List of items and service that require Prior Authorization
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This document lists Medicare procedure and HCPCS/U codes (items and services) that require prior authorization for the payer; it affects providers submitting prior authorization requests to Blue Cross Blue Shield - Wisconsin.
Multiple code entries and descriptions updated with a revision date of 2/11/2026.
Items and Services Requiring Prior Authorization
Prior Authorization Codes (partial)
Codes listed below require prior authorization.
Prior Authorization List Entries
Tests/procedure codes (examples) that require prior authorization from the payer:
Prior authorization required tests (partial list)
Partial list of tests/procedures requiring prior authorization; entries include panel size or minimum gene counts where specified.
Prior Authorization Requirement
Codes appearing in this document portion require prior authorization.
Prior Authorization code list (partial)
Partial extract — procedure and drug codes in this window require prior authorization.
Prior authorization stance for listed codes
Payer stance: the following listed Medicare procedure and drug codes require prior authorization.
Prior authorization list (partial)
Partial list of codes and descriptions requiring prior authorization (examples shown).
Prior Authorization Requirement (list)
Items and services enumerated here require prior authorization as indicated by the payer.
Prior authorization required codes (partial list)
Codes listed in this excerpt require prior authorization.
Prior authorization applicability by code
Applicability: codes in these sections require prior authorization as listed.
Prior Authorization Required Items (segment 11)
Segmented list — items and services shown here require prior authorization.
Prior Authorization Required Codes (excerpt)
Codes listed below (wheelchair and accessory HCPCS E-codes among others) require prior authorization before claim processing.
Prior authorization required — code list (excerpt)
Selected codes in radiology, respiratory, therapy and power mobility categories require prior authorization.
Prior Authorization Requirements (code list excerpt)
Excerpted items and services that require prior authorization (imaging, procedures, and surgical codes).
Prior authorization requirement list (partial)
Partial list (updated 2/11/2026) — providers must obtain prior authorization for the following example procedure and HCPCS codes before rendering services.
Representative Codes and Coding Notes
| 0237U | Cardiac ion channelopathies genomic sequence analysis panel |
| 0235U | PTEN full gene analysis |
| 0236U | SMN1 and SMN2 full gene analysis |
| 81455 | Targeted genomic sequence analysis panel, 51+ genes |
| 81223 | CFTR full gene sequence |
| 81224 | CFTR intron 8 Poly-T analysis |
| 81479 | Unlisted molecular pathology procedure |
| 81381 | HLA Class I Typing, High Resolution |
| 81170 | ABL1 gene analysis, variants in kinase domain; targeted sequence analysis (example cited) |
| 81165 | BRCA1 gene analysis; full sequence analysis (example cited) |
| 81120 | IDH1 common variants (eg, R132H, R132C) |
| 81203 | APC duplication/deletion variants |
| 81201 | APC full gene sequence |
| 81194 | NTRK translocation analysis |
| 81235 | EGFR common variants |
| 81270 | JAK2 V617F variant |
| 81415 | Exome sequence analysis |
| 81425 | Genome sequence analysis |
| 81522 | Oncology (breast), mRNA, gene expression profiling by RT-PCR of 12 genes |
| 81523 | Oncology (breast), mRNA, NGS gene expression profiling of 70 content genes |
| 0553U | Reproductive medicine, analysis of 24 chromosomes from embryonic trophectoderm |
| 81471 | X-linked intellectual disability duplication/deletion gene analysis (>=60 genes) |
