CurrentBlue Cross Blue Shield - TexasPolicy N/A

Preauthorization list for surgical and procedural CPT/HCPCS codes

This document lists procedure codes for which benefit preauthorization may be required and the medical record documentation typically requested by the payer; it is intended for providers submitting requests to Blue Cross Blue Shield - Texas (utilization management).

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyPreauthorization list for surgical and procedural CPT/HCPCS codes

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateSep 1, 2019

Next Review DateN/A

Key ActionObtain prior authorization through eviCore (1-855-252-1117 or https://www.evicore.com/healthplan/bcbs) when indicated and submit required documentation (history and physical, operative report, plan of care or letter of medical necessity) per code listing.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~200+procedure codes listed in this extract

20+CPT codes listed in this excerpt

H&P + LOMDocumentation frequently required

eviCoreDesignated prior auth vendor

MT MA exceptions

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.

Medicare Advantage exceptions noted

Coverage criteria and conditions

Transplant documentation criteria

Covered when required transplant documentation is submitted as specified for each CPT.

Transplant documentation requirement: If transplant approval on record: submit Date of Transplant; if no transplant approval: submit history and physical, transplant evaluation, and date of transplant.

Applies to listed donor/transplant CPTs (examples: 47133, 47135, 47140, 48550, 48551, 50300, 50320).

H&P and medical necessity documentation criteria

Covered when documentation of medical necessity and operative details are submitted.

H&P and medical necessity: Submit a recent history and physical, documentation of medical necessity, and the operative report as required for the listed CPTs.

Applies to urologic/pelvic, gender-related and other procedures (e.g., 51585, 51597, 53430, 53860, 54125, 54400, 57335, 57426, 58150).

eviCore prior authorization criteria

Prior authorization is required through eviCore for certain spine and pain management CPTs unless a Medicare Advantage exception is noted per code.

eviCore prior authorization: Providers must contact eviCore (phone 1-855-252-1117 or the eviCore BCBS portal) to obtain prior authorization for the listed spine/pain CPTs.

Applies to listed codes such as 62263, 62280, 62281, 62282, 62287, 62292, 62320–62327 and many spine surgery CPTs; some codes include plan-specific 'No Prior Auth' notes for MT/NM Medicare Advantage or MT Medicare Advantage effective dates, as indicated per code.

Operational coverage conditions

Covered when supported by the required documentation and prior authorization where indicated.

Letter of Medical Necessity and clinical documentation: Submit a Letter of Medical Necessity that specifies anticipated length of use and describes the medical condition (including mobility status) and, where stated, include history and physical, treatment plan, and chart notes from the ordering physician.

Applies to many HCPCS and DME entries (examples: E0770, E0782, E0830, E1036, E1161) and to home health/hospice services (G0151–G0156).

External prior review or vendor routing: Selected imaging, genetic/molecular, and specialty drug codes require prior authorization or review via eviCore per the code listing.

Examples include PET imaging and many advanced imaging/genetic test codes routed to eviCore; follow the per-code directions for prior authorization.

The presence of a CPT or HCPCS code on this administrative preauthorization list does not necessarily indicate coverage under a member's benefits contract. Providers must check member eligibility and benefits before rendering services and obtain any required preauthorization. Consult the member benefit booklet or customer service to confirm coverage for a specific service or supply.

Some spine and related procedure entries include plan-specific exceptions. Notes in the list identify that No Prior Auth is required for MT or NM Medicare Advantage Plan effective 4/1/2018 for certain spine/pain CPTs; other MT Medicare Advantage exceptions with differing effective dates may be shown inline per code. Verify the member's Medicare Advantage plan and applicable effective date before assuming prior authorization is not required.

Several listed T-codes carry an explicit per-code note stating No Prior Auth required for MT Medicare Advantage Plan (examples include 0214T, 0215T, 0216T, 0217T, 0218T and items such as 0274T/0275T). Where shown, these No Prior Auth statements are plan- and date-specific; providers must confirm the patient’s MT Medicare Advantage enrollment and the code’s effective date before proceeding without prior authorization.

