Commercial Pre-authorization List

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 request. 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.

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

• Pre-authorization is required for group #30000101-#30000112, #30000301, #30010403, #30010101-#30010112, #30010401, #30020101-#30020112, #30030101–#30030112, #37000101, #37000201, #37000301, #37000402, #37000501, #38001001, #38002001, #38003001, #38004001 and #38005001 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.

Pre-notification required for group #s 70000002, 70000004, 70000007, 70000008 and 70000012 only: 90935, 90937, 90945, 90947, 90951, 90952, 90953, 90954, 90955, 90956, 90957, 90989, 90993, G0308

• Group #s: 70000002, 70000004, 70000007: Submit pre-notification to AmeriBen via:
  • AmeriBen secure portal
  • Faxing AmeriBen's precertification request fax form to 1 (877) 955-3548

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

• E0747, E0748, E0749
• Administrative services only (ASO) group requests for E0747, E0748 and E0749 require pre-authorization through Regence.

• For all other commercial products:

  • Requests for E0747 require pre-authorization through Regence.
  • Requests for E0748 and E0749 are detailed in the "Physical Medicine" section and requests for authorization are submitted directly to eviCore healthcare (eviCore)

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, L5841, 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 Program

• Review the codes requiring authorization or notification in the Sleep medicine section on this list.

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

Familial Hypercholesterolemia (PDF) - GT11

• 81401, 81405, 81406, 81407

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

• 81210, 81275,81276, 81311, 81403, 81404, 0111U, 0471U

Preimplantation Genetic Testing of Embryos (PDF) - GT18

• 89290, 89291, 81228, 81229, 81349

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

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, 0478U, 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 Red Blood Cell Antigen Genotyping Using Maternal Plasma (PDF) - GT74

• 81403

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

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

• 81228, 81229, 81349, 81405, 0469U

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, 81419

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

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

• 0022U, 0037U, 0048U, 0211U, 0244U, 0250U, 0334U, 0379U, 0391U, 0444U, 0473U, 0498U, 0499U, 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, 0485U, 0487U, 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, Q4151, Q4154, Q4159, 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
• NOTE: For King County members only (Group #10017241) in addition to the services listed above, the below codes also require pre-authorization.
  • 11970, 11971, 13100, 13101, 13102, 14000, 14001, 14040, 14041, 14301, 14302, 15100, 15101, 15570, 15572, 15574, 15576, 15757, 15758, 15824, 15825, 15826, 15828, 15829, 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, 15847, 15876, 15877, 19300, 21137, 21138, 21139, 21172, 21175, 21179, 21180, 21270, 54400, 54401, 54405, 54406, 54408, 54410, 54411, 54415, 54416, 54417, 54440, 58661, 58720, 64856, 64892, C2622, L8630, L8631
  • Requests for pre-authorization for these members will be reviewed using the criteria outlined in the benefit booklet instead of the Medical Policy referenced above. Please contact Customer Service for additional information regarding the specific prior approval requirements and covered services.

• Note: For members of Group #10047366 only: The following procedure codes do not require pre-authorization for these services: 11920, 11921, 11950, 11951, 11952, 11954, 15820, 15821, 15822, 15823, 15830, 21120, 21121, 21122, 21123, 21125, 21127, 21208, 21209, 21210, 30400, 30410, 30420, 30430, 30435, 30450, 67900, 67901, 67902, 67903, 67904, 67906, 67908, L8600 (codes for specific procedures may require pre-authorization in other medical policies)

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

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
   2. Phone (855) 252-1115
   3. Fax (855) 774-1319
   4. View workarounds for eviCore system outages

Pain management

• To determine which program an ASO member participates in, use the Electronic Authorization application on Availity Essentials

• 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

• Some ASO groups may require authorization through either 1) our Physical Medicine program administered by eviCore, or 2) our surgery authorization program.
• To determine which program an ASO member participates in, use the Electronic Authorization application on Availity Essentials.
• The following services require authorization in any care delivery setting: 23470, 23472, 23473, 23474, 23700, 27125, 27132, 27134, 27137, 27138, 27445, 27486, 27487, 27488, 27570, 27580, 29868, 29899, 29904, 29905, 29906, 29907
  • In addition to clinical review, these services are subject to site-of-care review when delivered in an outpatient hospital setting: 23000, 23020, 23120, 23130, 23410, 23412, 23420, 23430, 23440, 23455, 23462, 23466, 27130, 27332, 27333, 27334, 27403, 27405, 27415, 27416, 27418, 27420, 27422, 27425, 27427, 27428, 27429, 27430, 27438, 27440, 27441, 27442, 27443, 27446, 27447, 29805, 29806, 29807, 29819, 29820, 29821, 29822, 29823, 29824, 29825, 29826, 29827, 29828, 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

Joint management site-of-care only

• We require authorization from eviCore for these procedures, only when care will be delivered in an outpatient hospital setting. Authorization is not required when procedures are performed in an ambulatory surgery center, physician office, emergency facility or urgent service: 20520, 20525, 20670, 20680, 20693, 20694, 23415, 23450, 23460, 23465, 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, 27335, 27424, 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, 29834, 29837, 29838, 29844, 29846, 29848

Spine

• Some ASO groups may require authorization through either 1) our Physical Medicine program administered by eviCore, or 2) our surgery authorization program.
• To determine which program an ASO member participates in, use the Electronic Authorization application on Availity Essentials.

