Highmark West Virginia FEP Prior Auth Policy Update

Organ/Tissue Transplants prior authorization stance

Procedures in the Organ/Tissue Transplants category require prior authorization for the listed enrollment types; Medicare/COB bypass is not applied for these entries.

ALL of the following

Organ/Tissue Transplant codes
- Codes such as G0343 (laparotomy for islet cell transplant, includes portal vein catheterization and infusion)
- S2053 (transplantation of small intestine and liver allografts)
- S2054/S2060 (transplantation of multivisceral organs / lobar lung transplantation)
- 0896T (addition for primary procedure)
- 32850 (cadaver donor preservation)
- 33930 (preservation)
- 44133 (donor enterectomy, open, with preparation/maintenance)
- 47146/47147 (backbench reconstruction/anastomosis for donor liver grafts)
- 48551/48552 (backbench preparation/reconstruction of pancreas allograft)
ALL of the following
- Bypass when Medicare/ COB Primary = No
- Needs Prior Authorization Standard/ Basic = Y
- Needs Prior Authorization / FEP Blue Focus = Y

Operational note: backbench preparation and related transplant-specific procedures listed above require prior authorization prior to scheduling or claim submission.

Authorization stance

Listed procedures require prior authorization as indicated; some procedures are authorized only 'BY EXCEPTION ONLY' per the referenced guidelines.

ALL of the following

Procedure groups
- Genital surgeries and prosthesis insertions (e.g., urethroplasty, penile/amputation/prosthesis codes) — may be 'BY EXCEPTION ONLY'
- Sex‑trait modification and certain reconstructive/plastic surgery codes — authorization often 'ONLY' or 'BY EXCEPTION ONLY' (see guidelines)
- ABA services (0362T, 0373T, 97151–97157) — require prior authorization
ALL of the following
- When line entry indicates 'BY EXCEPTION ONLY' or 'ONLY', follow guideline requirements referenced in the document

Procedure-level authorization notes

Authorization stance per listed procedure/code — summary of how line-item flags should be interpreted.

ALL of the following

If a line item shows 'Needs Prior Authorization Standard/ Basic = Y' or 'Needs Prior Authorization / FEP Blue Focus = Y', obtain prior authorization before service delivery.
If a line item shows 'Standard/ Basic = BY EXCEPTION ONLY' or 'ONLY', follow the referenced guidelines for exception criteria prior to requesting authorization.
If 'Bypass when Medicare/ COB Primary = Yes', Medicare/COB primary cases may bypass FEP prior authorization; otherwise authorization is required.

Providers should reference the specific line-item code entries in the FEP list for exact per-code flags and applicable guidance (e.g., sex‑trait modification qualifiers).

Sleep studies

Sleep study authorization rules.

ALL of the following

Sleep study CPTs
- 95782
- 95783
- 95803
- 95805
- 95807

Gene therapy / cellular immunotherapy

High-cost gene and cellular therapies require prior authorization; many entries also indicate Medicare/COB bypass when Medicare is primary.

ALL of the following

Representative J/Q codes
- J1411
- J1412
- J3387
- J3389
- J3391

Authorization and bypass summary

Summary: items listed generally require prior authorization unless a line entry indicates otherwise; many items also bypass authorization when Medicare/COB is primary.

ALL of the following

Default rule: Needs Prior Authorization = Y or FEP Blue Focus = Y for most listed items
Exception: Standard/Basic = N or 'BY EXCEPTION ONLY' entries — follow line-item qualifiers and referenced guidelines
Coordination-of-benefits: if 'Bypass when Medicare/ COB Primary = Yes', then Medicare/COB primary cases bypass FEP prior authorization

Operational note: where both Standard/Basic and FEP Blue Focus flags are present, use the per-code flags to determine which enrollment types require authorization.

Prior authorization coverage stance for L5xxx prosthetic/specialty DME

Coverage and authorization stance for listed L5xxx prosthetic and specialty DME codes — most require FEP Blue Focus prior authorization and often bypass when Medicare/COB is primary.

ALL of the following

Examples of L5xxx codes
- L5321
- L5331
- L5341
- L5500
- L5655

Authorization status for listed L-codes

Authorization and bypass indicators for listed L-codes in this excerpt.

ANY of the following

L5655 — Addition to lower extremity, socket insert, below knee; Bypass when Medicare/ COB = Yes; Standard/ Basic = N; Needs Prior Authorization / FEP Blue Focus = Y
L5656 — Addition to lower extremity, socket insert, knee disarticulation; Bypass when Medicare/ COB = Yes; Standard/ Basic = N; Needs Prior Authorization / FEP Blue Focus = Y
L5657 — Adjustable air/fluid/gel socket insert for limb volume management; Bypass when Medicare/ COB = Yes; Standard/ Basic = N; Needs Prior Authorization / FEP Blue Focus = Y

Many other L‑codes in the same excerpt follow the same pattern (Standard/Basic N; FEP Blue Focus Y; Medicare/COB bypass = Yes).

