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List of items and services requiring prior authorization
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A payer-level list enumerating procedure and HCPCS codes (Medicare descriptors) for items and services that require prior authorization for Blue Cross Blue Shield - Wisconsin members; affects providers submitting authorization requests.
Policy Summary
PayerBlue Cross Blue Shield - Wisconsin
PolicyList of items and services requiring prior authorization
Policy CodePolicy N/A
Change TypeAdministrative update (no material clinical changes)
Effective DateFeb 11, 2026
Last ReviewFeb 11, 2026
Next Review DateFeb 11, 2026
Key ActionObtain prior authorization for any listed Medicare/HCPCS/CPT code before submitting claims.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
Updated 2/11/2026document update date shown repeatedly
manyprocedure and DME codes listed
major categorywheelchair-related items
200+estimated codes in section
home healthhome health/hospice G-codes included
Codes Requiring Prior Authorization
Codes Requiring Prior Authorization
Listed below are codes for items and services that require prior authorization. This list is a partial excerpt of the full policy and includes CPT, HCPCS, and other Medicare procedure codes with brief descriptions. Codes are grouped into related clusters (therapy modalities; DME, orthotics/prosthetics, wheelchairs and accessories; home health/hospice G-codes; medications and biologics; complex procedures and devices; advanced diagnostics and molecular testing; surgical and implant procedures).
Medicare Procedure Code = 97012: Application of a modality to 1 or more areas; traction, mechanical.
Medicare Procedure Code = 90912: Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry, initial 15 minutes one-on-one.
Medicare Procedure Code = 92507: Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual.
Medicare Procedure Code = 97110: Therapeutic procedures, 1+ areas, each 15 min; therapeutic exercises.
Medicare Procedure Code = 97113: Aquatic therapy with exercises, each 15 min.
Medicare Procedure Code = 97124: Massage, each 15 min.
Medicare Procedure Code = 97035: Application of ultrasound, each 15 min.
Medicare Procedure Code = 97032: Electrical stimulation (manual), each 15 min.
Medicare Procedure Code = 97542: Wheelchair management (assessment, fitting, training), each 15 min.
Medicare Procedure Code = 97537: Community/work reintegration training, direct one-on-one, each 15 min.
Medicare Procedure Code = 97535: Self-care/home management training, direct one-on-one, each 15 min.
Medicare Procedure Code = 97530: Therapeutic activities, direct one-on-one, each 15 min.
Medicare Procedure Code = 97150: Therapeutic procedures, group (2+ individuals).
Medicare Procedure Code = E0483: High frequency chest wall oscillation system, includes accessories and supplies, each.
Medicare Procedure Code = E0447: Portable oxygen contents, liquid, 1 month's supply (prescribed amount at rest/night exceeds 4 LPM).
Medicare Procedure Code = E0604: Breast pump, hospital grade, electric.
Medicare Procedure Code = E0639: Patient lift, moveable from room to room with disassembly/reassembly.
Medicare Procedure Code = E0782: Non-programmable infusion pump.
Medicare Procedure Code = E0770: Functional electrical stimulator, transcutaneous; complete system.
Medicare Procedure Code = E0764: Functional neuromuscular stimulation, transcutaneous sequential muscle groups with computer.
Medicare Procedure Code = E0747: Electrical osteogen stimulator (not spine).
Medicare Procedure Code = E0760: Osteogen ultrasound stimulator.
Medicare Procedure Code = E0955: Wheelchair accessory, headrest, cushioned, prefabricated, each.
Medicare Procedure Code = E0953: Wheelchair accessory, lateral thigh or knee support, including fixed mounting hardware, each.
Medicare Procedure Code = E0951: Loop heel.
Medicare Procedure Code = E0856: Cervical traction device, cervical collar with inflatable air bladder.
Medicare Procedure Code = E0840: Traction device (trimmed/customized to specific patient).
Medicare Procedure Code = E2322: Power wheelchair accessory, hand control interface, multiple mechanical switches.
Medicare Procedure Code = E2321: Power wheelchair accessory, hand control interface, remote joystick.
Medicare Procedure Code = E2311: Power wheelchair accessory, electronic connection between wheelchair controller.
Medicare Procedure Code = E2301: Wheelchair accessory, power standing system, any type.
Medicare Procedure Code = E2294: Contour seat for pediatric size wheelchair.