• 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.

• To determine which program an ASO member participates in, use the Electronic Authorization application on Availity Essentials
• 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 the following Washington plans:

• Regence BlueShield (select counties in Washington) group and Individual members
• Regence BlueCross BlueShield of Oregon group and Individual members on one of our Clark County, Washington products

• Regence BlueShield of Idaho group and Individual members on one of our Asotin or Garfield County, Washington products

This mandate does not apply to the following members:

• Medicare Advantage
• Any individual or group plan not based in the state of Washington
• BlueCross BlueShield Federal Employee Program® (BCBS FEP®)

• Some Administrative Services Only plans*

*Some Administrative services only (ASO) groups may participate in this program. To determine whether your patient's plan participates in this program, use the Electronic Authorization application on Availity Essentials.

Contact Regence 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.

Note: The Radiology Quality Initiative (RQI) component of this program was phased out in 2023.

• 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, 33285, 36901, 36902, 36903, 36904, 36905, 36906, 37220, 37221, 37224, 37225, 37226, 37227, 37228, 37229, 37230, 37231, 37241, 37242, 37243, 37244, 92920, 92924, 92928, 92933, 92937, 92943, 93228, 93229, 93454, 93455, 93456, 93457, 93458, 93459, 93460, 93461, 93580, 93600, 93602, 93603, 93610, 93612, 93618, 93619, 93620, 93624, 93642, 93644, 93650, 93653, 93654, 93656, 93978, 93979, 93880, 93882, 93922, 93923, 93924, 93925, 93926, 93930, 93931, 0823T, 0825T, C1721, C1722, C1764, C1777, C1785, C1786, C1882, C1895, C1896, C1899, C2619, C2620, C2621, C7513, C7514, C7515, C7530, E0616, G0448, K0606
• Retrospective review is not allowed for cardiac rhythm monitors (93228 and 33285). Retrospective review is allowed for cardiac ablation and wearable and cardioverter defibrillators if records are received within 10 business days of the date of service.

Pre-authorization for certain specialty medications is required for Alsco Inc. (group #70000002) members. These members are part of our joint administration partnership with AmeriBen.

Pre-authorizations for Alsco members should be submitted to VIVIO Health Help Desk at 1 (925) 365-6600. Note: This phone number should only be used for pre-authorizing specialty medications for these members.

The following medications require pre-authorization for Alsco Inc. (group #70000002) members:

