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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.
Easily search for services by clicking on the bookmarks
shown at the left.
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HINT!
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
2 | P a g e ( C o n t i n u e d o n N e x t P a g e ) 1 0 2 0 1 7
An independent licensee of the Blue Cross and Blue Shield Association
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
3 | P a g e ( C o n t i n u e d o n N e x t P a g e ) 1 0 2 0 1 7
An independent licensee of the Blue Cross and Blue Shield Association
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)
Case Management Authorization
Required
Negative Pressure Wound Therapy (Wound Vac) (CPT E2402)
Case Management Authorization
Required
Psychiatric or Substance Abuse Admissions for Residential Treatment
Psychiatric or substance abuse for partial or intensive
outpatient treatment may need authorization.
Case Management Authorization
Required
Skilled Nursing Facility (Nursing Home)
Case Management Authorization
Required
TCU / Swing Bed / Sub-Acute / Extended Care Facility
Case Management Authorization
Required
Transplants Transplant Authorization
Required
Chiropractic Service Exceptions and Notes Required
Review Authorization Number
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
4 | P a g e ( C o n t i n u e d o n N e x t P a g e ) 1 0 2 0 1 7
An independent licensee of the Blue Cross and Blue Shield Association
Dental
For further information, see our Dental Reimbursement Guideline. Service Exceptions and Notes Required
Review Authorization Number
Anesthesia for Dental Procedures (CPT’s 00170)
Prospective Review is required for:
• 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
Review Authorization Number
Dermatoscopy (CPT 96904)
Prospective Review Required
Photodynamic Therapy (CPT 96567)
Prospective Review Required
PUVA / UVA Light Therapy (CPT’s 96900, 96912, 96920, 96921, 96922)
Prospective Review Required
Durable Medical Equipment Service Exceptions and Notes Required
Review Authorization Number
Breast Pump (Manual or Electric) (CPT E0602, E0603)
31715BPUMP-1
Breast Pump (Hospital Grade) (CPT E0604)
Prospective Review Required
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
5 | P a g e ( C o n t i n u e d o n N e x t P a g e ) 1 0 2 0 1 7
An independent licensee of the Blue Cross and Blue Shield Association
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)
Prospective Review is required for:
• 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
Review Authorization Number
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
6 | P a g e ( C o n t i n u e d o n N e x t P a g e ) 1 0 2 0 1 7
An independent licensee of the Blue Cross and Blue Shield Association
Cardiovascular Stress Test (CPT’s 93015, 93016, 93017, 93018)
3215STRESS-1 No Review Required
Chronic Pain Management Programs
Prospective Review Required
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)
Prospective Review Required
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
Prospective Review Required
Hyperbaric Treatments Prospective Review Required
Intra-Cardiac Catheter Ablation / Cardiac Ablation (CPT 93656 and 93657)
10515CABL-1 No Review Required
Intradiscal Electrothermal Therapy (IDET)
Prospective Review Required
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)
Prospective Review Required
Office Visits (CPT’s 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215)
2415OFF-1 No Review Required
7 | P a g e ( C o n t i n u e d o n N e x t P a g e ) 1 0 2 0 1 7
An independent licensee of the Blue Cross and Blue Shield Association
Out of United States Services ALL elective admissions and services received outside the
United States require prospective review
Prospective Review Required
PT/INR Monitoring in the Home (CPT’s G0248, G0249, G0250, 99363, and 99364)
10515INRM-1 No Review Required
Uvulopalatopharyngoplasty (UPPP)
Prospective Review Required
Virtual Colonoscopy (CPT’s 74261, 74262, 74263)
Prospective Review Required
Hospitalization Service Exceptions and Notes Required
Review Authorization Number
Inpatient Admissions (Hospitalization)
Click Here for further information.
Prior Authorization Review (PAR)
Required
Obstetrics and Gynecology Service Exceptions and Notes Required
Review Authorization Number
Assisted Reproductive Technology Ex. GIFT, ZIFT, ICSI, IVF
Prospective Review Required
Total Hysterectomy (Abdominal or Laparoscopic) (CPT’s 58150, 58571)
Prospective Review is required for:
• 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)
Prospective Review Required
Bone Growth Stimulator (CPT’s E0747, E0748, E0749)
Prospective Review Required
Carpal Tunnel Release (CPT’s 64719 & 64721
72915CARPL-1 No Review Required
8 | P a g e ( C o n t i n u e d o n N e x t P a g e ) 1 0 2 0 1 7
An independent licensee of the Blue Cross and Blue Shield Association
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)
Prospective Review is required for:
• 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
1 See Exception at the Bottom
Hip Resurfacing (CPT’s 29914, 29915, 29916)
2415HRES-1 No Review Required
1 See Exception at the Bottom
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.
