Prior authorization required for specified excision/lipectomy codes

For PA, WV, & DE members: Prior authorization is required for specified excision/lipectomy procedures. Providers must obtain prior authorization for excision of excessive skin and subcutaneous tissue (including lipectomy) when billed as reconstructive and/or cosmetic procedures (examples include CPT 15837, 15838, 15839 and related abdominal, buttock, forearm/hand, trunk, upper/lower extremity lipectomy codes).

• Affected CPT examples: 15837, 15838, 15839, 15847, 15876-15879, and other excision/lipectomy codes when billed as reconstructive and/or cosmetic.
• Authorization required when procedure is listed as Highmark Managed or marked with an authorization indicator (e.g., X).
• Check member-specific benefits (back of card, Availity, or BlueExchange) to confirm requirement prior to scheduling.

Foot and arthroscopy procedures — authorization required

For PA, WV, & DE members: Prior authorization is required for many foot surgery and arthroscopy procedures. This includes numerous listed CPT codes for reconstructive foot surgery, osteotomies, arthrodesis, and certain arthroscopic repairs/unlisted arthroscopy procedures.

• Examples of managed foot surgery CPTs: 28110, 28291, 28295, 28296, 28306, 28322, 28755 (and other listed codes).
• Arthroscopy and related unlisted arthroscopy codes (e.g., mappings such as 29892→29899/29999 for unlisted arthroscopy) may require authorization when indicated as Highmark Managed.
• When codes are mapped to alternative or unlisted procedure codes (per provider guidance), confirm authorization prior to performing service.

Prior authorization / managed status markers (partial)

Authorization (managed) status markers appear throughout the procedure lists. Providers should treat entries labelled 'Managed', 'Highmark Managed', or marked with 'X' as requiring prior authorization or additional management steps.

• The presence of 'Managed' or 'Highmark Managed' indicates the procedure is subject to prior authorization for PA, WV, & DE members.
• An 'X' in the listing denotes an authorization indicator for the listed procedure or code.
• If an entry is blank or not marked, verify member-specific benefits as some plan variations may still require authorization.

Prior authorization required — procedure list (excerpt)

This document contains an excerpted list of procedures that require prior authorization (Highmark Managed) for PA, WV, & DE members across multiple specialties. Providers must confirm authorization prior to performing or billing these services when indicated.

• Examples across specialties include: vascular, cardiac, spinal, prostatectomy, hysterectomy, foot surgery, arthroscopy, ophthalmic/reconstructive/cosmetic procedures, cochlear implantation, nuclear medicine studies, and DME/wheelchair accessories.
• Many entries include explicit CPT/HCPCS codes and mapping notes; use the code-level listings in this section to determine authorization needs.
• When a procedure is mapped to an unlisted or alternate code (e.g., 29892 mapped to 29999/30130/30400/31255/31257/31259 depending on context), confirm authorization based on the final billed code.

Prior authorization required for listed procedures (section extract)

For PA, WV, & DE members: Numerous procedures across sections are explicitly marked as requiring prior authorization (managed). Providers must obtain authorization for listed procedures noted as 'Highmark Managed' or otherwise indicated.

• Examples of managed procedures: prostatectomy (CPT 55845) marked Managed/X; various vascular, cardiac, sleep, and electrophysiology procedures listed with X indicators.
• When a procedure entry includes modality or gold-card eligibility notes, review those fields for additional authorization rules.
• If documentation or mapping is unclear in the excerpt, contact the plan or check Availity/BlueExchange for the definitive authorization requirement.

Spine surgery code mappings (partial)

Many spine surgery CPT codes are mapped and managed; prior authorization is required for listed spine procedures. Providers should reference the code mappings for authorization determination and for cases where procedures map to reconstructive/cosmetic or other modality categories.

• Representative spine CPT mappings include (partial list): 22595, 22802, 22804, 22808, 22810, 22812, 22899 and numerous decompression/corpectomy/laminectomy codes.
• Entries show mapping of spine surgery codes to other specialty descriptors in some cases; confirm the billed CPT and the corresponding managed status.
• Unlisted spine procedures (e.g., 22899) are managed and require prior authorization when used for percutaneous/minimally invasive sacroiliac or other spine arthrodesis procedures.

Ophthalmic / Reconstructive & Cosmetic surgery mappings — authorization

Ophthalmic, reconstructive and cosmetic surgery mappings are included and many such procedures are managed. Prior authorization is required when the procedures are listed as Reconstructive and/or Cosmetic and marked Managed.

• Listed CPTs associated with facial/cosmetic procedures and dermabrasion/chemical peels: 15775–15783, 15786–15793, 15819–15821, 15782–15783, and rhytidectomy/blepharoptosis repair CPTs (e.g., 15776, 15780–15783, 15786, 15788–15793, 67900–67999).
• Entries indicate reconstructive vs cosmetic modality; authorization may be required for reconstructive procedures noted as Managed and for cosmetic procedures dependent on plan rules.
• For eyelid/ocular procedures with unlisted codes (e.g., 67999, 68899), obtain prior authorization and submit supporting clinical documentation.

