List of procedures/DME requiring prior authorization
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This document lists procedures, drugs, and DME that require prior authorization for Highmark BlueShield members in Pennsylvania, West Virginia, and Delaware; it informs providers which codes/modalities may need authorization and plan-specific verification.
No material clinical or coverage changes in this revision.
Prior Authorization / Coverage Criteria
Verification requirement
Providers must verify member-specific authorization requirements; authorization requirements vary by plan.
Providers may call the number on the back of the member's card, check eligibility and benefits via Availity, or search BlueExchange through the provider portal.
Coverage stance for listed cardiac device/imaging codes
The following cardiac device and cardiac imaging procedure codes and mappings are designated in the authorization list; many are marked Gold Card Eligible.
Examples of mapped device/imaging entries
Authorization-required procedure listings (partial)
Partial listing of procedures and mapped codes that require prior authorization for PA, WV, and DE members.
Procedure examples requiring authorization
- Stereotactic implantation of neurostimulator electrode array (first array) (mapped to 61867) where listed.
Authorization criteria (partial)
Authorization requirement and program eligibility notes (partial).
Authorization-required services (partial list)
Selected service categories and codes from the authorization-required list (partial).
Selected categories and example codes
- Coronary angiography/heart catheterization codes (e.g., 93456–93461) are listed as requiring authorization; many are Gold Card Eligible.
- Home health and training service codes (e.g., G0151–G0156, G0299) require authorization; some entries note 'NOT APPLICABLE TO NY MEDICARE ADVANTAGE MEMBERS.'
Authorization list (partial)
Procedures and DME categories listed with authorization requirement and eligibility flags (partial).
Representative authorization list entries
- Joint surgery and intraoperative neuromonitoring codes (e.g., 27279–27280, 95940–95941) are listed and may be Gold Card Eligible.
- MRI/MRA codes across many anatomic sites (e.g., 70545–70549, 72141–72147, 72195–72197) appear on the authorization list, many marked Gold Card Eligible.
Authorization and designation criteria (nuclear medicine)
Authorization and designation notes for nuclear medicine procedures in this excerpt.
Scope of nuclear medicine entries
- Includes thyroid, whole-body, planar and tomographic (SPECT) localization studies and associated CPT/HCPCS codes (examples: 78014, 78016–78020, 78801–78804, 78830–78832).
- Entries describe tomographic (SPECT) radiopharmaceutical localization studies that may span multiple areas or acquisitions and note associated requirements for imaging (minimum 2 areas or separate acquisitions).
Authorization listing (partial)
Partial authorization listing showing nuclear medicine and related entries; some items include effective dates for occupational therapy codes.
Authorization requirement for listed procedures/injections (partial)
Procedure 78831 (SPECT radiopharmaceutical localization) and multiple injectable agents are listed as requiring authorization under the Highmark Managed program.
Examples of injectable agents associated with 78831
- Entries show 78831 paired with example J‑codes and drug names across the Nuclear Medicine = Oncology category.
Authorization listing (partial)
Authorization listing (partial) — nuclear medicine tomographic SPECT localization and multiple injectable oncology agents require prior authorization.
Authorization requirement (partial)
Partial listing indicating nuclear medicine oncology procedures and listed injections require authorization under Highmark Managed.
Prior authorization requirement (partial)
Prior authorization designation for listed items (partial).
Authorization requirement for listed nuclear medicine procedures and injectable oncology drugs
Portion of the policy showing that listed nuclear medicine procedures and specific injectable oncology agents require authorization under Highmark Managed plans.
Examples of injectable oncology agents requiring authorization
- Examples enumerated include amivantamab‑VMJW (Rybrevant), mirvetuximab soravtansine‑GYNX (Elahere), and calaspargase pegol‑MKNL (Asparlas).
Authorization criteria — nuclear medicine / oncology (partial)
Authorization criteria (partial) — SPECT localization procedure 78831 and associated injectables require prior authorization; coding associations are shown.
Associated injectables and coding associations
- Specific injectable agents are listed alongside 78831 (examples: amivantamab‑VMJW [Rybrevant], mirvetuximab soravtansine‑GYNX [Elahere], bendamustine), and these entries require authorization when billed in this context.
Authorization-required items — Nuclear Medicine / Oncology (partial)
Entries indicate nuclear medicine procedures and associated injectable products that require authorization for Highmark Managed plans; clinical criteria are not provided in these fragments.
