Blue Cross and Blue Shield of Vermont (BCBSVT) The Vermont Health Plan (TVHP) Access Blue New England (ABNE) SERVICES and DIAGNOSIS REQUIRING PRIOR APPROVAL If the service and applicable CPT or HCPC code appears below, then a prior approval is required for all* BCBSVT, TVHP and Access Blue New England products, even if the product is secondary to another carrier (including Medicare). Prior approval request forms are located on the bcbsvt.com provider website. The provider who is rendering the service(s) needs to submit the prior approval request, except radiology, which requires the ordering provider. We supply this list as a quick reference only. Please refer to the medical policies for full details of requirements. Please Note: Codes may not be all inclusive as the AMA and CMS code updates may occur more frequently then policy updates. *Federal Employee Program (FEP), State of Vermont and Fletcher Allen Health Insurance Programs have separate requirements, please see applicable lists. DIAGNOSIS Asperger’s Disorder Autistic Disorder Pervasive Developmental Disorder Childhood Disintegrative Disorder Rett Syndrome CPT or HCPC Code(s) Refer to the Autism Spectrum Disorder medical policy for specific details and age requirements. PROCEDURE Out of Network Providers/Facilities (managed care programs only) Excludes emergency room and urgent care facilities Out of State Inpatient Care – non Vermont contracted facilities Ambulance (non-emergent transport) Anesthesia (monitored) for Endoscopy or Colonoscopy Capsule Endoscopy (wireless) Chiropractic: After 12 initial visits NOTE: The State of Vermont Program has its own prior approval listing; however, chiropractic never requires prior approval for State of Vermont Employees. Chondrocyte Transplants Clinical Trials CPT or HCPC Code(s) All Cochlear Implants and Aural Rehabilitation Continuous Passive Motion (CPM) Equipment Benefits are only eligible if the member still has coverage for Autism Spectrum Disorder as defined by our “Autism Spectrum Disorder” medical policy. All All 00740, 00810 91110, 91111, 91112 All 27412, 27416, J7330, S2112 Refer to Clinical Trails medical policy for specific details and requirements. 69930, L8614, L8615, L8616, L8617, L8618, L8619, L8627, L8628, L8629 See Separate List for Specifics Medical Prior Approval Requirements for BCBSVT and TVHP Updated: October 17, 2014 moved vertebroplasty from its own category to be included with percutaneous vertebraplasty or vertebral augmentation and added “services” to the end. Dental All The exception is: Bone impacted teeth extraction when the benefit is applicable. The following soft oral tissue excisions and biopsies do not require prior approval: 40490, 40808, 40810, 40812, 40814, 40816, 40818, 41100, 41105, 41108, 41110, 41112, 41113, 41114, 41116, 41120, 41130, 41135, 41140, 41145, 41150, 41153, 41155, 41825, 41826, 41827, 42100, 42104, 42106, 42107, 42400, 42405, D7286, D7413, D7414, D7415, D7440, D7441 Orthognathic Surgery Durable Medical Equipment Electrical Stimulation Enteral Formulae and Parenteral Nutrition Gastric Electrical Stimulation Gender Reassignment Surgery Genetic Testing 21120, 21121, 21122, 21123, 21125, 21127, 21137, 21138, 21139, 21141, 21142, 21143, 21145, 21146, 21147, 21150, 21151, 21154, 21155, 21159, 21160, 21206, 21240, 21242, 21243, 21244, 21245, 21246, 21247, 21248, 21249 See Separate List for Specifics 64555, 64561, 64565, 64575, 64580, 64581, 95971, 95972, 95973 B4153, B4154, B4155, B4157, B4158, B4159, B4160, B4161, B4162, B4164 – B5200. Note: The Durable medical equipment prior approval list contains additional codes billable by DME suppliers. 43647,43648, 43881,43882, 64590, 64595, 95980, 95981,95982, C1767, C1778, C1820, L8680, L8685, L8686, L8687, L8688 Refer to the Gender Reassignment Surgery for Gender Dysphoria or Gender Reassignment Surgery 2013 UVM medical policies for specific details and requirements. All Except the following do not require prior approval: CPT codes 81508 through 81512- Fetal congenital abnormalities CPT 84704 - Gonadotropin, chorionic (HCG); free beta chain is NOT considered a genetic testing code by BCBSVT. Hip Resurfacing Hyperbaric Oxygen Therapy CPT 84163- Pregnancy - associated plasma protein - A is NOT considered a genetic testing code by BCBSVT. 27299, S2118 99183, C1300 or revenue code 0413 Medical Prior Approval Requirements for BCBSVT and TVHP Updated: October 17, 2014 moved vertebroplasty from its own category to be included with percutaneous vertebraplasty or vertebral augmentation and added “services” to the end. Medical Nutrition for Inherited Metabolic Disease Mental Health Services (non-emergency):     Out of Network Clinicians/Facilities Psychological Testing Electroconvulsive Therapy (ECT) Inpatient, Residential, Partial-hospitalization or Intensive Outpatient Mental Health Services Neurodevelopmental Screening (Pediatric) New Medical Procedures still considered investigational or experimental Nutritional Counseling After 3 initial visits for members diagnosed with a metabolic disease or an eating disorder. Orthotics Osteochondral Autograft Transfer System (OATS)/Mosaicplasty Percutaneous Radiofrequency Ablation