CurrentBlue Cross Blue Shield - TexasPolicy N/A

MAPD Benefit Prior Authorization Procedure Code List (Plastic/Reconstructive Surgery codes included)

A prior authorization procedure code list indicating CPT/HCPCS codes for which benefit prior authorization may be required for MAPD members; includes medical-records/documentation requirements and contact information for eviCore. Affects providers submitting authorizations for Blue Cross and Blue Shield of Texas MAPD members.

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyMAPD Benefit Prior Authorization Procedure Code List (Plastic/Reconstructive Surgery codes included)

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes

Effective Date01/01/2024

Next Review DateN/A

Key ActionVerify member benefits and obtain prior authorization via eviCore (1-855-252-1117 or https://www.evicore.com/healthplan/bcbs) when submitting requests for listed CPT/HCPCS codes.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

01/01/2024Document effective date

eviCoreAuthorization vendor

>=100Procedure codes in excerpt

YesRemoved codes noted

Coverage Criteria Overview

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.

The code list includes CPT and HCPCS codes for services that may require prior authorization. The presence of a code on this list does not guarantee coverage under a member's benefits — providers must verify eligibility and benefits with the member’s plan before rendering services and obtain prior authorization when required.

No additional coverage-criteria notes are explicitly stated in the provided excerpt.

The list includes several per-code maintenance notes showing codes that were added or removed on specific dates. Examples in the excerpt indicate multiple codes with "Removed" or "Added" annotations and associated effective dates; providers should rely on the listed per-code effective/removed dates when determining authorization applicability.

Codes marked with removal notes include entries such as 33208 Removed 1/1/2023 and 52648 Removed 1/1/2023, as well as numerous imaging and vascular study codes removed on other specified dates; consult the individual code rows for exact removal dates.

Example: 52648 (LASER SURGERY OF PROSTATE) is listed with an entry showing Removed 1/1/2023, indicating that this code was removed from the active list as of that date.

For the Montana Medicare Advantage (MT MAPD) plan the list notes that certain ultrasound/echo codes have No Prior Auth required effective 4/1/2018 in that specific plan; several of those same ultrasound/echo entries in this excerpt also show they were Removed 7/1/2023 from this MAPD list.

Multiple codes in the excerpt are explicitly marked Removed with specific dates. Examples include 90870 Removed 12/31/2023 (and several vascular/vascular-study codes) and multiple transcranial/vascular ultrasound entries marked Removed 7/1/2023.

Several additional entries show removal annotations with dates. For example, some U-/T-/temporary codes show Removed 10/1/2023 or Removed 12/31/2023 on the per-code lines — confirm per-code history when preparing authorization requests or billing.

No additional coverage criteria notes are explicitly stated in the referenced chunks beyond per-code documentation and effective/removed date annotations.

Inventory placeholder: miscellaneous coverage-criteria notes not present in the excerpt.

There are no explicit statements in these chunks declaring any codes as not medically necessary; the excerpt instead lists per-code medical-records/documentation requirements and prior authorization routing.

Procedure and HCPCS/CPT Code Lists

MAPD Prior Authorization - Orthopedic / Joint (selected CPT)CPTCovered

27096	Injection, sacroiliac joint
27125	Partial hip replacement (hip hemiarthroplasty)
27130	Total hip arthroplasty (primary)
27132	Revision of total hip arthroplasty (removal and replacement)
27134	Revision of total hip arthroplasty, with or without bone graft
27279	Arthrodesis, sacroiliac joint
27280	Fusion of sacroiliac joint
27332	Excision/repair procedures, knee (removal of knee cartilage)
27333	Excision/repair procedures, knee (removal of knee cartilage)
27334	Removal of knee joint lining (synovectomy)

1–10 of 45

1/5

MAPD Prior Authorization - Anesthesia / Bone Graft / StimulationCPTCovered

01939	Anesthesia for complex spine procedures (cervical/thoracic)
01940	Anesthesia for complex spine procedures (lumbar/sacral)
01941	Anesthesia, neuromodulation/intrathecal cervical/thoracic
01942	Anesthesia, neuromodulation/intrathecal lumbar/sacral
20930	Allograft morselized bone graft, spine, add-on
20931	Allograft structural bone graft, spine, add-on
20936	Bone graft, local, additional
20937	Bone graft morsel add-on
20938	Bone graft structural add-on
20974	Electrical bone stimulation

