List of items and services requiring Prior Authorization (partial — DME, mobility, devices, tests)
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This document lists specific DME, power wheelchair components, accessories, devices, drugs, and selected genetic/molecular tests that require prior authorization from Blue Cross Blue Shield - Wisconsin; it applies to providers submitting claims for those items. (Partial document: part 1 of 15.)
No material clinical or coverage changes in this revision.
Items and Services Requiring Prior Authorization
Items Requiring Prior Authorization (partial list)
Listed procedure codes and descriptions (partial list in this document part) require prior authorization.
ALL of the following
Prior authorization item list
Items requiring prior authorization include, but are not limited to, the following HCPCS/L/Codes:
ALL of the following
Prior authorization requirement (partial)
Codes listed below require prior authorization as indicated by the policy.
ALL of the following
Prior authorization requirement
Listed codes require prior authorization as indicated by the document header and code listings.
ALL of the following
Prior authorization list (genetic/molecular)
Tests and panels listed below require prior authorization:
ALL of the following
Prior authorization and panel content requirements
Listed tests require prior authorization and, where applicable, panels must include specified genes or meet minimum gene counts.
ALL of the following
- Prior authorization is required for each listed Medicare procedure code and the associated test description (see codes below).
Panel content and minimum gene count requirements
- 81413 — Cardiac ion channelopathies panel: must include sequencing of at least 10 genes (including ANK2, CASQ2, CAV3, KCNE1, KCNE2, KCNH2, KCNJ2, KCNQ1, RYR2, SCN5A)
- 81432 — Hereditary breast cancer-related disorders panel: must include sequencing of at least 10 genes (always including BRCA1, BRCA2, CDH1, MLH1, MSH2, MSH6, PALB2, PTEN, STK11, TP53)
- 81430 — Hearing loss panel: must include sequencing of at least 60 genes and copy number analyses for STRC and DFNB1 (GJB2/GJB6)
Prior authorization-required codes (excerpt)
Prior authorization required for the following Medicare procedure codes and described tests/items as listed.
ALL of the following
- All listed molecular pathology and genomic procedure codes require prior authorization per the payer.
Prior authorization required codes (excerpt)
Codes listed below are subject to prior authorization requirement.
ALL of the following
Prior authorization code list (partial)
Procedure codes listed below require prior authorization under this policy (partial list — part 9).
Prior authorization requirement list (codes only)
The document identifies services that require prior authorization; no clinical criteria or coverage rules are provided in this part — only the list of codes.
ANY of the following
- 62322 — Interlaminar epidural or subarachnoid lumbar or sacral injection; without imaging guidance
- 62323 — Interlaminar epidural or subarachnoid lumbar or sacral injection; with imaging guidance
- 63685 — Incision/placement, spinal neurostimulator pulse generator/receiver
- G0277 — Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval
Prior authorization required items (partial)
Codes and items listed below require prior authorization as part of the payer's administrative requirements (partial list).
ANY of the following
Code-based prior authorization list (partial)
Codes listed below are identified as requiring prior authorization per the payer.
Prior authorization requirement — listed codes
Listed procedure codes require prior authorization before services are provided or billed.
Prior authorization requirement — codes listed
Codes and descriptions requiring prior authorization (partial segment). Providers must obtain prior authorization for the listed services.
ALL of the following
Code-only prior authorization list
Codes requiring prior authorization (no additional criteria included in this part).
Representative HCPCS / CPT / L-Codes and Code Groups
| 97164 | Reevaluation of physical therapy established plan of care requiring components |
| 97755 | Assistive technology assessment, direct one-on-one contact, with written report, each 15 minutes |
| 97750 | Physical Performance Test, With Written Report, Each 15 Min |
| 97763 | Orthotic(s)/prosthetic(s) management and/or training, subsequent encounter, each 15 minutes |
| 62322 | Interlaminar epidural or subarachnoid lumbar or sacral injection; without imaging guidance |
| 62323 | Interlaminar epidural or subarachnoid lumbar or sacral injection; with imaging guidance |
| 63685 | Incision/placement, spinal neurostimulator pulse generator/receiver |
| G0277 | Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval |
| A7027 | Combination oral/nasal mask, used with continuous positive airway pressure |
| A7031 | Face Mask Interface, Replacement For Full Face Mask, Each |
| G0399 | Home sleep test (HST) with type III portable monitor, unattended |
| C9602 | Percutaneous transluminal coronary atherectomy with drug eluting intracoronary stent |
| 0909T | Replacement of integrated neurostimulation system, vagus nerve |
| 22810 | Arthrodesis, Anterior, Spinal Deformity; 4 To 7 Vertebral Segments |
| Q4102 | Oasis wound matrix, per square centimeter |
| 43257 | Esophagogastroduodenoscopy with delivery of thermal energy to LES/gastric cardia |
What Providers Must Do
Prior Authorization Requirement
Prior authorization is required for the listed items and services.
Prior Authorization — DME and Power Wheelchair Accessories
Providers must obtain prior authorization before supplying listed durable medical equipment, including power wheelchair accessories and other DME items.
