Items and services requiring prior authorization (partial list)
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This document lists durable medical equipment (DME), wheelchair components, power wheelchair accessories, respiratory and other medical devices and supplies that require prior authorization for Blue Cross Blue Shield - Wisconsin members. It applies to claims and prior authorization processes where the listed Medicare procedure codes are used.
No material clinical or coverage changes in this revision.
Items and Services Requiring Prior Authorization
Partial coverage stance
Items and services listed by Medicare procedure code require prior authorization; examples below are drawn from the partial list.
Enumerated prior authorization codes (excerpt)
Items listed below require prior authorization as indicated by HCPCS code and description (partial extract).
Prior Authorization Code List (partial)
Codes listed below require prior authorization before services/items are provided or billed.
Selected examples from the partial code list
- Biofeedback and hand orthosis L3918 (Biofeedback listed requires prior authorization).
- Wheelchair cushions and positioning devices (E2620–E2625 series).
Listed codes requiring prior authorization (partial list)
Listed services require prior authorization as shown by procedure code and description.
Representative service categories
- Cardiac and imaging procedures (examples: 93150 series, CT/MRI codes referenced in chunks).
Prior authorization required — partial list
Codes listed below in the document extract require prior authorization per the payer.
Prior authorization requirement (partial list)
Codes listed below in this window require prior authorization under the policy.
Prior authorization required codes (partial list — part 7)
Listed procedure and HCPCS/Q-codes require prior authorization per the payer; providers should refer to the full policy for clinical criteria, documentation requirements, and submission instructions.
Representative entries
Prior authorization requirement (partial list)
Codes listed require prior authorization prior to service. Providers should refer to the payer's authorization process for required clinical documentation and submission channels.
Prior authorization required — code list (partial)
Codes listed below require prior authorization per the payer's policy (partial list).
Prior authorization list (excerpt)
Items and services listed here require prior authorization:
Included item groups
Prior authorization code list
Codes and descriptions requiring prior authorization (no decision criteria provided in this excerpt).
Prior authorization requirement - code listings
Codes listed below are designated in this document as requiring prior authorization.
Representative listed entries
Prior authorization items (excerpt)
Items and services shown require prior authorization; individual entries are identified by procedure codes and brief descriptions.
Examples in this excerpt
- Injection, aflibercept-abzv (biosimilar) (listed as requiring prior authorization).
- Complex behavioral and assessment services (e.g., 0362T) are included in the prior authorization list.
Prior Authorization Code List (partial)
Codes listed below require prior authorization as indicated in the larger policy document.
Services requiring prior authorization (examples)
List of procedure and drug codes requiring prior authorization (partial segment).
Sample listed services
- Transcatheter implantation of wireless left atrial pressure sensor for long-term monitoring (0933T).
