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

View pre-authorization requirements for members of other Regence plans:

How to submit a pre-authorization request or notification

Expedited requests

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

  • Availity Portal: Read the information carefully to ensure your request meets the qualifications, then check the box on the form to attest that it is an expedited request
  • Via fax using the appropriate pre-authorization request form below

Online

Group, Individual and ASO members:

Phone or fax

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 pre-authorization request.

This applies to pre-authorizations for our group and Individual, Uniform Medical Plan (UMP) and Blue Cross and Blue Shield Federal Employee Program® (BCBS FEP®) members. It does not currently include Medicare Advantage pre-authorizations. View the services that may receive automated approval (PDF).

Joint administration members
Group # Pre-authorization form Fax Phone
#70000000 AmeriBen precertification request form 1 (877) 955-3548 1 (866) 947-9522
#70000002 AmeriBen precertification request form 1 (855) 836-3884 1 (855) 778-9047
#70000003 Innovative Care Management pre-authorization form (503) 654-8570 (503) 654-9447 or 1 (800) 862-3338
#70000004 AmeriBen precertification request form 1 (877) 955-3548 1 (855) 258-6451
#70000005 Innovative Care Management pre-authorization form (503) 654-8570 (503) 654-9447 or 1 (800) 862-3338
#70000007 AmeriBen precertification request form 1 (877) 955-3548 1 (866) 504-6812
#70000008 AmeriBen precertification request form 1 (855) 540-1980 1 (855) 240-3696
#70000009 AmeriBen precertification request form 1 (866) 748-6573 1 (866) 955-1490
#70000010 AmeriBen precertification request form 1 (866) 748-6574 1 (877) 955-1570

 

Pre-authorization requests

Type of service or request Online Phone Fax (only if unable to submit online). View facility concurrent review fax numbers (PDF)
Skilled nursing facility only Submit an electronic pre-authorization request through the Availity Portal 1 (844) 600-4376 Commercial and ASO:
1 (855) 848-8220
Long term acute care and inpatient rehabilitation 1 (800) 423-6884 Commercial and ASO:
1 (855) 848-8220
Chemical dependency and mental health 1 (800) 780-7881 Commercial and ASO:
1 (888) 496-1540
Transplants 1 (800) 423-6884 Commercial: 1 (800) 584-0689
ASO: 1 (844) 679-7764
Professional services and DME 1 (800) 423-6884 Commercial: 1 (855) 232-0085
ASO: 1 (844) 679-7763
Expedited requests 1 (800) 423-6884 Commercial: 1 (855) 240-6498
ASO: 1 (844) 679-7764

Radiology program

Codes requiring authorization are listed in the Radiology section below. View a list of groups and products that participate in this program (PDF).

Obtain an order number with AIM Specialty HealthSM:

Physical Medicine

Codes requiring authorization are listed in the Physical Medicine section below. View a list of groups and products that participate in this program (PDF).

Sleep Medicine

Codes requiring authorization are listed in the Sleep Medicine section below. View a list of groups and products that participate in this program (PDF).

Inpatient concurrent review

Type of service/request Phone Fax

Notifications for:

  • Inpatient admissions
  • Inpatient discharges
1 (800) 423-6884 1 (800) 453-4341

Clinical records for:

  • Skilled nursing
  • Long term acute care
  • Inpatient rehabilitation
1 (800) 423-6884 1 (844) 629-4404

 

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.

Pre-authorization review timeframes

Type of review Timeframe Additional time allowed for review if additional information is needed:
Urgent Fully insured, City & County Services: 2 business days or 72 hours, whichever occurs first

ASO groups: (excluding City & County Services): 72 hours
Must notify within 24 hours what additional information is needed. Must give no less than 48 hours to provide. Decision is due within 48 hours of receipt of the additional information.

ASO groups: 48 hours
Standard initial  Fully insured, City & County Services: 2 business days

ASO groups (excluding City & County Services): 15 calendar days
None

ASO groups: 15 calendar days
Concurrent 24 hours Must notify within 24 hours what additional information is needed. Must give no less than 48 hours to provide. Decision is due within 48 hours of receipt of the additional information

Note that additional timeframes are after receipt of the documentation or the timeframe for submission of the requested information has expired - whichever comes first.

