BCBS-WI SHBP Radiation Therapy Prior Auth

Coverage Criteria and Precertification Mapping

Precertification and routing criteria

Covered when prior authorization obtained through AIM as required

AIM prior auth requirement: Prior authorization must be obtained through AIM for specified non-emergency outpatient radiation therapy services (Intensity Modulated Radiation Therapy - IMRT, Proton Beam Radiation Therapy, Stereotactic Radiosurgery/Stereotactic Body Radiotherapy - SRS/SBRT, and brachytherapy) and for listed diagnostic imaging services as indicated in the precertification code list.

Radiation therapy performed as part of an inpatient admission is reviewed through Anthem's inpatient precertification process. Prior authorization through AIM is required for all Anthem members except members for whom SHBP Anthem is secondary coverage.

Precertification mapping (informational)

Codes listed with associated guideline references and responsible party

Code requires review: When a listed CPT/HCPCS/G/S code on the precertification list is assigned to a claim or authorization request AND the entry lists 'Responsible Party = Anthem - SHBP UM' or references AIM, the code is subject to utilization management review per the referenced guideline or AIM program mapping.

Consult the Criteria/Guideline identifier shown with each code (for example CG-SURG-97, CG-DME-15, ING-CC series) for the clinical medical necessity criteria and required documentation.

Prior authorization and guideline linkage

Codes listed with 'Anthem - SHBP UM' are subject to utilization management and must follow the referenced clinical guideline/policy for coverage determination.

Precertification mapping: Provider must obtain prior authorization for codes labeled 'Anthem - SHBP UM' and submit supporting documentation consistent with the cited clinical guideline or surgery policy for medical necessity determination.

The detailed medical necessity criteria and any 'not medically necessary' conditions are contained in the referenced CG-/SURG-/ING- policy documents (e.g., CG-SURG-24, SURG.00037).

Precertification and guideline linkage

Codes requiring review under SHBP utilization management and linked clinical guidelines

Code mapped to UM/CG: The code appears on the SHBP precertification list and is routed to Anthem - SHBP UM and to one or more internal clinical guideline identifiers (for example CG-DME-15, CG-MED-73, ING-CC series) for coverage determination.

Providers must submit precertification requests to Anthem - SHBP UM (or AIM where indicated) and reference the guideline identifier(s) listed with the code when requesting review.

Precertification mapping (informational)

Codes listed require precertification and reference separate policy/guideline documents for clinical criteria

Precertification mapping: Each listed HCPCS/CPT/S code is mapped to Anthem - SHBP UM and to one or more internal clinical guideline identifiers; the code list itself provides routing and guideline cross-reference but does not contain the clinical medical necessity decision rules.

Refer to the guideline code(s) shown with each billing code (e.g., CG-DME-31, CG-MED-23, ING-CC series) for the specific medical necessity criteria and documentation requirements.

Members with SHBP Anthem as secondary coverage are exempt from the AIM prior authorization requirement for the outpatient radiation therapy and imaging services otherwise routed to AIM. For other Anthem members, prior authorization for non‑emergency outpatient IMRT, proton beam therapy, SRS/SBRT and brachytherapy must be obtained through AIM as noted in the precertification routing guidance.

This section is primarily a code-to-program mapping: listed CPT/HCPCS codes are annotated with the assigned review pathway (for example, AIM or a specific program area such as Sleep Therapy or Radiation Therapy) and associated internal guideline identifiers. The excerpt does not present standalone clinical coverage rules — consult the referenced guideline IDs listed with each code for medical necessity criteria and exclusions.

Entries in this segment map procedure codes to the payer's utilization management pathway (commonly Anthem - SHBP UM) and to internal clinical guideline or surgery policy identifiers (e.g., CG-, SURG-, ING-CC). The document does not enumerate clinical coverage exclusions here; coverage decisions and any 'not medically necessary' determinations are made by applying the detailed criteria found in the cited guideline(s).

