Prior Authorization Required — Provider Verification and Authorization Methods

Prior authorization is required for many procedures, devices, and DME items listed below. Providers must obtain prior authorization before scheduling or performing these services to avoid claim denials or delays. Authorization methods: call the number on the back of the member's card, check eligibility/benefits via Availity, or search BlueExchange through the provider's portal. eviCore continues to manage certain Genetic Testing and Radiation Oncology programs for applicable lines of business — check the PRC for updates.

• Authorization effective date: 2025-10-01
• Authorization verification methods: phone (member card), Availity, BlueExchange

Procedure Authorization List (partial) — Surgical, Ophthalmic, Neurostimulator

The Highmark List of Procedures/IDME Requiring Authorization (effective 10/1/2025) includes numerous surgical procedures (reconstructive and cosmetic), ophthalmic/cataract and eyelid procedures, neurostimulators, cardiac device procedures, vascular and venous interventions, bariatric and transplant procedures, spine and neurosurgical procedures, and more. Providers must request prior authorization for procedures and report the applicable CPT/HCPCS or device codes when submitting requests.

• Examples include reconstructive/cosmetic procedures (e.g., abdominoplasty, suction-assisted lipectomy), genioPlasty and osteotomies, mastectomy and breast reduction/reconstruction codes
• Ophthalmic/cataract procedures including complex cataract with intraocular devices and anterior segment aqueous drainage devices
• Eyelid/blepharoptosis and other eyelid reconstructive procedures (e.g., codes 67900–67906, 67999)
• Neurostimulator implantation, revisions, and related electrode procedures (e.g., CPT 63664, 64561 and related codes)

Procedures Requiring Prior Authorization (partial) — Cardiac Devices & Transcatheter Procedures

Cardiac device implantations, replacements, revisions and removals require prior authorization. This includes pacemakers, implantable cardioverter-defibrillators (ICDs), leadless pacemakers, and procedures involving transvenous leads or generator changes. Related facility-only device HCPCS/C-codes for generators and leads are included on the authorization list.

• Examples of cardiac procedures: pacemaker insertion/replacement (single, dual, multi-lead), ICD insertion/replacement, lead revisions
• Transcatheter procedures requiring authorization include TAVR and transcatheter left atrial appendage closure when listed
• Facility device codes (e.g., ICD/pacemaker generators, lead HCPCS) and implantable device C-codes require authorization for facility claims

Procedures Requiring Authorization (excerpt) — Vascular, Venous, Sleep Studies, EP

Vascular and venous procedures such as endovenous ablation (laser, chemical adhesive/cyanoacrylate), stab phlebectomy, transcatheter stent placement, and carotid interventions appear on the authorization list. Sleep studies and comprehensive electrophysiology (including AF ablation with 3D mapping) are also included and require prior authorization.

• Endovenous ablation therapy of incompetent vein (CPT examples in the list: 36479, 36482)
• Stab phlebectomy (e.g., CPT 37766, 37780, 37785, 37788)
• Transcatheter placement of intravascular stents (cervical carotid)
• Comprehensive electrophysiologic evaluation and complex ablations (including pulmonary vein isolation with 3D mapping)

Procedures Requiring Authorization (partial list) — Nuclear Medicine & Echocardiography

The policy lists numerous nuclear medicine and radiopharmaceutical localization procedures that require prior authorization. Examples include thyroid uptake and imaging, parathyroid imaging, hepatobiliary, renal, pulmonary V/Q, bone scans, lymph imaging and other planar or tomographic nuclear studies. Echocardiography (TEE including probe placement and myocardial contrast perfusion echocardiography) and cardiac MRI for morphology/function when specified also require authorization.

• Thyroid imaging and quantitative uptake studies (listed)
• Parathyroid planar imaging and subtraction techniques
• Hepatobiliary and liver/spleen imaging; bone marrow and bone scans
• Transesophageal echocardiography (probe placement, acquisition, interpretation) and myocardial contrast perfusion echocardiography (listed)

Procedures Requiring Authorization (selection) — Bariatric, Spine, Neurostimulators

The list includes bariatric surgical procedures (e.g., sleeve gastrectomy, Roux-en-Y), select transplant procedures, complex spine surgeries (corpectomy, vertebral resection), hysterectomy with specific approaches, and various neurosurgical procedures — all flagged for prior authorization. Neurostimulator procedures (implants, revisions, paddle/plate revisions, sacral placements) are explicitly listed and require authorization.

