CurrentBlue Cross Blue Shield - WisconsinPolicy N/A
List of items and services requiring Prior Authorization
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This document lists Medicare procedure and drug codes for items and services that require prior authorization under Blue Cross Blue Shield - Wisconsin; it applies to billed services subject to the payer's authorization process.
Policy Summary
PayerBlue Cross Blue Shield - Wisconsin
PolicyList of items and services requiring Prior Authorization
Policy CodePolicy N/A
Change TypeNo material change
Effective DateFeb 11, 2026
Last ReviewFeb 11, 2026
Next Review DateN/A
Key ActionProviders must obtain prior authorization for the listed Medicare procedure and HCPCS codes before performing or billing those services.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
20+document chunks in this partial list
manyprocedure codes enumerated
drugs & procedurestypes of items listed
Partialfile scope
Items and Services Requiring Prior Authorization
General prior authorization requirement
Prior authorization is required for the items and services listed below. Providers must obtain prior authorization before performing or billing for these services. Failure to obtain prior authorization when required may result in denial of payment.
all of the following codes and services require prior authorization prior to services being rendered or billed:
- Infusion and immunoglobulin products (e.g., intravenous immune globulin codes and related administration)
- Durable medical equipment and power wheelchair groups and accessories (e.g., E0954–E0992 series, E2359–E2383, K-series power wheelchair codes K0040–K0879, K0800–K0879, K1007)
Representative Codes and Code Samples
Sample Medicare CPT/HCPCS codes listedmixed
| 27331 | Arthrotomy, Knee; W/Joint Exploration, Bx/Removal, Loose/Fb |
| 27138 | Revision, Total Hip Arthroplasty; Femoral Component Only, W/Wo Allograft |
| 29873 | Arthroscopy, Knee, Surgical; W/Lateral Release |
| 93461 | Catheter placement in coronary artery(s) for coronary angiography... with right and left heart catheterization |
| G0399 | Home sleep test (HST) with type III portable monitor... |
| 0216T | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint... |
sample listed HCPCS/CPT/Medicare codes from segmentmixed
sample procedure codes listedCPT
Power mobility and accessoriesHCPCSCovered
Sample procedure codes from this chunkmixedCovered
| K0891 | POWER WHEELCHAIR, GROUP 5 PEDIATRIC, MULTIPLE POWER OPTION, SLING/SOLID SEAT/BACK, PATIENT WEIGHT CAPACITY UP TO AND INC. |
| K0040 | Adjustable Angle Footplate |
| K0051 | Cam release assembly, footrest or legrest, replacement only, each |
| 15150 | Tissue cultured skin autograft, trunk, arms, legs; first 25 sq cm or less |
Examples of listed procedure/HCPCS/CPT codes in this segmentmixedCovered
| L5926 | Addition to lower extremity prosthesis, endoskeletal, knee disarticulation, end |
| Q4287 | Dermabind dl, per square centimeter |
| Q4301 | Activate matrix, per square centimeter |
| Q5148 | Injection, filgrastim-txid (Nypozi), biosimilar, 1 mcg |
| E0743 | External lower extremity nerve stimulator for restless legs syndrome, each |
| 0546T | Radiofrequency spectroscopy, real time, intraoperative margin assessment |
| E0604 | Breast pump, hospital grade, electric (AC and/or DC), any type |
| 15015 | Application of skin autograft; first 480 sq cm or less |
| 81449 | Targeted genomic sequence analysis panel, solid organ neoplasm, 5-50 genes |
| 97156 | Family adaptive behavior treatment guidance, each 15 minutes |
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Document update date
Document update dateUpdated : 2/11/2026
Policy effective/last review dateEffective/Last review: 2026-02-11
Update header appears on multiple pages'Updated : 2/11/2026' repeated across list segments
Test panel size thresholds referenced (diagnostic panels with thresholds)
Therapeutic drug monitoring panelsExamples include panels of 36+ drugs, 80+ drugs, 110+ drugs (LC‑MS/MS reporting), and panels reported as 90+ or 110+ drugs/substances
Genomic panel size rangesExamples include targeted genomic panels: 5–50 genes, 51+ genes, 83+ genes, and panels interrogating 311+ genes
Laboratory method referencedLC‑MS/MS reporting for multi‑drug therapeutic monitoring panels
per therapeutic dose (cellular therapies / CAR-T)
Unit of measure for cellular/CAR‑T therapiesPer therapeutic dose (e.g., Q2054/Q2055/Q2056 entries list CAR‑T products 'per therapeutic dose')
Example CAR‑T codes citedQ2054, Q2055, Q2056 listed with per therapeutic dose unit
Other gene therapy entries with same unitJ1414 (fidanacogene elaparvovec) noted 'per therapeutic dose'
Provider Requirements and Actionable Highlights
Prior Authorization
Prior Authorization Required
Prior Authorization Required — Providers must obtain prior authorization before performing or billing for the following services, equipment, devices, drugs, advanced therapies, diagnostics, and molecular/genetic tests. Failure to obtain prior authorization may result in claim denial or delayed payment.
