Services, Durable Medical Equipment (DME) and Prostheses requiring Prior Authorization

Effective 2/1/2020, Blue KC will no longer be accepting pre-determination requests from our providers however, providers may continue submitting pre-determination requests for Federal Employee Program (FEP) and Joint Administrative Account (JAA) lines of business. You can access the e-forms for these pre-determination requests here: Click Here

Prior Authorization

Prior Authorization General Request for Elective Surgery, Procedure, Service or DME

The following Services, Durable Medical Equipment (DME) and Prostheses or the rental of such equipment require prior authorization:

All scheduled medical and surgical admissions

Augmentation Mammaplasty
19324, 19325

Autologous Chondrocyte Implantation
29866, 29867

Bariatric Surgery
43644, 43770, 43771, 43772, 43773, 43774, 43775, 43843, 43845, 43846

Blepharoplasty
15820, 15821, 15822, 15823, 67900, 67901, 67902, 67903, 67904, 67906, 67908, 67909

Bone Growth Stimulation
20974, 20975, 20979, E0747, E0748, E0749, E0760

Chiropractic services performed by an out-of-network provider

Cochlear Device
69930, L8614, L8619

Deep Brain Stimulation
61863, 61864, 61867, 61868, 61885, 61886

Dental Implants, Bone Grafts/Reconstruction, Orthognathic Surgery
21050, 21060, 21070, 21120, 21121, 21122, 21123, 21125, 21127, 21141, 21142, 21143, 21145, 21146, 21147, 21150, 21151, 21154, 21155, 21188, 21193, 21194, 21195, 21196, 21198, 21199, 21206, 21207, 21208, 21209, 21210, 21215, 21240, 21241, 21242, 21243, 21244, 21245, 21246, 21247, 21248, 21249, 29804, D7940, D7941, D7943, D7944, D7945, D7946, D7947, D7948, D7949, D7950, D7995, D7996

Elective Pre-Operative Observation Status

Exceeding OT/PT/ST Benefit Limits for Developmental and Physical Disorders

External Defibrillator
K0606

Facet Joint Denervation
64633, 64634, 64635, 64636

Hypoglossal Nerve Stimulation
64568, 0466T, 0467T, 0468T

Molecular and Genetic Testing (Download Request Form from Blue KC Review Partner)*

*This change will be taking place effective 1/1/2020 upon employer group renewals. Please verify member’s employer group renewal date with Customer Service. To use Avalon’s Prior Authorization system, you require a user account to Avalon's Provider Portal. To request a new user account, email your lab's name, user name(s), email address, office phone number, supervisor's name and email address to Avalon-PAS-Help@avalonhcs.com. For questions or general assistance call 844-227-5769, or fax requests to 813-751-3760.

