Blue KC Commercial Prior Authorization and Notification List

Member IDs that begin with prefix RKC, RKQ, RRK, RRN, RKN, or RUK are for our Medicare Advantage network. YBD, YBG, YBS, YBM, YBT, YBX, YJV, YJW, YJJ, or YJT are for our Affordable Care Act network.

To access Prior Authorization forms for MA/ACA members use Prior Authorizations Forms.

For Federal Employee Program (FEP) members, please refer to the appropriate service brochures for services that require Prior Approval (https://www.fepblue.org/plan-brochures) OR call the customer service phone number on the back of the member’s ID card. Effective 2/1/2020, Blue KC discontinued accepting pre-determination requests. 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.

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

The following services require Prior Authorization (or notification):

  • All scheduled elective surgical admissions
  • All medical admissions
    • Acute Inpatient (hospital) admissions
    • Acute Rehab facilities
    • Inpatient Hospice
    • Long-term care facilities (LTAC & SNF)
  • All Clinical Trials
  • All items and services from out-of-network providers require prior authorization.
  • All Organ and Tissue Transplants (excluding corneal transplants)
  • Chiropractic services performed by an out-of-network provider
  • Exceeding OT/PT/ST Benefit Limits for Developmental and Physical Disorders
  • The following codes J3490, J3590, and C9399 are unlisted and do not require PA for all drugs associated with them; however, the following drugs that are listed under one of these codes do require PA:

    J3490/C9399 — Nulibry (fosdenopterin)
    J3590/C9399 — Zynteglo (betibeglogene autotemcel)

    If you have any questions or need help submitting a prior authorization, please call 816-395-3989 for assistance.

Additionally, the following services require Prior Authorization regardless of place of service or level of care:

