Commercial pre-authorization

Commercial Pre-authorization List

This Commercial Pre-authorization List includes services and supplies that require pre-authorization or notification for commercial plan products. Pre-authorization requirements on this page apply to our group, Individual, Administrative Services Only (ASO) and joint administration members.

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 the Availity Portal 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).

Medical management program

Authorization

Radiology program

Codes requiring authorization are listed in the Radiology section below. Determine whether your patient's plan participates in this program by using the electronic authorization tool on the Availity Portal. View information about this program (PDF).

Obtain an order number with AIM Specialty Health:

Physical Medicine

Codes requiring authorization are listed in the Physical Medicine section below. Determine whether your patient's plan participates in this program by using the electronic authorization tool on the Availity Portal. View information about this program (PDF).

Obtain or verify an authorization with eviCore healthcare

Sleep Medicine

Codes requiring authorization are listed in the Sleep Medicine section below. Determine whether your patient's plan participates in this program by using the electronic authorization tool on the Availity Portal. View information about this program (PDF).

Obtain an order number with AIM Specialty Health:

Joint administration members

Group #

Pre-authorization form

Fax

Phone

#70000000

1 (877) 955-3548

1 (866) 947-9522

#70000002

1 (855) 836-3884

1 (855) 778-9047

#70000003

(503) 654-8570

(503) 654-9447 or 1 (800) 862-3338

#70000004

1 (877) 955-3548

1 (855) 258-6451

#70000005

(503) 654-8570

(503) 654-9447 or 1 (800) 862-3338

#70000007

1 (877) 955-3548

1 (866) 504-6812

#70000008

1 (855) 540-1980

1 (855) 240-3696

#70000009

1 (866) 748-6573

1 (866) 955-1490

#70000010

1 (866) 748-6574

1 (877) 955-1570

#70000011

1 (877) 955-3548

1 (833) 951-1370

Pre-authorization for out-of-area (BlueCard) members

Members of some group health plans may have terms of coverage or benefits that differ from the information presented here. Refer to the Important Pre-authorization Reminders section for details. To verify coverage or benefits or determine pre-certification or pre-authorization requirements for a particular member, call 1-800-676-BLUE or send an electronic inquiry through your established connection with your local Blue Plan.

Online

  • Use the Electronic Provider Access (EPA) tool available in the Availity Portal. With EPA, you can gain access to an out-of-area member's Home Plan provider portal, through a secure routing mechanism and have access to electronic pre-service review capabilities.
  • Use our online tool to be automatically routed to the home plan's pre-authorization / pre-certification requirements. Launch the tool.

Phone

Call BlueCard Eligibility at 1 (800) 676-BLUE (2583). You will be asked for the member's prefix and the type of service for which you are calling:

  • Medical/surgical
  • Behavioral health
  • Diagnostic imaging/radiology
  • Durable medical equipment (DME)

Upon making your selection, you will be connected to the appropriate Blue Plan.

Electronic inquiry

Submit an ANSI 278 transaction (referral/authorization) to Regence.

Important pre-authorization reminders

  1. Failure to pre-authorize services subject to pre-authorization 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 the Availity Portal 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 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. Pre-authorization requirements are not dependent upon site of service. All CPT and HCPCS codes listed on our pre-authorization lists require pre-authorization. View list below for complete requirements.

Payment implications for failure to pre-authorize services

Failure to secure approval for services subject to pre-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.
  • 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.

Inpatient admissions

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 occurring on or after May 1, 2019. For more information, read our Frequently Asked Questions (PDF).
  • Notification of a hospital 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 is required via electronic medical record, when available. If electronic medical records are not available, notifications are 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.

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 is required via electronic medical record, when available. If electronic medical records are not available, notifications are required via fax. Learn more about this requirement.

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 Regence member. Subject to review.

Durable medical equipment

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)

  • E0760, 20979 - MCG ACG: A-414 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.
  • Effective September 1, 2020: Ultrasonic Bone Growth Stimulators will be reviewed with Regence Medical Policy DME #83.12 (PDF)

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

  • E0784, E0787, 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

Noninvasive Ventilators in the Home Setting (PDF)

  • E0466
  • Note: Due to the COVID-19 pandemic, pre-authorization requirements for noninvasive ventilators will be suspended until August 1, 2020

Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Conditions (PDF)

  • E0481, E0483

Power Wheelchairs: Group 3 (PDF)