1–10 of 11

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MAPD Prior Authorization - Maxillofacial / Facial ReconstructionCPTCovered

33412	Replacement of aortic valve (listed here for completeness)
33413	Replacement of aortic valve (alternative valve type)
33414	Replacement of aortic valve (complex)
33415	Revision subvalvular tissue
38205	Harvest, allogeneic hematopoietic stem cell
38206	Harvest, autologous hematopoietic stem cell
43645	Laparoscopic gastric bypass including small intestine
43770	Laparoscopic placement of gastric adjustable device (gastric band)
43771	Laparoscopic gastric procedure (related)
43772	Laparoscopic gastric procedure (related)

1–10 of 22

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MAPD Prior Authorization - Hip & Lower Extremity ProceduresCPTCovered

27125	Partial hip replacement
27130	Total hip arthroplasty
27132	Total hip arthroplasty (alternate coding)
27134	Revision of hip joint replacement
27279	Arthrodesis of sacroiliac joint
27280	Fusion of sacroiliac joint
29914	Hip arthroscopy with femoroplasty
29915	Hip arthroscopy acetabuloplasty
29916	Hip arthroscopy with labral repair

MAPD Prior Authorization - Cardiac / Thoracic (selected)CPTCovered

33412	Replacement of aortic valve
33413	Replacement of aortic valve (alternate)
33414	Replacement of aortic valve (complex)
33415	Revision subvalvular tissue

MAPD Prior Authorization - Transplant / Donor (selected)CPTCovered

38205	Harvest allogeneic stem cell (donor)
38206	Harvest autologous stem cell
47135	Liver transplantation
50365	Kidney transplantation

MAPD Prior Authorization - Gynecologic / Reproductive Selected CodesCPTCovered

55180	Revision of scrotum
55970	Sex transformation male to female
55980	Sex transformation female to male
56625	Complete removal of vulva
56800	Vaginal repair
56805	Repair of clitoris
56810	Repair of perineum
57106	Partial vaginectomy
57107	Partial vaginectomy (additional)
57110	Complete vaginectomy

1–10 of 33

1/4

MAPD Prior Authorization - Neurosurgery / Spine Imaging & ProceduresCPTCovered

60512	Autotransplant parathyroid
61630	Neurosurgical procedure (placeholder)
62115	Reduction of skull defect
62120	Repair skull cavity lesion
62263	Epidural lysis multiple sessions
62264	Epidural lysis single day
62280	Treatment of spinal cord lesion
62281	Treatment of spinal cord lesion (additional)
62287	Percutaneous discectomy
62320	Injection interlaminar cervical/thoracic

1–10 of 11

1/2

MAPD Prior Authorization - Imaging (CT/MRI/PET selected)CPTCovered

70486	CT maxillofacial without contrast
70487	CT maxillofacial with contrast
70488	CT maxillofacial w/o & w/ contrast
70490	CT soft tissue neck w/o contrast
70491	CT soft tissue neck w/ contrast
70492	CT soft tissue neck w/o & w/ contrast
70496	CT angiography head
70547	MR angiography neck w/o contrast
70548	MR angiography neck w/ contrast
70549	MR angiography neck w/o & w/ contrast

1–10 of 29

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Prior Authorization, Submission & Documentation Requirements

Prior Authorization

Prior authorization requirement

Providers must verify member eligibility and benefits prior to providing services. Prior authorization is required for the CPT/HCPCS codes listed on the MAPD Prior Authorization Procedure Code List effective 01/01/2024; presence of a code on the list does not guarantee coverage under a member's contract. Failure to obtain required prior authorization may result in claim denial.

Always check eligibility and member benefits before rendering services.
If a code is noted as managed by eviCore (green highlight), contact eviCore for prior authorization and medical records requests.

