Blue Cross OK Medicare Advantage Prior Auth Update

Coverage Criteria and List Notes

Prior authorization and documentation requirement

Covered when ALL of the following are met

Prior authorization and documentation: Attending physician obtains prior authorization for the services listed; submit required medical records (pre-operative evaluation, history & physical including functional impairment, operative report, and any code-specific documentation).

Except in urgent situations authorization must be obtained prior to service

The document is a payer-maintained prior authorization list effective 1/1/2024. The presence of a CPT or HCPCS code on this list does not guarantee coverage under a member's benefits contract; providers must always verify eligibility and benefits for the member prior to rendering services. The attending physician is required to obtain prior authorization for listed services except in urgent situations, and contact information for assistance is provided in the header (Customer Service and plan contacts).

When prior authorization or a medical-records request is indicated for a code, the listing specifies required documentation (for example: pre-operative evaluation, history and physical including functional impairment, operative report, and any code-specific items). Many entries also direct providers to eviCore for prior-authorization routing and submission instructions (phone and web portal).

The list notes that certain codes were removed from the active prior-authorization entries on specified dates. For example, 33208 is shown as Removed 1/1/2023, several miscellaneous molecular codes (e.g., 0012U, 0013U) were Removed 4/1/2023, and 0053U was Removed 10/1/2023.

Providers should treat a 'Removed' notation as an explicit removal of that code's prior-authorization entry as of the stated date and confirm current routing/coverage rules with the plan.

When an entry is marked 'Removed 1/1/2023' in the listing, it indicates that the prior-authorization/medical-records requirement for that code (or the eviCore routing instruction) was removed effective that date. Examples in the extract include procedural codes such as 33208 and vascular entries showing the same removal notation.

Check the entry date and any accompanying notes to determine whether removal refers to the code itself or previously applied eviCore routing or documentation requirements.

Several entries identify plan-specific exceptions stating 'No Prior Auth required for MT Medicare Advantage Plan'. For example, spine/pain and related codes routed to eviCore (e.g., 62263, 62264) include this note, as do multiple vascular and duplex study codes that list the MT Medicare Advantage exception with effective dates.

These plan-specific exemptions apply only to the named Medicare Advantage plan and effective dates shown; providers must still verify member-level coverage and whether other submission requirements (such as medical-records requests to eviCore) remain applicable.

The listing also documents No Prior Auth required for NM Medicare Advantage Plan for some items. Examples include 74712 and 74713, where the entry states No Prior Auth required for NM Medicare Advantage Plan effective 11/1/2018 and still references eviCore as the medical-records/prior-auth contact.

Plan-level exceptions for NM Medicare Advantage are displayed per-code with the effective date noted; providers should confirm whether the member’s plan and effective date match the exemption before assuming no authorization is required.

A group of radiation and nuclear procedure codes previously referenced eviCore for prior authorization have entries marked Removed 12/31/23. Examples include radiation delivery and brachytherapy codes such as 77387, 77401, 77402, and related codes that show the historic eviCore routing removed effective 12/31/23.

Where prior eviCore routing was removed, providers should verify current authorization requirements and submission channels with the plan before proceeding.

The document contains multiple groupings of codes and grouped removals/changes. For example, clusters of molecular/genomic and oncology-related U-codes and T-codes are listed together with eviCore routing and show a mixture of additions and removals across dates (added 10/1/2023 entries and removals on 4/1/2023 or 10/1/2023 are noted).

When codes are presented in grouped blocks, accompanying notes indicate whether the group uses eviCore for prior authorization, includes plan-specific exceptions, or reflects effective-date changes — review the group header and per-code notes for the exact status.

Numerous individual codes across the listing are marked as 'Removed' with specific removal dates. Examples in the extract include 90870 (Removed 12/31/23), 93880 and 93882 (Removed 7/1/2023), and vascular duplex codes such as 93978 (Removed 7/1/2023).

Each 'Removed' notation includes the effective removal date in the entry; providers should use that date to determine whether prior-authorization requirements remain active for a given code.

