Items and services requiring prior authorization
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This document lists specific procedure codes and descriptions for items and services that require prior authorization from Blue Cross Blue Shield - Wisconsin. It affects providers and facilities submitting claims for the listed Medicare procedure codes.
No material clinical or coverage changes in this revision.
Items and Services Requiring Prior Authorization
Prior authorization list (partial)
Procedure codes listed in this segment require prior authorization.
ALL of the following
- Listed procedure codes: Codes and descriptions enumerated in this segment (including CPT, HCPCS, PLA/U-codes and other Medicare procedure codes) require prior authorization before services are provided.
ALL of the following
- Providers must request prior authorization for items and services that match the listed procedure codes in this segment (see full policy for submission instructions).
Prior authorization requirement list (partial)
Listed procedure codes require prior authorization; examples across oncology, rare disease, pharmacogenomics, prenatal testing, and cytogenetics are included.
ALL of the following
ALL of the following
- This excerpt contains code listings only; specific clinical criteria or documentation requirements for approval are not present here and must be obtained from the full policy.
Prior authorization list (excerpt)
Items and services listed below require prior authorization. Specific clinical criteria and submission requirements are not included in this excerpt.
ALL of the following
ALL of the following
- Clinical coverage criteria and documentation instructions are not included in this excerpt; prior authorization approval depends on the full policy's clinical rules.
Prior authorization requirement — code list
Codes and descriptions that require prior authorization (excerpt):
ALL of the following
ALL of the following
- Providers must obtain prior authorization for services billed with the above codes; consult the full policy for clinical criteria and submission requirements.
Prior authorization stance for listed codes
Codes listed below in this document segment require prior authorization.
ALL of the following
- Therapeutic injectable and oncology J-codes (examples shown elsewhere in the document) are included in the prior authorization requirement for this segment.
ALL of the following
- This excerpt provides stance that the listed molecular tests, injections, biosimilars, immune globulins, and radiation/procedure codes are subject to prior authorization; specific clinical decision rules are in the full policy.
Prior authorization code list (part 6)
Codes and descriptions requiring prior authorization (partial list from document part 6).
ALL of the following
ALL of the following
- Professional, DME, device, and programmatic codes across these chunks are included on the prior authorization list; see the full policy for clinical/submission details.
Prior Authorization Code Set (partial)
Codes and descriptions listed require prior authorization per the payer policy.
ALL of the following
ALL of the following
- This is a partial code set excerpt; providers should reference the full code listing and clinical criteria in the complete policy for authorization decisions.
Prior authorization code list (partial)
The document identifies items and services that require prior authorization; no clinical coverage criteria or decision rules are included in these chunks — only code and description listings.
ALL of the following
- Because this excerpt contains only code/descriptions, clinicians must consult the full policy for approval criteria and required documentation.
ALL of the following
- Prior authorization is required for the listed items before provision or claim submission; see payer's authorization portal for instructions.
Prior authorization required — code list (partial)
Codes listed below require prior authorization per this policy document (partial list from chunks 144–163).
ALL of the following
ALL of the following
- This is a partial excerpt; clinical criteria for coverage (such as unit measures per sq cm for biologic products) are defined elsewhere in the full policy and must be consulted when submitting authorization requests.
Prior authorization required — code list (partial)
Codes listed below require prior authorization. Specific clinical or documentation criteria for approval are not present in this excerpt and must be retrieved from other parts of the policy.
ALL of the following
- Prosthetics and orthotics: A broad set of L-codes for prosthetics and orthotics are listed as requiring prior authorization (examples appear in the fuller code listing).
ALL of the following
- Approval of these items will depend on the full policy's clinical criteria, including unit measures for biologic products and maximum cell counts for CAR-T entries; consult the complete policy for details.
Prior authorization requirement — code list (partial)
Codes listed below each require prior authorization per the payer's policy.
ALL of the following
ALL of the following
- This excerpt lists categories and representative codes only; providers should use the full policy for the applicable clinical coverage criteria and authorization submission steps.
Prior authorization requirement by code list
Codes listed in this section require prior authorization as indicated by the policy update.
ALL of the following
ALL of the following
- The policy update date appears on these chunks (Updated: 2/11/2026); providers should reference the current policy version when submitting prior authorization requests.
Prior Authorization Required Items (partial list)
Procedures and supplies in this list require prior authorization per the payer.
ALL of the following
ALL of the following
- Coverage of these procedures and supplies depends on the full clinical coverage criteria and documentation requirements set forth in the complete policy.
