List of items and services requiring prior authorization
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A list of procedure and drug codes that require prior authorization from Blue Cross Blue Shield - Wisconsin; applicable to providers submitting claims for the listed Medicare procedure and drug codes.
No material clinical or coverage changes in this revision.
Codes That Require Prior Authorization
List-based prior authorization requirement (no criteria provided in this part)
Codes listed below require prior authorization as indicated by the payer.
Code-based prior authorization list (partial)
Codes listed in this document require prior authorization.
Listed codes requiring prior authorization (partial extract)
Codes listed below require prior authorization (partial list from document chunks 36–55):
Authorization-required codes (partial list)
Codes and descriptions listed here require prior authorization from the payer prior to service.
Prior authorization required codes (partial list)
Listed procedure codes require prior authorization as indicated by the policy list.
Codes requiring prior authorization — part 6
Codes listed below require prior authorization when billed.
Prior authorization requirement—code list
Codes and descriptions that require prior authorization (listed without individualized criteria in this window).
Prior authorization code list (partial document segment)
Codes listed below require prior authorization when billed to the plan.
Listed codes requiring prior authorization (partial)
Codes that require prior authorization (examples from this excerpt):
Prior Authorization Code List (excerpt)
Items and services listed below require prior authorization:
Enumerated prior-authorization code list
The document lists specific procedure codes and descriptions that require prior authorization.
Codes requiring prior authorization (partial list)
The following codes (HCPCS/CPT/J/temporary codes) and their described items/services are subject to prior authorization.
Prior authorization code list (partial — part 13)
Codes listed below require prior authorization.
Prior authorization required codes (partial list)
Procedure codes listed below require prior authorization.
Prior authorization requirement for listed codes
Codes listed require prior authorization before services will be approved.
Representative Codes and Examples
| 0490T | Autologous adipose-derived regenerative cell therapy for scleroderma in the hands; multiple injections |
| 23470 | Arthroplasty, Glenohumeral Joint; Hemiarthroplasty |
| 70486 | CT Scan, Maxillofacial Area; without contrast |
| 0633T | Computed tomography, breast, including 3D rendering, unilateral; without contrast |
| Q5120 | Injection, pegfilgrastim-bmez, biosimilar, 0.5 mg |
| 22633 | Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique; single interspace and segment; lumbar |
| G0277 | Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval |
| L8614 | Cochlear device, includes all internal and external components |
| Q4112 | Cymetra, injectable, 1cc |
| Q4142 | Xcm biologic tissue matrix, per square centimeter |
| E2313 | Power wheelchair accessory, harness for upgrade to expandable controller |
| E2226 | Manual wheelchair accessory, caster fork, any size, replacement only, each |
| E2364 | Power wheelchair accessory, u-1 non-sealed lead acid battery, each |
| K0020 | Fixed Adjust Armrest Pair |
| E0447 | Portable oxygen contents, liquid, 1 month's supply = 1 unit |
| K0886 | Power wheelchair, pediatric, multiple power option, sling/solid seat/back, weight capacity up to and incl. (Medicare) |
| K0884 | Power wheelchair, group 4 heavy duty, multiple power option, sling/solid seat/back, weight capacity 301-450 lb (Medicare) |
| K0880 | Power wheelchair, group 4 standard, multiple power option, sling/solid seat/back, weight capacity up to and incl. (Medicare) |
| 0744T | Insertion of bioprosthetic valve, open, femoral vein, including duplex ultrasound guidance |
| 96133 | Neuropsychological testing evaluation services, each additional hour |
| 96138 | Psychological or neuropsychological test administration and scoring by technician, first 30 minutes |
| Q9998 | Injection, ustekinumab-aekn (selarsdi), 1 mg |
| 64596 | Insertion or replacement of percutaneous electrode array, peripheral nerve, with integrated neurostimulator, including imaging guidance, when performed; initial electrode array |
| G2083 | Office or other outpatient visit for evaluation and management... provision of greater than 56 mg esketamine nasal self administration, includes 2 hours post administration observation |
| G2082 | Office or other outpatient visit for evaluation and management... provision of up to 56 mg of esketamine nasal self administration, includes 2 hours post administration observation |
What Providers Must Do
Prior Authorization Required
Prior authorization is required for the procedures, devices, supplies, drugs, biologics, wound matrices/allografts, neuropsychological testing, injectables, prosthetic/device additions, advanced cardiac/vascular device procedures and ablations, gene/molecular testing, and power/manual wheelchair items and accessories listed below. Submit prior authorization requests to Blue Cross Blue Shield - Wisconsin per standard PA processes before performing services or dispensing items.
- Includes surgical procedures, imaging, durable medical equipment (DME), prosthetics/orthotics, wheelchair bases, power wheelchair components and accessories, seating and positioning systems, wound grafts/matrices (Q-codes), injectable biologics (J-codes), cell and gene therapies (Q-/J-/CPT/HCPCS as listed), neurostimulator and cardiac device procedures, advanced ablation codes, and molecular/genomic test panels.