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

Powered Knee Prosthesis, Powered Ankle-Foot Prosthesis, Microprocessor-Controlled Ankle-Foot Prosthesis, and Microprocessor-Controlled Knee Prostheses (PDF)

  • L5856, L5857, L5858

Sleep Medicine Program

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

Genetic testing

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

  • 81162, 81163, 81164, 81165, 81166, 81167, 81212, 81215, 81216, 81217, 81307, 81308, 81321, 81322, 81323, 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

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

Preimplantation Genetic Testing of Embryos (PDF) - GT18

  • 89290, 89291, 81228, 81229

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

  • 81170, 81201, 81202, 81203, 81210, 81212, 81215, 81216, 81217, 81218, 81225, 81228, 81229, 81235, 81243, 81244, 81245, 81246, 81250, 81252, 81253, 81254, 81257, 81272, 81273, 81275, 81276, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81302, 81303, 81304, 81310, 81311, 81314, 81317, 81318, 81319, 81321, 81322, 81323, 81327, 81341, 81350, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 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, S3854

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

  • 81243, 81244

Genetic Testing for CADASIL Syndrome (PDF) - GT51

  • 81406

Genetic Testing for α-Thalassemia (PDF) - GT52

  • 81257, 81258, 81259, 81269, 81404

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

  • 81228, 81229, 0156U, S3870

Myeloid Neoplasms and Leukemia (PDF) - GT59

  • 81120, 81121, 81170, 81175, 81176, 81218, 81245, 81246, 81272, 81273, 81310, 81334, 81401, 81402, 81403, 0023U, 0046U, 0049U

PTEN Hamartoma Tumor Syndrome (PDF) - GT63

  • 81321, 81322, 81323

Evaluating the Utility of Genetic Panels (PDF) - GT64

  • 81162, 81163, 81164, 81165, 81166, 81167, 81170, 81175, 81176, 81201, 81202, 81203, 81210, 81212, 81215, 81216, 81217, 81218, 81225, 81228, 81229, 81235, 81243, 81244, 81245, 81246, 81250, 81252, 81253, 81254, 81257, 81272, 81273, 81275, 81276, 81288, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81302, 81303, 81304, 81310, 81311, 81314, 81317, 81318, 81319, 81321, 81322, 81323, 81327, 81341, 81350, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81412, 81432, 81433, 81434, 81437, 81438, 81443, 81450, 81455, 81470, 81471, S3854

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

Genetic Testing for Rett Syndrome (PDF) - GT68

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

Duchenne and Becker Muscular Dystrophy (PDF) - GT69

  • 81161, 81408

Genetic Testing for Predisposition to Inherited Hypertrophic Cardiomyopathy (PDF) - GT72

  • 81403, 81405, 81406, 81407, 81439, S3865, S3866

Fetal RHD 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

  • 81415, 81416

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

  • 81405, 81408

Genetic Testing; Invasive Prenatal Fetal Diagnostic Testing Using Chromosomal Microarray Analysis (CMA) (PDF) - GT78

  • 81228, 81229, 81405

Chromosomal Microarray (CMA) Testing for the Evaluation of Products of Conception and Pregnancy Loss (PDF) - GT79

  • 81228, 81229

Genetic Testing for Epilepsy (PDF) - GT80

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

Reproductive Carrier Screening for Genetic Diseases (PDF) - GT81

  • 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, 81120, 81121, 81162, 81210, 81235, 81275, 81276, 81292, 81295, 81298, 81311, 81314, 81319, 81321, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81445, 81455

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

  • 81405, 81406, 81408

Laboratory

Laboratory and Genetic Testing for use of Thiopurines (PDF)

  • 81306, 81335, 81401, 0034U, 0169U

Medicine

Charged-Particle (Proton) Radiotherapy (PDF)

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

Confocal Laser Endomicroscopy (PDF)

  • 43206, 43252, 88375

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

  • Please see the Inpatient admissions section for further information.

Gait Analysis (PDF)

  • 96000, 96001, 96002, 96003, 96004
  • Gait analysis may be considered medically necessary in children and adolescents with cerebral palsy to select surgical or other therapeutic interventions for gait improvement. All other indications for gait analysis and Paraspinal Surface Electromyography (EMG) (PDF) are considered investigational.

