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CurrentBlue Cross Blue Shield - TexasPolicy N/A

Prior Authorization Procedure Code List — Medicare Advantage

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A list of CPT/HCPCS procedure codes for which Blue Cross Medicare Advantage may require prior authorization and the medical record documentation to submit; intended for providers submitting claims or requesting authorization under Blue Cross Blue Shield - Texas Medicare Advantage plans.

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyPrior Authorization Procedure Code List — Medicare Advantage

Policy CodePolicy N/A

Change TypeAdministrative update (no material clinical changes)

Effective DateJan 1, 2023

Next Review DateN/A

Key ActionProviders must obtain prior authorization and submit required medical records (e.g., history & physical, operative report, Letter of Medical Necessity) or follow eviCore submission instructions when indicated.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

20+procedure codes shown in this excerpt

eviCoreexternal prior authorization vendor referenced

H&P & operative reportcommon required documentation

01/01/2023

policy effective date

Coverage and Authorization Criteria

General prior authorization coverage criteria (administrative)

Prior authorization is required for the listed procedure codes when the provider submits supporting documentation as specified.

Documentation requirement for bariatric codes: For bariatric procedure codes (examples: 43774, 43775, 43800, 43843, 43845): submit a history and physical, nutritional evaluation, psychological evaluation, documentation of prior weight-loss attempts, and documentation of social supports.

Documentation requirement for transplant-related codes: For transplant-related procedure codes (examples: 44132, 44133, 44135, 44136, 44137, 44715, 44720): if a transplant approval is on record submit the date of transplant; if no transplant approval is on record submit history and physical, transplant evaluation, and date of transplant.

Operative/medical necessity documentation: For many genitourinary, reproductive and related surgical codes (examples include 54125, 54240, 54304, 54400, 54401, 54405, 54520, 54660, 54690) submit a history and physical, documentation of medical necessity, and the operative report with the prior authorization request.

eviCore references: For specified interventional/spine and related codes (examples: 62263, 62264, 62280, 62281, 62282) follow the eviCore prior authorization routing and submission instructions (eviCore phone/portal) where indicated in the code list.

Generic prior authorization/medical necessity criteria

Covered when ALL of the following documentation is provided:

Documentation supports medical necessity: Letter of Medical Necessity describing the diagnosis, justification for the equipment/service, and anticipated length of need.

Functional status or evaluation included: History and physical including evaluation of abilities and limitations and relevant measurements (for wheelchair accessories this includes diagnosis, functional abilities/limitations, duration of condition, and upper‑extremity strength evaluation where applicable).

eviCore authorization when referenced: When a code entry references eviCore, prior authorization or submission of required medical records must be completed via the eviCore contact/portal indicated in the code list.

Some entries in the procedure code list include an explicit plan-specific note stating No Prior Auth required for MT Medicare Advantage Plan. When that note appears beside a code, providers should follow the code-specific instruction and are not required to obtain prior authorization for Montana Medicare Advantage members for that code. However, if medical records or eviCore contact information is listed for the same code, providers should still submit requested documentation only when required by the plan or vendor instructions to avoid processing delays.

Code 60219 is listed as PET imaging whole body; melanoma with the entry explicitly marked for non-covered indications. The listing indicates this PET whole-body service for melanoma is not covered for certain indications and references eviCore for medical-records requests or prior authorization review as noted in the code row.

This entry duplicates the PET imaging non-coverage note for code 60219: the policy lists 60219 — PET imaging whole body; melanoma as designated for non-covered indications and references eviCore for medical-records requests or review. Providers should treat the duplicate notes as confirmation of the code status and follow the eviCore contact instructions if a records request is indicated.

Procedure Codes and Coding Lists

Procedure codes (excerpt)CPT

01939	Anes nulyt agt crv/thrc
01940	Anes nulyt agt Imbr/sac
01941	Anes neuromd/ntrvrt crv/thrc
01942	Anes neuromd/ntrvrt Imbr/sac
11970	REPLACE TISSUE EXPANDER
15271	SKIN SUB GRAFT TRNK/ARM/LEG

Plastic/reconstructive and dermatologic codes (excerpt)CPT

15775	HAIR TRNSPL 1-15 PUNCH GRFTS
15776	HAIR TRNSPL >15 PUNCH GRAFTS
15777	ACELLULAR DERM MATRIX IMPLT
15780	DERMABRASION TOTAL FACE
15781	DERMABRASION SEGMENTAL FACE
15782	DERMABRASION OTHER THAN FACE
15783	DERMABRASION SUPRFL ANY SITE
15786	ABRASION LESION SINGLE
15787	ABRASION LESIONS ADD-ON
15788	CHEMICAL PEEL FACE EPIDERM

1–10 of 33

1/4

Additional procedure codes (excerpt)CPT

15876	SUCTION LIPECTOMY HEAD&NECK
15877	SUCTION LIPECTOMY TRUNK
15878	SUCTION LIPECTOMY UPR EXTREM
15879	SUCTION LIPECTOMY LWR EXTREM
17340	CRYOTHERAPY OF SKIN
17360	SKIN PEEL THERAPY
17380	HAIR REMOVAL BY ELECTROLYSIS
19316	SUSPENSION OF BREAST
19318	REDUCTION OF LARGE BREAST
19324	ENLARGE BREAST

