List of items and services requiring prior authorization (Medicare procedure code listing)
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This document lists durable medical equipment (DME), wheelchair components/accessories, respiratory and other device procedure codes that require prior authorization for Blue Cross Blue Shield - Wisconsin members. It affects providers and suppliers submitting claims for the listed Medicare procedure codes.
No material clinical or coverage changes in this revision.
Services and Procedure Codes Requiring Prior Authorization
Prior authorization code list (partial — this is one part of a multi-part listing)
This section enumerates procedure codes and descriptions for items and services that require prior authorization.
See full policy for complete list and documentation requirements.
Prior authorization coverage criteria — listed items (partial)
Items and services listed by Medicare/HCPCS procedure code in this document require prior authorization before coverage will be approved.
Codes requiring prior authorization (partial list)
Codes listed below require prior authorization prior to coverage; specific coverage criteria and documentation requirements are not included in this excerpt.
Prior authorization required codes (partial)
Listed procedure codes require prior authorization.
Prior authorization coverage stance
Listed services require prior authorization before billing/ordering.
Prior authorization requirement and panel composition notes
Procedure codes listed require prior authorization; some entries include required gene lists or minimum gene counts for panels.
Panel composition examples
- 81419 — Epilepsy genomic sequence analysis panel; must include specified genes such as ALDH7A1, SCN1A, SCN2A, etc.
- 81434 — Hereditary retinal disorders panel; must include sequencing of at least 15 specified genes
- 81430 — Hearing loss genomic panel; must include sequencing of at least 60 specified genes
Prior authorization code list (excerpt)
Procedure codes and brief descriptions requiring prior authorization include (non-exhaustive examples from this segment):
Example codes (excerpt)
- 0543U — Urine diagnostic algorithm reported as a probability index for bladder
- 0540U — Next-generation sequencing of 517 genes for solid tumor DNA from FFPE
- 81552 — Uveal melanoma mRNA gene expression profiling, 15 genes
- 81445 — Targeted genomic sequence analysis panel, solid organ neoplasm, 5-50 genes
- 0485U — Cell-free DNA and RNA NGS with interpretive report for germline and tumor variants
Prior authorization requirement - code list
Codes listed in this part require prior authorization before service is rendered or billed.
Prior authorization required codes (partial)
Codes listed require prior authorization.
Prior authorization code list (excerpt)
Codes listed below require prior authorization as indicated by the payer list.
Prior authorization requirement — code list
Codes in this list require prior authorization before claims will be processed as covered.
Authorization listing (codes only)
This excerpt lists codes that require prior authorization; no detailed clinical criteria or coverage conditions are included on these pages.
Prior authorization requirement - code list
Listed services and supplies require prior authorization as indicated by the presence of the code in this list.
Listing-based prior authorization criteria
Codes listed below are subject to prior authorization.
Prior authorization required codes (excerpt)
Codes listed below require prior authorization as indicated by the payer.
Representative Codes and Code Groups (examples from list)
| E2340 | Power wheelchair accessory, nonstandard seat frame width, 20-23 inches |
| E2508 | Speech generating device, synthesized speech, requiring message formulation by spelling |
| K0003 | Lightweight Wheelchair |
| K0848 | POWER WHEELCHAIR, GROUP 3 STANDARD, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY UP TO AND INCLUDING 300 POUNDS |
| L0488 | TLSO, Triplanar Control, One Piece Rigid Plastic Shell |
| L3918 | Hand orthosis, metacarpal fracture orthosis, prefabricated, off-the-shelf |
| L3981 | Upper extremity fracture orthosis, humeral, prefabricated, includes shoulder cap design |
| L9900 | Orthotic and prosthetic supply, accessory, and/or service component of another HCPCS L code |
| K0843 | POWER WHEELCHAIR, GROUP 2 HEAVY DUTY, MULTIPLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 301 TO 450 POUNDS |
| K0854 | POWER WHEELCHAIR, GROUP 3 EXTRA HEAVY DUTY, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY 601 POUNDS OR MORE |
| 97129 | Therapeutic interventions that focus on cognitive function, direct (one-on-one), initial 15 minutes |
| 90913 | Biofeedback training, perineal muscles, including EMG and/or manometry, each additional 15 minutes |
