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ModifiedBlue Cross Blue Shield - TexasPolicy N/A

Utilization management preauthorization coding list for plastic/reconstructive surgery

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List of CPT/HCPCS procedure codes and the associated preauthorization or medical records requirements for utilization management; intended for providers submitting authorizations and medical records to Blue Cross Blue Shield - Texas.

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyUtilization management preauthorization coding list for plastic/reconstructive surgery

Policy CodePolicy N/A

Change TypeAdded/Clarified U-code routing to eviCoredocumentation requirements clarified

Effective DateN/A

Next Review DateN/A

Key ActionContact eviCore (1-855-252-1117 or https://www.evicore.com/provider) and submit required history & physical, plan of care, and documentation of medical necessity when a listed code indicates eviCore prior authorization.

SourceLink

POLICY UPDATE CHANGES

Multiple CPT codes were assigned to eviCore prior authorization routing and some codes show shifted/added effective dates (e.g., 77520–77525 moved to Evicore 10/1/2025).

For certain codes (e.g., 72291, 72292, 77520–77525) specific prior authorization documentation is required: history and physical and results of previous diagnostic procedure report.

Multiple new U-codes (0335U through 0532U ranges) were added with associated eviCore prior authorization instructions.

Some codes have specified removal dates (e.g., 0380U and 0428U with 3/31/25 removal; 0456U removed 3/31/25).

Each listed U-code is annotated with 'eviCore - 1-855-252-1117 or https://www.evicore.com/provider' as the authorization contact.

120+procedure codes listed on pages 0-19

eviCorecodes managed by external manager (highlighted)

VariesDocumentation required

MT exceptionsNo Prior Auth effective 1/1/21

Coverage Criteria and General Notes

Prior authorization / documentation-based review

Coverage review and prior authorization are indicated when the listed code entry requires submission of clinical documentation to eviCore.

eviCore review / prior auth requirement: When a listed code entry specifies eviCore as the authorization vendor, the provider must contact eviCore (1-855-252-1117 or https://www.evicore.com/provider) and submit recent history and physical, plan of care, and documentation of medical necessity for clinical review prior to claim processing.

Applies to numerous T/U and other codes shown in this section (see code list).

The inclusion of a CPT or HCPCS code on this list is for utilization management and prior authorization reference only. Presence of a code on the list does not necessarily indicate coverage under a member’s benefits contract. Always verify eligibility and benefits with the member’s plan before providing services and submitting claims.

Multiple code entries in the list explicitly annotate No Prior Auth required for MT Medicare Advantage Plan effective 1/1/21. These annotations indicate that for members of that specific Medicare Advantage product (MT), pre-service authorization is not required for the noted CPTs despite the codes appearing on the utilization list.

The document repeats the same No Prior Auth required for MT Medicare Advantage Plan effective 1/1/21 language across multiple procedure groups (for example, knee reconstruction and shoulder arthroscopy entries). Where this language appears, it supersedes the general prior authorization routing noted for other members and providers for that specific plan.

Several entries note exceptions for Medicare Advantage plans (MT or NM) with explicit effective dates (for example, some spinal and neurostimulation codes list No Prior Auth required for MT or NM Medicare Advantage Plan effective 4/1/2018). Providers should use these plan‑ and date‑specific notes to determine whether prior authorization is required for a given member.

In the T/U code sections there are additional explicit No Prior Auth required for MT Medicare Advantage Plan annotations for select temporary and proprietary codes (e.g., entries such as 0213T–0216T). These lines indicate that for MT Medicare Advantage members the listed codes do not require pre-service authorization as of the stated effective dates.

Some newly added U-codes include inline removal dates. For example, 0380U and 0428U are annotated with removal information — 0428U removed 3/31/25 — and other U-code lines list Removed 3/31/25 or similar removal dates. Providers should not submit prior authorization requests for codes after their specified removal dates.

HCPCS code A9270 is explicitly listed as a Non-covered item or service in the document. This entry indicates that A9270 is not covered under the benefit filing and is annotated on the list accordingly.

Procedure and Billing Codes

Procedure codes (partial list shown)CPT

11970	REPLACE TISSUE EXPANDER
15271	SKIN SUB GRAFT TRNK/ARM/LEG
15775	HAIR TRNSPL 1-15 PUNCH GRFTS
15776	HAIR TRNSPL >15 PUNCH GRAFTS
15777	ACELLULAR DERM MATRIX IMPLT
15780	DERMABRASION TOTAL FACE
15781	DERMABRASION SEGMENTAL FACE
15782	DERMABRASION OTHER THAN FACE
15783	DERMABRASION SUPRFL ANY SITE
15786	ABRASION LESION SINGLE

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Procedure codes (continued)CPT

20930	SP BONE ALGRFT MORSEL ADD-ON
20931	SP BONE ALGRFT STRUCT ADD-ON
20936	SP BONE AGRFT LOCAL ADD-ON
20937	SP BONE AGRFT MORSEL ADD-ON
20938	SP BONE AGRFT STRUCT ADD-ON
20974	ELECTRICAL BONE STIMULATION
20975	ELECTRICAL BONE STIMULATION
21083	PREPARE FACE/ORAL PROSTHESIS
21085	PREPARE FACE/ORAL PROSTHESIS
21120	RECONSTRUCTION OF CHIN

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Spine and related procedure codesCPT

22505	MANIPULATION OF SPINE
22510	PERQ CERVICOTHORACIC INJECT
22511	PERQ LUMBOSACRAL INJECTION
22512	VERTEBROPLASTY ADDL INJECT
22513	PERQ VERTEBRAL AUGMENTATION
22514	PERQ VERTEBRAL AUGMENTATION
22515	PERQ VERTEBRAL AUGMENTATION
22526	IDET SINGLE LEVEL
22527	IDET 1 OR MORE LEVELS
22533	LAT LUMBAR SPINE FUSION

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Spine fusion codes (examples from chunk 18)CPT

22551	CPT 22551 (listed)
22552	CPT 22552 (listed)
22554	CPT 22554 (listed)

Procedure CPT codes listedCPT

22558	CPT 22558
22585	CPT 22585
22595	CPT 22595
22600	CPT 22600
22612	CPT 22612
22614	CPT 22614
22630	CPT 22630
22632	CPT 22632
22633	CPT 22633
22634	CPT 22634

