Obtain benefit prior authorization before service

Providers must obtain benefit prior authorization for the CPT/HCPCS procedure codes listed in this document before rendering services.

• Obtain authorization prior to performing services for listed codes.
• Check member eligibility/benefits — inclusion on this list does not guarantee coverage.

Follow per‑code documentation and routing instructions

The CPT codes listed have associated documentation or routing instructions; follow the per‑code notes when submitting authorization requests.

• Submit the specific chart notes, H&P, operative report, or appliance/sleep study documentation shown next to each CPT.
• Follow eviCore routing where an eviCore contact is indicated on the code line.

Use eviCore contact when indicated on CPT lines

Several CPTs in the list require prior authorization or are routed to eviCore for review; contact eviCore at 1‑855‑252‑1117 or via https://www.evicore.com/healthplan/bcbs when an eviCore reference appears.

• If eviCore is listed on the code line, call 1‑855‑252‑1117 or use the eviCore BCBS portal to request authorization.
• Codes without eviCore may still require PA — follow the code entry instructions.

Submit required clinical documentation with PA requests

MAPD prior authorization procedure codes require submission of the specified documentation (for example, recent history and physical, plan of care, operative report, or transplant approval/date) as listed per code.

• For transplant-related codes, if transplant approval is on record provide the date of transplant; if not, provide history & physical, transplant evaluation and date.
• Provide operative reports and documentation of medical necessity when specified.

Provide code‑specific documentation for MAPD PA

The MAPD prior authorization list includes procedure codes that require submission of specified documentation (e.g., H&P, operative report, transplant evaluation/date) when requesting authorization.

• Provide transplant approval/date or, if none, history & physical and transplant evaluation.
• Include operative/procedure report and documentation of medical necessity where requested.

Route prior authorization requests to eviCore when listed

Many listed procedure codes are routed to eviCore for prior authorization; providers must contact eviCore at 1‑855‑252‑1117 or via https://www.evicore.com/healthplan/bcbs to obtain authorization.

• When a code entry shows eviCore, use the eviCore phone or web portal for PA submission.
• Some entries also require H&P and documentation of medical necessity in addition to eviCore authorization.

Contact eviCore for imaging PA

Imaging CPT/HCPCS codes in the list require prior authorization or eviCore review; providers must contact eviCore (1‑855‑252‑1117 or https://www.evicore.com/healthplan/bcbs) for these services.

• This applies to CT, MRI and related advanced imaging codes shown on the code lines.
• Follow the per‑code requirements (history & physical, prior tests) where specified.

Obtain eviCore PA for CT/MRI and advanced imaging

Numerous CT and MRI spine, extremity, chest, abdomen/pelvis and related imaging codes require prior authorization via eviCore; use eviCore contact information provided on the code entries.

• Call eviCore at 1‑855‑252‑1117 or use the eviCore BCBS portal to request authorization for these CT/MRI codes.
• Include requested clinical documentation (e.g., H&P, prior diagnostic reports) as specified on the code line.

Follow eviCore instructions for fetal/specialized imaging

Fetal MRI and other specialized imaging/procedure codes reference eviCore for prior authorization; some fetal codes include plan‑specific historical notes (e.g., 'No Prior Auth required' for certain Medicare Advantage plans) which are plan‑specific exceptions.

• When eviCore is listed, contact eviCore for PA.
• Do not assume historical 'No Prior Auth' notes apply to all members — verify member plan and eligibility.

Contact eviCore for molecular/genomic code PA

CPT codes in the molecular/genomic and related sections are listed with eviCore as the prior authorization vendor; providers must contact eviCore (phone or web portal) for authorization for these codes.

• Molecular pathology/genomic CPTs require PA through eviCore.
• Use the eviCore BCBS portal or call 1‑855‑252‑1117 to submit requests and required documentation.

eviCore PA required for molecular/genomic CPTs

Prior authorization is required for listed molecular pathology/genomic CPT codes and is managed via eviCore; contact eviCore at 1‑855‑252‑1117 or through the eviCore BCBS web portal.

• Include any per‑code documentation requests noted on the code line when submitting PA.
• Check effective/add dates shown on entries when applicable.

Use eviCore for authorization/review of listed codes

Prior authorization or review for the listed codes is routed to eviCore; providers must use eviCore (phone 1‑855‑252‑1117 or the eviCore BCBS portal) to obtain authorization for these services.

