DraftHighmark West VirginiaPolicy N/A
Highmark Prior Authorization / Managed Procedure & DME Listing (Effective 10/1/2025)
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This document describes eviCore's management/postponement of prior authorization responsibilities for Genetic Testing and Radiation Oncology for Highmark West Virginia commercial and Medicare Advantage lines of business and provides a large listing of reconstructive/cosmetic procedure codes and modalities that are tracked for authorization/Gold Card eligibility. It affects Highmark West Virginia providers submitting authorizations for affected members.
Policy Summary
PayerHighmark West Virginia
PolicyPrior Authorization / Managed Procedure & DME Listing (effective 10/1/2025)
Policy CodePolicy N/A
Change TypeInformational — management/postponement noticenew effective listing
Effective DateOct 1, 2025
Next Review DateN/A
Key ActionProviders must verify member-specific authorization requirements by calling the number on the back of the member's card, checking eligibility/benefits via Availity, or searching BlueExchange through the provider portal.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
10/1/2025Effective date
2Programs postponed/managed
20+Procedure groups listed
15+HCPCS/CPT code chunks
Procedures and Items Requiring Prior Authorization
inv-01: Authorization-required procedure list
Procedures that require authorization (listed by code and description):
Highmark list header: procedures on the HIGHMARK LIST OF PROCEDURESIDME REQUIRING AUTHORIZATION effective 10/1/2025 are designated Highmark Managed and require prior authorization.
inv-02: Authorization-required procedures (excerpt)
Procedures and CPT codes requiring authorization (no additional coverage criteria present in this excerpt).
Examples (one or more may apply)
- Mammoplasty augmentation — CPT 19325 (MAMMOPLASTY AUGMENTATION; WITH PROSTHETIC IMPLANT) requires authorization.
- Breast unlisted/corrective procedures — unlisted breast procedure codes (e.g., 9499) and correction of inverted nipples (9355) require authorization.
inv-03: Authorization-required procedure entries (excerpt)
Procedures listed in this excerpt require prior authorization.
Nasal/sinus endoscopy with ethmoidectomy and related sinus procedures (e.g., CPTs 31253–31259) — listed as requiring authorization.
Cardiac device and transplant procedures (examples include pacemaker/ICD insertion/replacement/upgrades marked X; CPT examples appear in proximity) — listed as requiring authorization.
inv-04: Authorization criteria excerpt
Procedures listed below require prior authorization as indicated by the Highmark list (excerpt):
Cardiac device and implantable procedures
- Removal and replacement of pacemaker/ICD pulse generator and insertion/replacement of implantable defibrillator/pacemaker systems (items marked with 'X' in list) require prior authorization.
- Transcatheter cardiac procedures (e.g., TAVR/TAVI, transcatheter mitral valve repair, left atrial appendage closure) are included and require authorization.
Endovascular aortic and visceral repairs: Endovascular repair of infrarenal, thoracic and fenestrated visceral aortic endografts and related complex endovascular aortic procedures require authorization.
Varicose vein and endovenous ablation therapies: Sclerotherapy, mechanochemical ablation, radiofrequency/laser ablation, and chemical adhesive endovenous therapies (CPT series 36465–36482 and related codes) require authorization.
inv-05: Authorization-required procedure groups
Procedures listed below are included on the Highmark authorization list (partial extract). Providers must obtain authorization for these services prior to scheduling/claim submission.
inv-06: Authorization-required procedure lists
Procedures and codes requiring authorization (partial list).
Extensive procedure lists (including bariatric, hysterectomy, laparoscopy, and other surgical categories) are designated as requiring prior authorization effective 10/1/2025 per the Highmark list.
inv-07: Authorization requirement — listed procedures
Procedures listed in this segment require prior authorization for Highmark West Virginia members as indicated in the master list.
Surgical procedures across multiple specialties (including spine corpectomy, hysterectomy variants and other major surgeries) shown in this segment are included on the Highmark authorization master list and require prior authorization.
inv-08: Prior authorization criteria (listed items)
Authorization requirement applies to the listed procedures and codes.