1–10 of 30

1/3

Sternal / Hyoid proceduresCPT

21685	HYOID MYOTOMY & SUSPENSION
21740	RECONSTRUCTION OF STERNUM

Sternum and spine injection codesCPT

21742	REPAIR STERN/NUSS W/o SCOPE
21743	REPAIR STERNUM/NUSS W/SCOPE
22505
22510	PERQ CERVICOTHORACIC INJECT
22511	PERQ LUMBOSACRAL INJECTION

Orthopaedic, spine, and related surgical CPT codes (comprehensive list in excerpt)CPT

22512	VERTEBROPLASTY ADDL INJECT
22513	PERQ VERTEBRAL AUGMENTATION
22514	PERQ VERTEBRAL AUGMENTATION
22515	PERQ VERTEBRAL AUGMENTATION
22526	IDET SINGLE LEVEL
22527	IDET 1 OR MORE LEVELS
22533	LAT LUMBAR SPINE FUSION
22534	LAT THOR/LUMB ADDL SEG
22551	NECK SPINE FUSE&REMOV BEL C2
22552	ADDL NECK SPINE FUSION

1–10 of 84

1/9

Procedure CPT Codes (excerpt)CPT

27279	ARTHRODESIS SACROILIAC JOINT
27280	FUSION OF SACROILIAC JOINT
27332	REMOVAL OF KNEE CARTILAGE
27333	REMOVAL OF KNEE CARTILAGE
27334	REMOVE KNEE JOINT LINING
27335	REMOVE KNEE JOINT LINING
27403	REPAIR OF KNEE CARTILAGE
27412	AUTOCHONDROCYTE IMPLANT KNEE
27415	OSTEOCHONDRAL KNEE ALLOGRAFT
27416	OSTEOCHONDRAL KNEE AUTOGRAFT

1–10 of 95

1/10

Transplant and select cardiac codes (partial)CPT

32851	LUNG TRANSPLANT SINGLE
32852	LUNG TRANSPLANT WITH BYPASS
32853	LUNG TRANSPLANT DOUBLE
32854	LUNG TRANSPLANT WITH BYPASS
32855	PREPARE DONOR LUNG SINGLE
32856	PREPARE DONOR LUNG DOUBLE
33208	INSRT HEART PM ATRIAL & VENT

Cardiac procedure codes (partial)CPT

33404	PREPARE HEART-AORTA CONDUIT
33405	REPLACEMENT AORTIC VALVE OPN
33406	REPLACEMENT AORTIC VALVE OPN
33407	REPLACEMENT AORTIC VALVE OPN
33410	REPLACEMENT AORTIC VALVE OPN
33411	REPLACEMENT OF AORTIC VALVE
33412	REPLACEMENT OF AORTIC VALVE
33413	REPLACEMENT OF AORTIC VALVE
33414	REPLACEMENT OF AORTIC VALVE
33415	REVISION SUBVALVULAR TISSUE

1–10 of 18

1/2

Donor/heart transplant and relatedCPT

33930	REMOVAL OF DONOR HEART/LUNG
33933	PREPARE DONOR HEART/LUNG
33935	TRANSPLANTATION HEART/LUNG
33940	REMOVAL OF DONOR HEART
33944	PREPARE DONOR HEART
33945	TRANSPLANTATION OF HEART
34806	OPN AXISUBCLA ART EXPOS CNDT

Vascular and vein proceduresCPT

36468	NJX SCLRSNT SPIDER VEINS
36470	NJX SCLRSNT 1 INCMPTNT VEIN
36479
37225	FEM/POPL REVAS W/ATHER
37241	VASC EMBOLIZE/OCCLUDE VENOUS
37500	ENDOSCOPY LIGATE PERF VEINS

Stem cell and transplant-related codesCPT

38204	BL DONOR SEARCH MANAGEMENT
38205	HARVEST ALLOGENEIC STEM CELL
38206	HARVEST AUTO STEM CELLS
38230	BONE MARROW HARVEST ALLOGEN
38232	BONE MARROW HARVEST AUTOLOG
38240	TRANSPLT ALLO HCTIDONOR
38241	TRANSPLT AUTOL HCTIDONOR
38242	TRANSPLT ALLO LYMPHOCYTES

ENT and cleft proceduresCPT

40700	REPAIR CLEFT LIP/NASAL
40701	REPAIR CLEFT LIP/NASAL
40702	REPAIR CLEFT LIP/NASAL
40720	REPAIR CLEFT LIPINASAL
40761	REPAIR CLEFT LIP/NASAL
40820	TREATMENT OF MOUTH LESION
41512	TONGUE SUSPENSION
41530	TONGUE BASE VOL REDUCTION

Head, neck, esophagus and GI proceduresCPT

42145	REPAIR PALATE PHARYNX/UVULA
42200	RECONSTRUCT CLEFT PALATE
42205	RECONSTRUCT CLEFT PALATE
42210	RECONSTRUCT CLEFT PALATE
42215	RECONSTRUCT CLEFT PALATE
42220	RECONSTRUCT CLEFT PALATE
42225	RECONSTRUCT CLEFT PALATE
43112	ESPHG TOT WITHRCM
43122	PARTIAL REMOVAL OF ESOPHAGUS
43360	GASTROINTESTINAL REPAIR

1–10 of 11

1/2

Bariatric and related GI procedure codesCPT

43644	LAP GASTRIC BYPASS/ROUX-EN-Y
43645	LAP GASTR BYPASS INCL SMLL
43770	LAP PLACE GASTR ADJ DEVICE
43771	LAP REVISE GASTR ADJ DEVICE
43772	LAP RMVL GASTR ADJ DEVICE
43773	LAP REPLACE GASTR ADJ DEVICE
43774	LAP RMVL GASTR ADJ ALL PARTS
43775	LAP SLEEVE GASTRECTOMY
43800	RECONSTRUCTION OF PYLORUS
43843	GASTROPLASTY W/o V-BAND

