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    v1.0.28
    OpenPayerPolicy UpdatesPlastic/Reconstructive SurgeryBlue Cross Blue Shield Texas Prior Auth Code List …
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    CurrentBlue Cross Blue Shield - TexasPolicy N/A

    Prior authorization CPT/HCPCS procedure code list (Plastic/Reconstructive Surgery subset)

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    List of CPT and HCPCS procedure codes related to services/categories (including many plastic/reconstructive surgery codes) for which benefit preauthorization or medical-record documentation may be required for Blue Cross Blue Shield - Texas Medicare Advantage members.

    Policy Summary
    PayerBlue Cross Blue Shield - Texas
    PolicyPrior authorization CPT/HCPCS procedure code list (Plastic/Reconstructive Surgery subset)
    Policy CodePolicy N/A
    Change TypeAdministrative update — code list effective date
    Effective DateJul 1, 2023
    Next Review DateN/A
    Key ActionCheck member eligibility/benefits and obtain prior authorization via eviCore when indicated before rendering services.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    ~220+procedure codes listed in this partial extract
    Effective 7/1/2023prior authorization procedure code list effective date header
    Many codescommon documentation requested
    eviCorecodes externally managed

    Coverage Criteria Notes

    CPT code 33208 is listed with an Effective Date = Removed 1/1/2023, indicating this code was removed from the prior-authorization listing as of that date. The entry shows required documentation when it was listed was a recent history and physical, plan of care, and documentation of medical necessity prior to removal.

    CPT code 52648 is recorded with Effective Date = Removed 1/1/2023, indicating this prostate laser surgery code was removed from the active prior-authorization list effective that date. When listed, the entry referenced submission of a recent history and physical, plan of care, and documentation of medical necessity.

    Multiple CPT/ultrasound entries in the OB/ultrasound section are shown with Effective Date = Removed 7/1/2023 (examples include codes in the 768xx series such as 76802, 76805, 76810, 76811, 76812, 76813, 76885, 76886), indicating those prior-authorization rules or listing entries were removed effective 7/1/2023.

    Several entries explicitly note plan-specific exceptions: for example, codes such as C9757, E0471, E0748 and E0749 show the instruction "No Prior Auth required for MT Medicare Advantage Plan" with effective dates (e.g., 4/1/2018 or 1/1/21) — providers should verify plan-specific rules and contact the listed UM vendor when required.

    HCPCS code G0219 is listed as "PET imaging whole body; melanoma" and the entry notes its use in the document with the comment indicating non-covered indications may apply. The listed prior-authorization contact for this code is eviCore (phone/website) as shown in the entry.

    Policy Summary
    PayerBlue Cross Blue Shield - Texas
    PolicyPrior authorization CPT/HCPCS procedure code list (Plastic/Reconstructive Surgery subset)
    Policy CodePolicy N/A
    Change TypeAdministrative update — code list effective date
    Effective DateJul 1, 2023
    Next Review DateN/A
    Key ActionCheck member eligibility/benefits and obtain prior authorization via eviCore when indicated before rendering services.
    SourceLink
    On This Page
    Coverage Criteria NotesCPT / HCPCS / Other CodesProvider Actions, Prior Authorization & DocumentationBackground and ScopeDefinitions & Key Terms

