CurrentBlue Cross Blue Shield - OklahomaPolicy N/A

Medicare Advantage Prior Authorization List — Surgical/Procedural Codes

A prior authorization list for Blue Cross Medicare Advantage plans detailing procedures that require prior authorization and the documentation required from providers; applies to providers submitting claims for Medicare Advantage members of Blue Cross and Blue Shield of Oklahoma and affiliated Medicare Advantage organizations.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyMedicare Advantage Prior Authorization List — Surgical/Procedural Codes

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date1/1/2020

Next Review DateN/A

Key ActionObtain prior authorization before providing any listed procedures and submit the specified medical records (e.g., recent H&P, pre-op evaluation, operative report, Letter of Medical Necessity) or route requests to eviCore when indicated.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1/1/2020effective date shown

200+procedure codes listed (approx.)

eviCoreeviCore-managed

Somelocal plan exceptions noted

10/04/2019

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage criteria and general rules

General coverage criteria

Covered when prior authorization is obtained and necessary documentation is submitted as specified for each code.

Prior Authorization and Documentation

Authorization: Attending physician must obtain prior authorization for services listed on the Blue Cross Medicare Advantage Prior Authorization List (except in urgent situations).
Documentation: Submit required medical records/documentation with the authorization request (examples include: recent history and physical; pre-operative evaluation; operative report; documentation of functional impairment; plan of care; pathology report; photographs; Letter of Medical Necessity) as specified per code in the list.
eviCore-managed codes: For codes managed by eviCore (green-highlighted), submit the Medical Records Request/prior authorization to eviCore via 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs per the code-specific instructions.
Local plan exceptions: Local Medicare Advantage plan exceptions may apply (e.g., some codes noted 'No Prior Auth required' for specific MAPD plans/states); verify member benefits before submitting.
Denial Risk: Failure to obtain required prior authorization or to submit the specified medical records (including eviCore submission when indicated) may result in denial of coverage or payment delays.

Per-code Requirements: Provider must follow the per-code Medical Records Request information listed next to each CPT/HCPCS/J/K/L/G code (e.g., H&P, pre-op evaluation, operative report, transplant date/evaluation, nutritional/psychological evaluations for bariatric codes, Letter of Medical Necessity for DME/wheelchair/accessories, etc.).

The presence of a CPT/HCPCS code on this prior authorization list does not by itself guarantee coverage. Coverage is determined by each member’s benefit contract; benefits vary by plan and by Medicare Advantage organization. Providers should verify coverage against the member’s benefit booklet or contact Customer Service before performing services (Customer Service: 1-877-774-8592, business hours Monday–Friday 8 a.m.–8 p.m. CT).

Certain annotations in the list identify local plan exceptions. For example, select codes are marked No Prior Auth required for MT Medicare Advantage Plan effective 4/1/2018; when that annotation applies, prior authorization is not required for members of that Montana Medicare Advantage plan for the specified codes. Always confirm the member’s specific plan before submitting an authorization request.

Most procedures and CPT/HCPCS codes shown on this document require prior authorization. Providers must obtain authorization prior to the service except in urgent situations and must submit the medical records/documentation specified alongside each code (examples include recent history & physical, pre‑operative evaluation, operative report, and other items as indicated). Failure to obtain required authorization or to provide requested records may result in denial or nonpayment.

Notes in the list include local Medicare Advantage plan exceptions. These annotations (for example calling out specific states or plans) are limited to the codes indicated and do not change the general requirement that listed procedures require authorization except where an explicit local exception is stated. When an item is routed to eviCore, the list provides the eviCore contact for prior authorization and medical records submission.

Example of a local exception: some codes are annotated with No Prior Auth required for NM Medicare Advantage Plan effective 11/1/2018. This notation indicates the New Mexico Medicare Advantage plan referenced in the list does not require prior authorization for those specific codes; verify member plan details before proceeding.

Some listed imaging and G‑codes include clarifying language. For example, G0219 is shown in the document with the descriptor referencing whole‑body PET imaging and is noted in the list as used "for non‑covered indications" in the example entry; check the code description and associated annotation on the list when planning services.

The excerpted policy content does not include any explicit statements labeling listed services as not medically necessary. The list focuses on prior authorization requirements and per‑code documentation instructions; medical necessity determinations are made based on submitted clinical information and member benefits.

Procedure, CPT/HCPCS, J-, K-, L- and related code lists

Prior authorization and documentation requirements for providers

Prior Authorization

Prior Authorization Required

Prior authorization is required for the procedures listed on the Blue Cross Medicare Advantage Prior Authorization List effective 1/1/2020. Providers must obtain authorization prior to service except in urgent situations; failure to obtain required prior authorization or to submit required documentation may result in denial of coverage or delayed review.

Attending physician must obtain prior authorization except in urgent situations.
Contact Customer Service for additional prior authorization information: 1-877-774-8592 (Mon–Fri 8 a.m.–8 p.m. CT).

Prior Authorization

eviCore-managed Codes — Prior Authorization via eviCore

Certain codes and services on this list are managed by eviCore. For codes routed to eviCore, providers must request prior authorization and submit required medical records via eviCore’s phone or web portal.

eviCore contact: 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs.
Examples include bone graft (CPT 20930–20938) and electrical bone stimulation (20974, 20975).