Note: several vertebroplasty/vertebral augmentation CPT codes referenced in this list (for example, 22510–22515 and related entries) were noted as removed from SURG.00067 effective 4/15/2020. Providers should be aware of that policy change and consult the current surgery guideline (SURG.00067 / its successor) for the operative coverage status of those codes.

This code list segment does not itself enumerate coverage exclusions. Where exclusions or noncoverage exist, they will be defined in the clinical guideline or medical policy referenced alongside each code (for example, CG‑ or SURG‑policy identifiers shown in the table). Providers must consult the named guideline for exclusion or NMN language.

This section provides code listings and uses the designation Anthem - SHBP UM to indicate utilization management routing; it does not contain discrete clinical coverage criteria or stepwise medical necessity rules. Review and medical necessity decisions must follow the clinical guideline(s) referenced with each code.

Some codes and their policy mappings were converted or updated in the source (for example, earlier policy identifiers such as SURG.00028 were converted to internal guideline codes like CG‑SURG‑107 effective 9/1/2020). Providers should verify the current clinical guideline/policy identifier shown with each code when preparing precertification requests.

There are no explicit clinical exclusions stated in this extract. The table maps codes to Anthem utilization management and to internal clinical guideline references; any exclusions or not‑medically‑necessary determinations are specified within those referenced guideline documents rather than in the code list itself.

The entry for K0899 is described as “Power mobility device, not coded by DME PDAC or does not meet criteria,” which implies that items classified under K0899 may not meet coverage unless they satisfy DME coding/PDAC requirements or the CG‑DME‑31 criteria referenced in the listing. Providers should confirm DME PDAC coding and reference CG‑DME‑31 when submitting authorization requests for these devices.

This code list does not itself list explicit coverage exclusions. Any exclusions or determinations that a service is not medically necessary are defined in the clinical guideline or medical policy referenced for each code. Use the guideline identifier included with the code entry to locate applicable exclusion/NMN language.

Certain entries reference internal guideline IDs (for example, ANC.00007, CG‑SURG‑27, SURG.00037) that contain specific not‑medically‑necessary (NMN) criteria. This code list itself does not enumerate NMN conditions — check the cited guideline(s) for the detailed NMN rules applicable to a given code.

No explicit 'not medically necessary' statements appear directly in this code list segment. Coverage and NMN determinations are made by applying the referenced clinical guideline or medical policy associated with each listed code.

This extract does not specify conditions that are deemed not medically necessary. The code entries are routed to Anthem utilization management and link to internal guideline identifiers; NMN criteria, if any, are contained within the referenced guideline documents (for example, CG‑MED‑23 or SURG.00026).

The code list itself does not define not‑medically‑necessary conditions. For NMN language and application to a specific HCPCS/CPT code, refer to the guideline(s) listed with the code (examples in the list include CG‑MED‑23 and SURG.00026); those documents contain the explicit NMN criteria and clinical rationale.

Precertification Code Lists and Coding Details

Reviewed by AIM: Radiation Therapy (selected sample)CPT

19294	Preparation of tumor cavity with placement of radiation therapy applicator for intraoperative radiation therapy (IORT) concurrent with partial mastectomy
19296	Placement of radiotherapy afterloading expandable catheter into the breast for interstitial radiation
19297	Placement of radiotherapy afterloading expandable catheter into the breast for interstitial radiation
19298	Placement of radiotherapy afterloading brachytherapy catheters into the breast including imaging guidance
20555	Placement of needles or catheters into muscle and/or soft tissue for subsequent interstitial radioelement application
31643	Bronchoscopy with placement of catheter(s) for intrabronchial therapy
32701	Thoracic target delineation for stereotactic body radiation therapy (SRS/SBRT), entire course

