CurrentBlue Cross Blue Shield - TexasPolicy N/A

MAPD Prior Authorization Procedure Code List — Prior Authorization and Documentation Requirements

A procedural code list and associated preauthorization and documentation requirements for services that may require prior authorization under the MAPD benefit; intended for providers submitting claims to Blue Cross Blue Shield - Texas and for eviCore-managed codes.

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyMAPD Prior Authorization Procedure Code List — Prior Authorization and Documentation Requirements

Policy CodePolicy N/A

Change TypeAdministrative (no material clinical changes)

Effective DateApr 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization and submit required documentation (recent H&P, operative report, plan of care, and Letter of Medical Necessity) and contact eviCore when the code entry directs providers to that vendor.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

200+procedure codes listed or implied across document fragments

eviCoreexternal prior auth vendor referenced repeatedly

H&P oftenpre-op evaluation commonly requested

multiplecodes requiring transplant documentation

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codes with add/remove annotations

Coverage Criteria and Conditions

inv-01: Documentation and eviCore management requirements

Prior authorization and submission of supporting documentation as specified per code

Standard documentation requirements: Provider must submit pre-operative evaluation, history & physical including documentation of functional impairment and operative report for most listed procedures

Some procedures require additional items (photographs, pathology reports, weight/height, grams removed).

eviCore-managed codes: For specified codes (see code list) providers must contact eviCore at the provided phone number or website for management

The list highlights eviCore-managed codes in green

inv-02: PA routing and documentation notes

Coverage and PA routing notes for listed CPT codes

eviCore routing: Many musculoskeletal, arthroscopy, hip/shoulder/knee and spine procedure codes are routed to eviCore for prior authorization (contact eviCore 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs)

See individual code entries for specifics

No Prior Auth for MT Medicare Advantage: Multiple entries include the note 'No Prior Auth required for MT Medicare Advantage Plan' for specified codes (plan-specific exceptions)

Applies only where explicitly annotated in the code list

Required documentation: Several codes require pre-operative evaluation, history & physical including functional impairment and operative report; transplant and major cardiac procedures require recent H&P, plan of care, and documentation of medical necessity or transplant approval details

Documentation supports medical necessity/PA processing

inv-03: Required documentation conditions

Documentation requirements for listed surgical/transplant codes

Transplant-related documentation: If transplant approval on record: submit date of transplant; If no transplant approval: submit history and physical, transplant evaluation and date of transplant.

Applies to donor and transplant procedure codes (e.g., 32851-32856, 48550-48556, 50300-50340)

General surgical documentation: Submit history and physical and operative report and documentation of medical necessity for listed urologic, genital, abdominal and pelvic procedures

Examples include codes requiring H&P and operative report to determine medical necessity

inv-04: eviCore routing and exceptions

Routing to external review vendor for certain spine/pain procedures

eviCore routing: Some spine, neurosurgery and neuraxial procedure codes reference eviCore (phone/website) for prior authorization determinations; follow eviCore instructions where present

Entries often annotate plan-specific 'No Prior Auth required for MT/NM Medicare Advantage' where applicable

inv-05: Prior authorization routing

Coverage routing and documentation requirements as listed per code

eviCore routing: Many imaging and procedure codes list eviCore as the prior authorization contact or management vendor; some entries also specify required supporting documentation (H&P, operative report, prior diagnostic reports)

See per-code entry for exact required items (e.g., 72291, imaging CPTs)

inv-06: Procedures requiring H&P and operative report

Certain procedures require pre-op documentation to determine medical necessity

Documentation required: Codes such as 63620, 64530, 64555, 64561, 64565 and multiple ophthalmic/ocular and eyelid repair codes (e.g., 65710–65782, 67900–67924) require submission of history & physical and operative report or documentation of medical necessity

Failure to provide required documents may result in denial

inv-07: Discography (72291)

Discography prior auth requirements

72291 prior auth: Prior authorization for 72291 (discography) requires submission of history and physical and results of previous diagnostic procedure report

