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List of items and services that require Prior Authorization
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This document lists items and services that require prior authorization for Blue Cross Blue Shield - Wisconsin members; it affects providers and billing staff submitting requests for those listed procedure codes and related services.
Policy Summary
PayerBlue Cross Blue Shield - Wisconsin
PolicyList of items and services that require Prior Authorization
Policy CodePolicy N/A
Change TypeUpdated list (no material coverage changes)
Effective DateFeb 11, 2026
Last ReviewFeb 11, 2026
Next Review DateN/A
Key ActionObtain prior authorization for any listed Medicare/CPT/HCPCS procedure, drug, device, or test before submitting claims for coverage.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
20+Listed code groups
multipleGenomic & molecular tests
2/11/2026Document update
MultipleGenetic condition references
Services and Codes Requiring Prior Authorization
Services and Codes Requiring Prior Authorization
The following tests, procedures, devices, and items require prior authorization. This consolidated list includes individual gene tests, molecular pathology procedures, genomic panels, Medicare procedure codes, durable medical equipment, drugs, injections, implants, and other services identified by the payer as subject to prior authorization.
Medicare procedure codes for molecular pathology, genomic sequencing, and related laboratory tests (examples): 0016U, 0018U, 0022U, 0031U, 0032U, 0045U, 0205U, 0209U, 0215U, 0236U, 0306U, 0332U, 0340U, 0347U, 0348U, 0349U, 0350U, 0405U, 0409U, 0410U, 0419U, 0424U, 0434U, 0440U, 0449U, 0454U, 0469U, 0481U, 0493U, 0494U, 0497U, 0498U, 0499U, 0500U, 0506U, 0523U, 0529U, 0536U, 0537U, 0543U, 0547U, 0549U, 0555U, 0561U, 0562U, 0565U, 0566U, 0567U, 0569U, 0571U
Individual gene and targeted analyses (examples require prior authorization): CYP2D6 targeted sequence analyses (0073U, 0074U, 0075U, 0072U), COMT gene analysis (0032U), red blood cell antigen (fetal RhD) PCR and cfDNA assays (0536U, 0494U), BRCA1/BRCA2 full sequence and duplication/deletion analyses (81161, 81162, 81164), CFTR full sequence and variant-specific testing (81223, 81224, 81222, 81221), TP53 full gene sequence (81351), SMN1/SMN2 full gene analysis (0236U), and other single-gene analyses listed below (selected examples shown elsewhere in this section).
Genomic panels and exome/genome testing that require prior authorization (examples): multi-gene genomic sequence panels and panels for hereditary conditions and cancer predisposition (CPT/Medicare codes 81411–81419, 81425–81427, 81435, 81439–81441, 81470–81471, 81404, 81420, 81422, 81426), exome and genome sequencing and re-evaluation (81518, 81414, 81415, 81413, 81417, 81425, 81427), mitochondrial and large-panel testing (81440, 81456), and tumor/oncology-related NGS and methylation assays (e.g., 0340U, 0349U, 0340U, 0405U, 0569U, 0537U).
Pathology and cytogenomic tests requiring prior authorization (examples): cytogenomic microarray and constitutional analyses, genome-wide arrays and copy number analysis (81229, 81277, 81278, 81220, 81228), fetal aneuploidy and cell-free fetal DNA panels (81420, 81507), and related maternal-fetal genomic tests listed above.
Tests for minimal residual disease (MRD), tumor profiling, and liquid biopsy that require prior authorization (examples): MRD NGS of cell-free DNA (0306U, 0340U, 0340U, 0561U), pan-cancer and pan-tumor methylation/epigenomic assays (0332U, 0537U, 0569U), targeted ctDNA panels and tumor NGS from plasma or FFPE (0405U, 0571U, 0543U, 0499U, 0562U, 0567U).