Codes and Code Mappings
| 97151 | Behavior identification assessment used for initial or reassessment and treatment plan development |
| 97152 | Behavior identification supporting assessment |
| 97154 | Group adaptive behavior treatment by protocol, administered by a technician |
| 97155 | Adaptive behavior treatment protocol modification |
| 97156 | Family adaptive behavior treatment guidance |
| 97157 | Multiple-family group adaptive behavior treatment guidance |
| 97158 | Group adaptive behavior treatment with protocol modification |
| 0362T | Adaptive behavior assessment with technician assistance, each 15 minutes |
| 0373T | Adaptive behavior treatment with protocol modification |
| H0032 | Mental health service plan development by non-physician |
| 91110 | Capsule endoscopy, GI tract imaging with interpretation and report |
| 91111 | Capsule endoscopy, GI tract imaging |
| 33206 | Insertion/replacement of permanent pacemaker with lead(s) |
| 33207 | Insertion/replacement of permanent pacemaker with lead(s) |
| 33208 | Insertion of permanent pacemaker with transvenous electrodes; atrial and ventricular |
| 33214 | Revision/replacement of pacemaker system (dual chamber) |
| 33216 | Insertion of new pulse generator; single transvenous electrode |
| 33217 | Insertion of 2 transvenous electrodes |
| 33224 | Insertion of pacing electrode, cardiac venous system, for LV pacing (multiple related entries) |
| 43644 | Laparoscopy, surgical, gastric restrictive procedure with gastric bypass and Roux-en-Y |
| 43645 | Laparoscopy, gastric restrictive procedure with small intestine reconstruction |
| 43647 | Laparoscopy; implantation/replacement of gastric neurostimulator electrodes |
| 43770 | Placement of adjustable gastric restrictive device (gastric band) |
| 43771 | Revision of adjustable gastric restrictive device component only |
| 43772 | Removal of adjustable gastric restrictive device component only |
| 43773 | Removal and replacement of adjustable gastric restrictive device component |
| 43774 | Removal of adjustable gastric restrictive device and subcutaneous port components |
| 43775 | Longitudinal gastrectomy (sleeve gastrectomy) |
| 43842 | Gastric restrictive procedure without gastric bypass for morbid obesity |
| 33224 | Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, with attachment to previously placed pacemaker or ICD pulse generator (including revision of pocket, removal, insertion, and/or replacement of existing generator) |
| 33231 | Removal of permanent pacemaker pulse generator with replacement; multiple lead system (mapped in doc) |
| 33240 | Insertion of implantable defibrillator pulse generator only; with existing multiple leads (mapped) |
| 33249 | Insertion or replacement of permanent implantable defibrillator system with transvenous lead(s), single or dual chamber (mapped) |
| 33262 | Removal of implantable defibrillator pulse generator with replacement; single lead system (mapped) |
| 33263 | Removal of implantable defibrillator pulse generator with replacement; single lead system (alternate mapping) |
| 33264 | Removal of implantable defibrillator pulse generator with replacement; dual lead system (mapped) |
| 33270 | Removal of implantable defibrillator pulse generator with replacement; multiple lead system (mapped) |
| 33273 | Defibrillation threshold evaluation and device programming when performed (mapped) |
| 33274 | Repositioning of previously implanted subcutaneous ICD electrode (mapped) |
| 92928 | Percutaneous transluminal coronary angioplasty; single major coronary artery or branch |
| 92937 | Percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty; single major coronary artery or branch |
| 92943 | Percutaneous transluminal revascularization of or through coronary artery bypass graft; single vessel |
| 70460 | CT head without contrast (mapped in list) |
| 70470 | CT head with contrast (mapped in list) |
| 72125 | CT cervical spine without contrast (appears in list) |
| 74263 | CT colonography (screening) (appears in list) |
| 93350 | Echo for congenital cardiac anomalies / imaging add-on (appears in list) |
| 65771 | Eye surgery code listed (radial keratotomy/PRK related) |
| 93451 | Right heart catheterization (appears in list) |
| 93456 | Catheter placement in coronary artery(s) for coronary angiography |
| 93457 | with right heart catheterization |
| 93458 | with catheter placement(s) in bypass graft(s) |
| 93459 | with left heart catheterization including ventriculography |
| 93460 | with bypass graft angiography |
| 93461 | with right and left heart catheterization |
| 61885 | Insertion or replacement of cranial neurostimulator pulse generator |
| 63663 | Revision/replacement of spinal neurostimulator percutaneous electrode array |
| 64561 | Revision including replacement of spinal neurostimulator electrode plate/paddle(s) |
| 64581 | Open implantation of neurostimulator electrode array; sacral nerve |
| 64582 | Open implantation of hypoglossal nerve neurostimulator array |
| 64590 | Insertion or replacement of peripheral or gastric neurostimulator pulse generator |
| L8695 | Accessories, external recharging system for implantable neurostimulator |
| 74712 | Magnetic resonance imaging, fetal, single/first gestation |
| 74713 | Magnetic resonance imaging, fetal, each additional gestation |
| 76390 | MRI spectroscopy |
| 77021 | Unlisted MRI procedure / guidance for needle placement |