Required to support prior authorization review

inv-08: Prior authorization

Prior authorization required for the following codes through eviCore

eviCore prior auth: Provider must obtain prior authorization via eviCore (contact 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs) for the listed procedure, genetic and molecular codes before service

Applies to codes enumerated in the genetic/molecular and high-complexity procedure sections

inv-09: Documentation as a coverage condition

Coverage requires clinical documentation for specific procedures

Documentation: Recent history and physical, plan of care, and documentation of medical necessity must accompany prior authorization requests for specified procedures (examples: 91111, 91112, 91132, 91133, 92986–92993)

Omission of required documentation may result in denial

inv-10: Documentation-conditioned coverage

Coverage/authorization is conditioned on submission of specified clinical documentation:

General requirement: Provide the requested documentation (history and physical, Letter of Medical Necessity, treatment plan, prior interventions, operative reports) listed for the specific code

Applies across numerous device, DME and service codes in this section

inv-11: eviCore review

Some services require review or routing through eviCore:

eviCore routed codes: Codes routed to eviCore for prior authorization or utilization review per the entry (examples include E0748, E0749, G0252, G0219, home sleep test and various DME codes)

Follow eviCore contact instructions provided in listing

inv-12: Prior authorization and documentation criteria (administrative)

Prior authorization and documentation requirements vary by code; many entries include one of the following conditions

General documentation requirement: Submission of history and physical, chart notes from ordering physician, and treatment plan with a Letter of Medical Necessity is required for many codes

Required documentation content specified in per-code entries

eviCore prior authorization: Contact eviCore (1-855-252-1117 or https://www.evicore.com/healthplan/bcbs) for prior authorization for numerous listed codes

Explicitly specified for many entries

Code-specific additional requirements: Some codes include additional requirements such as minimum channels for home sleep tests (Type II = 7 channels; Type III = 4 channels; Type IV = 3 channels) or letters of medical necessity for DME

See per-code notes for details

inv-13: General prior authorization requirements

Covered with prior authorization and required documentation when indicated by code-specific entries

General prior auth and documentation requirements: For codes that reference eviCore or require documentation, prior authorization and submission of recent history and physical, plan of care, and documentation of medical necessity are required

Some codes specify eviCore review; contact details/URLs are provided in the list

The presence of a CPT or HCPCS code on this procedure list alone does not guarantee coverage. Coverage for any service or supply depends on the member’s specific benefit contract and medical necessity; providers must verify member eligibility and benefits before rendering services. Green-highlighted codes are managed by eviCore and may require vendor routing as noted in the list.

Certain entries on the list include plan-specific exceptions stating No Prior Auth required for MT Medicare Advantage Plan. Where that note appears (for example on multiple spine procedure lines), it applies only to the Montana Medicare Advantage plan variant named in the entry and does not remove the general expectation to verify coverage and prior authorization requirements for other members.

The notation No Prior Auth required for MT Medicare Advantage Plan is repeated across several orthopaedic and arthroscopy code entries (examples include knee revision and shoulder arthroscopy codes). These per-code exceptions are limited to the MT Medicare Advantage plan as annotated and do not alter the prior authorization requirements for other BCBS plan members.

Several spine and pain-management procedure entries reference eviCore for prior authorization routing but also include explicit notes that No Prior Auth is required for MT (or NM) Medicare Advantage Plan where annotated. Providers should follow the per-code note: when the MT/NM exception is present, that prior‑auth exemption applies only to the specified Medicare Advantage plan and not broadly to other members.

Multiple spine procedure lines (e.g., cervical and lumbar disk and laminotomy codes) explicitly include the statement No Prior Auth required for MT Medicare Advantage Plan. For codes routed to eviCore, providers should follow the entry-level instruction: obtain eviCore review when required except in instances where the MT MAP note specifically exempts that plan.

A cluster of T- and related imaging/procedure codes in this segment include the annotation No Prior Auth required for MT Medicare Advantage Plan effective 4/1/2018. The effective-date phrasing applies to the MT plan exception listed next to those specific codes; it does not mean a universal prior‑auth waiver for other BCBS plans or members.

