MAPD Benefit Prior Authorization Procedure Code List (prior authorization and documentation requirements)
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A searchable list of CPT and HCPCS procedure codes for which prior authorization may be required for MAPD members of Blue Cross and Blue Shield of Texas; informs providers about codes that may trigger prior authorization and required supporting documentation.
Codes 77520, 77522, 77523, and 77525 were added with an Effective Date of 1/1/24 and specific prior authorization documentation requirements.
Multiple imaging and radiation procedure codes were flagged as removed with effective dates of 7/1/2023 or 12/31/23 in this segment.
Coverage Criteria Overview
inv-01: Prior authorization requirement
Listed procedures may require prior authorization and documentation as specified per code.
Presence of a code on this list may indicate the service requires prior authorization; green-highlighted codes are managed by eviCore and require contacting eviCore as directed
inv-02: Authorization documentation criteria
Prior authorization is required and will be processed when accompanying required documentation is submitted.
For transplant-related procedures: if transplant approval is on record submit date of transplant; if not, submit history and physical and transplant evaluation
Applies to codes such as 43770-43775, 43845-43848
Applies to codes such as 41530 and 42145
inv-03: General prior authorization criteria
Prior authorization and required documentation must be submitted for the listed codes; medical necessity is judged based on the supplied documentation.
See individual code entries for exact required documents and eviCore contact instructions (e.g., eviCore 1-855-252-1117 or eviCore BCBS portal)
The presence of codes on this list does not necessarily indicate that a service is covered under a member's benefits contract. Providers must confirm member eligibility and benefits before rendering services or submitting prior authorization requests. Member benefit booklets or customer service should be consulted to determine whether a specific procedure or supply is a covered benefit.
Note: Code 33208 is marked as Removed (11/2023) in the procedure list; its removal may indicate that it is no longer subject to the prior authorization requirements in this listing as of that removal date.
Code 52648 is recorded as Removed (11/2023) in this list excerpt; it is no longer present on the active listing as of that removal date.
This document does not enumerate explicit coverage exclusions in the provided excerpts. Instead, entries primarily identify procedure codes that may require prior authorization and list the supporting documentation (for example, history & physical, operative report, transplant evaluation or date of transplant) that must accompany a prior authorization request.
Several procedure and radiation/molecular codes in the list are explicitly marked as Removed with specific removal dates (examples include entries removed 7/1/2023 or Removed 12/31/23). These removal notations indicate the codes are no longer active on this prior authorization list as of the stated dates.
Multiple entries in this segment are shown as Removed 12/31/23, meaning those codes were removed from the active prior-authorization code list effective that date.
Some codes in the list include the note Short description not available at time of distribution, indicating that certain descriptors were incomplete in this distribution. These entries still include prior authorization routing and documentation instructions where provided.
Entry note: 0163T is shown in the list with an Effective Date = Removed designation, indicating it is no longer active on this prior authorization list.
Across the listing there are multiple examples of codes marked as Removed with specific removal dates (for example, entries removed 10/1/23 or 12/31/23). These removal indications identify codes that are no longer included on this prior-authorization code list as of the stated dates.
Several HCPCS C9xxx codes and related drug-coded entries are explicitly noted as Removed 12/31/23 in the excerpt; these codes are no longer active on the procedure list effective that removal date.
Procedure and Coding Lists
| 21122 | RECONSTRUCTION OF CHIN. |
| 21123 | RECONSTRUCTION OF CHIN. |
| 21125 | AUGMENTATION LOWER JAW BONE. |
| 21127 | AUGMENTATION LOWER JAW BONE. |
| 21138 | REDUCTION OF FOREHEAD. |
| 21141 | LEFORT 1-1 PIECE WIO GRAFT. |
| 21142 | LEFORT 1-2 PIECE WIO GRAFT. |
| 21143 | LEFORT 1-3/> PIECE W/O GRAFT. |
| 21145 | LEFORT /-1 PIECE WI GRAFT. |
| 21146 | LEFORT 1-2 PIECE WI GRAFT. |
Actions Required by Providers
Obtain benefit prior authorization (eviCore-managed codes noted)
Providers must obtain benefit prior authorization for services/categories included on this list; codes highlighted as managed by eviCore require contacting eviCore for prior authorization or medical records requests.