If a listed procedure (CPT/HCPCS) is billed as shown on the Highmark Managed list, prior authorization is required prior to scheduling and claims submission.
Nuclear medicine tomographic studies: SPECT/SPECT-CT multi-area studies or studies requiring two or more areas, separate acquisitions or multi-day imaging are explicitly noted as requiring authorization.
inv-09: Authorization requirement for listed DME E-codes
Authorization required for listed HCPCS E-code items on facility claims.
Selected HCPCS E-code examples
- E0316 — listed as requiring authorization for facility claims (references to hospital beds & accessories in proximity).
- E0483 — high frequency chest wall oscillation air-pulse generator system (includes hoses and vest) is listed as Highmark Managed and requires authorization for facility claims.
- E0635 — patient lift, electric with seat or sling and multipositional patient support systems are designated Highmark Managed and require authorization for facility claims.
inv-10: Partial authorization criteria (code-level)
Selected HCPCS-coded DME items in this segment require authorization; some items are noted as facility-claim specific.
E0657 — segmental pneumatic appliance for use with pneumatic compressor (chest) is repeatedly listed in the segment and requires prior authorization; facility-claim notation appears in proximity.
E0483 — listed repeatedly as requiring authorization; associated descriptions reference compressor/trunk segmental pneumatic appliances and other DME.
inv-11: Authorization-required items in excerpt
Items listed in this excerpt are identified as 'Managed' or 'Highmark Managed', indicating they require authorization prior to payment.
ANY of the following
- Cardiac device generator systems and related DME (example: E0483 generator system, hoses and vest) are designated Highmark Managed and require authorization.
- Pneumatic compression devices and compressors (examples include E0667–E0675 and E0651–E0657 series) are listed and require authorization.
Therapy systems such as ultraviolet light therapy panels and osteogenesis stimulators are listed as requiring authorization.
inv-12: Authorization listing (excerpt)
Items listed as 'Highmark Managed' and shown by HCPCS code or descriptive name in this section require prior authorization; specific medical necessity criteria and documentation requirements are not present in this excerpt.
inv-13: Authorization required items
Items shown below are identified as requiring authorization under Highmark Managed products.
Speech-generating devices and speech-generating software (HCPCS E2510 and related entries) are repeatedly listed as Highmark Managed and require authorization.
inv-14: Authorization-required items
Items and service codes listed below are designated as requiring authorization under Highmark Managed (effective 10/1/2025).
ANY of the following
- E2298 — Speech generating device / complex rehabilitative power wheelchair accessory (power seat elevation, power standing system) is listed as Highmark Managed and requires authorization.
- E2343 — power wheelchair nonstandard seat (frame depth 22–25 inches) is listed and requires authorization.
- E2398 — dynamic positioning hardware for wheelchair seating/back is listed and requires authorization.
- E2301 — power seat elevation system / power standing system accessories are listed as requiring authorization.