Medicare Procedure Code = E2295: Manual wheelchair accessory for pediatric size, dynamic seating frame.
Medicare Procedure Code = E2231: Manual wheelchair accessory, solid seat support base (replaces sling seat).
Medicare Procedure Code = E2293: Contour back for pediatric size wheelchair.
Medicare Procedure Code = E2292: Planar seat for pediatric size wheelchair.
Medicare Procedure Code = E2291: Planar back for pediatric size wheelchair.
Medicare Procedure Code = E2228: Manual wheelchair accessory, wheel braking system and lock, complete, each.
Medicare Procedure Code = E2359: Power wheelchair accessory, group 34 sealed lead acid battery, each.
Medicare Procedure Code = E2361: Power wheelchair accessory, group 27 sealed lead acid battery, each.
Medicare Procedure Code = E2369: Power wheelchair component, drive wheel gear box, replacement only.
Medicare Procedure Code = E2368: Power wheelchair component, drive wheel motor, replacement only.
Medicare Procedure Code = E2364: Power wheelchair accessory, U-1 non-sealed lead acid battery, each.
Medicare Procedure Code = E2363: Power wheelchair accessory, group 24 sealed lead acid battery, each.
Medicare Procedure Code = E2371: Power wheelchair accessory, group 27 sealed lead acid battery.
Medicare Procedure Code = E2398: Wheelchair accessory, dynamic positioning hardware for back.
Medicare Procedure Code = E2397: Power wheelchair accessory, lithium-based battery, each.
Medicare Procedure Code = E2396: Power wheelchair accessory, caster fork, replacement only, each.
Medicare Procedure Code = E2391: Power wheelchair accessory, solid caster tire (removable), any size.
Medicare Procedure Code = E2392: Power wheelchair accessory, solid caster tire with integrated ...
Medicare Procedure Code = E2388: Power wheelchair accessory, foam drive wheel tire, any size, replacement only.
Medicare Procedure Code = E2390: Power wheelchair accessory, solid drive wheel tire.
Medicare Procedure Code = E2383: Power wheelchair accessory, insert for pneumatic drive wheel tire (removable).
Medicare Procedure Code = E2633: Wheelchair accessory, addition to mobile arm support, supinator.
Medicare Procedure Code = E1150: Wheelchair standard with leg rests.
Medicare Procedure Code = E1230: Power operated vehicle (scooter).
Medicare Procedure Code = E2203: Manual wheelchair accessory, nonstandard seat frame depth, replacement only.
Medicare Procedure Code = E2326: Power wheelchair accessory, breath tube kit for sip and puff interface.
Medicare Procedure Code = E2312: Power wheelchair accessory, hand or chin control interface, mini-proportional.
Medicare Procedure Code = E0957: Wheelchair accessory, medial thigh support, prefabricated, each.
Medicare Procedure Code = G0151: Services by a qualified physical therapist in home health/hospice, each 15 minutes.
Medicare Procedure Code = G0159: Qualified physical therapist services in home health for maintenance program, each 15 minutes.
Medicare Procedure Code = G0161: Qualified speech-language pathologist services in home health maintenance program, each 15 minutes.
Medicare Procedure Code = G0160: Qualified occupational therapist services in home health maintenance program, each 15 minutes.
Medicare Procedure Code = G0300: Direct skilled nursing services of a licensed practical nurse (LPN) in home health/hospice, each 15 minutes.
Medicare Procedure Code = G0496: Skilled services of an LPN in training/education of patient or family in home health/hospice, each 15 minutes.
Medicare Procedure Code = G0155: Services of clinical social worker in home health/hospice, each 15 minutes.
Medicare Procedure Code = G0495: Skilled services of an RN in training/education of patient or family in home health/hospice, each 15 minutes.
Medicare Procedure Code = G0494: Skilled services of an LPN for observation and assessment of patient's condition, each 15 minutes.
Medicare Procedure Code = G0493: Skilled services of an RN for observation and assessment of patient's condition, each 15 minutes.
Medicare Procedure Code = G0299: Direct skilled nursing services of an RN in home health/hospice, each 15 minutes.
Medicare Procedure Code = G0158: Services by a qualified occupational therapist assistant in home health/hospice, each 15 minutes.