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Knee reconstruction codesCPT

27425	CPT 27425 (listed with prior auth/eviCore notes in document)
27427	CPT 27427 (RECONSTRUCTION KNEE; eviCore noted)
27428	CPT 27428 (RECONSTRUCTION KNEE; eviCore noted)

Knee/leg-related and selected lower extremity codesCPT

27429	CPT 27429 (RECONSTRUCTION KNEE)
27430	CPT 27430 (REVISION OF THIGH MUSCLES)
27438	CPT 27438 (REVISE KNEECAP WITH IMPLANT)
27440	CPT 27440 (REVISION OF KNEE JOINT)
27441	CPT 27441 (REVISION OF KNEE JOINT)
27442	CPT 27442 (REVISION OF KNEE JOINT)
27443	CPT 27443 (REVISION OF KNEE JOINT)
27445	CPT 27445 (REVISION OF KNEE JOINT)
27446	CPT 27446 (REVISION OF KNEE JOINT)
27447	CPT 27447 (TOTAL KNEE ARTHROPLASTY)

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Shoulder arthroscopy codesCPT

29805	CPT 29805 (SHOULDER ARTHROSCOPY DX)
29806	CPT 29806 (SHOULDER ARTHROSCOPY/SURGERY)
29807	CPT 29807 (SHOULDER ARTHROSCOPY/SURGERY)
29819	CPT 29819 (SHOULDER ARTHROSCOPY/SURGERY)
29820	CPT 29820 (SHOULDER ARTHROSCOPY/SURGERY)
29821	CPT 29821 (SHOULDER ARTHROSCOPY/SURGERY)
29822	CPT 29822 (SHOULDER ARTHROSCOPY/SURGERY)
29823	CPT 29823 (SHOULDER ARTHROSCOPY/SURGERY)
29824	CPT 29824 (SHOULDER ARTHROSCOPY/SURGERY)
29825	CPT 29825 (SHOULDER ARTHROSCOPY/SURGERY)

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Hip and knee arthroscopy codesCPT

29860	CPT 29860 (HIP ARTHROSCOPY DX)
29861	CPT 29861 (HIP ARTHRO W/FB REMOVAL)
29862	CPT 29862 (HIP ARTHR0 W/DEBRIDEMENT)
29863	CPT 29863 (HIP ARTHR0 W/SYNOVECTOMY)
29866	CPT 29866 (AUTGRFT IMPLNT KNEE W/SCOPE)
29867	CPT 29867 (ALLGRFT IMPLNT KNEE W/SCOPE)
29868	CPT 29868 (MENISCAL TRNSPL KNEE W/SCPE)
29870	CPT 29870 (KNEE ARTHROSCOPY DX)
29871	CPT 29871 (KNEE ARTHROSCOPY/DRAINAGE)
29873	CPT 29873 (KNEE ARTHROSCOPY/SURGERY)

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Additional hip arthroscopy codesCPT

29914	CPT 29914 (HIP ARTHRO W/FEMOROPLASTY)
29915	CPT 29915 (HIP ARTHRO ACETABULOPLASTY)
29916	CPT 29916 (HIP ARTHRO W/LABRAL REPAIR)

Nasal reconstruction/revision and turbinate ablation codesCPT

30120	CPT 30120 (REVISION OF NOSE)
30400	CPT 30400 (RECONSTRUCTION OF NOSE)
30410	CPT 30410 (RECONSTRUCTION OF NOSE)
30420	CPT 30420 (RECONSTRUCTION OF NOSE)
30430	CPT 30430 (REVISION OF NOSE)
30435	CPT 30435 (REVISION OF NOSE)
30450	CPT 30450 (REVISION OF NOSE)
30460	CPT 30460 (REVISION OF NOSE)
30462	CPT 30462 (REVISION OF NOSE)
30801	CPT 30801 (ABLATE INF TURBINATE SUPERF)

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Lung transplant and donor preparation codesCPT

32850	CPT 32850 (DONOR PNEUMONECTOMY)
32851	CPT 32851 (LUNG TRANSPLANT SINGLE)
32852	CPT 32852 (LUNG TRANSPLANT WITH BYPASS)
32853	CPT 32853 (LUNG TRANSPLANT DOUBLE)
32854	CPT 32854 (LUNG TRANSPLANT WITH BYPASS)
32855	CPT 32855 (PREPARE DONOR LUNG SINGLE)
32856	CPT 32856 (PREPARE DONOR LUNG DOUBLE)

Cardiac and related procedure codesCPT

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

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Cardiac procedure codesCPT

33471	listed with prior authorization/documentation requirements
33474	REVISION OF PULMONARY VALVE; Recent history and physical, plan of care, and documentation of medical necessity
33475	REPLACEMENT PULMONARY VALVE; Recent history and physical, plan of care, and documentation of medical necessity
33476	REVISION OF HEART CHAMBER; Recent history and physical, plan of care, and documentation of medical necessity
33477	IMPLANT TCAT PULM VLV PERQ; Recent history and physical, plan of care, and documentation of medical necessity
33478	REVISION OF HEART CHAMBER; Recent history and physical, plan of care, and documentation of medical necessity
33548	MILD-MOD DEP SYMP BY DEPTOOL; Recent history and physical, plan of care, and documentation of medical necessity
33600	CLOSURE OF VALVE; Recent history and physical, plan of care, and documentation of medical necessity
33602	CLOSURE OF VALVE; Recent history and physical, plan of care, and documentation of medical necessity
33606	ANASTOMOSIS/ARTERY-AORTA; Recent history and physical, plan of care, and documentation of medical necessity