• Some entries include effective or prior dates—confirm the current applicability for the member.
• Provide the code‑specific documentation requested on the code line.

eviCore review required for U‑ and T‑codes

Prior authorization (or eviCore review) is indicated for the listed U‑ and T‑codes; providers must contact eviCore at 1‑855‑252‑1117 or via the eviCore BCBS portal as shown on the code entries.

• Follow per‑code instructions and include Recent H&P, plan of care, and documentation of medical necessity when requested for T‑codes.
• Use the eviCore contact method listed for submission.

Submit PA to eviCore for U/T/A and other eviCore‑listed codes

Prior authorization is required through eviCore for the listed U‑/T‑/A‑ and other procedure codes that reference eviCore; contact eviCore at 1‑855‑252‑1117 or via the eviCore website to request authorization.

• When a code line includes eviCore, submit PA via phone or the eviCore BCBS portal.
• Ensure any required clinical documents listed on the code line accompany the PA request.

Route PA requests for specified HCPCS codes to eviCore

These procedure and HCPCS codes are routed to eviCore for prior authorization; contact eviCore at 1‑855‑252‑1117 or via the eviCore BCBS provider portal when the code entry indicates eviCore routing.

• Use eviCore phone or web portal for PA submissions for these codes.
• Verify plan‑specific historical notes (e.g., MT Medicare Advantage exceptions) before assuming no PA is required.

Include H&P, plan of care, and medical necessity for specified C‑codes

Certain C‑codes require a recent history and physical, plan of care, and documentation of medical necessity when submitting prior authorization requests for those C‑codes.

• Include Recent H&P, plan of care, and documentation of medical necessity for codes such as C9076, C9600, C9739, and C9741 as listed.
• Failure to include required documentation may delay or result in denial.

Provide Letter of Medical Necessity and supporting records for HCPCS/CPT/E codes

Prior authorization or specific documentation (often a Letter of Medical Necessity) is required for the listed HCPCS/CPT/E codes; follow the per‑code documentation instructions when submitting a PA request.

• Many DME and wheelchair accessory codes require a Letter of Medical Necessity describing anticipated length of need and condition.
• Provide H&P, chart notes, treatment plan and upper extremity evaluation where specified.

Contact eviCore for PA per the code entry

Providers must contact eviCore (1‑855‑252‑1117 or via the eviCore BCBS portal) for prior authorization for the listed procedure codes that reference eviCore; the document repeatedly references eviCore as the PA vendor for these codes.

• Use the eviCore BCBS healthplan portal or phone number to submit PA requests.
• Attach the per‑code required documentation (H&P, operative report, transplant date, etc.).

Document conservative measures for post‑fusion spine codes

Conservative measures must be documented for some post‑fusion spine codes (for example, 22800, 22802, 22804, 22808–22812) prior to authorization.

• Include documentation of prior conservative treatment when requesting PA for the specified post‑fusion spine CPTs.
• Also submit H&P and operative report as required on those code lines.

Include H&P, pre‑op evaluation, and operative report when required

For listed procedures providers must submit a pre‑operative evaluation, history and physical (including functional impairment), and operative report as part of the prior authorization request when specified.

• Include height/weight, prior conservative treatment, pathology report or grams of tissue removed for breast reduction codes when indicated (e.g., 19318).
• Follow the per‑code required document list shown in the code entry.

Submit specific supporting documentation shown per code (examples)

Examples of required documentation include history and physical, documentation of medical necessity, operative report, type of appliance and history of recurring TMJ with diagnostic sleep studies where indicated for jaw/reconstruction codes.

• For jaw reconstruction CPTs (e.g., 21206–21270) submit chart notes specifying appliance type and TMJ history, and attach diagnostic sleep studies as noted.
• For other reconstructive codes, include operative reports and documentation of medical necessity.

Provide recent H&P, plan of care and medical necessity for selected codes

Recent history and physical, plan of care, and documentation of medical necessity are required for certain codes (for example, 22999); include these when requested on the code entry.

• Follow per‑code instructions — e.g., 22999 requires recent H&P, plan of care and documentation of medical necessity.
• Omissions may delay PA or lead to denial.

Commonly required pre‑op and operative documentation

Pre‑operative evaluation, history and physical (including functional impairment), and operative report are commonly required for many listed procedures; submit these records with the PA request when specified on the code line.