1–10 of 17

1/2

Transplant-related proceduresCPT

43999	STOMACH SURGERY PROCEDURE
44132	ENTERECTOMY CADAVER DONOR
44133	ENTERECTOMY LIVE DONOR
44135	INTESTINE TRANSPLNT CADAVER
44136	INTESTINE TRANSPLANT LIVE
47133	REMOVAL OF DONOR LIVER
47135	TRANSPLANTATION OF LIVER
48550	DONOR PANCREATECTOMY
48554	TRANSPL ALLOGRAFT PANCREAS
50300	REMOVE CADAVER DONOR KIDNEY

1–10 of 12

1/2

Ocular, reconstructive, and eyelid repair codesCPT

65710	CORNEAL TRANSPLANT
65730	CORNEAL TRANSPLANT
65750	CORNEAL TRANSPLANT
65755	CORNEAL TRANSPLANT
65780	OCULAR RECONST TRANSPLANT
65781	OCULAR RECONST TRANSPLANT
65782	OCULAR RECONST TRANSPLANT
67900	REPAIR BROW DEFECT
67901	REPAIR EYELID DEFECT
67902	REPAIR EYELID DEFECT

1–10 of 12

1/2

Eyelid repair/revision CPT codesCPTCovered

67906	EYELID DEFECT
67908	REPAIR EYELID DEFECT
67909	REVISE EYELID DEFECT
67911	REVISE EYELID DEFECT
67912	CORRECTION EYELID W/IMPLANT
67914	REPAIR EYELID DEFECT
67915	REPAIR EYELID DEFECT
67916	REPAIR EYELID DEFECT
67921	REPAIR EYELID DEFECT
67922	REPAIR EYELID DEFECT

1–10 of 12

1/2

Ear/temple/cochlear procedure codesCPTCovered

69300	REVISE EXTERNAL EAR
69320	REBUILD OUTER EAR CANAL
69604	MASTOID SURGERY REVISION
69714	IMPLANT TEMPLE BONE W/STIMUL
69715	TEMPLE BNE IMPLNT W/STIMULAT
69717	TEMPLE BONE IMPLANT REVISION
69718	REVISE TEMPLE BONE IMPLANT
69930	IMPLANT COCHLEAR DEVICE

Head/neck CT and MRI codesCPTCovered

70336	MAGNETIC IMAGE JAW JOINT
70450	CT HEAD/ BRAIN W/o DYE
70460	CT HEAD/BRAIN W/DYE
70470	CT HEAD/ BRAIN W/o & W/DYE
70480	CT ORBIT/EAR/ FOSSA W/o DYE
70481	CT ORBIT/EAR/ FOSSA W/DYE
70482	CT ORBIT/EAR/ FOSSA W/o & W/DYE
70486	CT MAXILLOFACIAL W/o DYE
70487	CT MAXILLOFACIAL W/DYE
70488	CT MAXILLOFACIAL W/o & W/DYE

1–10 of 24

1/3

Thorax/chest and spine CT/MRI codesCPTCovered

71250	CT THORAX W/o DYE
71260	CT THORAX W/DYE
71270	CT THORAX W/o & W/DYE
71271	CT THORAX LUNG CANCER
71275	CT ANGIOGRAPHY CHEST
71550	MRI CHEST W/o DYE
71551	MRI CHEST W/DYE
71552	MRI CHEST W/o & W/DYE
71555	MRI ANGIO CHEST W or W/o DYE
72125	CT NECK SPINE W/o DYE

1–10 of 28

1/3

Pelvis, discography, and upper extremity imaging codesCPTCovered

72191	CT ANGIOGRAPH PELV W/o & W/DYE
72192	CT PELVIS W/o DYE
72193	CT PELVIS W/DYE
72194	CT PELVIS W/o & W/DYE
72195	MRI PELVIS W/o DYE
72196	MRI PELVIS W/DYE
72197	MRI PELVIS W/o & W/DYE
72198	MR ANGIO PELVIS W/o & W/DYE
72291	DISCOGRAPHY CERVITHOR SPINE
72292	DISCOGRAPHY CERVITHOR SPINE

1–10 of 14

1/2

Abdomen/pelvis CT codesCPTCovered

74150	CT ABDOMEN W/o DYE
74160	CT ABDOMEN W/DYE
74170	CT ABDOMEN W/o & W/DYE
74174	CT ANGIOGRAPH ABD & PELV W/o & W/DYE
74175	CT ANGIO ABDOM W/o & W/DYE
74176	CT ABD & PELVIS W/o CONTRAST

Imaging CT/MRI/Angio codes (excerpt)CPT

73721	MRI JNT OF LWR EXTRE W/o DYE
73722	MRI JOINT OF LWR EXTR W/DYE
73723	MRI JOINT LWR EXTR W/o&W/DYE
73725	MR ANG LWR EXT W OR W/o DYE
74150	CT ABDOMEN W/o DYE
74160	CT ABDOMEN WIDYE
74170	CT ABDOMEN W/o & W/DYE
74174	CT ANGIO ABD&PELV W/o&W/DYE
74175	CT ANGIO ABDOM W/o & W/DYE
74176	CT ABD & PELVIS W/o CONTRAST

1–10 of 19

1/2

inv-91: Not applicable (key/value placeholder)

StatusNot applicable

inv-92: Effective date notes — Many codes include 'Effective Date = Prior to 9/1/2019' or specific effective dates

General effective date noteMany codes show 'Effective Date = Prior to 9/1/2019' or have blank effective date entries; when a specific effective date is provided it appears next to the individual code.