Additional cardiac procedure codesCPT

33608	REPAIR ANOMALY W/CONDUIT; Recent history and physical, plan of care, and documentation of medical necessity
33610	REPAIR BY ENLARGEMENT; Recent history and physical, plan of care, and documentation of medical necessity
33611	REPAIR DOUBLE VENTRICLE; Recent history and physical, plan of care, and documentation of medical necessity
33612	REPAIR DOUBLE VENTRICLE; Recent history and physical, plan of care, and documentation of medical necessity
33615	REPAIR MODIFIED FONTAN; Recent history and physical, plan of care, and documentation of medical necessity
33617	REPAIR SINGLE VENTRICLE; Recent history and physical, plan of care, and documentation of medical necessity
33619	REPAIR SINGLE VENTRICLE; Recent history and physical, plan of care, and documentation of medical necessity
33620	APPLY R&L PULM ART BANDS; Recent history and physical, plan of care, and documentation of medical necessity
33621	TRANSTHOR CATH FOR STENT; Recent history and physical, plan of care, and documentation of medical necessity
33622	REDO COMPL CARDIAC ANOMALY; Recent history and physical, plan of care, and documentation of medical necessity

Heart/lung donor and transplant codesCPT

33930	REMOVAL OF DONOR HEART/LUNG; If transplant approval on record: Date of Transplant; If no Transplant approval: History and Physical, Transplant evaluation, and date of transplant
33933	PREPARE DONOR HEART/LUNG; If transplant approval on record: Date of transplant; If no transplant approval: history and physical, transplant evaluation, and date of transplant
33935	TRANSPLANTATION HEART/LUNG; If transplant approval on record: Date of transplant; If no transplant approval: history and physical, transplant evaluation, and date of transplant
33940	REMOVAL OF DONOR HEART; If transplant approval on record: Date of Transplant; If no Transplant approval: History and Physical, Transplant evaluation, and date of transplant
33944	PREPARE DONOR HEART; If transplant approval on record: Date of transplant; If no transplant approval: history and physical, transplant evaluation, and date of transplant
33945	TRANSPLANTATION OF HEART; If transplant approval on record: Date of transplant; If no transplant approval: history and physical, transplant evaluation, and date of transplant

Vascular and vein procedure codesCPT

34806	OPN AX/SUBCLA ART EXPOS CNDT; Pre Operative Evaluation, History and Physical including results of Doppler studies, and Operative report
35879	REVISE GRAFT W/VEIN; If transplant approval on record: Date of transplant; If no transplant approval: history and physical, transplant evaluation, and date of transplant
36468	NJX SCLRSNT SPIDER VEINS; Pre-operative evaluation, history and physical including functional impairment, and operative report
36470	NJX SCLRSNT 1 INCMPTNT VEIN; Pre-operative evaluation, history and physical including functional impairment, and operative report
36479	ENDOVENOUS LASER VEIN ADDON; Pre-operative evaluation, history and physical including results of Doppler studies, and operative report
37241	VASC EMBOLIZE/OCCLUDE VENOUS; Pre-operative evaluation, history and physical including results of Doppler studies, and operative report

ENT/cleft palate procedure codesCPT

40700	REPAIR CLEFT LIP/NASAL; History and physical and operative report
40701	REPAIR CLEFT LIP/NASAL; History and physical and operative report
40702	REPAIR CLEFT LIP/NASAL; History and physical and operative report
42145	REPAIR PALATE PHARYNX/UVULA; History and physical, including sleep study results, results of CPAP trial
41530	TONGUE BASE VOL REDUCTION; History and physical, including sleep study results, results of CPAP trial
42200	RECONSTRUCT CLEFT PALATE; History and physical and operative report

Bariatric/gastric procedure codesCPT

43644	LAP GASTRIC BYPASS/ROUX-EN-Y; History and physical, nutritional evaluation, psychological evaluation, weight loss attempts, social supports
43645	LAP GASTR BYPASS INCL SMLL I; History and physical, nutritional evaluation, psychological evaluation, weight loss attempts, social supports
43770	LAP PLACE GASTR ADJ DEVICE; History and physical, nutritional evaluation, psychological evaluation, weight loss attempts, social supports
43771	LAP REVISE GASTR ADJ DEVICE; History and physical, nutritional evaluation, psychological evaluation, weight loss attempts, social supports
43772	LAP RMVL GASTR ADJ DEVICE; History and physical, nutritional evaluation, psychological evaluation, weight loss attempts, social supports
43846	GASTRIC BYPASS FOR OBESITY; History and physical, nutritional evaluation, psychological evaluation, weight loss attempts, social supports

GI/liver/intestine and donor/transplant codesCPT

43999	STOMACH SURGERY PROCEDURE; If transplant approval on record: Date of Transplant; If no Transplant approval: history and physical, transplant evaluation, and date of transplant
44132	ENTERECTOMY CADAVER DONOR; If transplant approval on record: Date of Transplant; If no Transplant approval: history and physical, transplant evaluation, and date of transplant
44133	ENTERECTOMY LIVE DONOR; If transplant approval on record: Date of Transplant; If no Transplant approval: history and physical, transplant evaluation, and date of transplant
47120	PARTIAL REMOVAL OF LIVER; History and physical and procedure report
47122	EXTENSIVE REMOVAL OF LIVER; History and physical and procedure report
47125	PARTIAL REMOVAL OF LIVER; History and physical and procedure report
47133	PARTIAL REMOVAL OF LIVER / REMOVAL OF DONOR LIVER; If transplant approval on record: Date of Transplant; If no Transplant approval: history and physical, transplant evaluation, and date of transplant
47420	INCISION OF BILE DUCT; History and physical and procedure report or transplant documentation if applicable

Transplant and related proceduresCPT

50320	PREP CADAVER RENAL ALLOGRAFT
50323	PREP CADAVER RENAL ALLOGRAFT (transplant approval/date requirements)
50325	PREP DONOR RENAL GRAFT
50327	PREP RENAL GRAFT/VENOUS
50328	PREP RENAL GRAFT/ARTERIAL
50329	PREP RENAL GRAFT/URETERAL
50340	REMOVAL OF KIDNEY
50365	TRANSPLANTATION OF KIDNEY
50370	REMOVE TRANSPLANTED KIDNEY
50380	REIMPLANTATION OF KIDNEY

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Genitourinary and genital proceduresCPT