| 0500U | Injection, donanemab-azbt, 2 mg |
| 0523U | Oncology (solid tumor), DNA, qualitative, NGS of SNV and indels in 22 genes |
| 0343U | Oncology (prostate), exosome-based analysis of 442 sncRNAs |
| 0331U | Optical genome mapping for copy number alterations and gene rearrangements |
| 81275 | KRAS variants in codons 12 and 13 |
| 81245 | FLT3 ITD variants |
| J7208 | Injection, factor viii, (antihemophilic factor, recombinant), pegylated-aucl, (jivi), 1 i.u.. |
| 0971T | Ablation, malignant breast tumor(s), percutaneous, laser, including imaging guidance when performed, each tumor. |
| Q4315 | RegeneLink Amniotic Membrane Allograft, per sq cm. |
| J3398 | Injection, voretigene neparvovec-rzyl, 1 billion vector genomes. |
| 0586T | Islet cell transplant, includes portal vein catheterization and infusion, including all imaging... |
| 92507 | Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual |
| 92508 | Treatment of speech, language, voice, communication, and/or auditory processing disorder; group, 2 or more |
| 92609 | Therapeutic services for the use of speech-generating device, including programming and modification |
| 92526 | Treatment, Swallowing Dysfunction &/Or Oral Function, Feeding |
| K08xx–K08xx | Multiple power wheelchair and power mobility HCPCS K-codes (groups 1–5, various capacities). |
| 0635T | Ct Scan, Maxillofacial Area; W/O Contrast Matl. |
| C8903 | Magnetic resonance imaging with contrast, breast; unilateral. |
| 93313 | Echocardiography, transesophageal, real-time with image documentation (2D) |
| 27446 | Arthroplasty, Knee, Condyle & Plateau; Medial/Lateral Compartment |
| 27486 | Revision, Total Knee Arthroplasty, W/Wo Allograft; 1 Component |
| 71552 | Mri, Chest; W/O Contrast Matl(S), Followed By Contrast Matl(S) & Further Sequences |
| 78813 | Positron emission tomography (PET) imaging; whole body |
| 33276 | Insertion of phrenic nerve stimulator system |
| 72146 | Mri, Thoracic Spine; W/O Contrast |
| 70553 | Mri, Brain; W/O Contrast, Then W/Contrast & Further Sequences |
What Providers Must Do
Prior Authorization Required - Molecular/Genetic Tests
Prior authorization is required for the following molecular, genetic, genomic tests and related injections. Providers must obtain prior authorization before scheduling or performing these services. This includes oncology panels, single-gene analyses, whole genome/mitochondrial testing, pharmacogenomic panels, cell‑free DNA assays, transplant donor‑derived cfDNA testing, targeted NGS panels, and other molecular pathology procedures listed below.
- Examples include (not exhaustive): 0237U, 0235U, 0236U, 0234U, 0267U, 0265U, 81170, 81165, 81120, 81522, 81523, 0553U, 81471, 81470, 0552U, 81465, 0555U, 81599, 0045U, 0022U, 0019U, 0157U, 0264U, 0162U, 0160U, 0159U, 0158U, 0299U, 0327U, 0391U, 0439U, 0493U, 0488U, 0481U, 0475U, 0474U, 0473U, 0538U, 0532U, 0540U, 0349U, 0318U, 81407, 81243, 81313, 0315U, 0536U, 81357, 81460, 81207, 0500U, 0523U, 0343U, 0331U, 81275, 81245, 81293, 0138U, 0569U, 0392U, 0350U, 0460U, 0485U, 0560U, 0070U, 0242U, 0332U, 0438U, 0405U, 0417U, 0297U, 0154U, 0534U, 0020M, 0478U, 0489U, 81210, 81334, 81493, 81121, 81162, 81172, 81254, 0300U, 0364U, 0049U, 0177U, 0137U, 0020M, 0307U, 0071U, 81363, 81255, 0315U, 0536U, 0536U, 0536U
Prior authorization required — genetic/molecular tests
Genetic and molecular oncology tests, pharmacogenomic testing, prenatal cfDNA assays, and other genetic/genomic procedures require prior authorization. This list includes single‑gene tests, multi‑gene panels, tumor sequencing (DNA/RNA), methylation assays, optical genome mapping, whole genome sequencing, microarray methylation, and other specialized molecular pathology procedures.