Prior Authorization

eviCore-managed anesthesia codes

Select anesthesia codes (e.g., 01939–01942 and related anesthesia procedure codes) are managed by eviCore. For these and other eviCore-managed codes, submit medical records and prior authorization requests to eviCore.

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

Prior Authorization

Prior authorization required for listed CPT codes

Many CPT procedure codes across specialties require prior authorization and/or submission of medical records. For codes routed to eviCore, providers must use the eviCore phone or portal to initiate authorization or respond to medical record requests.

eviCore phone: 1-855-252-1117
eviCore portal: https://www.evicore.com/healthplan/bcbs
Examples include imaging, spine, vascular, and genomic/molecular codes listed in the MAPD file.

Prior Authorization

Prior authorization required for listed arthroscopy/shoulder codes

Arthroscopy and shoulder procedure codes (examples: 29805–29828, 29827–29828) require prior authorization and are often managed via eviCore. Submit clinical documentation to support medical necessity when requested.

Contact eviCore for review and medical records requests: 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs
Include pre-operative evaluation, history and physical, operative report when applicable.

Prior Authorization

Prior authorization required for transplant-related codes

Transplant-related codes (examples: lung, heart, liver, bone marrow/stem cell donor/recipient codes such as 32851–32856, 33940–33945, 38232–38242, 38240–38241) require prior authorization. If transplant approval is already on record include the transplant date; if not, submit H&P, transplant evaluation, and transplant date.

If transplant approval on record: include Date of Transplant in submission.
If no approval on record: submit history & physical, transplant evaluation, and date of transplant.
Bone marrow/stem cell transplant codes require prior authorization and supporting documentation.

Prior Authorization

Prior authorization required (sample codes)

Certain sample codes from various specialties (e.g., 11970, 15271, 15775–15780) require submission of pre-operative evaluation, history & physical including documentation of functional impairment, and the operative report to support medical necessity.

Include pre-operative evaluation and H&P including functional impairment.
Include operative report and documentation of medical necessity.
These examples do not replace checking the full MAPD code list for other required documents.

Prior Authorization

Prior authorization for bariatric procedures

Bariatric procedure codes (examples: 43633, 43644–43645, 43770, 43775, 43843–43848) require prior authorization and specific pre-authorization documentation. Typical required records include history & physical, nutritional evaluation, psychological evaluation, documentation of weight loss attempts, and social supports.

History and physical
Nutritional and psychological evaluations
Documentation of prior weight loss attempts and social supports

Prior Authorization

Transplant-related prior authorization

Transplant-related procedures and cellular therapy codes (e.g., 0537T–0540T, 38232, 38240–38242) require prior authorization. Submit transplant approval if available; otherwise supply H&P, transplant evaluation, and transplant date. Cellular therapy ancillary codes require H&P, plan of care, and documentation of medical necessity.

If transplant approval on record: include transplant date.
If not: submit H&P, transplant evaluation, and date of transplant.
Cellular therapy ancillary codes: recent H&P, plan of care, and documentation of medical necessity.

Prior Authorization

Prior authorization required for listed procedure codes

Many procedures across specialties require prior authorization via eviCore (phone and portal). Providers should respond promptly to eviCore medical records requests and ensure required clinical documentation accompanies requests to avoid delays or denials.

eviCore phone: 1-855-252-1117
eviCore portal: https://www.evicore.com/healthplan/bcbs
Respond to medical records requests with H&P, operative report, and other code-specific documentation as listed.

Prior Authorization

Prior authorization required (select codes)

Select imaging, vascular, PET/proton therapy, and other specialty codes require eviCore prior authorization and specific documentation. Some codes have effective/removed dates noted—verify current status before submission.

Confirm whether a code was marked "Removed" on the effective list before billing.
Provide history & physical and prior diagnostic reports for proton therapy codes (77520, 77522, 77523, 77525).
Use eviCore phone/portal for imaging authorization requests.

