accessory, power seat elevation |
| E2300 | Wheelchair accessory, power seat elevation system |
| E2599 | Accessory for speech generating device, not otherwise classified |
| G0151 | Physical therapist services in home health/hospice, each 15 minutes |
| G0152 | Occupational therapist services in home health/hospice, each 15 minutes |
| G2082 | Office visit with esketamine up to 56 mg, includes observation |
| G2083 | Office visit with esketamine >56 mg, includes observation |
| G0422 | INTENSIVE CARDIAC REHABILITATION; WITH/WITHOUT CONTINUOUS ECG MONITORING WITH EXERCISE |
| G0423 | INTENSIVE CARDIAC REHABILITATION; WITHOUT EXERCISE |
| 69999 | Unlisted procedures related to the ear/temple/implant area (placeholder) |
| 77399 | Unlisted procedure, medical radiation physics/dosimetry/treatment devices |
| 77499 | Unlisted procedure, therapeutic radiology treatment management |
| 77799 | Unlisted Clinical Brachytherapy |
| 81479 | UNLISTED MOLECULAR PATHOLOGY |
| 81599 | UNLISTED MOLECULAR/GENOMIC |
| 86849 | Unlisted immunology procedure |
Prior Authorization Steps, Required Records, and Denial Risks
Eligibility and benefits check
Check member eligibility and benefits before rendering services. Prior authorization may be required for many listed CPT/HCPCS/Q-codes; presence on the list indicates a possible prior authorization requirement but does not guarantee coverage. Authorization or eligibility checks are not a guarantee of payment — benefits are determined at claim adjudication.
- Verify member eligibility and benefits prior to scheduling or performing services.
- If unclear, contact the number on the member ID or BCBSOK customer service.
Arthroscopy codes and insourcing
Arthroscopy (including shoulder and knee arthroscopy CPTs and unlisted arthroscopy codes) and many injection/drug requests are insourced to eviCore effective 1/1/2026. Use eviCore for prior authorization where indicated (follow eviCore submission instructions).
- Affected codes include multiple 298xx shoulder arthroscopy codes and 29870–29874, 29882–29884, and 29999 (unlisted arthroscopy).
- Insourced to eviCore effective 1/1/2026 (green-highlighted codes on original list).
Added procedure codes requiring review
Many procedure codes were added effective 1/1/2026 (and some replacement/added dates in 4/1/2026) and require pre-operative documentation and review. For newly added or unlisted procedure codes, submit a current history & physical (H&P) plus the operative/procedure report when available.
Transplant prior authorization/document submission
Transplant-related codes require that if transplant approval is already on record you provide the date of transplant; if no prior approval exists submit full transplant documentation including H&P and the transplant evaluation. Failure to provide transplant-specific documentation may trigger denial.
- When approval exists: include Date of Transplant on request.
- If no approval: submit recent History & Physical, transplant evaluation, and date of transplant.
- Applies to donor, preparation, and transplant CPTs (e.g., 32851–32856, 33930–33945, 47133–47147, 50300–50370, 48551–48556, 51580, etc.).
Bariatric prior authorization requirements
Bariatric procedures (laparoscopic gastric bypass, sleeve, gastric banding and related device procedures) require thorough pre-authorization documentation: history & physical, nutritional and psychological evaluations, documentation of prior weight loss attempts, and social supports.
Renal transplant prior auth notes
Renal and other abdominal transplant codes: if transplant approval exists, include the transplant date; if not, submit H&P, transplant evaluation and transplant date. New renal transplant CPTs added/modified may have updated effective dates and documentation expectations.
Newly added therapy/device codes
Many newly added therapy, device, and DME codes require a recent H&P plus a Letter of Medical Necessity (LOMN) and a treatment/plan of care. For implantable devices and advanced therapies, include plan of care and documentation of medical necessity.
- Examples: E0732–E0739, E0747–E0760 additions; E3200 and other rehabilitation systems (added 4/1/2026).
- DME and prosthetic codes (K- and L-codes) require LOMN and recent H&P/plan of care.
Injectable medication prior auth
Injectable medications and biologics (many J-, Q-, and Q5xxx codes) require submission of a recent History & Physical, ordering physician chart notes, treatment plan including condition being treated, and a Letter of Medical Necessity. Many of these were insourced to eviCore effective 1/1/2026.
- Examples: J0174–J0185, J0222–J0225, J0490–J0517, J0585–J0586, J2354–J2506, J9173–J9181, Q5103–Q5112, Q5153–Q5159, Q9996–Q9999.
- Provide H&P, chart notes from ordering physician, treatment plan, and Letter of Medical Necessity; follow eviCore routing when code is insourced.
Prior authorization documentation required
General required documentation for most prior authorization requests: a recent History & Physical (H&P), documentation of medical necessity, a treatment plan or plan of care, and ordering provider chart notes. Missing required records may result in denial.
- Standard documentation set: Recent H&P, statement/letter of medical necessity, treatment plan/plan of care, and relevant prior conservative therapy notes or diagnostic results.
- Requests missing these elements are at risk for denial.
Prior authorization required for J-codes (selected examples)
Selected J-codes and biologic/infusion drug codes require prior authorization with H&P, chart notes and treatment plan. Some J-codes are insourced to eviCore and must follow their submission process.
Prior authorization required for K-codes
K-codes for wheelchairs and power mobility devices require recent H&P, plan of care, and documentation of medical necessity. For complex or custom power mobility, include functional assessments and anticipated length of need.