51580	REMOVE BLADDER/REVISE TRACT
51585	REMOVAL OF BLADDER & NODES
51597	REMOVAL OF PELVIC STRUCTURES
53430	RECONSTRUCTION OF URETHRA
53860	TRANSURETHRAL RF TREATMENT
54125	REMOVAL OF PENIS
54240	PENIS STUDY
54304	REVISION OF PENIS
54400	INSERT SEMI-RIGID PROSTHESIS
54401	INSERT SELF-CONTD PROSTHESIS

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Vaginal and gender-affirming proceduresCPT

55970	SEX TRANSFORMATION M TO F
55980	SEX TRANSFORMATION F TO M
56625	COMPLETE REMOVAL OF VULVA
56800	REPAIR OF VAGINA
56805	REPAIR CLITORIS
56810	REPAIR OF PERINEUM
57106	REMOVE VAGINA WALL PARTIAL
57107	REMOVE VAGINA TISSUE PART
57110	REMOVE VAGINA WALL COMPLETE
57111	REMOVE VAGINA TISSUE COMPL

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Gynecologic procedures and abortion-related codesCPT

57426	REVISE PROSTH VAG GRAFT LAP
58150	TOTAL HYSTERECTOMY
58180	PARTIAL HYSTERECTOMY
58240	REMOVAL OF PELVIS CONTENTS
58285	EXTENSIVE HYSTERECTOMY
58672	LAPAROSCOPY FIMBRIOPLASTY
58760	FIMBRIOPLASTY
59840	ABORTION
59841	ABORTION
59850	ABORTION

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Misc procedures and spinal injectionsCPT

59897	MYOCARDIAL IMAGING MCG I&R
60512	AUTOTRANSPLANT PARATHYROID
61630	MYOCARDIAL IMAGING MCG I&R
62115	REDUCTION OF SKULL DEFECT
62120	REPAIR SKULL CAVITY LESION
62263	EPIDURAL LYSIS MULT SESSIONS

Spine, neurostimulation, and pain management proceduresCPT

62280	TREAT SPINAL CORD LESION
62281	TREAT SPINAL CORD LESION
62282	TREAT SPINAL CANAL LESION
62287	PERCUTANEOUS DISKECTOMY
62292	NJX CHEMONUCLEOLYSIS LMBR
62320	NJX INTERLAMINAR CRV/THRC
62321	NJX INTERLAMINAR CRV/THRC
62322	NJX INTERLAMINAR LMBR/SAC
62323	NJX INTERLAMINAR LMBR/SAC
62324	NJX INTERLAMINAR CRV/THRC

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Listed CPT Codes (partial document segment)mixed

63075	NECK SPINE DISK SURGERY
63076	NECK SPINE DISK SURGERY
63081	REMOVE VERT BODY DCMPRN CRVL
63082	REMOVE VERTEBRAL BODY ADD-ON
63620	SRS SPINAL LESION
63650	IMPLANT NEUROELECTRODES
63655	IMPLANT NEUROELECTRODES
63685	INSRT/REDO SPINE N GENERATOR
64451	NJX AA&/STRD NRV NRVTG SI JT
64479	INJ FORAMEN EPIDURAL C/T

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Imaging spine and pelvis codes routed to eviCoreCPT

72130	CT CHEST SPINE W/O & W/DYE
72131	CT LUMBAR SPINE W/O DYE
72133	CT LUMBAR SPINE W/O & W/DYE
72141	MRI NECK SPINE W/O DYE
72142	MRI NECK SPINE W/DYE
72146	MRI CHEST SPINE W/O DYE
72147	MRI CHEST SPINE W/DYE
72148	MRI LUMBAR SPINE W/O DYE
72149	MRI LUMBAR SPINE W/DYE
72156	MRI NECK SPINE W/O & W/DYE

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Effective / Added dates — examples

Example added 4/1/2022

What Providers Must Do

Prior Authorization

Check benefits — preauthorization may be required

Prior authorization or benefit preauthorization may be required for the procedure and HCPCS codes listed in this file; presence on the list does not guarantee coverage — verify member eligibility and benefits before rendering services.

Check member benefits and eligibility prior to service.
Green-highlighted codes indicate eviCore-managed items.

Prior Authorization

Route prior authorization to eviCore when indicated

When an entry lists eviCore, providers must route prior authorization requests and supporting clinical documentation to eviCore (phone 1-855-252-1117 or https://www.evicore.com/provider); some codes also note MT Medicare Advantage exceptions.

Contact eviCore at 1-855-252-1117 or via https://www.evicore.com/provider for prior authorization.
Note any ‘No Prior Auth required for MT Medicare Advantage Plan’ annotations on specific code lines.

Background and Scope

Background: this section enumerates surgical and related CPT/HCPCS codes across multiple specialties (notably spine, shoulder, hip, knee and selected imaging and genetic test codes) and indicates utilization management routing and documentation expectations. Many code lines identify an external prior authorization vendor (eviCore — contact information provided) and specify when providers must submit clinical records (for example, recent history and physical, plan of care, operative report) for review. Where noted, certain codes carry Medicare Advantage exceptions (for example, No Prior Auth required for MT Medicare Advantage Plan effective 1/1/21), and some temporary/U‑codes include added or removal dates that affect their applicability.

Definitions and Terms

Conservative measures/documentation — definition & triggers

DefinitionClinical records demonstrating prior non-surgical management (e.g., conservative care) including documentation of prior conservative measures such as physical therapy, medications, injections, or other nonoperative treatments

Trigger for submissionSubmit history and physical, operative report, and documentation of conservative measures when listed next to fusion or revision CPTs (examples: 22800, 22802, 22804, 22808, 22810, 22812)

Examples of required elementsDocumentation may include dates and duration of conservative therapy, objective functional impairment, prior imaging and responses to non-surgical interventions

eviCore — external utilization management reviewer

Vendor identityeviCore — external utilization management reviewer for prior authorization and clinical review (contact: 1-855-252-1117 or https://www.evicore.com/provider)

Policy Update Changes

2022-04-01codes_addedLatest

Multiple U/T codes (e.g., 0318U, 0319U, 0320U, 0326U) were added to the list and annotated with eviCore prior authorization routing.

2023-04-01codes_added

Additional U-code entries (selected oncology/genetic panels) were added (document notes additions on 4/1/2023 in the brief).

