prospective request certification) guideline · prospective request (pre-certification) guideline ....

PROSPECTIVE REQUEST

(PRE-CERTIFICATION) GUIDELINE

This guideline is provided to help you determine BCBSWY’s requirements for prospective requests to

establish medical appropriateness, necessity of services, and benefits prior to patient care. It represents

some of the most common services and therefore is not inclusive of all services.

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This guideline is updated regularly on our website: bcbswy.com/precert. We recommend

referring to the website each time you consider submitting prospective requests to determine

BCBSWY’s most current requirements.

Authorization numbers are included for services which do not require BCBSWY prospective requests

but may be necessary for use at your practice. For services which do require BCBSWY prospective

requests, complete the form on our website and submit it as instructed. Please only mark a prospective

request URGENT if failure to receive treatment will result in a life or limb threatening situation.

Otherwise, the request may be delayed in processing. (BCBSWY does not recognize scheduling conflicts

as an urgent request.)

BCBSWY’s Medical Policies are also available for your reference online. These Medical Policies are

used by BCBSWY to review prospective requests and are searchable by title, CPT code and

identification number.

Benefits will be denied if the patient is not eligible for coverage under the benefit plan on the date

services are provided or if services received are not medically appropriate and necessary. Inclusion of a

service on this guideline does not guarantee payment.

An independent licensee of the Blue Cross and Blue Shield Association

https://www.bcbswy.com/providers/preadmin/precert.html

https://www.bcbswy.com/docs/providers/precertification.pdf

https://www.bcbswy.com/providers/policy/

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Cancer Service Exceptions and Notes Required

Review Authorization Number

Brachytherapy Prospective Review Required

Chemotherapy Prospective Review Required

IMRT Prospective Review Required

Mastectomy for Diagnosis of Breast Cancer (CPT’s 19303, 19304)

Prospective Review is required for:

• Members with any other diagnosis.

• Any Services related to the mastectomy which are prophylactic in nature

2415MAST-1 No Review Required

Standard Radiation Therapy 3215RAD-1 No Review Required

Case Management

To obtain a Case Management Authorization, please contact 1-800-442-2376.

Service Exceptions and Notes Required Review

Authorization Number

Acute Rehabilitation Case Management Authorization

Required

Bili Lights / Bili Blanket (Photo Therapy)

Case Management Authorization

Required

PROSPECTIVE REQUEST (PRE-CERTIFICATION) GUIDELINE



Enteral Feeding Case Management Authorization

Required

Home Health Care Case Management Authorization

Required

Home IV Infusion Case Management Authorization

Required

Hospice Case Management Authorization

Required

Long Term Care Facilities (LTAC)


Required

Negative Pressure Wound Therapy (Wound Vac) (CPT E2402)


Required

Psychiatric or Substance Abuse Admissions for Residential Treatment

Psychiatric or substance abuse for partial or intensive

outpatient treatment may need authorization.


Required

Skilled Nursing Facility (Nursing Home)


Required

TCU / Swing Bed / Sub-Acute / Extended Care Facility


Required

Transplants Transplant Authorization

Required

Chiropractic Service Exceptions and Notes Required


Chiropractic Manipulative Treatment (CPT 98940, 98941)

Chiropractic Manipulative Treatment does not require

prospective review; however, many benefit plans have specific exclusions and

limitations.

3215CHIRO-1 No Review Required



Dental

For further information, see our Dental Reimbursement Guideline. Service Exceptions and Notes Required


Anesthesia for Dental Procedures (CPT’s 00170)


• Members 6 years of age and older

Prospective Review is not required for:

• Members under the age of 6

• Members with a contract alpha prefix of ZSC or Kid Care CHIP.

Members Age 6 and Older: Prospective

Review Required

Members Less Than Age 6 & ZSC:

3215DENANE-1 No Review Required

Dermatology Service Exceptions and Notes Required


Dermatoscopy (CPT 96904)

Prospective Review Required

Photodynamic Therapy (CPT 96567)


PUVA / UVA Light Therapy (CPT’s 96900, 96912, 96920, 96921, 96922)


Durable Medical Equipment Service Exceptions and Notes Required


Breast Pump (Manual or Electric) (CPT E0602, E0603)

31715BPUMP-1

Breast Pump (Hospital Grade) (CPT E0604)


Cooling Device / Game Ready Unit / CyroCuff (CPT’s E0218, E0236)

This item is not a benefit of a member’s health plans.

