List of items and services requiring prior authorization
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A catalog of Medicare procedure and supply codes for items and services that require prior authorization from Blue Cross Blue Shield - Wisconsin; applies to billing/authorization processes involving these codes.
No material clinical or coverage changes in this revision.
Codes and Services Requiring Prior Authorization
Codes requiring prior authorization (partial list — part 1 of 15)
Codes and short descriptions listed below require prior authorization.
Catalog-based prior authorization requirement
The following codes/items require prior authorization before claims payment or service delivery as listed in this policy segment.
Prior authorization code list (partial)
Codes listed below require prior authorization as indicated by the payer.
Listed codes requiring prior authorization (partial)
Codes in this section require prior authorization per the payer's policy; examples include injectable biologics, genetic tests, imaging, and surgical procedures.
Codes requiring prior authorization (partial list — part 5)
Codes listed below are identified as requiring prior authorization.
Prior authorization required list (partial)
Items and services listed below require prior authorization before claim adjudication.
ALL of the following
Prior Authorization Code List (Part 7)
Codes listed in these chunks require prior authorization per the payer's policy.
Prior authorization code list (partial — part 8)
Codes and descriptions that require prior authorization (code list only).
Prior authorization required — listed codes
Codes and descriptions requiring prior authorization (excerpt).
Prior Authorization Required - sample criteria set
Codes and brief descriptions identified in this section require prior authorization. The list includes, but is not limited to, molecular/genomic tests, certain injections and procedures, DME, sleep testing devices, and therapy/rehabilitation services.
ALL of the following
- 0214T–0217T (paravertebral facet injections), 0287U (oncology thyroid NGS of 112 genes), 0339T (transcatheter renal denervation), 0159U–0161U (mRNA sequence analyses for hereditary colon cancer), G0398 (home sleep study HST type II/IV), E0601 (CPAP device), 81415/81425 (exome/genome sequence analyses)
Codes Requiring Prior Authorization (examples)
Codes listed below require prior authorization prior to service delivery.
Prior authorization required codes (partial)
Codes listed below require prior authorization prior to claim/payment; providers must submit authorization requests for these services.
ALL of the following
- 63282 (inflatable penile prosthesis, multi‑component), 63290/63200/63250/63252 (laminectomy variants), 63051/63005/63017/63035 (laminoplasty/laminectomy variants), E1905 (virtual reality CBT device), 0545T/0572T (transcatheter and implantable electrode procedures), multiple specialty J‑codes (eg, J2860, J2941, J3060, J3111)
Codes requiring prior authorization (excerpt)
The following CPT/HCPCS/Medicare procedure codes require prior authorization as listed in this policy excerpt.
Prior Authorization Requirement
Listed procedure and U-codes require prior authorization prior to service.
Prior Authorization Code List (partial)
The following procedure codes and their descriptions are included in the payer's prior authorization requirement list (partial extract from document).
ALL of the following
- Sample catalog entries from this extract include major transplant and surgical codes (e.g., 47135 liver allotransplantation; 33945 heart transplant), revision arthroplasty codes (e.g., 27486, 27407), phrenic nerve stimulator system codes (93150–93153), multiple matrix/graft Q‑codes (Q4348–Q4353), and numerous advanced genomic and specialty J‑codes (see catalog).
Representative Codes and Coding Notes
| 92508 | Treatment of speech, language, voice, communication, and/or auditory processing disorder; group, 2 or more individuals |
| 97168 | Reevaluation of occupational therapy care/established plan of care requiring components |
| E0956 | Wheelchair accessory, lateral trunk or hip support, prefabricated, including fixed mounting hardware, each |
| K0886 | POWER WHEELCHAIR, GROUP 4 HEAVY DUTY, MULTIPLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 301 TO 450 POUNDS |
| E2508 | Speech generating device, synthesized speech, requiring message formulation by spelling |
| E1831 | Static progressive stretch toe device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories. |
| K0849 | POWER WHEELCHAIR, GROUP 3 STANDARD, CAPTAINS CHAIR, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS. |
| J2468 | Injection, palonosetron HCl (Avyxa), 25 mcg. |
| 77412 | Radiation treatment delivery, 3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational. |
What Providers Must Do / Authorization Actions
Prior authorization required — code list
This document lists Medicare procedure and HCPCS codes that require prior authorization.
Wheelchair accessories and components - Prior Authorization required
Various power and manual wheelchair accessories, controllers, batteries, seating and interfaces (codes include E2378, E2377, E2375, E2343, E2341, E2330, E2328, etc.) require prior authorization.
- E2378 — Power wheelchair component, actuator, replacement only
- E2375 — POWER WHEELCHAIR ACCESSORY, NON-EXPANDABLE CONTROLLER, INCLUDING ALL RELATED
- E2341 — Power wheelchair accessory, nonstandard seat frame width, 24-27 inches
- E2328 — Power wheelchair accessory, head control or extremity control interface, electronic, proportional
Wheelchairs and related accessories - Prior Authorization required
Pediatric and adult wheelchair models and special wheelchair sizes/features (examples: E1237, E1238, E1235 and related E12xx codes) require prior authorization.
- E1237 — Wheelchair, Pediatric Size, Rigid, Adjustable, Without Seating System
- E1238 — Wheelchair, Pediatric Size, Folding, Adjustable, Without Seating System
- E1235 — Wheelchair, Pediatric Size, Rigid, Adjustable, With Seating System
- E1226/E1224 — Manual semi-reclining and fully reclining back accessories (replacement)
Therapeutic devices and support equipment - Prior Authorization required
Therapeutic devices (stimulation, monitors), oxygen supplies, hospital beds, and orthoses listed in the document require prior authorization.
Prosthetics, orthotics and complex DME - Prior Authorization required
Prosthetic, orthotic items and complex DME (including powered wheelchair groups, ventilators, microprocessor prosthetic components and other assistive devices) require prior authorization.
Prior authorization requirement - code list
Prior authorization is required for the listed items and services; specific HCPCS/CPT/procedure codes and descriptions are provided in the document.
Prior authorization requirement - varied code types
The prior authorization list includes many code types across drugs, devices, procedures and diagnostics (J‑codes, Q‑codes, CPT procedure codes, U‑codes) that require prior authorization.
Prior authorization required codes (partial list)
A partial listing of specific Medicare procedure and HCPCS codes and descriptions that require prior authorization appears throughout the document.
Prior authorization required — codes list (part 5)
This section enumerates additional items and services (by Medicare procedure code and description) that require prior authorization; examples include advanced radiation delivery and specialty graft products.
Prior authorization required — code list (excerpt)
Providers must request prior authorization for the Medicare procedure/CPT/HCPCS codes and descriptions listed in the document; the excerpted list identifies items requiring authorization prior to service.
Prior Authorization Required Codes (partial list)
This document section enumerates specific Medicare/procedure codes and descriptions that require prior authorization (partial list provided in the excerpt).
Neurostimulator, radiosurgery, genetic testing
Cranial neurostimulator pulse generators/receivers, stereotactic radiosurgery, and specific genetic testing (BRCA1/BRCA2 duplication/deletion analysis) are listed as requiring prior authorization.
PET / PET-CT imaging
PET and PET/CT imaging procedure codes (78811–78816) — including limited area, skull base to mid-thigh, and whole body studies — require prior authorization.
Prior Authorization list (partial)
This partial prior authorization list includes numerous procedure codes and descriptions; providers must obtain prior authorization for listed services before billing or performing them.
Definitions and Terminology
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