- Prior authorization required for enumerated services including surgical procedures, imaging (CT, MRI, PET), radiation therapies (SRS, SBRT), implantable devices, neurostimulator implantation and programming, spine instrumentation and fusion procedures, arthroplasty revisions, transplant-related procedures, specialty drug infusions and injections, and select durable medical equipment (power wheelchairs, seating systems, oxygen equipment).
- Sample entries requiring prior authorization (partial list): J2860 (siltuximab injection), J1599 (IVIG non-lyophilized), 19298 (breast brachytherapy catheter placement), 57155 (uterine tandem/ovoid insertion), 63621/63620 (stereotactic radiosurgery spinal lesions), 77371-77373 (SRS/SBRT delivery).
- Additional entries include advanced imaging and interventional procedures: CT and MRI codes (70460, 70480, 70540-70543, 72128, 72131, 72147, 72158), PET codes (78811, 78812, 78814-78816), left heart catheterization, fluoroscopy/CT-guided injections (64480, 64491, 64494-64495), and selected sleep studies and home sleep testing (G0399, 95783, 95806).
- Selected codes (partial) requiring prior authorization: many injectable specialty drugs and biologics (J0129, J0178, J0202, J0221, J2350, J2356, J2357, J2778, J3590, J9318, J9356, J9353), advanced therapeutics (Q2056, Q5123, Q2041, Q4412), and CAR-T / cell therapies (Q2056, Q2041).
- Prior authorization required for equipment, wheelchair components and accessories (extensive E09xx–E26xx series and power wheelchair K08xx/K07xx/K08xx/K08xx entries) including power wheelchair groups K0824, K0837-K0869, K1007, and many E1xxx accessory codes (E0954–E1060, E2359–E2397, E2364, E2374, E2378, E2381–E2383, E2386–E2395).
- Itemized codes and devices requiring prior authorization (examples): cochlear implants and components (69930, L8614, L8627-L8628, L8619), implantable sensors and pulmonary artery pressure systems (C2624), osseointegrated implants (69714, 69717), penile prosthesis insertion (54405), implantable neurostimulator systems and leads (61885, 64505, 64555, 0917T, 0908T), and select wound matrices/grafts (Q41xx series, Q42xx series, A2002, A2019).
- Advanced therapies and diagnostics requiring prior authorization include CAR-T and autologous cell therapies (Q2056, Q2041, Q5123), next-generation sequencing panels and molecular testing (various 0###U codes and molecular pathology CPT/HCPCS: 81401, 81121, 81275, 81292, 81459, 81465, 81470 and multiple 01xxU–05xxU codes), and specialized laboratory tests (0547U, 0340U, 0368U, 0388U, 0405U).
- Examples of procedures and surgical codes requiring prior authorization: major spine procedures and instrumentation (22510, 22534, 22210, 22224, 22612, 22846), joint revision arthroplasty (27138, 27487), complex arthroscopy and reconstructive procedures (29807, 29822, 29824, 29825, 29873, 29879–29885), and transplant/donor procedures (44720-44721, 47133, 48550, 50360).