Prior authorization for listed L-codes
Listed L-codes and prosthetic/orthotic items require a Letter of Medical Necessity and supporting clinical information (recent H&P, plan of care, functional status and expected duration of need). Failure to include these may cause denial.
Prior authorization for listed implantable/device/drug Q-codes and advanced wound products
Implantable devices, specialized drugs, and advanced biologic wound products (many Q-codes and Q4xxx–Q41xx series) require prior authorization with recent H&P, plan of care, and documentation of medical necessity. Many wound/advanced biologic products added 1/1/2026 require the standard documentation set.
- Examples: Q0138, Q2041–Q2056, Q4101–Q4217, Q4150–Q4188 series added 1/1/2026.
- Submit H&P, plan of care, documentation of medical necessity, and if applicable operative or procedure reports.
Codes requiring medical records for authorization
Specific codes require code-level medical records along with H&P and statement of medical necessity. For cardiac and vascular procedures submit H&P, plan of care, and documentation of medical necessity; for certain vascular codes (e.g., 37241) include Doppler study results and the operative report.
Ambulance transport documentation
For ambulance and transport claims supply complete transport documentation (medical necessity for transport, times, pickup/drop-off, clinical notes). Missing ambulance documentation may trigger denial.
- Provide clinical justification for transport level and origin/destination.
- Ensure relevant chart notes and ambulance records accompany the authorization request or claim.
Procedure-specific required documentation (skin grafts, eyelid, breast, maxillofacial, spine)
For code-specific requests (skin grafts, eyelid/skin excision, breast procedures, maxillofacial, neck/thorax/spine, corneal transplant, eyelid/brow repairs) include pre-operative evaluation, history & physical, operative/procedure report, and documentation of functional impairment or medical necessity.
- Skin grafts (1527x series): recent H&P, plan of care, and documentation of medical necessity.
- Eyelid/eyebrow repairs and excisions (67900–67911 and 67999): pre-op evaluation, H&P, and operative report.
- Breast and maxillofacial procedures: H&P, operative report, and documentation of medical necessity/functional impairment where applicable.
Doppler and other diagnostic results required for select codes
Supply diagnostic results when specifically requested by code: e.g., Doppler study results must be included for 37241. Omissions of requested diagnostic reports or operative notes increase denial risk.
- 37241 explicitly requires Doppler results plus pre-op H&P and operative report.
- Always attach the diagnostic study or imaging report referenced in the code-level requirements.
Insufficient pre-op or missing documentation risk / Denial risk for missing authorization/documentation
Missing required pre-op, operative, or code-specific documents (H&P, operative/procedure reports, transplant evaluations, LOMN, treatment plan, ordering provider chart notes) may result in claim denial. Requests should be complete at time of submission to avoid processing delays.
- Incomplete supporting records for unlisted or newly added procedures often trigger denials.
- Documentation-triggered denials are a known risk; include all items listed in the code-specific request instructions.
Transplant-specific documentation (including pancreas/kidney/donor liver)
When a prior authorization approval exists for a transplant or transplant-related procedure, include the approval record/date of transplant on the request; if not available submit the full transplant evaluation, H&P and date. Donor liver, pancreas, and abdominal procedure requests have specific transplant documentation expectations.
- Donor and transplant CPTs (e.g., 47133–47147, 48551–48556, 49329) require transplant-specific documentation as noted.
- Pancreas/kidney transplant documentation: if approval exists, provide transplant date; if not, include full H&P and transplant evaluation.
Supplies, injection, DME and prosthetic documentation
For requests that reference supplies, injections, or implantable items include product identifiers, quantity, frequency, and clinical justification. For DME and prosthetics include a Letter of Medical Necessity and recent H&P/plan of care.
eviCore-managed prior authorization routing
eviCore-managed services (proton therapy and many specialty injections/infusions) require authorization via eviCore — contact eviCore at 1-855-252-1117 or through the eviCore provider portal. Follow eviCore routing/process for insourced codes.
Policy Scope and Purpose
Background: This document is an administrative prior authorization list covering a broad range of surgical, device, and procedural codes across specialties (including plastic/reconstructive, spine, orthopedic, transplant and others). It identifies codes for which prior authorization may be required and specifies the medical-records elements expected when seeking authorization or medical necessity review.
Key Terms and Annotations
Policy Updates and Material Changes
Multiple CPT/HCPCS codes (including replacement vascular codes and numerous L-/J-/K-/Q- series entries) were added with effective dates of 4/1/2026 requiring prior authorization and specified medical-record documentation.
Numerous CPT and HCPCS codes were added or moved into payer management with an effective date of 1/1/2026, and many require submission of history & physical, plan of care, and documentation of medical necessity for authorization.
Select procedure and drug codes were insourced from eviCore effective 1/1/2026, changing prior-authorization routing and reviewer for those codes.
Newly added transplant and donor procedure codes require transplant approval on record or submission of transplant evaluation, date of transplant, and related H&P for authorization.
Some specific code entries (replacement or device-related) show alternate effective dates (examples include entries effective 10/1/2025) noted in the listing.
Multiple vascular replacement codes (e.g., 37254–37263 series) are annotated as replacement codes effective 4/1/2026 and may have short descriptions updated on that date.
Certain renal transplant procedure codes (example: 50360) were added or modified with an effective date of 4/1/2026 and carry transplant-specific documentation requirements.
Primary effective date for many additions and documentation/prior-authorization requirements in this utilization-management listing is Jan. 1, 2026.
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