The prior authorization list is a resource for providers that lists the designated medical and surgical services and select prescription drugs which require prior authorization under a Blue Shield of California Promise Health Plan medical benefit. This list also includes specific equipment, services, drugs, and procedures requiring review or supplemental documentation prior to payment authorization.

Prior authorization for the services listed below is highly recommended. If authorization was not obtained prior to the service being rendered, the service will likely be reviewed for medical necessity at the point of claim.

While the list below covers the medical services, drugs, and procedures that require authorization prior to rendering a service, Blue Shield Promise may require additional information after the service has been provided. If we require further information to process the payment, Blue Shield Promise’s Claims Department will request specific information at that time. Please include medical records when you respond to a request from Blue Shield Promise’s Claims Department.

Please review our medical policies and verify that any service you are going to provide a Blue Shield Promise member is a covered benefit. You may review our medical policies online or contact Provider Services at (800) 468-9935, 8 a.m. to 5 p.m., Monday through Friday.

If prior authorization was obtained and you are submitting an offline (i.e., paper) claim, remember to attach a copy of the prior authorization letter.

SERVICE PROCEDURE (CPT) CODE
Allergist - Consult 99203, 99204, 99205, 99243, 99244, 99245, 99215
Allergist - Supplies 99070
Allergist - Spirometry 94010, 94060
Anesthesia services for dental procedures ANES, Z7500
Audiology consultations 99203, 99204, 99205, 99243, 99244
Audiology - Evoked Auditory Test 92587, 92558
Audiology - Follow-up visits up to x 3 99213-99214, 99215
Audiology - Hearing Quality Analysis 92524
Audiology - Hearing Testing 92550, 92553, 92555, 92556, 92557, 92565, 92582, 92587, 92588
Audiology - Nerve Conduction Test 95908
Audiology - Pure Tone Audiometry 92552
Audiology - Tympanometry 92567, 92568, 92550
Audiology - Visual Reinforcement Audiometry (VRA) 92579
Cardiology - Consults 99203, 99204, 99205, 99243, 99244
Cardiology - Stress Test and Holter Monitors 93015 / 93234
Cardiology - EKG 93000, 93005, 93010
Cardiology - Echocardiogram 93306, 93000, 93325, 93303, 93320
Cardiology - TTE 93351
Cardiology - Follow-up visits up to x 3 99213-99214, 99215
Cardiology - Breathing Capacity 94010
Cardiology - Evaluation of Wheezing 94060
Cardiology - Heart Cath 93451, 93453, 93456, 93457, 93460, 93461
Cardiology - Pacemaker device program eval 93279, 93280. 93288, 93283, 93289, 93290
Cardiology - Pacemaker Checks 93732
Cardiology - Oxygen Saturation 94760
Cardiology - Doppler Studies 93880, 93926, 93971
Dietary Consult All Codes
Dermatology - Consult (Exclusions: Nurse; MUST review: 1. Dx of: Acne, Alopecia, Keloid scars 2. Dermatology referral requests from Antelope Valley) 99203, 99204, 99205, 99243, 99244
Dermatology - Follow-up visits up to x 3 99213, 99214, 99215
Dermatology - Destruction of skin lesions 17111, 17108, 17999
Dermatology - Removal of skin tags 11200, 11201
Dermatology - Shave Lesion, Tray 11310, 11301, A4550, 11302, 11306, 11307
Dermatology - Inject Skin Lesions 11901, J3301, 11900
Dermatology - Biopsy 11100, 11101, 19802, 19802, A4215, A4550, A4649, 20206, 60100, 38505, 42400
Dermatology - Wound debridements 11056, 11055, 11042, 97568, 97597
Endocrinology - Consult 99203, 99204, 99205, 99243, 99244
Endocrinology - Follow-up visits up to x 3 99213, 99214, 99215
Endocrinology - Blood Glucose Test 82948, 82962
ENT - Consult 99203, 99204, 99205, 99243, 99244
ENT - Follow-up visits up to x 3 99213, 99214, 92557, 99215
ENT - Tympanometry 92567, 92550
ENT - Ear Microscopy 92504
ENT - Hearing Testing 92557
ENT - Diagnostic Laryngoscopy 31575