| 78012 | Thyroid uptake, quantitative |
| 78014 | Thyroid imaging (including vascular flow) |
| 78016 | Thyroid/met imaging |
| 78018 | Thyroid met imaging with additional studies |
| 78831 | Referenced/paired with 78832 or used in nuclear medicine SPECT multi-area studies |
| 78999 | Unlisted procedure, diagnostic nuclear medicine - radiation therapy (mapped from an entry) |
| 93312 | Treatment planning TEE 2D; includes probe placement, imaging/interpretation/report |
| 93313 | TEE placement of probe only |
| 93314 | TEE image acquisition, interpretation and report only |
| 93315 | Transesophageal echocardiography for congenital cardiac anomalies; full service |
| 93316 | TEE for congenital anomalies; probe placement only |
| 93317 | TEE image acquisition, interpretation and report only for congenital anomalies |
| 78831 | Nuclear medicine procedure; radiopharmaceutical localization (SPECT), minimum 2 areas or separate acquisitions |
| J9041 | Carfilzomib 0.1 mg (example listed) |
| J9047 | Referenced injection code in list |
| J9048 | Referenced injection code in list |
| J9049 | Referenced injection code in list |
| J9051 | Referenced injection code in list |
| J9054 | Referenced injection code in list |
| J9055 | Referenced injection code in list |
| J9056 | Referenced injection code in list |
| J9058 | Referenced injection code in list |
| 78831 | Tomographic (SPECT) radiopharmaceutical localization, minimum 2 areas or separate acquisitions |
| Amivantamab-vmjw injection, 2 mg (Rybrevant) — listed as requiring authorization | |
| Mirvetuximab soravtansine-gynx injection, 1 mg (Elahere) — listed as requiring authorization | |
| Calaspargase pegol-mknl, 10 units (Asparlas) — listed as requiring authorization |
What Providers Must Do
Verify Authorization Requirements
For PA, WV, & DE Members — How to verify authorization requirements: Providers must obtain prior authorization where indicated on the Highmark list. To verify a member’s specific authorization requirements, providers may: 1) call the number on the back of the member’s ID card; 2) check eligibility and benefits via Availity; or 3) search BlueExchange® through the provider’s local payer portal.
- Applies to Highmark BlueShield NENY members effective 2026-04-01.
- Authorization requirements vary by benefit plan — always verify for the specific member prior to scheduling.
Cardiac Device & Related Procedures – Prior Authorization Required
Prior authorization is required for listed cardiac device implantation, replacement, removal, device evaluation, and related procedures. Providers must obtain authorization per this policy before performing these services.
- Includes pacemaker and implantable cardioverter-defibrillator (ICD) generator insertion/replacement/removal and left ventricular pacing lead procedures (e.g., CPT 33224, 33231, 33240, 33249, 33262–33270 series as listed).
- Many cardiac device items are Gold Card Eligible for Highmark Managed members; confirm applicability per member plan.
Endovascular Repair — Extension Prosthesis (Initial Vessel)
Endovascular repair — extension prosthesis placement (initial vessel) requires prior authorization when listed.
- Procedure examples include placement of extension prosthesis distal to common iliac or proximal to renal arteries; list initial vessel separately in addition to primary procedure code.
Endovascular Repair — Extension Prosthesis (Additional Vessel)
Endovascular repair — extension prosthesis placement for each additional vessel requires prior authorization when listed.
- List each additional vessel treated separately in addition to the code for the primary procedure.
Endograft Enhanced Fixation Device Delivery
Transcatheter delivery of endograft enhanced fixation devices (anchors, screws, tacks) requires prior authorization when listed.
- Authorization applies to delivery/placement of enhanced fixation device(s) to the endograft and associated radiological supervision/interpretation.
PCI and Intracoronary Stent Placement
Percutaneous coronary interventions (PCI) and intracoronary stent placement require prior authorization when listed on the authorization list.
- Includes percutaneous transluminal coronary angioplasty and intracoronary stent placement codes (examples referenced in the list).
- Many PCI/stent items are Gold Card Eligible for Highmark Managed members; verify member-specific rules.
Transcatheter Closure of Interatrial Communication
Transcatheter closure of interatrial communications (e.g., ASD, Fontan fenestration) requires prior authorization when listed.
- Example procedure: percutaneous transcatheter closure of congenital interatrial communication with implant (listed as Gold Card Eligible where indicated).
- Providers must obtain authorization before performing transcatheter closure procedures.
Cardiac Contractility Modulation System Insertion/Replacement
Cardiac contractility modulation system insertion/replacement procedures require prior authorization when listed.
Cataract Removal with Aqueous Drainage Device Insertion
Cataract removal with insertion of an anterior segment aqueous drainage device (internal, without extraocular reservoir) requires prior authorization when listed.
- Includes extracapsular cataract removal with intraocular lens insertion plus anterior segment aqueous drainage device (CPT 66989 and related codes).