CPT 90283, 90284, 90291, 90371, 90378, 90375; HCPCS C9047, C9399, J0121, J0129, J0135, J0172, J0174, J0177, J0178, J0180, J0202, J0208, J0217, J0218, J0219, J0221, J0222, J0223, J0224, J0225, J0256, J0257, J0287, J0289, J0364, J0401, J0490, J0491, J0517, J0565, J0567, J0577, J0578, J0584, J0585, J0588, J0593, J0594, J0596, J0597, J0598, J0599, J0606, J0638, J0717, J0739, J0741, J0775, J0791, J0801, J0802, J0850, J0881, J0885, J0888, J0894, J0895, J0896, J0897, J1246, J1290, J1300, J1301, J1302, J1303, J1304, J1305, J1306, J1322, J1324, J1325, J1411, J1412, J1413, J1426, J1427, J1428, J1429, J1438, J1439, J1440, J1442, J1447, J1448, J1453, J1458, J1459, J1460, J1551, J1554, J1555, J1556, J1557, J1558, J1559, J1561, J1566, J1568, J1569, J1571, J1572, J1573, J1575, J1576, J1595, J1599, J1602, J1626, J1627, J1628, J1632, J1640, J1645, J1652, J1743, J1744, J1745, J1746, J1747, J1786, J1823, J1826, J1830, J1930, J1931, J1932, J1950, J1951, J1952, J1954, J2182, J2315, J2323, J2326, J2327, J2329, J2350, J2353, J2354, J2356, J2357, J2406, J2427, J2430, J2502, J2506, J2507, J2508, J2562, J2597, J2724, J2777, J2778, J2779, J2781, J2783, J2786, J2788, J2790, J2791, J2792, J2793, J2796, J2799, J2798, J2820, J2840, J2860, J2941, J2998, J3032, J3060, J3110, J3111, J3240, J3245, J3262, J3285, J3304, J3315, J3316, J3357, J3358, J3380, J3385, J3396, J3397, J3398, J3399, J3401, J3485, J3489, J3490, J3590, J7170, J7178, J7179, J7180, J7181, J7182, J7183, J7185, J7186, J7187, J7188, J7189, J7190, J7192, J7195, J7198, J7200, J7201, J7202, J7203, J7204, J7205, J7207, J7208, J7209, J7210, J7211, J7212, J7213, J7214, J7311, J7312, J7313, J7314, J7351, J7352, J7402, J7504, J7599, J7639, J7682, J9021, J9022, J9023, J9025, J9032, J9033, J9034, J9035, J9036, J9039, J9041, J9042, J9043, J9047, J9050, J9055, J9057, J9061, J9065, J9118, J9119, J9120, J9144, J9145, J9153, J9155, J9173, J9176, J9177, J9178, J9179, J9185, J9198, J9203, J9204, J9205, J9206, J9207, J9210, J9216, J9217, J9218, J9223, J9226, J9227, J9228, J9229, J9246, J9260, J9261, J9263, J9264, J9266, J9269, J9271, J9272, J9273, J9274, J9281, J9286, J9293, J9295, J9298, J9299, J9301, J9302, J9303, J9304, J9305, J9306, J9307, J9308, J9309, J9311, J9312, J9314, J9316, J9317, J9318, J9319, J9321, J9325, J9328, J9330, J9331, J9332, J9334, J9345, J9340, J9347, J9348, J9349, J9350, J9351, J9352, J9353, J9354, J9355, J9356, J9357, J9358, J9359, J9370, J9395, J9400, J9999, Q2041, Q2042, Q2043, Q2050, Q2053, Q2054, Q2055, Q2056, Q3027, Q3028, Q4074, Q4081, Q5101, Q5103, Q5104, Q5105, Q5106, Q5107, Q5108, Q5110, Q5111, Q5113, Q5114, Q5115, Q5116, Q5117, Q5118, Q5119, Q5120, Q5121, Q5122, Q5123, Q5124, Q5125, Q5126, Q5127, Q5128, Q5129, Q5130, Q5131, Q9991, Q9992, S0013, S0145, S0189.

View the Alsco Inc. Specialty Medications List (PDF) of specialty medications that require pre-authorization.

For Northwest Carpenters Health and Security Plan members, providers should contact Express Scripts by calling 1 (844) 581-4862 to determine requirements for the medical drugs covered under the pharmacy benefit. Note: This phone number should only be used for medical drugs for these members.

The following medical drugs are covered under the pharmacy benefit for Northwest Carpenters Health and Security Plan (group #10057623) members: CPT 90378 and HCPCS C9097, J0129, J0135, J0178, J0179, J0180, J0218, J0219, J0221, J0223, J0256, J0257, J0364, J0490, J0517, J0584, J0586, J0588, J0638, J0717, J0739, J0741, J0800, J0801, J0802, J0881, J0885, J1300, J1301, J1303, J1322, J1411, J1438, J1442, J1447, J1458, J1459, J1551, J1554, J1555, J1557, J1558, J1559, J1561, J1566, J1568, J1569, J1575, J1576, J1595, J1599, J1602, J1628, J1743, J1745, J1746, J1747, J1786, J1823, J1826, J1830, J1931, J1951, J2170, J2182, J2327, J2350, J2356, J2357, J2507, J2778, J2781, J2796, J2820, J2840, J2941, J3060, J3110, J3111, J3241, J3245, J3262, J3285, J3299, J3357, J3358, J3380, J3385, J3396, J3397, J3399, J7170, J7178, J7179, J7180, J7181, J7182, J7183, J7185, J7186, J7187, J7189, J7190, J7192, J7194, J7195, J7198, J7200, J7201, J7202, J7203, J7204, J7205, J7207, J7208, J7209, J7210, J7211, J7212, J7213, J7214, J7297, J7311, J7312, J7313, J7318, J7321, J7322, J7323, J7324, J7325, J7326, J7327, J7328, J7332, J7340, J7351, J7527, J7639, J7665, J7682, J7686, J8520, J8521, J8565, J8700, J8705, J9216, J9332, J9334, Q3027, Q3028, Q4074, Q5101, Q5103, Q5104, Q5106, Q5108, Q5110, Q5111, Q5120, Q5121, Q5122, Q5124, Q5125, Q5127, Q5128, Q5131, S0088, S0145.

Note: If these medical drugs are administered in the ED or as part of an inpatient hospital stay, the facility should follow the pre-authorization and admission notification requirements on our Commercial Pre-authorization List and submit claims for the services to Regence.