    CPT / HCPCS / Other Codes

    Procedure codes (group 2 continued)CPT
    27096INJECT SACROILIAC JOINT
    27125PARTIAL HIP REPLACEMENT
    27130TOTAL HIP ARTHROPLASTY
    27132TOTAL HIP ARTHROPLASTY
    27134REVISE HIP JOINT REPLACEMENT
    27137REVISE HIP JOINT REPLACEMENT
    27279(code listed in source)
    27280FUSION OF SACROILIAC JOINT
    27332REMOVAL OF KNEE CARTILAGE
    27333REMOVAL OF KNEE CARTILAGE
    1–10 of 18
    1/2
    Knee & lower extremity codes (group 2 cont)CPT
    27422REVISION OF UNSTABLE KNEECAP
    27424REVISION/REMOVAL OF KNEECAP
    27425LAT RETINACULAR RELEASE OPEN
    27427RECONSTRUCTION KNEE
    27428RECONSTRUCTION KNEE
    27429RECONSTRUCTION KNEE
    27430REVISION OF THIGH MUSCLES
    27438REVISE KNEECAP WITH IMPLANT
    27440REVISION OF KNEE JOINT
    27441REVISION OF KNEE JOINT
    1–10 of 17
    1/2
    Additional orthopedic codesCPT
    27557TREAT KNEE DISLOCATION
    27558TREAT KNEE DISLOCATION
    27690REVISE LOWER LEG TENDON
    27691REVISE LOWER LEG TENDON
    27692REVISE ADDITIONAL LEG TENDON
    28446PT TALK EVAL HLTHWKR RE MDD
    28890HI ENERGY ESWT PLANTAR FASCIA
    Arthroscopy and joint proceduresCPT
    29805SHOULDER ARTHROSCOPY DX
    29806SHOULDER ARTHROSCOPY/SURGERY
    29820SHOULDER ARTHROSCOPY/SURGERY
    29821SHOULDER ARTHROSCOPY/SURGERY
    29822SHOULDER ARTHROSCOPY/SURGERY
    29823SHOULDER ARTHROSCOPY/SURGERY
    29824SHOULDER ARTHROSCOPY/SURGERY
    29825SHOULDER ARTHROSCOPY/SURGERY
    29826SHOULDER ARTHROSCOPY/SURGERY
    29827ARTHROSCOP ROTATOR CUFF REPR
    1–10 of 11
    1/2
    Knee arthroscopy continuedCPT
    29874KNEE ARTHROSCOPY/SURGERY
    29875KNEE ARTHROSCOPY/SURGERY
    29876KNEE ARTHROSCOPY/SURGERY
    29877KNEE ARTHROSCOPY/SURGERY
    29880KNEE ARTHROSCOPY/SURGERY
    29881KNEE ARTHROSCOPY/SURGERY
    29882KNEE ARTHROSCOPY/SURGERY
    29883KNEE ARTHROSCOPY/SURGERY
    29884KNEE ARTHROSCOPY/SURGERY
    29885KNEE ARTHROSCOPY/SURGERY
    1–10 of 14
    1/2
    Arthroplasty and transplant relatedCPT
    29914HIP ARTHRO W/FEMOROPLASTY
    29915HIP ARTHRO ACETABULOPLASTY
    29916HIP ARTHRO W/LABRAL REPAIR
    30120REVISION OF NOSE
    30400RECONSTRUCTION OF NOSE
    30410RECONSTRUCTION OF NOSE
    30420RECONSTRUCTION OF NOSE
    30430REVISION OF NOSE
    30435REVISION OF NOSE
    30450REVISION OF NOSE
    Selected transplant & thoracic codesCPT
    30801ABLATE INF TURBINATE SUPERF
    30802ABLATE INF TURBINATE SUBMUC
    32850DONOR PNEUMONECTOMY
    32851LUNG TRANSPLANT SINGLE
    32852LUNG TRANSPLANT WITH BYPASS
    32853LUNG TRANSPLANT DOUBLE
    32854LUNG TRANSPLANT WITH BYPASS
    32855PREPARE DONOR LUNG SINGLE
    32856PREPARE DONOR LUNG DOUBLE

    Provider Actions, Prior Authorization & Documentation

    Prior Authorization

    Prior Authorization Required

    This list includes CPT and HCPCS codes for services that may require prior authorization. Presence on the list does not guarantee coverage — always check member eligibility and benefits before providing services. Failure to obtain required prior authorization or to confirm benefits may result in claim denial or lack of coverage.

    • Prior authorization required for many listed procedure codes.
    • Always verify member benefits/eligibility prior to rendering services.
    Documentation Required

    Examples: Prior-auth & Documentation Notes

    Examples from the code list show the type of documentation or routing required alongside each code. Some entries list specific medical-records items (H&P, operative report, plan of care), others direct providers to eviCore for prior authorization or records submission.