What Providers Must Do / Documentation & Authorization Steps

Prior Authorization

Check eligibility and preauthorization for listed procedure codes

These procedure codes are listed in the Medicare Advantage prior authorization procedure code list and may require preauthorization and submission of specified medical records before services are rendered; always check member eligibility and benefits first.

Examples include numerous CPT/HCPCS codes across surgical specialties (see code list).
Presence on the list does not guarantee coverage under a member's contract — confirm benefits prior to scheduling.

Prior Authorization

Route prior authorization for select spine/injection codes to eviCore

For select spine, vertebral augmentation and injection codes, providers must contact eviCore for prior authorization or follow eviCore's process via phone (1-855-252-1117) or the eviCore BCBS healthplan web portal.

Codes routed to eviCore include 22510–22515, 22526–22527 and many vertebral augmentation/injection entries.
Follow the eviCore phone or web portal instructions listed next to each code.

Background and Scope

This document is an administrative prior authorization procedure code list effective 01/01/2023. It provides CPT/HCPCS codes with short procedure descriptions and, where applicable, specifies required medical-record documentation and the external vendor contact (eviCore, phone 1-855-252-1117 or the eviCore BCBS healthplan web portal) to manage prior authorization or clinical review for listed codes.

Definitions and Key Terms

Transplant approval on record — definition

DefinitionTransplant approval on record = an existing authorization/approval for transplant documented with a date of transplant

If approval on recordWhen transplant approval is on record, providers should submit the date of transplant with the prior authorization request

If no approval on recordIf no transplant approval on record, submit history and physical, transplant evaluation, and date of transplant

Transplant approval on record — definition (variant)

MeaningIndication that the payer already has prior authorization/approval for a transplant (documented by transplant date)

Provider action if presentProvide the documented date of transplant when submitting authorization for related procedures

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyPrior Authorization Procedure Code List — Medicare Advantage

Policy CodePolicy N/A

Change TypeAdministrative update (no material clinical changes)

Effective DateJan 1, 2023

Next Review DateN/A

SourceLink

On This Page

Examples with 'Prior to 9/1/2019'Eyelid and head/neck imaging codes (e.g., 67906, 67909, 70540, 70542, 70543) include 'Effective Date = Prior to 9/1/2019'.

Codes with blank effective date fieldSome procedure entries (e.g., 43774, 43800, 67908, 67911) have an empty Effective Date field in the listing.

inv-93: Multi-positional patient transfer system weight capacity (E1035/E1036)

E1035 weight capacityMulti-positional patient transfer system (E1035): patient weight capacity up to and including 300 lbs.

E1036 weight capacityMulti-positional patient transfer system, extra-wide (E1036): patient weight capacity greater than 300 lbs.

Documentation requiredBoth E1035 and E1036 require a Letter of Medical Necessity supporting need for the wheelchair accessory.

Documentation Required

Submit H&P, operative report and conservative care documentation for fusion/major procedures

For post‑fusion and other major spine/fusion procedural codes, submit the patient's history and physical, operative report, and documentation of conservative measures as part of the prior authorization/medical record review.

Examples: 22800, 22802, 22804 and other post‑fusion codes list H&P, operative report, and documentation of conservative measures.

Billing Rule

Use eviCore contact for medical-records and prior authorization reviews

Many CPT procedure entries reference eviCore as the contact for medical-records requests and prior authorization review; providers must follow eviCore's submission instructions (phone 1-855-252-1117 or evicore.com/healthplan/bcbs) when indicated.

Multiple orthopaedic, spine and other surgical codes direct providers to eviCore for authorization/clinical review.

Prior Authorization

Provide transplant approval date or full transplant evaluation documentation

Transplant and donor procedure codes require prior authorization; if a prior transplant approval is on record submit the date of transplant, otherwise include history and physical, transplant evaluation, and date of transplant.

Applies to codes such as 32851–32856, 33930–33935, 38204–38242 and multiple donor/transplant CPT entries.
Failure to provide transplant approval/date or required transplant documentation may trigger additional requests or denial.

Documentation Required

Include H&P, plan of care, and medical necessity for cardiac prior auths

For listed cardiac procedures requiring prior authorization, submit a recent history and physical, the plan of care, and documentation of medical necessity with the prior authorization request.

Examples include 33404–33430 and other major cardiac surgical codes specifying H&P, plan of care, and medical necessity.

Documentation Required

Submit H&P, nutritional & psychological evaluations for bariatric/GI prior auths

Bariatric and related gastrointestinal procedure codes require prior authorization; include history and physical, nutritional and psychological evaluations, documentation of prior weight‑loss attempts, and social supports as specified.

Examples include 43644–43645, 43770–43775, 43800, 43843–43848.
Documentation must demonstrate prior weight loss attempts and available social supports where requested.

Documentation Required

Bariatric prior authorization — required documentation

Prior authorization for bariatric procedures requires submission of the history and physical, nutritional evaluation, psychological evaluation, documentation of weight‑loss attempts, and social supports when noted.