The extract includes examples of codes for which the listing explicitly notes No Prior Auth required for MT Medicare Advantage Plan along with effective dates. Examples include 62263 (spine/pain entry) and spinal implant/infusion device codes such as 62351 and 62360 which reference the MT Medicare Advantage exception.

Where such exceptions are present, they commonly include the effective date in the per-code entry; confirm the member’s plan and enrollment date before relying on the exception.

The extract shows multiple codes marked 'Removed' on different dates; examples include molecular/genomic codes like 0012U (Removed 4/1/2023), 0053U (Removed 10/1/2023), and oncology-related codes added and then removed within 2023 (e.g., 0386U added 7/1/2023 then Removed 10/1/23).

These date-specific removals mean the prior-authorization or eviCore routing guidance for the code changed on the listed date; check the latest plan guidance for current handling.

CPT / HCPCS / Other Code Lists

Dermatologic and Minor Plastic Procedure CodesCPTCovered

15775	HAIR TRANSPLANT 1-15 PUNCH GRFTS - Pre-op eval, H&P, operative report required.
15776	HAIR TRANSPLANT >15 PUNCH GRAFTS - Pre-op eval, H&P, operative report required.
15777	ACELLULAR DERMAL MATRIX IMPLANT - Pre-op eval, H&P, operative report required.
15780	DERMABRASION TOTAL FACE - Pre-op eval, H&P, operative report required.
15781	DERMABRASION SEGMENTAL FACE - Pre-op eval, H&P, operative report required.
15782	DERMABRASION OTHER THAN FACE - Pre-op eval, H&P, operative report required.
15783	DERMABRASION SUPERFICIAL ANY SITE - Pre-op eval, H&P, operative report required.
15786	ABRASION LESION SINGLE - Pre-op eval, H&P, operative report required.
15787	ABRASION LESIONS ADD-ON - Pre-op eval, H&P, operative report required.
15788	CHEMICAL PEEL FACE EPIDERMAL - Pre-op eval, H&P, operative report required.

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Excision / Revision / Body Contouring / Breast Procedure CodesCPTCovered

15819	PLASTIC SURGERY NECK - Pre-op eval, H&P, operative report required.
15820	REVISION OF LOWER EYELID - Pre-op eval, H&P, operative report and photographs required.
15821	REVISION OF LOWER EYELID (alternate) - Pre-op eval, H&P, operative report and photographs required.
15822	REVISION OF UPPER EYELID - Pre-op eval, H&P, operative report and photographs required.
15823	REVISION OF UPPER EYELID (alternate) - Pre-op eval, H&P, operative report and photographs required.
15824	REMOVAL OF FOREHEAD WRINKLES - Pre-op eval, H&P, operative report required.
15825	REMOVAL OF NECK WRINKLES - Pre-op eval, H&P, operative report required.
15826	REMOVAL OF BROW WRINKLES - Pre-op eval, H&P, operative report required.
15828	REMOVAL OF FACE WRINKLES - Pre-op eval, H&P, operative report required.
15829	REMOVAL OF SKIN WRINKLES - Pre-op eval, H&P, operative report required.

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Maxillofacial / Grafting / Related Procedure CodesCPTCovered

20975	ELECTRICAL BONE STIMULATION - Medical records request to eviCore for coverage; no prior auth for certain MA plans per notes.
21083	PREPARE FACE/ORAL PROSTHESIS - Pre-op eval, H&P, operative report required.
21085	PREPARE FACE/ORAL PROSTHESIS (alternate) - Submit chart notes including appliance type, recurrent TMJ history, and diagnostic sleep study copy.
21120	RECONSTRUCTION OF CHIN - Submit chart notes including appliance type, recurrent TMJ history, and diagnostic sleep study copy.
21121	RECONSTRUCTION OF CHIN (alternate) - Submit chart notes including appliance type, recurrent TMJ history, and diagnostic sleep study copy.
21122	RECONSTRUCTION OF CHIN (alternate) - Submit chart notes including appliance type, recurrent TMJ history, and diagnostic sleep study copy.
21123	RECONSTRUCTION OF CHIN (alternate) - Submit chart notes including appliance type, recurrent TMJ history, and diagnostic sleep study copy.
21125	AUGMENTATION LOWER JAW BONE - Submit chart notes including appliance type, recurrent TMJ history, and diagnostic sleep study copy.
21127	AUGMENTATION LOWER JAW BONE (alternate) - Submit chart notes including appliance type, recurrent TMJ history, and diagnostic sleep study copy.
21138	REDUCTION OF FOREHEAD - History and physical, documentation of medical necessity and prior reconstruction stages if done.

