MAPD Prior Authorization Procedure Code List — Prior Authorization and Documentation Requirements
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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.
No material clinical or coverage changes in this revision.
Coverage Criteria and Conditions
inv-01: Documentation and eviCore management requirements
Prior authorization and submission of supporting documentation as specified per code
Some procedures require additional items (photographs, pathology reports, weight/height, grams removed).
The list highlights eviCore-managed codes in green
inv-02: PA routing and documentation notes
Coverage and PA routing notes for listed CPT codes
See individual code entries for specifics
Applies only where explicitly annotated in the code list
Documentation supports medical necessity/PA processing
inv-03: Required documentation conditions
Documentation requirements for listed surgical/transplant codes
Applies to donor and transplant procedure codes (e.g., 32851-32856, 48550-48556, 50300-50340)
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
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
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
Failure to provide required documents may result in denial
inv-07: Discography (72291)
Discography prior auth requirements
Required to support prior authorization review
inv-08: Prior authorization
Prior authorization required for the following codes through eviCore
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
inv-10: Documentation-conditioned coverage
Coverage/authorization is conditioned on submission of specified clinical documentation:
Applies across numerous device, DME and service codes in this section
inv-11: eviCore review
Some services require review or routing through eviCore:
inv-12: Prior authorization and documentation criteria (administrative)
Prior authorization and documentation requirements vary by code; many entries include one of the following conditions
Required documentation content specified in per-code entries
Explicitly specified for many entries
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
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
| 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 |
| 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 |
| 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 |
| 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 |
| 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
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 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
- No Prior Auth exceptions noted for certain MT/NM Medicare Advantage plans — confirm plan-specific routing
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
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
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
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 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.
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
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
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
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
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 / 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
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
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