List of items and services requiring Prior Authorization
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A payer-administered list enumerating durable medical equipment (DME), wheelchair components/accessories, respiratory devices, and other items that require prior authorization for coverage under Blue Cross Blue Shield - Wisconsin; affects providers submitting prior authorization requests.
No material clinical or coverage changes in this revision.
Codes and Items Requiring Prior Authorization
Prior Authorization Code List (partial)
Codes listed below require prior authorization prior to billing or provision of items/services.
Prior authorization code groups
Items and services requiring prior authorization (partial list from document part):
ONE OF
- E23xx — power wheelchair accessories (head control interfaces, attendant controls, hand controls, batteries, caster components, nonstandard seat frames).
- E26xx / cushion series — wheelchair cushions, backs, positioning and custom-fabricated cushions (E2606–E2625 and related codes).
- L19xx–L70xx — orthoses and prosthetic components (powered extremity systems, myoelectric components) listed require prior authorization.
Coverage stance (partial)
This partial extract enumerates specific HCPCS/CPT codes that require prior authorization; inclusion on the list indicates authorization is required before coverage.
Prior Authorization Requirement - Excerpt
Listed procedure codes require prior authorization as indicated in this policy excerpt.
Prior authorization requirement for listed codes
Listed procedure codes require prior authorization before services are performed.
Prior authorization requirement for listed tests
Procedure codes and test descriptions listed in these chunks require prior authorization before coverage will be approved.
Prior authorization required codes (excerpt)
Procedure codes and brief descriptions requiring prior authorization (partial list from document fragment).
Code-based prior authorization requirement
Codes listed below require prior authorization before services are provided or billed.
ANY of the following
- Selected radiologic/therapeutic procedure T- and unlisted procedure codes and device/implantation entries shown in chunk 132 require prior authorization.
Prior authorization coverage stance
Listed procedures require prior authorization.
Prior authorization requirement (list-only, no criteria provided)
Codes shown in this part require prior authorization per the payer's administrative policy list.
Prior authorization code list (partial)
Codes enumerated below require prior authorization per this part of the policy.
Prior authorization — enumerated codes (partial)
Items and services enumerated below require prior authorization.
ANY of the following
Prior authorization requirement (code list)
Codes listed in this section require prior authorization as indicated by the policy.
Prior authorization list (Part 14)
This part lists codes that require prior authorization; it does not provide clinical criteria within these chunks.
Prior Authorization Codes (excerpt)
Codes listed require prior authorization as indicated by the document segment.
Representative Procedure and Supply Codes
| 97763 | Orthotic(s)/prosthetic(s) management and/or training, subsequent encounter, each 15 minutes |
| 97760 | Orthotic(s) management and training, initial orthotic encounter, each 15 minutes |
| 97542 | Wheelchair management (assessment, fitting, training), each 15 minutes |
| 97535 | Self-care/home management training, direct one-on-one contact, each 15 minutes |
| 97140 | Manual Therapy Techniques, 1+ Regions, Each 15 Min |
| 81350 | UGT1A1 gene analysis, common variants |
| 81335 | TPMT gene analysis, common variants |
| 81291 | MTHFR gene analysis, common variants |
| 81241 | F5 (Factor V) Leiden variant analysis |
| 81232 | DPYD gene analysis, common variants |
| 81230 | CYP3A4 gene analysis, common variants |
| 81227 | CYP2C9 gene analysis, common variants |
| 81226 | CYP2D6 gene analysis, common variants |
| 81455 | Targeted genomic sequence analysis panel, 51+ genes |
| 81459 | Solid organ neoplasm genomic sequence analysis panel |
| 81408 | Molecular pathology procedure level 9 |
| 81407 | Molecular pathology procedure level 8 |
| 81405 | Molecular pathology procedure level 6 |
| 81403 | Molecular pathology procedure level 4 |
| 81400 | Molecular pathology procedure level 1 |
| 81163 | BRCA1/BRCA2 full sequence analysis |
| 0334U | Targeted genomic sequence analysis, 84+ genes |
| 0244U | Comprehensive genomic profiling, 257 genes |
| 0213U | Whole genome and mitochondrial DNA sequence analysis |
| 0560U | Oncology targeted genomic sequence analysis, 33 genes |
| 0539U | Oncology MRD genomic sequence analysis, ctDNA |
| 0530U | Oncology ctDNA NGS of 152 genes |
| 0571U | Oncology DNA (80 genes) and RNA (10 genes) by NGS, plasma |
| 0537U | Oncology cell-free DNA epigenomic patterns, >2500 DMRs |
| 0488U | Fetal antigen noninvasive prenatal test, cfDNA sequence analysis |
| 81432 | Hereditary breast cancer-related panel, must include BRCA1/2 etc. |
| 81347 | SF3B1 gene analysis, common variants |
| 63042 | Laminotomy with partial facetectomy/foraminotomy; re-exploration, single interspace; lumbar |
| 70549 | MRA, Neck; W/O Contrast, Then W/Contrast & Further Sequences |
| A7035 | Headgear used with positive airway pressure device |
| K00XX | K00xx series (dental/related hardware) included where applicable |
| K07XX | K07xx series included |
| K08XX | K08xx series included |
| L19XX | L19xx series (misc orthotic/prosthetic) included |
| L20XX | L20xx series included |
| L30XX | L30xx series included |
| L70XX | L70xx series included |
| 057?U | 057?U series genomic/procedural U-codes included (e.g., 0571U) |
| 63042 | Laminotomy repairs / spine - included |
| 63045 | Laminectomy, Facetectomy & Foraminotomy, cervical - included |
Actionable Requirements for Providers and Billing Teams
Prior Authorization Required — Power Wheelchair Accessories and Speech Devices
Prior authorization is required for the following power wheelchair accessories and speech generating devices. Submit a prior authorization request before procurement or billing to avoid claim denials.
