Pre-authorization List

Expedited requests

Use this process only when the member or his/her physician believes that waiting for a decision under the standard time frame could place the member's life, health or ability to regain maximum function in serious jeopardy.

• Availity Essentials: Read the information carefully to ensure your request meets the qualifications, then check the box on the form to attest that it is an expedited request.

• Via fax using the appropriate pre-authorization request form below

Online

• Submit an electronic pre-authorization request, and supporting clinical documentation through Availity Essentials>Patient Registration>Authorizations & Referrals>Authorizations
  • Learn more about submitting requests through Availity
• Radiology and sleep medicine: Sign in to the Carelon Medical Benefits Management (Carelon) Provider Portal

• Physical medicine: Sign in to the eviCore portal or choose to be routed from Availity’s electronic authorization tool via single sign on.

Note: Check the status of your requests using the same platform you used to submit the request:

• Requests submitted through eviCore are updated on eviCore’s portal: evicore.com.
• Requests submitted through Carelon are updated on Carelon's portal: ProviderPortal.com.

• Requests submitted through Availity Essentials are updated in Availity: availity.com.

Fax

Submit the appropriate pre-authorization request form only if unable to submit online or if submitting an expedited request:

• Medical services (PDF)
• NICU/PICU Notification of Admission Form (PDF)
• Durable medical equipment (DME) (PDF)
• Skilled nursing facility (SNF), long term acute care (LTAC) and inpatient rehabilitation (PDF)

• Behavioral health facility submission forms. Tip: Download the form and then fill it out to avoid browser discrepancies.
  • Initial Request Form (PDF) (can be added to an Availity submission)
  • Concurrent Request Form (PDF)
  • Stepdown Request Form (PDF)
  • Discharge Notification Form (PDF)
• Applied Behavioral Analysis (ABA) Initial Request Form (PDF)
• Applied Behavioral Analysis (ABA) Concurrent Request Form (PDF)
• Transcranial Magnetic Stimulation (rTMS) Request Form (PDF) for initial and ongoing services

Direct clinical information reviews (MCG Health)

For select CPT codes, Availity's electronic authorization tool automatically routes you to MCG Health's website where you can document specific clinical criteria for your patient. If all criteria are met, you will see the approval on the Auth/Referral Dashboard soon after you click submit. Once all criteria are documented, you will then be routed back to Availity Essentials to attach supporting documentation and submit the request. Documenting complete and accurate clinical information for your patients helps to reduce the overall time it takes to review a pre-authorization request.

This applies to standard medical pre-authorizations for all of our members. View the services that may receive automated approval (PDF).

1. Failure to pre-authorize services subject to pre-authorization requirements or follow concurrent review requirements will result in an administrative denial, claim non-payment and provider and facility write-off. Members may not be balance billed.
2. Before requesting pre-authorization, please verify member eligibility and benefits via Availity Essentials as the member contract determines the covered benefits.
3. Verify that you are an in-network provider for each member to help reduce his or her out-of-pocket expense.
4. If services are to be rendered in a facility, the pre-authorization request submitted should designate the facility where the treatment will occur to ensure proper reconciliation with related inpatient claims.
5. Medical policies, MCG and CMS criteria may be used as the basis for service coverage determinations, including length of stay and level of care. Visit MCG's website for information on purchasing their criteria, or contact us and we will be happy to provide you with a copy of guidelines for specific services.
6. Some member contracts have specific pre-authorization requirements. The member's contract language will apply.
7. Emergency services do not require pre-authorization, but are subject to hospital admission notification and concurrent review requirements (see below).
8. Please note that a pre-authorization does not guarantee payment for requested services. (See #2 above). Our reimbursement policies may affect how claims are reimbursed. Payment of benefits is subject to pre-payment and/or post-payment review, and all plan provisions, including, but not limited to, eligibility for benefits and our Coding Toolkit clinical edits.
9. Investigational and cosmetic services and supplies are typically contract exclusions and are ineligible for payment. Unlisted codes may be used for potentially investigational services and are subject to review. Please refer to the Clinical Edits by Code list for additional information. View a sample non-covered member consent form (PDF).
10. All CPT and HCPCS codes listed on our pre-authorization lists require pre-authorization. View list below for complete requirements.

If Pre-Authorization requests are received requesting urgent/expedited review timeframes and the documentation provided does not meet the urgent/expedited criteria, the review will be reclassified to a standard review and standard timeframes will apply.

Urgent/expedited criteria is defined as one or more of the following:

• The member’s life, health or ability to regain maximum function is in serious jeopardy.
• The member’s psychological state is putting the life, health or safety of the member or others is in serious jeopardy.
• The member will be subjected to severe pain that cannot be adequately managed without the service.

Failure to secure approval for services subject to pre-authorization or concurrent review authorization will result in claim non-payment and provider write-off. Our members must be held harmless and cannot be balance billed.

Please note the following:

• Hospital claims for elective services that require pre-authorization will be reimbursed based upon the member's contract only when the physician or other health care professional has completed and received approval of the pre-authorization for the services. We therefore strongly suggest that facilities develop a method to ensure that required pre-authorization requests have been submitted by the physician or other health care professional and approved prior to admission of the patient.
• If the physician or other health care professional follows the pre-authorization requirements outlined on our pre-authorization lists, they will not be subject to any pre-authorization penalties for failure of the facility to provide the required inpatient admission and discharge notification. Stays that extend beyond the pre-authorized number of days require admission notification and concurrent review. If a facility fails to receive authorization for additional days, the additional days will be provider liability.
• A pre-authorization does not guarantee payment for requested services. Health Plan reimbursement policies may affect how claims are reimbursed and payment of benefits is subject to all plan provisions, including eligibility for benefits. Services must always be covered benefits and medically necessary.
• If an elective service that requires pre-authorization needs to occur during the course of an inpatient admission, and that need could not be foreseen prior to admission, the facility or provider can request pre-authorization for the service while the member is inpatient (before the service occurs). If pre-authorization does not occur during the stay, services are subject to review post-service for medical necessity.

There may be exceptions to obtaining pre-authorization. The six situations listed below may apply as part of our Extenuating Circumstances Policy Criteria (PDF):

1. Member presented with an incorrect member ID card or member number or indicated they were self-pay, and that no coverage was in place at the time of treatment, or the participating provider or facility is unable to identify from which carrier or its designated or contracted representative to request a pre-authorization.
2. Natural disaster prevented the provider or facility from securing a pre-authorization or providing hospital admission notification.
3. Member is unable to communicate (e.g., unconscious) medical insurance coverage. Neither family nor collateral support present can provide coverage information.
4. Compelling evidence the provider attempted to obtain pre-authorization. The evidence shall support the provider followed our policy and that the required information was entered correctly by the provider office into the appropriate system.
5. A surgery which requires pre-authorization occurs in an urgent or emergent situation. Services are subject to review post-service for medical necessity.

6. A participating provider or facility is unable to anticipate the need for a pre-authorization before or while performing a service or surgery.

Learn how to notify us about an extenuating circumstance (PDF) prior to claim submission,or how to appeal a claim that has been administratively denied.

See below for chemical dependency and mental health admissions.

Habilitative inpatient services

• Pre-authorization is required prior to patient admission.

Hospital admissions

• Pre-authorization is required for elective inpatient admissions.
• Notification of hospital admission and discharge required within 1 calendar day, regardless of federal holidays or day of the week.
• Notification is required via fax or by calling 1 (800) 423-6884. Providers should not call Customer Service to notify of patient admissions or discharge. Learn more about this requirement in the Facility Guidelines section of our Administrative Manual.

• Requests for concurrent medical necessity review must include diagnosis and clinical information regarding the member’s current inpatient stay. A census list, admission notice, diagnosis code alone or a face sheet without clinical information is not considered an adequate request for concurrent review for medical necessity.

Inpatient hospice

• Notification of admission or discharge is necessary within 24 hours of admission or discharge (or one business day, if the admission or discharge occurs on a weekend or a federal holiday). Notification of inpatient hospice admission and discharge required within 24 hours, regardless of federal holidays or day of the week.

Long-Term Acute Care Facility (LTAC)

• Pre-authorization is required prior to patient admission.