CPAP, Bi-PAP, and Related Supplies Ex. CPT’s E0601, E0470, E0562

2415CPAP-1 No Review Required

https://www.bcbswy.com/providers/dental/



Crutch Substitute (CPT E0118)

Prospective Review Required for patients who

are not recovering from

foot or ankle surgeries

10515CSUB-1 No Review Required for

Patients recovering from foot or ankle surgeries

Foot Inserts (CPT L3000)

Foot Inserts do not require prospective review; however,

many benefit plans have specific exclusions.

3215FOOT-1 No Review Required

Insulin, Insulin Pumps, Insulin Pump Supplies, and Continuous Glucose Monitoring Supplies

2415INSU-1 No Review Required

Oxygen Concentrator (Stationary) (CPT E1390)


• Portable Oxygen Concentrator (CPT’s E1392)

2415OXY-1 No Review Required

Oxygen Tanks (CPT E0431, E0433, E0434. E0435)

32015TANK-1 No Review Required

TENS Units (CPT E0720 and E0730)

10515TENS-1 No Review Required

General Service Exceptions and Notes Required


Ablation of Renal Tumor (CPT 50593)

10515ABLT-1 No Review Required

Ablation Therapy Prospective Review is required for ALL Ablation Therapy EXCEPT:

• Cardiac Ablation Therapy

• Endometrial Ablation Therapy

PROSPECTIVE

REVIEW REQUIRED FOR

ALL OTHER

Cardiac – 2415CABL-1 No Review Required

Endometrial – 2415EABL-1 No Review Required

Allergy Testing (CPT 95024, 95004)

Allergy Testing does not require prospective review;

however, many benefit plans have specific exclusions for

allergy testing.

3215ALLERGY-1 No Review Required

Anesthesia (Special Circumstances Only) (CPT Codes 99100, 99116, and 99135)

BCBSWY does not reimburse for CPT Codes 99100, 99116, and 99135. BCBSWY will reimburse providers in these situations under the general

anesthesia billing guidelines.

Cardiac Rehabilitation Prospective Review Required



Cardiovascular Stress Test (CPT’s 93015, 93016, 93017, 93018)

3215STRESS-1 No Review Required

Chronic Pain Management Programs


Colonoscopy (Diagnostic) (CPT 45378)

Colonoscopies for diagnostic purposes do not require

prospective review.

3215COLON-1 No Review Required

Diabetic Training (G0108)

3215DIAB-1 No Review Required

Diagnostic EGD (CPT 43235, 43239)

3215EGD-1 No Review Required

Electroconvulsive Shock Wave Therapy (ECT)


Epidural or Subarachnoid Lumbar or Sacral Injection (CPT 62311)

3215EPID-1 No Review Required

Gamma Knife Procedures Prospective Review Required

Genetic Testing Prospective Review Required

Growth Hormone Therapy Prospective Review Required

Hearing Aids, Cochlear Implants, Bone Anchored Devices, Osseo Integrated Implants


Hyperbaric Treatments Prospective Review Required

Intra-Cardiac Catheter Ablation / Cardiac Ablation (CPT 93656 and 93657)

10515CABL-1 No Review Required

Intradiscal Electrothermal Therapy (IDET)


Kidney Stone Treatment (CPT 50590)

3215KID-1 No Review Required

Needle EMG (CPT 95886)

2415NEMG-1 No Review Required

Nerve Conduction Studies (CPT’s 95911, 95912,95913)

2415NCS-1 No Review Required

Nerve Conduction Tests (Automated) (CPT 95905)


Office Visits (CPT’s 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215)

2415OFF-1 No Review Required



Out of United States Services ALL elective admissions and services received outside the

United States require prospective review


PT/INR Monitoring in the Home (CPT’s G0248, G0249, G0250, 99363, and 99364)

10515INRM-1 No Review Required

Uvulopalatopharyngoplasty (UPPP)


Virtual Colonoscopy (CPT’s 74261, 74262, 74263)


Hospitalization Service Exceptions and Notes Required


Inpatient Admissions (Hospitalization)

Click Here for further information.

Prior Authorization Review (PAR)

Required

Obstetrics and Gynecology Service Exceptions and Notes Required


Assisted Reproductive Technology Ex. GIFT, ZIFT, ICSI, IVF


Total Hysterectomy (Abdominal or Laparoscopic) (CPT’s 58150, 58571)


• Prophylactic Hysterectomy

2415THYS-1 No Review Required

Orthopedics Service Exceptions and Notes Authorization

Number Required Review

Artificial Disk Surgery (CPT’s 22856, 22861, 22864, 22857, 22852, 22865)


Bone Growth Stimulator (CPT’s E0747, E0748, E0749)


Carpal Tunnel Release (CPT’s 64719 & 64721

72915CARPL-1 No Review Required

https://www.bcbswy.com/providers/preadmin/preadmin.html



Cervical or Lumbar Spine Fusion (CPT’s 22612, 22614, 22630, 22551, 22552, 22632, 22633, 22842, 63030, 63035, 20930, 20931, 20932, 20933, 20934, 20935, 20936, 20937, 20938, 22845, 22841, 22843, 22844, 22846, 22847, 22848)


• Artificial Cervical or Lumbar Disc Surgery including removal and replacement

BCBSWY does not require pre-certification for the removal of fixation devices.