Codes explicitly listing these requirements include 43774, 43775, 43800, 43843, 43845.

Documentation Required

When transplant approval absent, submit H&P, transplant evaluation and transplant date

Transplant‑related procedure codes require prior authorization; if transplant approval is not on record, providers must submit history and physical, transplant evaluation, and the date of transplant with the request.

Applies to intestinal, liver, pancreas, kidney and other transplant CPT codes listed in the document.

Prior Authorization

Route epidural lysis and spinal canal treatment codes to eviCore

Select epidural lysis and spinal canal treatment codes are managed by eviCore; providers must route prior authorization and medical‑records requests to eviCore as indicated in the code list.

Examples include 62263–62264 and other epidural lysis/spinal canal procedure codes referencing eviCore.

Documentation Required

Provide H&P, medical necessity, and operative report for genitourinary/gender procedures

Genitourinary and gender‑related procedure codes require prior authorization and submission of history and physical, documentation of medical necessity, and the operative report as part of the request.

Examples include 53430, 53860, 54125, 54400, 54401, 55970–55980, 57291–57292.

Prior Authorization

Follow eviCore routing or plan‑specific prior auth exceptions for interventional/spine codes

Some interventional and spine procedure codes are routed to eviCore for prior authorization; a subset also notes 'No Prior Auth required for MT Medicare Advantage Plan' — follow the eviCore instructions or the plan‑specific guidance shown for each code.

Codes include various 62xxx–63xxx and other interventional spine entries that reference eviCore and may include plan exceptions.

Documentation Required

Submit H&P and operative report for skull repair/reduction and select neurosurgical codes

Certain neurosurgical and skull‑repair codes list an explicit medical‑records requirement: submit the history and physical and the operative report documenting medical necessity with the authorization request.

Examples include 62115 and select neurosurgical implant/reconstruction codes.

Documentation Required

Include pre‑op evaluation, H&P and operative report for eyelid procedure prior auths

Prior authorization for eyelid repair and revision codes requires submission of the pre‑operative evaluation, history and physical, and the operative report as part of the request.

Applies to codes 67906, 67908, 67909, 67911, 67912, 67914–67916, 67921–67924.

Prior Authorization

Obtain prior authorization (often via eviCore) for ear/head/neck procedures and imaging

Prior authorization is required for listed ear, temple, cochlear and head/neck imaging procedures; many of these entries require eviCore review or authorization as indicated.

Examples include 69300, 69320, 69714–69718, 69930 and multiple CT/MRI head/neck codes routed to eviCore.

Prior Authorization

Obtain prior authorization for CT/MRI codes (many routed to eviCore)

A broad set of CT and MRI codes across body regions require prior authorization; many entries specify eviCore as the authorization vendor and include the eviCore contact for submission.

Includes thorax, chest, spine, pelvis, extremity and abdomen/pelvis CT/MRI codes (e.g., 71250–71275, 71550–71555, 72125–72159, 73700–73725, 74150–74185).
Use eviCore phone 1-855-252-1117 or the eviCore web portal where indicated.

Prior Authorization

Send prior auth/medical records to eviCore (phone/web portal)

Prior authorization or medical‑records requests for many listed procedure codes are handled via eviCore; providers should contact eviCore by phone at 1‑855‑252‑1117 or use the eviCore BCBS healthplan web portal as shown next to each code.

This routing applies across imaging, genomic, radiation, and many interventional code groups in the list.

Prior Authorization

Obtain required prior auth/records via eviCore for listed codes

Prior authorization and/or medical‑records requests for the listed procedure codes must be obtained and provided through eviCore (phone or website) as indicated in the code list.

Providers must follow the code‑specific eviCore instructions printed beside each CPT/HCPCS entry.

Prior Authorization

Route authorization/medical‑records requests for specified codes to eviCore

The listed procedure codes require medical‑records request/prior authorization via eviCore (phone or web) as specified next to each code; follow the vendor's submission process for coverage determination.

Many genomics and advanced diagnostic codes (e.g., 81212–81223, 81450–81479) reference eviCore for authorization.

Prior Authorization

Contact eviCore (phone/web) for prior authorization of listed codes

Prior authorization is referenced for the listed procedure codes and medical‑records request/contact is via eviCore (1‑855‑252‑1117 or the eviCore website); follow the contact shown for each code.

Applies to many genomic, molecular and specialty procedure codes listed in the document.

Prior Authorization

Use eviCore for prior authorization/medical‑records requests for many T/U and HCPCS codes

Many listed procedure and HCPCS/T/U codes require prior authorization or a medical‑records request through eviCore; providers must use eviCore's phone or BCBS portal to submit requests and records.

Includes numerous T/U codes, molecular/genomic panels, and other specialized services that reference eviCore.

Documentation Required

Submit required medical records via eviCore for listed procedure/HCPCS/T/U codes

Prior authorization or a medical‑records request is required for the listed procedure and HCPCS/T/U codes; medical‑records requests are handled via eviCore (phone 1‑855‑252‑1117 or eviCore website) as indicated per code.

Providers must supply the documents specified next to each code (e.g., recent H&P, plan of care, LOMN) when contacting eviCore.

Prior Authorization

Route clinical review/prior‑auth requests for specified codes to eviCore

These codes indicate medical‑records request information and in several cases list eviCore as the contact for prior authorization or clinical review; providers should route records to eviCore when shown.

Includes selected C‑codes and other higher‑cost device/drug entries that require clinical review.