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.
  • 17999, 19303, 19316, 19318, 19324, 19325,19350, 53400, 53405, 53410, 53415, 53420, 53425, 53430, 54125, 54520, 54660, 54690, 55175, 55180, 56625, 56800, 56805, 57106, 57110, 57291, 57292, 57295, 57296, 57335, 57426, 58150, 58180, 58260, 58262,58270, 58275, 58290, 58291, 58353, 58356, 58541, 58542, 58543, 58544, 58550, 58552, 58553, 58554, 58563, 58570, 58571, 58572, 58573, C1813, 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, breast reconstruction, blepharoplasty, brow lift, chin implants, collagen injections, endometrial ablation, panniculectomy, and rhinoplasty. Check for codes in other areas of this pre-authorization list.
  • NOTE: For King County members (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, 15878, 15879, 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.

Hyperbaric Oxygen Therapy (PDF)

  • 99183, G0277

Intensity Modulated Radiotherapy (IMRT)

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

  • 38206, 38232, 38241

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

Surface Electromyography (SEMG) (PDF)

  • 96002, 96004

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

  • 90867, 90868, 90869

In Vivo Analysis of Colorectal Polyps (PDF)

  • 88375

Coverage of Treatments Provided in a Clinical Trial (PDF)

  • S9990, S9991, S9988

Sleep Medicine Program

Physical Medicine

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

Authorization is not required for an initial evaluation and management visit and up to a total of six consecutive treatment visits in a new episode of care for group and Individual members on any of our Washington-issued products for the following Physical Medicine program services:

  • Chiropractic
  • Acupuncture
  • Speech therapy
  • Physical therapy
  • Massage therapy
  • Occupational therapy

This authorization change applies to:

  • 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

It does not apply to the following members:

  • Medicare Advantage
  • Administrative services only
  • BlueCross BlueShield Federal Employee Program® (BCBS FEP®)

eviCore will identify members who have coverage issued in Washington state and who do not require an authorization until after the sixth consecutive treatment visit.

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

Physical therapy, speech therapy, occupational therapy (PT/ST/OT); chiropractic, complementary and alternative medicine

  • View information about this program (PDF).
  • 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, 97124, 97129, 97130, 97139, 97140, 97150, 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 97530, 97542, 97750, 97755, 97760, 97761, 97763, 97799, 97810, 97811, 97813, 97814, 98940, 98941, 98942, 98943, G0151, G0152, G0157, G0158, G0159, G0160, G0283, S8950, S9128, S9129, S9131, S9152

Pain management

  • View information about this program (PDF).
  • 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, 72275, 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 tool on the Availity Portal.
  • We require authorization from eviCore for these codes: 23470, 23472, 23473, 23474, 27125, 27130, 27132, 27134, 27137, 27138, 27416, 27438, 27440, 27441, 27442, 27443, 27445, 27446, 27447, 27486, 27487, 27488, 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

  • 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 tool on the Availity Portal.
  • 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, 63180, 63182, 63185, 63190, 63191, 63194, 63195, 63196, 63197, 63198, 63199, 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

Radiology

Contact Regence for pre-authorization for the following codes:

Computed Tomography to Detect Coronary Artery Calcification (PDF)

  • S8092

AIM Specialty Health

We partner with AIM to administer our radiology program which has two components: Radiology Quality Initiative (RQI) and Advanced Imaging Authorization. Please note, ASO groups who do not participate in the Advanced Imaging component still require an order number through the RQI component. Determine whether your patient's plan participates in this program by using the electronic authorization tool on the Availity Portal.

  • Sign in to AIM's ProviderPortal
  • Phone 1 (877) 291-0509
  • View workarounds for AIM system outages
  • Contact AIM to obtain an order number 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, 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, 78429, 78430, 78431, 78432, 78433, 78451, 78452, 78453, 78454, 78459, 78466, 78468, 78469, 78472, 78473, 78481, 78483, 78491, 78492, 78494, 78608, 78609, 78811, 78812, 78813, 78814, 78815, 78816, 93303, 93304, 93306, 93307, 93308, 93312, 93313, 93314, 93315, 93316, 93317, 93350, 93351, G0297, 0501T, 0502T, 0503T, 0504T

Sleep medicine

We partner with AIM to administer our Sleep Medicine program. Determine whether your patient's plan participates in this program by using the electronic authorization tool on the Availity Portal.

  • Login to AIM's ProviderPortal
  • Phone 1 (877) 291-0509
  • View workarounds for AIM system outages
  • Contact AIM to obtain an order number for the following codes: 95782, 95783, 95800, 95801, 95805, 95806, 95807, 95808, 95810, 95811, E0470, E0471, E0561, E0562, E0601, G0398, G0399, G0400

Specialty medications

CHG Healthcare Services and IEC Group members

Pre-authorization for certain specialty medications is required for CHG Healthcare Services (group #70000004) and IEC Group (group #70000000) members. These members are part of our joint administration partnership with AmeriBen.