Service Category Description Codes
Allografts & Bone Substitutes Osteochondral Allografts & Autologous Chondrocyte Implantation 27412, 27415, 27416, 28446, 29866, 29867
Bone Substitutes & Related Items C9359
Gastric Restrictive (Bariatric) Surgery Gastric Restrictive (Bariatric) Procedures 43644, 43770, 43771, 43772, 43773, 43774, 43775, 43843, 43845, 43846
Behavioral Health 90870, 96116, 96146
Blepharoplasty & Ptosis Repair Blepharoplasty 15820, 15821, 15822, 15823, 67900, 67901, 67902, 67903, 67904, 67906, 67908, 67909, 67914, 67915, 67916, 67917, 67921, 67922, 67923, 67924, 67950
Breast Surgery Augmentation Mammoplasty 19325
Mastectomy for Gynecomastia 19300
Reduction Mammaplasty 19318
Related Procedures to Other Breast Surgeries or Procedures 19303, 19307, 19316, 19328, 19330, 19340, 19357, 19361, 19364, 19367, 19368, 19369, 19380
Bone Growth Stimulators Bone Growth Stimulators 20974, 20975, 20979, E0747, E0748, E0749, E0760
Cancer Care Intensity Modulated Radiation Therapy (IMRT) 77385, 77386, G6015, G6016
Other Miscellaneous Cancer Care Procedures 0581T, 0582T, 17106, 17107, 17108, 19294, 58674
Optune E0766, A4555
Radiopharmaceutical A9513, A9596, A9601, A9607
Stereotactic Radiosurgery 61796, 61797, 61798, 61799, 61800, 63620, 63621, 77371, 77372, 77373, 77425, G0339, G0340
Cardiac Devices Ventricular Assist Device 33975, 33976, 33979
External Defibrillator K0606
Implantable Cardioverter Defibrillator (ICD) C1721, C1722, C1882
Cardiac Procedures Cardiac Defect Repair 0569T, 0570T, 93580
Electrophysiologic Study and Implantable Cardioverter Defibrillator Insertion 0571T, 0572T, 0577T, 33216, 33217, 33225, 33249, 33270, 93619, 93620, 93622, 93624, 93640, 93641, 93642
Miscellaneous Cardiac Procedures 33267, 33268, 33269, 33340
Durable Medical Equipment (DME) Myo-Electric Prostheses L5856, L5857, L5858, L5859, L5961, L6026, L6205, L6715, L6880, L6882, L6925, L6935, L6945, L6955, L6965, L6975, L7007, L7008, L7009, L7040, L7045, L7170, L7180, L7185, L7190, L7191, L7259, L7700, L8701
Cochlear Devices 69930, L8614, L8615, L8616, L8617, L8619, S2235
Cranial Remodeling Orthosis S1040
Sleep Apnea Devices E0486
Infusion Pumps Implantable E0782, E0783, E0785, E0786
Insulin Pump, External Ambulatory A9274, E0784
Speech Generating Devices E2500, E2502, E2504, E2506, E2508, E2510, E2511, E2512, E2599
Wheelchairs (and accessories) E0637, E0983, E0984, E0986, E0988, E1002, E1003, E1004, E1005, E1006, E1007, E1008, E1009, E1011, E1017, E1018, E1035, E1036, E1161, E1220, E1226, E1227, E1229, E1230, E1231, E1232, E1233, E1234, E1239, E1296, E1298, E1399, E2300, E2301, E2311, E2312, E2313, E2323, E2325, E2326, E2331, E2351, E2361, E2375, E2377, E2620, E2624, K0005, K0010, K0011, K0012, K0013, K0014, K0038, K0108, 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
Decubitus Care E0183
Facet Joint Procedures Facet Joint Denervation / Facet Neurotomy 64625, 64628, 64629, 64633, 64634, 64635, 64636, 0213T, 0214T, 0215T, 0216T, 0217T, 0218T
Gender Affirmation Gender Affirmation 15877, 17380, 54400, 54401, 54405, 55970, 55980, 57291, 57292, J9226
GI Tract Imaging Imaging of digestive tract done from the inside of the digestive tract 91110, 91111
Imaging of colon using capsule endoscope, with interpretation and report 91113
Hysterectomies Total Laparoscopic Hysterectomy 58541, 58542, 58543, 58544, 58548, 58550, 58552, 58553, 58554, 58571, 58572, 58573, 58575
Vaginal Hysterectomy 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58290, 58291, 58292, 58294
Medical-Pharmacy 90378, C1772, C9047, C9142, J0129, J0172, J0180, J0202, J0219, J0221, J0222, J0223, J0224, J0256, J0257, J0490, J0491, J0517, J0565, J0567, J0584, J0593, J0596, J0597, J0598, J0599, J0600, J0606, J0638, J0775, J0791, J0775, J0791, J0800, J0879, J0895, J0896, J0897, J1290, J1300, J1301, J1302, J1303, J1322, J1325, J1426, J1427, J1428, J1429, J1442, J1447, J1459, J1460, J0491, J1306, J1551, J1554, J1555, J1556, J1557, J1558, J1559, J1560, J1561, J1562, J1566, J1568, J1569, J1572, J1575, J1599, J1602, J1632, J1743, J1745, J1786, J1823, J1931, J1932, J2182, J2323, J2326, J2350, J2356, J2357, J2506, J2507, J2562, J2779, J2786, J2793, J2796, J3032, J3111, J3241, J3245, J3262, J3285, J3316, J3358, J3380, J3385, J3397, J3399, J3520, J7168, J7169, J7170, J7175, J7177, J7178, J7179, J7180, J7181, J7182, J7183, J7185, J7186, J7187, J7188, J7189, J7190, J7192, J7193, J7194, J7195, J7197, J7198, J7199, J7200, J7201, J7202, J7203, J7204, J7205, J7207, J7208, J7209, J7210, J7211, J7212, J7318, J7320, J7321, J7322, J7323, J7324, J7325, J7326, J7327, J7328, J7329, J7331, J7332, J7351, J7352, J7686, J9021, J9023, J9035, J9037, J9039, J9042, J9057, J9061, J9118, J9119, J9144, J9145, J9153, J9173, J9177, J9203, J9204, J9210, J9223, J9227, J9228, J9229, J9247, J9269, J9272, J9273, J9274, J9298, J9299, J9306, J9309, J9311, J9312, J9316, J9317, J9318, J9319, J9331, J9332, J9348, J9349, J9353, J9354, J9355, J9356, J9358, J9359, Q2043, Q4074, Q5101, Q5103, Q5104, Q5107, Q5108, Q5109, Q5110, Q5111, Q5112, Q5113, Q5114, Q5115, Q5116, Q5117, Q5118, Q5119, Q5120, Q5121, Q5122, Q5123, Q5125
Miscellaneous CAR T-cell Therapy 0537T, 0538T, 0539T, 0540T, Q2041, Q2042, Q2053, Q2054, Q2055, Q2056
Panniculectomy 15830
Scleral/Contact Lenses S0515, V2627, V2531, V2628
Skin & Skin Substitutes Q4101, Q4102, Q4105, Q4106, Q4107, sQ4114, Q4116, Q4122, Q4128, Q4132, Q4133, Q4145, Q4148
Other GI Procedures 43497
Unlisted Laparoscopic Procedure Stomach 43659
Molecular & Genetic Testing