• This requirement applies broadly across surgical and transplant codes; follow the per‑code entry for additional specifics.
• Failure to include these documents may trigger referral to eviCore or claim denial.

Include H&P, plan of care, operative report and study results as indicated

A recent history and physical, plan of care, pre‑operative evaluation, and operative/procedure report are commonly requested for authorization of many listed procedures; include results of specified studies (e.g., Doppler) when cited.

• For vascular and vein procedures include Doppler study results where requested (see 37241, 37722, etc.).
• For transplant codes, provide transplant approval/date or transplant evaluation as instructed.

Provide bariatric‑specific documentation when required

For bariatric and related GI procedures, required documentation may include history and physical, nutritional evaluation, psychological evaluation, weight‑loss attempts, and social supports as listed on the code entries.

• Provide the full pre‑operative workup (nutrition, psychological assessments) when submitting PA for bariatric procedures.
• Follow the per‑code documentation instructions on the code line.

Provide transplant approval/date or transplant evaluation and H&P

For many transplant‑related procedure codes, submit either the transplant approval on record with the date of transplant or, if no transplant approval, submit history and physical, transplant evaluation, and date of transplant.

• If transplant approval exists, provide the approval record and transplant date.
• If no prior approval, include H&P, transplant evaluation and proposed transplant date as part of the PA request.

Submit H&P and operative report for many reconstructive procedures

Pre‑operative evaluation, history and physical, and operative report are repeatedly required for many listed procedures (examples include corneal, eyelid and other reconstructive codes); submit these with PA requests when specified.

• For corneal/ocular reconstruction codes (e.g., 65755–65782, 67900 series) include H&P and operative report.
• Check the code line for any additional documentation required.

Include H&P and prior diagnostic report for discography

For discography (72291, 72292) prior authorization requires a history and physical and results of the previous diagnostic procedure report; include these with the PA submission.

• Attach the prior diagnostic procedure report(s) and H&P when requesting authorization for 72291 or 72292.
• Omission may result in referral or denial.

Provide H&P and prior diagnostic reports for proton treatment PA

Prior authorization for proton treatment codes (77520, 77522, 77523, 77525) requires history and physical and results of previous diagnostic procedure reports; provide those documents with the PA request.

• Attach prior diagnostic imaging/reports and H&P for proton therapy PA submissions.
• Follow the per‑code requirements listed on the code line.

Use eviCore phone or BCBS portal for PA contact

Providers must contact eviCore (1‑855‑252‑1117 or via the eviCore BCBS portal) for prior authorization for the listed procedure codes that specify eviCore as the authorization vendor.

• Use the eviCore phone number or the eviCore BCBS web portal to submit PA requests and documentation.
• Confirm any effective/add dates shown on the code line when applicable.

Attach H&P, plan of care and medical necessity for selected procedures

Recent history and physical, plan of care, and documentation of medical necessity are required for selected procedures (examples include 91111, 91112, 91132, 91133); include these documents when requesting authorization.

• Attach H&P, plan of care and documentation of medical necessity to the PA request for these GI and related procedure codes.
• Failure to include may delay authorization or lead to denial.

Follow eviCore and channel minimums for sleep study PA

Some sleep study and polysomnography codes reference eviCore contact for prior authorization and include plan‑specific exception remarks (e.g., MT Medicare Advantage Plan); verify plan and follow eviCore routing when indicated.

• For home sleep tests use the channel minimums specified on the code line (Type II = 7 channels, Type III = 4, Type IV = 3).
• Check MT plan notes before assuming no PA is required.

Include H&P, plan of care and medical necessity for specified T‑codes

Recent History and Physical, plan of care, and documentation of medical necessity are required for specified T‑codes; include these documents when submitting PA requests for those T‑codes.

• Provide H&P, plan of care and documentation of medical necessity for T‑codes that list those requirements.
• Use eviCore routing for T‑codes that reference eviCore.

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

For cellular therapy ancillary codes (0537T–0540T) prior authorization requires a recent history and physical, plan of care, and documentation of medical necessity; include these with the PA request.

• Attach H&P, plan of care and documentation of medical necessity for 0537T–0540T.
• Omission may result in denial.

Submit Letter of Medical Necessity and clinical records for C/E/DME codes

For specified C‑codes, include a recent history and physical, plan of care, and documentation of medical necessity; Letters of Medical Necessity or H&P/clinical notes are required for many E‑codes and DME items as shown.