Pre-authorization for certain medical drugs is required for WinCo (group #10034043) members. These members are part of WinCo Holdings, Inc., a Regence ASO group.

Pre-authorizations for WinCo members should be submitted to WellDyne Specialty Health by calling 1 (866) 240-2204. Note: This phone number should only be used for pre-authorizing medical drugs for these members.

The following medical drugs require pre-authorization for WinCo (group #10034043) members: J0180, J0585, J0586, J0587, J0588, J1306, J1459, J1460, J1551, J1554, J1555, J1556, J1557, J1558, J1559, J1560, J1561, J1566, J1568, J1569, J1745, J2327, J2350, J2357, J2506, J3357, J3558, Q5103, Q5104, Q5108, Q5111, Q5120, Q5121, Q9487 and Q9989.

For all other members - view pharmacy pre-authorization requirements and submit pre-authorization requests.

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

Anterior Abdominal Wall (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 K42.9, K43.2 or K43.9

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

Benign Prostatic Hyperplasia Surgical Treatments (PDF)

• 0421T, 53854, C2596

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

• NOTE: For members of Group # 10029722 only, the following procedure codes do not require pre-authorization: 58353, 58356, 58563.

Extracranial Carotid Angioplasty and Stenting (PDF)

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

Femoroacetabular Impingement Surgery (PDF)

• 29914, 29915, 29916
• We require pre-authorization for these codes for ASO groups that do not participate in the Physical Medicine program (eviCore) above. For fully insured groups and Individual plans, please review the "Physical Medicine" section above.

• Note: For members of Group # 10029722 only, the following procedure codes do not require pre-authorization: 29914, 29915, 29916.

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

• NOTE: For members of Group # 10029722 only, the following procedure codes do not require pre-authorization: 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 #30000101-#30000112, #30000301, #30010403, #30010101-#30010112, #30010401, #30020101-#30020112, #30030101–#30030112, #37000101, #37000201, #37000301, #37000402, #37000501, #38001001, #38002001, #38003001, #38004001 and #38005001 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

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

• NOTE: For members of Group # 10029722 only, the following procedure codes do not require pre-authorization: 21085, 21110, 21120, 21121, 21122, 21123.

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

• We require pre-authorization for these codes for ASO groups that do not participate in the Physical Medicine program (eviCore) above. For fully insured groups and Individual plans, please review the "Physical Medicine" section above.

Spinal Surgery - Cervical Fusion

• 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.
• 22551, 22552, 22554, 22853, 22854, 22859 - MCG ORG S-320
• 22600 - MCG ORG S-330

• We require pre-authorization for these codes for ASO groups that do not participate in the Physical Medicine program (eviCore) above. For fully insured groups and Individual plans, please review the "Physical Medicine" section above.

Spinal Surgery - Lumbar Fusion (PDF)

• 22533, 22853, 22854, 22558, 22859, 22612, 22630, 22633

• We require pre-authorization for these codes for ASO groups that do not participate in the Physical Medicine program (eviCore) above. For fully insured groups and Individual plans, please review the "Physical Medicine" section above.

Spinal Surgery - Percutaneous Vertebroplasty, Kyphoplasty, Sacroplasty, and Coccygeoplasty (PDF)

• 22510, 22511, 22512, 22513, 22514, 22515

• We require pre-authorization for these codes for ASO groups that do not participate in the Physical Medicine program (eviCore) above. For fully insured groups and Individual plans, please review the "Physical Medicine" section above.

Spinal Surgery - Artificial Intervertebral Disc (PDF)

• 22856, 22858
• We require pre-authorization for these codes for ASO groups that do not participate in the Physical Medicine program (eviCore) above. For fully insured groups and Individual plans, please review the "Physical Medicine" section above.

• Reminder: We consider lumbar artificial discs to be investigational, and investigational services are not covered.

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 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

Surgical Treatment for Lymphedema and Lipedema (PDF)

• Codes 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, 15876, 15877, 15878, 15879 require pre-authorization for Lipedema only with diagnosis codes Q82.0, R60.0, R60.9

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

• NOTE: For members of Group # 10029722 only, the following procedure codes do not require pre-authorization: 41120, 42160.

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

Transcatheter Heart Valve Procedures for Mitral or Tricuspid Valve Disorders excluding Transcatheter Edge-to-Edge Repair (TEER) (PDF)

• 0483T, 0484T

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 Botox.

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.

Transplants -  Stem Cell

• Reference our Medical Policy Manual for policies.

• 38205, 38206, 38232, 38240, 38241, 38242, 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 #30000101-#30000112, #30000301, #30010403, #30010101-#30010112, #30010401, #30020101-#30020112, #30030101–#30030112, #37000101, #37000201, #37000301, #37000402, #37000501, #38001001, #38002001, #38003001, #38004001 and #38005001