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 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/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.

Pre-authorization exception

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

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

Use PreManage for notification

We receive admissions and discharge information through PreManage.

Inpatient admissions

See below for chemical dependency and mental health admissions

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 for 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. Learn more about this requirement. If your facility submits electronic admission and discharge data to Collective Medical Technologies, we will receive it through PreManage/EDIE.

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. If your facility submits electronic admission and discharge data to Collective Medical Technologies, we will receive it through PreManage/EDIE.

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)

  • Regence requires the facility to specifically notify Regence when ECMO is initiated on a Regence member. Subject to review.

 

Chemical dependency and mental health

Pre-authorization is required for the services listed below. Emergency inpatient services do not require pre-authorization, but are subject to admission notification requirements.

  • Inpatient: Psychiatric or ASAM 4.0 Detoxification 
    • Notification of admission must be received within 24 hours of admission or the next business day (whichever comes first). Medical necessity review will be conducted.
  • Sub-Acute Detoxification/ASAM Level 3.7
    • Requires pre-authorization before the member is admitted for services. Under certain circumstances, pre-authorization requests can be made within 24 hours of admission or the next business day.
  • Residential treatment: Psychiatric or ASAM Level 3.5 for Substance Use Disorders 
    • Requires pre-authorization before the member is admitted for services. Under certain circumstances, pre-authorization requests can be made within 24 hours of admission or the next business day.
  • Partial hospitalization: Psychiatric or ASAM level 2.5 for Substance Use Disorders
    • Request for authorization is required no later than the day of admission.
  • Intensive outpatient: Psychiatric or ASAM level 2.1 for Substance Use Disorders
    • Request for authorization is required no later than the day of admission.
Medical necessity for behavioral health services is determined by:

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

Applied Behavior Analysis (ABA) Therapy

  • Procedure codes 0362T, 0373T, 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158
  • Procedure codes 97151, 97152, and 0362T: Pre-authorization is not required when 97151, 97152, and 0362T are used for initial ABA assessments, but pre-authorization is required when 97151, 97152, and 0362T are used for ABA reassessments.

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

  • Psychiatrist
  • Neurologist
  • Pediatric Neurologist
  • Developmental Pediatrician
  • Doctorate level psychologist
  • Advanced registered nurse practitioner

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

Allied health

Dental and orthodontic services for the treatment of craniofacial anomalies (PDF)

  • D5999, D7999, D8999
  • Note: This policy applies only to member contracts that are subject to H.B. 4128, a new section of the Oregon Insurance Code

 

Dialysis treatment

Dialysis treatment – applies to members of group #70000000, #70000002, #70000004, #70000007 and #70000008 only

90935, 90937, 90945, 90947, 90951, 90952, 90953, 90954, 90955, 90956, 90957, 90989, 90993, G0308

Submit pre-notification, for members of these employer groups, to AmeriBen via:

 

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)

Bone Growth Stimulators, Ultrasonic

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.
Insulin Infusion Pumps and Artificial Pancreas Device System (APDS) (PDF)
  • Effective November 1, 2019: E0784

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)
  • Effective November 1, 2019: E0466

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

  • E0481, E0483
Power Wheelchairs: Group 3 (PDF)
  • Effective November 1, 2019: 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
Programmable Pneumatic Compression Pumps (PDF)
  • E0652
Tumor Treating Fields Therapy (PDF)
  • E0766

View Sleep Medicine Management Program for other authorization requirements through AIM

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

 

Genetic testing

Genetic Testing for Alzheimer's Disease (PDF) GT01 81401, 81405, 81406
Genetic Testing for Hereditary Breast and/or Ovarian Cancer and Li-Fraumeni Syndrome (PDF) GT02 81162, 81163, 81164, 81165, 81166, 81167, 81212, 81215, 81216, 81217, 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 Cardiac Ion Channelopathies (PDF) GT07

81413, 81414

S3861

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
KRAS, NRAS and BRAF Variant Analysis and MicroRNA Expression Testing for Colorectal Cancer (PDF) GT13 81210, 81275, 81276, 81311, 81403, 81404
Preimplantation Genetic Testing of Embryos (PDF) GT18 89290, 89291
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, 81256, 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, 81413, 81470, 81471