AIM: Imaging, Radiosurgery, Radiation Therapy (selected sample)CPT

55875	Transperineal placement of needles or catheters into prostate for interstitial radioelement application
55899	Unlisted procedure, male genital system
55920	Placement of needles or catheters into pelvic organs for subsequent interstitial radiation
57155	Insertion of uterine tandem and/or vaginal ovoids for clinical brachytherapy
57156	Insertion of vaginal radiation afterloading apparatus for clinical brachytherapy
58346	Insertion, Heyman capsules, clinical brachytherapy
61796	Stereotactic radiosurgery; 1 simple cranial lesion
61797	Stereotactic radiosurgery; each additional simple cranial lesion
61798	Stereotactic radiosurgery; 1 complex cranial lesion
61799	Stereotactic radiosurgery; each additional complex cranial lesion

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Radiation Therapy – AIM Reviewed HCPCS/G codes (selected)HCPCS

G0458	Low dose rate (LDR) prostate brachytherapy services, composite rate
G6001	Ultrasonic guidance for placement of radiation therapy fields
G6002	Stereoscopic x-ray guidance for localization of target volume
G6003	Radiation treatment delivery, single treatment area, simple
G6015	Intensity modulated treatment delivery (IMRT), per treatment session
Q3001	Brachytherapy radioelements

AIM: Precertification – Imaging (CT/MRI/MRA) (sample)CPT

70450	CT Scan, Head/Brain; w/o contrast
70460	CT Scan, Head/Brain; with contrast
70470	CT Scan, Head/Brain; w/o then w/ contrast
70480	CT Scan, Orbit/Sella/Posterior Fossa; w/o contrast
70481	CT Scan, Orbit/Sella/Posterior Fossa; with contrast
70540	MRI, orbit/face/and/or neck; without contrast
70542	MRI, orbit/face/and/or neck; with contrast
70551	MRI, brain; without contrast
70552	MRI, brain; with contrast

Precertification, Submission & Documentation Actions for Providers

Prior Authorization

Prior Authorization Required — AIM

Many codes listed in this section require prior authorization (precertification) before services are rendered. AIM Specialty Health (AIM) is the designated prior authorization vendor for the outpatient radiation therapy and numerous diagnostic imaging and related CPT/HCPCS codes shown with an AIM assignment. Providers must obtain AIM precertification through AIM ProviderPortals (aimspecialtyhealth.com/goweb — select Anthem) or by calling AIM at 866-714-1103. Failure to obtain required precertification may result in claim denial or retrospective review.

AIM precertification required for listed CPT codes and radiation therapy services (IMRT, proton beam, SRS/SBRT, brachytherapy, IORT, brachytherapy planning and delivery codes).
Outpatient non-emergency IMRT, proton beam therapy, SRS/SBRT and brachytherapy require AIM prior authorization. Inpatient radiation therapy is reviewed via the inpatient precert process.
Submit AIM requests via AIM ProviderPortals at aimspecialtyhealth.com/goweb (select Anthem) or call 866-714-1103, Mon–Fri 8:00 AM–6:00 PM ET.

Prior Authorization

Prior Authorization Required — Anthem - SHBP UM

Some CPT, HCPCS, J- and K-/L-/Q-/A-codes are routed to Anthem – SHBP Utilization Management (Anthem - SHBP UM) for precertification and medical appropriateness review. When a code is listed with Responsible Party = Anthem - SHBP UM the provider must follow Anthem - SHBP UM submission and precertification procedures and reference the associated clinical guideline or policy ID shown in the list.

Policy Background

Background: AIM Specialty Health administers utilization management for diagnostic imaging, outpatient radiation therapy (including IMRT, proton beam, SRS/SBRT and brachytherapy) and outpatient sleep services for SHBP Anthem members. The precertification code list identifies codes routed to AIM or to Anthem - SHBP UM and points providers to the internal guideline references that define medical necessity and documentation requirements.

OpenPayer

SHBP Medical Policies & Clinical Guidelines Precertification Code List — Radiation Therapy and Related Services

Coverage Criteria and Precertification Mapping

Precertification Code Lists and Coding Details

Precertification, Submission & Documentation Actions for Providers

Policy Background

Definitions and Program Identifiers