Authorization stance (excerpt)

Authorization stance for listed prosthetic and specialty DME items in this excerpt: most are flagged for FEP Blue Focus authorization and bypass when Medicare/COB is primary.

ALL of the following

Examples: L5795 (specialty DME material — titanium/carbon fiber), L5810–L5824 series (knee‑shin system additions)
Bypass when Medicare/ COB Primary = Yes
Standard/ Basic = N for many entries; Needs Prior Authorization / FEP Blue Focus = Y

Action: submit FEP Blue Focus prior authorization for these specialty DME items unless Medicare/COB primary bypass applies.

Coverage criteria for listed prosthetic devices

Coverage criteria summary for listed prosthetic devices: most require FEP Blue Focus prior authorization and many bypass authorization when Medicare/COB is primary.

ALL of the following

Prior authorization required: Most listed prosthetic L‑codes show Needs Prior Authorization / FEP Blue Focus = Y while Standard/ Basic = N
Medicare/COB primary bypass: Many entries indicate 'Bypass when Medicare/ COB Primary = Yes' — coordination-of-benefits operational rule
Coding mapping: each line pairs an HCPCS L‑code with a description (e.g., L6384 = immediate post‑surgical rigid dressing; L5999 = lower extremity prosthesis NOS)

Providers should use the per‑code flags to determine whether to request FEP Blue Focus prior authorization or to apply Medicare/COB bypass handling.

Per-code authorization stance (excerpt)

Per-code authorization stance (excerpt) — examples of specific L‑codes with their authorization flags.

ANY of the following

L6600 — Upper extremity additions, polycentric hinge, pair; Standard/ Basic = N; Needs Prior Authorization / FEP Blue Focus = Y; Bypass when Medicare/ COB Primary = Yes
L6642 — Upper extremity addition, excursion amplifier, lever type; Standard/ Basic = N; Needs Prior Authorization / FEP Blue Focus = Y; Bypass when Medicare/ COB Primary = Yes
L6696 — Elbow custom fabricated socket insert (silicone gel) — Standard/ Basic Option = N; Needs Prior Authorization / FEP Blue Focus = Y; Bypass when Medicare/ COB Primary = Yes

These entries illustrate the recurring pattern: Standard/Basic often N, FEP Blue Focus Y, and Medicare/COB bypass = Yes.

Prior authorization and bypass criteria (summary)

Authorization summary for the prosthetic and specialty DME codes in this section.

ALL of the following

Most entries require prior authorization under FEP Blue Focus (Needs Prior Authorization / FEP Blue Focus = Y).
Standard/ Basic Option is commonly set to N for these items.
Many entries specify 'Bypass when Medicare/ COB Primary = Yes' — treat Medicare/COB primary cases as bypassing FEP prior authorization.

Operational action: for FEP members, obtain FEP Blue Focus prior authorization unless Medicare/COB primary applies and bypass is indicated.

Authorization flags by code (partial)

Authorization flags by code — selected HCPCS/L/E codes and their authorization/bypass indicators.

ANY of the following

L7404 — Disarticulation, acrylic material; Needs Prior Authorization = Y; Standard/ Basic = N; Bypass when Medicare/ COB Primary = Yes
L8040 — Nasal prosthesis provided by a non‑physician; Needs Prior Authorization / FEP Blue Focus = Y; Standard/ Basic = N; Bypass when Medicare/ COB Primary = Yes
E0265/E0266/E0277/E0985 etc. — Hospital beds, powered pressure‑reducing mattresses, wheelchair accessories: Needs Prior Authorization / FEP Blue Focus = Y; Bypass when Medicare/ COB Primary = Yes

Action: use these per‑code indicators to determine whether FEP Blue Focus prior authorization is required and whether Medicare/COB bypass applies.

Prior authorization and coordination-of-benefits indicators

Prior authorization and coordination-of-benefits indicators for listed E-codes and specialty DME items.

ALL of the following

Items such as E0985, E0986, E1002–E1007 (wheelchair accessories/power seating) and E2358–E2361 (batteries/accessories) show Needs Prior Authorization / FEP Blue Focus = Y
Standard/ Basic = N for these items — use FEP Blue Focus flags for authorization requirement
Bypass when Medicare/ COB Primary = Yes — Medicare/COB primary cases may bypass FEP prior authorization

Operational action: submit FEP Blue Focus prior authorization for listed E‑codes when payer enrollment requires it; verify Medicare/COB status for bypass handling.

Provider Authorization & Billing Guidance

Prior Authorization

Prior authorization requirement for listed procedures

Procedures and durable medical equipment listed in the FEP table require prior authorization as indicated; organ/tissue transplant codes are explicitly marked as needing prior authorization for Standard/Basic and FEP Blue Focus enrollment types.