Medicare Procedure Code = G0157: Services by a qualified physical therapist assistant in home health/hospice, each 15 minutes.
Medicare Procedure Code = G0156: Services of home health/hospice aide in home health/hospice, each 15 minutes.
Medicare Procedure Code = E0601: Continuous positive airway pressure (CPAP) device.
Medicare Procedure Code = 77371: Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course cranial lesion(s).
Medicare Procedure Code = J9022: Injection, atezolizumab, 10 mg.
Medicare Procedure Code = J9023: Injection, avelumab, 10 mg.
Medicare Procedure Code = J9203: Injection, gemtuzumab ozogamicin, 0.1 mg.
Medicare Procedure Code = Q5108: Injection, pegfilgrastim-jmdb (Fulphila), 0.5 mg.
Medicare Procedure Code = J9312: Injection, rituximab, 10 mg.
Medicare Procedure Code = Q5122: Injection, pegfilgrastim-apgf (Nyvepria), 0.5 mg.
Medicare Procedure Code = Q5118: Injection, bevacizumab-bvzr (Zirabev), 10 mg.
Medicare Procedure Code = J9207: Injection, ixabepilone, 1 mg.
Medicare Procedure Code = J9281: Mitomycin pyelocalyceal instillation, 1 mg.
Medicare Procedure Code = J9271: Injection, pembrolizumab, 1 mg.
Medicare Procedure Code = J9015: Injection, aldesleukin, per single use vial.
Medicare Procedure Code = J9032: Injection, belinostat, 10 mg.
Medicare Procedure Code = 57155: Insertion of uterine tandem and/or vaginal ovoids for clinical brachytherapy.
Medicare Procedure Code = 58346: Insertion, Heyman Capsules, clinical brachytherapy.
Medicare Procedure Code = 77338: Multi-leaf collimator device(s) for IMRT design and construction per IMRT course.
Medicare Procedure Code = 77317-77318: Brachytherapy isodose plan (simple/intermediate/complex) dosimetry codes.
Medicare Procedure Code = 22870: Insertion of interlaminar/interspinous process stabilization/distraction device, lumbar; second level.
Medicare Procedure Code = 0350T: Radiostereometric analysis (RSA) lower extremity(s).
Medicare Procedure Code = 0864T: Low-intensity extracorporeal shock wave therapy involving corpus cavernosum, low energy.
Medicare Procedure Code = 0565T: Autologous cellular implant derived from adipose tissue for treatment of knee osteoarthritis; harvesting and implant creation.
Medicare Procedure Code = 0546T: Radiofrequency spectroscopy, intraoperative margin assessment at partial mastectomy.
Medicare Procedure Code = 77261-77799 (selected): Special and complex radiation therapy related procedure codes requiring prior authorization.
Medicare Procedure Code = 19297-19298: Placement of radiotherapy afterloading brachytherapy catheters into the breast for interstitial radioelement application.
Medicare Procedure Code = 32701: Thoracic target delineation for SBRT, entire course.
Medicare Procedure Code = 67218: Destruction of localized lesion of retina by implantation radiation.
Medicare Procedure Code = J1459: Injection, triptorelin pamoate, 3.75 mg.
Medicare Procedure Code = J9295: IV immune globulin (Privigen), 500 mg.
Medicare Procedure Code = 29770-29999 (selected): Complex arthroscopy and orthopedic surgical procedures requiring authorization.
Medicare Procedure Code = K1027: Oral device/appliance used to reduce upper airway collapsibility, custom fabricated, includes fitting and adjustment (sleep apnea oral appliance).
Medicare Procedure Code = 72500-79999 (selected): High-complexity imaging, interventional, and procedural codes included across the list.
Medicare Procedure Code = 42100-79999: Additional advanced surgical, implant, and device codes listed throughout the source excerpt.
note: This section is a partial excerpt from the payer's comprehensive prior authorization code list (effective 2026-02-11). Providers should reference the full policy/code list for complete details, code modifiers, and any member- or service-specific conditions that apply.