Prior Authorization Required — Mobility, Orthotics, Prosthetics
Prior authorization is required for the listed mobility, orthotic, prosthetic, and accessory items and services in this part of the master list.
Prior Authorization Required — Orthoses/Prosthetics and Wheelchairs (partial list)
Obtain prior authorization for the codes and items listed that include orthoses, prosthetic components, power wheelchair accessories, and power wheelchairs.
Prior Authorization — Therapy, Modality, and Device Codes
Prior authorization is required for additional therapy, device, and assistive-technology codes listed in the document.
Prior Authorization — Listed Medicare Procedure Codes
The Medicare procedure codes and associated descriptions shown in this document are included on the payer's list of items and services that require prior authorization.
- The list contains multiple Medicare procedure codes across device, therapy, and laboratory categories that require prior authorization.
Prior Authorization — Genetic and Molecular Tests
Prior authorization is required for the genetic and molecular tests enumerated in this section.
- Includes single-gene tests, panels, exome/genome analyses, and molecular pathology procedure levels as listed elsewhere in the document.
Prior Authorization — Molecular Pathology and Genomic Panels
Molecular pathology procedure levels, genomic panels, and cell‑free assays listed (including high‑complexity panels) are subject to prior authorization.
Prior Authorization — Listed Genomic and Laboratory Procedure Codes
Prior authorization is required for the listed Medicare procedure codes and described genomic and specialized laboratory tests shown in this part of the list.
Prior Authorization — Procedure Codes and Items (excerpt)
Prior authorization must be obtained for the procedure codes and items enumerated in this segment of the master list (Medicare procedure codes shown).
- Example: molecular pathology procedure level 5 (81404) is included on the list.
Prior Authorization — Supplies and Drugs
Certain supplies and drugs listed require prior authorization before provision or billing.
- Examples include supplies for external tibial nerve stimulator and the donanemab injection (0500U).
Prior Authorization — Unlisted Molecular Pathology and Selected Genetic Codes
Prior authorization is required for the unlisted molecular pathology codes and specified molecular/genetic procedure codes enumerated in this section.
Prior Authorization — Additional Genetic Tests and Home Health/Hospice Services
Additional molecular pathology and genetic panels, and select home health/hospice G‑codes listed here, require prior authorization.
Prior Authorization — Injectable/Infusible Drugs and Biologics
Prior authorization is required for the listed injectable and infusible drugs, biologics, and specialty medication codes shown in the document.
Prior Authorization — Procedures, Devices, and Advanced Therapies
A broad set of procedure codes for device insertions, implants, remote monitoring, autologous cellular therapies, wound matrices, and related advanced therapies require prior authorization.
Prior Authorization — Code List (Part 9)
This continued section (part 9) lists Medicare procedure codes and descriptions that require prior authorization; providers must obtain prior authorization for these codes.
Prior Authorization — Procedures Requiring Authorization (partial list)
Obtain prior authorization for the procedural codes shown; this is a partial list and the full list continues in subsequent chunks.
Prior Authorization — Procedures and Implantable Devices
Prior authorization is required for additional procedure and implantable device codes such as neurostimulator and spinal implant procedures listed here.
Prior Authorization — Therapies and Injections
Prior authorization is required for the additional therapies, injectables, and procedural services listed in this segment.
Prior Authorization — DME, Grafts, and Implantable Devices
Durable medical equipment, grafts, implants, and device-related HCPCS/CPT codes shown in this section require prior authorization.
Prior Authorization — Additional Procedures and Services
Additional procedure and service codes listed in this part require prior authorization, including hyperbaric oxygen, sinus implant, virtual reality CBT device, and spinal procedures.
Prior Authorization Required (partial list)
Prior authorization is required for the procedure, HCPCS, and CPT codes enumerated in this portion of the master list (partial list); providers must obtain authorization before billing these services.
Prior Authorization — Code List (partial)
This section lists procedure and supply codes that require prior authorization; providers must obtain authorization for services billed under these codes.
- Examples include PAP mask and interface replacement items (A7027–A7038) and percutaneous coronary atherectomy (C9602).
Prior Authorization — Sample Procedure Codes
Providers must obtain prior authorization for the sample Medicare procedure codes shown; services billed under these codes require authorization.
Prior Authorization — Imaging, Devices, and Infusion Pumps
Additional imaging, device, and infusion pump codes listed in this document require prior authorization before services are provided.
Prior Authorization — Specific Procedure and HCPCS Codes (partial)
This section enumerates specific procedure and HCPCS codes (and descriptions) that require prior authorization; providers must secure authorization prior to providing or billing these services.
- Includes compression garments, arthrodesis codes, wound matrix Q‑codes, and polysomnography initiation codes (95783).
Prior Authorization Required — Code List (master list reference)
This document is part of a master list enumerating items and services that require prior authorization; specific codes are provided throughout and prior authorization must be obtained for those codes.
Definitions and Reference Notes
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