CurrentBlue Cross Blue Shield - WisconsinPolicy N/A
List of items and services requiring prior authorization (code list)
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A payer-maintained list enumerating specific procedure and HCPCS/CPT codes that require prior authorization for members; applies to providers submitting claims to Blue Cross Blue Shield - Wisconsin.
Policy Summary
PayerBlue Cross Blue Shield - Wisconsin
PolicyList of items and services requiring prior authorization (code list)
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateFeb 11, 2026
Last ReviewFeb 11, 2026
Next Review DateFeb 11, 2026
Key ActionProviders must request prior authorization for the procedure and HCPCS/CPT codes listed before submitting claims.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
Updated 2/11/2026document update date shown
multispecialtytypes of services
nationalgeographic applicability
~120+codes listed (excerpt)
Codes & Services Requiring Prior Authorization
Prior authorization — listed codes (partial)
Prior authorization — listed codes (partial). The following procedure codes and descriptions are included in the payer's prior authorization requirement (partial excerpt). Providers must obtain prior authorization before performing or billing these services.
A4438 — Adhesive clip applied to the skin to secure external electrical nerve stimulator controller, each (requires prior authorization).
15012 — Harvest of skin for autograft; each additional 25 sq cm (requires prior authorization).
15015 — Application of skin autograft; first 480 sq cm or less (requires prior authorization).
15016 — Application of skin autograft; each additional 480 sq cm (requires prior authorization).
15017 — Application of skin autograft; first 480 sq cm or less (requires prior authorization).
15018 — Application of skin autograft; each additional 480 sq cm (requires prior authorization).
C1734 — Orthopedic/device/drug matrix for opposing bone-to-bone or soft tissue-to-bone (implantable) (requires prior authorization).
15150 — Tissue cultured skin autograft, trunk, arms, legs; first 25 sq cm or less (requires prior authorization).
0823T — Transcatheter insertion of permanent single-chamber leadless pacemaker, right atrial, including imaging guidance (requires prior authorization).
15273 — Application of skin substitute graft to trunk, arms, legs, total wound surface area >=100 sq cm; first 100 sq cm (requires prior authorization).
0824T — Transcatheter removal of permanent single-chamber leadless pacemaker, right atrial, including imaging guidance (requires prior authorization).
C9796 — Repair of enterocutaneous fistula small intestine or colon with plug (e.g., porcine SIS) (requires prior authorization).
0825T — Transcatheter removal and replacement of permanent single-chamber leadless pacemaker, right atrial, including imaging guidance (requires prior authorization).
E0746 — Electromyograph biofeedback (requires prior authorization).
15783 — Dermabrasion; superficial, any site (requires prior authorization).
15826 — Rhytidectomy; glabellar frown lines (requires prior authorization).
Q4102 — Oasis wound matrix, per square centimeter (requires prior authorization).
Q4105 — Integra dermal regeneration template (DRT) or Integra Omnigraft dermal regeneration matrix, per sq cm (requires prior authorization).
95921 — Testing, autonomic nervous system; cardiovagal innervation (parasympathetic), per test (requires prior authorization).
95923 — Testing of autonomic nervous system function; vasomotor adrenergic innervations (requires prior authorization).
Q4115 — Alloskin, per square centimeter (requires prior authorization).
Q4116 — Alloderm, per square centimeter (requires prior authorization).
Q4121 — Theraskin, per square centimeter (requires prior authorization).
Q4122 — Dermacell, per square centimeter (requires prior authorization).
0217T — Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) (requires prior authorization).
0287U — Oncology (thyroid), DNA and mRNA, next-generation sequencing analysis of 112 genes (requires prior authorization).
0339T — Transcatheter renal sympathetic denervation, percutaneous approach; bilateral (requires prior authorization).
0347T — Placement of interstitial device(s) in bone for radiostereometric analysis (RSA) (requires prior authorization).
0408T — Insertion or replacement of permanent cardiac contractility modulation system; pulse generator with transvenous electrodes (requires prior authorization).
0411T — Insertion or replacement of permanent cardiac contractility modulation system; ventricular electrode only (requires prior authorization).
0413T — Removal of permanent cardiac contractility modulation system; transvenous electrode (requires prior authorization).
0415T — Repositioning of previously implanted cardiac contractility modulation transvenous electrode (requires prior authorization).
0416T — Relocation of skin pocket for implanted cardiac contractility modulation pulse generator (requires prior authorization).
0454U — Rare diseases, identification of structural variants by optical methods (requires prior authorization).
0466U — Cardiology (CAD), DNA, genome-wide association studies (564,856 SNPs) (requires prior authorization).
0469U — Rare diseases, whole genome sequence analysis for chromosomal abnormalities (requires prior authorization).