Rehabilitation

• Pre-authorization is required prior to patient admission.

Skilled Nursing Facility (SNF)

• Pre-authorization is required prior to patient admission.

Extracorporeal Circulation Membrane Oxygenation (ECMO) for the Treatment of Respiratory Failure in Adults (PDF)

• We require the facility to specifically notify us when ECMO is initiated on a BridgeSpan member. Subject to review.

Pre-authorization is required for the services listed below. For select CPT codes, including transcranial magnetic stimulation services, Availity's electronic authorization tool automatically connects to MCG Health's website where specific clinical criteria can be documented for your patient. If all criteria are met, an approval will be received on the Auth/Referral Dashboard. Emergency inpatient services do not require pre-authorization and are subject to admission notification requirements.

• Inpatient: Psychiatric or ASAM 4.0 detoxification
  • Notification of admission must be received within 24 hours of admission or the next business day (whichever comes first). Concurrent review will be required. Failure to follow concurrent review requirements will result in an administrative denial, claim non-payment and provider and facility write-off. Members may not be balance billed.
• Sub-acute detoxification or ASAM level 3.7
  • For services provided outside the state of Washington:
    • Requires pre-authorization before the member is admitted for services. Under certain circumstances, pre-authorization requests can be made within 24 hours of admission or the next business day.
  • For services provided inside the state of Washington
    • Notification of admission must be received within 24 hours of admission or the next business day (whichever comes first).
    • Initial assessment and initial treatment plan must be received within:
      • Two business days for inpatient or residential substance use disorder treatment services
      • Three business days for withdrawal management services
• Residential treatment: substance use disorders or ASAM level 3.5
  • For services provided outside the state of Washington:
    • Requires pre-authorization before the member is admitted for services. Under certain circumstances, pre-authorization requests can be made within 24 hours of admission or the next business day.
  • For services provided inside the state of Washington
    • Notification of admission must be received within 24 hours of admission or the next business day (whichever comes first).
    • Initial assessment and initial treatment plan must be received within:
      • Two business days for inpatient or residential substance use disorder treatment services
      • Three business days for withdrawal management services
• Residential treatment: Psychiatric
  • Requires pre-authorization before the member is admitted for services. Under certain circumstances, pre-authorization requests can be made within 24 hours of admission or the next business day.
• Partial hospitalization: Psychiatric or ASAM level 2.5 for substance use disorders
  • Request for authorization is required no later than the day of admission.

• Intensive outpatient: Psychiatric or ASAM level 2.1 for substance use disorders

  • Request for authorization is required no later than the day of admission.

Medical necessity for behavioral health services is determined by:

• Behavioral Health Medical Policies

• The American Society of Addiction Medicine's (ASAM) criteria (PDF) for chemical dependency services

View our resources and forms for behavioral health facilities and our behavioral health medical policies.

The following clinical providers, with expertise using evidenced-based tools to establish or confirm the diagnosis of autism and experience in developing multidisciplinary autism treatment plans, can provide the diagnostic assessment and comprehensive evaluation report, as well as recommending a treatment approach:

• Psychiatrist
• Neurologist
• Pediatric neurologist
• Developmental pediatrician
• Doctorate-level psychologist

• Advanced registered nurse practitioner

ABA therapy is for the treatment of autism spectrum disorders (ASD) when medically necessary.

Initial Treatment Request
Procedure codes: 0362T, 0373T, 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158

• Procedure codes 97151, 97152, and 0362T: Pre-authorization is not required when 97151, 97152, and 0362T are used for initial ABA assessments.
• Pre-authorization is only required for members 18 and older. Use the Availity Authorization tool if you are uncertain whether pre-authorization is required for a member.
• ABA therapy must be recommended or prescribed by a licensed provider experienced in the diagnosis and treatment of autism.

• Submit an ABA Initial Request Form (PDF)

View documentation requirements in our Applied Behavior Analysis for the Treatment of Autism Spectrum Disorder (PDF) medical policy, which include:

• Clinical evaluation, which includes confirmation of an ASD diagnosis, and recommended treatment approach from a clinician meeting the criteria above.
• ABA initial report that includes an ABA assessment treatment plan (to be completed by the lead behavior therapist).
• A cover letter may be submitted but is not required. A sample cover letter template (PDF) is provided for your reference.

• Other supporting documentation, if needed.

Concurrent Treatment Request (Reauthorization)

• Procedure codes 97151, 97152 and 0362T: Pre-authorization is required when 97151, 97152 and 0362T are used for ABA reassessments during course of treatment.
• Updated clinical documents should be submitted within 14 days of end of a current authorization.
• Submit an ABA Concurrent Request Form (PDF)
• Following the submission of the concurrent review documentation, we may request additional information prepared and submitted by a clinician meeting the above clinical criteria. The plan will specify what must be included in this report which is intended to assess progress and prospective treatment in further detail and may include a written clinical order, directive or prescription for ABA therapy services.

Enteral and Oral Nutrition Therapy in the Home Setting (PDF)

• Pre-authorization is required for group #39000201, #39000303 and #39000402 members: HCPCS codes B4034, B4035, B4036, B4081, B4082, B4083, B4087, B4088, B4105, B4148, B4149, B4150, B4152, B4153, B4154, B4155, B4157, B4158, B4159, B4160, B4161, B4162, B9002, B9998, S9434, S9435
• Note: Pre-authorization is not required for select inborn errors of metabolism. Use the Availity Authorization application to determine whether pre-authorization is required for a member.

Bone Growth Stimulators, Electrical (Osteogenic Stimulation) (PDF)

• E0747 - requires pre-authorization through BridgeSpan Health

• E0748, E0749 - requests for authorization are submitted directly to eviCore healthcare (eviCore). Learn more about this requirement and requesting authorization.

Ultrasonic Bone Growth Stimulators (Osteogenic Stimulation)(PDF)

• E0760, 20979

Definitive Lower Limb Prostheses (PDF)

• L5010, L5020, L5050, L5060, L5100, L5105, L5150, L5160, L5200, L5210, L5220, L5230, L5250, L5270, L5280, L5301, L5312, L5321, L5331, L5341, L5610, L5611, L5613, L5614, L5616, L5700, L5701, L5702, L5703, L5710, L5711, L5712, L5714, L5716, L5718. L5722, L5724, L5726, L5728, L5780, L5810, L5811, L5812, L5814, L5816, L5818, L5822, L5824, L5826, L5828, L5830, L5840, L5848, L5930, L5968, L5970, L5972, L5974, L5976, L5978, L5979, L5980, L5981, L5982, L5984. L5985, L5986, L5987

Insulin Infusion Pumps, Automated Insulin Delivery and Artificial Pancreas Device Systems (PDF)

• S1034

Myoelectric Prosthetic and Orthotic Components for the Upper Limb (PDF)

• L6026, L6693, L6715, L6880, L6881, L6882, L6925, L6935, L6945, L6955, L6965, L6975, L7007, L7008, L7009, L7045, L7180, L7181, L7190, L7191

Negative Pressure Wound Therapy in the Outpatient Setting (PDF)

• 97605, 97606, E2402
  The policy requires an initial pre-authorization for a 1-month therapeutic trial and then after one month, another pre-authorization for continuation is required demonstrating improvement in the wound.
  

Noninvasive Ventilators in the Home Setting (PDF)

• E0466

Power Wheelchairs: Group 3 (PDF)

• K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855, K0856, K0857, K0858, K0859, K0860, K0861, K0862, K0863, K0864

Powered and Microprocessor-Controlled Knee and Ankle-Foot Prostheses and microprocessor-Controlled Knee- Ankle Foot Orthoses (PDF)

• K1014, L5615, L5856, L5857, L5858

Sleep Medicine

• Review the codes requiring authorization or notification in the Sleep medicine section below on this list.
• View our Sleep Medicine Program for other authorization requirements through AIM.

Tumor Treatment Field Therapy (PDF)

• E0766

In compliance with WA HB 1689, guideline-recommended biomarker testing in patients with recurrent, relapsed, refractory, or metastatic cancer (including stage 3 or 4) will not require prior authorization for Washington members. This does not include non-specific molecular pathology codes (81400-81408).