Durable medical equipment (DME), prosthetics, orthotics, power wheelchairs, accessories and supplies requiring prior authorization (examples): numerous E- and L- codes and K-codes listed including but not limited to E0194, E0171, E0170, E0615, E0760, E0856, E0968, E0978, E0995, E1004, E1200, E1239, E1296, E1801, E2363–E2378, E2381–E2398, E2500–E2631, L3250, L5649, L5679, L7180, K0820, K0850, K0860–K0869, K0885, K0890–K0899, L0468
Wheelchair accessories and components (examples): accessories, batteries, chargers, cushions, power seating systems, head/chin controls, drive motors, caster forks, tires, and other replacement components (E2211, E2212, E2213, E2214, E2216, E2221, E2226, E2291–E2366, E2382–E2398, E2602–E2631, E2611–E2629).
Neurostimulation and implantable devices, leads and related procedures requiring prior authorization (examples): neurostimulator implantation and related electrode array procedures, sacral nerve stimulation, peripheral neurostimulator generators and replacements (64555, 64561, 64575, 64597, 64640, 32853, 33935, 50360).
High-cost drugs, biologics, gene therapies, and injections requiring prior authorization (examples): pegylated and specialty injections and gene therapies (J0219, J0225, J1323, J2507, J2778, J2941, J2998, J3380, J3385, J3393–J3399, J7172, J7175, J7180–J7202, J7207, J7209, J7322, J9034–J9036, Q4272–Q4397, Q4280, Q4282, Q4288, Q4391, Q4395, Q4397).
Surgical and complex procedural codes requiring prior authorization (examples): selected major surgical, transplant, spine, cranial, and complex orthopaedic procedures (41019, 50360, 55860, 55862, 55874, 55875, 57156, 61796–61799, 61800, 61889, 63302, 63306, 63655, 63053, 63200-range entries listed in source), and other high-resource procedures listed in this section.
Therapeutic and rehabilitative devices and services requiring prior authorization (examples): transcutaneous electrical nerve stimulation devices and supplies, tibial nerve stimulators, gait modulation systems, oxygen equipment and accessories, apnea monitors, breast pumps, hydrocollator units, and related codes (L1685, 0469U, 0498U, E0619, E0604, E0618, E0329, E0239, E0225, E0175, E0350, E0352).
All other codes and items explicitly listed in the payer's prior authorization list: this section includes many additional CPT/HCPCS/Medicare codes and unlisted procedure codes (e.g., 84999, 17999, 55899, J3590, 97139, 0930T, 0931T, 0910T, 0815T, 0620T, 0589U and other entries shown in the consolidated list above) — providers must obtain prior authorization prior to providing services associated with codes appearing in this policy.
Representative Codes and Code Groups
Oncology target panel examplesCPTCovered
Sample genetic/molecular procedure codes from listmixedCovered
| 81260 | Analysis of 3 gene variants related to age-related macular degeneration |
| 81290 | IKBKAP gene analysis (familial dysautonomia) common variants |
| 81351 | MCOLN1 gene analysis common variants |
| 81330 | TP53 full gene sequence |
| 81162 | BRCA1/BRCA2 full sequence and duplication/deletion analysis |
| 0236U | BRCA1/BRCA2 full sequence and duplication/deletion analysis (alternate listing) |
Sample listed Medicare procedure codes requiring prior authorization (part 6)mixedCovered
| E0995 | Wheelchair accessory, calf rest/pad, replacement only, each |
| E1004 | Wheelchair accessory, power seating system, recline only, with mechanical shear |
| L5969 | Addition to lower extremity prosthesis, endoskeletal knee shin system, microprocessor control feature, stance phase only |
| E0619 | Apnea Monitor, With Recording Feature |
DME / Mobility / O&P code groupsHCPCS | mixedCovered
| K08xx, K07xx, K08xx series | Power wheelchair groups and power mobility device codes (groups 1-5, multiple capacities and configurations) |
| E26xx - E27xx series | Wheelchair cushions, positioning, and related wheelchair accessories |
| L2xxx - L8xxx series | Orthotics and prosthetic device codes, custom fabricated components and additions |
| A4341-A4342 | Indwelling intraurethral drainage device and accessories |
Power wheelchair groups and heavy-duty equipmentHCPCSCovered