HCPCS code A9270 is identified in the list as a non-covered item or service. When submitting claims or prior authorization requests, do not assume coverage for A9270 and follow member benefit verification and payer guidance.

PET imaging code G0219 is listed with a specific note: PET imaging whole body; melanoma for non-covered indications. The entry also references eviCore for prior authorization routing; confirm the imaging indication and obtain any required review before proceeding.

Drug code J0584 (Crysvita) shows a temporal change in the listing: it was removed effective 12/31/2024 and then re-added effective 1/1/2025 with associated documentation requirements (history and physical, chart notes, treatment plan and Letter of Medical Necessity). Check the effective/removal dates shown on each code entry when determining prior authorization or coverage status.

CPT/HCPCS code lists and grouped code tables

Prior authorization, documentation and denial risk — actions for providers

Prior Authorization

Preauthorization may be required

This list includes CPT and HCPCS codes for which benefit preauthorization or additional clinical documentation may be required. Presence on the list does not guarantee coverage — always verify member eligibility and benefits prior to rendering services. Failure to obtain required prior authorization or to submit required documentation may result in claim denial or noncoverage.

Prior authorization may be required for many listed CPT/HCPCS codes — check member eligibility and benefits before providing services.
When prior authorization is required, eviCore Healthcare is the external review/prior authorization vendor for many codes. Contact eviCore at 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs for routing and submission.
Some plans and lines of business have plan-specific exceptions (for example: No Prior Auth required for MT Medicare Advantage Plan where noted in the per-code entries — follow the per-code notes).
Failure to obtain prior authorization or submit required supporting documentation (H&P, pre-op evaluation, operative report, transplant approval, Letter of Medical Necessity, etc.) may result in denial.
Many imaging, advanced imaging, nuclear medicine, genetic/molecular tests, J- and G-codes, selected drugs and DME items route to eviCore for prior authorization as indicated inline in the code list.

Policy background and scope

This document is an administrative preauthorization list used to identify services and supplies for which benefit preauthorization or specific documentation may be required. It is not a clinical coverage-criteria or medical-necessity policy and does not define clinical indications. Providers should use this list to determine authorization routing and typical documentation requests, but must refer to member benefits and clinical coverage policies for medical necessity determinations.

Definitions and key terms

Green highlighted codes — eviCore-managed

DefinitionGreen highlighted codes = codes managed by eviCore Healthcare

Provider routingeviCore contact: 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs (per entries)

ImplicationCodes highlighted green in the list require prior authorization or review via eviCore unless an explicit plan exception is noted

Transplant approval on record — submission instruction

Condition when presentTransplant approval on record = existing prior authorization/approval indicating transplant authorized; providers must submit Date of Transplant

If approval not on recordSubmit history and physical, transplant evaluation, and date of transplant where applicable

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyPreauthorization list for surgical and procedural CPT/HCPCS codes

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateSep 1, 2019

Next Review DateN/A

SourceLink

On This Page

Prior Authorization

eviCore Prior Authorization (examples)

For codes routed to eviCore, providers must contact eviCore by phone or submit via the eviCore BCBS webpage to request prior authorization. Typical contact: 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs.

Examples of services that commonly require eviCore prior authorization: advanced imaging (CT, MRI, PET), many spine and pain procedures, select genetic/molecular tests, proton therapy (codes 77520, 77522, 77523, 77525 added 1/1/24), and many J-/G-/C-/T-/U- codes as listed.
eviCore routing is indicated inline for specific CPT/HCPCS/other codes in the code list; follow the per-code instructions and any plan-specific exceptions shown inline.

Prior Authorization

eviCore Prior Authorization (spine and pelvis examples)

Spine, pelvis and related procedures frequently require prior authorization through eviCore and submission of clinical documentation. Where a Medicare Advantage plan exception is noted for a state/plan (e.g., MT Medicare Advantage), follow the per-code exception.