Representative CPT / HCPCS / Q / J / L / K Code Examples
Home health / hospice therapy and nursing service codesCPT/HCPCSCovered
Medicare procedure and HCPCS/Q-codes listedmixedCovered
| 27405 | Repair, Primary, Torn Ligament &/Or Capsule, Knee; Collateral |
| 27345 | Excision, Synovial Cyst, Popliteal Space |
| Q4350 | Palisade dm matrix, per square centimeter |
| 64582 | Open implantation of hypoglossal nerve neurostimulator array, pulse generator, and distal respiratory sensor electrode or electrode array |
| 70450 | CT Scan, Head/Brain; W/O Contrast |
| 70543 | MRI, orbit, face, and/or neck; without contrast followed by contrast |
Medicare CPT/HCPCS codes requiring prior authorization (excerpt)mixedCovered
| 29877 | Arthroscopy, Knee; Debridement/Shaving, Articular Cartilage (Chondroplasty) |
| 29875 | Arthroscopy, Knee; Synovectomy, Limited |
| C1820 | Generator, neurostimulator (implantable), with rechargeable battery and charging system |
| 93454 | Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injections; imaging supervision and interpretation |
| 63012 | Laminectomy with removal, abnormal facets, lumbar |
| A0428 | Ambulance service, basic life support, nonemergency transport (BLS) |
| L8679 | Implantable neurostimulator, pulse generator, any type |
| 62263 | Lysis, percutaneous, epidural adhesions, solution injection/mechanical with radiologic localization; 2 days or more |
| 29916 | Arthroscopy, hip, surgical; with labral repair |
| A2004 | Xcellistem, per square centimeter |
1–10 of 12
1/2
Sample codes from excerptmixed
| 0201T | Percutaneous sacral augmentation (sacroplasty), bilateral injections |
| 0200T | Percutaneous sacral augmentation (sacroplasty), unilateral injection(s) |
| 0165T | Revision including replacement of total disc arthroplasty, additional interspace |
| 0416T | Relocation of skin pocket for implanted cardiac contractility modulation pulse generator |
Representative surgical and cellular therapy codesmixed
| 29819 | Arthroscopy, Shoulder, Surgical; W/Removal, Loose/Fb |
| 22210 | Osteotomy of spine, posterior or posterolateral approach, 1 vertebral segment; cervical |
| Q2055 | Idecabtagene vicleucel, up to 460 million autologous BCMA-directed CAR T cells |
| Q2053 | Brexucabtagene autoleucel, up to 200 million autologous anti-CD19 CAR T cells |
Selected codes from Part 12mixedCovered
| Q5149 | Injection, aflibercept-abzv (Enzeevu), biosimilar, 1 mg |
| J9319 | Injection, romidepsin, lyophilized, 0.1 mg |
| Q2055 | Idecabtagene vicleucel including leukapheresis and dose preparation, per therapeutic dose |
| 33274 | Transcatheter insertion or replacement of permanent leadless pacemaker, right ventricular |
| J0174 | Injection, lecanemab-irmb, 1 mg |
| J3241 | Injection, teprotumumab-trbw, 10 mg |
| 75580 | Noninvasive estimate of coronary fractional flow reserve (FFR) from coronary CTA |
| 0597U | Oncology (breast), RNA expression profiling of 329 genes by targeted NGS and 20 proteins |
Selected laboratory, procedure and skin substitute codesmixed
| 0597U | Oncology (breast), RNA expression profiling of 329 genes and 20 proteins |
| 0088U | Transplantation medicine (kidney allograft rejection), microarray gene expression profiling of 1494 genes |
| 0524T | Endovenous catheter directed chemical ablation with balloon isolation of incompetent extremity vein |
| Q4320 | PelloGraft, per sq cm (skin substitute/graft) |
per square centimeter items
Billing unitMultiple biologic/wound matrix HCPCS Q-/A- codes in the list are specified 'per square centimeter' (e.g., A2004 Xcellistem; Q4124 OASIS ultra tri-layer wound matrix).
ExamplesA2004 (Xcellistem), A2001 (Innovamatrix), Q4124 (OASIS ultra tri-layer), Q4136 (Biovance) are listed with 'per square centimeter' descriptors.
Implication for claimsWhen a product description includes 'per sq cm', units billed should reflect the product area in square centimeters as shown in the Medicare descriptor.
skin graft area thresholds
Area thresholdsSeveral skin graft/autograft and skin substitute codes specify initial area thresholds (examples: 15150 and 15155 — 'first 25 sq cm or less'; 15015 — 'first 480 sq cm or less').