S3800, S3840, S3844, S3845, S3846, S3849, S3850, S3853, S3861, S3865, S3866

Biallelic RPE65 Variant-Associated Retinal Dystrophy (PDF) GT21 81406
Gene Expression Profiling for Melanoma (PDF) GT29 0081U
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

S3854

Genetic Testing for FMR1 and AFF2 Variants (Including Fragile X and Fragile XE Syndromes) (PDF) GT43 81243, 81244
Genetic Testing for Hereditary Hemochromatosis (PDF) GT48 81256
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) for the Genetic Evaluation of Patients with Developmental Delay, Intellectual Disability, Autism Spectrum Disorder or Congenital Anomalies (PDF) GT58

81228, 81229

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, 81256, 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, 81413, 81432, 81433, 81434, 81437, 81438, 81443, 81450, 81455, 81470, 81471

S3854

Methionine Metabolism Enzymes, including MTHFR, for Indications Other than Thrombophilia (PDF) GT65 81401, 81403, 81404, 81405, 81406
Diagnosis of Inherited Peripheral Neuropathies (PDF) GT66 81403, 81404, 81405, 81406
Genetic Testing: Rett Syndrome (PDF) GT68 81302, 81303, 81304, 81404, 81405, 81406
Duchenne and Becker Muscular Dystrophy (PDF) GT69 81161, 81408
Genetic Testing: Predisposition to Inherited Hypertrophic Cardiomyopathy (PDF) GT72

81403, 81405, 81406, 81407, 81439

S3865, S3866

Genetic Testing; Fetal RHD Genotyping Using Maternal Plasma (PDF)

GT74 81403

Genetic Testing; Genetic Testing for Macular Degeneration (PDF)

GT75 81401, 81405, 81408
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

 

Laboratory

Laboratory and Genetic Testing for use of Thiopurines (PDF)

  • 81306, 81335, 81401, 0034U

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.

Hyperbaric Oxygen Therapy (HBOT) (PDF)

  • 99183
  • G0277

Intensity Modulated Radiotherapy (IMRT)

Submit the IMRT Dose-Volume Summary Analysis form (PDF) when requesting pre-authorization for these services.

  • 77301, 77338, 77385, 77386
  • G6015, G6016

Please reference the following Medical Policies for further information:

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)

  • 37243, 79445
  • S2095

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

Surface Electromyography (SEMG) (PDF)
  • 96002, 96004
Transcranial Magnetic Stimulation as a Treatment of Depression and Other Disorders (PDF)
  • 90867, 90868, 90869
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, 19304, 19316, 19318, 19324, 19325,19350, 53400, 53405, 53410, 53415, 53420, 53425, 53430, 54125, 54520, 54660, 54690, 55175, 55180, 56625, 56800, 56805, 57106, 57110, 57335, 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 code17999 to request laser hair removal.
  • Effective October 1, 2019: 57291, 57292, 57295, 57296, 57426
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. 

In Vivo Analysis of Colorectal Polyps

  • 88375

Coverage of Treatments Provided in a Clinical Trial (PDF)

  • S9990, S9991, S9988

View Sleep Medicine Management Program for notification or authorization requirements

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

 

Pharmacy

View pharmacy pre-authorization requirements.

Intra-articular Hyaluronic Acid Derivatives (PDF) All intra-articular hyaluronic acid derivatives require pre-authorization; however, they are generally considered investigational or not medically necessary. Intra-articular hyaluronic acid derivatives include, but are not limited to, the following codes: J7321, J7323, J7324, J7325, J7326, J7327, J7328, Q9980.

A member consent form must be signed by our member indicating that he or she understands the specific services and/or supplies may be considered investigational, not medically necessary or non-covered and will result in financial liability to him or her.

 

Physical Medicine

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

Effective June 7, 2018, 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

Note: A "new episode of care" means treatment for a new or recurrent condition for which the patient has not been treated by the provider group within the previous ninety days and is not currently undergoing any active treatment.