Diagnosis codes Z800-Z803, Z8041 and Z8042 are no longer exempt from pre-authorization for Washington members.

Genetic Testing for Alzheimer's Disease (PDF) - GT01

• 81401, 81405, 81406

Genetic Testing for Hereditary Breast and Ovarian Cancer and Li-Fraumeni Syndrome (PDF) - GT02

• 0235U, 81162, 81163, 81164, 81165, 81166, 81167, 81212, 81215, 81216, 81217, 81307, 81308, 81321, 81322, 81323, 81351, 81352, 81404, 81405, 81406, 81432, 81433

Apolipoprotein E for Risk Assessment and Management of Cardiovascular Disease (PDF) - GT05

• 81401

Genetic Testing for Lynch Syndrome and APC-associated and MUTYH-associated Polyposis Syndromes (PDF) - GT06

• 0238U, 81201, 81202, 81203, 81210, 81288, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81317, 81318, 81319, 81401, 81406

Genetic Testing for Cutaneous Malignant Melanoma (PDF) - GT08

• 81404

Cytochrome p450 and VKORC1 Genotyping for Treatment Selection and Dosing (PDF) - GT10

• 81225, 81227, 81401, 81402, 81404, 81405, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076U

Genetic Testing; Familial Hypercholesterolemia (PDF) - GT11

• 81401, 81405, 81406, 81407

KRAS, NRAS and BRAF Variant Analysis and MicroRNA Expression Testing for Colorectal Cancer (PDF) - GT13

• 81210, 81275, 71276, 81311, 81403, 81404, 0111U

Preimplantation Genetic Testing of Embryos (PDF) - GT18

• 89290, 89291, 81228, 81229, 81349

Genetic Testing; IDH1 and IDH2 Genetic Testing for Conditions Other Than Myeloid Neoplasms or Leukemia (PDF) - GT19

• 81120, 81121

Genetic and Molecular Diagnostic Testing (PDF) - GT20

• 0232U, 0234U, 0235U, 0238U, 0244U, 81201, 81202, 81203, 81210, 81212, 81215, 81216, 81217, 81225, 81227, 81228, 81229, 81235, 81243, 81244, 81250, 81252, 81253, 81254, 81257, 81275, 81276, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81302, 81303, 81304, 81311, 81314, 81317, 81318, 81319, 81321, 81322, 81323, 81324, 81325, 81326, 81341, 81349, 81350, 81351, 81352, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81419, 81441, 81470, 81471, S3800, S3840, S3844, S3845, S3846, S3849, S3850, S3853, S3865, S3866

Biallelic RPE65 Variant-Associated Retinal Dystrophy (PDF) - GT21

• 81406

Gene Expression Profiling for Melanoma (PDF) - GT29

• 81552

BRAF Genetic Testing to Select Melanoma or Glioma Patients for Targeted Therapy (PDF) - GT41

• 81210

Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer (PDF) - GT42

• 81518, 81519, 81521, 81522, 81523, S3854

Diagnostic Genetic Testing for FMR1 and AFF2 Variants (Including Fragile X and Fragile XE Syndromes) (PDF) - GT43

• 81243, 81244

Noninvasive Prenatal Testing to Determine Fetal Aneuploidies, Microdeletions, Single-Gene Disorders, and Twin Zygosity (PDF) - GT44

• 81408, 81243

Genetic Testing for CADASIL Syndrome (PDF) - GT51

• 81406

Diagnostic Genetic Testing for α-Thalassemia (PDF) - GT52

• 81257, 81258, 81259, 81269, 81404

Genetic Testing; Primary Mitochondrial Disorders (PDF) - GT54

• 0417U, 81401, 81403, 81404, 81405, 81440, 81460, 81465

Targeted Genetic Testing for Selection of Therapy for Non-Small Cell Lung Cancer (NSCLC) (PDF) - GT56

• 0022U, 81210, 81235, 81275, 81276, 81404, 81405, 81406

Chromosomal Microarray Analysis (CMA) or Copy Number Analysis for the Genetic Evaluation of Patients with Developmental Delay Intellectual Disability, Autism Spectrum Disorder or Congenital Anomalies (PDF) - GT58

• 0209U, 81228, 81229, 81349, 0156U, S3870

Myeloid Neoplasms and Leukemia (PDF) - GT59

• 81120, 81121, 81351, 81352, 81401, 81402, 81403, 81450, 81451, 81455, 81456

PTEN Hamartoma Tumor Syndrome (PDF) - GT63

• 0235U, 81321, 81322, 81323

Evaluating the Utility of Genetic Panels (PDF) - GT64

• 81201, 81202, 81203, 81210, 81225, 81227, 81228, 81229, 81235, 81243, 81244, 81250, 81252, 81253, 81254, 81257, 81275, 81276, 81288, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81302, 81303, 81304, 81311, 81314, 81317, 81318, 81319, 81321, 81322, 81323, 81324, 81325, 81326, 81349, 81350, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81412, 81432, 81433, 81434, 81437, 81438, 81440, 81441, 81443, 81450, 81451, 81455, 81456, 81460, 81465, 81470, 81471

Genetic Testing for Methionine Metabolism Enzymes, including MTHFR (PDF) - GT65

• 81401, 81403, 81404, 81405, 81406

Diagnosis of Inherited Peripheral Neuropathies (PDF) - GT66

• 81403, 81404, 81405, 81406, 81324, 81325, 81326, 81448

Genetic Testing for Rett Syndrome (PDF) - GT68

• 0234U, 81302, 81303, 81304, 81404, 81405, 81406

Duchenne and Becker Muscular Dystrophy (PDF) - GT69

• 0218U, 81161, 81408

Fetal RHD Genotyping Using Maternal Plasma (PDF) - GT74

• 81403

Genetic Testing; Genetic Testing for Macular Degeneration (PDF) - GT75

• 81401, 81405, 81408

Whole Exome and Whole Genome Sequencing (PDF) - GT76

• 0214U, 0215U, 81415, 81416

Genetic Testing for Heritable Disorders of Connective Tissue (PDF) - GT77

• 81405, 81408

Genetic Testing; Invasive Prenatal Fetal Diagnostic Testing for Chromosomal Abnormalities (PDF) - GT78

• 81228, 81229, 81349, 81405

Genetic Testing for the Evaluation of Products of Conception and Pregnancy Loss (PDF) - GT79

• 81228, 81229, 81349

Genetic Testing for Epilepsy (PDF) - GT80

• 0232U, 81188, 81189, 81190, 81401, 81403, 81404, 81405, 81406, 81407

Reproductive Carrier Screening for Genetic Diseases (PDF) - GT81

• 81161, 81243, 81244, 81250, 81252, 81253, 81254, 81257, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81412, 81434, 81443, S3844, S3845, S3846, S3849, S3850, S3853

Genetic Testing: Expanded Molecular Panel Testing of Cancers to Select Targeted Therapies (PDF) - GT83

• 0022U, 0037U, 0048U, 0211U, 0244U, 0250U, 0334U, 0379U, 0391U, 0444U, 81120, 81121, 81162, 81210, 81235, 81275, 81276, 81292, 81295, 81298, 81311, 81314, 81319, 81321, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81445, 81449, 81455, 81456, 81457, 81458, 81459

Genetic Testing for Neurofibromatosis Type 1 or 2 (PDF) - GT84

• 81405, 81406, 81408

ClonoSEQ® Testing for the Assessment of Measurable Residual Disease (MRD) (PDF) - GT88

• 0364U

Circulating Tumor DNA and Circulating Tumor Cells for Management (Liquid Biopsy) of Solid Tumor Cancers (PDF)

• 0239U, 0242U, 0326U, 0388U, 0409U, 0428U, 81462, 81463, 81464

Laboratory Tests for Organ Transplant Rejection (PDF)

• 81595

Measurement of Serum Antibodies to Selected Biologic Agents (PDF)

• 80145, 80230, 80280

Bioengineered Skin and Soft Tissue Substitutes and Amniotic Products (PDF)