Sample Procedure, HCPCS, CPT and Drug Codes (Partial Examples)
| E2394 | POWER WHEELCHAIR ACCESSORY, DRIVE WHEEL EXCLUDES TIRE, ANY SIZE, REPLACEMENT |
| E2381 | POWER WHEELCHAIR ACCESSORY, PNEUMATIC DRIVE WHEEL TIRE, ANY SIZE, REPLACEMENT |
| E0425 | TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) DEVICE, FOUR OR MORE LEADS |
| K0003 | Lightweight Wheelchair |
| K0047 | Elevating legrest, upper hanger bracket, replacement only, each |
| K0848 | POWER WHEELCHAIR, GROUP 3 STANDARD, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS |
| K0806 | POWER OPERATED VEHICLE, GROUP 2 STANDARD, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS |
| K0899 | Power mobility device, not coded by DME PDAC or does not meet criteria |
| L3002 | Foot Insert Plastazote Or Eq |
| L3918 | Hand orthosis, metacarpal fracture orthosis, prefabricated, off-the-shelf |
| K0826 | POWER WHEELCHAIR, GROUP 2 VERY HEAVY DUTY, PATIENT WEIGHT CAPACITY 451 TO 600 POUNDS |
| K0843 | POWER WHEELCHAIR, GROUP 2 HEAVY DUTY, MULTIPLE POWER OPTION, PATIENT WEIGHT CAPACITY 301 TO 450 P. |
| E2374 | Power wheelchair accessory, hand or chin control interface, standard remote |
| E2327 | Power wheelchair accessory, head control interface, mechanical, proportional |
| 27407 | Repair, Primary, Torn Ligament &/Or Capsule, Knee; Cruciate |
| 27447 | Arthroplasty, Knee, Condyle & Plateau; Medial & Lateral Compartments |
| 70470 | CT Scan, Head/Brain; W/O Contrast, Then W/Contrast |
| 70553 | MRI, Brain; W/O Contrast, Then W/Contrast & Further Sequences |
| 63685 | Incision/Placement, Spinal Neurostimulator Pulse Generator/Receiver |
| 93458 | Catheter placement in coronary artery(s) for coronary angiography; with left heart catheterization |
| A0428 | Ambulance service, basic life support, nonemergency transport (BLS) |
| A0426 | Ambulance service, advanced life support, nonemergency transport, level 1 (ALS 1) |
| B4036 | Enteral feeding supply kit; gravity fed, per day |
| B4035 | Enteral feeding supply kit; pump fed, per day |
| B4034 | Enteral feeding supply kit; syringe fed, per day |
| Q4209 | Surgraft, per square centimeter |
| Q4211 | Amnion bio or Axobiomembrane, per square centimeter |
| Q4195 | PuraPly, per sq cm |
| 15273 | Application of skin substitute graft to trunk, arms, legs, total wound surface area >=100 sq cm; first 100 sq cm |
| 65779 | Placement of amniotic membrane on the ocular surface; single layer, sutured |
| 22632 | Arthrodesis, Post Interbody W/Laminect &/Or Diskect, Prep Interspace, Sngl Intrspc; Add'l Interspc. |
| C9360 | Dermal substitute, native, nondenatured collagen, neonatal bovine origin (SurgiMend Collagen Matrix), per 0.5 sq cm. |
| 22216 | Osteotomy, Spine, Posterior/Posterolateral Approach, 1 Vertebral Segment; Add'l Segment. |
| J0588 | Injection, incobotulinumtoxinA, 1 unit |
| 81298 | MSH6 gene analysis; full sequence analysis |
| 15837 | Excision, excessive skin and subcutaneous tissue; forearm or hand |
| 81353 | TP53 gene analysis; known familial variant |
| 0495T | Initiation and monitoring marginal (extended) cadaver donor lung(s) organ perfusion system |
What Providers Must Do (Prior Authorization Requirements)
Prior Authorization Required
Prior authorization is required for the items and services listed below. Providers must obtain prior authorization before rendering or ordering these items/services to avoid claim denials or delays.
- This list is a partial, consolidated excerpt updated 2/11/2026 and includes Durable Medical Equipment (DME), power wheelchairs and accessories, orthotics/prosthetics, advanced therapies and biologics, monitored and implantable device procedures, spine and interventional device procedures, therapy services, home health/hospice skilled services, selected surgical and imaging procedures, and specified drug J-/Q-/C-codes that require prior authorization.
DME / Power Wheelchair and Accessory Prior Authorization
Prior authorization is required for DME, power wheelchairs, power wheelchair accessories and related components. This includes power wheelchair bases (grouped by weight/capacity), power-operated vehicles, seating systems, cushions and backrests (including custom-fabricated and skin protection/positioning cushions), drive/drive-wheel components, caster tires and tubes, batteries and battery components, controllers and expandable controllers, hand/chin/head control interfaces (including sip-and-puff and chin cup interfaces), actuators, gearboxes, specialized pediatric and bariatric power wheelchair configurations, and replacement-only components.