ENT - Nasal Endoscopy 31231
ENT - Hearing Exam Codes 92553, 92555, 92556, 92557, 92565, 92568, 92579, 92582, 92587, X4500
ENT - Control of Nose Bleed 30901, 30902, 30903
ENT - Evaluation of Speech 92521, 92522, 92523, 92506, 99354, 99355
Gastroenterology - Consult 99203, 99204, 99205, 99243, 99244, 99245
Gastroenterology - Follow-up visits up to x 3 99213, 99214, 99215
Gastroenterology - Colonoscopy 45381, 45384, 43450, 48385
Gastroenterology - Abdominal Paracentesis 49080
General Surgery - Consult 99203, 99204, 99205, 99243, 99244, 99245
General Surgery - Follow-up visits up to x 3 99213, 99214, 99215
General Surgery - Circumcision 54150, 54160, 54161
General Surgery - Colonoscopy 45378 to 45380 (Biopsy single or more)
General Surgery - Endoscopy 43235 to 43239 (Biopsy single or more)
General Surgery - POH with Approval from IPA Z7500
Surgical Procedures (e.g. Lap chole, hysterectomy, hernia repair, etc.) 99213-99214, 99215
ENT - Hearing Testing 99203, 99204, 99205, 99243, 99244, 99245
Infectious Disease - Follow-up visits up to x 3 99213, 99214, 99215
Infectious Disease - Gentamicin J1580
Infectious Disease - PICC Line Insertion 36569
Hematology, Oncology - Chemotherapy (Outpatient)
Hematology, Oncology - Injectables
Hematology, Oncology - Consult 99203, 99204, 99205, 99243, 99244
Hematology, Oncology - Follow-up visits up to x 3 99213, 99214, 99215
Hematology, Oncology - CBC 85025
Home Health - Skilled Services G0162, G0154, G0299, G0300, G0151, G0159, G0152, G0160, G0153, G0156, G0155, S9123, S9124, Z5834, Z5835
Home Infusion Medication - Initial and Follow Ups ALL MEDICATIONS CODES ONLY
Home Infusion Per Diem Supplies - Initial and Follow Ups x 3 months S5035, S5036, S5108, S5109, S5110, S5111, S5115, S5116, S5180, S5181, S5497, S5498, S5501, S5502 S5517, S5518, S5520, S5521, S5522, S5523, S9061, S9097 S9098, S9122, S9123 S9124, S9127, S9128, S9129, S9131, S9208, S9209, S9211, S9212, S9213, S9214, S9325, S9326, S9327, S9328, S9329, S9330, S9331, S9335, S9336, S9338, S9339 S9340, S9341, S9342, S9343, S9345, S9346, S9347, S9348, S9351, S9353 S9355, S9357, S9359, S9361, S9363, S9364, S9365, S9366, S9367, S9368, S9370, S9372, S9373, S9374, S9375, S9376, S9377, S9379, S9474, S9490, S9494, S9497, S9500, S9501, S9502, S9503, S9504, S9537, S9538, S9542, S9559, S9560, S9562, S9590 99601 99602
Wound Care Supplies - Initial and Follow Ups x 3 months A4217, A4927, A6452, A4406, A4407, A4385, A4409, A4411, A4412, A4413, A4415, A4416, A4417,A4418, A4419, A4420, A6010, A6021, A6022, A6154, A6196, A6197, A6199, A6203, A6204, A6205, A6206, A6207, A6208, A6209, A6210, A6211, A6212,A6213, A6214, A6215, A6216, A6217, A6218, A6219, A6220, A6221, A6222,A6223, A6224, A6228, A6229, A6230,A6231, A6232, A6237, A6238, A6239, A6240, A6241, A6243, A6244, A6245, A6246, A6247, A6248, A6251, A6252,A6253, A6254, A6255, A6256, A6257, A6258, A6259, A6261, A6262, A6266,A6402, A6403, A6404, A6407, A6410,A6411, A6442, A6443, A6444, A6445, A6446, A6447, A6449 A6453, A6455, A6457
Medical Supplies - Initial and Follow Ups x 3 months A4216, A4310, A4314, A4322, A4326, A4332, A4338, A4351, A4353, A4354, A4358, A4367, A4371, A4385, A4394, A4406, A4409, A4419, A4425, A4450, A4452, A4456, A4554, A5061, A5120, A5051, A5052, A5053, A5054, A5055, A5056, A5057, A5061, A5062, A5062, A5063, A5071, A5072, A5073, A5081, A5082, A5083, A5093, A5105, A5112, A5113, A5200
Hospice Room and Board - Initial and Follow Up x 6 Months 658
Nephrology - Consult 99203, 99204, 99205, 99243, 99244
076_Nephrology - Follow-up visits 99213, 99214, 99215
Nephrology- Dialysis
Neurology - Consult 99203, 99204, 99205, 99243, 99244, 99245
Neurology - Follow up visits 99213, 99214, 99215
Neurology - All Diagnostic Testing
Nutritional Counselling (New) Z5020
OB High Risk or perinatal - Total Care (non-high risk OB visits 4x or more until delivery plus 6 weeks post-partum) 59400, 59401, 59402, 59403, 59404, 59405, 59406, 59407, 59408, 59409, 76825, 59025, Z codes, CPSP