Prior Authorization Code List (partial)
Codes listed below require prior authorization. The list includes procedure codes (T-codes, CPT), HCPCS/J-codes, and other identifiers.
ALL of the following
- Cardiac contractility modulation systems: Cardiac contractility modulation implant and related programming/removal codes (e.g., 0916T–0949T series) require prior authorization.
ALL of the following
- This partial list demonstrates the variety of code systems included; refer to the full policy for specific coverage rules and required supporting documentation.
Prior authorization required codes (partial)
Codes and descriptions listed require prior authorization.
ALL of the following
ALL of the following
- Authorization approval depends on the full policy's clinical criteria; this excerpt includes representative procedure listings only.
Code Tables and Examples
| 0571U | Oncology (solid tumor), DNA (80 genes) and RNA (10 genes), by next-generation sequencing, plasma |
| 0565U | Oncology (hepatocellular carcinoma), NGS methylation pattern assay, cell-free DNA |
| 0388U | Oncology (non-small cell lung cancer), NGS identifying SNVs, CNVs, indels |
| 81216 | BRCA2 gene analysis; full sequence analysis |
| 81449 | Targeted genomic sequence analysis panel, solid organ neoplasm, 5-50 genes |
| 81337 | SMN1 gene analysis; known familial sequence variant(s) |
| J9035 | Bevacizumab injection |
| J9317 | Sacituzumab govitecan-hziy, 2.5 mg |
| J9301 | Obinutuzumab, 10 mg |
| Q5110 | Filgrastim-aafi (biosimilar), 1 microgram |
| Q5107 | Bevacizumab-awwb (biosimilar), 10 mg |
| J1568 | Immune globulin (Octagam), IV, 500 mg |
| J9312 | Rituximab, 10 mg |
| J9024 | Atezolizumab, 5 mg with hyaluronidase |
| Q5111 | Pegfilgrastim-cbqv (biosimilar), 0.5 mg |
| 96138 | Psychological or neuropsychological test administration and scoring by technician, first 30 minutes |
| 96139 | Each additional 30 minutes (psych test admin by technician) |
| A4438 | Adhesive clip applied to the skin to secure external electrical nerve stimulator controller |
| J3398 | Injection, voretigene neparvovec-rzyl, 1 billion vector genomes |
| J0175 | Injection, donanemab-azbt, 2 mg |
| K0830 | POWER WHEELCHAIR, GROUP 2 STANDARD, SEAT ELEVATOR... |
| K0886 | POWER WHEELCHAIR, GROUP 4 HEAVY DUTY, MULTIPLE POWER OPTION, SLING/SOLID SEAT/BACK |
| K0890 | POWER WHEELCHAIR, GROUP 5 PEDIATRIC, SINGLE POWER OPTION |
| K0891 | POWER WHEELCHAIR, GROUP 5 PEDIATRIC, MULTIPLE POWER OPTION |
| K0898 | POWER WHEELCHAIR, NOT OTHERWISE CLASSIFIED |
| K0899 | Power mobility device, not coded by DME PDAC or does not meet criteria |
What Providers Must Do
Prior Authorization Required — sample codes from list
Prior authorization is required before providing the listed procedure codes and their described services (examples include 97129, 90913, 90901, 92507, 92508, 97110, 97035, 97033, 97026, 97024, 97018, 97016, 96001). Providers must submit a prior authorization request for these codes to obtain approval before delivering services.
Prior authorization required for listed tests
Prior authorization is required for the enumerated genetic, genomic, and molecular pathology tests shown in the policy excerpt (e.g., 0318U, 0314U, 0300U, 0297U, 0278U, 0339U, 0336U, 0334U, 0329U). Submit prior authorization for these tests before ordering or performing them.
Prior authorization required
Prior authorization is required for the long list of Medicare procedure codes and associated molecular/genomic analyses, multianalyte algorithmic assays, specialized laboratory tests, and selected devices/materials enumerated in the document (e.g., 81235, 81302, 81425, 0215U, 81599, multiple U-codes). Providers must obtain authorization prior to service delivery.
Prior authorization required for listed Medicare procedure codes
Providers must request prior authorization for the specified Medicare procedure codes shown with descriptions (examples include 0469U, 0465U, 0454U). Authorization is required before performing services corresponding to these codes.
Molecular pathology and oncology panels prior authorization
Additional molecular pathology and oncology panel tests (including tissue in situ hybridization and specified U-codes and molecular pathology levels) require prior authorization; providers must submit requests for these tests prior to service.