Pre-authorizations for CHG healthcare Services and IEC Group 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 CHG Healthcare Services (group #70000004) and IEC Group (group #70000000) members:
HCPCS J0129, J0135, J0178, J0180, J0207, J0221, J0222, J0256, J0257, J0289, J0364, J0490, J0567, J0585, J0586, J0587, J0588, J0596, J0599, J0597, J0598, J0604, J0638, J0640, J0641, J0642, J0717, J0795, J0800, J0850, J0881, J0885, J0894, J0897, J1290, J1300, J1303, J3111, J1322, J1324, J1325, J1428, J1438, J1439, J1442, J1458, J1459, J1460, J1555, J1556, J1557, J1559, J1561, J1566, J1568, J1569, J1572, J1575, J1595, J1602, J1626, J1628, J1645, J1726, J1729, J1743, J1744, J1745, J1746, J1786, J1826, J1830, J1930, J1931, J1950, J2170, J2182, J2323, J2326, J2350, J2353, J2354, J2357, J2430, J2502, J2505, J2507, J2778, J2786, J2788, J2790, J2791, J2792, J2793, J2796, J2840, J2941, J3060, J3110, J3240, J3262, J3285, J3315, J3357, J3380, J3385, J3397, J3485, J3490, J7170, J7179, J7181, J7182, J7183, J7185, J7186, J7187, J7189, J7190, J7192, J7193, J7194, J7195, J7197, J7198, J7200, J7201, J7202, J7205, J7207, J7209, J7210, J7211, J7312, J7321, J7322, J7323, J7324, J7325, J7326, J7327, J7503, J7527, J7639, J7682, J7686, J7699, J8499, J8520, J8521, J8565, J8700, J9000, J9015, J9019, J9025, J9035, J9040, J9041, J9042, J9047, J9050, J9055, J9057, J9065, J9119, J9130, J9150, J9171, J9181, J9185, J9190, J9202, J9210, J9213, J9214, J9215, J9216, J9217, J9225, J9226, J9250, J9262, J9263, J9264, J9265, J9266, J9267, J9269, J9271, J9299, J9303, J9305, J9306, J9312, J9315, J9340, J9351, J9355, J9357, J9370, Q2043, Q2050, Q3028, Q4074, Q5101, Q5103, Q5104, Q5106, Q5108, Q5117, S0090, S0108, S0148, S0190, and S9562; CPT 90371

Effective July 1, 2020, the following medications will require pre-authorization for CHG Healthcare Services (group #70000004) and IEC Group (group #70000000) members: HCPCS J9145, Q5111

Effective September 1, 2020, the following medications will require pre-authorization for CHG Healthcare Services (group #70000004) and IEC Group (group #70000000) members: HCPCS A9508, A9513, A9606, G9033, J0179, J0202, J0517, J0565, J0570, J0584, J0593, J0606, J0775, J0882, J0887, J0888, J1301, J1446, J1447, J1560, J1570, J1599, J1652, J2265, J2278, J2315, J2503, J2504, J2562, J2597, J2724, J2820, J2860, J3145, J3245, J3304, J3396, J3398, J3489, J3590, J7175, J7177, J7178, J7188, J7203, J7208, J7311, J7313, J7316, J7318, J7320, J7328, J7336, J7340, J7401, J7504, J8999, J9022, J9023, J9032, J9033, J9034, J9039, J9043, J9120, J9153, J9155, J9173, J9176, J9178, J9179, J9199, J9203, J9204, J9205, J9206, J9207, J9218, J9228, J9229, J9245, J9261, J9285, J9293, J9295, J9301, J9302, J9307, J9308, J9325, J9330, J9352, J9354, J9356, J9395, J9400, L8605, Q2041, Q2042, Q2049, Q5105, Q5110, Q5113, Q5114, Q5115, Q5116, Q9991, Q9992, S0088, S0137, S0140 and S0182.

