List of items and service that require Prior Authorization — Part (code list)
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This document lists specific procedure and supply codes that require prior authorization for Blue Cross Blue Shield - Wisconsin members; it applies to providers submitting claims for the listed services.
No material clinical or coverage changes in this revision.
Items and Services Requiring Prior Authorization
Prior authorization requirement (code list)
The listed procedure and supply codes require prior authorization before services are rendered or billed.
Prior authorization requirement
Codes listed require prior authorization prior to service.
Prior authorization requirement — code list
Codes listed require prior authorization before services are rendered or billed.
Prior authorization required for listed items
The document lists specific procedure and HCPCS/CPT codes that require prior authorization.
Prior authorization required — code-list based
Codes listed in this document require prior authorization; providers should obtain authorization before billing.
Prior Authorization Code List — Part 6
Codes listed below require prior authorization as indicated by the payer.
Prior authorization requirement (list entries)
Codes in this list require prior authorization; providers must obtain authorization before performing or billing for these services.
Prior authorization code list (partial)
Codes requiring prior authorization (partial list — administrative reference only).
Prior authorization requirement — Part 9
Listed procedure and HCPCS/J-codes require prior authorization as indicated; no specific clinical criteria are included in this part.
Coverage stance for listed items
Listed services require prior authorization before they are covered; providers must obtain authorization per payer procedures.
Prior Authorization — code list (partial)
Codes shown in this partial extract require prior authorization. Specific clinical criteria, documentation requirements, or exceptions are not present in this window.
Prior authorization requirement
Services and items listed require submission of a prior authorization request before coverage will be approved.
Prior Authorization Code List (partial)
Procedure codes requiring prior authorization (code list only in this fragment).
List-based prior authorization requirement
Codes listed below require prior authorization per the payer's policy; providers must obtain authorization before billing.
Prior Authorization Code List (partial)
Codes listed below require prior authorization.
Representative Codes and Code Groups
| 15013 | Preparation of skin autograft, requiring enzymatic processing; first 25 sq cm or less |
| 15018 | Application of skin autograft; each additional 480 sq cm |
| 15015 | Application of skin autograft; first 480 sq cm or less |
| 0466U | Cardiology (CAD), DNA, genome-wide association studies (564,856 SNPs), targeted variant genotyping |
| 0469U | Whole genome sequence analysis for chromosomal abnormalities, copy number variants |
| J9263 | Example J-code present in list (verify exact codes in full policy) |
What Providers Must Do
Radiation / Proton / Brachytherapy — Prior Authorization Required
Prior Authorization is required for radiation, proton therapy, stereotactic radiosurgery, and brachytherapy procedures listed below. Providers must obtain authorization prior to scheduling treatment and include clinical indication, lesion/site, prior therapies, and imaging/planning documentation.
Prior Authorization Required — Sample Codes
Prior authorization is required for many specified procedure and HCPCS/CPT codes. This list is extensive — submit prior auth requests referencing the exact code(s) and clinical documentation to support medical necessity.
PET / PET-CT Prior Authorization
PET and PET/CT imaging services require prior authorization. When requesting authorization, include the clinical indication, prior imaging results, and whether PET/CT fusion imaging (concurrent CT) is needed.
Prior Authorization Required — Surgical / DME / Drugs
Prior authorization is required for selected surgical procedures, durable medical equipment (DME), and drug administrations. Provide operative plans, expected implants/devices, and DME justification (functional need, measurements) with requests.
Prior Authorization Required — Assorted Codes (Partial List)
This section contains an assorted, partial list of codes that require prior authorization. Use the lists to confirm whether a requested service needs prior approval.
- Examples include implantable devices, dermal substitutes, advanced diagnostics, and behavioral/day services (see code excerpts throughout the list).
- When in doubt, submit a prior authorization request citing the specific code and clinical rationale.
Immune Globulins, Devices, and Genetic Tests — Prior Authorization
Immune globulins, specialty devices, and advanced genetic tests require prior authorization. Include diagnosis, prior therapies, lab results, and weight/dosing (for biologics) with the request.
- Immune globulins examples: J1557, J1569, J1572, J1599.
- Genetic and genomic tests: BRCA1/BRCA2 (e.g., 81215), MSH2/MSH6 (e.g., 81295, 81298), large panels and whole exome/mitochondrial testing (e.g., 0214U, 0215U, 81460).
- Device examples: cochlear implants and neurostimulator generators (L8614, L8682, C1767) — include device model and planned programming details.
DME and Surgical Prior Authorization
Durable medical equipment and many surgical procedures require prior authorization. Submit DME justification, patient's functional limitations, prior conservative therapies, and any measurements or fitting notes.
Prior Authorization Required — Listed Codes
Prior authorization is required for the extensive lists of codes shown throughout this document. Providers should reference the specific code group when submitting requests and attach all relevant clinical documentation.
- Included code categories: home-based services, attendant care, emergency response systems, and high‑cost graft/matrix products.
