CurrentBlue Cross Blue Shield - TexasPolicy N/A

Utilization management preauthorization list for selected CPT/HCPCS codes (Plastic/Reconstructive Surgery and related services)

This document lists procedure codes and the medical-records or preauthorization requirements associated with those codes for Blue Cross Blue Shield - Texas; it informs providers which documentation to submit and notes eviCore-managed codes. It affects providers submitting claims or requesting prior authorization for the listed procedures.

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyUtilization management preauthorization list for selected CPT/HCPCS codes (Plastic/Reconstructive Surgery and related services)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateSep 1, 2019

Next Review Date

Key ActionObtain prior authorization or submit the specified medical records (history & physical, operative report, treatment plan or Letter of Medical Necessity) for listed CPT/HCPCS/J codes and contact eviCore when indicated.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~200CPT codes listed in excerpt

200+Procedure/genetic codes shown

ManyeviCore-managed

H&PDocumentation commonly required

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Effective date marker

Coverage Criteria and Authorization Rules

Documentation-based coverage criteria — Covered when ALL of the following are met:

All required prior authorization requests must be submitted per-code and routed to the entity specified (eviCore when indicated).

Required clinical documentation must be included with the authorization request: recent history and physical, treatment plan or plan of care, operative report (if applicable), imaging reports, and a Letter of Medical Necessity when specified (DME, seating, custom devices).

For injectable therapies and J-/infusion codes include ordering physician chart notes, treatment plan including condition being treated, and prior treatment history when requested.

For power wheelchairs, seating and positioning accessories (K- and E- series codes) include anticipated length of use, functional status, mobility limitations, and specific justification for the accessory or custom component.

Transplant and implant procedures require pre-operative evaluation, full history & physical, and operative reports; missing documentation may result in denial.

Prior authorization must be obtained prior to the date of service when the code entry indicates so; historical notes reflect legacy entries but current authorization routing still applies.

When eviCore routing is specified, contact eviCore at 1-855-252-1117 or via https://www.evicore.com/healthplan/bcbs for submission details and to confirm required attachments.

Documentation-based coverage criteria — Coverage and authorization are contingent on documentation meeting medical necessity standards

If operative reports, pre-operative evaluations, or transplant documentation are missing, the request may be declined or returned for additional information.

DME and power wheelchair requests missing Letters of Medical Necessity, anticipated duration of need, or functional assessments are at high risk for denial.

Injectable and biologic therapy prior authorization requests without ordering physician chart notes, treatment plan, and indication may be denied or delayed.

Documentation may be requested post-submission; however, failure to provide required clinical records in a timely manner can lead to denial.

Providers must follow any additional code-specific documentation instructions listed on the policy (e.g., specific notes for spinal fusion, seating/positioning, implants).

inv-04: Prior authorization routing — Prior authorization routing

Prior authorization routing — Prior authorization routing

eviCore routing applies to select imaging (CT/MRI/MRA/PET), injections/biologics (selected J-codes), orthopedics (hip/knee/sacroiliac procedures), spine surgeries, implants, and selected DME/seating codes — follow per-code notes for exceptions.

Some entries note plan-specific exceptions (for example, No Prior Auth required for MT Medicare Advantage Plan for certain codes) — verify plan and effective dates before submission.

If prior authorization is routed to eviCore, include all required documentation at time of submission to avoid delays; use the eviCore web portal or phone contact to confirm required attachments.

CPT / HCPCS / Related Codes (Grouped)

Spine fusion and fixation CPT codesCPTCovered

22630	Lumbar spine fusion
22632	Spine fusion extra segment
22633	Lumbar spine fusion combined
22634	Spine fusion extra segment
22840	Post-fusion <6 vertebral segments
22841	Post-fusion 7-12 vertebral segments
22842	Post-fusion 13+ vertebral segments
22844	Insert spine fixation device
22845	Insert spine fixation device
22848	Insert pelvic fixation device

1–10 of 17

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Shoulder and related procedure CPT codesCPTCovered

23000	Removal of calcium deposits, shoulder
23020	Release shoulder joint
23120	Partial removal collar bone
23130	Removal of shoulder bone part
23440	Remove/transplant tendon, shoulder
23450	Repair shoulder capsule
23455	Repair shoulder capsule
23460	Repair shoulder capsule
23462	Repair shoulder capsule
23465	Repair shoulder capsule

