FEP and Postal Prior Approval List (partial)
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Lists procedure, diagnosis and ICD-10 principal procedure codes that require prior approval for Federal Employee Program (FEP) and Postal members and describes the specific forms and exceptions to use; affects providers submitting predetermination/prior approval requests for FEP/Postal members.
No material clinical or coverage changes in this revision.
Prior Approval and Coverage Criteria (FEP & Postal)
Prior approval requirement lists (partial)
The following procedure and diagnosis codes require prior approval for Federal Employee Program (FEP) and Postal members; see notes for diagnosis-linked exceptions and required forms.
Procedure groups requiring prior approval (examples)
- ICD‑10 Principal Procedure Code clusters (selected examples): 00JU0ZZ, 0RG74K0, 0RG74K1, 0SG03K0, 0SW00AZ (see full ICD‑10‑PCS lists)
Notations and exceptions
- Procedure codes marked with a single asterisk (*) require prior approval when billed with a Gender Dysphoria diagnosis (effective for services on/after 01/01/2024).
- Procedure codes marked with a double asterisk (**) require prior approval when billed with a cancer diagnosis.
- Sexual trait modification: effective 01/01/2026 this is no longer a covered benefit when related to Gender Dysphoria (applies to Blue Standard, Blue Basic, and Blue Focus).
Code-based coverage references
Code-based coverage references and brief applicability notes for selected services and diagnoses.
Code-level coverage/prior-approval rules (excerpt)
Product- and service-specific prior approval and coverage notes — excerpts for selected items.
Radiation therapy prior approval exceptions
Exceptions to prior-approval requirements for radiation therapy when billed with specified diagnosis codes.
Procedure codes referenced for radiation therapy
See the policy's diagnosis lists in the Radiation Therapy section (chunks 62, 65, 66) for the full set of diagnosis codes that exempt these procedures from prior approval.
Artificial insemination codes
Artificial insemination (AI) drugs and services that apply to Blue Standard, Blue Basic, and Blue Focus.
When providing AI drugs/services, follow prior approval requirements applicable to the member's product (submit prior approval where the overarching policy requires it).
High-cost drug prior authorization
High-cost provider-administered drugs (Buy-and-Bill) require prior approval via Blue Cross and Blue Shield of Tennessee Pharmacy Management.
Prior-authorization exceptions and notes
Selective prior-authorization exceptions and notes for individual drugs in the high-cost drug list.
ANY of the following
- Aloxi (J2469) does not require prior approval when the ordering provider is an oncologist (policy note appears in the high-cost drug mapping).
- Akynzeo (J1454) does not require prior approval when the ordering provider is an oncologist (noted in the high-cost drug list).
- Certain procedure-code-to-brand mappings include effective dates indicating when pharmacy prior approval became required or when the requirement was removed; consult the specific code entry (examples in chunks 71, 77, 79).
Refer to the high-cost drug tables in the policy for code-specific exceptions, brand mappings, and effective dates when determining whether prior authorization is required for a given product and ordering provider type.
Code Lists and Coding Notes
| 0813T | Bariatric surgery and related procedure code listed |
| C9784 | Additional HCPCS/CPT code listed for bariatric services |
| 0RG74K0 | ICD-10-PCS principal procedure code (listed) |
| 0RG74K1 | ICD-10-PCS principal procedure code (listed) |
| 0SG03K0 | ICD-10-PCS principal procedure code (listed) |
| 0SW00AZ | ICD-10-PCS principal procedure code (listed) |
| XRGA0R7 | ICD-10-PCS principal procedure code / cross-reference (listed) |
| F64.0 | Gender Dysphoria diagnosis code |
| F64.9 | Gender Dysphoria unspecified |
| E0265–E1009 | Specialty DME HCPCS codes listed in this section |
| K0841–K0899 | Additional Specialty DME K-codes |
| 0005U–81599 | Extensive list of genetic testing CPT/HCPCS codes requiring prior approval per rules |
| J0725 | Artificial Insemination (AI) drug HCPCS code |
| 00023615004 | Example NDC for AI drugs listed |
| 58321 | Artificial insemination service CPT/HCPCS code |
| 77520 | Proton beam therapy procedure code |
What Providers Must Do — Submission, Exceptions, and Billing
Required prior approval forms and submission channels
Submit prior approval requests using the Federal Employee and Postal Predetermination / Prior Approval form, the Federal Employee and Postal Hearing Aid Prior Approval form, or the Federal and Postal Employee Program Provider-Administered Medication Authorization Form. Do not use these forms for Utilization Management requests (inpatient, hospice, skilled nursing facility, residential, or ABA therapy); those should be sent to Utilization Management.