Organ/Tissue Transplants: Needs Prior Authorization Standard/Basic = Y; Needs Prior Authorization / FEP Blue Focus = Y.
Bypass when Medicare/COB = No for transplant entries.

Prior Authorization

Sex‑Trait Modification prior auth note

For services labeled '*Sex‑Trait Modification,' prior authorization applies only if treatment began prior to 01/01/2026; there is no benefit for treatment that began on or after 01/01/2026.

Billing Rule

Coordination of benefits/Medicare bypass

Many line items include a 'Bypass when Medicare/ COB' indicator; providers must follow that per‑item guidance because Medicare/COB primary cases may bypass the payer prior authorization requirement when the entry indicates 'Yes' or similar qualifiers.

Check the specific line item for 'Bypass when Medicare/ COB' before submitting an authorization request.
If entry shows 'Yes' or 'Bypass when Medicare/ COB Primary = Yes,' prior authorization is not required when Medicare/COB is primary.

Prior Authorization

Transplant prior authorization

Organ and tissue transplant procedures and related backbench graft preparation are listed as requiring prior authorization for both Standard/Basic and FEP Blue Focus enrollment types; Medicare/COB primary is not listed as bypass for these entries.

Backbench preparation entries: Needs Prior Authorization Standard/Basic = Y; Needs Prior Authorization / FEP Blue Focus = Y.
Bypass when Medicare/ COB Primary = No for transplant entries.

Prior Authorization

ABA services prior authorization

Applied behavioral analysis (ABA) service codes (0362T, 0373T, 97151–97157 series) are marked 'Needs Prior Authorization' for Standard/Basic and FEP Blue Focus; 'Bypass when Medicare/COB Primary' is No.

ABA codes listed require prior authorization for Standard/Basic = Y and FEP Blue Focus = Y.
Verify per‑code line entry before submission; Medicare/COB primary does not bypass these ABA authorizations.

Prior Authorization

Sex-trait modification authorization rules

Sex‑trait modification and related reconstructive/plastic surgery codes are subject to restrictive prior authorization qualifiers—many entries specify 'ONLY' or 'BY EXCEPTION ONLY' and reference 'SEE GUIDELINES ABOVE'.

Examples include CPT codes such as 11921, 15877, 19303, 19318, 19325, 19350, 19357 noted with 'BY EXCEPTION ONLY' or 'ONLY'.
Follow the referenced guidelines for exception criteria when a line item is marked 'BY EXCEPTION ONLY' or 'ONLY'.

Prior Authorization

Genital procedures prior authorization

Genital surgeries and penile/prosthesis insertion procedures are listed with prior authorization requirements or qualified as 'BY EXCEPTION ONLY'; providers must obtain authorization or follow guideline exceptions as specified on the per‑code line.

Codes such as 54400, 54401, 54660, 54520, 54690, 55175, and 55180 are shown with 'Needs Prior Authorization' = ONLY or BY EXCEPTION ONLY.
When a line shows 'SEE GUIDELINES ABOVE' follow that guidance to determine authorization need.

Prior Authorization

Prior authorization requirement summary

The FEP list repeatedly indicates that many procedures require prior authorization; entries include fields 'Needs Prior Authorization Standard/ Basic' and 'Needs Prior Authorization / FEP Blue Focus' with values like Y, ONLY, or BY EXCEPTION ONLY directing provider action.

Obtain prior authorization when the line item indicates 'Y' or when qualifier rules do not provide a bypass.
If an entry is 'ONLY' or 'BY EXCEPTION ONLY', follow the referenced guidelines before requesting authorization.

Billing Rule

Medicare/COB bypass guidance

Some entries include 'Bypass when Medicare/ COB' qualifiers such as 'BY EXCEPTION ONLY' or 'ONLY'; providers must check each line item's bypass field because coordination‑of‑benefits rules change whether payer authorization is required.

If the line indicates 'Bypass when Medicare/ COB = Yes' or 'Primary = Yes', authorization may be bypassed when Medicare/COB is primary.
If the line indicates 'BY EXCEPTION ONLY' follow the guideline exceptions noted on the table.

Documentation Required

Sex-trait modification authorization notes

Many entries are annotated with '*Sex-Trait Modification' or '*Sex-Trait Modification Facial Surgery'; these annotations indicate specialized authorization considerations and direct providers to 'SEE GUIDELINES ABOVE' for exception criteria.

Review the guideline text when a service is marked '*Sex-Trait Modification' or '*Sex-Trait Modification Facial Surgery'.
Authorization may be restricted to 'BY EXCEPTION ONLY' or similar qualifiers per the guideline.