1–10 of 16

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Hip, pelvis and lower extremity CPT codesCPTCovered

27096	Injection, sacroiliac joint
27125	Partial hip replacement
27134	Revise hip joint replacement
27137	Revise hip joint replacement
27138	Revise hip joint replacement
27279	Arthrodesis sacroiliac joint
27332	Removal of knee cartilage
27333	Removal of knee cartilage
27334	Remove knee joint lining
27335	Remove knee joint lining

1–10 of 33

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Vascular, transplant, and related CPT codesCPTCovered

33935	Repair modified Fontan — transplantation heart/lung (transplant-related documentation required)
33940	Repair modified Fontan — removal of donor heart (transplant-related documentation required)
33944	Repair modified Fontan — prepare donor heart
36468	Therapeutic apheresis/plasmapheresis (listed as related)
36470	Collection for therapeutic apheresis (listed)
37565	Ligation of neck vein
37650	Revision of major vein
37718	Ligate/strip short leg vein
37722	Ligate/strip long leg vein
37735	Removal of leg veins/lesion

1–10 of 22

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Maxillofacial, ENT, oral and related CPT codesCPTCovered

40700	Repair cleft lip/nasal
40701	Repair cleft lip/nasal
40702	Repair cleft lip/nasal
40720	Repair cleft lip/nasal
40761	Repair cleft lip/nasal
40820	Treatment of mouth lesion
41512	Tongue suspension
41530	Tongue base volume reduction
42145	Repair palate/pharynx/uvula
42200	Reconstruct cleft palate

1–10 of 16

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Bariatric, abdominal, and transplant-related CPT codesCPTCovered

43771	Lap revise gastric adjustment device
43772	Lap removal gastric adjustment device
43773	Lap replace gastric adjustment device
43774	Lap removal gastric adjustment all parts
43775	Lap sleeve gastrectomy
43800	Reconstruction of pylorus
43845	Gastroplasty duodenal switch
43846	(related bariatric codes)
43999	Stomach surgery procedure (unlisted)
44132	Enterectomy cadaver donor (transplant-related)

1–10 of 16

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Urologic, gender-affirming, and reproductive surgery CPT codesCPTCovered

51580	Remove bladder/revise tract (transplant context)
51585	Removal of bladder & nodes
55175	Insert multi-component penile prosthesis
55180	Insert multi-component penile prosthesis (revision)
55970	Sex transformation M to F procedures
55980	Sex transformation F to M procedures
56625	Complete removal of vulva
56800	Repair of vagina
56805	Repair clitoris
56810	Repair of perineum

1–10 of 18

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Gynecologic and obstetric CPT codesCPTCovered

57335	Repair urethrovaginal lesion — repair vagina
57426	Revise prosthetic vag graft lap
58150	Total hysterectomy
58180	Partial hysterectomy
58240	Removal of pelvis contents
58285	Extensive hysterectomy
58672	Laparoscopy fimbrioplasty
58760	Fimbrioplasty
59840	Abortion (various codes: 59840-59857 series)
59841	Abortion

1–10 of 17

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Neurosurgery, spine, and pain management CPT codesCPTCovered

60512	Autotransplant parathyroid (neurosurgical/ENT context referenced)
61630	(neurosurgery item listed)
62115	Reduction of skull defect
62120	Repair skull cavity lesion
62280	Treat spinal cord lesion
62281	Treat spinal cord lesion
62282	Treat spinal canal lesion
62287	Percutaneous discectomy
62292	Chemonucleolysis lumbar
62321	Injection interlaminar cervical/thoracic

1–10 of 26

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Prior Authorization, Documentation & Provider Responsibilities

Prior Authorization

Obtain prior authorization / submit required documentation

Prior authorization or submission of the specified medical records (e.g., pre-operative evaluation, recent history & physical, operative report) is required for the CPT codes listed in this policy; some entries indicate eviCore manages prior authorization and provide eviCore contact information.

Submit the documentation indicated beside each CPT code when requesting authorization.

Prior Authorization

Route spine/fusion authorization requests to eviCore

Many spine and fusion-related CPT codes require prior authorization routed to eviCore; contact eviCore at 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs when authorization is indicated.