• Bariatric surgeries: sleeve gastrectomy, Roux-en-Y and related restrictive procedures
• Spine surgeries: vertebral corpectomy, corpectomy for intraspinal lesion, thoracic/lumbar approaches (see list)
• Neurostimulators: percutaneous and open electrode implantation, revisions, sacral neurostimulator placements (CPT examples in list)

Ophthalmic / Cataract Procedures — Prior Authorization Required

Ophthalmic and cataract procedures requiring authorization include complex extracapsular cataract removal with insertion of intraocular lens prosthesis when complex techniques or devices are used (iris expansion, suture support, primary posterior capsulorrhexis) and when anterior segment aqueous drainage devices are implanted. Reconstructive eyelid procedures and unlisted lacrimal or eyelid procedures are also on the list.

• Complex cataract surgery with intraocular device use (listed under cataract/corneal surgery entries)
• Anterior segment aqueous drainage device implantation (e.g., trabecular meshwork or supraciliary devices)
• Eyelid reconstructive procedures and blepharoptosis repairs (codes 67900–67906, 67999 where applicable)

Authorization Required for Listed DME Items — Examples

A large range of DME items and accessories require prior authorization. Examples include hospital beds and safety/enclosure frames, high frequency chest wall oscillation systems, oral appliances for airway management, stationary liquid oxygen systems, powered air flotation beds and associated mattress overlays/pads, and other complex DME.

• Hospital bed types and accessories (e.g., E0296, E0316)
• High frequency chest wall oscillation systems (e.g., E0483)
• Oral appliance/appliance for airway management (e.g., E0635)
• Stationary liquid oxygen systems and powered air flotation beds/overlays (examples in list)

Authorization Required for Additional DME Items — Pneumatic Compression & Other Devices

Additional DME items requiring authorization include pneumatic compression systems and a wide range of pneumatic appliance HCPCS codes (E0651–E0675 and related), compressors, ultraviolet light therapy systems (E0691, E0693 series), and other specialized home medical equipment.

• Pneumatic compressors and segmental/nonsegmental pneumatic appliances (E0651–E0669, E0670–E0675 series)
• High pressure rapid inflation devices for arterial insufficiency (E0675 and related)
• Ultraviolet light therapy systems and panels (E0691, E0693)

DME and Selected Device Prior-Authorization List — HCPCS Examples

Highmark's prior-authorization list includes an extensive set of DME and selected device HCPCS E-codes. These cover hospital beds and accessories, mattresses and overlays, high frequency chest wall devices, oxygen systems, and numerous other DME categories. Providers must include HCPCS codes when requesting authorization.

• Facility/HCPCS examples from the list: E0187, E0193, E0197, E0296, E0316, E0372, E0483, E0635, E0642
• High frequency chest wall oscillation (E0483/E0500 series) and oxygen/home liquid systems are included
• Provide specific HCPCS when submitting authorization requests

Wheelchair Accessories and Transfer Systems — Prior Authorization Required

Wheelchair accessories, power add-on modules, and multi-positional patient transfer systems require authorization. This includes joystick power-add ons, power seating system accessories (tilt, recline, power seat elevation, power standing systems), dynamic positioning hardware, and multi-positional transfer systems with integrated seats and lifts.

• Manual wheelchair accessory power add-on to convert manual to motorized (joystick/tiller controls) — HCPCS examples: E0983, E0984
• Power seating system accessories (tilt/recline/elevating systems) — e.g., E1002, E1004–E1008 series
• Multi-positional patient transfer systems with integrated seats and lift functions (E1035 series)

Prior Authorization Required for Listed Wheelchairs and Accessories — Pediatric & Adult

Prior authorization is required for listed wheelchairs and pediatric wheelchair entries. Examples include pediatric tilt-in-space folding and rigid wheelchairs, pediatric power wheelchairs, seating systems, and heavy-duty wheelchairs. Providers must request authorization and supply HCPCS codes and device details.

• Pediatric tilt-in-space folding/adjustable wheelchairs and seating systems (HCPCS E1233, E1234, E1235, E1237)
• Pediatric power wheelchairs and powered vehicle entries (HCPCS E1238, E1239)
• Heavy-duty wheelchairs and special seating components (e.g., E1295)

Power/Manual Wheelchair Accessories and Batteries — Authorization Required

Power/manual wheelchair accessories and batteries are included on the authorization list. This covers complex rehabilitative accessories (power seat elevation, power standing systems), head control and extremity control interfaces, nonstandard seat frames and depths, and lead-acid battery groups for power wheelchairs. These items require prior authorization using the HCPCS codes in the list.

• Complex rehabilitative power wheelchair accessories (E2298 and related codes)
• Power wheelchair head control interfaces and electronic proportional control devices (E2327–E2329 series)
• Power wheelchair accessory batteries and battery groups (E2358, E2362)
• Nonstandard seat frame and depth accessories (E2341, E2343)