Per-additional-unit codingSome application codes list 'each additional' area units (e.g., 15018 each additional 480 sq cm) indicating how to bill beyond the initial threshold.
Skin substitute per‑area examplesQ4309 (VIA Matrix per sq cm), Q4307 (American Amnion per sq cm), Q4124 (OASIS ultra tri-layer wound matrix per sq cm) are shown in the list.
What Providers Must Do / Authorization Impacts
Prior Authorization
Prior Authorization Required
Prior authorization is required for the following procedure and supply codes. Submit prior authorization requests before providing services to avoid claim denials or delays. This list is an excerpt — refer to the payer for the complete code list and any updates.
- List updated: 02/11/2026
- Examples of codes requiring prior authorization include: E0673, E0672, E2351, L5856, L5857, L5859, L5973, E0616, E0113, E0175, E0249, E0239, E0352, E0350, E0615, E0710, E0675, E0880
- Wheelchair accessories and replacement parts requiring prior authorization: E0973, E0971, E0974, E0968, E0967, E0969, E0961, E0960, E0966, E0959, E0954, E0956, E0986, E0984, E0982, E0978, E0992, E0962, E2220, E2212, E2322, E2321, E2311, E2310, E2301, E2294, E2295, E2231, E2293, E2292, E2291, E2228, E2359, E2361, E2383, E2633, E1150, E1230, E2203, E2326, E2312, E0957
- Power mobility / complex rehab / K-codes requiring prior authorization: K0019, K0015, K0018, K0012, K0014, K0011, K0047, K0044, K0043, K0042, K0041, K0040, K0065, K0056, K0052, K0051, K1007, K0899, K0898, K0880, K0878, K0877, K0048
- Durable medical equipment and orthoses requiring prior authorization: L0488, L0468, L0974, L2126, L2037, L1970, L1940, L1910, L2134, L3253, L3252, L3224, L3225, L3030, L3020, L3003, L3010, L3002, L4055, L3999, L4056
- Selected therapies, implants, procedures and high-cost drugs requiring prior authorization: E0730 (TENS), J9022, J9023, J9203, J9999, J1453, J9313, J9204, J1627, J9153, J0185, J9311, J9303, J9039, J9057, J9351, J2354, J2506, J9119, J9229, J9264, J1559, J0888, J1442, J1552, J9345, J9266, J9308
- Advanced procedures and device/implant codes requiring prior authorization: 22870, 0350T, 0864T, 0565T, 0546T, 63082, 22630, 22843, 29871, 29880, 63003, 70482, 22844, 63252, 70470, 29824, 29821, 22512, 22511, 33276, 22513, 36260, 0308T, 70470, 29874, 27405, 27345, 27334, 27333, 27332, 27486, 27447
- Home health / hospice and selected G-codes requiring prior authorization: G0151, G0159, G0161, G0160, G0300, G0158, G0157, G0156, G0153, G0152, G0496, G0155, G0495, G0494, G0493, G0299, G0398, G0399, G0300
- Advanced imaging, sleep and respiratory device codes requiring prior authorization: 72158, 72196, 72194, 63102, 72128, 70488, 70336, 72148, 77047, 93151, 93153, 70482, 72133, 72194, G0400, 0216T, 70470
- Genomic and specialized lab testing requiring prior authorization (examples): 81228, 81221, 81422, 81405, 81315, 81237, 81338, 0350U, 0452U, 0466U, 81279, 81299, 81455, 81165, 81412, 0332U, 0306U, 0326U, 0307U, 0242U, 0239U, 0179U
- This excerpt is illustrative and not exhaustive; providers must verify the full, current prior authorization code list with Blue Cross Blue Shield - Wisconsin before delivering services.
Key Terms and Billing Notes
Prior authorization code entry
Entry formatEach listed entry is shown as 'Medicare, Procedure Code = [code]' with a brief Medicare description to denote items/services requiring prior authorization.
ScopeEntries include CPT, HCPCS (E-, L-, K-, Q-, J-) and Category III/unique U/T codes as shown in the document fragments.
Update timestampThe list header and many entries are marked 'Updated : 2/11/2026', indicating the effective update date of the code list.
Manual wheelchair accessory
DefinitionManual wheelchair accessory — items described in the list such as solid caster tires, foam caster tires, foam propulsion tires (e.g., E2222, E2219, E2218).