Examples include fusion codes such as 22534, 22551, 22552, 22558, 22600, 22612, 22614.

Background and Scope

This list associates specific procedural CPT/HCPCS codes with the documentation required for utilization review and authorization. For many surgical, implant, imaging, and DME codes the provider must submit a pre-operative evaluation, recent history & physical, operative report, and when applicable a Letter of Medical Necessity or other supporting evaluations to demonstrate medical necessity and permit prior-authorization review (many codes are routed to eviCore for review).

Definitions and Key Documents

Transplant approval on record

DefinitionTransplant approval on record indicates the member has documented transplant approval; if present, provide date of transplant instead of full transplant evaluation documents.

If approval not on recordSubmit history and physical, transplant evaluation, and date of transplant (or documentation of transplant evaluation and date).

Applicable codes exampleApplies to transplant-related CPTs listed (e.g., 33933–33945, 35879) which reference transplant approval or transplant evaluation requirements.

Letter of Medical Necessity (DME/wheelchair)

DefinitionLetter of Medical Necessity: a clinical document describing anticipated length of equipment use, the medical condition requiring the equipment including mobility status, and justification for the item.

Required content (examples)

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyUtilization management preauthorization list for selected CPT/HCPCS codes (Plastic/Reconstructive Surgery and related services)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateSep 1, 2019

Next Review Date

SourceLink

On This Page

eviCore authorization for spinal device/disc procedures

Insertion, revision, or removal of spinal fixation and artificial disc devices reference eviCore for prior authorization; follow eviCore routing and submit any documentation noted.

Examples include CPT codes 22843–22846, 22853, 22856–22862, 22864–22865.

Prior Authorization

eviCore authorization for hip/sacroiliac/knee procedures

Hip, sacroiliac, and knee CPT codes are frequently routed to eviCore for prior authorization; check the code entry for any Medicare Advantage exceptions and contact eviCore if authorization is required.

Examples include 27130, 27132, 27278–27280, 27403, 27412–27416.

Prior Authorization

Use eviCore for listed CPT prior authorizations

Prior authorization is required via eviCore (1-855-252-1117 or web portal) for numerous listed CPT codes unless the code entry explicitly notes an exception (e.g., No Prior Auth for MT Medicare Advantage Plan).

Confirm per-code notes for exceptions before proceeding.

Documentation Required

Submit per‑code required documentation with prior authorization

Prior authorization is required for the listed CPT codes and specific supporting documentation (e.g., history & physical, pre-operative evaluation, operative report) must be submitted as indicated for each code.

Follow the per-code documentation instructions shown in the policy when requesting authorization.

Prior Authorization

Prior authorization and transplant documentation

Transplant-related renal and kidney procedure codes require prior authorization; if transplant approval is on record provide the date of transplant, otherwise submit transplant evaluation and date of transplant with the request.

Applicable examples include 50300–50380 and 48550–48556 entries.

Prior Authorization

Route spine/neuromodulation/injection codes to eviCore

Many spinal, neuromodulation, injection, and related procedure codes require routing to eviCore for prior authorization; contact eviCore at 1-855-252-1117 or via the eviCore BCBS web portal for review.

Examples include 62263, 62320–62327, 62350–62362, 63650–63685, 64451–64495, 64510–64565.

Documentation Required

Submit H&P and operative report for genital/reproductive codes

For many genital, reproductive, and related procedure codes, providers must submit a History & Physical and documentation of medical necessity (including the operative report) when requesting prior authorization.

Examples include 51597, 53430, 53860, 54125, 54400–54401, 54520, 54660, 54690.

Prior Authorization

eviCore prior auth and operative documentation for implants

Many CPT codes in the list require prior authorization via eviCore; where specified, providers must include the History & Physical and operative report for implant and neuroelectrode procedures.

Implant/neuroelectrode examples: 64530, 64555, 64561, 64565.

Documentation Required

Include H&P and operative report for implant/block codes

Implant, neuroelectrode, and certain block procedure codes require submission of a History & Physical and the operative report as part of the prior authorization request.

Ensure operative report is included for codes such as 64530, 64555, 64561, 64565.

Prior Authorization

Obtain prior authorization for CPT/genetic test codes (eviCore referenced)

The listed CPT and genetic test codes require prior authorization (often via eviCore at 1-855-252-1117 or the eviCore BCBS web portal); follow the per-code prior‑authorization process shown in the policy.