| K0827 | Power wheelchair, group 2 very heavy duty, captains chair, patient weight capacity 451 to 600 pounds |
| K0815 | Power wheelchair, group 1 standard, sling/solid seat and back, patient weight capacity up to and including 300 pounds |
| K0848 | Power wheelchair, group 3 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds |
| K0852 | Power wheelchair, group 3 very heavy duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds |
| K0837 | Power wheelchair, group 2 heavy duty, single power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds |
Representative codes in this sectionmixedCovered
| J9305 | Injection, pemetrexed |
| Q4375 | Duograft ac, per square centimeter |
| 96113 | Developmental test administration, each additional 30 minutes |
| 96130 | Psychological testing evaluation services, first hour |
| 77470 | Special radiation treatment procedure (e.g., total body irradiation) |
| 77371 | Radiation treatment delivery, stereotactic radiosurgery (SRS) |
Selected Medicare/CPT codes requiring prior authorizationCPT | HCPCS | mixedCovered
Selected diagnostic and device implantation codesCPT | mixedCovered
Gene panel size examples
Range of panel sizesVaries widely — examples in the list include targeted panels as small as 16 genes and panels up to 152+ genes; some assays profile >2,500 differentially methylated regions (DMRs) or are whole-genome level tests
Large methylation assaysMethylation-based oncology assays described include tests analyzing >2,500 DMRs and assays detecting 6,626 epigenetic alterations
Whole-genome/whole-genome‑level testsDocument lists whole‑genome or genome-scale assays (eg, whole‑genome sequence analysis, optical genome mapping) described as larger than typical panels
Hybrid DNA/RNA panelsSome plasma-based oncology panels combine DNA and RNA targets (examples show DNA 80 genes + RNA 36 genes and similar hybrid panels)
Minimum gene count for panels
Cardiac ion channel panel minimumMust include sequencing of at least 10 genes (eg, ANK2, CASQ2, CAV3, KCNE1, KCNE2, KCNH2, KCNJ2, KCNQ1, RYR2, SCN5A)
Hereditary retinal / severe inherited conditionsSome disorder panels require ≥15 genes (eg, 81443 indicates panels must include sequencing of at least 15 genes for severe inherited conditions)
Hereditary cardiomyopathy panelMust include sequencing of at least 5 cardiomyopathy-related genes (eg, DSG2, MYBPC3, MYH7, PKP2, TTN)
Noonan / related spectrum (example range)Document shows panels with specified minimum counts across disorders (examples include panels requiring ≥9–10 genes for certain syndromes)
What Providers and Billing Staff Must Do
Prior Authorization
Prior Authorization — listed procedure codes and descriptions
Prior Authorization Required. The following items, tests, genetic/genomic panels, durable medical equipment (DME), wheelchairs and wheelchair components, prosthetics/grafts, therapeutics (injectable medications and biologics), imaging/interventional/spine procedures, therapy and modality services, and other high-cost services require prior authorization from Blue Cross Blue Shield - Wisconsin. Providers must obtain authorization before rendering these services to avoid claim denials or delays. The list below consolidates representative CPT/HCPCS/Medicare procedure and drug codes and descriptions that require prior authorization. This list was updated 2/11/2026.
- Prior authorization required tests (selected): Examples include specialized genetic and genomic tests and expression assays such as 0536U (Red blood cell antigen fetal RhD PCR), 0032U (Unlisted Chemistry Proc), 0031U–0075U series (COMT, CYP1A2, CYP2D6 targeted analyses), 81161 (DMD deletion/duplication), 81223–81224 (BRCA1/BRCA2 duplication/deletion analyses), 81221–81228 (CFTR analyses), 81407, 81408, 81418 (molecular pathology and pharmacogenomic panels), 81525/81529/81507/81522/81523 (mRNA/gene expression profiling assays), 81595/81554/81546/81599 (various expression and multianalyte assays), 0469U/0454U/0449U/0440U (whole genome/optical mapping/carrier screening panels), and many additional U- and T-codes listed in the master table below.