Prospective Review Required
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
1 See Exception at the Bottom
Radiofrequency / Rhizotomy Treatment
Prospective Review Required
Shoulder Arthroscopy (CPT’s 29822, 29825, 29826, 29827)
2415SHOU-1 No Review Required
1 See Exception at the Bottom
9 | P a g e ( C o n t i n u e d o n N e x t P a g e ) 1 0 2 0 1 7
An independent licensee of the Blue Cross and Blue Shield Association
SI Joint Injections (CPT 27096)
Prospective Review Required
Spinal Cord Stimulator (CPT’s L8690, L8685, L8688)
Prospective Review Required
Pharmacy / Drug Service Exceptions and Notes Required
Review Authorization Number
Botox Injections (Chemodenervation) (CPT’s J0585, J0586, J0587, J0588, 64612, 64613, 64615)
Prospective Review Required
Injectible Drugs (excluding Insulin)
Prospective Review Required
Implantable Drug Pump Prospective Review Required
Specialty Drugs Click Here for further information.
Prospective Review Required
Synagis Injections Prospective Review Required
Psychiatric Service Exceptions and Notes Required
Review Authorization Number
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
10 | P a g e ( C o n t i n u e d o n N e x t P a g e ) 1 0 2 0 1 7
An independent licensee of the Blue Cross and Blue Shield Association
Radiology Service Exceptions and Notes Required
Review Authorization Number
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)
Prospective Review is required for:
• 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.
Prospective Review is required for:
• MRI of the Breast (CPT’s 77058, 77059)
• Functional MRI (CPT’s 70554, 70555, 96020)
2415MRI-1 No Review Required
PET Scan’s
Prospective Review Required
Standard X-Ray 3215XRAY-1 No Review Required
11 | P a g e ( C o n t i n u e d o n N e x t P a g e ) 1 0 2 0 1 7
An independent licensee of the Blue Cross and Blue Shield Association
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
Review Authorization Number
Obstructive Sleep Apnea Surgery and Oral Appliances
Prospective Review Required
Attended Sleep Study / Polysomnography (CPT’s 95807, 95808, 95809, 95810, 95811)
Prospective Review is required for:
• Members under the age of 18
2415SLEEP-1 No Review Required
Unattended / Home Sleep Study (CPT’s 95806, G0398, G0399)
Prospective Review Required
Surgery
Service Exceptions and Notes Required Review
Authorization Number
Balloon Sinuplasty (CPT 31295, 31296, 31297)
Prospective Review Required
Blepharoplasty / Laser Eye Surgery (CPT’s 15820, 15821, 15822, 15823)
Prospective Review Required
12 | P a g e ( C o n t i n u e d o n N e x t P a g e ) 1 0 2 0 1 7
An independent licensee of the Blue Cross and Blue Shield Association
Breast Reduction / Reduction Mammoplasty
Prospective Review Required
Breast Reconstruction for Diagnosis of Breast Cancer (CPT’s 19350, 19357, 19380)
Prospective Review is required for:
• 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.
Prospective Review Required
Cystoscopy (CPT’s 52000, 51040)
3215CYST-1 No Review Required
EVLT, Phlebectomy, Sclerotherapy (CPT’s 36475, 36476, 36477, 36478, 36479, 36470, 36471, 37765, 37766)
Prospective Review Required
Kyphoplasty (CPT’s 22523, 22524, 22525)
Prospective Review Required
Laparoscopic Colectomy (CPT 44204)
3215LAPCOLE-1 No Review Required
Laparoscopic Cholecystectomy (CPT 47562, 47563)
3215LAP-1 No Review Required
1 See Exception at the Bottom
Lung Volume Reduction Surgery
Prospective Review Required
Panniculectomy Prospective Review Required
Platelet Rich Plasma (CPT 0232T)
Prospective Review Required
Resection of Inferior Turbinate (CPT 30140)
3215TURB-1 No Review Required
Prophylactic Services Example: Prophylactic Mastectomy, Oophorectomy
Prospective Review Required
Rhinoplasty Prospective Review Required
13 | P a g e ( C o n t i n u e d o n N e x t P a g e ) 1 0 2 0 1 7
An independent licensee of the Blue Cross and Blue Shield Association
Septoplasty (CPT 30520)
22615SEPT-1 No Review Required
Tonsillectomy / Anenoidectomy (CPT 42820)
3215TONSIL-1 No Review Required
1 See Exception at the Bottom
Vertebroplasty (CPT’s 22520, 22521)
Prospective Review Required
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.
Service Exceptions and Notes Required Review
Authorization Number
Applied Behavioral Therapy (ABA)
Prospective Review Required
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
prospective review; however, many benefit plans have specific visit limitations.
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.
14 | P a g e ( C o n t i n u e d o n N e x t P a g e ) 1 0 2 0 1 7
An independent licensee of the Blue Cross and Blue Shield Association
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
prospective review; however, many benefit plans have specific visit limitations.
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
Service Exceptions and Notes Required Review
Authorization Number
Weight Loss Prescription Medications
Prospective Review Required
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.