• A4100, A6460, A6461, Q4100, Q4101, Q4102, Q4105, Q4106, Q4107, Q4114, Q4116, Q4121, Q4122, Q4128, Q4132, Q4133, Q4140, Q4151, Q4154, Q4159, Q4168, Q4186, Q4187

Charged-Particle (Proton) Radiotherapy (PDF)

• 32701, 61796, 61797, 61798, 61799, 61800, 63620, 63621, 77301, 77338, 77371, 77372, 77373, 77432, 77435, 77520, 77522, 77523, 77525, G0339, G0340

Confocal Laser Endomicroscopy (PDF)

• 43206, 43252, 88375

Digital Therapeutic Products (PDF)

• 98978, A9291, A9292, E1905

Digital Therapeutic Products for Attention Deficit Hyperactivity Disorder (PDF)

• 98978, A9291

Digital Therapeutic Products for Chronic Low Back Pain (PDF)

• 98978, A9291, E1905

Digital Therapeutic Products for Substance Use Disorders (PDF)

• 98978, A9291

Digital Therapeutic Products for Amblyopia (PDF)

• A9292

Digital Therapeutic Products for Post-traumatic Stress Disorder and Panic Disorder (PDF)

• A9291

Extracorporeal Circulation Membrane Oxygenation (ECMO) for the Treatment of Respiratory Failure in Adults (PDF)

• Please see the Inpatient admissions section for further information.

Gender Affirming Interventions for Gender Dysphoria (PDF)

• 15775, 15776, 17380, 55970, 55980
• Codes 55970 and 55980 are non-specific. The specific procedure code(s) must be requested in place of these non-specific codes.
• 11920, 11921, 15771, 15773, 15774, 15825, 15828, 15829, 17999, 19303, 19316, 19318, 19325, 19350, 21125, 21127, 21137, 21139, 21141, 21142, 21143, 21145, 21146, 21147, 21188, 21193, 21194, 21195, 21196, 21208, 53400, 53405, 53410, 53415, 53420, 53425, 53430, 54125, 54400, 54401, 54405, 54520, 54660, 54690, 55175, 55180, 56625, 56800, 56805, 57106, 57110, 57291, 57292, 57295, 57296, 57335, 57426, 58353, 58356, 58563, C1813, C2622, L8600
• Use code 17999 to request laser hair removal.

• Gender affirming surgical interventions for gender dysphoria require pre-authorization. Codes for specific procedures might also be listed as requiring pre-authorization in other medical policies, including but not limited to:

  • Abdominoplasty - 15830
  • Adipose-derived Stem Cell Enrichment in Autologous Fat Grafting to the Breast - 15771
  • Breast Reconstruction - 19316, 19318, 19325, 19350, L8600
  • Blepharoplasty and Brow Lift - 15820, 15821, 15822, 15823, 67900, 67901, 67902, 67903, 67904, 67906, 67908, 67909, 67950
  • Chin Implants - 21120, 21121, 21122, 21123, 21209
  • Collagen Injections - 11950, 11951, 11952, 11954
  • Cosmetic and Reconstructive Procedures - 15771, 15773
  • Endometrial Ablation - 58353, 58356, 58563
  • Panniculectomy - 15830
  • Reconstructive Breast Surgery, Mastopexy, and Management of Breast Implants - 15771
  • Rhinoplasty - 30400, 30410, 30420, 30430, 30435, 30450

Hyperbaric Oxygen Therapy (PDF)

• 99183, G0277

Intensity Modulated Radiotherapy (IMRT)

• Submit the IMRT Pre-authorization Request Supplement Form (PDF) when requesting pre-authorization for these services. This form will help determine when the Dose Volume Summary Analysis is required.
• When required, color dose volume histograms must be in color
• 77301, 77338, 77385, 77386, G6015, G6016

• Please reference the following Medical Policies for further information:

  • Intensity Modulated Radiotherapy (IMRT) of the Central Nervous System (CNS), Head, Neck, and Thyroid (PDF)
  • Intensity Modulated Radiotherapy (IMRT) of the Thorax, Abdomen, Pelvis and Extremities (PDF)
  • Intensity Modulated Radiotherapy (IMRT) for Breast Cancer (PDF)
  • Intensity Modulated Radiotherapy (IMRT) for Tumors in Close Proximity to Organs at Risk (PDF)

Laser Interstitial Thermal Therapy (PDF)

• 61736, 61737

Low-Level Laser Therapy (PDF)

• 97037

Neurofeedback (PDF)

• 90875, 90876, 90901

Orthopedic Applications of Stem-Cell Therapy, Including Bone Substitutes Used with Autologous Bone Marrow (PDF)

• 38206, 38232, 38241

Progenitor Cell Therapy for the Treatment of Damaged Myocardium Due to Ischemia (PDF)

• 38205, 38206, 38240, 38241

Radioembolization, Transarterial Embolization (TAE), and Transarterial Chemoembolization (TACE) (PDF)

• 37243, 79445, S2095
• Note: Ovarian, Internal Iliac and Gonadal Vein Embolization as a Treatment of Pelvic Congestion Syndrome (PDF) is considered investigational.

Transcranial Magnetic Stimulation as a Treatment of Depression and Other Disorders(PDF)

• 0858T, 90867, 90868, 90869

• Submit the Transcranial Magnetic Stimulation (rTMS) Request Form (PDF) for initial and ongoing services

In Vivo Analysis of Colorectal Lesions (PDF)

• 88375

Coverage of Treatments Provided in a Clinical Trial (PDF)

• S9990, S9991, S9988

Sleep Medicine Program

• Review the codes requiring authorization or notification in the Sleep medicine section.
• View more information about this program.

View pharmacy pre-authorization requirements.

We partner with eviCore healthcare to administer our Physical Medicine program.

1. Review this entire page for similar services that require pre-authorization
2. Verify member benefits, eligibility and pre-authorization requirements on Availity Essentials
3. Determine whether a member's plan participates in this program by using the Electronic Authorization application on Availity Essentials

4. Obtain or verify an authorization with eviCore:

   1. Sign in to eviCore's portal or choose to be routed from Availity’s electronic authorization tool via single sign on
   2. Phone (855) 252-1115
   3. Fax (855) 774-1319
   4. View workarounds for eviCore system outages

Pain management

• We require authorization from eviCore for these codes: 00640, 22510, 22511, 22512, 22513, 22514, 22515, 27096, 61790, 61791, 62290, 62291, 62320, 62321, 62322, 62323, 62324, 62325, 62326, 62327, 62350, 62351, 62360, 62361, 62362, 63650, 63655, 63685, 64405, 64479, 64480, 64483, 64484, 64490, 64491, 64492, 64493, 64494, 64495, 64510, 64520, 64633, 64634, 64635, 64636, 72285, 72295, G0259, G0260