Several individual entries throughout the list carry the plan-specific annotation No Prior Auth required for MT Medicare Advantage Plan (examples appear adjacent to selected T-codes and some HCPCS entries). These annotations are per-code exceptions and should be interpreted as applying only to the annotated plan and code.

HCPCS code A9270 is listed in the document as a Non‑covered item or service in the cited entry. Providers should not assume coverage for A9270 and must verify member benefits or supporting policy language for any potential exceptions.

The entry for G0219 (PET imaging whole body; melanoma) is shown with language indicating non‑covered indications in the listing. Per the entry, coverage is limited by the specified indications and prior authorization routing where applicable; providers should consult the code line and member benefits for coverage determination.

Some code entries include administrative annotations indicating removal dates or per‑code exclusions (for example, codes marked 'Removed' with an effective date). These are code‑specific changes recorded in the list rather than broad clinical exclusion rules; consult each code line for any remove/add notes and effective dates.

Within the cited segments there are no broad, program‑level clinical exclusions described. Exclusionary language shown in the document is generally code‑specific (e.g., non‑covered entries such as A9270) rather than a list of blanket clinical exclusions.

Certain power‑mobility and prosthetic codes that lack PDAC coding or do not meet PDAC criteria (for example K0899 entries) remain on the list but still require submission of supporting clinical documentation (history & physical, plan of care, and/or a Letter of Medical Necessity) as specified. Inclusion on the list does not imply automatic coverage when PDAC or other product criteria are not met.

The cited document fragments do not include explicit determinations that any listed service is categorically 'not medically necessary.' Instead, the list maps codes to prior authorization routing and required supporting documentation; final medical necessity determinations depend on submitted clinical information and member benefits.

CPT/HCPCS Code Lists and Code-Specific Notes

Prior Authorization CPT CodesCPTCovered

43846	Gastric bypass for obesity
43847	Gastric bypass including small pouch
43848	Revision of gastroplasty
43886	Revision of gastric port (open)
43888	Change or removal of gastric port (open)
43999	Unlisted procedure, stomach; used for certain stomach surgeries
44132	Enterectomy, cadaver donor
44133	Enterectomy, living donor
44135	Intestine transplant, cadaver donor
44136	Intestine transplant, living donor

1–10 of 234

1/24

Transplant & Donor Surgical CPT CodesCPTCovered

50320	Removal of kidney, living donor
50325	Preparation of donor renal graft
50327	Preparation renal graft (venous)
50328	Preparation renal graft (arterial)
50329	Preparation renal graft/ureteral
50365	Transplantation of kidney
50370	Removal transplanted kidney
32851	Lung transplant, single
32853	Lung transplant, double
32855	Prepare donor lung single

1–10 of 19

1/2

Genomic, Molecular and U/T CodesmixedCovered

81186	CACNA1A gene known familial variant (example)
81189	CSTB gene full gene sequence (example)
81190	CSTB known family variant (example)
81195	OGM-Dx HemeOne
81201	APC gene full sequence
81202	APC gene known familial variants
81415	Exome sequence analysis
81418	Rx metabolic genomic sequencing panel
81425	Genome sequence analysis
81426	Genome sequence analysis

1–10 of 19

1/2

Imaging, MRI/CT/Angio CodesCPTCovered

70460	CT head/brain with contrast
70470	CT head/brain without & with contrast
71250	CT thorax without contrast
71260	CT thorax with contrast
72141	MRI neck spine without contrast
72142	MRI neck spine with contrast
72148	MRI lumbar spine without contrast
72149	MRI lumbar spine with contrast
70540	MRI orbit/face/neck without contrast
70542	MRI orbit/face/neck with contrast

1–10 of 18

1/2

Durable Medical Equipment (Sample HCPCS)HCPCSCovered

E0601	Continuous positive airway pressure (CPAP) device
E0638	Patient lift / standing frame (documentation required)
E0748	Osteogenesis stimulator, electrical, spinal applications
E0782	Implantable infusion pump
A0430	Fixed wing air ambulance
A7030	Full face mask for PAP device
A7027	Combination oral/nasal mask