Examples include 74178, 77021, and numerous molecular/pathology codes (81162–81402 range).

Prior Authorization

Refer listed molecular/proprietary codes to eviCore

These CPT/HCPCS and proprietary codes require prior authorization or referral to eviCore for review before services are provided; submit documentation per the code entry.

Examples include 81322–81402 and other listed molecular/genetic test codes.

Prior Authorization

Route additional molecular/specialty codes to eviCore

Additional U- and T-type molecular/specialized service codes are routed to eviCore; contact eviCore (1-855-252-1117 or evicore.com/healthplan/bcbs) as directed by each entry.

Examples include 0036U–0048U, 0087U–0103U, and related entries with effective dates.

Prior Authorization

eviCore routing required for listed alphanumeric codes

These alphanumeric codes indicate eviCore prior authorization or routing is required; providers must use the eviCore contact information provided in the policy.

Examples include 0087U, 0088U, 0094U, 0095T and others listed in this section.

Prior Authorization

Submit authorization requests to eviCore for listed codes

Codes in this section route to eviCore for prior authorization; use eviCore phone 1-855-252-1117 or the eviCore website to submit authorization requests as indicated.

Numerous U-codes (e.g., 0348U–0540U) and T-codes are included.

Prior Authorization

Contact eviCore for PAP/accessories and select imaging/device codes

Many PAP interfaces, accessories, select imaging and device codes require contacting eviCore for prior authorization or note 'No Prior Auth required for MT Medicare Advantage Plan' depending on the code entry; follow the specific instruction shown.

Examples include A7027–A7035 and C8903–C8908 series.

Prior Authorization

eviCore review for imaging and injectable drug codes

Prior authorization or eviCore review is required or referenced for a number of imaging and drug injection codes; contact eviCore (1-855-252-1117) or follow the eviCore URL referenced for authorization guidance.

Examples include PET imaging codes (G0219), J0129, and other J-code entries.

Prior Authorization

Obtain eviCore prior authorization for listed J-codes

Prior authorization must be obtained through eviCore (phone or web) for many listed J/HCPCS drug codes; include required documentation (history & physical, chart notes, treatment plan) as indicated.

Examples: J0222, J0248, J0256–J0257, J0364, J0490–J0491.

Documentation Required

Document clinical rationale for J-code authorizations

Numerous J-codes require prior authorization via eviCore and commonly require documentation such as a history & physical and a treatment plan when requesting authorization.

See policy entries for the specific J-code documentation requirements.

Prior Authorization

Prior authorization and documentation for K‑codes (power wheelchairs)

Many K-codes (power wheelchairs and components) require prior authorization or documented medical necessity; submit a recent history & physical, plan of care, and other documentation as specified.

Examples include K0813–K0880 series and K0870–K0886 entries with per-code documentation instructions.

Documentation Required

Authorization and documentation required for K- and L-codes

Prior authorization is implied for the listed K- and L-codes and requires submission of the specified documentation (Recent History & Physical, plan of care, and/or Letter of Medical Necessity with functional status and duration needed) to demonstrate medical necessity.

Provide Letters of Medical Necessity including anticipated length of use and functional status where indicated for L‑codes.

Documentation Required

Submit required clinical documentation with authorization requests

For each listed CPT code providers must submit the specified pre-operative evaluation, recent History & Physical (including functional impairment when noted), operative report, and any additional documentation specified (e.g., photographs, pathology) when requesting authorization.

Follow the per‑code 'Medical Records Request information required' instructions in the policy.

Prior Authorization

Contact eviCore for bone graft/bone stimulation codes

Some bone graft and bone stimulation codes reference contacting eviCore for prior authorization details; use the eviCore contact information provided in the policy.

Examples include 20930–20938 and 20974–20975.

Documentation Required

Provide H&P, operative report, and conservative measures for fusion codes

For selected fusion codes submit a history & physical, operative report, and documentation of prior conservative measures when requesting authorization.

Applicable codes include 22800, 22802, 22804, 22808, 22810, 22812.

Documentation Required

Document H&P and plan of care for artificial disc removal/revision

Removal or revision of artificial disc codes requires a recent history & physical, plan of care, and documentation of medical necessity when requesting prior authorization.