OB High Risk or perinatal - PCP requesting multiple ultrasounds (Normal OB)
OB High Risk or perinatal - Rhogam shots (part of total OB care) Automatic approval for all Rh negative moms G8809, G8810
OB High Risk or perinatal - Routine US and NST's (part of total OB care) 76801, 76805, 76813, 76816, 76817, 76820, 59025
OB High Risk or perinatal - Nucal Translucent (7-14 weeks gestation) 1st trimester screening (State Mandated) This is not High Risk and will be done by Perinatologist. 76801, 76813, 99243, 99203
OB High Risk or perinatal - Consult 99244, 99215
OB High Risk or perinatal - Breath Recording Infant 94772
OB High Risk or perinatal - Alpha-Fetoprotein 82105
Audiology - Visual Reinforcement Audiometry (VRA) OB High Risk or perinatal - Post-Partum Check
OB High Risk - Perinatology (HROB only) initial consult: HTN, Diabetes, GDM, PIH, Hyper/Hypo thyroidism, cardiac, seizure disorder 99243 or 99203
OB High Risk - Perinatology (HROB only) follow-up visits
OB High Risk - BPP (76818 & 76819), AFI (82143) BPP (76818 & 76819) AFI (82143)
OB High Risk - Multi -NSTs, US
OB High Risk - Genetic Testing
OB High Risk - Members in CM w/ HROB
OB High Risk - Fetal Echo 93325
Audiology - Follow-up visits up to x 3 76805, 76811
OB High Risk - Advanced Maternal Age
Gastroenterology - Abdominal Paracentesis
Occupational Therapy - Evaluation All Codes
Occupational Therapy - Therapeutic Exercise Initial up to 12 All Codes
Occupational Therapy - Therapeutic Exercise Additional Treatments after 12 All Codes
Optometry - Comprehensive eye exam/glasses ( EOC per County) 92004, V2020, 92340, 92341
Ophthalmology - Follow up visits up to x 3 92020, 99213, 99214, 99215
Ophthalmology - Echo Exam of Eye 76512, 76514, 76519
Ophthalmology - Visual Field Exam 92083
Ophthalmology - Computerized Scanning 92133, 92134
Ophthalmology - Refraction Determination 92015 (mcal only)
Ophthalmology - Special Eye Evaluation 92060, 92225, 92226
Ophthalmology - Eye Exam with Photos 92235, 92250
Ophthalmology - Serial Tonometry 92100
Ophthalmology - Injection 65800
Orthopedic - EMG All Codes
Orthopedic - Cast Removal 29705
Pain Management - Follow up visits x 6 99212, 99213, 99214, 99215
Pain Management - Drug test x 6 g0477
Pain Management - Drug Testing Multiple Classes G0431
Physical Therapy - Therapeutic Exercise: Initial and up to 12 All Codes
Physical Therapy - Therapeutic Exercise: Additional Treatments after 12 All Codes
Physical Therapy - Aquatic Therapy All Codes
Podiatry - Consult x 2 f/u (other Dx) 99202, 99203, 99204, 99205, 99244, 99245
Psychology, Psychiatry: Medicare- to BEACON, Medi-Cal - San Diego or LA County Mental Health - Consult, Therapy, ABA Must be sent to Beacon
Pulmonology - Consult 99202, 99203, 99204, 99205, 99244, 99245
Pulmonology - Follow up visits up to x 3 99213, 99214, 99215
Pulmonology - Sleep Study 95810
Pulmonology - PFT'S 94060, 94664, 94726, 94729, 95831
Pulmonology - Pulse Oximetry 94760
Pulmonology - Breathing Capacity 94375, 94010
Pulmonology - Pulmonary Stress Test 94621, 63300
Pulmonology - Blood Gases 82810
Pulmonology - Hempglobin 85018
Radiation Therapy ALL
Rheumatology - Consult 99202, 99203, 99204, 99205, 99244, 99245
Rheumatology - Follow up visits up to x 3 99213, 99214, 99215
Radiology, Imaging, Scans - Arterial Doppler 93925
Radiology, Imaging, Scans -Bone Scan 78300, 78306, 77080
Radiology, Imaging, Scans -Carotid Duplex 93880
Radiology, Imaging, Scans -CT Scans
Radiology, Imaging, Scans - Dexa Scan (Above 65) 77080, 77081
Radiology, Imaging, Scans - Doppler 93971
Radiology, Imaging, Scans - ECHO GIUDE FOR BX 76942
Radiology, Imaging, Scans - Echocardiogram 93306, 9332, 93303, 93320
Radiology, Imaging, Scans - Extremity Ultrasound 93970
Radiology, Imaging, Scans - Mammogram 77051, 77055, 77056, 77057, 76642, g0206
Radiology, Imaging, Scans - Computer Dx Mammogram 77051
Radiology, Imaging, Scans - Diagnostic Mammo Produc Dir G0204