Genetic and genomic testing and select injections requiring prior authorization
Certain genetic and genomic tests used to guide oncology therapy selection, assess minimal residual disease, or provide comprehensive tumor profiling require prior authorization. This also includes specified injections that are gene‑therapy or genetically-derived products.
Home health and hospice services requiring prior authorization
Home health and hospice services listed below require prior authorization. Obtain authorization prior to providing home health or hospice skilled services, therapy, or aide visits.
Specialty drugs, biologics, and device/procedure codes requiring prior authorization
Specialty drugs, biologics, CAR‑T, gene therapies, and selected high-cost injections/devices require prior authorization. This includes both branded, biosimilar, and novel agents listed in the payer's code list.
Prior Authorization required - codes list
Providers must obtain prior authorization for the extensive list of procedure and HCPCS/CPT codes in the payer's prior authorization list. The list includes surgical procedures, imaging, radiotherapy, implants, and many other services. Refer to the full code list prior to scheduling.
Additional Prior Authorization Items (devices and services)
Additional devices, supplies, and services require prior authorization. This includes wound matrices, amniotic membranes, graft products, specialized radiopharmaceuticals, monitoring devices, and selected DME accessories.
Prior Authorization List (continued)
This section continues the payer's comprehensive prior authorization list. Ensure prior authorization is obtained for any code included in the payer's roster before service delivery.
Prior Authorization List (additional)
Additional codes for prosthetics, injections, imaging, and biosimilars require prior authorization. Confirm authorization for orthotics/prosthetic additions and specified injectable agents.
Prior Authorization List (labs and injections)
Laboratory assays, specialized immunoassays, therapeutic drug monitoring panels, beta‑amyloid testing, and molecular pathology panels listed require prior authorization.
Prior Authorization List (surgical/devices)
Various surgical procedures, implantable devices, transplants, and complex operative services require prior authorization. This includes heart/lung transplant codes, organ procurement and transplant procedures, and advanced reconstructive surgeries.
Prior Authorization List (transplants, implants, DME)
Transplants, implantable devices, and durable medical equipment (DME) items require prior authorization. This includes ventricular assist devices, artificial hearts, dialysis machines, wearable artificial kidney, and other complex DME and implantable device codes.
Therapy and modality codes requiring prior authorization
Therapy, modality, and behavior treatment codes require prior authorization when listed. This includes individual and group speech, occupational, physical therapies, adaptive behavior treatment, and wheelchair management/training.
J-code injectables and biologics requiring prior authorization
Many J‑code injectables and biologics require prior authorization. This includes enzyme replacements, immunoglobulins, monoclonal antibodies, CAR‑T related codes, fusion proteins, and gene therapy injections.
DME, wheelchair, and accessory codes requiring prior authorization
Power and manual wheelchair components, accessories, and many DME codes require prior authorization. This includes power wheelchair groups, accessory parts, seating systems, batteries, drive wheels, and specialty components.
Expanded Prior Authorization List
The payer's expanded prior authorization list includes additional prosthetic/orthotic items, wheelchair accessories, power seating components, and other specialty DME and supplies. Confirm authorization for expanded components prior to delivery.
Wheelchair Accessories Prior Authorization
Wheelchair accessories and power seating system components require prior authorization. This includes tilt/recline systems, elevating leg rests, ventilator trays, specialized seating supports and pediatric seating systems.
Prior Authorization — Power Mobility and Complex DME (sample)
Power mobility, complex DME, and example entries for authorization: power operated vehicles, custom power wheelchair systems, HKAFO powered systems, and other complex mobility devices require prior authorization. Use the payer list to verify specific model/group codes.
Update note
This prior authorization list was updated on 2/11/2026. Providers must reference the most current list before authorizing or providing services. Contact the payer's provider services or utilization management for clarifications and to submit authorization requests.
- Update note: list effective/updated 2/11/2026 — verify for later updates prior to service date.
Definitions and Coding Guidance
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