Please review the complete list of specialty medications that require pre-authorization for these members:

Alsco Inc. members

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 90371; HCPCS J0129, J0135, J0178, J0180, J0207, J0221, J0222, J0256, J0257, J0289, J0364, J0490, J0567, J0585, J0586, J0587, J0588, J0596, J0597, J0598, J0599, J0604, J0638, J0640, J0641, J0642, J0717, J0795, J0800, J0850, J0881, J0885, J0894, J0897, J1290, J1300, J1303, J1322, J1324, J1325, J1428, J1438, J1439, J1442, J1458, J1459, J1460, J1555, J1556, J1557, J1559, J1561, J1566, J1568, J1569, J1572, J1575, J1595, J1602, J1626, J1628, J1645, J1726, J1729, J1743, J1744, J1745, J1746, J1786, J1826, J1830, J1930, J1931, J1950, J2170, J2182, J2323, J2326, J2350, J2353, J2354, J2357, J2430, J2502, J2505, J2507, J2778, J2786, J2788, J2790, J2791, J2792, J2793, J2796, J2840, J2941, J3060, J3110, J3111, J3240, J3262, J3285, J3315, J3357, J3380, J3385, J3397, J3485, J3490, J7170, J7179, J7181, J7182, J7183, J7185, J7186, J7187, J7189, J7190, J7192, J7193, J7194, J7195, J7197, J7198, J7200, J7201, J7202, J7205, J7207, J7209, J7210, J7211, J7312, J7321, J7322, J7323, J7324, J7325, J7326, J7327, J7503, J7527, J7639, J7682, J7686, J7699, J8499, J8520, J8521, J8565, J8700, J9000, J9015, J9019, J9025, J9035, J9040, J9041, J9042, J9047, J9050, J9055, J9057, J9065, J9119, J9130, J9150, J9171, J9181, J9185, J9190, J9202, J9210, J9213, J9214, J9215, J9216, J9217, J9225, J9226, J9250, J9262, J9263, J9264, J9265, J9266, J9267, J9269, J9271, J9299, J9303, J9305, J9306, J9312, J9315, J9340, J9351, J9355, J9357, J9370, Q2043, Q2050, Q3028, Q4074, Q5101, Q5103, Q5104, Q5106, Q5108, Q5117, S0090, S0108, S0148, S0190, S9562

Effective July 1, 2020, the following medications will require pre-authorization for Alsco Inc. (group #70000002) members: HCPCS J9145, Q5111

Effective September 1, 2020, the following medications will require pre-authorization for Alsco Inc. (group #70000002) members: HCPCS A9508, A9513, A9606, G9033, J0179, J0202, J0517, J0565, J0570, J0584, J0593, J0606, J0775, J0882, J0887, J0888, J1301, J1446, J1447, J1560, J1570, J1599, J1652, J2265, J2278, J2315, J2503, J2504, J2562, J2597, J2724, J2820, J2860, J3145, J3245, J3304, J3396, J3398, J3489, J3590, J7175, J7177, J7178, J7188, J7203, J7208, J7311, J7313, J7316, J7318, J7320, J7328, J7336, J7340, J7401, J7504, J8999, J9022, J9023, J9032, J9033, J9034, J9039, J9043, J9120, J9153, J9155, J9173, J9176, J9178, J9179, J9199, J9203, J9204, J9205, J9206, J9207, J9218, J9228, J9229, J9245, J9261, J9285, J9293, J9295, J9301, J9302, J9307, J9308, J9325, J9330, J9352, J9354, J9356, J9395, J9400, L8605, Q2041, Q2042, Q2049, Q5105, Q5110, Q5113, Q5114, Q5115, Q5116, Q9991, Q9992, S0088, S0137, S0140 and S0182.

View the list of specialty medications that will require pre-authorization for these members:

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

Surgery

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, 19366
  • Notes:

    • Codes 11950, 11951, 11952, 11954, 15769, 15771, 15772, and 19366 require pre-authorization authorization (see other sections of this pre-authorization list) except when used for autologous fat grafting and adipose-derived stem cell enrichment for augmentation or reconstruction of the breast, where it is considered, and will deny as, investigational
    • 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 Ostial Dilation for Treatment of Sinusitis (PDF)

  • 31295, 31296, 31297, 31298

Bariatric surgery (PDF)

  • 43644, 43770, 43771, 43772, 43773, 43774, 43775, 43820, 43846, 43848, 43860, 43886, 43887, 43888

Blepharoplasty and Brow Ptosis Repair (PDF)

  • 15820, 15821, 15822, 15823, 67900, 67901, 67902, 67903, 67904, 67906, 67908, 67909, 67950
  • Effective October 1, 2020: Updating medical policy title to Blepharoplasty, Repair of Blepharoptosis, and Brow Ptosis Repair

Chemical Peels (PDF)

  • 15788, 15789, 15792, 15793, 17360

Cochlear Implant (PDF)