81120, 81121, 81161, 81162, 81163, 81164, 81165, 81166, 81167, 81170, 81171, 81172, 81173, 81175, 81176, 81177, 81178, 81179, 81180, 81181, 81182, 81183, 81184, 81185, 81187, 81188, 81189, 81200, 81201, 81202, 81203, 81204, 81205, 81206, 81207, 81208, 81209, 81210, 81212, 81215, 81216, 81217, 81218, 81219, 81222, 81223, 81224, 81225, 81226, 81227, 81228, 81229, 81230, 81231, 81232, 81233, 81234, 81235, 81236, 81237, 81238,81239, 81240, 81241, 81242, 81243, 81244, 81245, 81246, 81247, 81249, 81250, 81251, 81252, 81254, 81255, 81256, 81257, 81259, 81260, 81265, 81266, 81269, 81270, 81271, 81272, 81273, 81274, 81275, 81276, 81277, 81283, 81284, 81285, 81286, 81287, 81288, 81290, 81291, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81301, 81302, 81304, 81305, 81306, 81307, 81308, 81309, 81310, 81311, 81312, 81313, 81314, 81315, 81316, 81317, 81318, 81319, 81320, 81321, 81322, 81323, 81324, 81325, 81328, 81329, 81330, 81331, 81332, 81333, 81334, 81335, 81336, 81343, 81344, 81345, 81346, 81350, 81355, 81361, 81363, 81364, 81381, 81400, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81410, 81411, 81412, 81413, 81414, 81415, 81416, 81417, 81425, 81426, 81427, 81430, 81431, 81432, 81433, 81434, 81435, 81436, 81437, 81438, 81439, 81440, 81442, 81443, 81445, 81448, 81450, 81455, 81460, 81465, 81470, 81471, 81479, 81500, 81503, 81504, 81518, 81519, 81520, 81521, 81522, 81525, 81538, 81539, 81540, 81542, 81545, 81551, 81552, 81595, 81599, 84999, 86849, 87901, 87903, 87904, 87906, 87999, 88240, 88241, 88245, 88248, 88249, 88261, 88262, 88263, 88264, 88267, 88269, 88271, 88272, 88273, 88274, 88275, 88280, 88283, 88285, 88289, 88291, 88363, 89240, S3800, S3840, S3841, S3842, S3844, S3845, S3846, S3849, S3850, S3853, S3854, S3861, S3865, S3866, 0002M, 0003M, 0003U, 0005U, 0010U, 0012U, 0013U, 0014U, 0016U, 0017U 0018U, 0021U, 0022U, 0023U, 0026U, 0027U, 0029U, 0030U, 0031U, 0032U, 0033U, 0034U, 0036U, 0037U, 0040U, 0045U, 0046U, 0047U, 0048U, 0049U, 0050U, 0053U, 0055U, 0056U, 0067U, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076U, 0087U, 0089U, 0090U, 0092U, 0094U, 0101U, 0102U, 0103U, 0111U, 0113U, 0118U, 0129U, 0133U, 0136U

The following genetic CPT codes will require review through Blue KC prior to group renewal dates in 2020.

Genetic Testing for Breast Cancer
81162, 81163, 81164, 81165, 81166, 81167, 81212, 81215, 81216, 81217

Genetic Testing for Colon Cancer
81201, 81202, 81203, 81210, 81288, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81301, 81317, 81318, 81319

Intensity Modulated Radiation Therapy (IMRT)
77301, 77338, 77385, 77386, G6015, G6016

Infusion Pumps, Implantable
E0782, E0783, E0785, E0786

Insulin Pump, External Ambulatory
E0784, A9274

Lumbar Fusion Surgery ** (Download Request Form from Blue KC review partner): Effective 1/1/20, Blue KC will prior authorize the listed lumbar fusion surgery in place of eviCore. Please place any prior authorization request here.

0195T, 0196T, 22533, 22534, 22558, 22853, 22854, 22858, 22612, 22614, 22630, 22632, 22633, 22634, 22800, 22802, 22804, 22808, 22810, 22812, 22859, 22867, 22868, 22869, 22870, 62380

** Procedure level authorization does not apply to members in the following plan types: Missouri Health Insurance Pool or Employer/Labor Union Funded Health Plans (also known as ASO or JAA). All inpatient hospital admissions require prior authorization.

Mastectomy for Gynecomastia
19300

Myo-Electric Prostheses
L5856, L5857, L5858, L5859, L5961, L6026, L6205, L6715, L6880, L6925, L6935, L6945, L6955, L6965, L6975, L7007, L7008, L7009, L7040, L7045, L7170, L7180, L7185, L7186, L7190, L7191, L7259

Optune
E0766, A4555

Organ and Tissue Transplants (excluding cornea transplants)

Out of network services for HMO members

Osteochondral Allografts
27412, 27415, 27416, 28446, 29866, 29867

Phrenic Nerve Stimulation
64585, 64590, 64595, L8679, L8680, L8681, L8683, L8685, L8686, L8687, L8688, L8689, L8695

Radiology Services ( Download Request Form from Blue KC review partner)
High Tech Radiology which include MRI, MRA, Nuclear Medicine, Cardiac Nuclear Medicine, CT, CTA, Echocardiogram, Stress Echocardiogram, and PET scans **