of Liver Plastic and Cosmetic (this is not an all inclusive list): Abdominoplasty Blepharoplasty B9998, S9434, S9435 All (non-emergency as noted) 96110 and related codes All 97802, 97803, S9452, S9470 Refer to the medical policy for Nutritional Counseling for specific detail of eligible diagnosis. Unlisted codes L2999 and L3999 regardless of cost and any line item with a purchase or rental price greater than $500 27415, 27416, 28446, 29866, 29867 47382 15830, 15847 Malar Augmentation, prosthetic material Otoplasty Pectus Excavatum/Pectus Carinatum repair Psoralens with Ultraviolet A Rhino/Septorhinoplasty Tarsorrhaphy 15820, 15821, 15822, 15823, 67900, 67901, 67902, 67903, 67904, 67906, 67908 19301, 19302, 19303, 19316, 19318, 19324, 19325, 19328, 19330, 19340, 19342, 19350,19357, 19361, 19364, 19366, 19367, 19368, 19369, 19370, 19371, 19380, 19396, S2066, S2067, S2068 15788, 15789, 15792, 15793 17340, 17360 15780, 15781, 15782, 15783, 15786, 15787 19300 Q4117, Q4118, Q4119, Q4120, Q4121 11950, 11951, 11952, 11954, 11960 17106, 17107, 17108, 30120 21282 15830, 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, 15847 21270 69300, 69310, 69320, 69399 21740, 21742, 21743 96912 30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462 67901, 67902, 67903, 67904, 67908, 67909, 67911 Tattooing of Skin 11920, 11921, 11922 Breast repair/re-construction **Except for patients with diagnosis of breast cancer, where prior authorization is not required for reconstructive procedures Chemical Peels Cryotherapy for Acne Dermabrasion Gynecomastia Hyalomatrix/Burn Care Injections (Collagen) Laser Treatment Lateral Canthopexy Lipectomy/Panniculectomy **Except for patients with diagnosis of breast cancer, Medical Prior Approval Requirements for BCBSVT and TVHP Updated: October 17, 2014 moved vertebroplasty from its own category to be included with percutaneous vertebraplasty or vertebral augmentation and added “services” to the end. where prior authorization is not required for reconstructive procedures Testicular Prosthesis Insertion 54660 Polysomnography & MSLT (Sleep Lab and/or Sleep Studies) 95782, 95805, 95807, 95808, 95810 Prescription Drugs Prosthetics See Separate List for Specifics Unlisted codes L2999, L3999, L5999, L7499, L8039, L8499 and L8699 regardless of cost and any other orthotic (or prosthetic) with a line item with a purchase or rental price greater than $500 Radiology * (BCBSVT does not have a prior approval requirement for radiology services provided to Access Blue New England members) Outpatient: *Computed Tomography Scans (CT) Computed Tomographic Angiography (CTA) Echocardiography (Stress, Transesophageal and Resting Transthoracic) Magnetic Resonance Angiography (MRA) *Magnetic Resonance Imaging (MRI) Magnetic Resonance Spectroscopy (MRS) Nuclear Cardiology Positron Emission Tomography (PET) T codes including virtual colonoscopy Function Brain MRI ALL Radiology prior approval requests must be submitted by the ordering provider through AIM Specialty Health by phone (800) 701-0080 or at www.aimspecialtyhealth.com *CT & MRI guided procedures do not require prior approval Radiation Treatment 77424, 77425, 77469, 77520, 77522, 77523, 77525 Rehabilitation (inpatient, including skilled nursing facilities) Substance Abuse Services (non-emergency) All   Out of Network Clinicians/Facilities Inpatient, Residential, Partial-hospitalization or Intensive Outpatient Substance Abuse Services All (non-emergency as noted) Surgery: Aqueous Shunt 66183 Bariatric (obesity) Surgery 43644, 43645, 43770, 43771, 43772, 43773, 43774, 43775, 43842, 43843, 43845, 43846, 43847, 43848, 43886, 43887, 43888 Endovascular Procedures 34841, 34842, 34843, 34844, 34845, 34846, 34847, 34848 Meniscal Transplantations 29868 Medical Prior Approval Requirements for BCBSVT and TVHP Updated: October 17, 2014 moved vertebroplasty from its own category to be included with percutaneous vertebraplasty or vertebral augmentation and added “services” to the end. Percutaneous Vertebroplasty or Vertebral Augmentation Services Sacroiliac Joint Pain Temporomandibular Joint Manipulation and Anesthesia Transcatheter Aortic Valve Replacement (TAVR/TAVI) Tumor Embolization Varicose Veins/Venous Insufficiency and other Vascular Procedures Transcutaneous Electrical Nerve Stimulation (TENS)/Neuromuscular Electrical Stimulators (NMES) 22520, 22521, 22522, 22610, 22612,72291, 72292 0334T, 27096, 27280, 27299, G0259, G0260 21073 33361, 33368, S2095 36468, 36479, 37760, S2202 63650, 63688, 33362, 33363, 33364, 33365, 33366, 33367, 33369 36469, 36470, 36471, 36475, 36476, 36478, 37243, 37500, 37700, 37718, 37722, 37735, 37761, 37765, 37766, 37780, 37785, 37799, 63655, 63661, 63662, 63663, 63664, 63685, 64550, 64577, 64580, 64581, 95971, 95972, 95973 (see the Durable Medical Equipment list for equipment and supplies requiring prior approval) Transplants (excludes Cornea and Kidney) UPPP/Somnoplasty (palatopharynogoplasty) All 42145 Medical Prior Approval Requirements for BCBSVT and TVHP Updated: October 17, 2014 moved vertebroplasty from its own category to be included with percutaneous vertebraplasty or vertebral augmentation and added “services” to the end.