- Use the Provider-Administered Medication Authorization Form for Buy-and-Bill/high-cost drug prior approval submissions when instructed.
- Submit Buy-and-Bill prior approval via Availity or by phone as specified in the Buy-and-Bill/high-cost drugs section.
Asterisk notation—diagnosis-linked prior approval
Procedure codes marked with a single asterisk (*) require prior approval when billed with Gender Dysphoria diagnosis codes; procedure codes marked with a double asterisk (**) require prior approval when billed with cancer diagnosis codes.
- Single asterisk (*) note effective for services incurred on or after January 1, 2024.
- Double asterisk (**) applies to specified oral/maxillofacial procedure codes when billed with cancer diagnoses.
Sexual trait modification coverage removed for Gender Dysphoria
Effective 01/01/2026, sexual trait modification is no longer a covered benefit when related to Gender Dysphoria for Blue Standard, Blue Basic, and Blue Focus.
- This change applies to dates of service on or after January 1, 2026.
Hospice prior approval — timing and diagnosis conditions
For dates of service on or after January 1, 2026, prior approval is required for the listed hospice procedure and revenue codes only when the member’s diagnosis is one of the enumerated Z-codes; prior to 01/01/2026 prior approval was required regardless of diagnosis. From 01/01/2026 onward, only inpatient hospice requires prior approval.
Product-specific prior approval applicability (imaging, respiratory, sleep studies)
Certain imaging, respiratory, and sleep-study procedure codes require prior approval depending on product: CT/MRI/PET codes apply to Blue Focus; selected respiratory codes apply to Blue Focus; selected sleep study/professional codes apply to Blue Standard and Blue Basic with place-of-service restrictions.
- CT/MRI/PET examples applying to Blue Focus include codes in chunk 38 (e.g., 70450–70498, 70540–70559, 71550–71555).
- Respiratory codes applying to Blue Focus include 93797, 93798, S9472 and associated codes (chunk 40).
- Sleep study professional codes applying to Blue Standard/Blue Basic include 95782–95811 when place of service is appropriate (chunk 41).
Prior approval for Buy-and-Bill high-cost drugs — submission instructions
Buy-and-Bill high-cost drugs listed require prior approval through Blue Cross and Blue Shield of Tennessee Pharmacy Management. Submission should be via Availity or by phone at 1-800-924-7141 and use the Federal Employee Program Provider-Administered Medication Authorization Form.
- High Cost Drugs section identifies NDC-to-procedure code mappings and instructs Buy-and-Bill prior approval submission via Availity or phone.
- Use the Provider-Administered Medication Authorization Form when submitting these pharmacy prior approval requests.
Pharmacy prior approval mapping examples (HCPCS/J-code flags and dates)
The high-cost drug table maps HCPCS/J-codes to pharmacy prior-approval flags and effective dates (examples include J3262 = Actemra; J2469 = Aloxi with oncologist exception noted).
- Example mapping: J3262 — 1 = Actemra; 2 = Pharmacy prior approval required (effective 10/1/2019).
- Examples show pharmacy prior approval flags and effective dates for many J-/HCPCS codes (see chunks 71 and 77).
No prior approval required for select radiation therapy diagnoses
No prior approval is required for proton beam therapy, stereotactic radiosurgery (SRS), or stereotactic body radiation therapy (SBRT) when billed with the listed cancer diagnosis codes provided in the document.
Definitions, Notational Keys, and Coverage Notes
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