2415CFUSE-2 No Review Required

1 See Exception at the Bottom

Epidural / Facet Joint Injection (CPT’s 64470, 64472, 64475, 64476, 64479, 64480, 64483, 64484, 64486, 64487, 64488, 64489, 64490, 64491, 64492, 64493, 64494, 64495)

32515FACJ-1 No Review Required

Hip Arthroplasty, Total Hip Replacement, and Revision (CPT 27130)

2415HIP-1 No Review Required


Hip Resurfacing (CPT’s 29914, 29915, 29916)

2415HRES-1 No Review Required


Interspinous Fixation Devices (22840, 22851)

For further explanation regarding these devices, please

see Medical Policy 7.01.138 and 7.01.107

Traditional cages, screws, and

rods are based on medical necessity and do not require

prospective review.


Traditional cages, screws, and rods are based on

medical necessity and do not require prospective

review.

Knee Arthroscopy, Total Knee Replacements, and Revisions (CPT’s 29876, 29877, 27447, 29881, 29877)

2415KNEE-2 No Review Required


Radiofrequency / Rhizotomy Treatment


Shoulder Arthroscopy (CPT’s 29822, 29825, 29826, 29827)

2415SHOU-1 No Review Required


https://www.bcbswy.com/providers/policy/



SI Joint Injections (CPT 27096)


Spinal Cord Stimulator (CPT’s L8690, L8685, L8688)


Pharmacy / Drug Service Exceptions and Notes Required


Botox Injections (Chemodenervation) (CPT’s J0585, J0586, J0587, J0588, 64612, 64613, 64615)


Injectible Drugs (excluding Insulin)


Implantable Drug Pump Prospective Review Required

Specialty Drugs Click Here for further information.


Synagis Injections Prospective Review Required

Psychiatric Service Exceptions and Notes Required


Diagnostic Evaluation (CPT 90791)

Diagnostic Evaluation does not require prospective review; however, many

benefit plans have specific limitations.

3215PSYEV-1 No Review Required

Psychological Testing (CPT 96101)

Psychological Testing does not require prospective review; however, many

benefit plans have specific limitations.

31715PSYTST-1

Psychotherapy (CPT 90832, 90833, 90834, 90837)

Psychotherapy does not require prospective review;

however, many benefit plans have specific limitations.

3215PSYCH-1 No Review Required

https://www.bcbswy.com/SpecialtyDrugList



Radiology Service Exceptions and Notes Required


Computed Tomography (CT) –

Abdomen (CPT’s 74176, 74177, 74178) Brain (CPT’s 70450, 70470) Chest (CPT’s 71250, 71260) Facial Bones (CPT’s 70486, 70487, 70488) Guide (CPT 77013) Lower Extremity (CPT’s 73700, 73701) Orbits (CPT’s 70480, 70481, 70482) Pelvis (CPT’s 72192, 72193, 72194) Spine/Neck (CPT’s 72125, 72126, 70491, 70490, 72128, 72129, 72131, 72132) Upper Extremity (CPT’s 73200, 73201)


• Heart CT (CPT’s 75571, 75572, 75573, 75574)

• Facial CT for Dental / Trudenta Therapy

2415CT-1 No Review Required

Echocardiography (Echo) (CPT’s 93303, 99304, 93306, 93307, 93351)

2415ECHO-1 No Review Required

Magnetic Resonance Imaging (MRI) All MRI’s except those stated under the exceptions column do not require review by BCBSWY.