0042T, 0439T, 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, 73221, 73222, 73223, 73225 73700, 73701, 73702, 73706, 73718, 73719, 73720, 73721, 73722, 73723, 73725, 74150, 74160, 74170, 74174, 74175, 74176, 74177, 74178, 74181, 74182, 74183, 74185, 74261, 74262, 74263, 74712, 74713, 75557, 75559, 75561, 75563, 75565, 75572, 75573, 75574, 75635, 76376, 76377, 76380, 76391, 76497, 76498, 77021, 77022, 77046, 77047, 77048, 77049, 77078, 77084, 78431, 78434, 78451, 78452, 78453, 78454, 78466, 78468, 78469, 78472, 78473, 78481, 78483, 78491, 78492, 78494, 78496, 78499, 78608, 78609, 78811, 78812, 78813, 78814, 78815, 78816, 78999, 93303, 93304, 93306, 93307, 93308, 93312, 93313, 93314, 93315, 93316, 93317, 93350, 93351, 93352, 93356, C8900, C8901, C8902, C8903, C8904, C8905, C8906, C8907, C8908, C8909, C8910, C8911, C8912, C8913, C8914, C8918, C8919, C8920, C8921, C8922, C8923, C8924, C8925, C8926, C8928, C8929, C8930, G0235, G0252, G0297, S8035, S8037, S8042, S8092

** Members in groups not delegated to eviCore may require prior authorization for the following services:

  • MRI of the Breast
    77046, 77047, 77048, 77049, C8903, C8904, C8905, C8906, C8907, C8908
  • MRI ordered by a chiropractor
  • PET Scans
    78459, 78491, 78492, 78608, 78609, 78811, 78812, 78813, 78814, 78815, 78816, G0235, G0252

Radiopharmaceutical
C9031, A9513

Reduction Mammaplasty
19318

Rhinoplasty
30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462

Sacral Nerve Neuromodulation
64561, 64581, 64585, 64590, A4290, E0745

Scleral Lens
S0515, V2627, V2531

Sleep Study
95810, 95811, 95805

Spinal Cord Stimulation
20974, 20975, 63650, E0748, E0749

Speech Generating Device
E2351, E2500, E2502, E2504, E2506, E2508, E2510, E2511, E2512, E2599

Stereotactic Radiosurgery
61796, 61797, 61798, 61799, 61800, 63620, 63621, 77371, 77372, 77373,G0339, G0340

Surgical Treatment for Gender Dysphoria
55970, 55980

Vagus Nerve Stimulation
61885, 61886, 64553, 64568, 64569, 64570

Ventricular Assist Device
0048T, 0049T, 0050T, 33975, 33976

Wheelchairs (Power, Specially Sized or Constructed, Custom) or Power Operated Vehicle
E0983, E0984, E0986, E1220, E1230, E1239, K0010, K0011, K0012, K0013, K0014, K0800, K0801, K0802, K0806, K0807, K0808, K0812, K0813, K0814, K0815, K0816, K0820, K0821, K0822, K0823, K0824, K0825, K0826, K0827, K0828, K0829, K0830, K0831, K0835, K0836, K0837, K0838, K0839, K0840, K0841, K0842, K0843, K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855, K0856, K0857, K0858, K0859, K0860, K0861, K0862, K0863, K0864, K0868, K0869, K0870, K0871, K0877, K0878, K0879, K0880, K0884, K0885, K0886, K0890, K0891, K0898, K0899

To submit a prior authorization request you may fax or mail your request.

For the most timely response, fax the request to 816-926-4253. Requests may also be mailed to:

Blue Cross and Blue Shield of Kansas City
Attention: Prior Authorization, Mail Stop B5A1
P.O. Box 411878
Kansas City, MO 64141-1878

Please include any supporting medical information in your fax. Please allow at least 36 hours (to include one business day) from the date of receipt of all necessary information for a prior auth determination. To check the status of a prior authorization, call the Customer Service number listed on the member ID card.

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