Sleep Study and Polysomnography CodesCPTCovered

95783	Polysomnogram <6 yrs CPAP/BiPAP
95800	Sleep study unattended
95801	Sleep study unattended with analysis
95805	Multiple sleep latency test
60398	Home sleep test type II — minimum channels defined
60399	Home sleep test type III — minimum channels defined
G0400	Home sleep test type IV — minimum 3 channels

Cardiac / Valve Revision CodesCPTCovered

92986	Revision of aortic valve
92987	Revision of mitral valve
92990	Revision of pulmonary valve
92992	Revision of heart chamber

Selected Drug/J-code and Injectable ExamplesNDCCovered

J1427	Viltepso (golodirsen) — documentation / prior auth as noted
J1428	Eteplirsen (Exondys 51) — documentation / prior auth as noted
J0881	Darbepoetin alfa (injectable) — documentation/prior auth where indicated
J0885	Epoetin alfa (injectable) — documentation/prior auth where indicated
J1745	Infliximab injection
J1561	Immune globulin — documentation/prior auth

Provider Steps: Prior Auth, Documentation & Submission

Prior Authorization

Eligibility & Benefits Verification

Verify member eligibility and benefits prior to scheduling services. Code presence on this list does not guarantee coverage — check the member benefit booklet or contact customer service. Some codes are managed by eviCore; referrals or prior authorization must be submitted to eviCore when indicated.

Always verify eligibility and benefits before rendering services
Codes highlighted as eviCore-managed require referral/prior authorization to eviCore

Prior Authorization

Prior Authorization Required / eviCore Routing

Preauthorization (prior authorization) is required for many listed CPT, HCPCS, T-, and DME/device codes. For items managed by eviCore, submit requests to eviCore (1-855-252-1117 or https://www.evicore.com/healthplan/bcbs). Failure to obtain required prior authorization or to include required documentation may result in denial or delayed payment.

Prior authorization required for numerous CPT/HCPCS and T-code procedures listed in this document
eviCore contact: 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs

Policy Background

This document is a MAPD prior authorization procedure code list and associated documentation requirements. It identifies codes that may require prior authorization, notes codes managed by the eviCore vendor, and specifies per‑code documentation expectations (for example, pre‑operative evaluation, history & physical, operative reports, transplant dates or evaluations, and Letters of Medical Necessity). It is not a standalone medical‑necessity policy; providers must verify member eligibility and submit the clinical documentation listed with each code when requesting authorization.

Definitions and Vendor Contacts

eviCore-managed codes (highlighted; vendor contact info)

eviCore-managed codesCodes highlighted in green on the list are managed by eviCore Healthcare; providers must contact eviCore for prior authorization (phone 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs).

Contact methodsTelephone: 1-855-252-1117; Web: https://www.evicore.com/healthplan/bcbs — use per-code routing as noted on the list.

ScopeeviCore manages numerous CPT/HCPCS and genetic/molecular codes across the document; check the code line for green/highlighted designation.

If transplant approval on record (definition/note)

DefinitionIf transplant approval is on record, provider should submit the date of transplant to satisfy documentation requirements for the referenced code(s).

When applicable

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyMAPD Prior Authorization Procedure Code List — Prior Authorization and Documentation Requirements

Policy CodePolicy N/A

Change TypeAdministrative (no material clinical changes)

Effective DateApr 1, 2025

Next Review DateN/A

SourceLink

On This Page

No Prior Auth exceptions noted for certain MT/NM Medicare Advantage plans — confirm plan-specific routing

Documentation Required

Required Clinical Documentation (summary)

Many surgical, implant, transplant, and major-procedure codes require submission of specific clinical documentation with the authorization request. Common required documents include recent history & physical (H&P), pre-operative evaluation, operative reports, plan of care, and documentation of conservative treatments tried. Missing documentation is a frequent cause for denial.