Policy background and scope

This prior authorization list applies to providers submitting claims for Blue Cross and Blue Shield of Oklahoma Medicare Advantage members and affiliated Medicare Advantage organizations. It identifies surgical and procedural CPT/HCPCS codes that require prior authorization and specifies the medical records/documentation that must be submitted with the authorization request. Some codes are managed by the external vendor eviCore (green highlighted) and include eviCore contact information for Medical Records Requests and prior authorization processing.

Key definitions and terms

Codes managed by eviCore — definition

DefinitionGreen highlighted codes are managed by eviCore healthcare (eviCore).

ImplicationCodes shown in green require eviCore review/medical records request as specified in the list.

ReferenceSee document header identifying green highlighted codes as managed by eviCore.

eviCore — third-party utilization management vendor

Vendor nameeviCore healthcare (eviCore)

Phone1-855-252-1117

Web portal

Document updates and version history

2020-01-01effective_dateLatest

Prior Authorization List for Blue Cross Medicare Advantage plans became effective; document header and multiple code entries show 'Effective 1/1/2020', establishing the list's effective date.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyMedicare Advantage Prior Authorization List — Surgical/Procedural Codes

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date1/1/2020

Next Review DateN/A

SourceLink

On This Page

Prior Authorization

Spine / Neuro Procedures — eviCore Prior Authorization Required

Many spine and neurosurgical procedures require prior authorization and are handled through eviCore. For these procedures providers must submit the specified medical records and obtain eviCore authorization prior to scheduling.

Common spine CPTs requiring eviCore review: 22612, 22614, 22630, 22632, 22633, 22634, 22841–22848, 22853–22862, 63001–63056, 63685, 62350–62362, 62380, etc.
Required records frequently include recent History & Physical, operative report, documentation of conservative measures, and imaging results.
Some spinal injection and implant codes (e.g., 64479–64495, 62350–62362) also route to eviCore.

Documentation Required

Injection / Implant Procedures — Documentation and eviCore Authorization

Injection and implant procedures (including intravitreal, intra-articular, spine injections, and implantable devices) on the list require prior authorization; many of these are routed to eviCore and require submission of clinical records.

Examples: intravitreal implants and injections (J7311–J7313, J7316), spine infusion/implant devices (62350–62362), and joint injection biologics (J7320–J7321).
Providers should include H&P, prior diagnostic results, treatment history, and operative reports as applicable.

Documentation Required

Ophthalmology / Eyelid Procedures — Required Documentation

Ophthalmology and eyelid procedures require specific pre-operative documentation with prior authorization requests. Submit pre-operative evaluation, recent history and physical including functional impairment, and operative report when applicable.

Codes include corneal transplants (65710, 65730, 65750, 65755, 65757), ocular reconstruction (65780–65782), and eyelid repair/ptosis codes (67900–67908).
Failure to provide the required H&P and operative report may delay or result in denial.

Note

Prior Authorization Required Codes — Coverage Note

The presence of a code on this list indicates that prior authorization is required to confirm coverage for Medicare Advantage plans effective 1/1/2020. Member benefits vary; inclusion on this list does not guarantee coverage under every member contract.

Providers should verify member benefits and obtain prior authorization before performing services.
Green-highlighted codes in the source indicate eviCore-managed items.

Note

Local Plan Exceptions / 'No Prior Auth' Notes

Some local plan exceptions are noted on the list. Certain state Medicare Advantage plans are annotated as having 'No Prior Auth required' for specific codes—examples include Montana (MT) and New Mexico (NM) exceptions with stated effective dates.

No Prior Auth required for MT Medicare Advantage Plan effective 4/1/2018 for many ultrasound, sleep, and selected procedural codes.
No Prior Auth required for NM Medicare Advantage Plan effective 11/1/2018 appears for select imaging/genetic codes.

Prior Authorization

Selected Ultrasound and Imaging CPTs — eviCore Routing

Selected ultrasound CPTs and other imaging codes on the list require prior authorization via eviCore, though some include plan-specific 'No Prior Auth' exceptions. Providers should check the code-level entry for eviCore routing and any local-plan exceptions.

Example ultrasound/imaging CPTs routed to eviCore: 76506, 76536, 76604, 76641–76642, 76700–76706, 76870–76872, 76881–76886, 76970–76979.
Check entries for 'No Prior Auth required for MT Medicare Advantage Plan' where applicable.

Prior Authorization

eviCore Prior Authorization and Medical Records Submission

Where eviCore prior authorization is required, providers must submit medical records and documentation to eviCore (phone or web). Failure to obtain eviCore authorization or to submit requested records may result in denial or additional review.

Submit records to eviCore: 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs.
Commonly requested records: recent History & Physical (H&P), pre-op evaluation, operative reports, imaging results, plan of care, conservative treatment documentation, and Letters of Medical Necessity (LOMN) when relevant.