Examples in listE2222 (solid caster tire replacement), E2219 (foam caster tire), E2218 (foam propulsion tire) are explicitly listed.
Prior authorization requirementManual wheelchair accessories shown in the list require prior authorization before coverage as indicated by their presence on the list.
Power wheelchair accessory
DefinitionPower wheelchair accessory — components and replacement parts for power wheelchairs listed (batteries, drive motor/gearbox, caster forks, dynamic positioning hardware).
Examples in listE2371 (sealed lead acid battery), E2397 (lithium-based battery), E2368 (drive wheel motor replacement), E2396 (caster fork replacement) are listed.
AuthorizationPower wheelchair accessories and components in the list require prior authorization prior to reimbursement.
Procedure code listing
ContentThe document lists Medicare procedure/CPT/HCPCS codes and brief descriptions that require prior authorization (examples across chunks include 27405, Q4350, 70450, 70543, 0117U).
Code typesIncluded code types span CPT procedure codes, HCPCS Q-/A-/E-/L-/K- codes, and unique U/T laboratory/genomic codes as shown in the excerpts.
No clinical criteria in excerptThis segment of the policy is a code list only; individual clinical criteria and documentation instructions are not included in these chunks.
Definition of Prior Authorization (short)
Short definitionPrior Authorization — the payer requirement that the specified listed procedure, HCPCS/CPT/J-/Q- codes and services must be pre‑approved before reimbursement.
FunctionEnsures items/services enumerated in the code list are reviewed and approved by the payer prior to performance and claim submission.
Evidence in sourceThe list header and multiple chunk notes repeatedly state entries 'require Prior Authorization' (see chunks 54–55, 72).
Prior authorization list (this segment)
What this segment isThis segment is a code-based portion of the payer's prior authorization list: procedure, HCPCS, J-/Q-/U-codes and brief Medicare descriptions enumerated as items that require prior authorization.
Sample categoriesIncludes injectable oncology/biologic drugs (J/Q codes), skin substitutes/grafts (Q/A codes), and specialty laboratory/genomic U-codes in this segment.
Provider action impliedProviders should obtain prior authorization for any listed code before performing the service or submitting claims, per the payer's administrative requirement.
Prior Authorization (definition)
Formal definitionPrior Authorization — the payer requirement that specified listed procedure, HCPCS/CPT/J-/Q- codes and services must be pre‑approved before reimbursement, as shown by the repeated list headings and entries.
Where statedExplicitly described in the document's list headings and in chunk-level introductory language (chunks 54–55).
Applies toAll enumerated codes in the list excerpt (DME, home health/hospice G-codes, injectable medications, procedures, imaging, genomic tests).
PET/CT
DefinitionPET/CT — PET provides metabolic imaging while CT provides detailed anatomical imaging; combined PET/CT fuses both for precise anatomical localization and improved interpretation (see Medicare descriptors for codes 78814–78816).
Reporting guidanceReport 78814 for limited-area PET/CT (e.g., head and neck), 78815 for skull base to mid‑thigh, and 78816 for whole‑body PET/CT as explained in the document.
RationaleConcurrent PET/CT corrects PET spatial resolution limitations by fusing metabolic and anatomic data for accurate localization.
per square centimeter / per cc billing
Billing units noteSome HCPCS entries include metric billing units such as 'per square centimeter' or 'per cc' (examples: Q-series wound matrices and certain skin graft products), indicating how supply products are billed by area or volume.
ExamplesQ4350 (Palisade dm matrix per sq cm), A2001 (Innovamatrix per sq cm), various entries reference 'per 0.5 cc' or 'per cc' in the list.
Claims implicationWhen present, these unit descriptors must be used to determine correct item quantity on claims (area or volume-based units rather than single-item counts).
prior_auth
Core meaning'prior_auth' in this document denotes that the listed procedure or supply code requires prior authorization from the payer before the service is covered or reimbursed.
EvidenceMultiple chunks and list headings explicitly state entries 'require Prior Authorization' or are part of the 'List of items and service that require Prior Authorization'.
Affected code typesApplies to CPT, HCPCS (E/L/K/Q/J), Category III and U-codes enumerated throughout the list segments.
area-based skin graft codes
Area‑based skin graft codesCodes such as 15150/15155 (tissue cultured skin autograft — 'first 25 sq cm or less') and 15015/15018 (skin autograft application — 'first 480 sq cm or less' and 'each additional 480 sq cm') indicate initial-area thresholds for billing.