- Genetic and genomic tests (sample): Genomic sequence analysis panels and molecular pathology procedures require prior authorization. Representative codes: 81418 (drug metabolism genomic panel, >=6 genes), 81459/81457/81455/81463/81479/81441/81420/81422/81404 (molecular pathology levels and targeted panels), 0111U/0420U/0425U/0497U/0538U/0523U/0500U/0494U/0506U and numerous gene‑specific CPT/HCPCS codes (e.g., 81121, 81166–81167, 81161–81162, 81220–81228, 81316–81325, 81330–81334, 81351). Authorization is required for panels interrogating sequence variants, copy number variants, rearrangements, and cell-free DNA analyses.
- Pharmacogenetic tests and expression assays: Prior authorization required for pharmacogenomic and pharmacogenetic testing including code G9143 (warfarin responsiveness by genetic technique), 81418 (pharmacogenomics panels), 81542/81525/81529 and other mRNA/expression assays (e.g., 81522, 81523, 81554, 81595). Unlisted molecular pathology (81479) and unlisted multianalyte assays with algorithmic analysis (81599) also require authorization.
- Therapeutics and biologics (selected J-/Q-/C- codes): Many high-cost injectables and biologics require prior authorization. Representative codes include J0218, J0174, J1301, J1304, J1305, J1302, J1303, J1448, J1551, J1554, J1555, J1561, J1566, J1568, J1575, J1951, J2506, J2507, J2797, J2860, J2998, J3380, J3385, J3388, J3389, J7199, J7200–J7209, J7211–J7212, J7312–J7314, J7321–J7328, J9334, J9353–J9356, J9380, J9395, Q5101, Q5111–Q5117, Q5124–Q5129, Q5135–Q5146, Q5155 and many additional J- and Q-codes listed in the master list. Includes biosimilars and injection formulations.
- Durable Medical Equipment (DME), wheelchairs, wheelchair components and accessories: Prior authorization required for many E-, K-, L-, and A-codes for wheelchairs, power wheelchair accessories, cushions, custom fabrication and replacement components. Representative codes include E0601 (CPAP device), E0239, E0175, E0350–E0352, E0615, E0710, E0720, E0734, E0736, E0738, E0739, E0734, E0738, E0953–E1004, E1160, E1221–E1239, E1296, E1827, E2322, E2351, E2360–E2370, E2384–E2389, E2611–E2629, E2630–E2631, K0017, K0018, K0051–K0072, K0739, K0808–K0814, L0468, L5991, L7009, L8045 and others. Custom cushions, power seating components, wheelchair drives, batteries, chargers, and specialized prosthetic/orthotic features require prior authorization.
- Prosthetics, grafts, membranes, and skin substitutes: Prior authorization required for numerous Q-codes and graft/product codes. Representative codes: Q4311–Q4335, Q4330–Q4431, Q4272–Q4282, Q4299, Q4303, Q4314–Q4319, Q4322–Q4329, Q4331–Q4333, Q4341, Q4352, Q4362, Q4375–Q4416, Q4431, C1889 and associated product codes (per square centimeter graft/allograft products).
- Imaging, interventional, and spine procedures (selected): Prior authorization required for many advanced imaging, interventional, and spine procedures including CT heart with contrast (75573/75573 series), CT/MRI spine and musculoskeletal imaging (70486, 70553–70554, 72133, 72193), MR spectroscopy (76390), cardiac/vascular interventional codes (93457, 93922, 93931, 93979), neurostimulator implantation and revisions (61889, 64561, 64597, 64596, 64590, 64575, 64555), spinal decompression/laminotomy/laminectomy and complex spine codes (63051, 63053, 22802, 22861, 22865, 22224, 22861), percutaneous disc procedures (62287, 62280, 62287), and a broad set of image‑guided, catheter‑based and device implantation codes (C1735, C1736, C9145, C9762, C9808).
- Interventional spinal procedures requiring prior auth (examples): Code 252 chunk examples include laminotomy/laminectomy (interlaminar approach) for decompression of neural elements under indirect image guidance (single or multiple levels) — representative CPT range includes 63051, 63053, 22802, 22224 and related codes for decompression, fusion, and implant procedures. These procedures require prior authorization prior to scheduling.