Examples: 22864, 22865 and revision/removal entries.

Documentation Required

Include pre-op evaluation, H&P, and operative report for shoulder procedures

Pre-operative evaluation, history & physical, and operative report are required documentation for many shoulder procedure codes; include these when submitting authorization requests.

Examples include 23410, 23412, 23415, 23420, 23430.

Documentation Required

Attach pre-operative H&P and operative report as required

Pre-operative evaluation, history & physical (including functional impairment when specified), and operative report are frequently required for authorization of listed procedures; ensure these documents are included per the code entry.

Check each code's 'Medical Records Request information required' field and attach the listed documents.

Documentation Required

Provide transplant approval or transplant evaluation documentation

For transplant-related CPTs, include transplant approval on record (date of transplant) or, if not available, submit a history & physical, transplant evaluation, and date of transplant with the authorization request.

Applicable examples: 32855–32856, 33933–33945, 35879 and related transplant codes.

Documentation Required

Follow per‑code required clinical documentation

Submit a recent history & physical, pre-operative evaluation, operative report, and when applicable a transplant evaluation or transplant approval on record as specified by the code entry.

Follow the per-code instruction for documentation required to support medical necessity.

Documentation Required

Include bariatric-specific evaluations and documentation

For bariatric procedures include a history & physical, nutritional evaluation, psychological evaluation, documentation of weight loss attempts, and documentation of social supports when requesting authorization.

Applicable codes include 43644–43645, 43770–43775, 43843–43848.

Documentation Required

Provide History & Physical and operative report for surgical procedures

For many listed procedures the provider must submit a History & Physical and documentation of medical necessity including the operative report when requesting authorization.

This is a common requirement across numerous CPT entries in the policy.

Documentation Required

Include H&P, pre-op evaluation, operative report for implants

For many surgical and implant procedures submit a pre-operative evaluation, history & physical, and the operative report; some implants also require documentation of prior device use and level of impairment.

Examples include cochlear/hearing implants and various implantable neuro devices.

Documentation Required

Submit H&P and prior diagnostic reports for proton treatment codes

Proton treatment codes require prior authorization with submission of a history & physical and results of previous diagnostic procedure reports as specified.

Applicable CPTs: 77520, 77522, 77523, 77525.

Documentation Required

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

Recent history & physical, plan of care, and documentation of medical necessity are required for certain procedures and codes added on specific dates; include these documents when indicated.

Examples include 91132–91133, 92986–92993, and newly added J-codes (e.g., J1411–J1413).

Documentation Required

Submit progress notes and physician order for ambulance (A0430/A0435)

A0430 ambulance transport requires submission of progress notes for the last 24 hours, the physician order, and medical records supporting the rationale for transport prior to transport; missing these may trigger denial.

Ensure all supporting clinical records accompany the prior authorization/claim for ambulance services.

Denial Risk

Risk of denial if eviCore prior authorization not obtained

A failure to obtain required prior authorization through eviCore (phone 1-855-252-1117 or eviCore web portal) for listed procedure codes where eviCore is specified may result in denial of coverage.

Obtain eviCore authorization before performing procedures when listed as the review vendor.

Denial Risk

Denial risk for missing documentation on spine fusion codes

Failure to submit a required history & physical, operative report, and documentation of conservative measures for the listed spine fusion codes (e.g., 22800, 22802, 22804, 22808, 22810, 22812) may risk denial.

Attach documentation of conservative measures when requested for post-fusion and anterior-fusion codes.

Denial Risk

Denial risk for missing pre-op/operative reports for vascular/vein codes

Omitting the required pre-operative evaluation, history & physical, relevant study results (e.g., Doppler), and operative report for vascular/vein procedures may trigger denial.

Examples include 36479, 37241, 37500, 37700–37761 entries.

Denial Risk

Denial risk for missing H&P and operative report on listed CPTs

Failure to submit required H&P and operative report for listed CPT codes (e.g., 51597, 53430, 53860, 54125, 54240, 54304, 54400, 54401) may result in adverse processing or denial.

Ensure H&P and operative report accompany authorization requests for these codes.

