List of items and services that require Prior Authorization
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A payer-maintained list of Medicare procedure and drug codes that require prior authorization for services and injectable drugs; affects providers submitting claims to Blue Cross Blue Shield - Wisconsin.
No material clinical or coverage changes in this revision.
Coverage Criteria — Prior Authorization Required
General requirement
Codes listed require prior authorization per payer listing (partial content shown).
Prior authorization required — code enumeration
Codes listed require prior authorization as indicated by the payer's policy list.
Coding — Representative Procedure and Drug Codes
| No codes listed |
| 63035 | Laminotomy (hemilaminectomy), with decompression of nerve root(s); each additional interspace |
| 63001 | Laminectomy, W/O Facetectomy/Foraminotomy/Diskectomy, 1/2 Segments; Cervical |
| 70546 | MRA, Head; W/O Contrast Matl(S), Followed By Contrast Matl(S) & Further Sequences |
| 70496 | Computed tomographic angiography, head, with contrast material(s) |
| 75574 | Computed tomographic angiography, heart, coronary arteries and bypass grafts, with contrast material |
| J2797 | Injection, rolapitant, 0.5 mg |
| E0486 | Oral device/appliance used to reduce upper airway collapsibility, custom fabricated |
| G0399 | Home sleep test (HST) with type III portable monitor |
| 22853 | Insertion of interbody biomechanical device(s) with integral anterior instrumentation |
| 22864 | Removal of total disc arthroplasty (artificial disc), anterior approach, single interspace; cervical |
| 22868 | Insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, with open decompression, lumbar; second level |
| Q2043 | Sipuleucel-t, minimum of 50 million autologous cd54+ cells activated with pap-gm-csf, per infusion |
| J9295 | Injection, necitumumab, 1 mg |
| J9153 | Injection, liposomal, daunorubicin and cytarabine |
| 95783 | Polysomnography; younger than 6 years with initiation of CPAP/BiPAP, attended |
| 22513 | Percutaneous vertebral augmentation (kyphoplasty), thoracic, 1 vertebral body |
| 70470 | CT Scan, Head/Brain; W/O Contrast, Then W/Contrast |
| 78813 | PET imaging; whole body |
| 93306 | Echocardiography, transthoracic, real-time with image documentation (2D) |
| 29883 | Arthroscopy, Knee, Surgical; W/Meniscus Repair, Medial & Lateral |
| 29871 | Arthroscopy, Knee, Surgical; Infection, Lavage & Drainage |
| 77046 | Magnetic resonance imaging, breast, without contrast material; unilateral |
| 70544 | MRA, Head; W/O Contrast Matl(S) |
| J0896 | Injection, luspatercept-aamt, 0.25 mg |
| C2624 | Implantable wireless pulmonary artery pressure sensor with delivery catheter |
| B9002 | Enteral nutrition infusion pump, any type |
| E0471 | Respiratory assist device, bi-level pressure capability, with back-up rate |
| J7402 | Mometasone furoate sinus implant (sinuva), 10 micrograms |
| 21086 | Impression & Custom Preparation; Auricular Prosthesis |
| 48554 | Transplantation, Pancreatic Allograft |
| 0413U | Optical genome mapping for copy number alterations |
| L8701 | Powered upper extremity range of motion assist device, custom fabricated |
| L8623 | Lithium ion battery for cochlear implant processor, replacement |
| Q2041 | Marstacimab-hncq injection, 0.5 mg |
| Q2054 | Lisocabtagene maraleucel, up to 110 million autologous anti-CD19 CAR-positive viable T cells |
| J9035 | Bevacizumab injection |
| J9144 | Daratumumab, 10 mg and hyaluronidase-fihj |
| J9312 | Rituximab, 10 mg |
| E0601 | Continuous positive airway pressure (CPAP) device |
| 96130 | Psychological testing evaluation services; first hour |
| 81519 | Oncology (breast), mRNA, RT-PCR of 21 genes, recurrence score |
Provider Actions — Prior Authorization & Billing Guidance
PET / PET-CT prior authorization
Prior Authorization is required for PET and PET/CT imaging procedures. PET (positron emission tomography) detects positron-emitting radionuclides from a radiopharmaceutical to show metabolic activity; CT (computed tomography) provides detailed anatomic imaging. Concurrent PET/CT corrects PET spatial-resolution limitations by fusing metabolic and anatomic data for precise localization. Use CPT/HCPCS 78811–78816 for PET imaging and 78814–78816 for concurrently acquired PET/CT as described: 78811/78812/78813 for PET limited area/skull base–mid-thigh/whole body (older PET-only descriptors), and 78814 (limited-area PET/CT), 78815 (skull base–mid-thigh PET/CT), 78816 (whole-body PET/CT). Providers must obtain prior authorization before scheduling PET or PET/CT studies.
- Prior authorization required for PET/PET-CT procedures (CPT/HCPCS 78811–78816, 78814–78816).
- PET provides metabolic imaging; CT provides anatomic localization — concurrent PET/CT fusion is often necessary for accurate interpretation.
- Report code 78814 for limited-area PET/CT (e.g., head/neck); 78815 for skull base to mid-thigh; 78816 for whole body.
Prior Authorization Required - Code List (partial)
Prior authorization is required for numerous procedure, device, durable medical equipment (DME), genetic/molecular test, and drug/biologic codes. The list below is a partial excerpt of codes that require prior authorization; providers must consult the full prior authorization list and secure approval prior to service delivery.