Code Listings and Code Groups
Reconstructive/Cosmetic CPT Codes (covered)CPTCovered
| 19325 | Mammoplasty augmentation; with prosthetic implant |
| 9355 | Correction of inverted nipples |
| 9396 | Preparation of moulage for custom breast implant (unlisted) |
| 9499 | Unlisted procedure, breast |
Spine Surgery CPT Codes (covered)CPTCovered
| 21899 | Unlisted procedure, neck or thorax (spine) |
| 22548 | Vertebral corpectomy (vertebral body resection), single segment; cervical |
| 22590 | Arthrodesis anterior transoral or extraoral technique; clivus-C1-C2 (atlas-axis) |
| 22595 | Arthrodesis, posterior technique craniocervical (occiput-C2) |
| 22802 | Arthrodesis, posterior, for spinal deformity, to 12 vertebral segments |
Representative CPT Codes (covered)CPTCovered
| 22804 | Arthrodesis anterior for spinal deformity; 2-3 vertebral segments |
| 22808 | Arthrodesis anterior for spinal deformity; 2-3 vertebral segments (alternate listing) |
| 22810 | Arthrodesis anterior for spinal deformity; 4 or more vertebral segments |
| 30400 | Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip |
Tonsil & Adenoid CPT Codes (covered)CPTCovered
| 42821 | Tonsillectomy and adenoidectomy; age 12 or over |
Referenced Unlisted CPTs (covered)CPTCovered
| 42299 | Unlisted procedure, palate/uvula |
| 43659 | Unlisted laparoscopy procedure, stomach |
| 43881 | Implantation or replacement of gastric neurostimulator electrodes, open |
| 43999 | Unlisted procedure, stomach |
| 49999 | Unlisted procedure, abdomen |
| 50542 | Laparoscopic ablation of renal mass |
| 55810 | Prostatectomy; perineal radical |
| 55812 | Prostatectomy; perineal radical with lymph node biopsy(s) |
| 55845 | Prostatectomy, retropubic radical; with lymph node biopsy(s) |
| 55866 | Prostatectomy, retropubic radical; with bilateral pelvic lymphadenectomy |
1–10 of 17
1/2
DME HCPCS Examples (covered)HCPCSCovered
DME E-code Items Requiring Authorization (covered)HCPCSCovered
| E0316 | Safety enclosure frame/canopy for use with hospital bed |
| E0372 | Powered air over overlay for mattress |
| E1002 | Wheelchair accessory, power seating system, recline |
| E1035 | Multi-positional patient transfer system |
| E1233 | Wheelchair, pediatric size, tilt-in-space rigid; adjustable without seating system |
| E2298 | Complex rehabilitative power wheelchair accessory, power seat elevation system |
HCPCS Codes Referenced (covered)HCPCSCovered
| E2510 | Speech generating device; synthesized speech, permitting multiple methods of message formulation and multiple methods of device access |
| E2599 | Accessory for speech generating device, not otherwise classified |
| E2628 | Wheelchair accessory, mobile arm support |
| E2358 | Power wheelchair accessory group 34 non-sealed lead acid battery |
| E2362 | Power wheelchair accessory group 24 non-sealed lead acid battery |
| E2398 | Wheelchair accessory dynamic positioning hardware |
| E0983 | Joystick control manual wheelchair accessory power add-on |
| E0984 | Tiller control manual wheelchair accessory power add-on |
Highlighted HCPCS & Authorization Flags (covered)HCPCSCovered
| E0635 | Oral appliance/appliance used to reduce upper airway collapsibility — AUTHORIZATION FLAGGED (X) |
Wheelchair & Accessory HCPCS Requiring Authorization (covered)HCPCSCovered
| E1007 | Multi-positional patient transfer system, with integrated seat, up to 300 lbs |
| E1008 | Multi-positional patient transfer system, with integrated seat, up to 300 lbs (alternate) |
| E1017 | Heavy duty manual wheelchair, each |
| E1238 | Power wheelchair, pediatric size not otherwise specified |
| E1239 | Power wheelchair, pediatric size |
| E1295 | Heavy duty wheelchair; fixed full length arms, elevating legrest |
| E2328 | Power wheelchair accessory, head control or extremity control interface, electronic proportional |
What Providers Must Do
Prior Authorization
Prior Authorization Required
Prior authorization is required for many procedures, devices and services listed on Highmark West Virginia's Managed/Highmark list effective 10/01/2025. Providers must obtain prior authorization before scheduling or performing these services for members when applicable to the member's benefit plan; verify member-specific requirements via the member ID card, Availity eligibility and benefits, or the provider portal/PRC. Failure to obtain required authorization may result in claim denial or member financial liability.
- Prior authorization required for listed reconstructive/cosmetic procedures (see Highmark List of Procedures/IDME Effective 10/1/2025).
- Breast procedures (e.g., mammoplasty augmentation with prosthetic implant 19325; correction of inverted nipples 9355; unlisted breast procedures 9499) require prior authorization.
- Spine surgery procedures (multiple arthrodesis and corpectomy codes including 22548, 22590, 22595, 22802, 22804, 22808, 22810, etc.) require prior authorization.