Prior Authorization Requirement - segment
This document segment identifies multiple items and services (molecular/genetic tests, injections, implants, biosimilars, immune globulins, radiation delivery, and select procedure codes) that require prior authorization; providers must follow the payer's prior authorization process before providing these services.
- Category-level requirement: molecular/genetic tests, injectable biologics, implants, DME, and radiation/procedure codes listed in this segment.
Prior Authorization Required Items (section)
This section enumerates items and services that require prior authorization (numerous Medicare procedure codes and descriptions). Providers must obtain prior authorization for items listed in this section before service or claim submission.
- The section contains numerous code entries across clinical categories that require prior authorization; see specific codes elsewhere in the list for examples.
Prior Authorization Required Codes (partial list)
The policy lists numerous procedure and HCPCS/CPT codes and descriptions that require prior authorization. Providers must submit authorization requests for any services billed with the listed codes.
- This is a partial list; examples appear throughout the document (see molecular tests, injectable drugs, DME, implants).
Prior authorization required — code list (partial)
This portion of the document enumerates specific procedure codes and descriptions that require prior authorization; providers should check the listed codes and request authorization prior to providing the service.
Update notice
Check the update timestamp shown on many list entries (Updated: 2/11/2026) when preparing and submitting prior authorization requests; the policy's code listings reflect this update date.
- Multiple chunks in the document display "Updated : 2/11/2026"—verify the current list before submission.
Prior authorization required — listed procedure codes
Providers must obtain prior authorization for the Medicare procedure codes listed in chunks 144–145 (examples include K0849, K0859, K0884, L4055, L5910, L5926, L6880, L7009, L7191, Q4225, Q4232, Q4268, Q4273). Submit authorization requests before providing these items.
Additional prior authorization codes
Additional J-, Q-, S- and T-codes listed in the policy require prior authorization; providers must include these codes in prior authorization submissions when applicable (examples include J9245, J9326, Q4400, T2039, Q4386, Q4406, S5130, S9480, S5165).
Hemophilia and intra-articular injection codes
Hemophilia factor products and intra‑articular hyaluronan injections shown in the list (multiple J-codes such as J7195–J7212 and hyaluronan J7321–J7331 series) require prior authorization; obtain authorization before dispensing or administering.
- Hemophilia and factor examples: J7195 (factor IX), J7200–J7203 series; Hyaluronan examples: J7324–J7331 (intra-articular hyaluronan derivatives).
Prior authorization — listed Q-codes and injections
Prior authorization is required for the listed Q-codes representing biosimilars, amniotic/biologic wound products, and other injectable products (e.g., Q4366, Q4367, Q4369, Q4391, Q5099, Q5100, Q5108, Q5124, Q5126, Q5129, Q5134, Q5147–Q5155, Q9997–Q9999).
Prior authorization — power wheelchairs and complex DME
Prior authorization is required for the listed power wheelchair, power mobility, and complex DME HCPCS/K codes (many K- and K0-series codes such as K0838, K0842, K0843, K0848, K0850–K0864, K0868–K0886, K0890–K0899, K1007). Providers must submit authorization before ordering or providing these items.
Prior authorization — prosthetics, orthotics, neurostimulation, cochlear devices
A broad set of prosthetic, orthotic, neurostimulator, cochlear, myoelectric and related L‑codes require prior authorization (examples include L8680, L8687, L8692–L8693, L8701–L8702, L6925, L6935, L6945, L6955, L6965, L6975, L7045, L7180–L7190, L8686, L8045, L8619, L8623, L8627–L8628 and numerous additional L‑codes).
Prior authorization — DME/power mobility and wheelchair components
Prior authorization is required for specified DME/power mobility HCPCS/K codes and wheelchair components (examples include K0886, K0890, K0891, K0898, K0899, K1007 and orthosis/part codes such as L0112, K0045, K0052, K0056, K0065).
Prior authorization — injectable drugs and biologics
Prior authorization is required for the injectable medications and biologics listed (selected J‑codes such as J9210, J9216, J9248, J9272, J9274, J9294, J9296, J9297, J9304, J9314, J9319, J9321, J9332, J9333, J9334, J9347, J9348, etc.). Providers must secure authorization before administration or billing.
Prior authorization — professional/skilled services
Prior authorization is required for specified professional and skilled service codes (including G‑ and service codes for skilled nursing/training and partial hospitalization services such as G0493, G0494, G0495, G0496 and H0035).
- Examples: G0493–G0496 (skilled observation/training services), H0035 (partial hospitalization).