- Many of these entries are marked Gold Card Eligible for Highmark Managed members — verify member eligibility.
Cochlear Device Implantation and Components
Cochlear implant procedures and device components require prior authorization when listed.
Myocardial PET Imaging (Perfusion/Metabolic/AQMBF)
Myocardial PET imaging (perfusion, metabolic, and Absolute Quantitation of Myocardial Blood Flow — AQMBF) requires prior authorization when listed.
Coronary Angiography / Heart Catheterization
Coronary angiography / heart catheterization and related procedures require prior authorization when listed on the Highmark authorization list.
- Examples include catheter placement in coronary arteries for coronary angiography with right heart catheterization (CPT 93456) and related left/right heart catheterization codes (CPT 93457, 93458, 93593–93597 series).
- Many heart cath items are Gold Card Eligible for Highmark Managed members; verify per-member requirements.
Heart Cath / Electrophysiology Procedures
Heart catheterization and electrophysiology procedures (diagnostic and ablation) require prior authorization when listed.
- Includes comprehensive electrophysiologic evaluation with catheter insertion and ablation (e.g., CPT 93653) and other EP procedure codes listed.
- Obtain authorization before scheduling electrophysiology procedures.
Home Health Services / Training
Home health services and home care training require prior authorization when listed.
Hospital Beds, Accessories, Hyperbaric Therapy
Hospital beds, accessories, and hyperbaric therapy items require prior authorization when listed.
Hysterectomy and Inpatient Detoxification Services
Hysterectomy procedures and inpatient detoxification/rehabilitation services require prior authorization when listed.
Intraoperative Monitoring, Joint Surgery, Listening Devices, MRI/MRA
Intraoperative neurophysiologic monitoring, certain joint surgery, assistive listening devices, and MRI/MRA studies require prior authorization when listed.
- Intraoperative monitoring codes: 95940, 95941, G0453. Joint surgery examples: 27279, 27280. Assistive listening device codes: V5281, V5282. MRA/MRI examples: 70545–70549, 71555, 72159 series — many marked Gold Card Eligible for Highmark Managed members.
- Obtain authorization for intraoperative monitoring billed in addition to the primary procedure.
List Requiring Authorization (Partial)
This section is a partial representation of the Highmark list of procedures and DME that require prior authorization. Providers must consult the full Highmark authorization list for complete code-level details and any Gold Card eligibility notes.
- The full list includes a broad range of imaging, procedures, DME, home health, and drug injection items effective 04/01/2026.
- Gold Card Eligible entries may be exempted for certain providers/members — verify via eligibility tools prior to ordering.
Prior Authorization — Nuclear Medicine Procedures and Injectable Oncology Agents
Prior authorization is required for the nuclear medicine procedures and associated injectable oncology agents listed. Radiopharmaceutical localization SPECT procedures (tomographic SPECT, minimum two areas or separate acquisitions) require authorization when billed as listed.
- Example nuclear medicine procedure group: radiopharmaceutical localization of tumor/inflammatory process by tomographic SPECT (CPT 78831 mapped to multiple codes in the list).
- Authorization required for myocardial SPECT, thyroid imaging, whole-body scans and other nuclear medicine services as specified.
Drug Injection Codes Requiring Authorization (Partial)
Certain drug injection / J-code items associated with nuclear medicine oncology procedures require prior authorization when listed.
- Examples of associated J-codes and HCPCS listed: J9058, J9059, J9061, J9063, J9118, J1323, J1326, J1448, J1932, J1950 and others appearing in the oncology injectables portion of the list.
- Specific injectable agents referenced include amivantamab (Rybrevant), mirvetuximab soravtansine (Elahere), calaspargase pegol (Asparlas), elranatamab (Elrexfio), zolbetuximab (Vyloy), trilaciclib (Cosela), and leuprolide depot formulations.
Associated Drug J‑Codes and Injectable Oncology Agents
Associated drug J‑codes and oncology injectable agents tied to nuclear medicine and oncology services are included in the authorization requirements and must be authorized when listed.
- Multiple entries map CPT/HCPCS nuclear medicine procedure codes (e.g., 78831) to specific J-codes — confirm both the imaging procedure and the injectable agent require authorization.
- When a radiopharmaceutical localization study includes an associated injectable listed by J-code, obtain authorization for both the imaging and the drug as applicable.
Prior Authorization Required — Nuclear Medicine Oncology Procedures/Injectables
Prior authorization is required for nuclear medicine oncology procedures and injectables listed on the Highmark authorization list effective 04/01/2026.
- Examples: radiopharmaceutical localization SPECT procedures billed with associated J-codes (J9059, J9061, J9063, J9118, and related codes) require authorization.
- Providers must obtain authorization for both imaging (e.g., SPECT localization) and the specified injectable oncology agents when both are listed.
Definitions and Flags
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