Procedures and Surgical Codes Requiring PA
Selected procedure and service codes throughout the document require prior authorization. Examples include (but are not limited to) surgical spine and large-joint arthroplasty procedures, interventional cardiac/vascular device insertions and replacements, advanced ablation procedures, and other high-cost or high-risk procedures.
Wheelchairs, Bases, Components, and Accessories
Prior authorization is required for wheelchair bases, power wheelchairs, manual wheelchairs, seating systems, and many accessories and replacement components listed below. This includes both complete bases/POV groups and numerous HCPCS/E and K/K0 codes for components and accessories.
- Power/manual wheelchair bases and groups: K0001–K0018 series, K00xx–K08xx group codes (eg, K0001, K0003, K0006, K0007, K0010–K0018, K0077, K0070, K0733, K0812, K0820–K0886).
- Power wheelchair components and accessories: E2310, E2321–E2377 series (drive motors, controllers, batteries, chargers, joysticks, interfaces, expandable controllers, hand/chin control interfaces).
- Manual wheelchair accessories and parts: E2201–E2228, E2211–E2222, E2213–E2222 (tires, handrims, armrests, footrests, wheel locks).
- Seating and positioning cushions and components: E2602–E2631 (skin protection, positioning, custom cushions, pressure-relief cushions).
- Replacement and specialized parts: K0072, K0077, K0040–K0076, K0801–K0886, L5827, L5950-series where applicable.
Biologics and Injectable Specialty Drugs
Biologics, injectable specialty drugs, and related high-cost infusible or implantable therapies require prior authorization. This includes many J‑codes and related HCPCS product codes listed in the policy.
- Selected injectable biologics and specialty drug J-codes requiring PA: J0175, J0217, J0218, J0222, J0223, J0491, J1301–J1307 series, J1426–J1429, J1449, J1632, J1951, J1954, J3241, J3245, J3247, J3263, J3358, J3380, J3385, J7178–J7187, J7203, J7314, J7351–J7356, J737x where listed. (See full list above for all specific J-codes.)
Neuropsychological Testing, Injectables, Prosthetic/Device Additions
Neuropsychological and psychological testing services, certain injectables administered in-office, and additions to prosthetic devices or implantable neurostimulators require prior authorization.
- Neuropsychology and psychological testing codes requiring PA: 96130, 96131, 96132, 96133, 96137, 96138, 96139, 96152, 96153, 97152, 97157.
- Injectables and device-related injection codes: J0219, J1304, J1307, J1954 and other in-document J-codes used for in-clinic injectable therapies.
- Device/prosthetic additions and evaluations requiring PA: L5991, L8614–L8628 (cochlear devices), L5827, L595x–L699x series for prosthetic additions and control modules.
Wound Grafts, Wound Matrices, Amniotic/Allograft Products
Wound grafts, biologic wound matrices, amniotic membrane products, and injectable or topical wound therapies listed by Q‑codes and other product HCPCS require prior authorization prior to use.
- Representative wound and graft HCPCS/Q-codes requiring PA: Q4101–Q4139, Q4143–Q4359, Q4360–Q4369, Q4272–Q4286, Q4311–Q4333, Q4354–Q4366, Q4320–Q4333 series (eg, Apligraf Q4101, Grafix Q4133, Alloderm Q4116, Biovance Q4283, many others listed).
- Injectable wound and biologic products requiring PA: G0465 (PRP), G0277 (hyperbaric oxygen), autologous cellular implants (eg, 0566T, 0565T), and listed J/C/Q product codes for wound-care biologics.
Cardiac/Vascular Device Procedures and Advanced Ablation
Cardiac and vascular device procedures, advanced electrophysiology and ablation codes, transcatheter valve and leadless pacemaker procedures, implantable cardiac contractility modulation systems, left atrial pressure sensors, and other advanced cardiovascular interventions require prior authorization.
- Representative cardiac/vascular procedure codes requiring PA: 33274 (leadless pacemaker insertion), 0823T–0825T (leadless pacemaker atrial chamber codes), 0571T/0918T/0919T–0926T (cardiac contractility modulation system insertion/removal/programming), 0933T (wireless left atrial pressure sensor implantation), 0545T (transcatheter tricuspid annulus reconstruction), 0645T, 0620T, 0747T (cardiac focal ablation with radiation), 75580 (noninvasive coronary FFR), and other advanced device/interventional codes listed in the policy.
Cell, Gene, and Advanced Therapeutics
Cell therapies, gene therapies, high-cost specialty biologic infusions, and related advanced therapeutics (including CAR-T and other autologous/allogeneic cell products) require prior authorization. This also includes specific high-cost injectable products and specialty implants referenced by J- and Q-codes.
Molecular and Genomic Tests
Molecular and genomic testing panels (CPT/HCPCS/PLA/U codes), comprehensive genomic profiling, targeted panels, whole genome/mitochondrial testing, and other advanced laboratory tests listed require prior authorization. This includes solid organ neoplasm panels, cfDNA panels, and various oncology and hereditary testing panels enumerated in the policy.
List Format and Definitions
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