- Transplant procedures and cardiac device procedures (including lung transplant codes 32851–32854 and pacemaker/ICD insertion/replacement/upgrade codes 33206, 33208, 33264, 33340, 33340-series, etc.) require prior authorization.
- Neurostimulator and related procedures (spinal and peripheral neurostimulator implantation, revisions, and gastric neurostimulator procedures including 63664, 64561, 64561-series, and gastric neurostimulator codes 43881, 43887, 43999, 43659) require prior authorization.
- Varicose vein procedures and endovenous ablation therapies (e.g., 36465–36482, 37700, 37718, 37722, 37799 and related ligation/stripping/stab phlebectomy codes) require prior authorization.
- Nuclear medicine procedures (planar and SPECT/SPECT-CT radiopharmaceutical localization codes and mappings such as 78800, 78801–78816 series, SPECT with CT mappings) require prior authorization.
- Cardiac procedures and imaging (including comprehensive electrophysiologic evaluations, transcatheter procedures such as TAVR, myocardial contrast perfusion echocardiography, transesophageal echocardiography, and other listed cardiac intervention codes) require prior authorization.
- Speech therapy services (e.g., 92507, 92508, 92526) and speech-generating devices/software (E2510 and related HCPCS) require prior authorization.
- Sleep studies (polysomnography codes 95810 and related, portable monitoring and attended studies) require prior authorization.
- DME, prosthetics and wheelchair accessories identified on the list require prior authorization (examples below).
- Pediatric wheelchairs and power wheelchair accessories (E1233, E1234, E1235, E2295, E2298, E2301, E2324, E2327, E2328, E2329, E2341, E2343, E2358, E2362, E2398) require prior authorization.
- Power wheelchair seat/battery accessories and nonstandard seating components require prior authorization.
- Pneumatic compression devices and compressors (E0637–E0652; E0655–E0665; E0657; E0660; E0665; E0670–E0675 and related codes) require prior authorization.
- Selected HCPCS/DME codes of special note requiring authorization: E0316 (safety enclosure/frame for hospital bed) — authorization required for facility claims; E0483 (high frequency chest wall oscillation generator/system — appears multiple times on list) — authorization required; E0635 (patient lift, electric/multipositional patient support systems) — authorization required.
- Therapy systems and other DME (ultraviolet light therapy panels E0691/E0693, osteogenesis stimulators E0760/E0694) require prior authorization.
- Home health and behavioral health services, and many ambulatory/residential behavioral health and substance use service codes (examples: G0151, G0155, H0012, H0017, H0022, H0043, H2001, H2012, H2013, H2022) are designated Highmark Managed and require prior authorization.
- Providers should confirm Gold Card eligibility or other delegated authorization pathways where indicated.
- When in doubt, contact Highmark West Virginia or check the provider portal/PRC for the member’s specific plan requirements before rendering services.