Joint management site-of-service

• We require authorization from eviCore for these codes: 20520, 20525, 20670, 20680, 20693, 20694, 23000, 23020, 23120, 23130, 23410, 23412, 23415, 23420, 23430, 23440, 23450, 23455, 23460, 23462, 23465, 23466, 23515, 23550, 23615, 23630, 23655, 23665, 24105, 24305, 24340, 24341, 24342, 24343, 24345, 24346, 24357, 24358, 24359, 24505, 24516, 24530, 24538, 24545, 24546, 24575, 24579, 24586, 24605, 24620, 24635, 24655, 24665, 24666, 24685, 25000, 25107, 25111, 25112, 25118, 25210, 25215, 25240, 25260, 25270, 25280, 25290, 25295, 25310, 25320, 25360, 25390, 25447, 25505, 25515, 25545, 25565, 25574, 25575, 25600, 25605, 25606, 25607, 25608, 25609, 25628, 25645, 25652, 25825, 26011, 26020, 26055, 26080, 26121, 26123, 26145, 26160, 26236, 26320, 26340, 26350, 26356, 26370, 26410, 26418, 26426, 26440, 26445, 26480, 26516, 26520, 26525, 26540, 26541, 26608, 26615, 26650, 26665, 26676, 26725, 26727, 26735, 26746, 26756, 26765, 26785, 26850, 26860, 26951, 26952, 27130, 27332, 27333, 27334, 27335, 27403, 27415, 27416, 27418, 27420, 27422, 27424, 27425, 27427, 27428, 27429, 27430, 27438, 27440, 27441, 27442, 27443, 27446, 27447, 27605, 27606, 27612, 27620, 27625, 27626, 27650, 27652, 27654, 27659, 27675, 27676, 27680, 27685, 27687, 27690, 27691, 27695, 27696, 27698, 27705, 27752, 27762, 27766, 27769, 27781, 27784, 27786, 27788, 27792, 27810, 27814, 27818, 27822, 27823, 27840, 28002, 28005, 28008, 28010, 28022, 28035, 28060, 28062, 28080, 28086. 28090, 28092, 28110, 28112, 28113, 28116, 28118, 28119, 28120, 28122, 28124, 28160, 28190, 28192, 28200, 28208, 28230, 28232, 28234, 28238, 28250, 28270, 28272, 28285, 28288, 28289, 28291, 28292, 28295, 28296, 28297, 28298, 28299, 28300, 28304, 28306, 28308, 28310, 28313, 28315, 28322, 28415, 28445, 28465, 28475, 28476, 28485, 28505, 28515, 28525, 28555, 28585, 28615, 28645, 28715, 28725, 28740, 28750, 28755, 28810, 28820, 28825, 29805, 29806, 29807, 29819, 29820, 29821, 29822, 29823, 29824, 29825, 29826, 29827, 29828, 29834, 29837, 29838, 29844, 29846, 29848, 29860, 29861, 29862, 29863, 29866, 29867, 29870, 29871, 29873, 29874, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889, 29891, 29892, 29893, 29894, 29895, 29897, 29898, 29914, 29915, 29916

• Note: Site-of-service pre-authorization is not required when procedures performed in an ambulatory surgery center, physician office, or emergency facility for urgent services

Joint management

• We require authorization from eviCore for these codes: 23000, 23020, 23120, 23130, 23410, 23412, 23420, 23430, 23440, 23455, 23462, 23466, 23470, 23472, 23473, 23474, 23700, 27125, 27130, 27132, 27134, 27137, 27138, 27332, 27333, 27334. 27403, 27405, 27415, 27416, 27418, 27420, 27422, 27425, 27427, 27428, 27429, 27430, 27438, 27440, 27441, 27442, 27443, 27445, 27446, 27447, 27486, 27487, 27488, 27570, 27580, 29805, 29806, 29807, 29819, 29820, 29821, 29822, 29823, 29824, 29825, 29826, 29827, 29828, 29860, 29861, 29862, 29863, 29866, 29867, 29868, 29870, 29871, 29873, 29874, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889, 29891, 29892, 29893, 29894, 29895, 29897, 29898, 29899, 29904, 29905, 29906, 29907, 29914, 29915, 29916

Spine

• We require authorization from eviCore for these codes: 20931, 20937, 20938, 22100, 22101, 22102, 22103, 22110, 22112, 22114, 22116, 22206, 22207, 22208, 22210, 22212, 22214, 22216, 22220, 22222, 22224, 22226, 22325, 22326, 22327, 22328, 22510, 22511, 22512, 22513, 22514, 22515, 22532, 22533, 22534, 22548, 22551, 22552, 22554, 22556, 22558, 22585, 22590, 22595, 22600, 22610, 22612, 22614, 22630, 22632, 22633, 22634, 22800, 22802, 22804, 22808, 22810, 22812, 22818, 22819, 22830, 22840, 22842, 22843, 22844, 22845, 22846, 22847, 22848, 22849, 22850, 22852, 22853, 22854, 22855, 22856, 22858, 22859, 63001, 63003, 63005, 63011, 63012, 63015, 63016, 63017, 63020, 63030, 63035, 63040, 63042, 63043, 63044, 63045, 63046, 63047, 63048, 63050, 63051, 63055, 63056, 63057, 63064, 63066, 63075, 63076, 63077, 63078, 63081, 63082, 63085, 63086, 63087, 63088, 63090, 63091, 63101, 63102, 63103, 63170, 63172, 63173, 63185, 63190, 63191, 63197, 63200, 63250, 63251, 63252, 63265, 63266, 63267, 63268, 63270, 63271, 63272, 63273, 63275, 63276, 63277, 63278, 63280, 63281, 63282, 63283, 63285, 63286, 63287, 63290, 63295, 63300, 63301, 63302, 63303, 63304, 63305, 63306, 63307, 63308, E0748, E0749, S2350, S2351

Physical therapy, speech therapy, occupational therapy (PT/ST/OT)

The initial evaluation and treatment visit does not require pre-authorization. If additional treatment is medically necessary, eviCore requires that a pre-authorization request be submitted within seven days of the initial visit.

• Members aged 17 and younger: Select pediatric diagnosis codes are excluded from the program (PDF).

• We require authorization from eviCore for these codes: 92507, 92508, 92521, 92522, 92523, 92524, 92526, 92597, 92607, 92608, 92609, 92610, 92626, 92627, 92630, 92633, 95851, 95852, 96105, 97012, 97014, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036, 97039, 97110, 97112, 97113, 97116, 97129, 97130, 97139, 97140, 97150, 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 97530, 97542, 97750, 97755, 97760, 97761, 97763, 97799, G0151, G0152, G0157, G0158, G0159, G0160, G0283, S8950, S9128, S9129, S9131, S9152

Pre-authorization is not required for an initial evaluation and management visit and up to six consecutive treatment visits (for a total of seven) in a new episode of care. After the patient’s sixth treatment visit an authorization is required.

We define a "new episode of care" as treatment for a new condition or diagnosis for which the patient has not been treated by a provider within the same tax ID number and specialty within the previous 90 days and is not undergoing any active treatment for that condition or diagnosis. Anything beyond a new episode of care requires an authorization. When a member receives treatment for the same episode of care by different provider specialties, each provider specialty receives six treatment visits without requiring pre-authorization. View our FAQ (PDF) for more clarification on an episode of care.

The Physical Medicine program services include:

• Physical therapy
• Occupational therapy

• Speech therapy

This mandate applies to members on one of our Washington products.

Contact BridgeSpan Health for pre-authorization for the following codes:

Computed Tomography to Detect Coronary Artery Calcification (PDF)

• S8092

Wireless Capsule Endoscopy for Gastrointestinal (GI) Disorders (PDF)

• 0651T, 91110, 91111, 91113

We partner with Carelon to administer our radiology program. Determine whether your patient's plan participates in this program by using the Electronic Authorization application on Availity Essentials.

• Sign in to Carelon's ProviderPortal
• Phone 1 (877) 291-0509
• View workarounds for Carelon system outages

• Contact Carelon to request pre-authorization for the following codes: 70336, 70450, 70460, 70470, 70480, 70481, 70482, 70486, 70487, 70488, 70490, 70491, 70492, 70496, 70498, 70540, 70542, 70543, 70544, 70545, 70546, 70547, 70548, 70549, 70551, 70552, 70553, 70554, 70555, 71250, 71260, 71270, 71271, 71275, 71550, 71551, 71552, 71555, 72125, 72126, 72127, 72128, 72129, 72130, 72131, 72132, 72133, 72141, 72142, 72146, 72147, 72148, 72149, 72156, 72157, 72158, 72159, 72191, 72192, 72193, 72194, 72195, 72196, 72197, 72198, 73200, 73201, 73202, 73206, 73218, 73219, 73220, 73225, 73718, 73719, 73720, 73721, 73722, 73723, 73725, 73221, 73222, 73223, 73700, 73701, 73702, 73706, 74150, 74160, 74170, 74174, 74175, 74176, 74177, 74178, 74181, 74182, 74183, 74185, 74712, 75557, 75559, 75561, 75563, 75572, 75573, 75574, 75635, 76391, 77046, 77047, 77048, 77049, 77078, 77084, 78012, 78013, 78014, 78015, 78016, 78018, 78070, 78071, 78072, 78075, 78102, 78103, 78104, 78185, 78195, 78201, 78202, 78215, 78216, 78226, 78227, 78230, 78231, 78232, 78258, 78261, 78262, 78264, 78265, 78266, 78278, 78290, 78291, 78300, 78305, 78306, 78315, 78429, 78430, 78431, 78432, 78433, 78445, 78451, 78452, 78453, 78454, 78456, 78457, 78458, 78459, 78466, 78468, 78469, 78472, 78473, 78481, 78483, 78491, 78492, 78494, 78579, 78580, 78582, 78597, 78598, 78600, 78601, 78605, 78606, 78608, 78609, 78610, 78630, 78635, 78645, 78650, 78660, 78700, 78701, 78707, 78708, 78709, 78725, 78740, 78761, 78800, 78801, 78802, 78803, 78804, 78811, 78812, 78813, 78814, 78815, 78816, 78830, 78831, 78832, 93303, 93304, 93306, 93307, 93308, 93312, 93313, 93314, 93315, 93316, 93317, 93350, 93351, 0042T, 0648T, 0649T

We partner with Carelon to administer our Sleep Medicine program. Determine whether your patient's plan participates in this program by using the Electronic Authorization application on Availity Essentials.