This change took place 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, username(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.
Molecular & Genetic Testing 81120, 81121, 81161, 81162, 81163, 81164, 81165, 81166, 81167, 81168, 81170, 81171, 81172, 81173, 81175, 81176, 81177, 81178, 81179, 81180, 81181, 81182, 81183, 81184, 81185, 81187, 81188, 81189, 81191, 81192, 81193, 81194, 81200, 81201, 81202, 81203, 81204, 81205, 81206, 81207, 81208, 81209, 81210, 81212, 81215, 81216, 81217, 81218, 81219,81220, 81221, 81222, 81223, 81224, 81225, 81226, 81227, 81228, 81229, 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, 81278, 81279, 81283, 81284, 81285, 81286, 81287, 81288, 81290, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81301, 81302, 81304, 81305, 81306, 81307, 81308, 81309, 81310, 81311, 81312, 81314, 81315, 81316, 81317, 81318, 81319, 81320, 81321, 81322, 81323, 81324, 81325, 81328, 81329, 81330, 81331, 81333, 81334, 81335, 81336, 81338, 81339, 81343, 81344, 81345, 81346, 81347, 81348, 81349, 81350, 81351, 81352, 81355, 81357, 81360, 81361, 81363, 81364, 81381, 81400, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81410, 81411, 81412, 81413, 81414, 81415, 81416, 81417, 81419, 81430, 81431, 81432, 81433, 81434, 81435, 81436, 81437, 81438, 81439, 81442, 81443, 81445, 81448, 81450, 81455, 81460, 81465, 81479, 81541, 81518, 81519, 81520, 81521, 81522, 81523, 81542, 81546, 81552, 81595, 81599, 84999, 86849, 87999, 88240, 88241, 88245, 88248, 88249, 88261, 88262, 88263, 88264, 88267, 88269, 88271, 88272, 88273, 88274, 88275, 88280, 88283, 88285, 88289, 88291, 88363, 89240, G9143, S3800, S3840, S3841, S3842, S3844, S3845, S3846, S3849, S3850, S3853, S3854, S3861, S3865, S3866, S3870, 0001U, 0005U, 0016U, 0017U, 0022U, 0023U, 0026U, 0027U, 0030U, 0034U, 0037U, 0040U, 0046U, 0047U, 0048U, 0049U, 0050U, 0084U, 0087U, 0101U, 0102U, 0103U, 0111U, 0118U, 0129U, 0155U, 0169U, 0171U, 0172U, 0177U, 0179U, 0180U, 0181U, 0182U, 0183U, 0184U, 0185U, 0186U, 0187U, 0188U, 0189U, 0190U, 0191U, 0192U, 0193U, 0194U, 0195U, 0196U, 0197U, 0198U, 0199U, 0200U, 0201U, 0204U, 0211U, 0221U, 0222U, 0230U, 0231U, 0232U, 0233U, 0234U, 0235U, 0236U, 0237U, 0238U, 0239U, 0242U, 0244U, 0245U, 0246U, 0250U, 0252U, 0268U, 0269U, 0270U, 0271U, 0272U, 0273U, 0274U, 0276U, 0277U, 0287U, 0326U, 0334U
Neurostimulators Neurostimulators 20974, 20975, 61863, 61864, 61867, 61868, 61880, 61885, 61886, 61888, 63650, 63655, 63661, 63662, 63663, 63664, 63685, 63688, 64553, 64555, 64561, 64568, 64569, 64570, 64575, 64581, 64582, 64583, 64584, 64585, 64590, 64595, 95961, 95962, 95970, A4555, E0745, E0748, E0749, L8679, L8680, L8681, L8683, L8685, L8686, L8687, L8688
Orthognathic Procedures 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, 21208, 21209, 21210, 21215, 21240, 21242, 21243, 21244, 21245, 21246, 21247, 21248, 21249, 29804, D7940, D7941, D7943, D7944, D7945, D7946, D7947, D7948, D7949, D7950, D7995, D7996
Orthopedic Procedures Hip (Arthroscopy & Arthroplasty) 27125, 27130, 27132, 27134, 27137, 27138, 29861, 29862, 29863, 29914, 29915, 29916
Knee (Arthroscopy & Arthroplasty) 27445, 27446, 27447, 27486, 27487, 29866, 29867, 29868, 29870, 29871, 29873, 29874, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889
Shoulder Arthroscopy, Acromioplasty & Rotator Cuff Repair 23130, 23410, 23412, 23415, 23420, 29826, 29827
Radiology Services