2024-04-01codes_added

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyUtilization management preauthorization coding list for plastic/reconstructive surgery

Policy CodePolicy N/A

Change TypeAdded/Clarified U-code routing to eviCoredocumentation requirements clarified

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

0318U and 0319U annotated as added 4/1/2022

Example added 7/1/20220329U shows added 7/1/2022 in list previews

Example added 4/1/2023Multiple U-codes (e.g., 0335U, 0340U) annotated as Added 4/1/2023

eviCore contact noted with date linesLines with added dates also include 'eviCore - 1-855-252-1117 or https://www.evicore.com/provider'

Patient weight capacity examples (E1035/E1036)

E1035 capacityPatient weight capacity up to and including 300 lbs

E1036 capacityPatient weight capacity greater than 300 lbs

Documentation requirement for accessoriesLetters of Medical Necessity are required to support wheelchair accessories where indicated

Prior Authorization

Knee reconstruction codes — contact eviCore as listed

Knee reconstruction CPTs (e.g., 27427, 27428) are annotated to contact eviCore for prior authorization; some lines also indicate 'No Prior Auth required for MT Medicare Advantage Plan effective 1/1/21.'

For codes 27427 and 27428 contact eviCore (1-855-252-1117 or https://www.evicore.com/provider) for authorization as indicated.
Verify Medicare Advantage (MT) exceptions noted on the code line.

Prior Authorization

Shoulder arthroscopy — eviCore prior authorization

Shoulder arthroscopy CPTs (e.g., 29805–29828 series) include eviCore contact instructions for prior authorization; some entries also show MT Medicare Advantage no‑auth notes.

Contact eviCore at 1-855-252-1117 or https://www.evicore.com/provider when eviCore is shown on the code line.
Confirm any MT Medicare Advantage exceptions before submission.

Prior Authorization

Hip/knee arthroscopy — follow eviCore routing

Hip and knee arthroscopy codes are routed to eviCore for prior authorization where noted; verify any MT Medicare Advantage plan exceptions on the code lines.

Use eviCore (1-855-252-1117 or https://www.evicore.com/provider) for authorization when listed.
Check code-specific MT Medicare Advantage no‑prior-auth annotations.

Documentation Required

Lung transplant — transplant approval/documentation required

Lung transplant and donor preparation CPTs (32850–32856) require transplant approval on record or submission of transplant-specific documentation (date of transplant, transplant evaluation, history & physical) prior to claim processing.

If transplant approval is on record: provide Date of Transplant.
If approval is not on record: submit history and physical, transplant evaluation, and date of transplant.

Documentation Required

Nose/turbinate procedures — pre-op evaluation and H&P required

Nasal reconstruction, revision, and inferior turbinate ablation codes (e.g., 30120, 30400–30462, 30801–30802) require a pre-operative evaluation and a history & physical documenting functional impairment and the operative report.

Include pre-operative evaluation and H&P showing functional impairment.
Attach the operative report with the prior authorization request.

Note

Check prior authorization timing and effective dates

Several code lines include historical timing notes — many codes list 'Prior to 9/1/2019' as the effective date; providers should use the effective/added date on each code line to determine applicability and prior‑auth timing.

Review the code line effective/added date (e.g., 'Prior to 9/1/2019', 'Added 4/1/2023', or move-to‑eviCore dates) when preparing authorization.
Date annotations affect whether prior authorization was required historically or under current routing.

Documentation Required

Vascular/vein/transplant donor codes — prior auth & documentation

Vascular, vein, and transplant donor-management codes list prior‑to timing and require associated pre-operative evaluations and reports; if transplant approval is not on record, submit H&P, transplant evaluation, and date of transplant.

Provide pre-operative evaluation, H&P, Doppler results where specified, and operative report.
For donor/transplant codes, supply transplant approval/date or the transplant evaluation and H&P.

Prior Authorization

eviCore required for spine and pain procedures

Many spinal, neurostimulation, and pain procedure codes require prior authorization via eviCore; providers must contact eviCore (1-855-252-1117 or https://www.evicore.com/provider) unless a Medicare Advantage exception is listed.

Use eviCore contact information on the code line for authorization submission.
Confirm any plan-specific exceptions (e.g., MT/NM Medicare Advantage notes).

Prior Authorization

Contact eviCore for prior authorization as indicated

Multiple CPT entries in the document instruct providers to contact eviCore for prior authorization (phone 1-855-252-1117 or https://www.evicore.com/provider) — follow eviCore processes for submission and review.

Contact eviCore at 1-855-252-1117 or via the provider portal for authorization.
Submit required clinical documentation through eviCore as specified on the code line.

Prior Authorization

Prior authorization required via eviCore for listed CPTs

Certain CPT codes explicitly state 'Prior Authorization Required via eviCore' — providers must obtain prior authorization from eviCore using the contact information shown on the code line before services are rendered.

Follow eviCore prior authorization instructions found adjacent to the CPT code in the list.
Do not submit claims for these codes without eviCore authorization when indicated.

Prior Authorization

Selected codes routed to eviCore — proton codes date notes

Selected imaging and proton treatment codes are routed to eviCore for prior authorization; proton treatment codes (77520, 77522, 77523, 77525) include move-to‑eviCore date annotations (Moved to eviCore 10/1/2025).

For proton treatment codes (77520–77525) submit H&P and prior diagnostic procedure reports as specified.
Observe annotated dates (e.g., 'Moved to Evicore 10/1/2025') when determining routing.

Prior Authorization

eviCore authorization required for procedure and genetic codes

Prior authorization for many procedure and genetic testing codes is routed through eviCore; providers must use eviCore (1-855-252-1117 or https://www.evicore.com/provider) for authorization and submission.

Submit clinical documentation to eviCore per the instructions on each code line.
Check code-specific documentation requirements (H&P, plan of care, diagnostic reports).

Prior Authorization

eviCore prior authorization for molecular/genetic CPTs

The listed molecular/genetic CPT codes (e.g., 81411, 81412, 81413, 81415, etc.) are routed to eviCore for prior authorization; contact eviCore at 1-855-252-1117 or https://www.evicore.com/provider.