Prior authorization — communication devices and wheelchair seating
Prior authorization is required for speech‑generating devices, wheelchair cushions/positioning items, and related accessories listed (e.g., E2506, E2508, E2511, E2602, E2604, E2605–E2626). Obtain authorization before providing these devices or accessories.
Power wheelchair accessory - foam caster tire
The power wheelchair accessory "POWER WHEELCHAIR ACCESSORY, FOAM CASTER TIRE, ANY SIZE, REPLACEMENT ONLY, EACH" is listed as requiring prior authorization; obtain authorization before replacement accessory supply orders.
Power wheelchair accessories and stretch devices
Multiple power wheelchair accessories and static/dynamic stretch device codes (E2391–E2398, E1801, E1818, E1821, E1823, E1828–E1831, E1905) require prior authorization; providers must request authorization before supplying these accessories or devices.
Monitors and manual wheelchair accessories
Blood glucose monitors and numerous manual wheelchair accessory codes (E2100, E2101, E2201, E2204–E2219, etc.) are listed as requiring prior authorization; secure authorization prior to provision.
- Examples: E2100 (blood glucose monitor with voice synthesizer), E2216–E2219 (manual wheelchair foam/foam-filled tires/accessories).
Complex wheelchair and pediatric wheelchair codes
Complex wheelchair accessories, pediatric wheelchair codes, and power seating/standing system accessories (E2221, E2224–E2227, E2292–E2313, E1195, E1221–E1240, E1270–E1298) require prior authorization; obtain prior authorization before ordering these items.
DME, dialysis equipment, and wheelchair accessories
Durable medical equipment miscellaneous, dialysis equipment, and additional wheelchair accessories listed (E1399, E1500, E1540, E1550, E1560, E1570, E1580, E1590, E1600, E1610, E1620, E1632, E1635, E1701, E1702, etc.) require prior authorization prior to provision.
Seating systems, wheelchair mods, and stimulators
Power seating systems, wheelchair modifications, ambulatory devices, external stimulators, and related devices (E1002–E1034, E1060, E1083–E1093, E1160–E1180, E0743–E0764, E0770–E0830) require prior authorization; providers must request authorization before ordering or delivering these items.
Traction, monitoring, compression, and nerve stimulation devices
Traction devices, monitors, standing frames, pneumatic appliances, compression pumps, and TENS/non‑invasive nerve stimulators listed (E0840–E0959, E0610–E0638, E0720–E0735) require prior authorization; secure authorization before providing these devices or services.
Beds, oxygen, phototherapy, and hydrotherapy equipment
Hospital and pediatric beds, phototherapy units, hydrocollator units, oxygen systems, and related items (e.g., E0300, E0316, E0329, E0350, E0425, E0447, E0455, E0483, E0175–E0239 series) require prior authorization prior to provision.
Implants, neurostimulators, radiopharmaceuticals, and infusion/feeding pumps
Implantable procedures, neurostimulator generators, radiopharmaceuticals, enteral/parenteral infusion pumps and feeding supplies listed (C9796, C9807, C9808, D7996, E0113, C8003, C9047, C9145, C9360, C9727, B9002, B9006, C1734, C1736, C1764, C1820, A9543, A9580, A9590, A9607, B4034–B4036) require prior authorization before implantation, infusion or device provision.
Prior Authorization requirement — listing
This section lists the Medicare procedure codes and descriptions that require prior authorization; providers should reference the enumerated codes and request authorization prior to delivering the corresponding services.
- The listing covers a broad set of device, procedure, drug, and test codes—see the document's specific code entries for operational detail.
Transplant and VAD/heart procedures
Major transplant procedures and mechanical circulatory support (VAD/heart) procedures (e.g., codes listed such as 47145, 44720, 44132, 44136, 33982, 33927, 33945) require prior authorization; providers must obtain authorization before performing transplant or VAD/heart operations.
Prior Authorization Required Codes (partial list)
This partial list contains numerous procedure and drug codes that require prior authorization; providers should consult the full policy for complete code listings and submit prior authorization requests accordingly.
- The partial list includes T‑codes, CPT codes, HCPCS/J‑codes and other identifiers across device, drug, and procedure categories.
Prior Authorization required items (partial list)
This part of the policy lists items and services that require prior authorization (the part contains numerous Medicare procedure codes and descriptions). Providers must secure authorization for any listed item before service delivery.
Definitions and Notes
Panel Thresholds, Dose Limits, and Other Coding Notes
Document Updates
Multiple pages of the prior authorization code list were updated and display 'Updated : 2/11/2026' as the list timestamp; providers should check the update timestamp when submitting prior authorization requests.
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