• MRI of the Breast (CPT’s 77058, 77059)

• Functional MRI (CPT’s 70554, 70555, 96020)

2415MRI-1 No Review Required

PET Scan’s


Standard X-Ray 3215XRAY-1 No Review Required



Standard Ultrasound Abdomen (CPT’s 76700, 76705, 93975, 76770, 76775) Breast (CPT’s 76645, 19100, 19000) Chest (CPT 76604) Extremity (CPT’s 93925, 93923, 93926, 93922, 93970,93965, 76881, 76882, 93923, 93922, 93970, 93930, 93931, 76881, 76882) General (CPT’s 76870, 76830, 76856, 86857, 27094) OB (CPT’s 76801, 76805, 76810, 76817) Thyroid (CPT’s 76536, 60001)

31715ULTRA-1 No Review Required

Sleep Category Service Exceptions and Notes Required


Obstructive Sleep Apnea Surgery and Oral Appliances


Attended Sleep Study / Polysomnography (CPT’s 95807, 95808, 95809, 95810, 95811)


• Members under the age of 18

2415SLEEP-1 No Review Required

Unattended / Home Sleep Study (CPT’s 95806, G0398, G0399)


Surgery



Balloon Sinuplasty (CPT 31295, 31296, 31297)


Blepharoplasty / Laser Eye Surgery (CPT’s 15820, 15821, 15822, 15823)




Breast Reduction / Reduction Mammoplasty


Breast Reconstruction for Diagnosis of Breast Cancer (CPT’s 19350, 19357, 19380)


• Members with any other diagnosis.

Note: Cosmetic procedures are not a benefit.

2415BREC-1 No Review Required

Cataract Surgery (CPT 66984)

3215CAT-1 No Review Required

Cosmetic / Plastic Surgery Plastic Surgery performed for cosmetic reasons is not a benefit of a member’s health

plan.


Cystoscopy (CPT’s 52000, 51040)

3215CYST-1 No Review Required

EVLT, Phlebectomy, Sclerotherapy (CPT’s 36475, 36476, 36477, 36478, 36479, 36470, 36471, 37765, 37766)


Kyphoplasty (CPT’s 22523, 22524, 22525)


Laparoscopic Colectomy (CPT 44204)

3215LAPCOLE-1 No Review Required

Laparoscopic Cholecystectomy (CPT 47562, 47563)

3215LAP-1 No Review Required


Lung Volume Reduction Surgery


Panniculectomy Prospective Review Required

Platelet Rich Plasma (CPT 0232T)


Resection of Inferior Turbinate (CPT 30140)

3215TURB-1 No Review Required

Prophylactic Services Example: Prophylactic Mastectomy, Oophorectomy


Rhinoplasty Prospective Review Required



Septoplasty (CPT 30520)

22615SEPT-1 No Review Required

Tonsillectomy / Anenoidectomy (CPT 42820)

3215TONSIL-1 No Review Required


Vertebroplasty (CPT’s 22520, 22521)


Therapy

Many benefit plans have specific visit limitations or maximums. To inquire, please contact our Member Services Department at 1-800-442-2376. The Healthcare Online Resource (THOR)

can also be utilized to find this information.



Applied Behavioral Therapy (ABA)


Electrical Stimulation Therapy (CPT 97032, 97033, 97014)

Electrical Stimulation Therapy does not require

prospective review; however, many benefit plans have specific visit limitations.

3215ESTIM-1 No Review Required

Hot or Cold Pack Therapy (CPT 97010)

Hot or Cold Pack Therapy does not require prospective

review; however, many benefit plans have specific

visit limitations.

3215HOT-1 No Review Required

Manual Therapy (CPT 97140)

Manual Therapy does not require prospective review;

however, many benefit plans have specific visit

limitations.

3215THER-1 No Review Required

Mechanical Traction Therapy (CPT 97012)

Mechanical Traction Therapy does not require


3215MECH-1 No Review Required

Neuromuscular Reeducation (CPT 97112)

Neuromuscular Reeducation does not require prospective

review; however, many benefit plans have specific

visit limitations.

3215NEURO-1 No Review Required

Occupational Therapy (CPT 97003)

ALL benefits and the determination if an authorization is necessary are determined by Case Management. To obtain a Case Management

Authorization, please contact 1-800-442-2376.

https://www.bcbswy.com/providers/thor/



Physical Therapy Evaluation and Re-Evaluation (CPT 97002, 97001)

Physical Therapy does not require prospective review;

however, many benefit plans have specific visit

limitations.

3215PT-1 No Review Required

Therapeutic Activities and Exercise (CPT 97530, 97110)

Therapeutic Activities and Exercise does not require


3215THERAPY-1 No Review Required

Ultrasound Therapy (CPT 97035)

Ultrasound Therapy does not require prospective review; however, many

benefit plans have specific visit limitations.

3215ULTHER-1 No Review Required

Weight Loss



Weight Loss Prescription Medications


Weight Loss Surgery Prospective Review Required

1 Members belonging to the CRUM Electric group are subject to Prospective Request (Pre-certification) for this service. BCBSWY provides administrative services for this group.

prospective request certification) guideline · prospective request (pre-certification) guideline ....

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