Include recent History & Physical (H&P) and pre-operative evaluation showing functional impairment when requested
Operative report must be submitted when available
Plan of care and documentation of prior conservative measures (when specified)
Transplant codes: if transplant approval exists, submit date of transplant; if not, submit H&P, transplant evaluation and date of transplant

Prior Authorization

Spine Surgery Routing

Spine surgery and related codes (e.g., 63020, 63030, 22630, 22800, 22802, 22804, 22808, 22810, 22858, 22859, 22860, 22861, 22862, 22864, 22865, etc.) are routed to eviCore for review. Submit history and physical, operative report, and documentation of conservative measures as requested. Note plan-specific exceptions (e.g., no prior authorization required for certain MT/NM Medicare Advantage plans) — verify per-member.

Submit H&P, operative report, and conservative treatment documentation for spine fusion and post-fusion codes
eviCore routing applies for many spine codes; contact eviCore for prior authorization
Confirm any plan-specific exceptions before proceeding

Prior Authorization

Pain / Injection Procedures Routing

Pain management and injection procedures (including paravertebral/injection CPTs and block/denervation codes such as 64451, 64479-64495 series, 64510, 64520, 64530, 64625, 64633-64636, 64685, etc.) are frequently routed to eviCore. For certain injections and neurostimulator implants, submit H&P, documentation of prior interventions, and operative reports where applicable. Some injection procedures may have plan exceptions (verify member).

Provide history and physical and documentation of prior conservative interventions
Neuroelectrode implants and spinal generators require operative report and supporting clinical notes
eviCore should be contacted for prior authorization when codes are marked as eviCore-managed

Prior Authorization

Imaging and Discography Routing

Imaging procedures (CT, MRI, MR angiography, CT angiography, spine imaging and discography) and select advanced imaging T-codes require prior authorization or eviCore review. For discography (72291, 72292) submit H&P and results of prior diagnostic procedures. For spine and other imaging, include prior diagnostic results when requested.

Discography (72291, 72292): history & physical and results of previous diagnostic procedures required for prior authorization
Spine imaging (72141-72158, 72191-72199 series): routed to eviCore
CT/MRI head, neck, chest, abdomen and angiography codes listed are eviCore-managed — include prior diagnostics when requested

Prior Authorization

Prior Authorization for Proton Treatment

Proton therapy codes (77520, 77522, 77523, 77525) require prior authorization and specific clinical documentation: history and physical and results of previous diagnostic procedures. These proton treatment codes were added effective 1/1/2024 — ensure the required documentation is included with requests.

Proton treatment codes added 1/1/2024 (77520, 77522, 77523, 77525)
Submit H&P and prior diagnostic results for prior authorization of proton treatment

Documentation Required

T-codes and Cellular Therapy Documentation

Cellular therapy ancillary and many T-code procedures (0537T–0540T, 0609T–0649T, selected 06xx/07xx T-codes) require recent history & physical, plan of care, and documentation of medical necessity. T-codes and certain advanced diagnostic/ancillary codes are routed to eviCore for prior authorization.

Cellular therapy ancillary codes (0537T–0540T): recent H&P, plan of care, documentation of medical necessity
Select T-codes (0609T–0649T, 0697T–0713T, etc.) require eviCore review and prior authorization
Many T-codes were implemented with effective dates noted; check the date when submitting

Denial Risk

Transplant Documentation & Denial Risk

Transplant and donor procedures (e.g., 32850–32854, 48550–48556, 50300–50380, 51585, 51597, and other transplant-related codes) require transplant-specific documentation. If transplant approval is on record, submit the date of transplant. If not, include history & physical, transplant evaluation, and the transplant date. Missing transplant documentation increases denial risk.

If transplant approval exists: submit date of transplant
If no approval: include H&P, transplant evaluation, and transplant date
Transplant-related requests must include the transplant evaluation and supporting clinical records to avoid denials

Documentation Required

Per-code Required Supporting Documentation

Per-code supporting documentation varies — follow the specific code guidance in the procedure list. Examples include: operative reports for surgical and implant codes (e.g., 63650, 63655, 64555 series), Letter of Medical Necessity for DME, mobility devices and wheelchair accessories (E- and K-codes), and H&P plus diagnostic study results for advanced diagnostics and genetic testing. Incomplete or missing required documentation commonly leads to denials.