Documentation Required

Authorization/documentation for ophthalmic and oculoplastic procedures

Ophthalmic and oculoplastic procedure codes (e.g., corneal transplant 65710–65755, ocular reconstruction 65780–65782, eyelid/oculoplasty 67900–67924) require pre-operative evaluation, history & physical, and operative report when requested for authorization.

Submit pre-operative evaluation, H&P, and operative report.
Respond to eviCore requests for additional documentation as applicable.

Prior Authorization

Authorization requirements for hearing implants

Hearing implant and ear implant procedures (e.g., 69714–69718, 69930) require prior authorization and documentation of prior hearing device use, level of hearing impairment, pre-operative evaluation, and operative report.

Document previous use of hearing aids and level of hearing impairment.
Include pre-operative evaluation and operative report.
Contact eviCore when codes are routed to eviCore for authorization.

Prior Authorization

Prior authorization required for listed codes

The MAPD list includes numerous codes routed to eviCore for prior authorization and medical records requests. Providers must use the eviCore contact methods for authorization and to submit clinical documentation.

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

Prior Authorization

Additional genomic/molecular codes requiring prior authorization

Genomic and molecular testing codes (CPT and U-codes, e.g., 81162–81350 series, 81430–81460 series, many U-codes) frequently require prior authorization and are managed by eviCore. Submit test-specific clinical documentation per eviCore instructions.

Contact eviCore for authorization and medical records requests: 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs
Provide relevant clinical history and test indication when requesting authorization.

Prior Authorization

Codes requiring eviCore prior authorization/medical records

Codes that require eviCore prior authorization/medical records include many imaging, spine, vascular, genetic, oncology, and specialty treatment codes. Use the eviCore phone or portal for both initial prior authorization requests and to submit requested records.

eviCore phone: 1-855-252-1117
eviCore portal: https://www.evicore.com/healthplan/bcbs
Examples: spine fusion (22533–22634), vascular studies, advanced imaging (70450, 70540), genomic panels.

Documentation Required

Prior authorization and required documentation

Prior authorization and required documentation varies by code. Where listed, submit the specific medical records requested (examples below). Failure to submit required documentation may delay review or result in denial.

Commonly required items: pre-operative evaluation, history & physical, operative report, diagnostic study results, plan of care, letters of medical necessity.
For durable medical equipment and complex mobility devices, include functional status, duration, goals, and anticipated equipment need.

Denial Risk

Denial risk from missing prior authorization / benefit limits

Failure to obtain required prior authorization, to check benefit limits, or to submit requested clinical documentation may result in claim denial. Presence of a code on the MAPD list does not guarantee coverage—verify member contract terms.

Obtain prior authorization when required; missing prior auth is a common denial trigger.
Verify member benefits and coverage prior to performing services.

Denial Risk

Documentation-triggered denials

Denials may be triggered specifically by missing clinical documentation or failure to respond to eviCore medical records requests. Providers should proactively submit required H&P, operative reports, diagnostic testing, and letters of medical necessity with the authorization request.

Examples of documentation-triggered denials: missing H&P, missing operative report, lack of transplant approval/ evaluation documentation, no CPAP trial documentation where required.

Denial Risk

Denial risk for missing documentation

Missing or incomplete documentation submitted to eviCore (or not submitted at all) increases the risk of denial or delayed authorization. Ensure all code-specific documents listed on the MAPD file accompany prior authorization requests.

Verify and include code-specific documentation: history & physical, operative report, diagnostic test results, functional assessments, letters of medical necessity.

Denial Risk

Documentation-dependent denials

Many MAPD-listed codes explicitly require submission of clinical documentation (H&P, operative report, diagnostic results) to demonstrate medical necessity. Providers must supply these documents at time of authorization or in response to eviCore requests to avoid denial.

Examples: spine procedures often require H&P, operative report, and documentation of conservative measures; cardiac/vascular procedures require H&P, plan of care, and diagnostic testing results.

Denial Risk

Missing documentation risk

If required documentation is missing at time of submission, authorization may be denied or deferred. Providers should review the MAPD list for code-specific documentation requirements and include those materials with the prior authorization request.

Missing documentation commonly cited: letters of medical necessity for HCPCS E-codes, CPAP trial results for sleep surgery codes, transplant evaluation for transplant procedures.