• Login to Carelon's ProviderPortal
• Phone 1 (877) 291-0509
• View workarounds for Carelon system outages

• Contact Carelon to request pre-authorization for the following codes: 95782, 95783, 95805, 95807, 95808, 95810, 95811, E0470, E0471, E0561, E0562, E0601

We partner with Carelon to administer our cardiology program. Determine whether your patient's plan participates in this program by using the electronic authorization application on Availity Essentials.

• Login to Carelon's ProviderPortal
• Phone 1 (877) 291-0509
• View workarounds for Carelon system outages

• Contact Carelon to request pre-authorization for the following codes: 33206, 33207, 33208, 33212, 33213, 33214, 33221, 33227, 33228, 33229, 33230, 33231, 33240, 33249, 33270, 33271, 33274, 37220, 37221, 37224, 37225, 37226, 37227, 37228, 37229, 37230, 37231, 92920, 92924, 92928, 92933, 92937, 92943, 93454, 93455, 93456, 93457, 93458, 93459, 93460, 93461, 93978, 93979, 93880, 93882, 93922, 93923, 93924, 93925, 93926, 93930, 93931, C1721, C1722, C1777, C1785, C1786, C1882, C1895, C1896, C1899, C2619, C2620, C2621, G0448

• Effective July 1, 2024: 33285, 93650, 93653, 93654, 93656, 93228, 93229, C1764, E0616, K0606

Ablation of Primary and Metastatic Liver Tumors (PDF)

• 47370, 47371, 47380, 47381, 47382, 47383

Adipose-derived Stem Cell Enrichment in Autologous Fat Grafting to the Breast (PDF)

• 15769, 15771, 15772, 11950, 11951, 11952, 11954

• Note: Codes 19380 and 19499 do not require pre-authorization but are considered, and will deny as, investigational when used for autologous fat grafting and adipose-derived stem cell enrichment for augmentation or reconstruction of the breast

Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions (PDF)

• 27412, J7330, S2112

Balloon Dilation of the Eustachian Tube (PDF)

• 69705, 69706

Balloon Ostial Dilation for Treatment of Sinusitis (PDF)

• 31295, 31296, 31297, 31298

Bariatric surgery (PDF)

• 43644, 43771, 43772, 43773, 43774, 43775, 43820, 43845, 43846, 43848, 43860, 43886, 43887, 43888

Blepharoplasty, Repair of Blepharoptosis, and Brow Ptosis Repair (PDF)

• 15820, 15821, 15822, 15823, 67900, 67901, 67902, 67903, 67904, 67906, 67908, 67909, 67950

Bronchial Valves (PDF)

• 31647, 31648, 31649, 31651

Chemical Peels (PDF)

• 15788, 15789, 15792, 15793, 17360

Cochlear Implant (PDF)

• 69930, L8614, L8619, L8627, L8628

Cosmetic and Reconstructive Procedures (PDF)

• 11920, 11921, 11922, 11950, 11951, 11952, 11954, 15769, 15771, 15772, 15773, 15774, 17106, 17107, 17108, 19355, 21230, 21244, 21245, 21246, 21248, 21249, 21295, 21296, 41510, 49250, 54360, 67950, 69300, G0429
• Pre-authorization is required EXCEPT when services are rendered in association with breast reconstruction and nipple/areola reconstruction following mastectomy for breast cancer.

• Note: Codes 19380 and 19499 do not require pre-authorization but are considered, and will deny as, investigational when used for autologous fat grafting and adipose-derived stem cell enrichment for augmentation or reconstruction of the breast

Cryosurgical Ablation of Miscellaneous Solid Tumors Outside of the Liver (PDF)

• 31641, 32994, 50542

Deep Brain Stimulation (PDF)

• 61850, 61860, 61863, 61864, 61867, 61868, 61885, 61886

Endometrial Ablation (PDF)

• 58353, 58356, 58563

Extracranial Carotid Angioplasty and Stenting (PDF)

• 37215, 37216, 37217, 37246, 37247, C7532

Femoroacetabular Impingement Surgery (PDF)

• See the Physical Medicine section above.

Gastric Electrical Stimulation (PDF)

• 43647, 43881, 64590, 64595, E0765

Gastroesophageal Reflux Surgery (PDF)

• 43279, 43280, 43281, 43282, 43325, 43327, 43328, 43332, 43333, 43334, 43335, 43336, 43337

Hypoglossal Nerve Stimulation (PDF)

• 64568, 64582, 64583

Hysterectomy (PDF)

• Pre-authorization is required for group #39000201, #39000303 and #39000402 members: CPT codes 58150, 58152, 58180, 58260, 58262, 58267, 58270, 58275, 58280, 58290, 58291, 58292, 58294, 58541, 58542, 58543, 58544, 58550, 58552, 58553, 58554, 58570, 58571, 58572, 58573
• Pre-authorization is only required for diagnosis related to abnormal uterine bleeding, pelvic pain (including pain related to endometriosis, ensure placement, prior endometrial ablation, and vaginal agenesis), chronic pelvic inflammatory disease, pelvic adhesive disease, pelvic venous congestion, adenomyosis, cervical intraepithelial neoplasia, and leiomyoma. Please refer to the Medical Policy for specific ICD-10 diagnoses that require pre-authorization.

Transcutaneous Bone Conduction and Bone-Anchored Hearing Aids (PDF)

• 69714, 69710, 69716, 69717, 69719, 69726, 69729, 69730, L8690, L8691, L8692, L8694

Implantable Peripheral Nerve Stimulation and Peripheral Subcutaneous Field Stimulation (PDF)

• 64585, 64590, 64595, 64596, 64597, 64598

Laser Treatment for Port Wine Stains (PDF)

• 17106, 17107, 17108

Leadless Cardiac Pacemakers (PDF)

• 0823T, 0824T, 33274

Left-Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation (PDF)

• 33340

Magnetic Resonance (MR) Guided Focused Ultrasound (MRgFUS) and High Intensity Focused Ultrasound (HIFU) Ablation (PDF): "

• 0398T, 55880

Microwave Tumor Ablation (PDF)

• 32998, 50592

Occipital Nerve Stimulation (PDF)

• 61885, 61886, 64553, 64568, 64569, 64585, 64590, 64596, 64597, 64598
• Occipital Nerve Stimulation is considered investigational for all indications, including but not limited to headaches

• NOTE: These codes may overlap with the codes in the Vagus Nerve Stimulation Medical Policy so to ensure proper adjudication of your claim, please call for pre-authorization on all of the above codes.