- Prior Authorization Code List (selected segments, consolidated): refer to enumerated codes across the document including — injectables/biologics (J01xx–J99xx entries listed), DME/HCPCS (E0xxx, K0xxx series), procedure CPT/TC (0xxxx–04xxx and 20000–69999 series), and molecular/genetic tests (0####U and 8#### series).
- Molecular / Genetic Testing Prior Authorization: Molecular pathology and genetic sequencing panels and targeted assays (examples included in list): 0138U, 0179U, 0300U, 0340U, 0368U, 0388U, 0403U, 0405U, 0410U, 0417U, 0440U, 0469U, 0599U, and numerous CPT molecular codes (812xx, 814xx, 81546, 81459, 81465).
Definitions and Formatting Notes
Prior Authorization List — definition and note about listing by Medicare code and description
DefinitionA consolidated list of items and services shown by Medicare procedure/HCPCS/CPT code and short description that require prior authorization from the payer
Presentation noteEntries are shown line‑by‑line as 'Medicare, Procedure Code = <code>' with a short Medicare description
Provider implicationPresence of a code on the list indicates prior authorization must be obtained before billing/coverage
PET/CT definition (Positron emission tomography combined with CT)
PET/CT definitionPositron emission tomography combined with computed tomography: PET provides sensitive metabolic imaging while CT supplies detailed anatomic localization; concurrent PET/CT fuses metabolic and anatomic data
Relevant CPT/HCPCS examplesCodes 78811, 78812, 78814, 78815, 78816 referenced for PET and PET/CT imaging
Clinical notePET alone has spatial resolution limitations corrected by fused PET/CT imaging for precise localization
Image-guided spinal injections — note about add-on codes and imaging guidance
Image‑guided spinal injections — noteFacet joint and transforaminal epidural injections in the list specify imaging guidance (fluoroscopy or CT) and include add‑on codes for additional levels (listed separately)
Examples of listed codes64480, 64484, 64491, 64492, 64493, 64494, 64495 referenced for image‑guided spinal injections
Coding practice noteAdditional levels are billed as separate 'add‑on' entries in the list (List separately in addition to code for primary procedure)
Prior authorization list (Medicare-coded services) — formatting definition
Formatting definitionLine items are presented by Medicare coding line: 'Medicare, Procedure Code = <code>. Medicare, Description = <short description>'
Coding systemsEntries include CPT, HCPCS/Q/J codes and Medicare‑specific procedure formatting
Use in documentThis line‑item format is used throughout the prior authorization list to enumerate covered codes
sleep study (unattended) — short definition
Sleep study (unattended) — short definitionUnattended sleep study: simultaneous recording with minimum of heart rate, oxygen saturation, and respiratory analysis (eg, by airflow or peripheral arterial tone)
Example code95801 referenced as 'sleep study, unattended' in the list
ContextListed under items requiring prior authorization when shown in the document
Prior Authorization — short label
Short labelPrior Authorization
MeaningA payer requirement that approval be obtained before certain items or services will be covered
Appears as headerPresented as 'List of items and service that require Prior Authorization' and includes update date
Prior authorization list format — items shown by Medicare code and short description
List formatItems shown by Medicare procedure/HCPCS/CPT code with a short Medicare description (line‑by‑line)
Example line'Medicare, Procedure Code = <code>. Medicare, Description = <short description>'
IncludesProcedure codes, J/Q codes, genomic test codes and per‑unit measures where applicable
Prior Authorization list — simple label
Simple labelPrior Authorization list
UsageUsed as the document title/header for enumerated codes requiring prior authorization
Provider action impliedProviders must check the list and obtain authorization for listed items before billing
Items and services that require prior authorization — label
LabelItems and services that require prior authorization
ScopeIncludes drugs, procedures, DME, wound products, advanced diagnostics, and genetic testing codes
ImplicationPresence on list indicates prior authorization requirement prior to coverage/payment
Prior authorization list — label repeated