Terms and Flags Used in the List
Modality
Modality designationReconstructive and/or Cosmetic — used throughout the document to classify procedure codes
Used for many code groupsApplied to listed reconstructive/cosmetic CPTs such as excisions, lipectomy, rhinoplasty, and related procedures
Appears with 'Highmark Managed' labelModality entries are shown alongside payer designation to indicate applicability to managed authorization list
Excision, excessive skin and subcutaneous tissue
TermEXCISION, EXCESSIVE SKIN AND SUBCUTANEOUS TISSUE
Associated codesExamples in list include CPTs 5830, 5832, 5833, 5836, 5837, 5838
ContextListed as Reconstructive and/or Cosmetic under Highmark Managed authorization list
Rhytidectomy (facelift) / neck with platysmal tightening
TermRHYTIDECTOMY; FOREHEAD RHYTIDECTOMY; NECK WITH PLATYSMAL TIGHTENING
Associated codeCPT 5824 referenced for rhytidectomy entries
Gold Card fieldGold Card Eligible field shown for these entries in the source (often empty)
Managed Highmark / Highmark Managed
LabelHighmark Managed / Managed Highmark
MeaningDesignation used throughout the list to indicate items requiring Highmark management/prior authorization
Applied toProcedures, CPT and HCPCS codes, and DME entries in the authorization list
Arthrodesis
DefinitionArthrodesis — surgical fusion of vertebral segments (referenced across multiple spine surgery entries)
Associated codesExamples include CPTs 22548, 22590, 22595, 22802, 22808, 22810
Authorization statusArthrodesis entries appear on the Highmark list and require prior authorization
Managed
LabelManaged
UsageUsed interchangeably with 'Highmark Managed' to identify items subject to management/prior authorization
Appears onMultiple procedure and device listings across the document
Reconstructive and/or Cosmetic
DesignationReconstructive and/or Cosmetic — clinical classification used in the listing
Applies toBreast procedures, excisions, lipectomy, rhinoplasty, rhytidectomy and related CPT entries
Shown with payer labelsDisplayed alongside 'Highmark Managed' to indicate authorization applicability
TAVR/TAVI and related transcatheter valve procedures
TermTranscatheter aortic valve replacement (TAVR/TAVI)
Approaches notedPercutaneous femoral, open femoral, axillary, transaortic, transapical approaches are referenced
AuthorizationTAVR/TAVI procedures are included on the Highmark list and marked as requiring authorization
Fenestrated visceral aortic endograft
TermFenestrated visceral aortic endograft
DescriptionEndovascular repair of visceral aorta using fenestrated endografts with associated radiological supervision and target zone angioplasty
AuthorizationListed as Highmark Managed and requires prior authorization
designation indicating that the procedure/service requires management review and prior authorization by Highmark
Indicator'Highmark Managed' designation indicates the procedure/service requires management review and prior authorization by Highmark
Where usedAppears next to many CPT/HCPCS entries across the document (procedures, nuclear medicine, DME)
ActionProviders must obtain prior authorization for items labeled 'Highmark Managed' before claim submission
Authorization requirement
RequirementPrior authorization required for listed procedures
EvidenceHeader and multiple procedure groups state items require authorization effective 10/1/2025
Provider actionObtain prior authorization before scheduling/claim submission for listed items
Unlisted procedure
DefinitionUnlisted procedure — a procedure not specifically described by an existing CPT code (unlisted code placeholders like 43999, 49999 are used)
Document inclusionMultiple unlisted procedure entries appear in the list and are designated as requiring authorization
Coding noteWhen billing unlisted procedures, use the appropriate unlisted CPT and supporting documentation as required by payer
Payer designations used in the list
Payer labelsHighmark Managed / Highmark — payer designations used to indicate which products or plan designs the authorization requirement applies to
ScopeAppears throughout the equipment, DME and procedure sections to signal applicability
Provider implicationCheck member-specific plan/payer designation when requesting authorization
'X' flag
Flag symbol'X' flag — indicator used next to items that appear to denote an authorization requirement or special managed flag
Document examplesUsed in nuclear medicine block and other entries to mark specific CPT/HCPCS lines
Interpretation'X' denotes special attention; providers should follow payer guidance when 'X' is present
Tomographic nuclear medicine imaging with/without concurrently acquired CT for anatomical review
TermSPECT/CT — tomographic nuclear medicine imaging with or without concurrently acquired CT for anatomical review
Authorization specificsSPECT/SPECT‑CT procedures and multi‑area or multi‑day imaging are listed as requiring prior authorization
Minimum imaging ruleMinimum two areas or separate acquisitions/multi‑day imaging triggers authorization requirement
Ambulance HCPCS
CategoryAmbulance HCPCS — codes representing ground and air ambulance transport services (A0426, A0430, A0431, A0432 referenced)