Follow per-code documentation instructions
Individual codes on the list include per-code medical records request instructions that specify the type of documentation to submit (examples: history & physical, pre-operative evaluation, operative report, functional impairment, specimen weight).
- Reduction mammoplasty (19318) — operative report and number of grams removed ([[chunk 9]]).
- Many reconstructive and dermabrasion codes — pre-operative evaluation, H&P, operative report (chunks 3–4).
- Transplant codes — transplant evaluation and date of transplant or transplant approval on record (chunks 43, 51).
Route prior authorization requests to eviCore when indicated
Prior authorization requests for many listed codes are handled by eviCore; providers must contact eviCore at 1-855-252-1117 or use the eviCore BCBS web portal when the code entry directs to eviCore.
- Spine, implant, imaging, molecular and many procedure entries list eviCore as the contact for medical records/prior authorization (see code entries).
Arthroplasty/arthroscopy: obtain eviCore authorization
Selected arthroplasty and arthroscopy codes in the list require authorization through eviCore; follow the per-code eviCore routing instructions noted in the entry.
- Examples include multiple shoulder/hip/knee arthroscopy and arthroplasty entries that reference eviCore for prior authorization.
Submit required medical records with prior auth requests
The listed procedure codes require prior authorization; per-code entries instruct providers to submit the specified medical records (e.g., history & physical, operative report, transplant evaluation) to eviCore or BCBS as noted.
- Transplant and major surgical codes commonly require H&P, plan of care, and documentation of medical necessity (chunks 43–51).
- Many musculoskeletal and reconstructive codes specify pre-op evaluation, H&P and operative report (chunks 36–41).
Support prior authorization with specified medical records
Prior authorization is required for the listed procedure codes and must be supported by the code-specific medical records (examples: history & physical, operative report, transplant evaluation and date of transplant, nutritional/psychological evaluations for bariatric procedures).
- Bariatric codes (e.g., 43775) — H&P, nutritional and psychological evaluations, documentation of weight-loss attempts and social supports (chunk 60).
- Transplant-related codes — transplant evaluation/date of transplant or transplant approval on record (chunks 43, 51).
Provide H&P and operative report where required
These procedure codes require prior authorization and submission of specified medical records (history & physical, documentation of medical necessity, operative report or pre-operative evaluation) as listed per code entry.
- Genitourinary, reproductive and gynecologic procedure entries list required H&P and operative reports (chunks 72–74).
Spine/epidural/implant codes — eviCore review required
Certain spine, epidural and implantable device procedure codes require prior authorization or review via eviCore; the code entries list eviCore contact information for routing.
- Examples include codes in ranges 62263–62362 and 63001–63076 which reference eviCore for prior authorization (chunks 79–81).
Imaging codes: prior authorization often routed to eviCore
Prior authorization is required for the listed imaging procedure codes; many imaging entries instruct providers to route requests and medical records to eviCore for review.
- CT/MRI and advanced imaging codes frequently include eviCore contact (chunks 94, 108–111).
Follow eviCore routing and per-code documentation for listed procedures
These procedure codes require prior authorization through eviCore or have specific prior authorization documentation requirements; follow the per-code medical records request instructions.
Radiation/proton therapy: submit H&P and prior diagnostic reports
Providers must follow the listed medical records request process for these radiation and proton therapy codes and submit requested documentation (contact eviCore at 1-855-252-1117 or use the eviCore BCBS web portal when indicated).
Molecular/genetic/oncology codes: prior auth via eviCore
The listed procedure codes require prior authorization/medical records request via eviCore (1-855-252-1117) or the eviCore BCBS portal before services are rendered; follow the per-code contact instructions.