Label repeatedPrior authorization list
Document usageRepeated as section headings throughout the code list to denote segments of enumerated codes
IndicatorOften accompanied by an 'Updated : 2/11/2026' date stamp
Date shown indicates when listed items were last revised
Date indicator meaningDate shown (e.g., 'Updated : 2/11/2026') indicates when the listed items were last revised
LocationsDate stamp appears on multiple chunks/sections of the document
ImplicationCodes shown reflect the list status as of that update date
Prior Authorization — definition of requirement
Definition of requirementPrior authorization is a payer requirement that approval be obtained before certain listed items or services will be covered
Action for providersObtain prior authorization for any code present on the list before performing or billing the service
Document functionThis document enumerates the specific Medicare procedure and HCPCS codes subject to that requirement
Therapeutic drug monitoring panels — definition and examples of panel sizes
Therapeutic drug monitoring panels — definitionLaboratory panels analyzing large numbers of drugs/substances (examples: 36+, 80+, 90+, 110+ drugs) reported via LC‑MS/MS; used for pain, depression, anxiety, and medication monitoring
Example codes0518U (90+ drugs), 0519U (110+ drugs), and similar panel codes referenced in the list
Reporting methodLC‑MS/MS with algorithmic or quantitative reporting noted in descriptions
Line-item format for code entries — 'Medicare, Procedure Code = <code>'
Line‑item format example'Medicare, Procedure Code = <code>' used as the line‑level entry format throughout the list
Followed by descriptionEach line continues with 'Medicare, Description = <short description>'
Used for clarityStandardized format supports quick lookup and crosswalk to coding systems
Prior Authorization (label repeated)
LabelPrior Authorization
Document roleHeader/section label used repeatedly to denote the payer's authorization requirement list
Associated dateFrequently paired with the update stamp 'Updated : 2/11/2026'
unit of measure used for skin substitute / amniotic membrane products — 'per sq cm'
Unit of measure for skin substitutes/amnion productsPer sq cm (per square centimeter) used for many listed skin substitute and amniotic membrane products
Example codesQ4186, Q4187, Q4301, Q4292 and others list 'per square centimeter' in descriptions
ImplicationAuthorization and billing units are based on area (sq cm) for these products
unit of measure used for cellular therapies and CAR-T products — 'per therapeutic dose'
Unit of measure for cellular therapies/CAR‑TPer therapeutic dose (used for CAR‑T and other cell therapy codes listed)
Example CAR‑T codesQ2054 (lisocabtagene), Q2055 (idecabtagene), Q2056 (ciltacabtagene) shown with 'per therapeutic dose'
Billing implicationAuthorization and payment evaluated per therapeutic dose rather than per mg or per administration
Listed procedure or code — note about prior authorization list entry format
Listed procedure or code — noteEach prior authorization entry is shown as a listed procedure or code line referencing the Medicare procedure code and short description
Entry usePresence on the list designates the item/service as subject to prior authorization
Cross‑referenceLine format facilitates mapping to provider billing codes for authorization requests
Molecular/genetic testing — note that genomic/molecular testing panels are included
Molecular/genetic testing includedGenomic and molecular testing panels and sequence analysis codes (eg, 5–50 gene panels, 51+ genes, whole mitochondrial genome, targeted panels, single‑gene analyses) are included in the prior authorization list
Example codes81459, 81455, 81465, 81470, 0138U, 0179U and numerous U‑codes/other genomic CPT codes are listed
ImplicationPrior authorization required for listed molecular/genetic testing procedures before coverage
Policy Summary
PayerBlue Cross Blue Shield - Wisconsin
PolicyList of items and services requiring Prior Authorization
Policy CodePolicy N/A
Change TypeNo material change
Effective DateFeb 11, 2026
Last ReviewFeb 11, 2026
Next Review DateN/A
Key ActionProviders must obtain prior authorization for the listed Medicare procedure and HCPCS codes before performing or billing those services.
SourceLink
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