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

Predetermination

Predetermination is a voluntary pre-service review and is strongly recommended for those services indicated in medical policy as "sometimes investigational" or "not medically necessary." To access our Medical Policy, review our Medical Policy.

Prior Authorization

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

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

Chiropractic services performed by an out-of-network provider

Cochlear Device
69930, L8614, L8619

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

Genetic Testing for Breast Cancer
81162, 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)
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, 62830

** 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

Organ and Tissue Transplants (excluding cornea transplants)

Out of network services for HMO members

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, 0399T, 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, 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, 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
    77058, 77059, 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

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

Surgical Treatment for Gender Dysphoria
55970, 55980

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

Varicose Vein Treatment
S2202, 36465, 36466, 36470, 36471, 36475, 36476, 36478, 36479, 37500, 37760, 37761

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

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

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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