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Spine / Orthopedic / Joint Procedure CodesCPTCovered

22514	(Listed Spine procedure) - Submit history and physical, documentation of medical necessity, operative report.
22515	(Listed Spine procedure) - Submit history and physical, documentation of medical necessity, operative report.
22526	IDET SINGLE LEVEL - eviCore contact; effective date noted in source.
22527	IDET 1 OR MORE LEVELS - eviCore contact; effective date noted in source.
22533	LAT LUMBAR SPINE FUSION - eviCore contact; documentation required.
22534	LAT THOR/LUMB ADDL SEG - eviCore contact; documentation required.
22551	NECK SPINE FUSE & REMOV BELOW C2 - eviCore contact; documentation required.
22552	ADDITIONAL NECK SPINE FUSION - eviCore contact; documentation required.
22554	NECK SPINE FUSION - eviCore contact; documentation required.
22558	LUMBAR SPINE FUSION - eviCore contact; documentation required.

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Large Group: Orthopedic/Joint/Knee/Hip/Shoulder/Arthroscopy CodesCPTCovered

22843	INSERT SPINE FIXATION DEVICE - eviCore contact; documentation required.
22844	INSERT SPINE FIXATION DEVICE - eviCore contact; documentation required.
22845	INSERT SPINE FIXATION DEVICE - eviCore contact; documentation required.
22846	INSERT SPINE FIXATION DEVICE - eviCore contact; documentation required.
22847	INSERT SPINE FIXATION DEVICE - eviCore contact; documentation required.
22848	INSERT PELVIC FIXATION DEVICE - eviCore contact; documentation required.
22853	INSERT BIOMECHANICAL DEVICE - eviCore contact; documentation required.
22854	INSERT BIOMECHANICAL DEVICE - eviCore contact; documentation required.
22856	CERVICAL ARTIFICIAL DISKECTOMY - eviCore contact; documentation required.
22857	LUMBAR ARTIFICIAL DISKECTOMY - eviCore contact; documentation required.

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Cardiac / Thoracic / Transplant Procedure Codes (selected)CPTCovered

33412	REPLACEMENT OF AORTIC VALVE - Recent H&P, plan of care, documentation of medical necessity required.
33413	REPLACEMENT OF AORTIC VALVE - Recent H&P, plan of care, documentation of medical necessity required.
33414	REPLACEMENT OF AORTIC VALVE - Recent H&P, plan of care, documentation of medical necessity required.
33415	REVISION SUBVALVULAR TISSUE - Recent H&P, plan of care, documentation of medical necessity required.
33419	MAMMO ASSESS INC XRAY DOCD - Recent H&P, plan of care, documentation of medical necessity required.
33420	REVISION OF MITRAL VALVE - Recent H&P, plan of care, documentation of medical necessity required.
33422	REPLACEMENT OF AORTIC VALVE - Recent H&P, plan of care, documentation of medical necessity required.
33425	REPAIR OF MITRAL VALVE - Recent H&P, plan of care, documentation of medical necessity required.
33426	REPAIR OF MITRAL VALVE - Recent H&P, plan of care, documentation of medical necessity required.
33427	REPAIR OF MITRAL VALVE - Recent H&P, plan of care, documentation of medical necessity required.