Implant/neuroelectrode codes (e.g., 63650, 63655, 64555, 64561, 64565): submit H&P, operative report and documentation of medical necessity
Wheelchair accessories and K-/E-codes: Letter of Medical Necessity, H&P, plan of care and functional status required
DME/devices: history & physical and prior interventions should be provided where specified
Genetic/molecular tests and many J-/Q-/U-/T-codes are routed to eviCore with code-specific document requirements

Prior Authorization

eviCore Referral / Contact

eviCore referral/contact: use eviCore for preauthorization and clinical review when codes indicate eviCore management. Contact eviCore at 1-855-252-1117 or submit via https://www.evicore.com/healthplan/bcbs. Routing to eviCore increases the risk of denial if required clinical documentation is missing — include H&P, prior interventions, operative reports, and LOMN as specified.

eviCore contact: 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs
Include all code-specific documentation with eviCore submissions to reduce denial risk
Codes marked as eviCore-managed require referral/prior authorization through eviCore

Documentation Required

Required Clinical Documentation (examples)

Documentation examples and common requirements: recent history & physical (showing functional impairment when requested), operative report, plan of care, results of prior diagnostic studies (imaging, Doppler, sleep study results), prior conservative treatment documentation, and Letters of Medical Necessity for DME, prosthetics, and wheelchair accessories. Provide ordering physician notes and treatment plans when requested.

H&P showing functional impairment for many pre-op surgical authorizations
Operative reports required for surgical and implant codes
Diagnostic results (e.g., Doppler, sleep study) when listed
LOMN required for many DME, prosthetic and wheelchair accessory requests
Ordering physician chart notes and treatment plans support medical necessity

Step Therapy

Step Therapy / Drug Prior Authorization

Step therapy and other utilization management requirements may apply for certain drugs and injectable therapies — follow the code-specific guidance and eviCore drug-review routing where indicated. When step therapy or drug prior authorization applies, include treatment history and relevant chart notes.

Follow drug-specific prior authorization and step therapy requirements for injectable therapies listed
Provide prior treatment history and clinical rationale when step therapy documentation is required
Many specialty drugs and biologics are routed to eviCore

Applies to multiple transplant/donor procedure codes (examples: 32851-32856, 48550-48556, 50300-50323).

If not on recordIf no transplant approval is on record, providers must instead submit H&P, transplant evaluation and date of transplant (per-code note).

Pre-operative H&P + functional impairment (definition)

DefinitionPre-operative evaluation includes a recent history and physical documenting functional impairment; operative report supports medical necessity for listed surgical procedures.

Typical componentsMay include documentation of prior conservative therapies, diagnostic study results, and operative findings as indicated per code line.

Use for PAThese documents are commonly required to support prior authorization requests for surgical and implant procedures.

If transplant approval on record — note (alt chunk)

If transplant approval on record (alternate)When a prior transplant approval exists in plan records, submit the transplant date; this satisfies the per-code transplant documentation requirement.

Codes referencedApplies to donor/transplant codes such as 48550, 48551, 48552, 48554, 48556 and similar.

Administrative noteAlso observe any 'Prior to' date annotations on the code line.

If no Transplant approval — provider must submit H&P, transplant evaluation

Requirement when no transplant approval existsProvider must submit a recent history & physical, transplant evaluation, and the date of transplant for codes requiring transplant documentation.

Applies toDonor/transplant procedure codes (examples: 32851–32856, 38240–38242, 48550–48556, 50300–50323).

Denial riskFailure to provide these documents may trigger denial or delay of prior authorization processing.

eviCore (definition)

DefinitioneviCore is a third‑party utilization management vendor referenced throughout the document as the prior authorization contact for many codes.

Contact infoPhone: 1-855-252-1117; Web: https://www.evicore.com/healthplan/bcbs — use per code as indicated.