0474T — Insertion of anterior segment aqueous drainage device, with creation of intraocular reservoir (requires prior authorization).
0474U — Hereditary pan-cancer genomic sequence analysis panel (requires prior authorization).
E0743 — Power wheelchair accessory, group 34 sealed lead acid battery, each (requires prior authorization).
Representative CPT / HCPCS / Medicare Codes
Representative CPT codesCPTCovered
| 22861 | Insertion, posterior segmental instrumentation (e.g., pedicle fixation), 3 to 6 vertebral segments |
| 31647 | Bronchoscopy, flexible or rigid, with transbronchial lung biopsy |
| 38215 | Bone marrow or blood cell harvesting for transplantation; allogeneic donor |
| 20974 | Muscle or myocutaneous free flap with microvascular anastomosis |
| 97763 | Orthotic/Prosthetic Management and Training; initial or subsequent prosthetic training, 15 minutes |
| 72130 | CT scan, lumbar spine; without contrast |
| 70553 | MRI, brain (including brain stem); without and with contrast |
| 33945 | Insertion or replacement of intra-aortic balloon catheter, percutaneous |
Representative HCPCS / Medicare codesHCPCSCovered
Selected procedure codes (partial excerpt)mixedCovered
| L5859 | Prosthetic knee component, powered swing-phase control (HCPCS example) |
| 33945 | Insertion or replacement of intra-aortic balloon catheter (CPT) |
| 97763 | Orthotic/Prosthetic training, per 15 minutes (CPT) |
| Q5114 | Trastuzumab biosimilar injection (HCPCS) |
| S9366 | Home health aide S-code (HCPCS) |
| 22861 | Posterior segmental instrumentation, 3-6 segments (CPT) |
| 38215 | Hematopoietic progenitor cell transplantation procedure (CPT) |
Representative mixed codesmixed
| S9366 | Home health aide services, per hour (S-code example) |
| Q5114 | Injection, trastuzumab-dkst, biosimilar (Ogivri), 10 mg |
| 22861 | Posterior segmental instrumentation (CPT) |
| 72130 | CT lumbar spine; without contrast (CPT) |
| 70553 | MRI brain without and with contrast (CPT) |
| 38215 | Hematopoietic progenitor cell transplant donor procedure (CPT) |
| 20974 | Free flap with microvascular anastomosis (CPT) |
| 31647 | Bronchoscopy with transbronchial biopsy (CPT) |
Selected genetic, molecular, imaging and testing codesmixedCovered
| 72130 | CT lumbar spine; without contrast (CPT) |
| 70553 | MRI brain; without and with contrast (CPT) |
| 97763 | Orthotic/prosthetic training, per 15 minutes (CPT) |
| 33945 | Insertion/replacement of intra-aortic balloon catheter (CPT) |
| 38215 | Hematopoietic progenitor cell collection/transplant (CPT) |
| 20974 | Free muscle/myocutaneous flap w/ microvascular anastomosis (CPT) |
| 31647 | Bronchoscopy with transbronchial biopsy (CPT) |
Representative codes (neutral)mixed
Procedure and Q-code examplesmixedCovered
| Q5114 | Trastuzumab-dkst, biosimilar, 10 mg (HCPCS) |
| S9366 | Home health aide services (S-code example) |
| 22861 | Posterior segmental instrumentation (CPT) |
| 72130 | CT lumbar spine without contrast (CPT) |
| 70553 | MRI brain without and with contrast (CPT) |
| 38215 | Hematopoietic progenitor cell transplant donor procedure (CPT) |
| 20974 | Free flap with microvascular anastomosis (CPT) |
What Providers Must Do
Prior Authorization
Prior authorization required — code list
Medicare procedure/CPT/HCPCS codes listed on the payer’s prior authorization list (excerpt). Providers must request prior authorization for the following codes: 78483, 78350, 21121, 78468, 21142, 21125, 21159, G0341, 21160, 21155, 21154, 21740, 43257.
Prior Authorization
Prior authorization required — listed codes
Numerous Medicare procedure and HCPCS codes are included on the payer’s list and require prior authorization; providers must request prior authorization for the listed items and services before rendering or billing them.
Prior Authorization
Prior authorization required — listed codes
This section enumerates Medicare procedure and HCPCS codes that require prior authorization as part of the payer's list; examples include D7948 (LeFort II/III osteoplasty) and E0170 (commode chair with integrated seat lift).
Prior Authorization
Advanced procedures and assays
Advanced imaging, implantable device programming, and specialized oncology/genomic assays listed require prior authorization; examples include 93150 (therapy activation of implanted phrenic nerve stimulator) and 0435U (oncology chemotherapeutic drug cytotoxicity assay).