Prior Authorization

Prior authorization requirement summary (facial/reconstructive procedures)

Facial and reconstructive procedures flagged as 'Sex‑Trait Modification Facial Surgery' commonly carry 'Needs Prior Authorization' qualifiers like 'BY EXCEPTION ONLY' or 'ONLY'—providers must secure authorization or apply exception rules as directed in the guidelines.

Example CPTs include 21121, 21123, 21125 with 'Needs Prior Authorization Standard/Basic = BY EXCEPTION ONLY' or 'ONLY'.
Follow 'SEE GUIDELINES ABOVE' for criteria when entries are qualified.

Prior Authorization

Prior authorization for sleep studies

Sleep studies performed outside the home are listed as 'Needs Prior Authorization Standard/ Basic = Y' for the Standard/Basic enrollment; many of these entries show 'Needs Prior Authorization / = N' and may bypass prior authorization under the FEP Blue Focus flag—check the specific code line.

Codes such as 95782, 95783, 95803, 95805, 95807, 95808, 95811 require Standard prior authorization = Y.
'Bypass when Medicare/ COB = Yes' is indicated for sleep study lines; confirm payer status before submitting.

Prior Authorization

Prior authorization for gene/cellular therapies

Gene therapy and cellular immunotherapy J‑codes are explicitly listed as requiring prior authorization under Standard/Basic and FEP Blue Focus; several entries also note 'Bypass when Medicare/ COB = Yes' for Medicare/COB primary cases.

Examples: J1411, J1412, J3387, J3389, J3391, J3392 are marked 'Needs Prior Authorization Standard/ Basic = Y' and 'Needs Prior Authorization / = Y'.
Verify the per‑code 'Bypass when Medicare/ COB' flag—many gene/cellular therapy entries show Medicare/COB bypass = Yes.

Prior Authorization

Prior authorization required for listed procedures/DME

The document lists numerous procedure and DME items that require prior authorization—many entries are marked 'Needs Prior Authorization = Y' or 'FEP Blue Focus = Y'; providers must submit authorization requests for those line items unless a bypass applies.

Confirm whether Standard/Basic, FEP Blue Focus, or Medicare/COB bypass conditions apply for each code before submission.
Follow FEP Blue Focus authorization pathways for items flagged 'FEP Blue Focus = Y'.

Prior Authorization

Prior authorization requirement for listed L5xxx prosthetic/specialty DME

A large group of L5xxx prosthetic and specialty DME codes are shown with 'Needs Prior Authorization / FEP Blue Focus = Y' and 'Standard/ Basic Option = N'; many of these entries indicate 'Bypass when Medicare/ COB Primary = Yes'.

Examples include L5321, L5331, L5341, L5500 and many other L5xxx codes requiring FEP Blue Focus authorization.
Confirm Medicare/COB primary status—many L‑code entries bypass authorization when Medicare/COB is primary.

Billing Rule

Prior authorization and Medicare/COB bypass indicators for listed L-codes

Specific L‑codes in the list (e.g., L5655, L5656, L5657) are shown with Bypass when Medicare/COB = Yes, Standard/Basic prior authorization = N, and Needs Prior Authorization / FEP Blue Focus = Y; providers should follow these flags per item.

L5655: Addition to lower extremity, socket insert, below knee — Bypass when Medicare/COB = Yes; Standard/Basic = N; FEP Blue Focus = Y.
L5656 and L5657 follow the same pattern—confirm payer before requesting authorization.

Prior Authorization

Authorization flags for exoskeletal and pelvic-control items

Certain exoskeletal and pelvic‑control prosthetic items are listed with 'Bypass when Medicare/COB Primary = Yes', 'Standard/Basic prior auth = N', and 'FEP Blue Focus prior auth = Y'; obtain FEP Blue Focus authorization when applicable and confirm Medicare/COB status.

Examples: L5694 (pelvic control belt), L5710 (exoskeletal knee‑shin addition) are flagged FEP Blue Focus = Y and bypass Medicare/COB = Yes.
If Medicare/COB is primary, prior authorization may be bypassed per the entry.

Prior Authorization

Prior authorization requirement summary for listed specialty DME/prosthetic L-codes

The specialty DME/prosthetic L‑code sections repeatedly require prior authorization under FEP Blue Focus (Needs Prior Authorization / FEP Blue Focus = Y) while often marking Standard/Basic as N and indicating Medicare/COB primary bypass = Yes for many lines.

Most specialty L‑codes in this section: Standard/Basic = N; Needs Prior Authorization / FEP Blue Focus = Y; Bypass when Medicare/ COB Primary = Yes.
Submit FEP Blue Focus authorization requests for items flagged 'Y' unless Medicare/COB primary applies.

Prior Authorization

Examples of L-codes requiring prior authorization

Examples of L‑codes requiring prior authorization under FEP Blue Focus include advanced prosthetic components such as L5827 (fluid swing and stance phase control), L5840 (multi‑axial pneumatic swing phase control), and L5856 (microprocessor control feature additions).