Radiology, Imaging, Scans - MRI any codes for mri
Radiology, Imaging, Scans - MUGA 78472
Radiology, Imaging, Scans - PET Scan ALL
Radiology, Imaging, Scans - Plain films (1 to 3 views) 70110, 70140, 70160, 70360, 70200, 70210, 70220, 70260, 71010, 71020, 71030, 71101, 71111, 71120, 71030, 72040, 72050, 72070, 72100, 72110, 72190, 72202, 72220, 72072, 72090, 73000, 73030 73060, 73090, 73092, 73110, 73130, 73140, 74455, 73510, 72520, 73562, 73590, 73552, 73564, 73565, 74000, 73610, 73630, 73650, 74220, 74230, 76080, 77057
Radiology, Imaging, Scans - Radiation Therapy ALL
Radiology, Imaging, Scans - Ultrasound Soft Tissue 76999
Speech Therapy - Pediatric (Also refer for Linked Services) All Codes
Speech Therapy - Adult All Codes
Ultrasounds - Abdominal Ultrasound - RUQ pain 74290, 74291, 76700, 76705
Ultrasounds - Breast Ultrasound- breast mass G0206, 77641, 76645, 76642, 76641
Ultrasounds - Pelvic Ultrasound - pelvic pain 76856, 76857, 76830
Ultrasounds - Scrotal Ultrasound for mass/pain 76870
Ultrasounds - Head/neck Ultrasound 76536
Ultrasounds - Extremity Study 76775, 93970
Ultrasounds - Venous Doppler 93970, 93923, 93925
Ultrasounds - Thyroid 76700, 76705, 78006
Ultrasounds - Extracranial study 93880
Ultrasounds - Retroperitoneal 76770
Ultrasounds - Renal Ultrasound 76770
Ultrasounds - 2D Echo 93306
Ultrasounds - Transrectal Ultrasound 76872
Ultrasounds - Soft Tissue Ultrasound 76999
Urology - Consult 99202, 99203, 99204, 99205, 99244, 99245
Urology - Follow up visits up to x 3 99213, 99214, 99215
Urology - Vasectomy Z9780
Urology - Bladder scan (ultrasound) 51798
Urology - Electro-Uroflowmetry 51741
Urology - Bladder Irrigation 51700
Urology - Bladder Catheter Insertion 51703
Urology - Bladder Catheter Change 51703
Urology - Urine Capacity 51703
Urology - Urinalysis 51703
Vascular Surgery - Consult 99202, 99203, 99204, 99205, 99244, 99245
Vascular Surgery - Follow up visits up to x 3 99213, 99214, 99215
Durable Medical Equipment - New Request ($150 and below)
Durable Medical Equipment - Extension or Renewal
Durable Medical Equipment - Cane E0100
Durable Medical Equipment - CPAP Supplies Per Allowable (When CRAP Approved) All Codes
Durable Medical Equipment - Incontinent Supplies Per Allowable A4332, A6250, A7927
Durable Medical Equipment - Diapers and Liners Per Allowable T4525, T4526, T4527, T4535, T4536, T4537, T4541
Durable Medical Equipment - Indwelling Catheter Per Allowable A3353, A4351
Durable Medical Equipment - Diabetic Shoes L3030,L3221,L2999, L3215, A5500 x2
Durable Medical Equipment - Shoe Inserts A5512 x 6 /year
Durable Medical Equipment - Special Formula - Premature Infants
Durable Medical Equipment - Glucometers/Lancets & Test Strips (Advanced Diabetic Supply) Glucometer - E0607 / Lancets - A4259
Durable Medical Equipment - Hearing Aid MEDICAL ONLY
Durable Medical Equipment - Hearing Aid Repair V5014 UP TO X4-MEDICAL ONLY
Durable Medical Equipment - Medical Supplies
Durable Medical Equipment - Nebulizer (Asthma) J44 CODES E0570
Durable Medical Equipment - Ostomy Skin Barrier Per Allowable A4371
Durable Medical Equipment - Ostomy Supplies Per Allowable All codes
Durable Medical Equipment - Orthotic any "L" code
Durable Medical Equipment - Wrist Brace L3908
Durable Medical Equipment - Procrit-Epogen Injections
Durable Medical Equipment - Prosthetic
Durable Medical Equipment - Synagis Injections X7441, X7439
Durable Medical Equipment - Crutches E0114
Durable Medical Equipment - Walker, Walker with Seat E0135, E0143, E0156
Durable Medical Equipment - Wheelchair (Manual) K0001
Durable Medical Equipment - Wheelchair (Power)
Durable Medical Equipment - Scooter
Durable Medical Equipment - Wound Vac
Durable Medical Equipment - All Extension for CPAP/BiPAP, Manual Wheelchairs (if initial auth reviewed and approved)
Transportation - Non-Emergency Medical Transport, Non-Medical Transport A0100, A0420, A0425, A0428, A0130, A0434, A0999, T2005