Orthognathic surgery (PDF)

• 21085, 21110, 21120, 21121, 21122, 21123, 21125, 21127, 21141, 21142, 21143, 21145, 21146, 21147, 21150, 21151, 21154, 21155, 21159, 21160, 21188, 21193, 21194, 21195, 21196, 21198, 21206, 21208, 21209, 21210, 21215, 21230, 21295, 21296

• Codes 21145, 21196, 21198 require pre-authorization EXCEPT when the procedure is performed for oral cancer dx codes: C01, C02-C02.9, C03-C03.9, C04-C04.9, C05-C05.9, C06, C06.2, C06.9, C09-C09.9, C10-C10.0, C41-C41.1, C46.2, D00-D00.00, D10, D10.1-D10.9, D16.4-D16.5, D37-D37.0, D49-D49.0

Ovarian, Internal Iliac and Gonadal Vein Embolization, Ablation, and Sclerotherapy (PDF)

• 37241

Panniculectomy (PDF)

• 15830

Pectus Excavatum and Carinatum Surgery (PDF)

• 21740, 21742, 21743

Percutaneous Angioplasty and Stenting of Veins (PDF)

• 37238, 37239, 37248, 37249

Phrenic Nerve Stimulation for Central Sleep Apnea (PDF)

• C1823

Radiofrequency Ablation of Tumors (RFA) Other Than the Liver (PDF)

• 20982, 31641, 32998, 50542, 50592, 58580, 58674

Reconstructive Breast Surgery/Mastopexy, and Management of Breast Implants (PDF)

• 11920, 11921, 15769, 15771, 15772, 19316, 19318, 19325, 19328, 19330, 19340, 19342, 19350, 19355, 19370, 19371, L8600
• Pre-authorization is required EXCEPT when services are rendered in association with breast reconstruction and nipple/areola reconstruction following mastectomy for breast cancer. However, if autologous fat grafting with adipose-derived stem cell enrichment is used for augmentation or reconstruction of the breast it would be considered investigational.

• Note: Codes 19380 and 19499 do not require pre-authorization but are considered, and will deny as, investigational when used for autologous fat grafting and adipose-derived stem cell enrichment for augmentation or reconstruction of the breast

Reduction Mammoplasty (PDF)

• 19318

Responsive Neurostimulation (PDF)

• 61850, 61860, 61863, 61864, 61885, 61886, 61889, 61891

Rhinoplasty (PDF)

• 30120, 30400, 30410, 30420, 30430, 30435, 30450

Sacral Nerve Neuromodulation (Stimulation) for Pelvic Floor Dysfunction (PDF)

• 0786T, 0787T, 64561, 64581, 64585, 64590, 64595, 64596, 64597, 64598

• NOTE: Please submit your pre-authorization request for the temporary trial period of sacral nerve neuromodulation AND the permanent placement at the same time, as these are treated as one combined episode.

Sacroiliac Joint Fusion (PDF)

• 27278, 27279, 27280

Spinal Cord and Dorsal Root Ganglion Stimulation (PDF)

• 0784T, 0785T, 63650, 63655, 63685
• Review the "Physical Medicine" section above for spine authorization requirements from eviCore.

• NOTE: Please submit your pre-authorization request for the temporary trial AND the permanent placement at the same time.

Spinal Pre-authorization

• Review the "Physical Medicine" section above for spine authorization requirements from eviCore.

• View our Physical Medicine program for spinal pre-authorization requirements through eviCore.

Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy

• 32701, 61796, 61797, 61798, 61799, 61800, 63620, 63621, 77301, 77338, 77371, 77372, 77373, 77432, 77435, C9795, G0339, G0340
• Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy of Intracranial, Skull Base, and Orbital Sites (PDF)
• Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy for Tumors Outside of Intracranial, Skull Base, or Orbital Sites (PDF)

Surgical Site of Service - Hospital Outpatient (PDF)

• 11755, 14040, 14060, 15851, 17311, 17313, 30130, 30140, 30520, 30802, 31200, 31205 31525, 31574, 31591, 32408, 32555, 32557, 38221, 38222, 42821, 42826, 42831, 43235, 43237, 43238, 43239, 43242, 43245, 43246, 43247, 43248, 43249, 43250, 43251, 43254, 43260, 43261, 45378, 45379, 45380, 45381, 45384, 45385, 45386, 45390, 45398, 46505, 46607, 49082, 49422, 50430, 51715, 52001, 52235, 52287, 52450, 53445, 54150, 54161, 54162, 54163, 54164, 54300, 54450, 54840, 55040, 55041, 55700, 56810, 57283, 58263, 62270, 63661, 63663, 64418, 64425, 64530, 64610, 64642, 64644, 64646, 64702, 64718, 64719, 64721 64774, 64795, 64831, 65756, 65779, 65780, 65855, 66183, 66761, 66840, 66850, 67028, 67218, 68320
• NOTE: Pre-authorization is not required when procedures performed in an ambulatory surgery center, physician office, or emergency facility for urgent services or when the member is age 17 or younger
• If faxing a pre-authorization for these services, submit the Surgical Site of Service Additional Information Form (PDF) with the Medical Services (PDF) pre-authorization request form.
• Effective March 1, 2024: 10060, 10061, 10080, 10081, 10120, 10121, 10140, 10160, 10180, 11000, 11010, 11012, 11042, 11044, 11200, 11310, 11402, 11403, 11404, 11406, 11420, 11421, 11422, 11423, 11424, 11426, 11440, 11441, 11442, 11443, 11444, 11446, 11450, 11451, 11462, 11463, 11470, 11471, 11601, 11602, 11603, 11604, 11606, 11620, 11621, 11622, 11623, 11624, 11626, 11640, 11641, 11642, 11643, 11644, 11646, 11730, 11750, 11760, 11765, 11770, 11772, 11900, 12001, 12002, 12011, 12020, 12031, 12032, 12034, 12035, 12037, 12041, 12042, 12051, 13120, 13121, 13131, 13132, 13151, 13152, 13160, 14020, 15120, 15220, 15240, 15760, 17000, 17110, 17111, 19020, 19101, 19110, 19112, 19120, 19125, 20200, 20205, 20220, 20225, 20240, 20526, 20600, 20604, 20605, 20606, 20610, 20611, 20912, 21011, 21012, 21013, 21014, 21029, 21030, 21031, 21040, 21046, 21048, 21315, 21320, 21325, 21330, 21335, 21336, 21337, 21356, 21550, 21552, 21554, 21555, 21556, 21557, 21920, 21930, 21931, 21932, 22900, 22901, 22902, 22903, 23030, 23071, 23075, 23140, 23150, 24000, 24006, 24065, 24066, 24071, 24073, 24075, 24076, 24101, 24110, 24120, 24130, 24147, 24200, 24201, 24366, 25071, 25073, 25075, 25076, 25085, 25109, 25120, 25130, 25350, 26070, 26105, 26110, 26111, 26113, 26115, 26180, 26200, 26210, 26357, 26432, 26433, 26500, 26530, 26542, 26841, 26862, 27006, 27043, 27045, 27047, 27048, 27062, 27093, 27095, 27310, 27323, 27324, 27327, 27328, 27329, 27337, 27339, 27340, 27345, 27347, 27613, 27614, 27618, 27632, 27634, 27638, 27640, 27720, 28011, 28039, 28041, 28043, 28045, 28047, 28100, 28103, 28104, 28126, 28666, 29835, 29900, 29901, 30000, 30020, 30100, 30110, 30115, 30117, 30118, 30220, 30310, 30580, 30630, 30801, 30901, 30903, 30930, 31020, 31030, 31032, 31238, 31526, 31528, 31529, 31530, 31535, 31536, 31540, 31541, 31545, 31570, 31571, 31575, 31576, 31578, 31611, 31622, 31623, 31624, 31625, 31628, 31652, 31820, 36010, 36215, 36246, 36556, 36569, 36571, 36581, 36582, 36589, 36590, 37607, 38500, 38505, 38510, 38520, 38525, 38740, 38760, 40490, 40510, 40520, 40525, 40530, 40808, 40810, 40812, 40814, 40816, 41010, 41100, 41105, 41108, 41110, 41112, 41113, 41116, 42100, 42104, 42106, 42330, 42335, 42405, 42408, 42410, 42415, 42420, 42425, 42440, 42450, 42500, 42650, 42800, 42804, 42808, 42810, 42870, 43191, 43195, 43197, 43200, 43211, 43212, 43213, 43214, 43215, 43216, 43217, 43220, 43226, 43227, 43229, 43231, 43232, 43233, 43240, 43241, 43243, 43244, 43253, 43259, 43266, 43270, 43450, 43453, 44340, 44360, 44361, 44364, 44369, 44376, 44377, 44380, 44381, 44382, 44385, 44386, 44388, 44389, 44391, 44392, 44394, 44408, 44705, 45100, 45171, 45172, 45190, 45305, 45330, 45331, 45332, 45333, 45334, 45335, 45337, 45338, 45340, 45341, 45342, 45346, 45347, 45349, 45350, 45382, 45388, 45389, 45391, 45392, 45393, 45505, 45541, 45560, 45905, 45910, 45915, 45990, 46020, 46030, 46040, 46045, 46050, 46060, 46080, 46083, 46200, 46220, 46221, 46230, 46250, 46255, 46257, 46258, 46260, 46261, 46262, 46270, 46275, 46280, 46285, 46288, 46320, 46606, 46610, 46612, 46615, 46700, 46750, 46910, 46917, 46922, 46924, 46930, 46940, 46945, 46946, 47000, 49083, 49500, 49505, 49507, 49520, 49521, 49525, 49550, 49553, 49650, 49651, 49900, 50435, 50575, 50590, 50688, 51040, 51102, 51600, 51610, 51702, 51710, 51720, 51726, 51728, 51729, 52000, 52005, 52007, 52204, 52214, 52224, 52234, 52240, 52260, 52265, 52275, 52276, 52281, 52282, 52283, 52285, 52300, 52310, 52315, 52317, 52318, 52320, 52325, 52327, 52330, 52332, 52341, 52344, 52351, 52352, 52353, 52354, 52356, 52500, 52601, 52630, 52640, 53020, 53200, 53230, 53260, 53265, 53270, 53440, 53450, 53500, 53605, 53665, 54001, 54055, 54057, 54060, 54065, 54100, 54110, 54512, 54530, 54600, 54620, 54640, 54700, 54830, 54860, 55000, 55060, 55100, 55110, 55120, 55250, 55400, 55500, 55520, 55540, 56405, 56420, 56440, 56441, 56442, 56501, 56515, 56605, 56620, 56700, 56740, 56821, 57000, 57061, 57065, 57100, 57130, 57135, 57210, 57240, 57250, 57260, 57268, 57282, 57287, 57300, 57400, 57410, 57415, 57420, 57421, 57425, 57452, 57454, 57456, 57461, 57500, 57505, 57510, 57513, 57520, 57522, 57530, 57700, 57720, 57800, 58100, 58120, 58558, 58560, 58561, 58565, 58662, 58670, 58671, 58700, 58925, 59200, 64600, 64647, 64776, 64782, 64784, 64788, 64835, 65275, 65400, 65420, 65426, 65435, 65436, 65710, 65730, 65750, 65755, 65772, 65778, 65800, 65815, 65820, 65850, 65865, 65875, 65920, 66020, 66170, 66172, 66179, 66180, 66184, 66185, 66250, 66682, 66710, 66711, 66762, 66821, 66825, 66852, 66982, 66983, 66984, 66985, 66986, 66987, 66988, 67005, 67010, 67015, 67025, 67031, 67036, 67039, 67040, 67041, 67042, 67043, 67101, 67105, 67107, 67108, 67110, 67113, 67120, 67121, 67141, 67145, 67210, 67220, 67221, 67228, 67311, 67312, 67314, 67316, 67318, 67345, 67400, 67412, 67414, 67420, 67445, 67550, 67560, 67700, 67800, 67801, 67805, 67808, 67810, 67825, 67840, 67875, 67935, 67961, 67966, 67971, 67973, 67975, 68100, 68110, 68115, 68135, 68440, 68530, 68700, 68720, 68750, 68761, 68801, 68811, 68815, 69000, 69100, 69110, 69140, 69145, 69205, 69222, 69310, 69320, 69421, 69424, 69433, 69436, 69440, 69450, 69502, 69505, 69550, 69602, 69610, 69620, 69631, 69632, 69633, 69635, 69636, 69641, 69642, 69643, 69644, 69645, 69646, 69650, 69660, 69661, 69662, 69666, 69801, 69805, 69806, G0104, G0105, G0106, G0120, G0121, G0122