• Provide a Letter of Medical Necessity for DME items (E‑codes) detailing anticipated length of need and condition.
• Include H&P, plan of care and medical necessity documentation for C‑codes listed on the code lines.

Provide Letter of Medical Necessity and supporting clinical records for DME/wheelchair accessories

Providers must supply a Letter of Medical Necessity (including anticipated length of need and description of the medical condition/use) and, where specified, a history and physical, chart notes, treatment plan, and evaluation of upper extremity strength or mobility status for DME and wheelchair accessory prior authorization.

• Include detailed functional status and anticipated duration of need in the Letter of Medical Necessity.
• Attach H&P and ordering physician chart notes and treatment plan as required.

Attach H&P, chart notes, treatment plan and LOMN where requested

Required documentation commonly includes history and physical, chart notes from the ordering physician, treatment plan and a Letter of Medical Necessity; include these with PA requests when specified on the code entry.

• Ensure the Letter of Medical Necessity describes condition, anticipated length of need, and functional limitations.
• Attach H&P, chart notes and treatment plan to support medical necessity.

Risk of claim denial without prior authorization

Failure to obtain prior authorization for codes on this list may result in claim denial; always verify member eligibility and benefits prior to rendering services.

• Check member benefit booklet or contact customer service to confirm coverage.
• Obtaining PA as required reduces risk of claim denial.

Include H&P, operative report and medical necessity to avoid denial

Failure to submit required history and physical, documentation of medical necessity, and operative report when requested may result in denial or referral to eviCore for review.

• When a code line requests H&P, operative report and medical necessity documentation, include them with the PA request.
• Missing these documents can trigger denial or additional review.

Document conservative measures for post‑fusion spine codes to avoid denial

Lack of documentation of conservative measures for certain post‑fusion spine codes (e.g., 22800–22812) may trigger denial; include documentation of prior conservative treatment when requested.

• Document conservative therapies attempted and duration when requesting PA for post‑fusion spine CPTs.
• Also submit H&P and operative report as specified.

Provide required pre‑op H&P and operative report to prevent denial

Absence of required pre‑operative evaluation, history and physical, or operative report where specified may trigger denial for codes that list those documentation requirements.

• For codes with per‑code documentation notes (e.g., certain knee and lower extremity codes), include H&P and operative report.
• Prior to service, confirm required documents are on file for PA submission.

Submit H&P, operative report and required study results or risk denial

Lack of pre‑operative evaluation, history and physical, operative/procedure report, or results of required studies (e.g., Doppler) may trigger denial or require prior authorization per the listed codes.

• Include Doppler results for vein procedures when requested (see 37241, 37722, etc.).
• Submit H&P and operative/procedure reports for surgical codes as listed.

Provide transplant approval/date or transplant evaluation to avoid denial

For transplant‑related procedure codes, absence of transplant approval on record or missing transplant evaluation/date may trigger denial or additional prior authorization requirements; provide transplant approval/date or transplant evaluation and date if no approval exists.

• If transplant approval is on record, submit the approval and the transplant date.
• If not, include H&P, transplant evaluation and proposed transplant date with the PA request.

Ensure submission of all specified documentation to prevent denial

Prior authorization may be required and documentation must be submitted; failure to provide required history and physical, transplant evaluation, procedure report, or date of transplant when specified could lead to denial.

• Review per‑code instructions and include all requested documents when submitting PA.
• Missing items may result in denial or delayed authorization.

Submit H&P and medical necessity documentation when requested

Failure to submit history and physical and documentation of medical necessity (including operative report) when requested may trigger denial.

• When codes request H&P and documentation of medical necessity, include them to support the PA request.
• Omissions can result in denial or referral for additional review.

Obtain eviCore authorization for eviCore‑routed imaging/procedures

Prior authorization or eviCore review is required for many listed imaging and procedure codes; contact eviCore at 1‑855‑252‑1117 or https://www.evicore.com/healthplan/bcbs to obtain authorization.

• Use the eviCore phone number or BCBS portal for PA submissions for imaging and many procedural codes.
• Failure to obtain eviCore PA may lead to denial.

Attach H&P and prior diagnostic reports for discography PA

For discography (72291, 72292) provide a history and physical and results of previous diagnostic procedure report with the prior authorization request.