Examples: many spine surgery, fusion and augmentation codes (22510–22515, 22526–22527, 22533–22534, 22551–22558, 22800–22812, 22840–22841, 22867–22870, 22862, 22999, 63001–63082, 63620, 63650, 63655, 63685, 64451, 64479–64495, etc.) indicate eviCore prior authorization and require recent H&P, operative reports, and documentation of medical necessity.
Certain post-fusion or revision codes require documentation of conservative measures prior to approval (see per-code notes for conservative measures documentation).

Prior Authorization

eviCore Prior Authorization (extremity examples)

Upper and lower extremity advanced imaging and certain extremity procedures route to eviCore for prior authorization; submit required clinical documentation as specified.

Examples: CT/MRI of upper extremity (73200–73206, 73218–73223, 73225) and lower extremity (73700–73706, 73718–73725) require eviCore prior authorization where indicated.
Extremity surgical procedures listed also often require H&P and operative report submission for prior authorization.

Prior Authorization

eviCore Prior Authorization (abdominal/pelvic examples)

Abdominal, pelvic, colonography and fetal MRI studies listed require prior authorization through eviCore; prior authorization requests should include relevant diagnostic reports and history.

Examples: CT abdomen/pelvis (74150–74178), MRI abdomen/pelvis (74181–74183, 74185), CT colonography (74261–74263), pelvic CT/MRI (72191–72198), and fetal MRI (74712–74713).
Provide history and relevant prior diagnostics when requesting prior authorization.

Prior Authorization

eviCore Prior Authorization (advanced imaging and proton therapy)

Advanced imaging procedures, 3D rendering, MRI guidance, and proton therapy codes require prior authorization through eviCore; some proton therapy codes were added 1/1/24 and require prior auth with diagnostic procedure reports.

Examples: 3D rendering and advanced post-processing (76376–76377, 76380, 76390–76391), MRI guidance codes (77021–77022), breast MRI (77046–77049), and proton therapy (77520, 77522, 77523, 77525).
For proton therapy codes (added 1/1/24), submit H&P and results of previous diagnostic procedure report as part of the prior authorization request.

Prior Authorization

eviCore Prior Authorization (nuclear medicine examples)

Nuclear medicine and PET imaging codes route to eviCore for prior authorization; provide supporting clinical documentation when requested.

Examples: nuclear medicine codes (78012–78020, 78070–78075, 78102–78104, 78140, 78185, 78195, 78201–78266, 78300, 78813–78816, 78830, etc.) and PET codes (78814–78816, G0219, G0235, G0219) indicate eviCore routing.
Per-code notes list eviCore contact information for prior authorization.

Documentation Required

Prior authorization / LOMN requirements

Many HCPCS E-, G-, J-, and DME codes require a Letter of Medical Necessity (LOMN) and supporting clinical documentation (anticipated length of use, condition, mobility status) when prior authorization is requested.

DME examples that frequently require a LOMN: E0635, E0638, E0641–E0642, E0650–E0676, E0747–E0769, E0770, E0782–E0783, wheelchair accessories (E1002–E1005, E1161, E1220, etc.).
LOMN should include anticipated length of need, description of medical condition requiring the device, mobility status, and any prior interventions tried.

Documentation Required

Required documentation

Providers must supply the specific clinical documentation indicated in the per-code entries when requesting prior authorization or when submitting claims for certain procedures. Commonly requested items are listed below.

Common documentation: recent History & Physical (H&P), pre-operative evaluation, operative report, treatment plan, plan of care, and documentation of medical necessity including functional impairment.
For imaging and specialty services: relevant diagnostic reports, prior imaging, results of prior conservative therapy, and letters of medical necessity when required.
For sleep, TMJ and facial appliance procedures: submit chart notes including appliance type, history of recurrent TMJ, and copy of diagnostic sleep studies where specified (examples: 21085, 21120–21127, 70336).
For breast reduction/related procedures (example CPT 19318 and related codes): include patient height/weight, prior conservative treatment, pathology where applicable, and operative report.

Documentation Required

Required clinical documentation

Certain procedures and DME require specific clinical items listed inline — examples include vascular/vein procedures, transplant-related procedures, bariatric surgery and home health/hospice services.