- When multiple codes apply to a single episode of care, include a procedure narrative mapping codes to planned services.
Prior Authorization Required — Codes (Excerpt)
Some codes are shown as excerpts here; the payer's master prior authorization list includes many additional entries. Always check the most current list before performing services.
- Excerpt examples include Q‑series graft/membrane products, specialty injections, and emergency response service codes (S5160–S5165).
- Submit requests referencing the effective date (2026‑02‑11) to ensure the correct policy version is applied.
Prior Authorization — Updated Codes
The prior authorization list is periodically updated. Providers must use the updated code list for submission and verify whether recently added or revised codes require advance approval.
Prior Authorization — Continued Extensive Code List
The long code list continues across sections and includes advanced procedural and image‑guided therapies, molecular diagnostics, and high‑cost implants. Provide comprehensive clinical notes and procedural plans when requesting authorization.
Advanced Procedural & Imaging‑Guided Therapies — Prior Authorization
Advanced procedural and imaging‑guided therapies (e.g., ablation, transcatheter interventions, organ‑specific machine perfusion) require prior authorization with procedural plans, imaging, and multidisciplinary justification.
Transplantation & Genomic Sequencing — Prior Authorization
Transplantation procedures and comprehensive genomic sequencing require prior authorization. For transplant‑related services include donor/recipient documentation, organ allocation details, and perfusion/processing plans. For genomic testing include rationale, specimen type, and whether testing is proband or trio/comparator.
Prior Authorization Required — Select Codes
Select procedure codes across specialties require prior authorization. Always reference the precise CPT/HCPCS code in requests and attach supporting diagnostics, prior treatments, and consultation notes.
Prior Authorization — Molecular/Genetic and Surgical Procedures
Molecular, genetic, and many surgical codes require prior authorization. For molecular testing provide prior pathology, staging, and how results will change management.
Mobility Devices — Prior Authorization
Mobility devices, power wheelchairs, and numerous related accessories require prior authorization. Provide mobility assessments, justification for chosen group/class, patient weight and functional needs, and documentation of previous mobility aids tried.
Prior Authorization Required — Procedure Codes (Partial List)
This document includes many partial lists of procedure codes requiring prior authorization across specialties. Always consult the comprehensive payer code list and include clear clinical justification with submissions to avoid delays or denials.
- Examples across orthopedics, arthroplasty, neurostimulation, and wound matrices are included in the master list.
- If a code is not explicitly listed but the service is high‑cost or implantable, consider prior authorization in advance.
Equipment & Devices — Prior Authorization
Equipment, devices, and varied procedures (including wound matrices, skin substitutes, and implantable systems) on the list require prior authorization. Attach product identifiers, planned quantities (e.g., square centimeters for grafts), and clinical rationale.
Varied Procedures & Devices — Prior Authorization
Varied procedures and devices across inpatient and outpatient settings require prior authorization. Confirm site‑of‑service billing rules and include pre‑op evaluations, device models, and expected follow‑up programming or maintenance.
- Examples include complex spinal instrumentation, craniofacial reconstruction (211xx series), ocular surface reconstruction with amniotic membrane (65778–65780).
- If a device requires postoperative programming/interrogation, include expected follow‑up codes in the authorization request.
Home Infusion & Nursing Services — Prior Authorization
Home infusion therapy, private duty nursing, and other home health services listed require prior authorization. Provide care plans, infusion regimens, volumes/daily totals (for TPN), and catheter care needs.
Biosimilars, Grafts/Matrices — Prior Authorization
Biosimilars, grafts/matrices, and numerous wound/skin products listed require prior authorization. When requesting, state product name, per‑unit measure (e.g., per sq cm or per 0.5 cc), and prior conservative care.
- Biosimilar injectables examples: Q5101–Q5135 and Q5110–Q5126 series (filgrastim, pegfilgrastim, trastuzumab, bevacizumab biosimilars).
- Graft/matrix examples: Q42xx–Q44xx and Q41xx ranges (many specific brand/product codes listed); indicate exact square centimeters or cc to be used.
Specialized Devices & High‑Cost Therapies — Prior Authorization
Specialized devices and high‑cost therapies such as CAR‑T, autologous cell therapies, implanted neurostimulators, and cochlear systems require prior authorization. Include multidisciplinary treatment plans, authorization for leukapheresis/dose prep when applicable, and anticipated number of infusions or device components.
Codes Requiring Prior Authorization — Partial Lists
This section contains numerous partial lists of codes that require prior authorization. Providers should not rely on excerpts alone — submit a prior authorization request for any high‑cost, implantable, or novel service and include the code(s) and full supporting documentation.
- Partial lists include wheelchair accessories, rehabilitation systems, ambulatory devices, and many Q‑series products.
- When planning care across multiple specialties, consolidate requested codes and supporting documents into a single comprehensive prior authorization submission where possible.
Key Terms and Document Notes
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