Prior Authorization
Prior authorization required — interventional procedures
Interventional pain and regional block procedure codes require prior authorization; listed examples include 64480 (transforaminal epidural, cervical/thoracic additional level) and 64483 (transforaminal epidural lumbar/sacral).
Prior Authorization
Examples of procedure codes requiring prior authorization
Specific Medicare procedure codes and descriptions require prior authorization, including echocardiography codes 93312 and 93350 and neuropsychological testing codes 96132 and 96130; providers must obtain prior authorization before billing these services.
Prior Authorization
Cardiac, transplant, neuromodulation, genomic
Cardiac device, transplant/islet cell, neuromodulation and advanced imaging/genomic assay codes require prior authorization; illustrated entries include 0571T (implantable cardioverter‑defibrillator with substernal electrode) and 0584T–0586T (islet cell transplant codes).
Prior Authorization
Genomics, ophthalmology, grafts, pacemakers, surgical/device
Genomic sequencing panels, ocular drainage devices, skin graft/skin substitute procedures, leadless pacemaker procedures and other surgical/device codes require prior authorization; examples include 0454U, 0466U, 0474T, 15015 and Q4305.
Note
Prior authorization required — code list (partial)
This section (partial) lists specific procedure and HCPCS/Q‑codes that require prior authorization; providers should reference the payer’s list for applicable codes and obtain authorization before services.
Note
Prior authorization update note
Multiple codes and device/product Q‑codes and descriptions are enumerated as requiring prior authorization; note: the list was updated 2/11/2026.
Terminology & Short Definitions
PET/CT imaging descriptions
DefinitionPET/CT combines positron emission tomography (PET) — which detects positron-emitting radiopharmaceuticals to show metabolic or biochemical activity — with computed tomography (CT) that produces thin, cross-sectional anatomical images; fused PET/CT corrects PET spatial-resolution limitations by providing precise anatomical correlation.
Limited-area PET/CT (report code)Report 78814 is used for concurrently acquired PET/CT imaging of a limited area (e.g., head and neck only).
Skull base to mid-thigh PET/CT (report code)Report 78815 is used for PET/CT imaging from the skull base to the mid-thigh.
Whole-body PET/CT (report code)Report 78816 is used for whole-body PET/CT scanning.
Clinical rationalePET is highly sensitive to tumor metabolic activity while CT provides detailed size, shape, and location; combined PET/CT improves diagnostic accuracy by fusing metabolic and anatomic data.
Prior authorization
Prior authorization — definitionA requirement that certain items or services listed by procedure code must receive payer approval before they are provided or billed.
Applies toProcedure codes enumerated on the payer-maintained list (Medicare/CPT/HCPCS/Q/J codes).
Update noteList content is maintained and updated (example update date shown: 2/11/2026).
Prior authorization list (code-based)
Update datePrior Authorization list updated: 2/11/2026.
Included items (examples)Application of skin autograft (15018); tissue cultured skin autograft (15150); leadless pacemaker insertion/removal/replacement (0823T, 0824T, 0825T).
ScopeA compilation of Medicare-coded procedures, HCPCS, CPT, and device/Q-codes requiring prior authorization.
Prior Authorization — requirement
Requirement summaryProviders must obtain prior authorization for items and services enumerated by code on the payer's list before providing or billing those services.
Where statedDocument repeatedly states that listed procedure codes require prior authorization (see list headers and provider action notes).
Provider actionRequest authorization in advance when billing for listed codes; failure to obtain prior authorization may affect coverage/payment.
Prior authorization
Prior authorization — definition (duplicate)Requirement for payer approval of certain procedure-coded items/services prior to provision or billing.
Examples listedThe document lists numerous Medicare/HCPCS/CPT procedure codes that require prior authorization.
MaintenanceList entries and update timestamps (e.g., 2/11/2026) indicate active maintenance of the PA list.
Prior Authorization List (section)
Section summaryThis section compiles Medicare procedure/CPT/HCPCS codes and descriptions that require prior authorization; examples include molecular/genetic panels and select injections/procedures.
Code examples81450 (targeted genomic sequence analysis panel), 81300 (MSH6 gene analysis), 81170 (ABL1 gene analysis).
UseReference section when determining whether a genomic/molecular test or related procedure requires prior authorization.
Prior authorization
Prior authorization — definition (short)Payer approval required before services listed by procedure code are provided or billed.
Document contextHeader and repeated statements in the list indicate prior authorization is required for enumerated items.
Provider implicationProviders should consult the list and obtain authorization prior to service delivery for listed codes.
Prior authorization
Prior authorization — definition (short)Prior authorization is required for the listed power wheelchair components and accessories before coverage/payment.
Example codesE2369, E2370, E2372, E2373 (power wheelchair components/accessories).
