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Prior Authorization Request for Reduction Mammaplasty

Blue KC will provide coverage for a reduction mammaplasty when it is determined to be medically necessary.

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* Required Field

Enter Patient Information

Review Type:

i

i

i
Blue KC ID (Not SS#): *
- -

Patient First Name: *
Patient Middle Initial:
Patient Last Name: *
Date of Birth: *
Patient Group ID: *
ICD-10 Diagnosis Codes: *
Diagnosis Codes must be 3-8 characters along with decimals
Codes must be 3 - 8 characters along with decimals.
CPT or HCPCS Codes:*
(Include modifiers if applicable)
CPT/HCPCS codes must contain 5-9 charactersUnits may contain up to 3 characters
Units:*
Date of Service/Admission Date: *

* Required Field

Enter Provider Information

Contact First Name: *
Contact Last Name: *
Contact Email Address:
Contact Phone No:*
Contact Phone Ext:
Contact Fax No:*
Provider ID OR NPI: *
- I am an Ordering Physician
- I am a Servicing Physician
Ordering Physician/Provider Name:
Ordering Physician's Address:
Ordering Physician's City:
Ordering Physician's State:
Ordering Physician's Zip:
Ordering Physician's Email Address:
Ordering Physician's Phone No:
Ordering Physician's Fax No:*
Servicing Physician's Name:
Servicing Physician's Address:
Servicing Physician's City:
Servicing Physician's State:
Servicing Physician's Zip:
Servicing Physician's Email Address:
Servicing Physician's Phone No:
Servicing Physician's Fax No:*
Facility/Supplier Name: *
Facility NPI:
Facility/Supplier Address: *
Facility/Supplier City: *
Facility/Supplier State: *
Facility/Supplier Zip: *

Procedure is scheduled as:
23-hr observation
Outpatient
Inpatient

If this procedure is due to part of reconstruction after mastectomy for the diagnosis of breast cancer, per State mandate the procedure is covered. Please submit only diagnosis code for breast cancer and the following CPT codes of 19318 (50), 19324 and 19140. We do not need photos or symptoms. This will assist in payment on claims.

Please complete the following:

History of condition (including duration of condition):

Bra size and cup: Member's height: Member's weight:
Number of grams to be removed (right): (left):
YesNoIntertrigo between pendulous breast and chest wall
YesNoShoulder, neck or back pain r/t macromastia unresponsive to conservative treatment

If yes, document treatment:

Please enter Document Treatment.

Photographs are NOT required for review. The pathology report will need to be submitted with your claim to verify the actual amount of tissues removed.

Please attach relevant clinical documentation.*

Choose a file or files to attach * (File types accepted: jpg, txt, doc, docx, pdf, xls, xlsx, ppt, pptx, rtf, tiff, and tif)

To upload multiple files, hold down the CTRL key while selecting multiple documents then click open.

Checking this box will send a copy of your form to the email address provided.

If you experience issues submitting this form, please print and fax it to (816) 817-8211.

If you have questions, contact Blue KC at (816) 395-3989.

Cancel

Your prefix is on the front of your Member ID card. See the sample ID card above. If you do not have your member ID card, contact the Customer Service department by clicking Contact Us, or calling 816-395-3558 or 888-989-8842.

IMPORTANT: If you are an FEP Member, enter "NA" into the Prefix field.

Your member ID is a unique number that identifies your plan. It is on the front of your Member ID card. See the sample ID card above. If you do not have your member ID card, contact the Customer Service department by clicking Contact Us, or calling 816-395-3558 or 888-989-8842.

Your Suffix is a two digit number located on your Member ID card. See the sample ID card above. If you do not have your member ID card, contact the Customer Service department by clicking Contact Us, or calling 816-395-3558 or 888-989-8842.

For Blue Card members, suffix is not required.

Prior Authorization Request for Reduction Mammaplasty

Enter Patient Information

Enter Provider Information

Please complete the following:

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