- Representative HCPCS/Codes: K0011, K0800, K0820, K0821, K0824, K0826, K0828, K0840, K0843, K0850, K0854, K0858, K0859, K0862, K0864, K0868, K0869, K0880, K0886, K0898
- Power wheelchair accessories and components: E2324, E2325, E2361, E2369, E2373, E2374, E2376, E2377, E2381, E2382, E2383, E2384, E2385, E2386, E2387, E2388, E2389, E2390, E2391, E2392, E2394
- Seating/cushion/back HCPCS: E2602, E2604, E2606, E2608, E2609, E2611, E2612, E2613, E2614, E2615, E2616, E2617, E2619, E2620, E2621, E2622, E2623, E2624, E2625, E2626, E2628, E2629, E2633
Therapy Services Prior Authorization
Prior authorization is required for therapy and related services including outpatient physical therapy, occupational therapy, speech-language pathology, assistive technology assessments, orthotic/prosthetic management and training, biofeedback, therapeutic modalities, and group therapy when listed below. This also includes services performed in home health or hospice settings by PT/OT/SLP and therapy assistant services that are separately listed.
Home Health / Hospice Skilled Services Prior Authorization
Prior authorization is required for home health and hospice skilled services when billed with the listed home health/hospice HCPCS/G-codes. This includes skilled nursing (RN/LPN) observation and assessment, therapist and therapy assistant services, clinical social worker services, home health/hospice aide services, and training/education visits.
Advanced Therapies, Biologics, and Device-Related Services Prior Authorization
Prior authorization is required for advanced therapies, biologics, grafts, wound products, cellular and tissue-based products, enteral/parenteral pumps and supply kits, remote monitoring devices, certain injections and infusion-related products, and selected procedure-related Q-/C-codes. This includes dermal substitutes, cultured skin autografts, amniotic/placental matrices, flowable wound matrices, and specialty wound products as listed.
- Representative codes and products: Q4111–Q4189, Q4190–Q4257 (various wound/amnion/dermal matrices), A2004–A2029 (wound matrices), B4034–B4148 (enteral/parenteral supply kits and pumps), B9002/B9004 (infusion pumps), C9353/C9356 (collagen/porous tendon matrix), C2624/C9360 (implantable sensors and dermal substitutes), selected autologous/allograft and graft product codes (e.g., 15017, 65778–65780)
Monitoring, Sleep Studies, and Implantable Device Procedures Prior Authorization
Prior authorization is required for monitoring, sleep studies, and procedures involving implantable devices, including polysomnography studies, multiple sleep latency testing, cardiac implantable device interrogation/programming, wireless pulmonary artery pressure sensors, implantable phrenic nerve stimulator interrogation/programming, insertions/removals/revisions of implantable monitors and stimulators, and long-term hemodynamic monitoring device procedures.
- Representative CPT/HCPCS: 95801, 95805–95811 (polysomnography/MSLT), 33276–33289 (phrenic nerve stimulator and implantable cardiac device procedures), 33280–33289, 33277–33279, 33285, 33288–33289, 33281, 33285, 33288–33289, 33291 series; 33288–33289; 33289; 33285; 93279–93290-style interrogation/programming codes (including remote interrogation codes 0948T/0949T/0926T) and codes for implantation/removal of implantable monitoring devices (e.g., 33285, 33288, 33289, 33276, 33277, 33278) and 33289–33290 device monitoring
Spine and Interventional Device Procedures Prior Authorization
Prior authorization is required for spine, vertebral augmentation, arthrodesis and other interventional spine procedures and for intervertebral device insertions and related instrumentation. This includes kyphoplasty/vertebroplasty, spinal fusion/arthrodesis (anterior/posterior/interbody), osteotomies, insertion of intra-arterial infusion pumps, and insertion of intervertebral biomechanical devices and cages.
