The following is an excerpted, consolidated list of procedures, HCPCS/CPT codes, and DME items that require prior authorization from Highmark Delaware effective 2025-10-01. Entries shown as Managed / Highmark Managed indicate the item is subject to Highmark or eviCore prior-authorization programs. This is a non-exhaustive excerpt; providers must verify authorization requirements for specific members and benefits.
Highmark Managed — Reconstructive and/or Cosmetic procedures (examples): CPT 15876, 15877, 15878, 15879 (suction-assisted lipectomy variants); excision of excessive skin/subcutaneous tissue (abdominoplasty) listed separately in addition to primary code.
Highmark Managed — Destruction of cutaneous vascular proliferative lesions (laser techniques): CPT 7106, 7107, 7108 (quantity/size distinctions, e.g., ≤50 sq cm, >50 sq cm, and unlisted skin procedures).
Highmark Managed — Mastectomy and breast procedures (examples): unlisted and specific mastectomy codes including partial (lumpectomy/segmentectomy) and simple/complete mastectomy codes (e.g., 7999, 9301, 9303, 9318) — reduction and reconstructive entries indicated.
Highmark Managed — Genio/plasty and facial osteotomies: CPT 21110 (genioplasty/augmentation/ sliding osteotomies and prosthetic material entries).
Highmark Managed — Spine and joint surgery (examples): multilevel anterior arthrodesis for spinal deformity (8+ vertebral segments), sacroiliac joint arthrodesis (percutaneous or open) and related unlisted spine procedure codes (e.g., 27279, 27280).
Highmark Managed — Foot surgery examples: bunionette/osteotomy and hallux rigidus correction (e.g., CPT 28110, 28291).
Highmark Managed — Thoracic, transplant, and cardiac procedures (examples): lung transplant single/double (CPT 32853, 32854), thoracoabdominal aortic aneurysm repair, endovascular repair of descending thoracic aorta (with left subclavian coverage), and numerous cardiac device insertions/replacements (many entries flagged with X indicating authorization required).
Highmark Managed — Cardiac devices and leadless/defibrillator/pacemaker procedures: multiple device insertion, replacement, and generator procedures are designated requiring prior authorization (entries annotated with X).
Highmark Managed — Varicose vein treatments and related endovenous procedures: CPTs 36465, 36470, 36473, 36479, 36482 and related endovenous ablation, sclerotherapy, stab phlebectomy and ligation/division procedures require authorization.
Highmark Managed — Bariatric surgery and related procedures: sleeve gastrectomy, vertical-banded gastroplasty, Roux-en-Y and duodenal switch/ biliopancreatic diversion procedures, open revisions, neurostimulator electrode implantation/removal and unlisted bariatric procedure codes (examples include CPTs 43633, 44135, 44136, 43881, 43887, 43999).
Highmark Managed — Hysterectomy and select spine-corpectomy/corpectomy-related procedures: select laparoscopic vaginal hysterectomy codes (uterus ≤250 g with adnexal removal) are cross-referenced with spine corpectomy codes and flagged for authorization in certain combinations (e.g., CPT 63055, 63101).
Highmark Managed — Cochlear implant and select nuclear medicine imaging: cochlear device implantation (e.g., CPT 69930) and specified thyroid/nuclear medicine scans and radiopharmaceutical localization procedures (examples include CPTs in 78800 series) are indicated as requiring prior authorization.
Highmark Managed — Nuclear medicine multi-area or multi-day imaging and radiopharmaceutical localization of tumor/inflammatory processes: planar single-area and multi-area studies (including vascular flow and blood pool imaging) and certain whole-body scans require authorization (entries annotated X where applicable).
Highmark Managed — Speech therapy services (examples): treatment codes for speech/language/voice/auditory processing and swallowing therapy (e.g., CPTs 92508, 92526) listed as requiring authorization for applicable populations.
Highmark Managed — Myocardial contrast perfusion echocardiography (add-on or separate reporting) and certain ambulance transport services (A0426, A0430, A0431) are designated for authorization review when billed in facility settings.
Highmark Managed — DME and cardiac-related DME (examples): a range of HCPCS E-codes for hospital bed accessories, oxygen systems, high-frequency chest wall oscillation systems, standing frame/tiltable systems (E0372, E0636–E0642, E0651–E0660, E0483, E0486), and other compression/pneumatic devices are listed as requiring prior authorization for facility claims.
Highmark Managed — Pneumatic/compression devices and accessories (examples): E0651, E0652, E0657, E0660 and related trunk/segmental/full-leg devices are shown with managed status and require prior authorization.
Highmark Managed — Wheelchairs and wheelchair accessories (examples): power add-on kits converting manual to power wheelchairs, joystick/tiller controls, power seating system components (tilt/recline/power seat elevation), multi-positional transfer systems (E0983, E0984, E1002, E1004, E1006, E1007, E1008, E1017, E1060, E1083, E1100, E1220, E1227) and related pediatric specially constructed wheelchairs (E1233, E1234, E1235) are subject to prior authorization.
Highmark Managed — Power wheelchair batteries, nonstandard seating, complex rehabilitative power wheelchair accessories (E2298, E2343, E2358, E2362, E2398) require authorization.
Highmark Managed — Speech generating devices and accessories (examples): E2510, E251x series, E2362, E2599, E2628 and other speech-assistive device codes and mounting/accessory items are listed as requiring prior authorization.
Highmark Managed — Accessories for speech-generating devices and wheelchair mounting hardware (examples): E2628 and related mounting/accessory codes require prior authorization and may need documentation of device necessity and justification.
Provider/Billing Note: Prior authorization must be obtained before scheduling or delivering services/items listed above. When submitting authorization requests include the relevant CPT/HCPCS code(s), clinical indication, and supporting documentation. Failure to obtain prior authorization may result in claim denial or payment delay.