For many groups, free-standing and outpatient high-tech radiology services such as MRI, MRA, CT, CTA, PET, echocardiogram, nuclear imaging and cardiac imaging are handled by eviCore. To submit a prior authorization request through eviCore please contact them directly via phone: 1-888-693-3211 (7:00 am-8:00 pm CST); fax: 1-888-693-3210 or web: www.evicore.com. The request form can be downloaded here. If you require web assistance, please contact eviCore via phone 1-800-575-4594 or E-mail: online@evicore.com. Members in groups not delegated to eviCore require prior authorization for these services through Blue KC.
Hi Tech Radiology Services & Cardiac Imaging (MRI, MRA, Nuclear Medicine, CT, CTA, Echocardiogram, Stress Echocardiogram, PET Scans) 0042T, 0398T, 0439T, 0609T, 0610T, 0611T, 0612T, 0623T, 0624T, 0625T, 0626T, 0633T, 0634T, 0635T, 0636T, 0637T, 0638T, 0648T, 0649T, 70336, 70450, 70460, 70470, 70480, 70481, 70482, 70486, 70487, 70488, 70490, 70491, 70492, 70496, 70498, 70540, 70542, 70543, 70544, 70545, 70546, 70547, 70548, 70549, 70551, 70552, 70553, 70554, 70555, 71250, 71260, 71270, 71271, 71275, 71550, 71551, 71552, 71555, 72125, 72126, 72127, 72128, 72129, 72130, 72131, 72132, 72133, 72141, 72142, 72146, 72147, 72148, 72149, 72156, 72157, 72158, 72159, 72191, 72192, 72193, 72194, 72195, 72196, 72197, 72198, 73200, 73201, 73202, 73206, 73218, 73219, 73220, 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, 77520, 77522, 77523, 77525, 75557, 75559, 75561, 75563, 75565, 75571, 75572, 75573, 75574, 75635, 76376, 76377, 76380, 76391, 76497, 76498, 77021, 77022, 77046, 77047, 77048, 77049, 77078, 77084, 78429, 78430, 78431, 78432, 78433, 78434, 78451, 78452, 78453, 78454, 78459, 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, 93319, 93350, 93351, 93352, 93356, 93593, 93594, 93595, 93596, 93597, C8900, C8901, C8902, C8903, C8905, C8906, C8908, C8909, C8910, C8911, C8912, C8913, C8914, C8918, C8919, C8920, C8921, C8922, C8923, C8924, C8925, C8926, C8928, C8929, C8930, C9762, C9763, G0235, G0252, S8035, S8037, S8042, S8092
ENT Procedures Rhinoplasty 30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462, 30465
Septoplasty 30520
Uvulopalatopharyngoplasty 42145
Sleep Studies Sleep Studies 95805, 95808, 95810, 95811
Spinal Procedures

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.
Spinal Procedures 0098T, 20930, 22533, 22534, 22548, 22551, 22552, 22554, 22558, 22585, 22612, 22614, 22630, 22632, 22633, 22634, 22800, 22802, 22804, 22808, 22810, 22812, 22842, 22843, 22844, 22849, 22853, 22854, 22856, 22858, 22859, 22861, 22864, 22867, 22868, 22869, 22870,  27279, 27280, 62350, 62351, 62360, 62361, 62362, 62380, 63020, 63035, 63040, 63043, 63045, 63048, 63052, 63053, 63075, 63076, 63655, 63661, 63662, 63663, 63664, 63685
Transplant Transplant S2053, S2054, S2055, S2060, S2061, S2065, 0584T, 0585T, 0586T, 32850, 32851, 32852, 32853, 32854, 33927, 33928, 33929, 33930, 33935, 33940, 33945, 38240, 38241, 44132, 44133, 44135, 44136, 47133, 47135, 47140, 47141, 47142

To submit a prior authorization request you may also fax or mail your request. For the timeliest response, fax the request to 816-926-4253 using this form.

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 determination. To check the status of a prior authorization, call the Customer Service number listed on the member ID card.

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