Covered when documentation requirements and prior authorization conditions are met for the listed CPT codes.
General requirement: Provider must submit required documentation and obtain prior authorization where indicated for the listed CPT/HCPCS codes.document submission and prior authorization where noted
Required documentation commonly includes a recent history and physical, plan of care, operative report, and any code‑specific studies or evaluations (e.g., Doppler results, sleep study/CPAP trial, transplant evaluation). See code group entries for exact documentation items.
Transplant‑related procedures: For transplant or donor procedures, if a transplant approval date is on record submit the Date of Transplant; if no transplant approval is on record, submit a recent history and physical, transplant evaluation, and the date of transplant.transplant approval on record OR H&P + transplant evaluation + date of transplant
Applies to listed transplant and donor CPTs (examples in document include 33930, 33933, 33935, 33940, 33944, 33945, 38204–38242, 47133–47147, 48550–48556, 50300–50380).
Cardiac valve procedures: For cardiac valve revision/replacement procedures, submit a recent history and physical, plan of care, and documentation of medical necessity.recent H&P, plan of care, documentation of medical necessity
Examples include CPTs 33463–33478 and related valve procedure codes.
Vascular and venous procedures: For vascular and venous procedure codes, submit pre‑operative evaluation, history and physical (including results of Doppler studies where indicated), and the operative report.pre‑operative evaluation, H&P including study results, operative report
Applies to codes such as 36468, 36470, 36479, 37241, 37500, 37650, 37700 series.
ENT, cleft, and upper airway procedures: Submit history and physical and operative report; for certain airway procedures include sleep study results and CPAP trial documentation when specified.H&P, operative report, sleep study/CPAP results when required
Examples: 40700–40761, 41512, 41530, 42145, 42200–42225.
Bariatric procedures: For bariatric and related procedures, prior authorization requires history and physical, nutritional and psychological evaluation, documented weight loss attempts, and social supports.H&P, nutritional & psychological evals, documented weight loss attempts, social supports
Examples include 43644–43645, 43770–43775, 43843–43848, 43886, 43888.
Spine and epidural procedures: When eviCore routing is indicated, prior authorization must be obtained through eviCore (phone or web) for the listed spinal and epidural CPTs; submit history and physical and operative report as specified.prior authorization via eviCore when routed
See spine code group entries (examples: 62263, 62280–62327, 63001–63035) for individualized notes and any Medicare Advantage exceptions.
Documentation items (code‑specific — ONE or more may apply): Provide one or more of the following as required by the specific code: recent history and physical; operative report; plan of care; diagnostic study results (e.g., Doppler, sleep study); pathology or grams of tissue removed (for reduction mammaplasty); Letter of Medical Necessity documenting anticipated length of use and functional status (for many HCPCS E‑codes).
Prior authorization routing and contact: When a code is indicated as routed to eviCore, providers must obtain prior authorization from eviCore by phone at 1‑855‑252‑1117 or via https://www.evicore.com/healthplan/bcbs.
Failure to obtain required prior authorization or to submit required documentation may result in claim denial.
Exceptions and non‑covered items: Follow plan‑specific exceptions noted in the code lists (for example certain T‑series/U‑codes show 'No Prior Auth required for MT Medicare Advantage Plan'); A9270 is listed as non‑covered. When an exception is listed for a code, follow the exception language for that payer/plan.