These L‑codes are marked 'Needs Prior Authorization / FEP Blue Focus = Y' and often 'Bypass when Medicare/ COB Primary = Yes'.
Confirm per‑code flags before requesting authorization.

Prior Authorization

Prior authorization required for listed prosthetic L‑codes

Multiple prosthetic L‑codes (e.g., L5999, L6000, L6010) are listed with 'Needs Prior Authorization / FEP Blue Focus = Y' and 'Standard/ Basic = N'; many of these entries also indicate Medicare/COB primary cases bypass authorization.

Providers must request FEP Blue Focus authorization for these L‑codes when FEP is primary payer.
If 'Bypass when Medicare/ COB Primary = Yes' applies, do not submit prior authorization when Medicare/COB is primary.

Prior Authorization

Prior authorization requirement for listed DME/prosthetic codes

Specific DME and prosthetic HCPCS L‑codes in the upper‑extremity group (e.g., L6600, L6642, L6696) list prior authorization indicators and often show Medicare/COB bypass = Yes; obtain authorization under FEP Blue Focus when indicated.

L6600: Needs Prior Authorization / FEP Blue Focus = Y; Bypass when Medicare/ COB Primary = Yes.
Many upper‑extremity L‑codes show Standard/Basic = N and FEP Blue Focus = Y.

Prior Authorization

Authorization flags and program options

Most lines for specialty prosthetic items include 'Needs Prior Authorization / FEP Blue Focus = Y' while 'Standard/Basic' is frequently marked N; providers must use the FEP Blue Focus authorization pathway for flagged items.

Review each line for the 'Needs Prior Authorization / FEP Blue Focus' flag before ordering equipment or scheduling procedures.
If Standard/Basic = N, do not rely on the standard prior authorization pathway for FEP cases—follow FEP Blue Focus process.

Billing Rule

Coordination of benefits bypass note

Many specialty DME and prosthetic entries include 'Bypass when Medicare/ COB Primary = Yes'—confirm coordination‑of‑benefits status because Medicare/COB primary cases commonly bypass the FEP prior authorization requirement for these items.

When Medicare/COB is primary and the line shows 'Bypass when Medicare/ COB Primary = Yes', do not submit a prior authorization to FEP.
If payer status is unclear, verify primary payer before initiating authorization.

Prior Authorization

Prior authorization requirement summary

This section's specialty DME/prosthetic items are subject to FEP Blue Focus prior authorization requirements; Standard/Basic authorization is generally not required for these entries (Standard/Basic = N) so providers should pursue FEP Blue Focus authorization when FEP is primary payer.

Confirm FEP Blue Focus = Y on the line item before submitting the FEP authorization request.
If Standard/Basic = N, follow FEP Blue Focus procedures rather than standard authorization channels.

Billing Rule

Coordination-of-benefits bypass note

Many listings indicate 'Bypass when Medicare/COB Primary = Yes'—meaning when Medicare or another payer is primary, the FEP authorization requirement may be bypassed for those items; check per‑line guidance.

Do not submit FEP prior authorization when Medicare/COB is primary and the line indicates bypass = Yes.
If the entry reads 'BY EXCEPTION ONLY' follow the guideline exceptions.

Prior Authorization

Prior authorization required for listed specialty DME/prosthetic codes

Numerous specialty DME and prosthetic codes are shown with 'Needs Prior Authorization = Y' under the FEP Blue Focus program while Standard/Basic is marked N; providers must request authorization for these items when FEP is the primary payer.

Examples include L7404–L7406 entries requiring prior authorization when FEP is primary.
Confirm whether Medicare/COB primary status applies; many entries show bypass = Yes.

Prior Authorization

Non-physician maxillofacial/craniofacial prostheses authorization

Maxillofacial and craniofacial prostheses provided by non‑physicians (e.g., L8040–L8044) are listed as 'Needs Prior Authorization / FEP Blue Focus = Y' and indicate 'Bypass when Medicare/ COB Primary = Yes'—obtain FEP authorization when FEP is primary payer.

L8040, L8041, L8042 entries: Needs Prior Authorization / FEP Blue Focus = Y; Bypass when Medicare/COB Primary = Yes.
If Medicare/COB is primary, do not submit FEP prior authorization per the bypass flag.

Prior Authorization

Complex DME prior authorization (beds, mattresses, wheelchair accessories)

Complex DME such as hospital beds, powered pressure‑reducing mattresses, and wheelchair power add‑on accessories are included and flagged for prior authorization under FEP Blue Focus; many of these entries also bypass authorization when Medicare/COB is primary.

Examples: E0277 (powered pressure‑reducing air mattress), E0266 (hospital bed with mattress) — Needs Prior Authorization / FEP Blue Focus = Y; Bypass when Medicare/COB Primary = Yes.
Obtain FEP authorization when FEP is primary; do not when Medicare/COB is primary and the line indicates bypass = Yes.