Documentation Required

Durable Medical Equipment / Wheelchairs / Orthoses — Prior Authorization & Documentation

Many HCPCS, J-, K-, and L-codes on the list require prior authorization and specific documentation. Wheelchair and power mobility (K-codes), wheelchair accessories, and orthoses (L-codes) typically require H&P, plan of care, and Letters of Medical Necessity as specified.

K-code examples: K0004–K0014, K0800–K0899 — require history & physical or clinical notes and anticipated length of use.
L-code examples (TLSO/LSO): L0456–L0486, L0631, L0637 — require Letter of Medical Necessity including length of time equipment needed and functional status.

Prior Authorization

J-Codes and Biologic Injections — eviCore Records Request Required

Prior authorization is required for many J-codes and biologic drugs on the list; eviCore manages medical records requests and authorization for these medications. Some J-codes will also require H&P and ordering physician chart notes or treatment logs.

Examples of J-codes routed to eviCore: J0129, J0178, J0202, J0490, J0717 series through many oncology and biologic J-codes listed (see source list).
Factor and biologic J-codes (e.g., J7189–J7195) often require history & physical, ordering physician notes, and treatment logs.

Documentation Required

Required Medical Records and Supporting Documentation per Procedure

Providers must include the required supporting documents with prior authorization requests for surgical and device procedures. Typical supporting documents include: recent History & Physical, pre-operative evaluation, operative reports, imaging and diagnostic results, documentation of conservative treatment, plan of care, nutritional/psychological evaluations for bariatric cases, and transplant approval records when applicable.

Transplant codes: if transplant approval on record, provide date of transplant; if not, provide H&P, transplant evaluation, and transplant date when available.
Bariatric codes (e.g., 43645, 43770–43775, 43846–43848): include H&P, nutritional and psychological evaluations, weight-loss attempts, and social supports.
Discography codes (72291–72292): include H&P, prior diagnostic results, and procedure reports for prior authorization.

Documentation Required

Ambulance / Transport Documentation Requirements

Ambulance and transport-related services require specific recent documentation with prior authorization requests. Typical requirements include physician orders and progress notes within the last 24 hours and supporting clinical records.

Ambulance-specific documentation: progress notes from the last 24 hours, physician order, and supporting medical records.
Failure to provide required transport documentation may result in denial.

Denial Risk

Denial Risk — Missing Records or eviCore Authorization

Failure to submit required medical records, Letters of Medical Necessity, or to obtain eviCore prior authorization for eviCore-managed items may trigger denial or additional review. Providers should ensure all requested documents are included with the authorization request.

Missing H&P, operative reports, plan of care, or LOMN for DME/wheelchair requests commonly triggers denials.
If eviCore requests additional records and they are not provided, authorization may be denied or delayed.

Note

Where to Submit Prior Authorization Requests and Medical Records

Where to submit prior authorization requests and medical records: for eviCore-managed codes contact eviCore at 1-855-252-1117 or via https://www.evicore.com/healthplan/bcbs. For other Blue Cross prior authorization inquiries contact the payer’s Customer Service number shown on the member ID card.

eviCore submission: 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs.
Blue Cross Customer Service for general prior authorization information: 1-877-774-8592.

Note

New Code Notices

New or recently added codes on the list are noted in the source (e.g., J2350 marked as 'New code effective'). Providers should review code-level annotations for new-code notices and ensure appropriate authorization/record submission for new codes.

Example: J2350 (ocrelizumab) is annotated as a new code effective on the list; it requires eviCore records requests.

Documentation Required

Specialty Documentation Examples (Nasal, Cardiac/Vascular, Discography)

Specific examples of documentation requirements for select specialties: nasal reconstruction/revision (pre-op evaluation, H&P including functional impairment, and operative report); cardiac/vascular revisions (H&P, plan of care, and documentation of medical necessity); discography (H&P, prior diagnostic results, procedure reports).

Nasal reconstruction/revision codes (30120, 30400–30462, 30801–30802): provide pre-op evaluation, H&P including functional impairment, and operative report.
Cardiac/vascular codes (e.g., 34806, 35879): include H&P, Doppler or vascular study results, plan of care, and operative report.

https://www.evicore.com/healthplan/bcbs

eviCore — external vendor for prior authorization and records

RoleExternal vendor used for prior authorization and medical records review for specified codes.

Contact detailseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs for submission of requests and medical records.

ScopeMany imaging, radiation, specialty drug, and procedure codes on the list route to eviCore for medical records requests/prior authorization.

Medical Records Request / Prior Authorization

Action requiredSubmit a Medical Records Request to eviCore for review/authorization of specified procedure codes prior to service.

How to submitContact eviCore by phone (1-855-252-1117) or via the BCBS eviCore healthplan portal; include required documentation per code.

TimingObtain authorization prior to service except in urgent situations; failure to obtain may result in denial.

Letter of Medical Necessity

PurposeProvider-authored justification describing the need for the equipment or service.

ContentsInclude diagnosis, functional limitations, anticipated length of use, previous experience with similar equipment, and justification for specific features or weight capacity.

When requiredOften required for wheelchair/power mobility, seating accessories, speech generating devices, and other DME; submit with Medical Records Request or prior authorization.