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 and Garfield County, Washington products

It does not apply to the following members:

  • Medicare Advantage
  • Administrative services only (please view our Program participation list for additional information)
  • Uniform Medical Plan (UMP)
  • 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. Verify member benefits and eligibility on the Availity Portal
  2. Review this entire page for similar services that require pre-authorization
  3. Determine whether a member participates in this program (PDF)
  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

We require authorization from eviCore for these codes. View a list of groups and products that participate in this program (PDF).

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

92507, 92508, 92521, 92522, 92523, 92524, 92526, 92597, 92607, 92608, 92609, 92610, 92626, 92627, 92630, 92633, 95831, 95832, 95833, 95834, 95851, 95852, 96105, 97012, 97014, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036, 97039, 97110, 97112, 97113, 97116, 97124, 97127, 97139, 97140, 97150, 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 97530, 97533, 97542, 97750, 97755, 97760, 97761, 97763, 97799, 97810, 97811, 97813, 97814, 98940, 98941, 98942, 98943, G0151, G0152, G0515, G0157, G0158, G0159, G0160, G0283, S8950, S9128, S9129, S9131, S9152

Pain management

We require authorization from eviCore for these codes. View a list of groups and products that participate in this program (PDF).

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

We require authorization from eviCore for these codes. 

Note: Some ASO groups may require authorization through either 1) our Physical Medicine program administered by eviCore, or 2) our Surgery authorization program. Follow these steps to determine which program an ASO member participates in:

  1. Review Physical Medicine program (eviCore) requirements: View a list of groups and products that participate in this program (PDF). Currently, only a few ASO groups participate in the Joint management component. If the ASO group does not participate, go to step 2.
  2. Review our Surgery authorization requirements: If an ASO group does not participate in the Physical Medicine program, review the Surgery section below for other pre-authorization requirements.

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

We require authorization from eviCore for these codes. 

Note: Some ASO groups may require authorization through either 1) our Physical Medicine program administered by eviCore, or 2) our Surgery authorization program. Follow these steps to determine which program an ASO member participates in:

  1. Review Physical Medicine program (eviCore) requirements: View a list of groups and products that participate in this program (PDF). Currently, only a few ASO groups participate in the Spine component. If the ASO group does not participate, go to step 2.
  2. Review our Surgery authorization requirements: If an ASO group does not participate in the Physical Medicine program, review the Surgery section below for other pre-authorization requirements.

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
Dopamine Transporter Imaging Single-Photon Emission Computed Tomography (DAT-SPECT) (PDF)
  • A9584, 78607

Single Photon Emission Computed Tomography (SPECT) of the Brain (PDF)

  • 78607

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. View a list of groups and products that participate in this program (PDF).

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, 77046, 77047, 77048, 77049, 77078, 77084, 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. View a list of groups and products that participate in this program (PDF).

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 (group #70000004) and IEC Group (group #70000000) members - Pre-authorization for certain specialty medications is required. These members are part of our joint administration partnership with AmeriBen. Pre-authorizations for CHG HEALTHCARE SERVICES AND IEC GROUP MEMBERS ONLY should be submitted to VIVIO Health Help Desk at *1 (800) 470-4034. Note: This phone number should only be used for pre-authorizing specialty medications for these members.

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

Specialty medications for CHG Healthcare Services (group #70000004) and IEC Group (group #70000000) members