- Power wheelchair accessories: nonstandard seat frame widths (E2340, E2341), head/ extremity control interfaces and hand control interfaces (E2328, E2322, E2323, E2330, E2331), attendant control (E2331), sip-and-puff breath tube kit (E2326), lithium-based batteries (E2397), caster wheels (E2395), dynamic positioning hardware for back (E2398), and other listed E23xx/E25xx accessories.
- Speech generating devices and software: speech generating software for PC/PDA (E2511), synthesized speech requiring spelling (E2508), digitized speech devices (E2506, E2502).
Prior Authorization Required — Wheelchair Cushions and Backs
Prior authorization is required for wheelchair cushions, backs, positioning, and custom-fabricated cushions and related replacement parts.
- Skin protection and positioning wheelchair seat cushions (E2622–E2625, E2607, E2608).
- General use and positioning wheelchair back cushions, posterior/lateral positioning backs, replacement covers (E2611, E2612, E2613, E2615, E2616, E2617, E2619).
- Custom fabricated cushions and backs (E2609, E2617) and replacement covers (E2619).
Prior Authorization Required — Wheelchair Bases and Components
Prior authorization is required for manual and power wheelchair bases, components, replacement parts, and related K-codes. Requests should include device details and justification.
- Wheelchair bases and frames (K0006, K0007, K0009, K0010, K0012).
- Footplates, footrest components, arm pads, caster and wheel assemblies, swingaway/detachable footrests (K0040–K0043, K0019, K0071, K0070, K0069, K0052, K0051, K0077).
- Power wheelchair group codes (K0733, K0801, K0802, K0806, K0838, K0841, K0842, K0848, K0851) and power mobility devices not otherwise classified (K0899).
Prior Authorization Required — Prosthetics/Orthotics and Complex Devices
Prior authorization is required for advanced prosthetic and orthotic devices, powered orthoses, complex prosthetic components, and miscellaneous DME/prosthetic codes listed. Include clinical documentation and device specifications with the request.
- Custom and molded footwear/orthoses and related replacements (L3020–L3340, L4055).
- Powered upper extremity assist devices, myoelectric and electric prosthetic components, multiaxial ankles, pylons, and complex joint components (L5920–L8999 series as listed above).
- Miscellaneous DME/prosthetic miscellaneous codes and components (E1399, K0108, E0746).
Prior Authorization Requirement (partial)
Partial extract — many additional items and services require prior authorization. This list is not exhaustive; confirm requirements for items not explicitly enumerated here before providing or billing.
- Providers must verify prior authorization requirements for any DME, prosthetic/orthotic, mobility device, implantable device, advanced imaging, interventional procedure, molecular/genomic test, wound/graft product, and select therapy codes prior to service.
- When in doubt, submit a prior authorization request including clinical rationale and supporting documentation.
Prior Authorization Required — Genomic and Molecular Tests (including reproductive, oncology, hereditary, pharmacogenomic, and specialized diagnostics)
Prior authorization is required for a broad set of molecular, genomic, oncology, hereditary, reproductive, pharmacogenomic, and specialized diagnostic tests listed below. Requests must include test name, CPT/HCPCS/LOINC as applicable, clinical indication, prior testing performed, and expected impact on management.
- Reproductive medicine/preimplantation genetic assessment and noninvasive prenatal tests (e.g., 0555U, 81546, 0553U, 0552U, 0489U, 0471U, 0532U, 0488U).
- Oncology targeted panels, whole-exome/genome, tumor tissue and cell-free (cfDNA) NGS panels, methylation assays, and expression profiling (e.g., 0444U, 0487U, 0444U, 0449U, 0444U series, 81449, 81451, 81456, 81457, 81464, 81463, 81462, 81479, 0565U, 0566U).
- Hereditary disorder panels, exome and genome sequencing, re-analysis of prior exome/genome data (81415, 81416, 81417, 81419, 81425, 81426, 81427, 0213U, 0567U).