- Many molecular/genetic and oncology codes require eviCore routing (chunks 154–156).
Submit eviCore prior auth requests and required documentation
Prior authorization is required for the listed procedure codes; many entries instruct providers to request approval via eviCore (phone or web) and to supply the specified documentation per code.
- Large groups of U-/T-/CPT codes across the list reference eviCore for prior authorization and specify documentation types (chunks 162–181).
Additional U-/T-codes — prior auth and eviCore routing
The listed procedure and injection codes require prior authorization and/or medical record submission; many entries route providers to eviCore (phone or website) for prior authorization processing.
- Additional U-codes and T-codes indicate eviCore as the medical records request contact (chunks 190–199).
HCPCS/HCPCS C codes: prior authorization required per code
The listed HCPCS/C codes are included in the MAPD prior authorization procedure code list and require prior authorization or medical records submission as specified; follow per-code instructions for eviCore routing where listed.
- HCPCS A/C and C9xxx entries reference eviCore for medical records/prior authorization (chunks 216, 223).
DME/wheelchair/speech devices: provide LOMN or H&P
Prior authorization is required for durable medical equipment, wheelchair accessories, and speech generating devices listed; submit the required Letter of Medical Necessity or history & physical as specified per code.
- Traction equipment (E0890) — Letter of Medical Necessity with anticipated length of use and condition (chunk 234).
- Wheelchair accessories (E1161, E2300) — H&P detailing diagnosis, abilities/limitations, duration, and relevant strength evaluation (chunks 238, 240).
- Speech generating devices (E2504–E2510) — Letter of Medical Necessity including length of time needed and functional status (chunks 243–245).
Contact eviCore for imaging/procedure codes where listed
Certain imaging and procedure codes require eviCore review/authorization; providers should contact eviCore as directed in the specific code entry (phone or eviCore BCBS web portal).
- Examples: PET, colon screening, and selected advanced imaging/procedures reference eviCore (chunks 247, 251–253).
Drugs/procedures/injections: prior auth and medical records via eviCore
These listed procedure and injection codes require prior authorization and/or submission of medical records; many entries route providers to eviCore for the prior authorization process — submit the per-code documentation requested.
- Many drug/injection and advanced procedure codes reference eviCore and request H&P, plan of care, and documentation of medical necessity (chunks 253–271).
Attach required supporting documentation (examples)
Required supporting documentation varies by code but commonly includes pre-operative evaluation, history & physical, operative report, documentation of functional impairment or medical necessity, pathology reports for reduction mammoplasty, or other specified chart notes.
- Reduction mammoplasty — operative report and specimen weight (chunk 9).
- Eyelid/ocular procedures — photographs or operative report where noted (chunks 3, 90).
ECT (90870): submit H&P, ordering physician notes, treatment plan
For electroconvulsive therapy (90870), include a history & physical, chart notes from the ordering physician, and the treatment plan with the prior authorization or medical records request.
- 90870 entry lists H&P, ordering physician chart notes, and treatment plan as required documentation (chunk 165).
Policy Background
Background: This file is an administrative prior authorization procedure code list and not a clinical practice guideline. It enumerates CPT and HCPCS codes for which benefit prior authorization and/or submission of supporting medical records may be required and provides routing/contact details (for example, eviCore) and per-code documentation requirements.
Definitions and Key Terms
Coding-specific Requirements and Key Values
Policy Revision History
Proton therapy CPT codes 77520, 77522, 77523, and 77525 were added to the prior authorization list with an effective date of 1/1/24 and require submission of history and physical plus prior diagnostic procedure reports for prior authorization.
Multiple radiation and related procedure codes (examples in the list) were marked 'Removed 12/31/23' in the radiation and related code segment.
At least one previously listed CPT code (52648) and code 33208 were noted as removed effective 11/2023 in the list.
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