Skin substitute per‑area examplesA2004 (Xcellistem), A2001 (Innovamatrix), Q4309 (VIA Matrix), Q4307 (American Amnion) are shown with 'per sq cm' descriptors in the list.
Billing considerationProviders must bill area-based units consistent with the 'first' and 'additional' thresholds shown in the Medicare descriptions when submitting claims.
Updated 2/11/2026 (note)
Update noteList header and multiple entries are marked 'Updated : 2/11/2026', indicating the code list was updated on that date.
Where shownThe 'Updated : 2/11/2026' timestamp appears repeatedly in headers and chunk labels throughout the document segments.
Effective trackingProviders should reference the 2/11/2026 update when confirming which codes are current on the prior authorization list.
Medicare, Procedure Code
Term meaning'Medicare, Procedure Code' is the identifier used in the list to denote the procedure or supply code (CPT/HCPCS/U/T) and is followed by a brief Medicare description.
UsageEach list entry begins with 'Medicare, Procedure Code = [code]' as the canonical entry format in this document.
Code systems includedIncludes CPT procedure codes, HCPCS Q-/A-/E-/L-/K- codes, J-codes and unique U/T laboratory/genomic codes as shown in the list excerpts.
Updated (date label)
Label meaning'Updated' alongside entries denotes the last update timestamp for the list or entry (document shows 'Updated : 2/11/2026').
Where usedThe 'Updated' date appears in chunk headers and alongside many code list segments; use this date to identify the most recent published list snapshot.
Provider actionConfirm code applicability against the 'Updated' date to ensure authorization requirements reflect the latest list version.
Prior Authorization (term repeat)
Term restatementPrior Authorization — preauthorization requirement for listed items/services; entries in this list indicate codes that must be approved prior to service.
Document usageThe term is used as the heading for the enumerated code lists and guides provider action to request approval before performing services.
Applies toAll code categories included in the list segments (DME, procedures, imaging, drugs, grafts, genomic tests).
Medicare Procedure Code (term)
Term usage'Medicare Procedure Code' entries provide the code and brief description for services/items that require prior authorization under the payer list.
ExamplesEntries include procedural codes (e.g., 27405), device/supply Q-codes (e.g., Q4350), and imaging CPT codes (e.g., 70450) as shown in the source excerpts.
Action requiredProviders should treat any 'Medicare Procedure Code' entry in this list as requiring prior authorization prior to provision and billing.
cell-free circulating DNA (cfDNA) testing and MRD assays
What cfDNA/MRD refers toCell-free circulating DNA (cfDNA) testing and MRD assays are listed (examples: 0326U, 0306U, 0307U, 0242U, 0239U) representing NGS‑based cfDNA and MRD panels that require prior authorization.
Examples in listCodes include 0326U (cfDNA 83+ genes), 0306U (MRD NGS targeted sequencing, baseline), 0239U (cfDNA 311+ genes), and 0307U (MRD subsequent assessment).
ImplicationThese genomic/cfDNA and MRD tests require prior authorization per the document; providers should submit authorization requests prior to testing.
next-generation sequencing
DefinitionNext‑generation sequencing (NGS) — genomic sequencing methods referenced by code descriptors (e.g., targeted genomic panels, NGS MRD assays) such as codes 0306U, 0326U, 0388U that require prior authorization.
ExamplesCodes referencing NGS include 0306U (MRD NGS targeted sequencing), 0326U (cfDNA NGS panel 83+ genes), 0388U (NGS for non‑small cell lung cancer), and 81455 (targeted genomic sequence panel 51+ genes).
Prior authorization noteNGS-based panels and large targeted sequence analyses included in the list must obtain prior authorization as indicated by their presence in the genomic code segments.
Policy Summary
PayerBlue Cross Blue Shield - Wisconsin
PolicyList of items and services requiring prior authorization
Policy CodePolicy N/A
Change TypeAdministrative update (no material clinical changes)
Effective DateFeb 11, 2026
Last ReviewFeb 11, 2026
Next Review DateFeb 11, 2026
Key ActionObtain prior authorization for any listed Medicare/HCPCS/CPT code before submitting claims.
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OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.