    • Examples of documentation: Pre-operative evaluation, recent History & Physical including functional impairment, operative report, plan of care, documentation of medical necessity.
    • Examples of routing: eviCore phone 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs.
    Prior Authorization

    eviCore Prior Authorization / Contact

    Many procedure and drug codes are managed by eviCore. When eviCore is indicated, providers must contact eviCore for prior authorization requests or medical-records submission.

    • eviCore contact: 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs.
    • Use eviCore portal or phone for prior authorization routing and to submit requested records.
    Prior Authorization

    Transplant Prior Authorization & Documentation

    Transplant-related CPTs require either documentation that transplant approval is on record, or full transplant evaluation documentation. If approval is on record, submit the date of transplant; if not, submit History & Physical, transplant evaluation, and the planned date of transplant.

    • If transplant approval on record: submit Date of Transplant.
    • If no approval: submit History & Physical, transplant evaluation, and date of transplant.
    • Applies to codes such as 32852–32856, 33930–33935, 38204–38206, 44132–44137, 47146–47147 and others listed.
    Documentation Required

    Surgical / Procedural Prior Authorization & Documentation

    Major surgical and implant procedures typically require pre-operative evaluation, a recent History & Physical (including functional status when noted), plan of care, operative report, and documentation of medical necessity. For device revisions/removals include a recent H&P and plan of care.

    • Required clinical documentation: recent History & Physical, plan of care, operative report, documentation of medical necessity.
    • Revisions/removals (e.g., 22864, 22865): include recent H&P and plan of care.
    • Cardiac procedures (e.g., 33208, 33404–33415) and many vascular procedures list the same requirements.
    Prior Authorization

    eviCore Routing for Specific Spine Codes

    Certain spine and musculoskeletal procedure codes explicitly route prior authorization to eviCore for clinical review. Providers must contact eviCore for these spine-specific codes to avoid utilization delays.

    • eviCore routing required for many spine codes (examples include 20936–20938, 22510–22515, 22533–22558, 22634, 22840, 22861–22870, 22867–22869).
    • Noting plan-specific exceptions: some Medicare Advantage plans (e.g., MT) have 'No Prior Auth' notes for certain codes — verify plan rules.
    Prior Authorization

    Transplant CPT Prior-authorization / Documentation

    Transplant CPTs have a consistent approach: if transplant approval exists, provide the transplant date; if not, include the full transplant evaluation and H&P. Failure to provide required transplant documentation may result in denial.

    • Transplant CPT examples necessitating this approach: 32852–32856, 33930–33945, 38204–38206, 38230–38242, 44132–44137, 47146–47147, 44715, 48550.
    • Missing transplant approval date or evaluation documentation risks denial.
    Documentation Required

    Implant Procedure Documentation / Prior Authorization

    Implant and device procedures require device-specific documentation in addition to standard operative records. When implant/revision codes are billed, include prior use of device-related therapies and levels of impairment where applicable.

    • Examples: cochlear and temporal bone implants (69714–69718, 69930) require pre-op evaluation, operative report, prior hearing aid use, and level of hearing impairment.
    • Neuroelectrode implants (e.g., 63650, 63655, 64555, 64561, 64565) require H&P and operative report; some are routed to eviCore.
    Documentation Required

    eviCore Prior Authorization / Medical-Records Requirement

    Where eviCore is listed as the medical-records/request route, providers must submit records and prior-authorization requests through eviCore by phone or via the eviCore web portal.

    • Medical records/prior authorization submission route: eviCore 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs.
    • eviCore-managed documentation applies to many imaging, genetic, oncology, infusion, and specialty procedure codes.
    Prior Authorization

    Prior Authorization and Medical Records Routing

    Codes that indicate prior authorization and medical-records routing to eviCore must be routed accordingly. Failure to use the specified routing (phone or web) can delay reviews or cause denials.