Prior Authorization

eviCore routing for select spinal codes

eviCore is the designated prior authorization routing for many spinal codes and other high-cost interventions. Use eviCore contact methods for prior authorization and to submit medical records.

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

Documentation Required

Medical records required for proton therapy codes

For proton therapy and other advanced radiation treatment codes (e.g., 77520, 77522, 77523, 77525), include history & physical and results of prior diagnostic procedures when submitting for prior authorization. Some proton codes were added or had removal dates—confirm current billing status.

Include H&P and previous diagnostic procedure reports.
Verify whether codes were added 1/1/24 or removed at year-end as noted.

Note

General medical records request contact

For general medical records and prior authorization submissions, use eviCore contact information. The MAPD list repeatedly references eviCore as the submission route for many codes.

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

Note

Where to send prior auth and medical records

Where the MAPD list specifies where to send prior authorization requests or medical records, use eviCore (phone or portal). For non-eviCore-managed codes, follow the payer-specific instructions in the member's benefit materials or contact BCBS Texas customer service.

eviCore phone: 1-855-252-1117
eviCore portal: https://www.evicore.com/healthplan/bcbs
Contact BCBS Texas customer service to verify non-eviCore routes or member-specific requirements.

Prior Authorization

Genetic/molecular test documentation routing

Genetic and molecular test authorizations are routed to eviCore for review. Providers should include clinical indications and any prior relevant testing when requesting authorization for genomic panels and molecular diagnostics.

Include clinical history and prior test results when applicable.
Use eviCore phone/portal for submission: 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs.

Note

Submission contact

Use eviCore contact methods (phone and portal) as the primary submission contact for codes routed to eviCore. For code-specific documentation requirements, follow the MAPD list entries.

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

Documentation Required

Medical records / documentation requirements

Across the MAPD list, many codes require submission of medical records and documentation to support prior authorization. Follow the code-specific 'Medical Records Request information required' notes—these commonly request H&P, operative reports, diagnostic testing, letters of medical necessity, and plan of care.

Typical required documents: history & physical, operative report, diagnostic study results, letters of medical necessity, plan of care.
For equipment (HCPCS E-codes), include anticipated duration of equipment need and functional descriptions.

Documentation Required

Medical records/documentation requests

Certain codes list explicit medical records or documentation requests (examples across specialties). Providers must supply these items when requested to support medical necessity and expedite authorization.

Facial/jaw/reconstructive codes: chart notes, appliance type, TMJ history, sleep study results where applicable.
Venous procedures: pre-op evaluation, H&P, duplex study results.
DME/complex mobility: letter of medical necessity, functional and mobility documentation, duration and goals.

Documentation Required

Required submission route and examples of documentation

The MAPD list identifies the required submission route (often eviCore) and examples of documentation to include with prior authorization requests. Consolidate code-specific documents per the MAPD notes to reduce risk of incomplete requests.

When listed, send records to eviCore (phone or portal).
Include code-specific documentation (H&P, operative report, diagnostic results, LOMN) as indicated.

Documentation Required

Letter of medical necessity requirement

Letters of medical necessity are required for many durable medical equipment (E-codes) and complex device requests. Include description of condition, anticipated duration of equipment need, and functional limitations.

Letter of medical necessity should state anticipated duration of need and condition being treated.
Include diagnosis, abilities/limitations, prior treatments, and goals when requesting complex mobility devices.

Documentation Required

History and physical / prior treatments

History and physical should be included with many prior authorization requests—especially for surgical procedures, transplants, and complex device requests. Document prior treatments and comorbidities where requested.

Include H&P with documentation of comorbidities, prior interventions, and relevant diagnostic findings.
Provide operative reports and treatment plans where applicable.

Documentation Required

Functional and mobility documentation

For complex mobility and power wheelchair requests, include functional assessments: diagnosis, abilities/limitations, duration of impairment, goals, prior equipment trials, and evaluation of upper extremity strength when applicable.

Provide evaluation of upper extremity strength and activities of daily living.
State duration of condition and anticipated benefit/goals of equipment.

