Blue KC Commercial Prior Authorization and Notification List
Effective April 19, 2021

Please check back on April 19, 2021 to ensure you have the most up-to-date copy of this list.

Member IDs that begin with prefix RKC, RKQ, RRK, or RRN are for our Medicare Advantage Network. To access this information for a Medicare Advantage member please go to the Medicare Advantage Prior Authorizations Forms and navigate to the Submit Requests by Fax or Email section.

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.

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 Out of Network services for HMO members
  • 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

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
Bariatric Surgery Bariatric Procedures 43644, 43770, 43771, 43772, 43773, 43774, 43775, 43843, 43845, 43846
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 19324, 19325
Mastectomy for Gynecomastia 19300
Reduction Mammoplasty 19318
Other Mastectomies and Related Procedures 19303, 19307, 19340, 19357, 19361, 19364, 19367, 19368, 19369
Bone Growth Stimulators Bone Growth Stimulators 20974, 20975, 20979, E0747, E0748, E0749, E0760
Cancer Care Intensity Modulated Radiation Therapy (IMRT) 77301, 77338, 77385, 77386, G6015, G6016
Optune E0766, A4555
Radiopharmaceutical C9031, A9513
Stereotactic Radiosurgery 61796, 61797, 61798, 61799, 61800, 63620, 63621, 77371, 77372, 77373, G0339, G0340, 77261, 77262, 77263, 77293, 77295, 77300, 77321, 77331, 77332, 77334, 77336, 77370, 77432
Cardiac Devices Ventricular Assist Device 0048T, 0049T, 0050T, 33975, 33976
External Defibrillator K0606
Implantable Cardioverter Defibrillator (ICD) C1721, C1722, C1882
Cardiac Procedures Cardiac Septal Defect; Atrial Transcatheter Closure 93580
Electrophysiologic Study and Implantable Cardioverter Defibrillator Insertion 0571T, 33216, 33217, 33225, 33249, 33270, 93619, 93620, 93621, 93622, 93624, 93640, 93641, 93642
Durable Medical Equipment (DME) Myo-Electric Prostheses L5856, L5857, L5858, L5859, L5961, L6026, L6715, L6880, L6882, L6925, L6935, L6945, L6955, L6965, L6975, L7007, L7008, L7009, L7045, L7190, L7191, L7259, L7700, L8701, 97763
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) E0983, E0984, E0998, 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, E2361, E2375, E2377, E2620, E2624, K0005, K0010, K0011, K0012, K0013, K0038, K0108, K0800, K0801, K0802, K0806, K0807, K0808, K0812, 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, K0986
Facet Joint Procedures Facet Joint Denervation / Facet Neurotomy 64625, 64633, 64634, 64635, 64636, 0213T, 0214T, 0215T, 0216T, 0217T, 0218T
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, 58293, 58294
Miscellaneous Gender Dysphoria Surgery 55970, 55980
Panniculectomy 15830
Scleral Lens S0515, V2627, V2531
Skin & Skin Substitutes Q4101, Q4102, Q4105, Q4106, Q4107, Q4116, Q4128, Q4132, Q4133, Q4145, Q4148
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, 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, 81278, 81279, 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, 81338, 81339, 81343, 81344, 81345, 81346, 81347, 81348, 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, 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, 81529, 81538, 81539, 81540, 81542, 81545, 81546, 81551, 81552, 81595, 81599, 84999, 86849, 87901, 87903, 87904, 87906, 87999, 88240, 88241, 88245, 88248, 88249, 88261, 88262, 88263, 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, 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, 81278, 81279, 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, 81338, 81339, 81343, 81344, 81345, 81346, 81347, 81348, 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, 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, 81529, 81538, 81539, 81540, 81542, 81545, 81546, 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, 0172U
Neurostimulators Deep Brain Stimulators 61863, 61864, 61867, 61868, 61885, 61886, 61880, 61888, 95961, 95962, 95970, 95983, 95984
Spinal Cord Stimulators 20974, 20975, E0748, E0749, 63650, 63655, 63661, 63662, 63663, 63664, 63685, 63688
Peripheral Nerve Stimulators 61885, 61886, 61888, 64553, 64555, 64561, 64568, 64569, 64570, 64575, 64581, 64585, 64590, 64595, 95970, 95971, 95972, 95976, 95977, 0466T, 0467T, 0468T, A4290, A4555, C1767, C1778, C1787, C1816, C1820, C1822, C1823, C1883, C1897, E0720, E0730, E0745, L8679, L8680, L8681, L8683, L8685, L8686, L8687, L8688, L8689, L8695
Orthognathic Procedures Orthognathic Surgery 21050, 21060, 21070, 22120, 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, D7959, 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 Hi Tech Radiology Services & Cardiac Imaging (MRI, MRA, Nuclear Medicine, CT, CTA, Echocardiogram, Stress Echocardiogram, PET Scans) 0042T, 0439T, 0609T, 0610T, 0611T, 0612T, 0633T, 0634T, 0635T, 0636T, 0637T, 0638T, 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, 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, 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, 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.
Lumbar Fusion Surgery 22533, 22534, 22558, 22585, 22612, 22614, 22630, 22632, 22633, 22634, 22800, 22802, 22804, 22808, 22810, 22812, 22842, 22843, 22844, 22849, 22853, 22854, 22859, 22864, 22867, 22868, 22869, 22870, 62380
Anterior Arthrodesis of the Spine 22548, 22551, 22552, 22554, 22585
Cervical Diskectomy, Microdiskectomy, Foraminotomy, Laminotomy 63020, 63035, 63040, 63043, 63045, 63048, 63075, 63076
Cervical Disk Arthroplasty 22856, 22858, 22861, 22864, 0098T
Intrathecal Pump Implantation 62350, 62351, 62360, 62361, 62362

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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