- Therapy and modality services: Prior authorization required for certain therapy, modality, and rehabilitation services including CPT codes for adaptive behavior treatment (97153, 97156, 97157), occupational/physical therapy and specialized modalities (97110, 97112, 97113, 97116, 97124, 97129, 97130, 97140, 97530, 97535, 97533, 97542, 97750–97763, 97032–97039, 97022–97028, 97150, 97164, 97168), group and intensive outpatient bundles (G0137, 90867, 90869), and selected testing/evaluation services (96130, 96137, 96113).
- Sample prior authorization procedure lines and Medicare procedure codes (selected excerpts): Examples from the full list include 0536U, 81161, 81223, 81407, 81418, 81525, 81529, 0425U, 0497U, 0538U, 0494U, 81479, G9143, 01558U/0469U/0454U/0449U series, many 0xxU and T-codes, J-codes (J9034, J9035, J9042–J9047, J9055–J9060 series), Q-codes (Q5111–Q5117, Q5124–Q5136, Q4154–Q4362), E-codes for DME (E0601, E2360–E2629, E0953–E0995), L- and K-codes for prosthetics and wheelchair parts, and numerous procedure codes for imaging and surgery (63051, 63053, 62133, 72133, 75573, 93700 series).
- Prior authorization list (partial, part 12) and continued codes: The policy includes an extensive master list (multiple parts) of procedure and product codes requiring prior authorization — providers must consult the payer authorization portal or contact customer service for the complete, current list and to submit prior authorization requests.
- Provider action: Obtain prior authorization before scheduling or furnishing any listed service. When submitting authorization requests, include clinical documentation that supports medical necessity (indications, prior treatments, test results, relevant genetic/family history for genetic testing, and device/prosthetic measurements when applicable).
- Operational note: Preservation of prior authorization requirements and codes — this consolidated summary highlights representative codes and categories. The full authoritative and detailed code list (including all U-, T-, Q-, J-, E-, L-, K-, A-, C-, and CPT codes referenced) was updated on 2/11/2026 and must be used for authorization determinations. Contact BCBS‑WI provider services or use the electronic prior authorization tool for submission and verification.
Terms and Definitions Used in This List
Medicare, Procedure Code — Entry format definition
Entry format definitionEntries present line-by-line as 'Medicare, Procedure Code = [code]. Medicare, Description = [description]' to identify listed tests/services
Purpose of code fieldProvides the billing/identification code (CPT/HCPCS/Medicare procedure code) associated with each listed item
Accompanying descriptionEach code line includes a brief narrative description (test method, specimen, gene/marker counts, or clinical indication)
Cell-free DNA (cfDNA) / circulating tumor DNA (ctDNA)
DefinitionNoninvasive blood-based DNA tests (cfDNA/ctDNA) — assays that analyze cell-free DNA from plasma/whole blood for tumor profiling or minimal residual disease (MRD)
Examples in listIncludes next-generation targeted sequencing of cfDNA for patient-specific panels and plasma DNA assays reporting SNVs, indels, copy number alterations and fusions (eg, 0349U, 0562U, 0571U)
Use casesUsed for baseline tumor profiling, subsequent MRD assessments, and methylation‑based cancer detection in plasma specimens
IBMFS — Inherited bone marrow failure syndromes examples
IBMFS examplesInherited bone marrow failure syndromes noted include Fanconi anemia, dyskeratosis congenita, Diamond-Blackfan anemia, Shwachman-Diamond syndrome, and GATA2 deficiency syndrome
ContextListed under genomic sequence analysis panels (Medicare, Procedure Code = 81441) as an indication for multi-gene panels
Associated service typeGenomic sequencing panels for inherited marrow failure are included on the prior authorization list
Genome — sequence analysis for unexplained constitutional or heritable disorder or syndrome
DefinitionGenome — sequence analysis refers to whole‑genome or comparator genome sequencing for unexplained constitutional or heritable disorders or syndromes (eg, rapid genome sequence analysis, exome/genome sequencing entries)
Examples citedIncludes rapid sequence analysis with comparator genomes (0425U/0420U) and whole‑genome sequence analysis combining short and long reads (0567U)
Re-evaluation noteExome/genome re-evaluation (re-analysis) of previously obtained sequence is specifically listed (chunk 38/60) and requires prior authorization