Prior Authorization

Prior authorization required for listed E-codes / specialty DME

Cochlear implant and specialty E‑code items (examples: E0985, E0986, E1002, E1003, E1230, E2310, E2358) are flagged 'Needs Prior Authorization / FEP Blue Focus = Y' with Standard/Basic = N and often show 'Bypass when Medicare/COB Primary = Yes'; submit authorization requests accordingly.

Confirm per‑code FEP Blue Focus flag before ordering cochlear implant or specialty DME items.
If 'Bypass when Medicare/ COB Primary = Yes' applies, do not request FEP authorization when Medicare/COB is primary.

Billing Rule

Prior authorization requirement and Medicare/COB bypass

Many implant/prosthetic device and specialty DME lines (including power wheelchair accessories) require FEP prior authorization and indicate Medicare/COB primary cases bypass authorization; providers must check the per‑item flags before seeking authorization.

Per‑line examples: E2373–E2375 and K0837–K0838 entries show Needs Prior Authorization / FEP Blue Focus = Y and Bypass when Medicare/ COB Primary = Yes.
Verify primary payer and per‑code flags prior to submission.

Prior Authorization

Prior authorization requirement for listed implants/prosthetic devices and specialty DME

Multiple K‑series implant/prosthetic and power mobility device codes are listed with 'Needs Prior Authorization' and FEP Blue Focus indicators; providers should request authorization under FEP Blue Focus for those entries when FEP is the primary payer.

Examples: K0837, K0838 (power wheelchair/group 2 entries) — Needs Prior Authorization / FEP Blue Focus flagged.
Confirm Medicare/COB status; many K‑codes bypass authorization when Medicare/COB is primary.

Prior Authorization

Prior authorization requirement for bariatric surgery codes

Bariatric surgery CPT/HCPCS codes shown (e.g., 0813T, 43290, 43644, 43645) require prior authorization; the table lists Standard/Basic Option = Y and Needs Prior Authorization / FEP Blue Focus = Y and often indicates 'Bypass when Medicare/COB Primary = Yes'.

Obtain prior authorization for bariatric procedures under the Standard/Basic and FEP Blue Focus pathways when FEP is primary.
If Medicare/COB is primary and the line indicates bypass = Yes, prior authorization may not be required.

Terms and Flags Used

FEP enrollment codes

FEP enrollment codes - Standard Option104, 105, 106, 33D, 33E, 33F

FEP enrollment codes - Basic Option111, 112, 113, 33A, 33B, 33C

FEP enrollment codes - FEP Blue Focus131, 132, 133, 35A, 35B, 35C

Bypass when Medicare/COB

MeaningIndicates whether prior authorization is bypassed when Medicare or another payer is primary (coordination of benefits)

Common valuesYes; No; BY EXCEPTION ONLY; ONLY

Actionable guidanceIf 'Bypass when Medicare/ COB = Yes' and Medicare/COB is primary, do not submit FEP prior authorization

Backbench standard preparation of donor graft

TermBackbench standard preparation of donor graft

DescriptionPreparation of donor graft (e.g., cadaver donor whole liver graft) prior to allotransplantation including dissection and preparation of vessels and ducts

Authorization stanceNeeds Prior Authorization Standard/Basic = Y; FEP Blue Focus = Y; Bypass when Medicare/COB Primary = No

Authorization designation indicating requirement for special review/guidelines

Designation'BY EXCEPTION ONLY' — authorization required only by exception per referenced guidelines

Where usedApplied to many sex‑trait modification and facial/reconstructive procedure entries

Provider actionSee guidelines referenced in document for exception criteria when this designation appears

Needs Prior Authorization

Definition'Needs Prior Authorization' indicates the procedure or item requires prior authorization

Typical flagsValues observed include Y, ONLY, BY EXCEPTION ONLY depending on entry

ProgramsApplied to Standard/Basic and/or FEP Blue Focus as indicated per line item

Bypass when Medicare/COB

Definition'Bypass when Medicare/ COB = Yes' indicates prior authorization is bypassed when Medicare or other primary payer applies

ExamplesSleep studies outside the home and many gene/cellular therapy entries note Medicare/COB bypass = Yes

Operational impactIf Medicare/COB is primary and bypass = Yes, do not obtain FEP prior authorization

Sex-Trait Modification

TermSex‑Trait Modification

ContextApplied as a label to many codes (including facial surgery) and often paired with special authorization rules (ONLY / BY EXCEPTION ONLY)

Authorization noteEntries marked 'Sex‑Trait Modification' reference guidelines above for exception criteria and prior authorization requirements

BY EXCEPTION ONLY (authorization qualifier)

Qualifier'BY EXCEPTION ONLY' — authorization qualifier used for Standard/Basic prior authorization in many facial/reconstructive entries

