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Medicare Advantage Services requiring Prior Authorization 

 

Prior authorization is required for:

Procedures:  (click here for a list of procedure codes) 

  • Automatic Implanted Cardioverter Defibrillator (AICD)
  • Dental surgery related to an accident
  • Joint replacement surgery
  • Nasal and sinus surgery
  • Cosmetic surgery
  • Spinal surgery
  • Surgical treatment of obesity
  • Transplants (organ, tissue, etc)
  • Experimental or investigational procedures
  • Blepharoplasty
  • Cochlear implants

Inpatient Admissions:

  • Acute inpatient hospital to include Mental health/Substance abuse
  • Rehabilitation facility
  • Skilled nursing facility
  • Sub-acute and transitional care facility
  • Long-term acute care facility

Durable Medical Equipment/Prosthetics and Orthotics (DMEPOS):

  • DME >$500 (including rental to purchase)
  • Orthotics and Prosthetics >$500

Services:

  • Services not routinely covered by Medicare (may be submitted for review)
  • Home health services
  • Home IV services
  • Enteral Nutrition
  • Hyperbaric oxygen therapy
  • Mental health/Substance abuse treatment (non-office, outpatient)
  • Non-emergent ambulance transport
  • Outpatient therapy (Physical, occupational, speech)
  • Cardiac and Pulmonary Rehab
  • Total parenteral services
  • Genetic testing

 

The following procedure codes require prior authorization. This list is not all-inclusive. Modifications are made based on coding updates or when the requirement for prior authorization of a service changes. Providers will be given 30 days notice on any additions to services requiring prior authorization.
(Last updated 06/04/2013)

Services or procedures considered to be Investigational only will not appear on the prior authorization list. Services considered to be cosmetic only will not appear on the prior authorization list.

For a list of advanced imaging services requiring prior authorization through AIM, please click here.

If you are already securely logged in and would like to submit your request online click on “Authorization Submission.”
To login/enroll in our online “Authorization Submission,” please click hyperlink.

In order to clarify prior authorization requirements for Medicare Advantage members, Blue Cross of Idaho has created the following index of CPT/HCPCS codes. Although prior authorization requirements are currently in place for Medicare Advantage, effective January 1, 2010, providers may utilize the following list to determine what services require review by Blue Cross of Idaho.
Unlisted procedure codes are not prior authorized but reviewed retrospectively from the operative report.

To 'Search' for a Code: Hold CTRL key, type the letter F for Find Dialogue Box, Type in code and hit enter (make sure you are the beginning of the page first)


 

 Click on the Section Name if you wish to view descriptions for listed CPT/HCPCS codes 

 