| 92507 | Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual |
| 97164 | Reevaluation of physical therapy established plan of care requiring components |
| 97124 | Therapeutic Procedure; Massage |
| 97116 | Therapeutic Procedure; Gait Training |
| 97113 | Therapeutic Procedure; Aquatic Therapy w/Exercises |
| 97530 | Therapeutic activities, direct one-on-one each 15 minutes |
| 97535 | Self-care/home management training, direct one-on-one each 15 minutes |
| 97168 | Reevaluation of occupational therapy plan of care |
| 97755 | Assistive technology assessment with written report, each 15 minutes |
| 97150 | Therapeutic procedures, group (2+ individuals) |
| 97140 | Manual therapy techniques, each 15 minutes |
| 0162U | Hereditary colon cancer (Lynch) targeted mRNA sequence analysis panel |
| 0071U | CYP2D6 full gene sequence analysis |
| 0242U | Targeted genomic sequence analysis panel, cfDNA 55-74 genes |
| 0332U | Oncology pan-tumor genetic profiling of 8 epigenetic markers |
| 0539U | Oncology ctDNA 152 genes, next-generation sequencing |
| 0560U | Oncology MRD genomic sequence analysis, cfDNA, whole blood and tumor tissue baseline |
| 81162 | BRCA1 and BRCA2 full sequence and duplication/deletion analysis |
| 81161 | DMD deletion and duplication analysis |
| 0138U | BRCA1/BRCA2 mRNA sequence analysis (listed separately) |
| 93303 | Transthoracic echocardiography, congenital cardiac anomalies; complete |
| 93304 | Transthoracic echocardiography, congenital cardiac anomalies; follow-up/limited |
| 93315 | Echocardiography, transesophageal, congenital anomalies; with probe, image, interpretation & report |
| 93317 | Echocardiography, transesophageal, congenital anomalies; image, interpretation & report |
What Providers Must Do (Prior Authorization and Submission Requirements)
Prior authorization required items (partial list)
Lists Medicare procedure codes that require prior authorization for items and services (durable medical equipment, wheelchair accessories, respiratory devices, pediatric beds, therapy devices).
- Provider must obtain prior authorization for the Medicare/HCPCS procedure codes listed before the service is provided or billed.
Prior authorization required — selected DME/wheelchair accessories and speech devices
Provider must obtain prior authorization for the listed power wheelchair accessories, speech-generating devices/software, and wheelchair accessories (examples: E2340, E2330, E2331, E2328, E2326, E2341, E2322, E2323, E2511, E2508, E2506, E2502, E2398, E2397, E2395) prior to providing or billing these items.
Prior authorization required — seating, cushions, wheelchair components, and DME
Numerous seating, cushions, back supports, wheelchair foot/arm components and other DME (examples include E2624, E2625, E2623, E2622, E2617, E2621, E2620, E2619, E2615, E2616, E2613, E2611, E2607, E2612, E2608, E2609, E2606, E2605, E2603, E2632, L3250, E1354) require prior authorization; obtain authorization before provision or billing.
Prior authorization required — power mobility devices and groups
Power mobility devices and related high-cost mobility equipment (multiple K- and E- group codes such as E0761, K0195, K0806, K0801, K0802, K0733, K0848, K0841, K0842, K0838, K0839, K0837, K0836, K0835, K0831, K0829, K0830, K0827, K0823, K0822, K0816, K0815, K0814, K0812, K0808, K0863, K0861, K0860, K0859, K0857, K0856, K0855, K0852, K0853, K0851, K1007, K0899, K0891, K0884) require prior authorization; providers must secure authorization prior to delivery or billing.
Prior authorization required — orthotics, prosthetics, and miscellaneous DME
Orthoses, prosthetic components, powered ROM devices, upper-extremity and other miscellaneous DME (examples: L0488, L0632, L0492, L0974, L3002, L2186, L2134, L2126, L2038, L1970, L1940, L1910, L5940, L5701, L5679, L5671, L5673, L3999, L4055, L3340, L3253, L3252, L3225, L3224, L3030, L3020, L7045, L8702, L7191, L6975, L7008, L7007, L6925, L7181, L6881, L6715) require prior authorization; obtain prior authorization before provision or billing.
Prior Authorization requirement list (partial)
This list identifies items and services that require prior authorization; providers must obtain prior authorization for the listed HCPCS/CPT/Medicare procedure codes before coverage will be approved.
Prior Authorization requirement (excerpt)
Prior authorization is required for the listed procedure codes and services (partial list shown); obtain authorization before providing or billing these services.
Prior authorization required for listed molecular/genomic tests
Provider must obtain prior authorization for the listed molecular and genomic procedure codes and associated descriptions (examples include 0414U, 0379U, 0403U, 81162, 81161, 81171, 81164, 81163, 81224, 81221, 81459, 81458, 81457, 81455) prior to testing or billing.
