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Services requiring Prior Authorization

Prior authorization for the following may not be required for specific employer contracts but will be reviewed upon request:

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

  • Dental surgery related to an accident
  • Eyelid surgery
  • Invasive treatment of lower extremity veins
  • Nasal and sinus surgery
  • Jaw Surgery
  • Reconstructive and plastic surgery
  • Spinal surgery
  • Surgery for snoring or sleep problems
  • Surgical treatment of obesity
  • Transplants (organ, tissue, etc..)
  • Experimental or investigational procedures

Admissions:

  • Acute inpatient hospital
  • Newborns requiring care beyond the normal newborn period
  • Long term acute care hospital (LTACH)
  • Rehabilitation and long-term care facility
  • Skilled nursing facility
  • Sub-acute and transitional care

Note: Emergency admissions, please notify Blue Cross of Idaho within one business day following admission.

Durable Medical Equipment:

  • DME >$500(including rental to purchase)
  • Orthotics and Prosthetic >$500(coverage may depend on member contract)
  • Oral Appliances for Sleep Apnea
  • Hospital grade Breast Pumps

Services:

  • Genetic testing
  • Home health services
  • Outpatient IV Therapy for Infusion drugs as listed on BCI Website
  • Hospice services
  • Hyperbaric oxygen therapy
  • Non-emergent ambulance transport   

The following procedure codes require prior authorization. This list is not all-inclusive.   We make additions and deletions as new issues arise or the requirement for prior authorization of a service changes.These policies may not apply to all lines of business such as Federal Employee Program, Medicare Advantage and certain self-insured groups.                                                                                                    (Last updated 02/28/2014)

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 Specialty Health, 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.

For Blue Cross of Idaho`s definition of medically necessary and investigational, please click here. 
Unlisted procedure codes are not prior authorized but reviewed retrospectively from the operative report.
For Medications requiring prior authorization for our Commercial members, please click here.
For questions, please contact the Medical Management Department at 1-800-743-1871.  Please fax requests for service to 208-331-7344.

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 at 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 

Dermatology                                                  15780, 15781, 15782, 15783, 15786, 15787, 15788, 15789, 15792, 15793, 96920, 96921, 96922 
Cardiac Procedures S0345, S0346, S0347
Plastic Surgery  15822, 15823, 15824, 15826, 15830, 17106, 17107, 17108, 19300, 19316, 19318, 19324, 19325, 19328, 19330, 19355, 19370, 19371, 19396, 67900, 67901, 67902, 67903, 67904, 67906, 67908, 67909 
Hyperbaric Oxygen  99183, A4575, C1300 f
Spinal Surgeries  0092T, 0095T, 0098T, 0195T, 0196T, 0309T, C9729, 20930, 20931, 20936, 20937, 20938, 20982, 22220, 22222, 22224, 22226, 22520, 22521, 22522, 22523, 22524, 22525, 0202T, 22532, 22533, 22534, 22548, 22551, 22552, 22554, 22556, 22558, 22585, 22586, 22590, 22595, 22600, 22610, 22612, 22614, 22630, 22632, 22856, 22857, 22861, 22862, 22864, 22865, 22899, 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
Other Spine Procedures  63600, 63610, 63650, 63655, 63660, 63685, 63688, 64553, 64555, 64560, 64561, 64565, 64573, 64575, 64577, 64580, 64581, 72291, 72292
Mouth/Jaw Procedures 21125, 21127, 21137, 21138, 21139, 21141, 21142, 21143, 21145, 21146, 21147, 21150, 21151, 21154, 21155, 21159, 21160, 21175, 21188, 21193, 21194, 21195, 21196, 21198, 21199, 21206, 21208, 21209, 21210, 21215, 21230, 21235, 21244, 21245, 21246, 21247, 21248, 21249, 29800, 29804
Miscellaneous 28735, 32664, 36515, 36516, 41874, 58750, 64611, 64612, 64614, 77301, 77338, 77418, 77520, 77522, 77523, 77525, 90378, A9276, A9277, A9278, A9279, S1040, S2066, S2067, S2068, XXXXX - Humanitarian Device
Sinus Surgery 

21685, 30120, 30400, 30410, 30420, 30520, 31020, 31030, 31032, 31040, 31050, 31051, 31070, 31075, 31080, 31081, 31084, 31085, 31086, 31087, 31090, 31200, 31201, 31205, 31225, 31230, 31237, 31239, 31240, 31254, 31255, 31256, 31267, 31276, 31287, 31288, 31295, 31296, 31297, 41512, 42140, 42145

Veins 36470, 36471, 36475, 36476, 36478, 36479, 37500, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37785, S2202
Gastric Surgery  43644, 43645, 43770, 43771, 43772, 43773, 43774, 43775, 43842, 43843, 43845, 43846, 43847, 43848, 43886, 43887, 43888
Hearing Devices  69710, 69714, 69715, 69717, 69718, 69930, L8614, L8619
Imaging 78459, 78491, 78492, 78608, 78609, 78811, 78812, 78813, 78814, 78815, 78816, G0219, G0252, S8085
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, 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, 81287, 81290, 81291, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81301, 81302, 81303, 81304, 81310, 81315, 81316, 81317, 81318, 81319, 81321, 81322, 81323, 81325, 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, 81507, 88245, 88248, 88249, 88261, 88262, 88263, 88264, 88267, 88269, 88271, 88272, 88273, 88274, 88275, 88291, S3800, S3833, S3834, S3840, S3841, S3842, S3844, S3845, S3846, S3849, S3850, S3852, S3853, S3855, S3861, S3865, S3866, S3870
Stem-Cell Transplants 38204, 38205, 38206, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230, 38240, 38241, 38242
Cartilage Transplants 27412, 27415, 27416
Islet Transplants  G0341, G0342, G0343, S2102
Other Ablation Procedures  20982, 32998, 37204, 37241, 37243, 47370, 47380, 47382, 50592
All Solid Organ Transplants require prior authorization  

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.