Note

Check device code notes for prior‑auth status and use eviCore when required

Some respiratory and positive‑airway device codes note prior authorization status changes or plan‑specific exceptions; where prior authorization is required the eviCore contact is listed — verify the code‑specific note before submitting.

Examples: E0485–E0601 and related A‑codes where notes may indicate 'No Prior Auth required' for certain Medicare Advantage plans.

Documentation Required

Include Letter of Medical Necessity and H&P for DME/device prior auths

For many DME and device codes, prior authorization requires a Letter of Medical Necessity and history and physical that describe anticipated length of use, the medical condition, and functional/mobility status; include the specific evaluation details requested for wheelchair accessories.

Examples include E0635–E0764, E0830–E1036, and various E1xxx entries requiring LOMN and H&P.
Wheelchair documentation examples include diagnosis, abilities/limitations, duration of condition, prior use of similar equipment, and upper extremity strength.

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Step Therapy

Step therapy

No step therapy requirements are specified in this policy excerpt.

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Documentation Required

Submit pre‑op evaluation, H&P (functional impairment) and operative report

For many listed procedures providers must submit the pre‑operative evaluation, a recent history and physical documenting functional impairment, and the operative report; some codes additionally request photographs, pathology reports, weight/height, grams of tissue removed, or copies of diagnostic studies.

These documentation requirements appear across plastic/reconstructive, breast, and other surgical code entries.

Billing Rule

Send prior auth medical records to eviCore (phone or web)

Certain codes designate eviCore as the point of contact for medical‑records requests and prior authorization submissions; providers must send requested records to eviCore by phone or via the eviCore BCBS healthplan portal.

Use eviCore phone 1-855-252-1117 or evicore.com/healthplan/bcbs as listed next to codes.

Documentation Required

Provide H&P, operative report and documentation of medical necessity as requested

Commonly required medical records include a history and physical, operative report, and documentation of medical necessity; some codes also request plan of care or documentation of conservative measures.

Examples across the list include requirements for H&P, operative report, plan of care, and conservative care documentation for spine and transplant codes.

Prior Authorization

Follow eviCore referral/contact instructions for spine and orthopaedic codes

Many spine, injection, augmentation and orthopaedic procedure codes direct providers to eviCore (phone or web) for prior authorization or specify eviCore as the medical‑review contact; follow those instructions when shown.

Examples include vertebral augmentation, fusion, arthroplasty and many orthopaedic arthroscopy codes.

Documentation Required

Include pre‑op eval, H&P, operative report, and transplant documentation when applicable

Required clinical documentation commonly includes a pre‑operative evaluation, history and physical that documents functional impairment, the operative report, and transplant documentation where applicable.

Transplant entries specifically request either the transplant approval date or, if absent, the full transplant evaluation and date.

Documentation Required

Provide transplant approval date or transplant evaluation and date when not on record

For transplant‑related codes provide either the prior transplant approval date or, if no approval is on record, submit history and physical, transplant evaluation, and the date of transplant with the prior authorization request.

Applicable to lung, heart, liver, kidney, pancreas, intestine and related donor/transplant procedure codes.

Documentation Required

Submit recent H&P, plan of care and operative report for cardiac/vascular codes

Many cardiac, vascular and other complex procedure codes require a recent history and physical, the plan of care, and an operative report (where applicable) to support medical necessity for prior authorization.

Failure to provide these items may result in denial or delays in authorization.

Documentation Required

Bariatric prior auths — include nutritional & psychological evaluations

Include nutritional and psychological evaluations, H&P, and documentation of prior weight‑loss attempts and social supports for bariatric procedure prior authorization requests.

Required for codes such as 43644–43645, 43770–43775, 43843–43848 and related bariatric entries.

Documentation Required

Summary: commonly requested documentation for prior authorization

Commonly requested documentation for listed procedure codes includes history and physical, nutritional evaluation, psychological evaluation, operative report, transplant evaluation and documentation of medical necessity as applicable.

Providers should review the code‑specific entry for exact document requirements.

Prior Authorization

eviCore authorization required for select spinal/epidural lysis codes

Some spinal and epidural lysis CPT codes specifically reference eviCore for authorization instructions; follow the eviCore contact information provided in those code entries.

Examples include 62263–62264 and related epidural lysis/spinal canal treatment codes.

Documentation Required

Provide H&P, medical necessity and operative report (ocular/eyelid include pre‑op eval)

For many listed procedures providers must submit history and physical, documentation of medical necessity, and the operative report; for ocular and eyelid procedures include the pre‑operative evaluation as specified.

Ocular and eyelid entries (e.g., 67906–67924, 65710–65755) explicitly list pre‑op eval, H&P and operative report.

Documentation Required

Submit Pre‑Op Eval, H&P and Operative Report for surgical prior auths

Surgical procedures such as eyelid and ear operations require submission of a pre‑operative evaluation, a history and physical, and the operative report as part of the prior authorization request.

Examples: eyelid codes 67906–67924 and ear/temple codes 69300–69930.

Billing Rule

Authorize imaging via eviCore (phone/web) when indicated

For many imaging codes the prior authorization routing is via eviCore; providers should contact eviCore at 1‑855‑252‑1117 or via evicore.com/healthplan/bcbs as indicated next to each code.

This applies across CT, MRI, PET and other advanced imaging entries in the list.

Billing Rule

Where to send prior authorization requests/medical records

Where the code list indicates, send prior authorization requests and requested medical records to eviCore by phone (1‑855‑252‑1117) or via the eviCore BCBS web portal as shown next to the code.