AuthorizationAmbulance transport HCPCS codes are included on the Highmark list and flagged for authorization
Provider actionObtain prior authorization for included ambulance services where required by member plan
Highmark Managed
LabelHighmark Managed — repeated payer designation indicating managed/prior authorization requirement
Applies toUsed across DME, wheelchair, device and procedure listings to mark authorization applicability
ActionFollow Highmark prior authorization process for items labeled Highmark Managed
facility claims
ScopeFacility claims — authorization requirement applies to facility claim billing for the listed DME E-codes (e.g., E0316, E0483)
ExamplesE0316 and E0483 are shown with 'FOR FACILITY CLAIMS ONLY' in the source
Provider noteConfirm claim type (facility vs professional) when submitting authorization and claims for E-code items
Requires Authorization
RequirementRequires Authorization — prior authorization is required for items listed in this document
Document headerMultiple headers and section introductions state entries are on the 'Highmark List of Procedures/IDME Requiring Authorization'
Provider actionObtain authorization before scheduling or billing listed services/devices
E0483
CodeE0483 — generator system (includes hoses and vest), high frequency chest wall oscillation air-pulse generator system
ContextE0483 is listed as Highmark Managed and requires authorization (appears in multiple entries)
Related itemsE0483 entries appear alongside oral appliance/airway devices in the DME section
Pneumatic/compression device
DefinitionPneumatic/compression device — pneumatic appliance entries (segmental and nonsegmental) listed with multiple E-codes
ExamplesE0655–E0665 and other E06xx codes for segmental/nonsegmental pneumatic appliances and compressors are included
AuthorizationPneumatic compression devices and related compressors are designated Highmark Managed and require authorization
Wheelchair accessory (power add-on)
DefinitionWheelchair accessory (power add-on) — accessory to convert a manual wheelchair to motorized with joystick or tiller control
CodesExamples include E0983, E0984 and other power add-on accessory codes listed as Highmark Managed
AuthorizationThese accessories are designated 'Highmark Managed' and require prior authorization
Highmark Managed
LabelHighmark Managed — repeated payer designation used throughout the list
MeaningIndicates Highmark management and prior authorization requirement for the listed item
Provider implicationFollow Highmark authorization processes for items with this label
Multi-positional patient transfer system, integrated seat
TermMulti-positional patient transfer system, integrated seat — transfer system operated by caregiver with integrated passenger seat
CapacityListed with patient weight capacity up to and including 300 lbs (HCPCS E1035/E1036 examples)
AuthorizationDesignated Highmark Managed and requires prior authorization
Speech generating device / software
TermSpeech generating device / software — synthesized speech devices or programs permitting multiple methods of message formulation and device access (HCPCS E2510/E2298 referenced)
Repeated listingSpeech generating devices and software are repeatedly listed as Highmark Managed and require authorization
Provider actionObtain prior authorization for speech generating devices and related software/accessories as listed
Power wheelchair accessory
DefinitionPower wheelchair accessory — includes power seat elevation, power standing systems, nonstandard seat frame dimensions, batteries, and control interfaces
Example codesE2298, E2343, E2358, E2362, E2398 and E2301 appear in the list as managed items
AuthorizationPower wheelchair accessories are designated Highmark Managed and require prior authorization
Speech Generating Device
TermSpeech Generating Device — synthesized speech permitting multiple methods of message formulation and device access
HCPCS exampleE2510 / E2298 referenced for speech generating devices in the managed list
Authorization noteListed as Highmark Managed and requires prior authorization
Power wheelchair accessory
DefinitionPower wheelchair accessory — includes nonstandard seats, lead acid batteries, dynamic positioning hardware, mounting hardware, head control interfaces, and power standing/seat elevation systems
Codes listedExamples include E2343 (nonstandard seat frame depth), E2358/E2362 (lead acid batteries), E2398 (dynamic positioning hardware), E2301 (power seat elevation)
AuthorizationThese accessories are designated Highmark Managed and require prior authorization
Policy Summary
PayerHighmark West Virginia
PolicyPrior Authorization / Managed Procedure & DME Listing (effective 10/1/2025)
Policy CodePolicy N/A
Change TypeInformational — management/postponement noticenew effective listing
Effective DateOct 1, 2025
Next Review DateN/A
Key ActionProviders must verify member-specific authorization requirements by calling the number on the back of the member's card, checking eligibility/benefits via Availity, or searching BlueExchange through the provider portal.
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