Vascular/vein procedures: pre-op evaluation, H&P, Doppler results and operative report (examples: 36468, 36470, 37241, 37500, 37565, 37650, 37700, etc.).
Bariatric surgery (43644, 43645, 43770–43775, 43843, 43845, etc.): History and physical, nutritional and psychological evaluations, documentation of prior weight loss attempts, and social supports.
Home health/hospice codes (G0151–G0162): H&P, ordering physician chart notes, treatment plan and Letter of Medical Necessity.

Documentation Required

Required documentation for surgical procedures

Many surgical procedures require recent H&P, operative reports, and documentation of medical necessity and prior conservative care where applicable. Submit these documents with prior authorization requests or when billed if requested.

Examples: reconstructive, ocular, cardiac revision, transplant and many other surgeries list H&P and operative report as required (see per-code entries such as 11970, 15271, 19325–19355 series, 21083–21127, 32850–32854, 33933–33945, 47133–47143, 48550–48556, 50300–50323, etc.).
For selected procedures (e.g., discography 72291–72292, proton therapy 77520–77525), include prior diagnostic procedure reports as part of the authorization submission.

Prior Authorization

Transplant-related prior authorization/documentation

Transplant-related procedures and donor procedures require either documentation that transplant approval is on record (provide Date of Transplant) or submission of H&P, transplant evaluation materials, and the date of transplant when approval is not on record. Missing transplant approval or requisite documentation may trigger denial.

Examples: lung transplant (32850–32854), liver donor/recipient procedures (47133–47143), pancreas donor/transplant (48550–48556), kidney donor/removal (50300, 50320), hematopoietic cell transplant (38240–38242), and multiple cardiac/heart–lung transplant codes (33933–33945, 33940).
If transplant approval is on record: submit Date of Transplant. If not: submit history and physical, transplant evaluation, and planned date of transplant.

Documentation Required

Transplant documentation for liver donor procedures

For donor-specific transplant procedures (liver donor, lung donor, pancreas donor, living kidney donor), the same requirement applies: provide Date of Transplant if approval is on record; otherwise submit H&P and transplant evaluation documentation.

Examples: donor procedures include 32850 (donor pneumonectomy), 47133/47140/47141/47142/47143 (donor liver removal/prep), 48550–48552 (donor pancreatectomy/prep), and 50320 (remove kidney living donor).

Documentation Required

Transplant documentation for pancreas and kidney procedures

For pancreas and kidney transplant procedures and related donor procedures, provide Date of Transplant if approval is on record; otherwise provide H&P, transplant evaluation, and transplant date as part of the authorization or documentation package.

Examples: pancreas codes 48550–48556 and kidney donor/removal codes 50300–50323 require transplant-specific documentation as described inline.

Documentation Required

History/Plan/Medical necessity

When prior authorization is required, submit clinical history demonstrating medical necessity (history/plan, documentation of conservative measures where applicable) and any other items enumerated on the per-code entry. Missing H&P, plan of care, or operative report may result in denial.

Documentation commonly required: recent H&P, plan of care, operative report, documentation of conservative measures, diagnostic test results, and previous treatment attempts.
Lack of these items is a common reason for administrative denial or referral back to eviCore for review.

Documentation Required

Documentation Required for Selected Procedures

Specific procedures have explicit documentation requirements to justify medical necessity — for example, discography and certain advanced imaging/proton therapy codes require H&P and prior diagnostic procedure reports for prior authorization.

Examples: discography codes 72291–72292: include history and physical and results of prior diagnostic procedures; proton therapy codes 77520–77525: include H&P and prior diagnostic procedure report.
Follow the per-code instructions for the exact documentation required when submitting for prior authorization.

Denial Risk

Risk of denial without required auth/docs

For many services, the absence of prior authorization or required documentation may result in claim denial. Providers should proactively obtain prior authorization when indicated and upload or provide the required supporting records.