  • 69930, L8614, L8619, L8627, L8628

Cosmetic and Reconstructive Surgery (PDF)

  • 11920, 11921, 11922, 11950, 11951, 11952, 11954, 15769, 15771, 15772, 15773, 15774, 19355, 21244, 21245, 21246, 21248, 21249, 21295, 21296, 41510, 49250, 54360, 69300, G0429, Q2026, Q2028
  • Pre-authorization is required EXCEPT when services are rendered in association with breast reconstruction and nipple/areola reconstruction following mastectomy for breast cancer.
  • Notes:

    • Codes 11950, 11951, 11952, 11954, 15769, 15771, 15772 and 19366 require pre-authorization (see other sections of this pre-authorization list) except when used for autologous fat grafting and adipose-derived stem cell enrichment for augmentation or reconstruction of the breast, where it is considered, and will deny as, investigational
    • 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 Organ, Pulmonary, and Breast Tumors (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

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.

Gastric Electrical Stimulation (PDF)

  • 43647, 43881, 64590, E0765

Gastroesophageal Reflux Surgery (PDF)

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

Hypoglossal Nerve Stimulation (PDF)

  • 64568, 0466T

Hysterectomy Surgery (PDF)

  • 58150, 58152, 58180, 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58290, 58291, 58292, 58293, 58294, 58541, 58542, 58543, 58544, 58550, 58552, 58553, 58554, 58570, 58571, 58572, 58573
  • Pre-authorization is only required for diagnoses related to abnormal uterine bleeding, pelvic pain (including pain related to endometriosis, Essure 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 the specific ICD-10 diagnoses that require pre-authorization.
  • Note: Hysterectomy procedures for the indication of gender dysphoria are subject to the Gender Affirming Interventions for Gender Dysphoria medical policy (PDF)

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

  • 69714, 69710, 69715, 69717, 69718, L8690, L8691, L8692, L8694

Implantable Cardiac Defibrillator (PDF)

  • 33230, 33231, 33240, 33249, 33270, 33271, C1721, C1722, C1882
  • Pre-authorization is required EXCEPT when the member is age 17 or younger

Implantable Peripheral Nerve Stimulation for Chronic Pain of Peripheral Nerve Origin (PDF)

  • 64555, 64575, 64590

Laser Treatment for Port Wine Stains (PDF)

  • 17106, 17107, 17108

Leadless Cardiac Pacemakers (PDF)

  • 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)

  • C9747, 0398T

Microwave Tumor Ablation (PDF)

  • 32998, 50592

Occipital Nerve Stimulation (PDF)

  • 61885, 61886, 64553, 64555, 64568, 64575, 64590, 0466T
  • 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 Vein and Gonadal Vein Embolization, Ablation, and Sclerotherapy (PDF)

  • 37241

Panniculectomy (PDF)

  • 15830

Pectus Excavatum (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

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

  • 11920, 11921, 11950, 11951, 11952, 11954, 15769, 15771, 15772, 19316, 19318, 19324, 19325, 19328, 19330, 19340, 19342, 19350, 19355, 19366, 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.
  • Notes:

    • Codes 11950, 11951, 11952, 11954, 15769, 15771, 15772 and 19366 require pre-authorization (see other sections of this pre-authorization list) except when used for autologous fat grafting and adipose-derived stem cell enrichment for augmentation or reconstruction of the breast, where it is considered, and will deny as, investigational
    • 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

Rhinoplasty (PDF)

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

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

  • 64561, 64581, 64590
  • 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)

  • 27279, 27280

Spinal Cord and Dorsal Root Ganglion Stimulation (PDF)

  • 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 (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

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 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

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, 0466T

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 Hernia Repair (PDF)

  • 15734, 49560, 49565, 49652, 49654, 49656
    • Pre-authorization for 15734 required only with diagnosis code K43.0, K43.1, K43.2 K43.6, K43.7 or K43.9 for component separation technique (CST)
    • Pre-authorization for 49652 required only with diagnosis code K43.9 for ventral hernia

Transplants and ventricular assist devices

Transplants - 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 - Isolated Small Bowel Transplant (PDF)

  • 44135, 44136

Transplants - 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

Utilization management

Air Ambulance Transport (PDF)

  • A0435, A0430, S9960
  • Pre-authorization is required prior to elective fixed wing air ambulance transport.
  • Emergency air ambulance transports will be reviewed retrospectively for medical necessity; clinical documentation will be requested, if needed, upon receipt of the electronic claim.