Use eviCore contact information on the code line for authorization.
Include required documentation specified (e.g., H&P, plan of care).

Prior Authorization

Sleep studies — eviCore routing and MA exceptions

Most sleep study CPT codes list eviCore for prior authorization; some lines include 'No Prior Auth required for MT Medicare Advantage Plan' exceptions — verify plan-specific requirements.

Contact eviCore for authorization when indicated (1-855-252-1117 or https://www.evicore.com/provider).
Confirm MT Medicare Advantage exceptions shown on specific code lines.

Prior Authorization

General eviCore routing — contact and submission

Numerous codes throughout the list are routed to eviCore for prior authorization — providers should contact eviCore (1-855-252-1117 or https://www.evicore.com/provider) and follow eviCore submission procedures.

Use the eviCore phone number or provider portal shown on the code line for authorizations.
Attach the clinical documentation items requested on the code line when submitting.

Note

Medicare Advantage (MT) prior‑auth exceptions — verify per code

Examples in the list show MT Medicare Advantage prior‑auth exceptions (e.g., certain sleep study codes and others annotated 'No Prior Auth required for MT Medicare Advantage Plan effective 1/1/21'); verify these plan exceptions before requesting authorization.

Check the code line for any 'No Prior Auth required for MT Medicare Advantage Plan' statement.
Do not assume a code requires eviCore authorization for MT Medicare Advantage members if the exception is shown.

Prior Authorization

T/U codes — eviCore review and prior authorization required

Many T and U codes require prior authorization or eviCore review; contact eviCore at 1-855-252-1117 or via https://www.evicore.com/provider for review and to submit the required documentation.

Provide recent history & physical, plan of care, and documentation of medical necessity where specified.
Use eviCore processes for T/U codes that list eviCore contact.

Prior Authorization

U-codes — contact eviCore for authorization

U-codes in the 0335U–0532U range are annotated with eviCore contact information; prior authorization via eviCore (phone or web) is indicated for these U-codes.

Follow eviCore submission instructions shown with each U-code.
Observe added/removed dates on U-code lines for applicability.

Prior Authorization

Codes routed to eviCore — follow utilization management routing

Multiple codes are explicitly routed to eviCore for utilization management and prior authorization; providers must contact eviCore (1-855-252-1117 or https://www.evicore.com/provider) as indicated on the code line.

Use eviCore contact information on the code line to initiate authorization.
Submit the clinical documentation requested by the code entry through eviCore.

Prior Authorization

Prior authorization required via eviCore for specified HCPCS/C codes

Specified codes (e.g., C9399, C9757, E0470, E0471) require prior authorization through eviCore; prior authorization must be obtained before those services are provided.

Obtain prior authorization via eviCore prior to service for codes annotated as requiring eviCore authorization.
For ambulance code A0430, submit progress notes for the last 24 hours, physician order, and supporting medical records.

Documentation Required

Submit required supporting medical documentation with requests

Providers must submit the medical records specified on each code line — examples include recent history & physical, plan of care, operative report, diagnostic procedure reports, and photographs where requested.

Include History & Physical and operative report where indicated.
Provide diagnostic reports (e.g., results of previous procedures or Doppler studies) when requested on the code line.

Documentation Required

Spine CPTs — H&P, operative report, and conservative care documentation required

For specific spine CPTs (e.g., 22800, 22802, 22804, 22808, 22810, 22812, 22864, 22865) prior authorization or review requires submission of a recent history and physical, the operative report, plan of care, and documentation of conservative measures as indicated.

Attach documentation of prior conservative care when requested.
Include operative report and H&P to support medical necessity for fusion and fixation codes.

Documentation Required

Pre-op evaluation and operative report required for select reconstructive/transplant procedures

Pre-operative evaluation, history & physical including functional impairment, and the operative report are required documentation for multiple reconstructive and transplant procedures as noted on the code lines.

Ensure H&P documents functional impairment where specified.
Provide operative report and any transplant-specific evaluations when applicable.

Documentation Required

Transplant codes — supply transplant approval or full transplant documentation

For lung transplant codes, if transplant approval is on record submit the Date of Transplant; if not, provide history and physical, transplant evaluation, and the date of transplant as part of the authorization package.

If transplant approval exists: submit the date of transplant.
If not: include H&P and transplant evaluation documentation.

Documentation Required

Cardiac procedures — H&P, plan of care, and medical necessity documentation required

Numerous cardiac procedure codes require recent history and physical, a plan of care, and documentation of medical necessity to support prior authorization and claim processing.

Attach H&P, plan of care, and medical necessity documentation for cardiac valve and related procedures.
Follow the code-line instructions for any additional required records.

Documentation Required

Vascular/vein procedures — Doppler and operative documentation required

For many vascular and vein procedures (e.g., 34806, 36479, 37241), include a pre-operative evaluation, history & physical with Doppler results where specified, and the operative report with the authorization.

Provide Doppler study results when requested.
Include operative report and H&P documenting functional impairment or indications.

Documentation Required

Donor/transplant codes — submit transplant approval or full documentation

For donor/transplant procedure codes (e.g., 33930, 33933, 33935, 38205, 38206), if transplant approval is on record submit the Date of Transplant; if not, include history & physical, transplant evaluation, and date of transplant.

Provide Date of Transplant when approval exists.
If approval is absent, submit H&P and transplant evaluation documentation.

Documentation Required

Provide recent H&P, plan of care, and operative report where specified

Many listed codes require recent clinical documentation such as a history and physical, plan of care, and operative report to establish medical necessity; include these documents when submitting authorizations or claims.

Always include H&P and plan of care when requested on the code line.
Attach operative reports for surgical procedures to support medical necessity.

Documentation Required

Transplant codes — date-of-transplant or full evaluation required

For transplant codes, if transplant approval is on record submit the Date of Transplant; otherwise provide history and physical, transplant evaluation, and the date of transplant as required documentation.

Date of Transplant suffices if approval is on file.
If not, include full transplant evaluation and H&P.

Documentation Required

Implantation and block/operative procedures — H&P and operative report required

Certain implantations and block/operative procedures require submission of history & physical, documentation of medical necessity, and operative report when indicated (examples listed with respective code lines).

