CurrentCapital BluecrossPolicy N/A

Authorization Request Form — Surgical/Procedural Prior Authorization

This document is an authorization request form used by providers to request utilization management review for planned procedures, surgeries, or related services for Capital Bluecross members. It collects patient, provider, facility, procedure, diagnosis, clinical status, comorbidities, and procedural adjunct information required for prior authorization decisions.

Policy Summary

PayerCapital Bluecross

PolicyAuthorization Request Form — Surgical/Procedural Prior Authorization

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed authorization form with procedure and diagnosis codes plus imaging, surgical plan, and documentation of all conservative therapies with durations.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~40form fields to complete (approximate)

2UM contact lines

1 noteRequired attachments

Coverage and Authorization Prerequisites

Authorization prerequisites

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Form completion: Completed authorization form with member demographics, provider and facility identifiers (TIN, NPI, addresses, contact names and phones), requested procedure and CPT/HCPCS or ICD procedure codes, diagnosis codes, and anticipated surgery date.

See form fields in chunk 0

Clinical attachments: Imaging reports, a surgical plan, and documentation of ALL conservative (non-operative) therapies attempted with the duration of each must be attached.

Required attachments and note regarding missing documentation in chunk 1

Risk and comorbidity information: Patient height, weight, BMI, comorbidity checklist (e.g., diabetes, hypertension, cardiac history, COPD, dialysis, cancer), Activities of Daily Living (ADL) functional status, and current health status must be provided to inform perioperative risk assessment.

See comorbidity and ADL fields in chunk 0 and health status in chunk 1

Adjunct materials/products: If allograft, autograft, BMP, stem cells, or CPT 20930 are requested, include product/vendor details and indicate tissue type where applicable.

Product/vendor and CPT 20930 fields in chunk 1

None explicitly listed on the form. The authorization form itself does not contain a separate exclusions list or itemized coverage criteria that would deny coverage; instead it focuses on collecting the administrative, coding, clinical, and attachment information necessary for Utilization Management to review the request (for example: procedure code, co-surgeon/assistant information, and product/graft use selections).

The form does not state specific conditions that are "not medically necessary." Medical necessity determinations are implied to be made by Utilization Management after review of the completed form and submitted supporting documentation (clinical status, comorbidities, imaging, surgical plan, prior conservative therapies, and product/graft details where applicable).

Provider Responsibilities and Submission Requirements

Prior Authorization

Prior authorization submission — submit completed form with required codes and dates

Submit a completed Authorization Request Form to Utilization Management that includes the requested procedure and procedure code(s) (CPT/HCPCS or ICD procedure codes), diagnosis code(s), anticipated surgery date, and all supporting documentation listed on the form.

Requested Procedure and CPT/HCPCS or ICD Procedure Code(s)
Diagnosis Code(s)
Anticipated Surgery Date
Supporting documentation as listed on the form

Step Therapy

Conservative therapy documentation — list therapies and duration

Document all prior conservative (non-operative) therapies that have been attempted and record the duration for each therapy on the form, as the note indicates lack of this information may affect authorization.

List each conservative therapy attempted
Provide duration for each therapy

Documentation Required

Required attachments — imaging, surgical plan, and conservative therapy documentation

Attach required clinical materials to the authorization: imaging reports, the planned surgical procedure/operative plan, and clinical documentation of all conservative therapies attempted including duration.

Imaging reports (relevant radiology studies)
Surgical plan/operative plan
Clinical notes documenting conservative treatments and durations

Documentation Required

Form completion details — provide member, provider, and facility identifiers

Complete all member, provider, and facility identification fields on the form including member demographics, provider and facility identifiers (TIN, NPI), addresses, contact names and phone/fax numbers, and the requested procedure details.

Member name, DOB, Member ID
Provider name, Provider TIN, Provider NPI, Provider contact name/phone/fax, addresses
Facility name, Facility TIN, Facility NPI, Facility contact name/phone/fax, facility addresses
Requested procedure and procedure code fields

Denial Risk

Missing required documentation — risk of incomplete review or denial

Failure to include imaging reports, the surgical plan, and clinical documentation of all conservative therapies with durations may result in an incomplete review, delay, or denial of the authorization request.

Missing attachments can delay utilization management review
Omitted conservative therapy durations or imaging/surgical plan may risk denial

Policy Background

This authorization request form is used to collect perioperative risk factors and procedural details that inform the Utilization Management review for planned surgical or procedural services. It captures the patient's current health status (ranging from normal healthy through severe life‑threatening disease), psychosocial/substance abuse status, comorbid conditions via checklist, and functional considerations such as planned use of co‑surgeons or surgical assistants. The form also requests details about biologic or graft materials (allograft, autograft, BMP, stem cells) and, if applicable, tissue type when CPT 20930 is requested, as well as the procedure code and planned personnel. These data, together with required attachments (imaging reports, surgical plan, and documentation of all prior conservative therapies with duration), enable Utilization Management to assess procedural appropriateness and perioperative risk during the prior authorization decision.

Comorbidities and Conservative Therapies

Comorbidities checklist to inform perioperative risk assessment

DiabetesDiabetes that requires medication or insulin (Type I or Type II); A1C level field provided on form

HypertensionHypertension requiring medication

Cardiac disease / CHFPrevious cardiac event and congestive heart failure (CHF) listed separately to capture cardiac risk

Pulmonary disease / COPDHistory of severe COPD and dyspnea (captures symptomatic pulmonary disease)

Renal disease / dialysisDialysis and acute renal failure are included to identify renal failure or dialysis dependence

Active / disseminated cancerDisseminated cancer (active metastatic disease) captured on checklist

Non-operative treatments attempted prior to requesting surgery (must include duration for each)

Physical therapy / rehabilitationDocument prior physical therapy attempts and duration (form requires listing of ALL conservative therapies and duration)

Medications / injectionsDocument prior medication management and any injections (e.g., corticosteroid) and duration/response

Activity modification / bracing / assistive devicesDocument trials of activity modification, bracing, or assistive devices with duration

Rest / home exercise programsDocument home exercise programs or rest periods attempted and their duration

Other non-operative interventionsInclude any other conservative treatments (e.g., orthotics, weight loss, smoking cessation efforts) with duration; NOTE: imaging reports and surgical plan must also be included