Procedure Code List 

Automatic Implanted Cardioverter Defibrillator (AICD)   33230, 33231, 33240, 33249, 33262, 33263, 33264, C1721, C1722, C1777, C1882, C1895, C1896, C1898, C1899
Cochlear Implant 69714, 69715, 69717, 69718, 69930, L8614, L8615, L8616, L8617, L8618, L8619, L8621, L8622, L8623, L8624, L8627, L8628, L8629, L8690, L8691, L8692
Joint Replacement Surgery 23470, 23472, 24360, 24361, 24362, 24363, 24365, 24366, 25332, 25441, 25442, 25443, 25444, 25445, 25446, 25447, 25449, 27125, 27130, 27132, 27134, 27137, 27138, 27412, 27437, 27438, 27440, 27441, 27442, 27443, 27445, 27446, 27447, 27486, 27487, 27700, 27702, 27703
Nasal and Sinus Surgery 30120, 30400, 30410, 30420, 30520, 31020, 31030, 31032, 31040, 31050, 31051, 31070, 31075, 31080, 31081, 31084, 31085, 31086, 31087, 31090, 31200, 31201, 31205, 31225, 31237, 31239, 31240, 31254, 31255, 31256, 31267, 31276, 31287, 31288, 31295, 31296, 31297, 41512, 42145
Reconstructive and Plastic Surgery 15821, 15822, 15823, 15824, 15826, 15830, 17106, 17107, 17108, 19300, 19316, 19318, 19324, 19325, 19328, 19330, 19355, 19370, 19371, 67900, 67901, 67902, 67903, 67904, 67906, 67908, 67909
Spinal Surgery 0092T, 0095T, 0098T, 20930, 20931, 20936, 20937, 20938, 20982, 22220, 22222, 22224, 22226, 22520, 22521, 22522, 22523, 22524, 22525, 0202T, 0309T, 22532, 22533, 22534, 22548, 22551, 22552, 22554, 22556, 22558, 22585, 22586, 22590, 22595, 22600, 22610, 22612, 22614, 22630, 22632, 22633, 22634, 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, 72291, 72292
Surgical Treatment of Obesity 43644, 43645, 43770, 43771, 43772, 43773, 43774, 43775, 43845, 43846, 43847
Transplants 29868, 32851, 32852, 32853, 32854, 33930, 33933, 33935, 33940, 33944, 33945, 38204, 38205, 38206, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38232, 38240, 38241, 38242, 38243, 44715, 44720, 44721, 44799, 47144, 47145, 48550, 48551, 48552, 48554, 48556, 48999, 50300, 50320, 50323, 50325, 50327, 50328, 50329, 50340, 50360, 50365, 50370, 50380, 65710, 65730, 65750, 65755, 65756, 65757, G0341, G0342, G0343
Implantable Neurostimulators 61850, 61860, 61863, 61864, 61867, 61868, 61870, 61875, 61885, 61886, 61888, 63650, 63655, 63685, 63688, 64553, 64555,  64561, 64565, 64568, 64580, 64581, 0160T, 0161T, L8680, C1778, C1897
Home Health Services All Home Health Services require prior authorization.
Home IV Services  All Home IV Services require prior authorization.
Enteral Nutrition/Total Parenteral Services 99601, 99602,  B4035, B4036, B4081, B4082, B4083, B4100, B4102, B4103, B4104, B4149, B4150, B4152, B4153, B4154, B4155, B4157, B4158, B4159, B4160, B4161, B4162, B4164, B4168, B4172, B4176, B4178, B4180, B4185, B4189, B4193, B4197, B4199, B4216, B4220, B4222, B4224, B5000, B5200, B9000, B9002, B9004, B9006, B9998, B9999
Hyperbaric Oxygen Therapy  99183, C1300
Mental Health/Substance Abuse All inpatient stays and Partial Hospitalizations require prior authorization.
Outpatient Therapy (Physical, Occupational, Speech) All Outpatient Therapy (including Physical, Occupational and Speech) requires prior authorization.
Cardiac and Pulmonary Rehab All Cardiac and Pulmonary Rehabilitation Services require prior authorization.
Genetic Testing  81161, 81200, 81201, 81202, 81203, 81205, 81206, 81207, 81208, 81209, 81210, 81211, 81212, 81213, 81214, 81215, 81216, 81217, 81220, 81221, 81222, 81223, 81224, 81225, 81226, 81227, 81228, 81229,f 81235, 81240, 81241, 81242, 81243, 81244, 81245, 81250, 81251, 81252, 81253, 81254, 81255, 81256, 81257, 81260, 81261, 81262, 81263, 81264, 81265, 81266, 81267, 81268, 81270, 81275, 81280, 81281, 81282, 81290, 81291, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81301, 81302, 81303, 81304, 81310, 81315, 81316, 81317, 81318, 81319, 81321, 81322, 81323, 81324, 81325, 81326, 81330, 81331, 81332, 81340, 81341, 81342, 81350, 81355, 81370, 81371, 81372, 81373, 81374, 81375, 81376, 81377, 81378, 81379, 81380, 81381, 81382, 81383, 81400, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 83890, 83891, 83892, 83893, 83894, 83896, 83897, 83898, 83900, 83901, 83902, 83903, 83904, 83905, 83906, 83907, 83908, 83909, 83912, 83913, 83914, 88245, 88248, 88249, 88261, 88262, 88263, 88264, 88267, 88269, 88271, 88272, 88273, 88274, 88275, 88280, 88283, 88285, 88289, 88291
Miscellaneous G0166, 20527, 26341, 28735, 32664, 33361, 33362, 33363, 33364, 33365, 33367, 33368, 33369, 41874, 58750, 64611, 64612, 64614, 64615, 92971, 0256T, 0318T

If you are already securely logged in and would like to submit your request online click on “Authorization Submission.”
To login/enroll in our online “Authorization Submission,” please click hyperlink.
If you would like a .pdf version of our prior authorization form, please click here.