ImplicationStandard/Basic prior authorization may be required only in exceptional cases per guidelines

Provider stepConsult the referenced guidelines above when this qualifier appears on an entry

Medicare/COB bypass

Typical valueBypass when Medicare/ COB Primary = Yes for many gene therapy, cochlear implant, prosthetic and specialty DME entries

EffectMedicare or other primary payer cases bypass the FEP prior authorization requirement when this field = Yes

ExamplesCochlear implants (69930, L8614) and many L-/E-/K-codes list Bypass when Medicare/ COB Primary = Yes

Medicare/COB bypass

Common settingMany specialty DME/prosthetic L-codes show 'Bypass when Medicare/ COB Primary = Yes'

Typical authorization flagsStandard/Basic Option = N; Needs Prior Authorization / FEP Blue Focus = Y for listed L-codes

Provider instructionWhen Medicare/COB is primary and bypass = Yes, do not submit FEP prior authorization for these L-codes

Alternate authorization requirement flag (FEP Blue Focus)

Flag nameFEP Blue Focus prior authorization flag

MeaningNeeds Prior Authorization / FEP Blue Focus = Y indicates prior authorization is required under the FEP Blue Focus program

ContrastEntries often show Standard/Basic Option = N while FEP Blue Focus = Y (alternate program requirement)

Medicare/COB primary bypass

DefinitionMedicare/COB primary bypass = Yes indicates the FEP prior authorization requirement is bypassed when Medicare or other COB is primary

PrevalenceRepeated across many prosthetic and DME line items (L-codes, E-codes, K-codes)

Operational noteConfirm primary payer status before submitting FEP authorization when this flag is present

FEP Blue Focus prior authorization flag

FlagFEP Blue Focus prior authorization indicator

UsageApplied to many prosthetic/specialty DME entries to denote FEP-specific authorization requirement (Needs Prior Authorization / FEP Blue Focus = Y)

Provider actionSubmit to FEP Blue Focus authorization workflow when flag = Y and Medicare/COB does not bypass

Standard/Basic Option flag

FlagStandard/Basic Option = N indicates standard/basic prior authorization pathway is not required for listed items

ContrastOften paired with FEP Blue Focus = Y for the same entry

ImplicationProviders should follow FEP Blue Focus process rather than Standard/Basic when present

Bypass when Medicare/COB

Repeating noteBypass when Medicare/ COB = Yes appears frequently for specialty DME and prosthetic L-codes

Operational implicationMedicare/COB primary cases often bypass FEP authorization for these items

CheckingVerify Medicare/COB primary status before requesting FEP authorization

Prior authorization flags

SummaryMultiple entries across the document show 'Needs Prior Authorization' for procedures/DME (Standard/Basic and/or FEP Blue Focus)

ExamplesOrgan/Tissue Transplants, Gene Therapy, ABA services, many prosthetic and specialty DME codes

ActionObtain prior authorization per the applicable enrollment/program flags unless Medicare/COB bypass applies

FEP Blue Focus

Program nameFEP Blue Focus

MeaningFlag indicating items requiring focused FEP prior authorization (Needs Prior Authorization / FEP Blue Focus = Y)

Common patternOften used when Standard/Basic Option = N but FEP Blue Focus = Y

Bypass when Medicare/COB Primary

Definition'Bypass when Medicare/ COB Primary = Yes' — prior authorization is bypassed when Medicare/COB is primary payer

Where seenFrequently present on L- and E-code prosthetic/DME entries in the document

Provider guidanceIf Medicare/COB is primary and this flag = Yes, do not pursue FEP Blue Focus authorization

Medicare/COB bypass

UsageMedicare/COB bypass = Yes is applied to many high-cost therapy and prosthetic/DME entries

EffectBypasses FEP prior authorization when Medicare/COB is primary

ConfirmVerify primary payer before submitting authorization requests

FEP Blue Focus authorization flag

FlagFEP Blue Focus authorization flag = Y indicates FEP-specific prior authorization required

Typical pairingStandard/Basic = N with FEP Blue Focus = Y across many specialty DME/prosthetic entries

ActionFollow FEP Blue Focus authorization procedures when flag is present

Bypass when Medicare/COB Primary

DefinitionBypass when Medicare/ COB Primary = Yes (repeated operational note)

ImplicationMedicare/COB primary cases bypass the FEP prior authorization requirement for many listed items

Provider stepDo not request FEP authorization when Medicare/COB is primary and bypass flag is Yes

FEP Blue Focus prior authorization flag

FlagNeeds Prior Authorization / FEP Blue Focus = Y

MeaningItem is included in the FEP Blue Focus list requiring FEP-specific prior authorization

Typical contrastStandard/Basic Option often set to N when this flag = Y

Bypass when Medicare/COB primary

Definition'Bypass when Medicare/ COB Primary = Yes' indicates authorization may be bypassed if Medicare or other coordination-of-benefits payer is primary