Re-evaluation of exome/genome
Re-analysis/re-evaluation definedRe-evaluation of exome/genome — re-analysis of previously obtained exome or genome sequence for updated knowledge or unrelated conditions is listed and requires prior authorization
Referenced entryDocument explicitly lists re-evaluation of prior exome sequence as a listed item (chunk 38) and includes genome comparator sequencing entries (chunk 60)
PurposeCaptures updated variant interpretation or new findings from previously generated sequence data
Genomic sequence analysis panel
DefinitionGenomic sequence analysis panel — a panel that includes sequencing of a specified minimum number of genes for a named disorder or indication (eg, cardiac ion channel panel ≥10 genes; hereditary retinal panels ≥15 genes)
Examples of panel sizingExamples include targeted panels of 5–51+ genes and high‑complexity oncology panels (eg, 81455 for ≥51 genes; 81459/81457 for solid organ neoplasms)
Included analysesPanels may include DNA and RNA analysis, copy number and structural variant interrogation, and microsatellite instability where indicated
Molecular pathology procedure levels
Level codes referencedMolecular pathology procedure levels referenced in the list include level indicators such as MOLECULAR PATHOLOGY PROCEDURE LEVEL 2, 5, and higher (codes like 81401, 81404 are shown)
ExamplesDocument lists specific molecular pathology level codes (eg, 81401 = level 2; 81404 = level 5) and higher-level entries in the molecular pathology series
ContextUsed to classify molecular pathology service complexity within the prior authorization list
Cytogenomic constitutional microarray analysis
DefinitionCytogenomic constitutional microarray analysis — genome‑wide microarray interrogation for copy number and SNP variants to detect chromosomal abnormalities (listed as 81229, 0209U, etc.)
Examples/codesEntries include cytogenomic microarray analysis codes (eg, 81229, 0209U) and related genome‑wide analysis descriptors
Use caseUsed for constitutional/heritable disorder evaluation and preimplantation or prenatal chromosome-level analysis
Medicare, Procedure Code — billing/HCPCS/CPT-like code used in the list
DefinitionMedicare, Procedure Code — billing/HCPCS/CPT-like code used in the list to identify specific tests, procedures, drugs, or devices that require prior authorization
Purpose in documentEach line begins with 'Medicare, Procedure Code =' followed by a code and paired description to indicate the item requiring prior authorization
Code systems representedIncludes CPT, HCPCS, Medicare/HCPCS L-/E-/K-/J-/Q-type codes and miscellaneous unlisted codes
List of items and service that require Prior Authorization
DefinitionList items requiring prior authorization — the document enumerates specific procedure and product lines that must obtain prior authorization before service/claim processing
Typical contentsIncludes individual gene tests, genomic panels, molecular pathology procedures, mRNA/expression assays, device accessories, injections, and DME items
Action for providersProviders must secure prior authorization for services and codes enumerated in the list prior to providing the service
Power Wheelchair Groups
Power wheelchair groupsPower wheelchair group codes (groups 1–5) and specific K-codes for varying weight capacities and configurations are listed (eg, K0813, K0848, K0837)
Accessories and componentsAssociated wheelchair accessories and replacement components (K0072, K0070, K0069, etc.) require prior authorization as listed
Related code seriesDocument lists K‑series codes alongside E‑series power mobility accessories and L‑codes for orthotics/prosthetics in the mobility section
L-codes (O&P)
L-code meaningL-codes denote orthotic and prosthetic items, including custom-fabricated components and additions (examples shown: L5673, L5671, L5987)
Examples listedThe document lists multiple L-code entries for additions, test sockets, and myoelectric components (eg, L5673, L5987, L6965)
Context in prior auth listOrthotic and prosthetic supply codes and custom additions require prior authorization when listed
prior authorization
DefinitionPrior authorization — payer requirement that certain procedures, services, devices, or drugs obtain approval before provision to be eligible for coverage
Document evidenceThe list repeatedly labels entries 'List of items and service that require Prior Authorization' and shows 'Updated : 2/11/2026' for sections