    • Prior authorization and medical records routing: follow the routing specified with each CPT/HCPCS entry.
    • Use eviCore contact information provided on the code list for submission.
    Prior Authorization

    DME Device Prior-auth / Contact

    Some DME, respiratory, and sleep-related HCPCS codes require prior authorization or medical-records review via eviCore. For DME items, letters of medical necessity and specific clinical details are often required.

    • DME device contact: eviCore 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs.
    • Examples: A4604, A7027–A7046 series; many E-codes (E0470, E0485, E0641, E0783) require eviCore or Letter of Medical Necessity.
    • Letters should include anticipated duration of need, diagnosis, mobility status, and other clinical details.
    Prior Authorization

    eviCore Prior Authorization Required for Injections / Drugs

    Certain injection, infusion, and specialty drug administration codes require eviCore prior authorization. Providers must route these to eviCore and supply any requested clinical documentation.

    • Injection/drug codes managed by eviCore include many J-, C-, and 03XXX series entries (examples: J0881, 01300, A9513, C9062, C9076, J1561).
    • Contact eviCore for prior authorization and submit supporting clinical records as requested.
    Documentation Required

    Medical Necessity Documentation Required

    Medical necessity and clinical documentation underlie many authorization decisions. Prepare to submit a concise Letter of Medical Necessity and supporting records (H&P, progress notes, diagnostic results) when requested.

    • Letter of Medical Necessity should state diagnosis, functional status, anticipated duration of need, prior conservative treatments tried, and device specifics when applicable.
    • Commonly requested records: History & Physical, operative/procedure report, diagnostic study results, plan of care.
    Denial Risk

    Prior Authorization & Documentation Denial Risk

    Failure to obtain required prior authorization (or to contact eviCore when indicated) or failure to submit requested medical records increases the risk of utilization review delays and claim denials.

    • Prior authorization risk: rendering services without authorization may result in denial or non-covered status.
    • If eviCore is referenced for a code, not contacting eviCore may cause denial or delay.
    Documentation Required

    Medical Records Submission Required

    When medical-record submission is required, providers must include the requested documents. Omission of required records (e.g., H&P, operative report, transplant eval) can result in denial.

    • Medical records submission required examples: H&P, operative report, treatment plan, diagnostic test results, chart notes from ordering physician.
    • Missing H&P or operative report for major surgical CPTs may trigger denial.
    Note

    Prior Authorization Status Changes / Plan Exceptions

    The code list includes plan-specific notes (for example, 'No Prior Auth required for MT Medicare Advantage Plan effective 1/1/21' on certain codes). Always check plan-specific prior authorization status — some codes were removed or had status changes effective 7/1/2023.

    • Prior authorization status changes / removal notes appear on some entries (e.g., 'Removed 7/1/2023' or 'Removed 1/1/2023').
    • Verify current plan rules and effective dates before submission.
    Documentation Required

    Transport and DME Documentation

    When transportation (ambulance) or DME-related services are requested, include transport progress notes, physician orders, and any other supporting documentation requested in the code entry to justify coverage.

    • Ambulance (A0430): submit progress notes for the 24 hours prior to transport, physician order, and supporting medical records justifying the transport.
    • DME items often require Letter of Medical Necessity and functional status documentation.
    Documentation Required

    Letter of Medical Necessity & Supporting H&P Details

    Specific device or accessory requests (wheelchair accessories, speech generating devices, implantable infusion systems) commonly require a Letter of Medical Necessity and detailed H&P describing functional limitations and expected duration of need.

    • Wheelchair accessories (E2300, E2373, E2609, etc.): Letter of Medical Necessity plus H&P documenting diagnosis, functional status, and equipment justification.
    • Speech generating devices (E2504–E2510, E2599): Letter of Medical Necessity including length of need and functional status.
    Prior Authorization

    Imaging & Specialty-Service Prior-auth Channel

    Many imaging, radiation, genetic, molecular, and oncology-related codes are directed to eviCore for pre-review and records submission. Use the eviCore channel specified on each code entry for prior authorization and supporting documentation.