Denial Risk

Denial risk for missing prior authorization or documentation

Lack of required prior authorization or required documentation (history & physical, operative report) for listed CPT codes may trigger denial; confirm per-code authorization requirements before providing services.

Verify both authorization routing and per-code documentation requirements.

Denial Risk

Denial risk for missing prior auth on molecular/pathology codes

Claims for many molecular pathology and procedure codes require prior authorization or eviCore review; absence of the required prior authorization may trigger denial or routing delays.

Examples include 81322–81408 and related genomic/molecular codes.

Denial Risk

Denial or routing issues if eviCore review not obtained

Failure to obtain eviCore review/authorization for listed eviCore‑routed codes (for example 0087U, 0088U, etc.) may result in denial or routing issues.

Use eviCore contact information provided in each code entry to submit requests.

Documentation Required

Ambulance transport documentation requirement

A0430 requires submission of progress notes for the last 24 hours, physician order, and medical records supporting the rationale for transport prior to transport; omitting these may trigger denial.

Denial Risk

Non-covered HCPCS (A9270) — risk if billed

Some items are identified as 'Non-covered item or service' (A9270); billing these without coverage justification may result in denial.

Documentation Required

Letter of Medical Necessity required for many DME/wheelchair items

Lack of a Letter of Medical Necessity that includes anticipated length of use, description of the medical condition, and mobility status may trigger denial for multiple wheelchair accessory and DME HCPCS codes.

Applicable examples: E0635, E0638, E0641, E0642, E1005–E1036, E2300–E2330, E2609–E2621.

Documentation Required

Provide LOMN for custom cushions and positioning backs

Absence of the required Letter of Medical Necessity for custom cushions and positioning backs (e.g., E2609, E2615, E2620, E2621) may result in non-coverage.

Letters must document anticipated length of use and patient functional status.

Prior Authorization

Obtain eviCore authorization before administering listed injectables

Lack of prior authorization through eviCore for listed injectable drugs (when eviCore is specified) may trigger claim denial; contact eviCore before administering these agents.

Examples include many J-codes in the J0222–J9334 ranges that reference eviCore.

Documentation Required

Include H&P, chart notes, and treatment plan for J-code authorizations

For many J-codes, lack of a recent H&P, chart notes from the ordering physician, and a treatment plan including the condition being treated may trigger denial of authorization or payment.

Include ordering physician chart notes and a clear treatment plan with the authorization request.

Denial Risk

DME/K-code denial risk for missing H&P, plan of care, or medical necessity

Absence of a recent history & physical, plan of care, and documentation of medical necessity may trigger denial for many K-codes (power wheelchairs); ensure these documents are provided with the authorization.

Provide functional assessments and anticipated length of use where requested.

Denial Risk

Missing required documentation for HCPCS/K/L codes may trigger denial

Lack of required documentation (e.g., Recent History & Physical, plan of care, or Letter of Medical Necessity) for listed HCPCS/K- and L-codes may result in denial; attach the specified documents with the authorization or claim.

Letters must include length of time needed, functional status if applicable, and a description of the medical condition.

Anticipated length of time patient will require equipment; description of medical condition and mobility status; item-specific justification (e.g., functional limitations, prior use).

Applies toMany DME and wheelchair accessory HCPCS/CPT codes (examples: E1005–E1012, E1035–E1036) require a Letter of Medical Necessity per the policy.

Letter of Medical Necessity (prosthetics/advanced DME)

DefinitionLetter of Medical Necessity: a document that includes length of time equipment is needed, the patient's functional status (if applicable), and a description of the medical condition to justify the equipment.

Required detailsFunctional status assessment, anticipated duration of need, description of medical condition, and any device-specific justification (e.g., upper extremity strength for power seating accessories).

When submittedRequired for many L‑ and K‑codes and for pediatric/advanced prosthetic L‑codes as specified in the policy (see L69xx/L69xx entries).

Recent History and Physical

DefinitionRecent History and Physical: a current history and physical examination accompanied by a plan of care and documentation of medical necessity, commonly required for K‑code (power wheelchair) authorization.

Required componentsCurrent clinical H&P, plan of care, documentation of medical necessity including anticipated length of use for wheelchairs, and functional assessment as applicable.

Applies toRequired for many K‑codes (power wheelchairs) such as K0870–K0880 and related K‑group entries where the policy specifies H&P and plan of care submission.