Implication for claimsServices provided without required prior authorization for listed codes may not be eligible for coverage
Entry format — presentation
Entry presentation formatEntries are presented as 'Medicare, Procedure Code = [code]. Medicare, Description = [description]' to identify the code and its narrative description
Consistent useThis entry format is used across the document to list the procedures and brief descriptions that require prior authorization
ExamplesLines such as 'Medicare, Procedure Code = 0536U. Medicare, Description = ...' illustrate the format
Prior Authorization — listed procedure/drug codes
Prior Authorization — listed procedure/drug codesProcedure and drug codes shown in the document (CPT/HCPCS/J-/Q-/E-/L-/K-series) are explicitly identified as requiring prior authorization in the listed sections
ExamplesSelected entries include high-cost injectables (J-codes), genomic tests, imaging procedures, and DME codes
Provider actionProviders should reference the enumerated codes in the list to determine prior authorization requirements before service delivery
Prior Authorization — implied requirement
Implied requirement by headingsThe repeated headings and section labels indicate prior authorization is required for the listed codes and services throughout the document
Update timestampMultiple sections are marked 'Updated : 2/11/2026', indicating the effective update date for the entries shown
ScopeApplies across diverse clinical areas including genetic testing, imaging, DME, and injectables as enumerated
Prior Authorization — payer requirement
Prior authorization definition (payer requirement)A payer requirement that certain procedures, services, devices, or drugs obtain approval before provision to be eligible for coverage
Billing code usageEntries use Medicare/HCPCS/CPT codes to identify items requiring prior authorization; examples include J2507, 32853, and G0342 in the document
Provider implicationPrior authorization must be obtained prior to delivering listed services to ensure coverage eligibility
Medicare Procedure/HCPCS/CPT codes
Billing code systemsMedicare Procedure/HCPCS/CPT codes (including J-, Q-, G-, E-, K-, L- series) are used to identify services and supplies in the list
FunctionCodes serve to classify and bill for the specific test, device, injection, or procedure that requires prior authorization
ExamplesDocument examples include J2507 (pegloticase), G0342 (islet cell transplant laparoscopy), and multiple CPT imaging and procedure codes
Interventional spinal injections
Interventional spinal injectionsIncludes injection procedures for epidural or paravertebral approaches (eg, codes 62322, 64493) and related image‑guided injections listed as requiring prior authorization
ExamplesDocument lists lumbar interlaminar epidural injections (62322) and paravertebral facet injections with image guidance (64493) among prior authorization entries
Related proceduresAdjacent spine procedures (eg, laminotomy/laminectomy codes) are also enumerated in nearby sections
PET imaging
PET imaging — scope and codesPET imaging entries note scope (limited area, skull base to mid‑thigh, whole body) with report guidance and reference to imaging codes (78811, 78812, 78813)
PurposeThese PET entries indicate metabolic/biochemical functional imaging for tumor evaluation and are listed as requiring prior authorization
Production noteSpecifies radionuclides must be produced in a cyclotron or generator for certain PET studies (contextual description provided)
Prior authorization — general note
Prior authorization — general noteListed procedures and codes throughout the document require payer approval prior to service delivery; headings state 'List of items and service that require Prior Authorization' repeatedly
Provider actionProviders must obtain prior authorization for the enumerated codes to be eligible for coverage; the list spans diagnostics, therapeutics, devices and DME
Document currencyMultiple sections include 'Updated : 2/11/2026' demonstrating the update date for the entries shown
Policy Summary
PayerBlue Cross Blue Shield - Wisconsin
PolicyList of items and services that require Prior Authorization
Policy CodePolicy N/A
Change TypeUpdated list (no material coverage changes)
Effective DateFeb 11, 2026
Last ReviewFeb 11, 2026
Next Review DateN/A
Key ActionObtain prior authorization for any listed Medicare/CPT/HCPCS procedure, drug, device, or test before submitting claims for coverage.
SourceLink
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