Follow the code‑specific submission pathway (phone or portal) printed beside each CPT/HCPCS entry.

Documentation Required

Submit medical records to eviCore as requested

Medical records or request information must be provided to eviCore (phone 1‑855‑252‑1117 or via evicore.com/healthplan/bcbs) as indicated for listed procedure codes; respond promptly to any eviCore records request.

Failure to supply requested records to eviCore may delay authorization or lead to retrospective review.

Billing Rule

Use eviCore contact for medical‑records requests

Medical‑records request contact for many codes is eviCore; providers should use eviCore phone 1‑855‑252‑1117 or the eviCore BCBS portal to submit records as listed for each code.

The code list repeats eviCore contact information beside numerous CPT/HCPCS entries.

Documentation Required

Provide recent H&P, plan of care and documentation of medical necessity when requested

Various listed codes require submission of a recent history and physical, plan of care, and documentation of medical necessity; some also request treatment plans, chart notes, or other specific documents.

This requirement appears for T‑codes, oncologic, imaging and other specialty procedures.

Documentation Required

eviCore requests H&P, plan of care and medical necessity for specified T codes

For certain T codes eviCore requests a recent history and physical, plan of care, and documentation of medical necessity as part of the prior authorization or medical‑records review.

Examples include 0178T, 0179T, 0180T and other specified T codes.

Documentation Required

Supply H&P, plan of care and medical necessity for cellular therapy ancillary codes

For cellular therapy ancillary codes and selected advanced procedures, provide a recent history and physical, the plan of care, and documentation of medical necessity when requested.

Applies to codes 0537T–0540T and similar entries that list these document types.

Documentation Required

LOMN and H&P required for many DME/device prior auths

Many DME and device codes require a Letter of Medical Necessity or a history and physical that outlines anticipated length of use, the condition being treated, and functional/mobility status where applicable.

Examples include E0635, E0641, E0747, E0830, E1002, E1003 and numerous E‑series wheelchair/accessory codes.

Prior Authorization

eviCore routing for A‑codes and selected A9xx device codes

For many A‑codes and A95xx entries medical‑records requests are routed to eviCore when prior authorization or clinical review is required; follow the eviCore contact instructions provided.

Examples include A7036–A7046, A9513 and A9543.

Documentation Required

LOMN content expectations for equipment/accessory prior auths

Most entries for equipment and accessories require a Letter of Medical Necessity describing anticipated length of need, the medical condition requiring the equipment, and the patient’s functional or mobility status.

Providers should include evaluation details such as diagnosis, duration of condition, prior use of equipment, and strength assessments as applicable.

Documentation Required

Provide detailed wheelchair documentation (diagnosis, function, duration, prior use, strength)

For wheelchair accessories and specialized wheelchairs include diagnosis, abilities/limitations, duration of condition, prior experience with similar equipment, and an upper‑extremity strength evaluation where requested.

Examples include E1002, E1003, E1035, E1036, E1161 and multiple E23xx/E26xx wheelchair accessory codes.

Denial Risk

Check member eligibility and benefits before rendering services

Rendering services without first checking member eligibility and benefits or obtaining required preauthorization may result in denial of coverage; verify eligibility and benefits before performing services.

The policy header reminds providers that presence of a code on the list does not guarantee coverage under a given member contract.

Denial Risk

Risk of denial for 21685 without H&P and operative report

Failure to submit the history and physical and documentation of medical necessity including the operative report may trigger denial for hyoid myotomy and suspension (code 21685).

Code 21685 explicitly lists H&P, documentation of medical necessity and operative report as required.

Denial Risk

Denial risk for sternum and select spine procedures if H&P/operative report missing

Missing a recent history and physical, the operative report, or documentation of medical necessity may trigger medical‑records requests and potential denial or delay for listed sternum and select spine procedure codes.

Examples include codes 21742, 21743 and 22505 which require H&P, operative report and medical necessity documentation.

Denial Risk

Transplant codes — missing documentation may trigger additional requests

Missing required documentation for transplant codes (for example, lack of transplant approval on record) may trigger additional documentation requests and delay authorization or coverage decisions.

If transplant approval is on record submit the transplant date; if not, provide H&P, transplant evaluation and date of transplant.

Denial Risk

Denial risk if transplant approval date or transplant evaluation not provided

Failure to provide the transplant approval date or required transplant documentation (history and physical, transplant evaluation, date of transplant) for transplant procedure codes may lead to denial.

Applies to lung, heart, liver, kidney, pancreas, intestine and bone marrow/stem cell transplant codes.

Denial Risk

Denial risk for cardiac/vascular codes without H&P, plan of care, or medical necessity

Lack of a recent history and physical, an explicit plan of care, and documentation of medical necessity for cardiac and vascular procedure codes may result in denial of prior authorization.

Providers must include H&P, plan of care and medical necessity for codes like 33404–33430 and revision/repair cardiac codes.

Denial Risk

Transplant prior auths require full evaluation if approval not on record

If transplant approval is not on record, prior authorization requests for transplant‑related procedure codes require submission of history and physical, transplant evaluation, and the date of transplant; failure to do so may trigger denial.

This requirement is repeated across multiple transplant and donor CPT entries.

Denial Risk

Operative report and H&P required for urologic/reproductive codes — risk of denial if missing

For many urologic and reproductive procedures, failure to submit the history and physical, documentation of medical necessity, and the operative report may lead to denial of prior authorization.