Surgical Treatments for Hyperhidrosis (PDF)

• 32664, 64818, 69676

• Code 32664 only requires pre-authorization for hyperhidrosis diagnoses L74.510 L74.511, L74.512, L74.513, L74.519, L74.52, R61

Surgeries for Snoring, Obstructive Sleep Apnea Syndrome, and Upper Airway Resistance Syndrome (PDF)

• 21121, 21122, 21141, 21145, 21196, 21198, 21199, 21685, 41120, 42140, 42145, 42160

• Codes 21145, 21196, 21198, 41120, 42160 do not require pre-authorization when the procedure is performed for oral cancer dx codes: C01, C02-C02.9, C03-C03.9, C04-C04.9, C05-C05.9, C06, C06.2-C06.9, C09-C09.9, C10-C10.0, C41-C41.1. C46.2, D00-D00.00, D10, D10.1-D10.9, D16.4-D16.5, D37-D37.0, D49-D49.0

Temporomandibular Joint (TMJ) Surgical Interventions

• Visit MCG's website for information on purchasing their criteria, or contact us and we will be happy to provide you with a copy of the specific guideline.
• 21010 - MCG A-0522
• 21050 - MCG A-0523
• 29800, 29804 - MCG A-0492

• 21240, 21242, 21243 - MCG A-0523

Transcatheter Aortic-Valve Implantation for Aortic Stenosis (PDF)

• 33361, 33362, 33363, 33364, 33365, 33366

Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease (GERD) (PDF)

• 43192, 43201, 43236

• Note: Codes 43201 and 43236 may also be used for the administration of Botox for indications unrelated to GERD. Botox requires pre-authorization by Pharmacy. Learn more about submitting a pre-authorization request for Boxtox.

Transurethral Water Vapor Thermal Therapy and Transurethral Water Jet Ablation (Aquablation) of the Prostate (PDF)

• 0421T, 53854, C2596

Vagus Nerve Stimulation (PDF)

• 61885, 61886, 64553, 64568, 64569, E0735

Varicose Vein Treatment (PDF)

• 0524T, 36465, 36466, 36470, 36471, 36475, 36476, 36478, 36479, 36482, 36483, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37785, S2202

• Note: Code 37241 is not appropriate to use in the coding of varicose vein treatment

Ventral (Including Incisional) Hernia Repair (PDF)

• 15734, 49591, 49593, 49595, 49613, 49615, 49617, 49621
  • Pre-authorization for 15734 required only with diagnosis code K42.0, K42.1, K42.9, K43.0, K43.1, K43.2 K43.6, K43.7, K43.9, K45.0, K45.1, K45.8, K46.0, K46.1, K46.9 or M62.0
  • Pre-authorization for codes 49591, 49593, 49595, 49613, 49615, 49617, 49621 only required with diagnoses codes K43.2 or K43.9 for ventral hernia repair

Transplants - Stem Cell

• Reference our Medical Policy Manual for policies.

• 38205, 38206, 38232, 38240, 38241, 38242, 38243, S2140, S2142, S2150

Transplants - Islet Transplantation (PDF)

• 48160, 0584T, 0585T, 0586T, G0341, G0342, G0343

Transplants - Heart (PDF)

• 33945

Transplants - Heart-Lung (PDF)

• 33935

Transplants - Lung and Lobar Lung (PDF)

• 32851, 32852, 32853, 32854, S2060

Transplants - Small Bowel, Small Bowel/Liver, and Multivisceral Transplant (PDF)

• 44135, 44136, 47135, 48554, S2053, S2054, S2152

Transplants - Liver Transplant (PDF)

• 47135

Transplants - Pancreas Transplant (PDF)

• 48554, S2065, S2152

Ventricular Assist Devices and Total Artificial Hearts (PDF)

• 33927, 33928, 33929, 33975, 33976, 33977, 33978, 33979, L8698

Air Ambulance Transport (PDF)

• A0435, A0430, S9960
• Pre-authorization is required prior to elective fixed wing air ambulance transport.
• Emergency air ambulance transports may be reviewed retrospectively for medical necessity.
• HCPCs codes A0431, A0436, S9961 will be reviewed post-service for members of groups #39000201, #39000303 and #39000402