Operational guidanceCheck primary payer before submitting FEP Blue Focus authorization requests

PrevalenceCommon across L-/E-/K-code specialty DME entries

Authorization flags

CategoryAuthorization flags

Typical patternStandard/Basic = N; Needs Prior Authorization / FEP Blue Focus = Y for many prosthetic/specialty DME items

Medicare/COBBypass when Medicare/COB Primary = Yes appears frequently with these flags

Needs Prior Authorization

ScopeMany procedures (organ/tissue transplants, select surgeries, DME) list 'Needs Prior Authorization'

Enrollment impactApplies to Standard/Basic and FEP Blue Focus enrollment types as indicated per line item

Provider requirementObtain prior authorization prior to service when required and when Medicare/COB bypass does not apply

Bypass when Medicare/ COB

Definition'Bypass when Medicare/ COB' indicates whether authorization is bypassed when Medicare/COB is primary

ExampleSleep studies outside the home: Bypass when Medicare/ COB = Yes; Standard/Basic = Y; FEP = N

GuidanceIf bypass = Yes and Medicare/COB is primary, do not submit FEP authorization

Medicare/COB bypass

DefinitionMedicare/COB bypass = Yes indicates the item bypasses FEP authorization when Medicare or coordination-of-benefits is primary

ExamplesGene therapy/CAR-T codes and cochlear implant components show Medicare/COB primary = Yes

Provider actionVerify primary payer before initiating FEP Blue Focus authorization for these items

FEP Blue Focus prior authorization

FlagNeeds Prior Authorization / FEP Blue Focus = Y

ContextApplied to many high-cost gene/cellular therapies and specialty DME entries

Billing noteSome J-codes and CAR-T related codes also show Medicare/COB bypass = Yes

Standard/Basic prior authorization flag

FlagStandard/Basic Option = N (where shown) indicates standard/basic prior authorization not required

ContrastSome categories require Standard/Basic = Y (e.g., Organ/Transplant), others show N

Provider implicationFollow the specific flag per line item rather than assuming uniform requirement

FEP Blue Focus flag indicating items requiring FEP-specific prior authorization

MeaningFlag indicating items that require FEP-specific prior authorization (Needs Prior Authorization / FEP Blue Focus = Y)

Where usedCommon across L-/E-/K-code specialty DME and many implant/prosthetic listings

Operational noteWhen present, submit authorization through FEP Blue Focus workflow unless bypass applies

Items do not require prior authorization when Medicare or coordination of benefits (COB) is primary payer

StatementItems do not require FEP prior authorization when Medicare or coordination of benefits is primary if 'Bypass when Medicare/COB Primary = Yes'

ExamplesSleep studies, many prosthetic/L-code and implant entries list this bypass

ActionConfirm primary payer to determine whether to request FEP authorization

FEP Blue Focus

TermFEP Blue Focus (program flag)

MeaningDesignates items subject to focused FEP prior authorization review (Needs Prior Authorization / FEP Blue Focus = Y)

Provider implicationFollow FEP Blue Focus submission process for items flagged as such

Standard/Basic Option

TermStandard/Basic Option

Example valueStandard/Basic Option = Y for some categories (e.g., bariatric surgery entries) and = N for many prosthetic/DME entries

ActionCheck the per-line 'Standard/Basic' flag to determine whether standard prior authorization is required

L5530	ADD, ANTERIOR BRIM ELASTIC SLEEVE, BELOW KNEE SOCKET
L5535	ADD, SHIM, BELOW KNEE SOCKET
L5540	ADDITION, SUSPENSION, BELOW KNEE, NEOPRENE CUFF
L5560	ADD, DISTAL, ABOVE KNEE PROSTHETIC SOCKET INSERT
L5570	ADD, SUSPENSION, ABOVE KNEE, SLEEVE
L5580	ADDITION, PISTON OR SIMILAR DEVICE, PROSTHETIC
L5590	ADDITION, SHOCK OR ENERGY STORING DEVICE
L5595	ADDITION, ROTATION UNIT, PROSTHETIC ANKLE-FOOT
L5600	ADD, PROSTHETIC LINER, SPECIFIED MATERIAL
L5610	ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS

S2083	ADJUSTMENT OF GASTRIC BAND DIAMETER VIA SUBCUTANEOUS PORT
C9784	INJECTION OR ASPIRATION LIGATION OF SALINE GASTRIC RESTRICTIVE PROCEDURE, ENDOSCOPIC SLEEVE GASTROPLASTY, INTRALUMINAL TUBE INSERTION (LISTED FOR FACILITY CHARGING)

OpenPayer

FEP list of procedures and durable medical equipment requiring prior authorization

Coverage and Authorization Criteria

Code Lists (CPT / HCPCS / L / K / J / E Series)

Provider Authorization & Billing Guidance

Terms and Flags Used