Applies to codes such as 54125, 54400–54405, 57106–57111 and related genitourinary entries.

Denial Risk

Risk of denial or delay when required documentation is not submitted

Failure to submit required documentation (history and physical, documentation of medical necessity, operative report) for listed procedure codes may trigger medical‑records requests and potential denial or delay.

This general requirement is shown for multiple surgical and implantable procedure codes in the list.

Denial Risk

Denial risk for eyelid procedures if pre‑op eval, H&P, or operative report missing

Failure to submit the required pre‑operative evaluation, history and physical, and operative report may trigger denial for listed eyelid repair/revision codes if those documents are not provided.

Eyelid codes 67906–67924 explicitly require pre‑op evaluation, H&P and operative report.

Denial Risk

Denial risk if eviCore prior authorization for imaging/CT/MRI is not obtained

Authorization routed through eviCore for many imaging, CT and MRI codes; lack of eviCore prior authorization when indicated may risk denial of coverage.

Providers should use eviCore phone 1-855-252-1117 or the eviCore BCBS portal for these authorizations.

Denial Risk

Avoid denial: submit records/authorization requests to eviCore when indicated

Failure to submit required medical records or prior authorization requests to eviCore (contact 1‑855‑252‑1117 or the eviCore web portal) may trigger denial or require retrospective review.

Repeated eviCore contact instructions appear throughout the code list — follow them to avoid delays or denials.

Denial Risk

Denial risk for missing eviCore authorization or records

Failure to obtain authorization or provide medical records via eviCore when indicated may result in denial of coverage for the listed procedure codes.

This is a general advisory repeated in multiple code entries.

Denial Risk

Contact eviCore for medical‑records requests to avoid denial

Failure to request medical records or prior authorization through eviCore (contact listed repeatedly) may trigger denial of coverage for listed procedure codes; use the eviCore contact shown in the code list.

eviCore phone: 1-855-252-1117; portal: evicore.com/healthplan/bcbs.

Denial Risk

Denial risk when required documentation is incomplete

Lack of required documentation (e.g., recent history and physical, plan of care, documentation of medical necessity) for listed procedure codes may trigger denial — include all documents specified with the code.

Many entries explicitly state which documents are required; provide those to support medical necessity.

Documentation Required

Provide requested records to eviCore promptly to avoid delays/denials

Medical records requested for listed codes must be sent to eviCore (phone/website) as indicated; failure to supply requested records to eviCore may trigger denial or prior authorization delay.

Providers should respond promptly to eviCore requests to avoid delays.

Note

Check plan‑specific 'No Prior Auth required' notes before submitting

Some procedure codes include notes that 'No Prior Auth required for MT Medicare Advantage Plan' — submitting unnecessary prior authorization requests or not following the indicated pathway may lead to administrative denial or processing issues; verify plan‑specific notes before submitting.

Examples: 0095T, 0098T, 0163T–0165T and multiple other entries include plan‑specific exception notes.

Denial Risk

Insufficient documentation may cause denial

Failure to submit required documentation (recent H&P, plan of care, documentation of medical necessity, progress notes, physician order) with the prior authorization request may trigger denial for listed codes.

Ensure all requested document types are included with the initial submission to minimize denials.

Documentation Required

High‑cost/implantable procedures — include H&P, plan of care and medical necessity

Requests for certain high‑cost or implantable procedures (e.g., C9076, C9600, C9741, C9739) require a recent history and physical, plan of care, and documentation of medical necessity; absence of these documents may trigger denial.

Check the code‑specific entry for exact document requirements before submission.

Denial Risk

LOMN/H&P missing for equipment/accessories may cause denial

Failure to provide a Letter of Medical Necessity or required history/physical and supporting documentation may trigger denial for listed equipment and accessory codes.

Examples include E0830, E0856, E0942, E1002 and many wheelchair/accessory codes.

Prior Authorization

Refer eviCore‑referenced services to eviCore to avoid denial

Services that reference eviCore require referral to eviCore for prior authorization or clinical review; lack of eviCore authorization may lead to denial—use the eviCore contact provided in the code entry.

This applies to PET imaging, advanced therapy and other eviCore‑referenced services (e.g., 60219, 60235, 60339–60340).

Provider action if absentSubmit history and physical, transplant evaluation, and date of transplant if approval is not on record

Transplant approval on record — definition (variant)

Contextual definition'Transplant approval on record' signals existing authorization; absent approval triggers full transplant documentation requirements

Documentation required when absentHistory and physical, transplant evaluation, and the date of transplant must be submitted

Applies toTransplant-related procedure codes (e.g., lung, heart, intestinal donor/transplant codes) listed in the code list

eviCore — external prior authorization vendor

eviCore roleeviCore is the external vendor used by the plan to manage prior authorization and medical-records requests for many imaging and procedure codes

Contact infoeviCore contact: phone 1-855-252-1117 or the eviCore BCBS healthplan web portal (evicore.com/healthplan/bcbs)

When to useFollow eviCore instructions where a code entry explicitly references eviCore for prior authorization or medical records submission

Letter of Medical Necessity — definition and expected contents

DefinitionLetter of Medical Necessity = provider-authored letter that explains diagnosis, condition requiring the equipment/service, and anticipated length of need

Expected contentsShould include anticipated length of time equipment is required, description of medical condition, and justification of functional need

Additional supporting documentationFor DME/wheelchair items include history and physical, evaluation of abilities/limitations, and specific measurements as applicable