- Single-gene and targeted gene analyses (BRCA1/2, TP53, PALB2, MSH2/MSH6/MLH1/PMS2, JAK2, EGFR, FLT3, KIT, NTRK, and many others listed as 81x/81xx/81xxx codes and U-codes).
- Pharmacogenomic and drug metabolism panels (CYP2D6, CYP2C19, CYP2C9, TPMT, DPYD, UGT1A1, VKORC1, G9143, 81225, 81355 etc.).
- High-resolution HLA typing, donor-derived cell-free DNA for transplant monitoring, and other specialized tests (e.g., 81381, 0540U, 0543U, 0493U).
- Unlisted molecular pathology procedures and any novel assays (e.g., 81479, 81401) — include full test methodology and intended clinical use.
Prior Authorization Required — Listed Procedures and Interventional/Implantable Services
Prior authorization is required for the listed procedures, implants, imaging, interventional, spine, orthopedic, cardiac, and selected surgical services. Provide clinical indication and relevant imaging/lab results with the request.
- Orthopedic and spine surgeries including arthroplasty, arthrodesis, osteotomy, laminectomy/laminotomy, corpectomy, and complex revisions (multiple codes listed).
- Cardiac catheterization and angiography procedures (93454–93461 series) and selected interventional cardiac procedures.
- Advanced imaging (CT, MRI, PET/PET-CT) and specialized imaging-guided interventions (codes 77046–77049, 71271, 71275, 72198, 70496, 75557/75559, 78811–78816, 78812, 78813, 78815).
- Neurosurgical and implantable device procedures (neurostimulators, cochlear implants — 69930, L8627/L8628, L8614).
Prior Authorization — Additional Items (therapy, home health/hospice, training)
Additional prior authorization items include selected home health/hospice service G-codes, therapy and training CPT codes, and specified miscellaneous procedure and drug codes. Submit supporting documentation showing medical necessity.
- Home health/hospice per-15-minute service codes (G0151, G0157, G0153, G0155, G0156, etc.).
- Therapy, training, and assistive technology assessment codes (97110–97140 series, 97533–97542, 97750–97763, 97537, 97535, 97761).
- Speech-language therapy, SGD-related therapeutic services, and biofeedback codes (92507, 92609, 90901–90913, E2511-related services).
Prior Authorization Required — Transport, Wound Products, and Nutrition-Related Items
Prior authorization is required for transport services (ambulance), wound/dermal matrix and amniotic membrane graft products (extensive Q-code list), and enteral/parenteral nutrition pumps and supply kits. Include product details, size/area, and clinical justification.
- Ambulance transport codes (A0426, A0428) require prior authorization for nonemergent transports as listed.
- Enteral and parenteral feeding pumps and supply kits (B4034–B4036, B9002, B9004).
- Wound matrices, grafts, collagen/nerve wraps, and amniotic membrane-derived products (extensive Q-code list: Q4111 through Q4257 and related product codes).
Prior Authorization — Imaging, Cochlear Implants, Wound Systems and Devices
Prior authorization is required for selected imaging items, cochlear implants and components, hyperbaric oxygen, and other devices. For cochlear implants include device model and component details; for imaging include indication and prior imaging if applicable.
Prior Authorization Required — Amniotic Membrane and Wound Graft Product Codes (Q-codes)
Extensive list of amniotic membrane, wound graft, and derived biologic product Q-codes require prior authorization. Provide product name, quantity (sq cm or mg/cc), wound description, prior conservative care, and expected benefit.
- Amniotic membrane and derived wound matrix products (numerous Q-codes).
- Provide square centimeters or mg/cc per application and clinical rationale for use (e.g., chronic nonhealing wound despite standard care).
- Include documentation of prior treatments (offloading, debridement, infection control, vascular assessment) when applicable.
Prior Authorization Required — Code List (partial)
This section contains a partial code list of many additional items and services that require prior authorization. Always consult the full code list when planning care or prior to submitting claims.
- When submitting a prior authorization request reference the specific code(s) and attach relevant documentation (clinical notes, imaging, test results, product specifications).
- Failure to obtain prior authorization where required may result in claim denial or member liability.
Prior Authorization Requirement (list segment)
Prior authorization requirement (list segment) — several additional procedure, supply, and drug codes across the document require prior authorization. Review the full list and include required clinical documentation with requests.
- Radiation therapy, brachytherapy, complex intracavitary applications, and specialized oncology procedures (codes such as 19296, 77763, 77432).
- Novel device/biologic add-on products (Q4403–Q4414) and advanced laboratory tests (0596U).
- Provide expected benefit, prior standard treatments, and how the procedure/test will change management.
Key Terms and Definitions
Document Updates and Effective Dates
This policy list was last updated on 2/11/2026. The document header on the listed pages shows the effective/update date for the code list and referenced procedure entries.
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