Cochlear device and unlisted procedure mappings — authorization

Cochlear device implantation and related unlisted procedure codes are managed and require prior authorization. Providers should submit documentation supporting medical necessity for cochlear device implantation and related device procedures.

• Managed cochlear device CPTs include codes such as 69714 and 69930 (cochlear device implantation) and other osseointegrated implant codes.
• Unlisted procedure codes for implantation or devices (e.g., 67999, 68899 where applicable) are also managed and require prior authorization.
• Confirm whether the procedure includes mastoidectomy or other concurrent ENT procedures and include supporting operative/clinical notes with the authorization request.

Nuclear Medicine authorization code list (partial)

An extensive set of nuclear medicine CPT codes and mappings are listed as managed with authorization indicators. Many thyroid/met imaging, parathyroid, bone, GI, pulmonary, brain, and SPECT/CT studies are marked requiring prior authorization for PA, WV, & DE members.

• Representative nuclear medicine CPTs requiring authorization (partial): 78012–78075, 78102–78291, 78300–78315, 78445, 78456–78458, 78579–78582, 78597–78605, 78610, 78630–78635, 78645, 78830–78832, 78831, 78832, 78845 and other tomographic/SPECT/CT codes.
• Multiple entries show an 'X' authorization indicator for thyroid/met imaging with additional studies and for many SPECT/CT and tomographic nuclear medicine procedures.
• When ordering nuclear medicine studies, verify the specific CPT and whether it is marked Managed/X; obtain prior authorization and include relevant clinical indications and prior imaging results.

Authorization indicators for listed procedures

Authorization indicators are used throughout the lists to denote procedures requiring management. Providers must look for 'Managed', 'Highmark Managed', and 'X' markers next to procedures/codes to determine when prior authorization is necessary.

• 'Managed' or 'Highmark Managed' identifies services that require prior authorization or other management processes.
• An 'X' beside a procedure or code is an explicit authorization indicator in these listings.
• If an item is unmapped or the indicator is missing, providers should verify eligibility and prior authorization requirements via the member's benefit plan channels.

Prior authorization required — wheelchair accessories & power seating

Prior authorization is required for numerous wheelchair accessories and power seating features. Providers must obtain authorization for complex power seating systems, power seat elevation or standing systems, and many powered wheelchair accessories.

• Managed HCPCS examples for powered seating and accessories: E1005–E1007, E2298, E2301, E2324 and related E- and K- codes for power seating features.
• Features such as power seat elevation systems, power standing systems, chin/head control interfaces, and complex seating accessories are listed as Highmark Managed and typically require prior authorization.
• Submit clinical justification and mobility assessments when requesting authorization for power seating and accessory items.

Prior authorization required for listed wheelchair/DME items

Many wheelchair, powered mobility device, and DME items are managed and require prior authorization for PA, WV, & DE members. Providers must confirm authorization for both base devices and numerous accessory components prior to delivery.

• Managed wheelchair/DME HCPCS and K-codes include but are not limited to: E0295–E0372 (beds/overlays), E0440, E0483, E0486, E0635 (patient lifts), E1005–E1007 (power seating), E2230, E2295, E2298, E2301, E2324, E2630, E2632, K0005, K0010–K0014, K0050, K0098, K0606 and others listed in the section.
• Accessories and features (e.g., power seat elevation, standing systems, suspension supports, pediatric dynamic seating frames, drive belts) are often managed and may require detailed clinical documentation.
• When billing wheelchair or powered vehicle items, ensure prior authorization is obtained where indicated and include supporting documentation such as clinical need, functional assessment, and supplier quotes.

Items requiring management/prior authorization

Certain items and accessories (wheelchair accessories, powered mobility features, hospital beds, oxygen systems, patient lifts and other DME) are explicitly listed as requiring management/prior authorization. Providers must follow prior authorization processes and include appropriate clinical documentation.

• Hospital bed types and accessories (E0295–E0316), powered air overlays (E0372), oxygen and supplies (E0440), patient lifts (E0635), pneumatic appliances (E0666–E0667), chest wall oscillation systems (E0483), and oral devices (E0486) are examples of managed DME.
• Wheelchair accessories and complex rehabilitative features (E1005–E1007, E2298, E2301, E2324, E2630/E2632, etc.) require prior authorization.
• Confirm plan-specific requirements and provide functional assessments, trial documentation, and supplier information with authorization requests.

Prior authorization required for listed wheelchair/DME codes

Multiple wheelchair, powered vehicle, and accessory HCPCS/K-codes are designated Highmark Managed and require prior authorization. Providers must ensure authorization for the specified codes and features before dispensing.

• Managed wheelchair and powered vehicle codes (partial): K0005, K0010–K0014, K0098, K0606 and a range of HCPCS E- and E/K- codes for accessories and components.
• Specific managed features include programmable control parameters, tremor dampening, standing systems, elevation systems, head/chin control interfaces, and other complex rehab technology features.
• Authorization submissions should include comprehensive evaluations, justification for selected features, and documentation of medical necessity per plan requirements.