RoleeviCore manages prior authorization reviews and routing for selected CPT/HCPCS and genetic/molecular codes highlighted in the list.

Pre-operative evaluation / History and Physical / Operative report (definition)

DefinitionPre‑operative evaluation, History and Physical (H&P), and the operative report are clinical documents frequently required to support prior authorization for surgical and implant procedures.

Content examplesH&P should include diagnosis, comorbidities, prior treatments, functional limitations; operative report documents intraoperative findings and procedures performed.

Use in submissionsInclude these documents with PA requests as specified per code to avoid processing delays or denials.

eviCore (definition/alt)

eviCore (alternate definition)eviCore is the external prior authorization and clinical review vendor named across many entries; providers are directed to contact eviCore for management of listed codes.

Access methods1-855-252-1117 or https://www.evicore.com/healthplan/bcbs — follow code-specific routing instructions.

Applies toGenetic/molecular panels, imaging, spine, device, and many procedure codes that are highlighted/marked for eviCore review.

eviCore (contact info reference)

eviCore contact referenceUse eviCore phone 1-855-252-1117 or web portal https://www.evicore.com/healthplan/bcbs for prior authorization submissions and routing for codes annotated as eviCore-managed.

Vendor roleeviCore performs utilization review and authorization decisions for listed codes per the document annotations.

Per-code instructionFollow the per-code line note that indicates eviCore routing; not all codes on the list are routed to eviCore.

Added/Removed annotations (definition)

Added/Removed annotationsMany code entries include 'Added' or 'Removed' date annotations (examples: codes added 4/1/2024 or Removed 3/31/25); consult the individual code line for exact administrative dates.

Effect on coverageA 'Removed' annotation indicates the code was removed from the list effective the listed date; verify current status before requesting authorization.

RecordkeepingDocument per‑code effective/add/remove dates when tracking prior authorizations and appeals.

Letter of Medical Necessity (definition)

Letter of Medical Necessity (LMN)A clinician‑signed Letter of Medical Necessity should describe the diagnosis, functional impairment, anticipated length of use, and rationale linking the equipment/service to the patient’s condition.

When requiredLMNs are commonly required for DME, wheelchair accessories, osteogenesis stimulators, and prosthetic additions as specified per code line.

ContentsInclude treatment plan, prior interventions tried, mobility status, and expected duration of need to support authorization.

History and Physical (definition)

History and Physical (H&P)A clinical record documenting diagnosis, comorbidities, prior treatments, functional limitations, and relevant operative reports — frequently required to support prior authorization requests.

Use casesRequested for surgical procedures, transplants, DME, and many device/prosthetic authorizations as specified per code.

Submission guidanceAttach the H&P and any supporting diagnostic reports to the PA request to reduce risk of denial or delay.

eviCore (contact reference)

eviCore (contact reference)eviCore is the utilization management vendor referenced for prior authorization; contact 1-855-252-1117 or use https://www.evicore.com/healthplan/bcbs for code routing and submission.

When to useFollow per-code annotation indicating eviCore routing; not all codes on the list require eviCore review.

DocumentationSubmit required clinical documentation via eviCore when routing is indicated (H&P, operative report, LMN, etc.).

Letter of Medical Necessity (LMN) — definition

LMN (alternate)Letter of Medical Necessity is a treatment plan document explaining the condition being treated and justification for the requested service, often required for DME and device codes.

Typical elementsDiagnosis, functional limitations, anticipated duration of need, prior equipment experience, and mobility status.

SubmissionInclude LMN with PA requests where the code line specifies to avoid non-authorization.

eviCore (definition/alternate)

eviCore (definition/alternate)eviCore is the third‑party utilization management vendor referenced repeatedly for prior authorization and clinical review; contact via 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs.

ScopeeviCore covers a broad set of services including imaging, genetic/molecular testing, spine/pain procedures, DME, and specialty drugs per the code list.

Provider actionWhen a code line indicates eviCore routing, providers should submit PA requests and required documentation to eviCore using the provided contact methods.