Procedures Requiring Prior Authorization (Partial List)
Prior authorization is required for numerous surgical, imaging, and other procedures listed in the partial code list. Providers should verify prior authorization requirements for the specific CPT/HCPCS code(s) listed before scheduling or performing the service.
- Sample procedure codes included in the partial list (not exhaustive): 29805, 29806, 29819, 29822, 29886–29892, 29914–29916, 27125, 27130, 27403, 27407–27446, 27486, 27488, 27496 series, 31242, 31574, 70470–70492, 70480–70486, 70491–70492, 71271, 63001–63076, 63035–63051, 63250–63290, 63305, 63688, 69930, 70336, 70549
Prior Authorization — Code List (Partial)
The code lists above are a partial segment of the full prior authorization list; additional codes (including many Q-/J-/A-/C-/G-/L-/K-/E- codes and recently added entries) require prior authorization. The list was updated 02/11/2026; providers must reference the payer's current prior authorization portal or contact the payer for the full, authoritative list and submission instructions.
- Updated entries effective 2/11/2026 include new implants, biologic grafts, skin graft application codes, expanded arthroplasty/arthrodesis/spine entries, additional power wheelchair accessories and DME components, expanded wound product/Q-code entries, updated therapy and home health/hospice G-codes, and new drug J-codes and infusion-related codes (see Advanced Therapies and Drugs sections).
Prior Authorization Required Items — Sample Entries
Examples of specific items and sample entries from the prior authorization list are provided below to help providers recognize commonly affected items and services. This is illustrative only — obtain prior authorization for any listed code prior to service.
- Sample DME / Accessory entries: E0650, E0466, E0660, E0652, E0666, E0665, E0672, E0673, E2351, E0175, E0113, E0352
- Sample Orthotic/Prosthetic entries: L3918 (hand orthosis), L3981, L9900, L3010, L6965, L7009, L5856, L5858, L5969, L5973
- Sample Therapy entries: 97110, 97112, 97116, 97124, 97130, 97140, 97150, 97164, 97168, 97750, 97755, 97760–97763
- Sample Home Health / Hospice entries: G0151, G0153, G0155, G0156, G0157, G0158, G0299, G0300
- Sample Advanced therapy / wound product entries: Q4111–Q4190 range, A2004–A2029, C9353/C9356
- Sample Monitoring / Implantable device entries: 33276–33289, 33280–33289, 33285, 33288, 33289, 0948T, 0949T
Updated Prior Authorization Entries (2/11/2026)
Updated entries effective 02/11/2026 are included throughout this list. Providers should confirm whether a given code was added or modified in the 2/11/2026 update and follow the payer's current prior authorization submission process for those codes.
- Notable 02/11/2026 updates: expanded power wheelchair accessory listings (E23xx, E24xx series), additional L- and K- prosthetic/orthotic codes, broad additions to wound product Q-codes (Q41xx–Q43xx ranges), new device and implant codes (C- and A- series), updated home health/hospice G-codes, added therapy CPTs and assistive technology assessment codes, and newly listed drug J-/Q-/C- codes (see Drugs section).
Drugs Requiring Prior Authorization (Examples)
Certain drugs and biologic products require prior authorization when billed under J-/Q-/C- or specific HCPCS codes. Providers must obtain prior authorization for these drug products prior to administration or pharmacy billing.
- Example drug/biologic J-/Q-/C- codes requiring prior authorization (examples only): J9022 (nivolumab equivalent examples), J3263 (toripalimab-tpzi), J7356 (foscarbidopa/foslevodopa), J9382 (zenocutuzumab-zbco), J0175 (donanemab-azbt), J1307 (crovalimab-akkz), Q5104/Q5106/Q5108 (biosimilars/biologics), Q2058 (CAR-T product), selected oncology/infusion drugs (J9xxx series), and injectable biosimilars/monoclonal antibodies listed in the full code list.
Formatting, Code Groupings, and Key Terms
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