FEP list of procedures and durable medical equipment requiring prior authorization
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A fee-for-service (FEP) list of procedures and durable medical equipment that require prior authorization for enrolled members in DE, NY, PA, and WV; affects providers submitting authorization requests for those enrollment codes.
No material clinical or coverage changes in this revision.
Coverage and Authorization Criteria
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)
- 0896T (addition for primary procedure)
- 32850 (cadaver donor preservation)
- 33930 (preservation)
- 44133 (donor enterectomy, open, with preparation/maintenance)
ALL of the following
- Bypass when Medicare/ COB Primary = No
- Needs Prior Authorization Standard/ Basic = Y
- Needs Prior Authorization / FEP Blue Focus = Y
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)
ALL of the following
- When line entry indicates 'BY EXCEPTION ONLY' or 'ONLY', follow guideline requirements referenced in the document
- When line entry indicates Y, obtain prior authorization per payer process
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
- Needs Prior Authorization Standard/ Basic = Y for listed attended sleep studies outside the home
- Needs Prior Authorization / = N for FEP Blue Focus (per line entries) — follow per-code flag
- Bypass when Medicare/ COB = Yes; Medicare/COB primary cases may bypass prior authorization
Action: submit authorization for attended polysomnography per payer process when not bypassed by Medicare/COB.
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
- Needs Prior Authorization Standard/ Basic = Y
- Needs Prior Authorization / FEP Blue Focus = Y
- Bypass when Medicare/ COB Primary = Yes for many gene/cellular therapy entries
Action: submit prior authorization for listed gene and cellular immunotherapies per payer requirements; confirm Medicare/COB status to determine bypass applicability.
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
- Standard/ Basic Option = N for many listed L‑codes
- Needs Prior Authorization / FEP Blue Focus = Y
- Bypass when Medicare/ COB Primary = Yes (most entries)
Operational note: obtain FEP Blue Focus authorization for L‑code items flagged Y unless Medicare/COB is primary and bypass applies.
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
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
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
- 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.
Code Lists (CPT / HCPCS / L / K / J / E Series)
| 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 |
| E2366 | BATTERY, RECHARGEABLE, FOR POWERED WHEELCHAIR |
| 43775 | LAPAROSCOPY, SURGICAL, GASTRIC RESTRICTIVE PROCEDURE; WITH INTRAGASTRIC BALLOON PLACEMENT OR RELATED PROCEDURE |
| 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) |
Provider Authorization & Billing Guidance
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.
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.
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.
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.
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.
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'.
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.
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.
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.
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 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.
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.
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.
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 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'.
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.
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.
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.
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 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 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.
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.
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 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.
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 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.
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.
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 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.
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 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.
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
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