Include H&P and operative report for implantation and specified block/operative procedures (e.g., 63620, 64530, 64555).
Document medical necessity in the plan of care.

Documentation Required

Ocular procedures — pre-op and operative documentation required

Ocular reconstructive and corneal transplant codes (e.g., 65730–65782) request a pre-operative evaluation, history & physical, and operative report as part of prior authorization or claim review.

Submit H&P and operative report for corneal and ocular reconstructive transplants.
Ensure documentation shows indications and functional impairment where relevant.

Documentation Required

Required prior authorization documentation — H&P and diagnostic reports

For certain procedures (e.g., 72291, 72292, and proton treatment codes 77520–77525) prior authorization requires submission of a history & physical and the results of previous diagnostic procedure reports.

Include H&P and prior diagnostic procedure reports (e.g., discography reports) with the prior authorization request.
Proton treatment codes require H&P plus results of previous diagnostic procedure report per the code line.

Prior Authorization

Contact eviCore for authorization — use phone or provider portal

Providers must contact eviCore (1-855-252-1117 or https://www.evicore.com/provider) to initiate utilization management/prior authorization for codes that list eviCore on the code line.

Use the eviCore phone number or web portal provided next to the code in the list.
Submit all required clinical documents through eviCore as instructed.

Note

Use eviCore contact and code effective dates on code lines

eviCore contact information and code effective/added dates are provided inline; use the contact (1-855-252-1117 or https://www.evicore.com/provider) and the code line date to determine current authorization routing.

Confirm code applicability using the effective/added date shown on the code line.
Use the eviCore contact on the code line for prior authorization submissions.

Documentation Required

Submit H&P, plan of care, and medical necessity for listed procedures

For some procedures (examples: 91111, 91112, 91132, 91133, 92986–92993) the code lines specify recent history & physical, plan of care, and documentation of medical necessity should be submitted with the authorization request.

Attach H&P, plan of care, and medical necessity documentation for these procedures.
Follow the code-line instructions when preparing the prior authorization packet.

Documentation Required

T/U codes — H&P, plan of care, and medical necessity required

Multiple listed codes (e.g., 0178T, 0179T, 0180T, 0195T, 0196T) require recent history & physical, plan of care, and documentation of medical necessity; submissions listing eviCore contact will be reviewed by eviCore.

Provide H&P, plan of care, and documentation of medical necessity for T/TU codes when required.
Use eviCore contact information for submission and review where shown.

Documentation Required

U-codes — submit authorization and documentation via eviCore

For many listed U-codes each entry is annotated with eviCore contact information; providers should use eviCore processes to submit clinical documentation for authorization.

Submit U-code authorization requests and supporting documentation via eviCore as indicated.
Observe each U-code’s added date and any removal annotations when applicable.

Documentation Required

Ambulance (A0430) — progress notes, physician order, and supporting records required

Ambulance code A0430 requires submission of progress notes for the last 24 hours prior to transport, the physician order, and medical records supporting the rationale for transport with the authorization request.

Include progress notes covering the 24 hours before transport.
Attach the physician order and supporting medical records that justify the transport.

Documentation Required

Procedure codes — H&P, plan of care, and medical necessity documentation

Many procedural codes require a recent history & physical, plan of care, and documentation of medical necessity; include these records with prior authorization or when filing claims as specified on the code line.

Attach H&P and plan of care to demonstrate medical necessity.
Provide operative reports and diagnostic results when requested.

Documentation Required

Cellular therapy ancillary codes — H&P and plan of care required

Cellular therapy ancillary codes (e.g., 0537T–0540T) require recent history & physical, plan of care, and documentation of medical necessity to support authorization and processing.

Provide H&P, plan of care, and documentation of medical necessity for cellular therapy ancillary codes.
Follow the code-line date and eviCore routing when submitting.

Documentation Required

Include Letter of Medical Necessity / detailed H&P when requested

Examples of required documentation include a Letter of Medical Necessity or History & Physical detailing condition, anticipated length of need, comorbidities, prior interventions, and functional limitations — include these when requested on the code line.

Provide Letter of Medical Necessity where requested.
Document prior interventions and functional limitations in the H&P.

Denial Risk

Denial risk — missing preauthorization or required documentation

Failure to obtain required benefit preauthorization or to submit required medical records (H&P, pre-op evaluation, operative report, photographs, pathology report, grams removed for reduction mammoplasty, etc.) where listed may result in claim denial or delay.

Obtain preauthorization when the code line indicates prior authorization is required.
Submit all code‑specified records to avoid denial or processing delays.

Denial Risk

Documentation triggers — spine fusion and fixation codes

Failure to submit history & physical, operative report, and documentation of conservative measures for specified spine fusion and fixation CPTs may trigger prior authorization review or denial.

Include documentation of conservative (non‑surgical) care when the code line requests it.
Attach H&P and operative report for spine fusion/fixation codes to support necessity.

Denial Risk

Denial risk — not obtaining eviCore prior authorization

Failure to obtain prior authorization from eviCore for codes that list eviCore contact may lead to denial or pre‑service requirement; route requests to eviCore for those codes.

Do not bypass eviCore for codes that explicitly list eviCore contact.
Obtain eviCore authorization prior to service when required by the code line.

Denial Risk

Transplant denial risk — missing approval or transplant documentation

For lung transplant-related codes, absence of transplant approval on record requires submission of history & physical, transplant evaluation, and date of transplant; lack of these documents may lead to denial.

If transplant approval is not on record, include H&P, transplant evaluation, and date of transplant.
Missing transplant documentation can trigger non-authorization or denial.

Documentation Required

Transplant documentation requirement — supply H&P and transplant evaluation if no approval on file

If transplant approval is not on record for donor/transplant related codes, required documentation includes history & physical, transplant evaluation, and date of transplant — absence of these records may trigger denial.

Provide H&P and transplant evaluation when approval is absent.
Include date of transplant or documentation of approval to support claim.

Documentation Required

H&P and operative documentation — required for many procedures

Many procedure code lines require a 'Recent history and physical, plan of care, and documentation of medical necessity' or a pre-operative evaluation and operative report; missing these items may result in denial.