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Additional Selected Procedure Codes (miscellaneous surgical/diagnostic)CPTCovered

37500	ENDOSCOPY LIGATE PERFORATING VEINS - Pre-op eval, H&P, operative report required.
37565	LIGATION OF NECK VEIN - Pre-op eval, H&P, operative report required.
37650	REVISION OF MAJOR VEIN - Pre-op eval, H&P, operative report required.
37700	REVISE LEG VEIN - Pre-op eval, H&P, operative report required.
37718	LIGATE/STRIP SHORT LEG VEIN - Pre-op eval, H&P, operative report required.
37722	LIGATE/STRIP LONG LEG VEIN - Pre-op eval, H&P, operative report required.
37735	REMOVAL OF LEG VEINS/LESION - Pre-op eval, H&P, operative report required.
37760	RADICAL LIGATION LEG VEINS - History and physical and operative report required.
38204	BLOOD DONOR SEARCH MANAGEMENT - If transplant approval on record provide date; otherwise history, transplant eval, date of transplant required.
38205	HARVEST ALLOGENEIC STEM CELL - If transplant approval on record provide date; otherwise history, transplant eval, date of transplant required.

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Prior Authorization, Submission, and Documentation Requirements

Prior Authorization

Prior Authorization via eviCore

Prior authorization required for many codes — contact eviCore. Providers must obtain prior authorization prior to services except in urgent situations. Many codes listed on this document are managed by eviCore Healthcare; contact eviCore at 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs to initiate prior authorization or submit medical records.

eviCore prior authorization and medical records portal: https://www.evicore.com/healthplan/bcbs
eviCore phone: 1-855-252-1117
Blue Cross Medicare Advantage Customer Service (general PA questions): 1-877-774-8592 (Business hours M-F 8 a.m. - 8 p.m. CT)

Note

Prior Authorization Status and Plan Exceptions

Prior authorization status — plan-specific exceptions noted. Some codes require eviCore-managed prior authorization while others show plan-specific 'No Prior Auth required' exceptions (for example, various MT Medicare Advantage Plan and NM Medicare Advantage Plan entries). Always verify member-specific benefits and any state/plan exceptions before proceeding.

Policy Background and Scope

Background: This prior-authorization list groups a large number of procedural CPT and HCPCS codes used across specialties — prominently including plastic/reconstructive surgery, head and neck, breast procedures, grafting, and related services. The purpose is to identify codes that typically require an attending physician to obtain prior authorization for Blue Cross Medicare Advantage members and to specify commonly requested supporting documentation.

The listing emphasizes that common documentation elements include a pre-operative evaluation, history and physical (including functional impairment where specified), operative report, and code-specific items (for example, photographs for eyelid revision or grams of tissue removed for breast reduction). Many imaging, diagnostic, and specialized procedure codes are routed to the external vendor eviCore for prior-authorization and medical-records submission.

Definitions and Key Terms

Prior authorization list — definition of list purpose

PurposeA payer-maintained list of CPT/HCPCS codes for which the attending physician must obtain prior authorization for Blue Cross Medicare Advantage members (obtain prior authorization prior to service except in urgent situations).

ScopeApplies to services outlined on the Blue Cross Medicare Advantage Prior Authorization List (effective 1/1/2024) and to providers submitting claims to Blue Cross and Blue Shield of Oklahoma Medicare Advantage plans.

NotesPresence of a code on the list does not guarantee coverage under a member's benefits contract — verify eligibility and benefits prior to rendering services.

If transplant approval on record — operational definition

When transplant approval is on fileIf transplant approval exists in the record, reviewers request only the Date of Transplant for applicable transplant-related procedure codes (e.g., 33945, 35879, 44715).

Policy Changes and Revision History

2023-12-31removal

Multiple radiation and nuclear procedure codes previously routed to eviCore for prior authorization were removed from the list effective 12/31/2023 (examples include codes 77371–77373, 77385–77387, 77401–77407, 77412, 77423–77425, select A-codes such as A9513, A9543, A9590, A9606).

2023-07-01removal

Several ultrasound and vascular imaging codes and other entries were removed effective 7/1/2023 (examples: 76506, 76536, 76604, 76641–76642, 76700–76776, 76800–76831, and multiple vascular duplex codes).

2024-01-01additionLatest