ImplicationReplacement parts and specialized wheelchair accessories on the list require preauthorization per payer policy.
Listed codes
Listed codes — definitionHCPCS/Medicare procedure codes shown in the document identify items/services that require prior authorization under the payer's policy.
Code systems representedMedicare procedure codes, CPT, HCPCS, J/Q temporary codes and device/product codes are included.
Provider noteConfirm requirement by checking the payer list entry for each specific code before service provision.
Prior authorization list (Medicare codes)
Medicare code list — usageMedicare procedure codes and descriptions listed indicate services requiring prior authorization per this payer-maintained list.
Examples includedImaging codes (70540), genomic sequence analysis (0364U), interventional injections (64480).
ActionProviders must request prior authorization for the Medicare-coded services listed prior to rendering care or submitting claims.
Prior Authorization list
Payer-maintained PA list — definitionA payer-maintained list of procedure codes and descriptions for which providers must obtain approval before services are rendered or billed.
List characteristicsIncludes Medicare procedure codes, CPT/HCPCS, U/Q/J codes, genomic panels, imaging, devices, drugs, and DME.
Reference instructionProviders should consult this list and the associated code descriptions when determining PA requirements.
Office visits associated with supervised esketamine nasal administration
G2082 / G2083 — office visits for supervised esketamine administrationG2082: Office/outpatient visit for established patient with supervision and provision of up to 56 mg esketamine nasal self-administration, includes 2 hours post-administration observation; G2083: Same for greater than 56 mg.
Service contextThese office/outpatient E/M visits are associated with supervised esketamine nasal administration including required observation time.
PA implicationThese codes are listed in the PA list and require prior authorization when included on the payer's list.
Autologous platelet rich plasma (PRP) for diabetic chronic wounds/ulcers (includes administration)
Autologous PRP for diabetic chronic wounds/ulcers — codeG0465: Autologous platelet rich plasma (PRP) for diabetic chronic wounds/ulcers, using an FDA-cleared device; includes administration, dressings, phlebotomy, centrifugation, and all related services.
Service componentsProcedure description explicitly includes administration and associated tasks (dressings, phlebotomy, centrifugation).
PA implicationG0465 is listed as requiring prior authorization per the payer list.
Prior Authorization
Prior Authorization — definition (duplicate)Payer approval required in advance for listed procedure-coded items/services.
Document emphasisThe header and multiple list entries reiterate the PA requirement for enumerated codes.
Provider actionVerify PA requirement on the payer list prior to service delivery and claim submission.
Genomic sequence analysis panel
Genomic sequence analysis panel — definitionA genomic sequence analysis panel sequences multiple genes for a given condition and specifies a minimum number of genes to be included (examples: hearing loss panels, aortic dysfunction panels, mitochondrial gene panels).
Panel examples81410 (aortic dysfunction/dilation panel, ≥9 genes), 81442 (Noonan spectrum disorders panel, ≥12 genes), large mitochondrial panels (≥100 genes) referenced.
Use casePanels are used for hereditary/rare disease, oncology, and other indications where multi-gene interrogation is required; listed panels require prior authorization.
Neuropsychological testing evaluation services
Neuropsychological testing evaluation services — definitionEvaluation services by a qualified professional that include integration of patient test data, interpretation of standardized test results and clinical data, clinical decision making, treatment planning, reporting, and interactive feedback; codes listed for first hour and additional hours.
Code examples96132 (neuropsychological testing evaluation services; first hour), 96130/96131 (psychological testing evaluation services; first hour and additional hours).
PA implicationThese testing/evaluation service codes are listed and require prior authorization per the payer list.
Prior authorization
Prior authorization — short requirementPrior authorization must be obtained for items and services enumerated by procedure code on the payer's list prior to provision or billing.
List referenceMultiple list headers and provider action notes in the document state this requirement.
Provider responsibilityCheck the payer-maintained list for PA requirements for specific procedure codes before scheduling or rendering services.
Prior authorization code list
Prior authorization code list — descriptionEntries labeled 'Medicare, Procedure Code' with accompanying descriptions indicate services requiring prior authorization as listed.
ExamplesA broad set of codes are shown (imaging, genomic testing, therapy, implants, and others) — see entries such as 66840, 66920, and numerous genomic U/CPT codes for examples.
ImplicationProviders must obtain authorization for these enumerated Medicare procedure codes prior to service delivery or claim submission.
Policy Summary
PayerBlue Cross Blue Shield - Wisconsin
PolicyList of items and services requiring prior authorization (code list)
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateFeb 11, 2026
Last ReviewFeb 11, 2026
Next Review DateFeb 11, 2026
Key ActionProviders must request prior authorization for the procedure and HCPCS/CPT codes listed before submitting claims.
SourceLink
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