Risk of denial applies across service types including surgical procedures, imaging, transplant-related services, DME, J- and G-code drug injections, and home health/hospice services.
Per-code notes specify when a Medicare Advantage plan exception (for example MT Medicare Advantage) means No Prior Auth is required — ensure the patient's plan and effective dates are verified.

Documentation Required

Documentation may be required for ambulance and related transport services

Certain ambulance and transport services and related codes may require submission of H&P, physician order, and documentation of medical necessity. Lack of these documents may result in denial or referral for prior authorization.

When requesting prior authorization or supporting a claim for ambulance/transport, include H&P, physician orders, and documentation that transport was medically necessary per the per-code requirements.

Denial Risk

Documentation triggers for denial

Documentation triggers for denial: absence of recent H&P, operative report, plan of care, Letter of Medical Necessity, documentation of prior conservative measures, or transplant approval where applicable.

Providers should include anticipated length of use and supporting clinical rationale when submitting LOMNs for DME and HCPCS items (examples: E0635, E0638, E0641, E0650 series, E0764, E0770, etc.).
If required documentation is missing, the prior authorization request or claim may be denied or pended for additional information.

Documentation Required

DME documentation requirements

DME and certain HCPCS items commonly require a Letter of Medical Necessity (LOMN) and other clinical documentation describing condition, anticipated length of need, and mobility status. Absence of a LOMN may trigger denial or a request for additional information.

Examples: E0635, E0638, E0641–E0642, E0650–E0676, E0760–E0769, E0770, and other E-codes listed require LOMN or history and physical documentation as specified.
When submitting prior authorization or claims for DME, attach the LOMN detailing anticipated duration and medical rationale.

Prior Authorization

External review vendor requirement / Authorization contact

eviCore is the designated external review/prior authorization vendor for many codes. Providers must follow the eviCore referral process and submit required clinical information to eviCore when indicated in the per-code entries.

Authorization contact: eviCore Healthcare at 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs.
Per-code notes specify when eviCore prior authorization is required and when plan-specific exceptions (e.g., MT Medicare Advantage) apply.

Note

Plan-specific prior auth variance

Plan-specific prior authorization requirements vary. Certain Medicare Advantage plans and state plans have in-line exceptions indicating No Prior Authorization required — follow the per-code notes to determine applicability.

Example: multiple codes include the note 'No Prior Auth required for MT Medicare Advantage Plan effective 1/1/21' or earlier effective dates for MT or NM Medicare Advantage — verify the member's specific plan and effective dates.
If a per-code exception applies to the member's plan, the code may not require prior authorization; nonetheless, providers should still confirm coverage via eligibility and benefits.

Documentation Required

TMJ/sleep study documentation

Providers: include the documentation specified for TMJ and sleep-related facial/maxillofacial procedures when requesting authorization — chart notes, appliance details, and diagnostic sleep study results or CPAP trial results if applicable.

Examples: codes 21085, 21120–21127 and related facial/oral reconstruction codes require chart notes including type of appliance, history of recurrent TMJ, and copies of diagnostic sleep studies.
Sleep study and CPAP documentation: for upper airway procedures include sleep study results and results of a CPAP trial where specified (examples: 41530, 42145).

Documentation Required

Breast reduction documentation

When requesting coverage for breast reduction or related breast procedures, include patient height/weight, prior conservative treatment, pathology when applicable, and the operative report.

Example codes in this category include breast reconstruction and reduction series (see per-code entries such as 19325, 19328, 19330, 19340, 19342, 19350, 19355 and related codes).

Documentation Required

Documentation commonly required: history

Preserve the per-code notes: many codes explicitly require recent H&P, operative report, plan of care, documentation of conservative measures and other items. Submit these documents with the initial prior authorization request to reduce risk of denial or delay.

Documentation commonly requested across the code list: recent history & physical, pre-op evaluation, operative report, plan of care, documentation of medical necessity, prior conservative treatment notes, and diagnostic test results.
Examples: see numerous per-code entries throughout the list (selected examples provided elsewhere in this section).

Applies toDonor/transplant CPTs (examples: 47133–47147, 48550–48556, 50300–50370) as listed