Attach recent H&P, plan of care, and medical necessity documentation for codes that list these requirements.
Operative report should be included when requested on the code line.

Denial Risk

Transplant-related documentation missing — denial risk

Lack of required transplant approval or missing documentation (H&P, transplant evaluation, date of transplant) for transplant-related CPTs may trigger non-authorization or denial; provide the specified records to avoid denial.

If transplant approval exists, submit the Date of Transplant.
If not, provide H&P, transplant evaluation, and date of transplant as required.

Documentation Required

Required clinical documentation — H&P, plan of care, operative report

Provide a recent history & physical, plan of care, and operative documentation for implantation, cellular therapy ancillary codes, and other procedures when requested; absence of these records may trigger eviCore review or denial.

Include H&P, plan of care, and operative report for implantation and cellular therapy ancillary codes.
Use eviCore submission pathways where the code line lists eviCore.

Denial Risk

Denial risk — missing pre-op evaluation, H&P, or operative report

Failure to submit required pre-operative evaluation, history & physical, and operative report where specified (examples include codes such as 63620, 64530, 64555, 65710–65782, 67900–67924) may lead to claim denial or delay.

Attach H&P and operative report for the listed codes.
Confirm any additional documentation (e.g., photos, pathology) requested on the code line.

Denial Risk

Denial risk — not using designated prior authorization vendor (eviCore)

Not routing prior authorization requests to eviCore for codes that list eviCore contact (e.g., many imaging and spine/neuro codes) may trigger denial or processing issues; use eviCore as the designated prior‑auth vendor.

Do not submit authorization requests through other vendors when eviCore is specified.
Follow eviCore’s submission instructions to avoid delays or denials.

Denial Risk

Missing prior authorization documentation — risk for codes like 72291/72292

If required prior authorization documentation (e.g., history & physical and prior diagnostic reports) is missing for codes such as 72291 and 72292, claims may be denied; include the specified documents with the prior authorization.

Provide H&P and results of previous diagnostic procedure reports (e.g., discography) for 72291/72292.
Use eviCore contact information on the code line to submit these documents for authorization.

Prior Authorization

eviCore utilization management review required for imaging/genetic codes

Claims for listed imaging and genetic procedure codes are subject to eviCore utilization management review; lack of prior authorization through eviCore (1-855-252-1117 or https://www.evicore.com/provider) may trigger denial.

Submit imaging/genetic procedure prior authorization requests to eviCore as directed.
Include required clinical documentation per the code‑line instructions.

Prior Authorization

Genetic/molecular CPTs — prior authorization via eviCore required

Claims for listed genetic/molecular CPT codes may require prior authorization through eviCore; absence of such authorization could result in claim denial — contact eviCore at 1-855-252-1117 or via their provider portal.

Verify eviCore routing on the genetic/molecular CPT code line before ordering the test.
Provide H&P and any additional documentation requested with the authorization.

Documentation Required

Documentation tied to medical necessity — include H&P and plan of care

Some procedures require recent H&P, plan of care, and documentation tied to medical necessity (examples provided on the code lines); absence of these documents may trigger denial or eviCore review.

Include a clear plan of care and medical necessity rationale in the H&P.
Supply requested diagnostic reports and prior treatment documentation.

Documentation Required

Documentation triggers for selected T-codes — H&P and plan of care required

For selected codes (e.g., 0178T, 0179T, 0180T) lack of a recent history & physical, plan of care, and documentation of medical necessity may trigger denial or requirement for eviCore review — include these items with the authorization.

Provide recent H&P, plan of care, and clear documentation of medical necessity for these T-codes.
Use the eviCore contact shown on the code line for submission and review.

Documentation Required

Documentation-triggered review — supply required records to avoid eviCore follow-up

Lack of required documentation where listed may trigger a requirement for eviCore review or additional prior authorization; provide the H&P, plan of care, operative report, and diagnostic results specified on the code line to avoid review delays.

Submit all code-specified records to eviCore when the code line directs eviCore routing.
Address any documentation deficiencies before claim submission to reduce denial risk.

Prior Authorization

eviCore prior authorization required for listed U-codes

Claims for the listed U-codes may be subject to eviCore utilization management; providers must contact eviCore at 1-855-252-1117 or via https://www.evicore.com/provider for authorization as indicated on each U-code line.

Use the eviCore phone number or web portal provided on the U-code line to request authorization.
Include the clinical documentation specified with the U-code entry.

Documentation Required

Ambulance documentation triggers — submit progress notes and physician order

Ambulance transport (A0430) documentation triggers include progress notes for the last 24 hours prior to transport, the physician order, and medical records supporting the rationale for the transport.

Attach physician order and supporting medical records with the authorization.
Provide progress notes covering the 24 hours before transport.

Documentation Required

Procedure codes — H&P and medical necessity documentation required

Providers must submit a recent history & physical, plan of care, and documentation of medical necessity for many procedure codes (examples include C9076 and others listed); missing these records may cause denial.

Include H&P, plan of care, and medical necessity documentation when the code line requests them.
Attach any additional specified records (e.g., operative reports) to support the claim.

Denial Risk

Denial triggers (general) — missing medical necessity or prior auth

Lack of documentation of medical necessity or failure to obtain prior authorization from eviCore (where specified) may trigger claim denial; ensure required authorizations and records are in the file before submitting claims.

Obtain eviCore prior authorization when the code line directs.
Include all code‑specified documentation demonstrating medical necessity.

eviCore is referenced for many listed imaging, genetic, T/U and U-code entries where prior authorization or review is required

Submission noteWhen eviCore is indicated providers must submit recent history and physical, plan of care, and documentation of medical necessity to eviCore for review

Certain U-codes received added dates (example: 0426U noted as added 4/1/24 in the source/brief).

2025-10-01vendor_routing_change

Select proton treatment CPTs (77520, 77522, 77523, 77525) were moved to eviCore routing effective 10/1/2025.

2025-03-31codes_removed

Some U-codes were assigned removal dates (examples include 0380U, 0428U, 0456U with removal effective 2025-03-31).