Prior authorization required — genetic/molecular assays
Lists procedure codes and descriptions for genetic and molecular assays that require prior authorization; providers must secure prior authorization before performing or billing these assays.
Prior authorization requirement — molecular/genetic and diagnostic procedures
Lists specific molecular, genetic, and diagnostic procedure codes and descriptions (examples include 0543U, 0540U, 88365, 0076U, 0179U, 0031U, 0229U, 0438U) that require prior authorization; providers must obtain authorization prior to testing or billing.
Prior authorization — device supplies
Includes supplies and accessories for devices (example: supplies for external tibial nerve stimulator) identified as requiring prior authorization; obtain authorization before dispensing or billing.
Molecular pathology/genetic tests - prior authorization required
This part lists specific molecular pathology and genetic procedure codes that require prior authorization (examples include 0424U, 81256, 81257, 0217U, 0262U, 0016U, 0049U, 0562U); prior authorization must be obtained before testing or billing.
Home health and hospice services - prior authorization required
Home health and hospice service CPT/HCPCS codes (examples: G0151, G0153, G0157, G0493, G0494, G0299, G0152, G0159, G0160) require prior authorization; providers must obtain authorization before rendering or billing these services.
Injectable drugs and biologics - prior authorization required
Numerous injectable drugs, biologics, and biosimilars (examples include J9035, J9144, J9301, J9299, Q2043, Q5110, Q5107 and many other J/Q codes listed) require prior authorization; obtain authorization prior to administration or billing.
Prior Authorization - code list (partial)
This section enumerates procedure and HCPCS/CPT codes that require prior authorization; providers must obtain authorization prior to service delivery or billing.
Prior Authorization Required Codes (excerpt)
This document enumerates specific procedure and supply codes that require prior authorization; providers must obtain authorization before providing or billing the listed items.
Prior authorization required — selected wound care, enteral/parenteral supplies and implants
These Medicare procedure and HCPCS codes (examples shown: A2004, A2006, A2007, B4036, B4035, B4034, B9004, B9002, C9356, C9353, C9355, C9361, 15155) are listed as items and services that require prior authorization; secure authorization prior to provision or billing.
Prior authorization required — hyperbaric, implants, devices and spinal/urologic procedures
Additional codes requiring prior authorization include hyperbaric oxygen (G0277), sinus implants (J7402), virtual reality CBT device (E1905), and multiple spinal and urologic procedures (examples: 63035, 63001, 63017, 63047, 53454, 53451, 63051, 53860). Obtain prior authorization before performing or billing.
Medicare procedure codes requiring prior authorization (excerpt)
Examples of Medicare procedure codes requiring prior authorization shown include cardiac blood pool imaging (69717) and replacement osseointegrated implant, temporal bone (69714); obtain authorization before providing or billing these services.
DME / device / coronary intervention codes
Multiple DME/device and coronary intervention codes (examples: A7035, A7034, A7031, A7033, A7028, A7029, A7030, A7027, A7045, A7046, A7038, A7036, A7037, C9602, C9600) are listed as requiring prior authorization; secure authorization before provision or billing.
Diagnostic/surgical/interventional codes
Sleep testing, oral prosthesis impressions, biologic injections, disc arthroplasty removal/revision, and sacroplasty codes (examples: G0399, G0398, 0964T, 0630T, 0629T, 0095T, 0965T, 0218T, 0200T, 0201T) require prior authorization; obtain authorization prior to testing, procedure or billing.
Prior authorization required codes (partial list)
This section lists individual Medicare procedure and HCPCS/Q-codes and descriptions that require prior authorization; providers must obtain authorization before providing or billing the listed services.
Imaging prior authorization entries
Includes imaging modalities (PET/CT, MRI) and descriptions where prior authorization is required; obtain authorization prior to scheduling or billing these imaging services.
Prior authorization requirement — listed codes
Procedure and HCPCS/Q-codes listed in this section require prior authorization per the policy; providers must secure authorization prior to service delivery or billing.
Imaging and radiation therapy prior authorization
Advanced imaging (PET, MRI, CT) and radiation therapy delivery and planning codes are included in the list of services requiring prior authorization; providers must obtain prior authorization before performing or billing these services.
Prior authorization requirement - list of codes (part 15)
This document lists Medicare procedure codes and descriptions that require prior authorization; providers must obtain authorization before billing these services (part 15 of the list).
Definitions and Code Terms
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