The following medications require pre-authorization: C9015, C9029, J0129, J0135, J0180, J0207, J0221, J0256, J0257, J0364, J0490, J0585, J0587, J0588, J0596, J0597, J0598, J0604, J0638, J0641, J0717, J0795,J0800, J0850, J0881, J0885, J0886, J0894, J0897, J1290, J1300, J1322, J1324, J1325, J1438, J1439, J1440, J1441,  J1453, J1458, J1459, J1460, J1555, J1556, J1557, J1559, J1561, J1566, J1568, J1569,  J1572, J1575, J1585, J1595, J1599, J1602, J1645, J1726, J1729, J1743, J1744, J1745, J1786, J1826, J1830, J1930, J1931, J1950, J2170, J2182, J2323, J2350, J2353, J2354, J2357, J2430, J2505, J2507, J2778, J2786, J2788, J2790, J2791, J2792, J2793, J2796, J2840, J2941, J3060, J3110, J3240, J3262, J3285, J3315, J3355, J3357, J3380, J3485, J5106, J7179, J7180, J7181, J7182, J7183, J7185, J7186, J7187, J7189, J7190, J7192, J7193, J7194, J7195, J7197, J7198, J7200, J7201, J7202, J7205, J7207, J7209, J7210, J7211, J7325, J7515, J7516,  J7639, J7682, J7686, J7687, J7688, J7679, J7799, J8521, J8565, J9020, J9025, J9035, J9040, J9041, J9047, J9050, J9055, J9065, J9130, J9150, J9171, J9185, J9202, J9213, J9214, J9215, J9216, J9217, J9225, J9226, J9250, J9262, J9263, J9264, J9265, J9266, J9267, J9299, J9305, J9310, J9318, J9328, J9340, J9351, J9355, J9357, Q2050, Q3026, Q3028, Q4074, Q5102, Q5104, Q5108, Q9995, S0090, S0148 and S9562

Please review the complete list of specialty medications that require pre-authorization (PDF) for these members because some of the medications do not have J codes and are therefore not listed above.

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)
  • 19366

Notes:

  • Codes 11950, 11951, 11952, 11954, 19366, 19380, 19499, and 20926 are considered investigational when used for autologous fat grafting and adipose-derived stem cell enrichment for augmentation or reconstruction of the breast and will deny as investigational. 
  • Codes 11950, 11951, 11952, 11954, and 19366 require pre-authorization for other services on this pre-authorization list.
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, 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
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, 19355, 21244, 21245, 21246, 21248, 21249, 21295, 21296, 41510, 49250, 54360, 69300
  • G0429, Q2026, Q2028

Codes 11950, 11951, 11952, 11954 are considered investigational when used for autologous fat grafting and adipose-derived stem cell enrichment for augmentation or reconstruction of the breast and will deny as investigational. Please see the Adipose-derived Stem Cell Enrichment in Autologous Fat Grafting to the Breast section.

Pre-authorization is required EXCEPT when services are rendered in association with breast reconstruction and nipple/areola reconstruction following mastectomy for breast cancer.

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 / 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

Visit MCG's website for information on purchasing their criteria, or contact us at the phone number(s) above and we will be happy to provide you with a copy of the specific guideline.

Pre-authorization is required for:

  • MCG S-650: 58150, 58152, 58180
  • MCG S-660: 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58290, 58291, 58292, 58293, 58294
  • MCG S-665: 58541, 58542, 58543, 58544, 58550, 58552, 58553, 58554,58570, 58571, 58572, 58573

Pre-authorization is NOT required for: Hysterectomy surgery associated with the following ICD-10 diagnoses:

  • Cancer: C53.0-C53.9, C54.0-C54.3, C54.8-C54.9, C55, C56.1-C56.9, C57.00-C57.8, C58, C79.60-C79.62, C79.82, D06.0-D06.9, D49.59
  • Uterovaginal or cervical stump prolapse: N81.2-N81.4, N81.85

Note: Hysterectomy procedures for the indication of gender dysphoria are subject to the Transgender Services 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
Magnetic Resonance (MR) Guided Focused Ultrasound (MRgFUS) and High Intensity Focused Ultrasound (HIFU) Ablation (PDF)
  • C9747, 0398T

Microwave Tumor Ablation

  • 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, 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.

11950, 11951, 11952, 11954, 19366, 19380, 20926 are considered investigational when used for autologous fat grafting and adipose-derived stem cell enrichment for augmentation or reconstruction of the breast and will deny as investigational.  Please see the Adipose-derived Stem Cell Enrichment in Autologous Fat Grafting to the Breast section.

Reduction Mammoplasty (PDF)
  • 19318
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 preauthorization 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
  • 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
  • 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
Surgical Treatments for Hyperhidrosis (PDF)
  • 32664, 64818, 69676
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)
  • 49560, 49565, 49654, 49656
  • Effective September 1, 2019: 15734, 49652

Notes:

  • Pre-authorization for 15734 required only with diagnosis code K43.2 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
  • 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; please submit clinical documentation and rationale for this form of transportation with your claim.