Denial Risk

Billing removed codes risks denial

When codes are marked "Removed" or have specific effective/removed dates on the MAPD list, verify billing status before submission—using a removed code may result in denial.

Confirm whether code was removed on the date indicated before billing.
If a code was replaced, use the current authorized code.

Policy Background and Scope

Background: This procedural code list is used to support utilization management and prior authorization processes for MAPD members. It enumerates procedures across specialties, specifies per-code medical-records and documentation requirements (for example, history and physical, operative reports, letters of medical necessity), and routes many prior authorization and medical-records requests to a third-party vendor, eviCore (contact and portal shown on the list). The list is intended to guide providers when preparing authorization requests and required documentation.

Definitions and Key Terms

Green highlighted codes

DefinitionGreen highlighted codes are managed by eviCore healthcare

ActionContact eviCore for medical records requests or prior authorization as indicated on code entries

ReferenceSee eviCore routing notes and phone/URL on listed codes

eviCore — prior authorization / medical records contact

Vendor nameeviCore (utilization management vendor)

Phone1-855-252-1117

Portalhttps://www.evicore.com/healthplan/bcbs (use for medical records/prior authorization submission)

Functional impairment — required documentation

Required clinical infoClinical information demonstrating functional impairment must be included in pre-operative evaluation/history & physical for nasal/ENT procedures

ExamplesFunctional limitations, symptom severity, impact on ADLs, and objective findings relevant to nasal/ENT condition

Where to includeDocument in history and physical and pre-operative evaluation as part of medical records for prior authorization

Transplant approval on record — submission guidance

When transplant approval on recordSubmit the date of transplant in lieu of full transplant documentation when 'If transplant approval on record' is specified

If no approval on recordProvide history and physical, transplant evaluation, and date of transplant

Applicable codesExamples include 38232, 38240, 38241, 38242 and other transplant-related codes listed

CPAP trial / sleep study requirement

When requiredCPAP trial results and sleep study results are required when indicated for tongue base or palate procedures

Documentation examplesSleep study report and CPAP trial response included in history & physical or pre-op evaluation

Relevant codesExamples: 41530 (tongue base volume reduction), 42145 (palate repair) reference CPAP/sleep study in medical records request

Utilization management vendor for imaging/procedures

VendoreviCore (utilization management vendor) handles many imaging/procedure prior authorizations

ContactPhone: 1-855-252-1117; Portal: https://www.evicore.com/healthplan/bcbs

ScopeReferenced repeatedly for imaging, genetic, and many procedure prior authorization and medical records requests

eviCore — third-party utilization management vendor

eviCore roleThird-party utilization management vendor for medical records requests and prior authorization processing

Contact info1-855-252-1117 or https://www.evicore.com/healthplan/bcbs

UseSubmit prior authorization requests and associated medical records per-code via eviCore as indicated

Letter of medical necessity — definition

DefinitionLetter of medical necessity: written justification including anticipated length of time equipment will be required and description of the medical condition and mobility status

When requiredFrequently required for HCPCS E-codes (e.g., standing frames, pneumatic devices, wheelchair accessories)

IncludeClinical rationale, prior treatments tried, expected duration of need

History and physical — definition / examples

DefinitionHistory and physical: clinical notes documenting comorbidities, previously tried interventions, and operative reports when available

Use in prior authRequired across many listed procedure codes to demonstrate medical necessity

ExamplesInclude comorbid conditions, conservative care attempts, objective findings, and operative details when applicable

Document Updates & Effective Dates

Core summary: This MAPD Benefit Prior Authorization Procedure Code List is effective 01/01/2024 and the document includes an update note of Updated June 2024.

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyMAPD Benefit Prior Authorization Procedure Code List (Plastic/Reconstructive Surgery codes included)

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes

Effective Date01/01/2024

Next Review DateN/A

Key ActionVerify member benefits and obtain prior authorization via eviCore (1-855-252-1117 or https://www.evicore.com/healthplan/bcbs) when submitting requests for listed CPT/HCPCS codes.

SourceLink

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