• Attach prior diagnostic procedure reports and H&P to the PA submission for 72291/72292.
• Lack of these documents may trigger denial.

Obtain eviCore PA where indicated to avoid denial

Failure to obtain prior authorization from eviCore for listed CPT codes may lead to denial; eviCore contact information is provided on the code entries for PA submission.

• When a CPT line references eviCore, contact eviCore at 1‑855‑252‑1117 or use the eviCore BCBS portal to request authorization.
• Claims may be denied if eviCore PA is not obtained where required.

Obtain eviCore PA for molecular/genetic codes to avoid denial

Claims for the listed molecular/genetic procedure codes may be denied if prior authorization is not obtained via eviCore; the code entries reference eviCore as the authorization vendor for each code.

• Submit PA for molecular/genetic codes through eviCore using the provided contact methods.
• Include per‑code required documentation with the PA request.

Use eviCore for oncology/molecular test PA to reduce denial risk

Failure to obtain prior authorization from eviCore for listed oncology and molecular testing codes may result in denial or referral to eviCore for review.

• Use eviCore contact methods shown on the code lines for PA submissions.
• Provide the documentation requested on the code line to support medical necessity.

Provide H&P, plan of care and medical necessity for listed procedures to avoid denial

For certain procedures (e.g., 91111, 91112, 91132, 91133, 92986, 92990, 92992, 92993) lack of recent history and physical, plan of care, and documentation of medical necessity may trigger denial.

• Include recent H&P, plan of care and documentation of medical necessity for these specified procedures.
• Omissions may result in denial or referral.

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

Lack of a recent history and physical, plan of care, and documentation of medical necessity is indicated as required documentation for several T codes; include these documents when requesting prior authorization.

• Provide Recent H&P, plan of care and documentation of medical necessity for T‑codes that list these requirements.
• Failure to include them may lead to authorization delays or denial.

Provide required documentation for cellular therapy ancillary codes to avoid denial

Lack of required documentation (recent history and physical, plan of care, documentation of medical necessity) for cellular therapy ancillary codes (0537T–0540T) may trigger denial; include these records with the PA request.

• Attach H&P, plan of care and documentation of medical necessity for 0537T–0540T.
• Missing documentation may result in denial.

Obtain eviCore PA for U‑codes and other eviCore‑listed items

Failure to obtain eviCore prior authorization where indicated for numerous U‑codes and other listed codes may result in service denial; contact eviCore (1‑855‑252‑1117 or via the eviCore website) as shown on code entries.

• Use the eviCore BCBS portal or phone to submit PA for U‑codes and other eviCore‑listed items.
• Include all required supporting documentation to reduce denial risk.

Include H&P, plan of care and medical necessity for specified C‑codes

Lack of recent history and physical, plan of care, and documentation of medical necessity may trigger denial for certain C‑codes (e.g., C9076, C9600, C9739, C9741); include these documents with PA requests.

• Attach Recent H&P, plan of care and medical necessity documentation for the listed C‑codes.
• Omission can lead to denial.

Submit Letter of Medical Necessity for required E‑codes

Absence of a Letter of Medical Necessity for multiple E‑codes (e.g., E0635, E0638, E0641, E0650, E0652) may lead to denial; supply the LOMN with anticipated length of need and condition description when requested.

• Provide LOMN detailing anticipated duration, condition, and functional limitations for DME items when listed.
• Attach H&P and chart notes as specified.

Provide H&P, chart notes, treatment plan and LOMN for wheelchair accessories

Lack of required history and physical, chart notes, treatment plan, or Letter of Medical Necessity for wheelchair power seat elevation/standing system accessories may trigger denial; include these elements with the PA request.

• Provide evaluation of upper extremity strength and functional needs where requested for E2300/E2301 accessories.
• Include H&P, treatment plan and LOMN to support the request.

Obtain eviCore PA and submit required documentation to avoid denial

Failure to obtain prior authorization via eviCore (1‑855‑252‑1117 or https://www.evicore.com/healthplan/bcbs) where listed may trigger denial; many entries list required documentation such as history & physical, chart notes, treatment plan and Letter of Medical Necessity that must accompany the PA.

• Use eviCore contact methods where the code entry references eviCore.
• Attach all per‑code documentation (H&P, chart notes, treatment plan, LOMN) to avoid denial.