Genetic testing prior authorization required

Genetic testing codes listed require prior authorization before services are rendered. Submit prior authorization for any of the listed CPT/HCPCS/Proprietary codes to avoid denial or penalty.

• Prior authorization required for all listed genetic testing codes.
• Include clinical documentation supporting medical necessity with the request.

Prior approval required for selected therapies and gender-affirming surgery

Prior approval is required for selected high-cost therapies and for gender-affirming surgeries. Requests must list all anticipated procedures and estimated dates when applicable.

• Proton Beam Therapy: prior approval required except for members aged 21 and younger or for specified neoplasm indications.
• Stereotactic Radiosurgery / Stereotactic Body Radiation Therapy: prior approval required except for specified indications (brain, eye choroid/ciliary body, certain benign cranial neoplasms, functional/neuralgic/AVM conditions).
• Gender-affirming Surgery: prior approval request must include all planned surgical procedures and estimated procedure dates; examples of relevant codes include 11920–11922, 17380, 19303, 19318, 19350, 53430, 54400–54405, 54660, 55175–55180, 55899, 55970–55980, 56625, 57110, 58150–58573, 58661, 58720, 58999, C1813, C2622.

Penalties for failure to obtain required precertification/prior approval

Failure to obtain required precertification or prior approval will result in provider financial penalties as specified by the plan.

• Inpatient admissions: obtain admission precertification and any required continued-stay reviews; maternity and urgent/emergent admission rules apply as noted in policy.
• Prior approval is required for many services (see therapy, transplant, genetic testing, and high-cost drug sections); lack of prior approval may trigger the $100 penalty for other services.

Transplant prior authorization and designated center requirements

Prior approval (preauthorization) and documentation requirements for transplant services.

• Schedule transplant only after obtaining prior approval; verify whether the transplant must be performed at a designated Blue Distinction Center.
• Include supporting documentation with the prior approval request per transplant program requirements.
• Donor codes listed are exempt from penalty if prior approval is not obtained, but transplant program rules and coverage limits still apply.