- Selected procedure codes include stereotactic radiosurgery and stereotactic body radiation therapy (e.g., 61796, 61798, 63620, 63621, 77371–77373).
- Selected imaging and diagnostic codes (e.g., MRI brain with contrast 70552; cardiac MRI 75559; breast MRI 77046/77047; PET/PET-CT 78811–78816).
- Selected advanced and novel procedures and therapies (e.g., percutaneous allogeneic cellular/tissue disc injection 0628T; cardiac contractility modulation system insertion 0411T–0416T).
- Selected drug and biologic J-/Q-codes (e.g., J2860 siltuximab; J1599 IVIG NOS; Q2043 sipuleucel-T; multiple biosimilars Q51xx/Q52xx).
- Selected genetic and molecular tests (e.g., 81413, 81442, 81165, 81223, 81245, and various U-codes and multigene panels).
- DME/power mobility codes and accessories (extensive K- and E-codes listed elsewhere in the full prior auth list).
Prior Authorization required — code list (part 6)
This section continues the prior authorization code list; it includes additional procedure, genetic test, and DME codes that require prior authorization. The list below is a representative sample and not exhaustive — obtain prior authorization for listed items before claim submission.
- Interventional pain injections and image-guided facet/epidural injections (64490–64495, 64492–64494).
- Therapies requiring device or implant authorization (spinal instrumentation and disc arthroplasty codes 22848, 22853, 22858, 22862, 22864, 22868).
- Selected CPT/HCPCS for advanced wound matrices, biologic grafts, and skin substitutes (Q41xx–Q44xx series, A2002, A2017).
- Selected neurostimulation and implantable systems (64590, 64590 series; 0910T/0914T where applicable).
Prior authorization required — examples
Examples of items and services that require prior authorization include (but are not limited to): high-cost biologics, CAR-T and gene therapies, specialized imaging and interventional procedures, complex spine surgeries, and custom or high-capacity power wheelchairs and accessories. Prior authorization must be obtained prior to the service to avoid denials.
- High-cost/complex biologics and cellular therapies: CAR-T and autologous cell therapies (Q2041, Q2054, Q2055, Q2057, Q5147, Q5149, J3399).
- Examples of high-cost injectables: siltuximab (J2860), certain IVIG products (J1599, J1552), enzyme replacement or specialty infusions (J0218, J2508).
- Advanced procedures and device insertions: stereotactic radiosurgery (61796, 61798), laminotomy/laminectomy and complex spine (63001, 63017, 63035, 63250–63287 range), total disc arthroplasty (22858, 22862, 22864).
- Advanced imaging and testing: PET/PET-CT (78811–78816), cardiac MRI with stress (75559), multigene and genomic panels (81413, 81439, 81442, 81449).
- DME and power mobility examples: Group 3–5 power wheelchairs and specialized components/accessories (K08xx–K10xx, E23xx–E26xx series).
Prior authorization required — selected codes and descriptions (excerpt)
Selected codes and descriptions (excerpt) requiring prior authorization — representative highlights. This is an excerpt; the full code list contains many additional codes across procedure, DME, drug, and laboratory code sets.
- J2860 — Injection, siltuximab, 10 mg.
- J1599 — Injection, immune globulin, intravenous, non-lyophilized, not otherwise specified, 500 mg.
- 61796, 61798 — Stereotactic radiosurgery, simple and complex cranial lesions.
- 78814–78816 — PET/CT imaging codes for limited area, skull base–mid-thigh, and whole body.
- Q2043 — Sipuleucel-T (per infusion) and other cellular therapies (Q20xx/Q51xx codes).
- K0851, K0859, K0864, K0880, K0886 — Power wheelchair group codes (heavy duty, very heavy duty, extra heavy duty categories).
- E2370, E2396, E2373 — Power wheelchair components and accessories (integrated drive motor, caster fork, hand/chin control interface).
- 81413, 81442, 81165 — Targeted genomic panels and BRCA/other hereditary gene full-sequence analyses.
DME and power wheelchair prior authorization items
Durable medical equipment, power wheelchair bases, group classifications, and many wheelchair accessories require prior authorization. This includes both complete power wheelchairs (group-coded K-codes) and numerous replacement parts, batteries, controls, seating and positioning components (E- and K-series), plus related custom-fabricated orthoses and seating systems. Obtain prior authorization for these items in advance to ensure coverage.
- Power wheelchair group codes (examples): K0801–K0886, K0890–K0899, K1007 — group classifications for power wheelchairs including standard, heavy duty, very heavy duty, extra heavy duty, pediatric, and not otherwise classified devices.
- Power wheelchair components and accessories: E2370 (integrated drive wheel motor), E2373 (hand/chin control interface, compact joystick), E2396 (caster fork), E2377–E2385 series (expandable controllers, actuators, pneumatic tires, inserts, tubes).
- Replacement parts and small components: K0044, K0045, K0051, K0069–K0071, K0733 — footrests, brackets, wheel assemblies, batteries and related replacement items.
- Seating and pressure management cushions/backs: E2602–E2628 series — skin protection and positioning cushions, custom-fabricated backs, and related items.
- Orthoses and spine supports: L0468, L0488, L0492, L0632, L0974 — TLSO/LSO and custom orthotic devices requiring prior authorization.
- Custom fabrication and complex systems: K1007 (powered HKAFO and complex robotic or powered orthotic systems) and L8699 (prosthetic implant NOS).
Definitions and Key Terms
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