    • Imaging prior auth channel and records: eviCore 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs for CT, MRI, angiography, PET, and advanced imaging codes.
    • eviCore-directed documentation applies across radiology, radiation oncology, molecular pathology, and specialized testing codes.
    Documentation Required

    Required Clinical Documentation (H&P, Operative Report, Plan of Care)

    For many services the policy requires history and physical, operative report, and documentation of medical necessity — consolidate these as the core required documentation for surgical, implant, and other major procedures.

    • Required clinical documentation: recent History & Physical, operative/procedure report, plan of care, documentation of medical necessity.
    • Venous procedures often additionally require Doppler study results when specified.
    Note

    No Step-Therapy Rules Listed on This Table

    Some entries note that no step therapy algorithm is specified on the list even when eviCore is the authorization manager. When drugs or therapies are listed (e.g., C9055, C9062) no explicit step-therapy rules are included here — follow benefit plan drug policies as applicable.

    • No step therapy rules listed on this CPT/HCPCS prior-auth list; refer to pharmacy/drug policy documents for step therapy requirements.
    • Authorization-managed drugs still require eviCore routing where indicated.

    Background and Scope

    Background: This document is an administrative Medicare Advantage prior-authorization procedure code list effective 7/1/2023. It enumerates CPT and HCPCS codes and, where applicable, the specific medical-record items requested for review (for example: history & physical, plan of care, operative report). Presence of a code on this list does not guarantee coverage; providers must verify member benefits and obtain prior authorization or submit medical records through the designated vendor (eviCore) when indicated.

    Definitions & Key Terms

    Transplant approval on record — submit Date of Transplant
    Action when transplant approval existsIf transplant approval is on record, submit the Date of Transplant instead of full transplant evaluation records
    Alternate submission when no approval existsIf no prior transplant approval exists, submit history and physical, transplant evaluation, and date of transplant
    Applies toTransplant CPTs such as 32852–32856, 33930–33935, 38204–38206, 44135–44137 (and others) per code entries
    Transplant approval on record — provider submission guidance
    Provider submission requirementWhen a prior transplant authorization/approval is documented by the payer, providers should supply the Date of Transplant (do not resubmit full prior-approval)
    If no approval existsProvide history and physical, transplant evaluation, and date of transplant for review
    Referenced transplant CPTsExamples include 44135–44137 (intestinal), 32852–32856 (lung), 38204–38206 (stem cell/bone marrow) and others listed
    eviCore — utilization management vendor contact
    Vendor name & phoneeviCore — contact 1-855-252-1117 for prior authorization and medical-record requests
    Vendor websitehttps://www.evicore.com/healthplan/bcbs (use for prior auth submissions and medical records routing)
    Use caseseviCore is referenced for medical-record review and prior authorization routing for many imaging, spine, molecular and other listed CPT/HCPCS codes
    History & Physical / Operative Report — clinical records requested
    Primary documents requestedHistory & Physical (recent) and Operative Report are explicitly requested to support medical necessity for many procedures
    When requiredCommonly requested for implants, transplants, revisions, and major surgical CPTs (examples in document: 19316, 65710–65782, 64633, 69717–69930)
    Additional requested itemsMay include pre‑operative evaluation, plan of care, functional status, pathology report, photographs or device-specific information where noted
    Designated utilization management vendor — eviCore contact
    Designated vendor contacteviCore — phone 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs for medical records and prior authorization submissions
    Submission expectationMedical records and prior authorization requests for listed CPTs should be routed to eviCore per the utilization management process entries
    Applies broadly toMany imaging, molecular, genomic, transplant and procedural CPT/HCPCS entries in the list reference eviCore for requests
    eviCore — BCBS Texas designated utilization management vendor
    Role of eviCoreThird‑party utilization management vendor designated by BCBS Texas to process prior authorizations and medical-record requests for listed services
    How to reachPhone: 1-855-252-1117; Portal: https://www.evicore.com/healthplan/bcbs — use per code-specific entries
    Codes routed to eviCoreMany spine, imaging, molecular, injectable and specialty procedure codes in this list require eviCore routing (see individual code entries)