provider connection

Prior Authorization List

The list below includes specific medical services and procedures requiring review and/or supplemental documentation prior to payment authorization. Use this list to ensure compliance with Blue Shield of California's requirements for prior authorization and improve the speed and efficiency of the claims processing.

Blue Shield of California Providers

For more information on obtaining prior authorization review refer to your provider manual. Remember to attach a copy of the prior authorization letter to claims submitted offline (i.e., paper).

Prior Authorization Requirements for Out-of-Area Blue Plan Members
View medical policy and general prior authorization requirements for your patients who are covered by an out-of-area Blue Plan.

Radiology and Imaging Services

Prior authorization medical necessity reviews are recommended for certain non-emergency outpatient radiology procedures (CT, MRI, MRA, PET, cardiac nuclear medicine) for Administrative Services Only (ASO), Direct Contracting and PPO plans. Review requests for services within California are performed by National Imaging Associates. Visit the NIA website to use this service, or call (888) NIA-BLUE (642-2583).

Submit out of state and Point of Service (POS) authorization requests to Blue Shield for select radiological procedures. See list below.

Musculoskeletal Services

Prior authorization medical necessity reviews are recommended for certain spinal procedures (spinal surgery, spinal injections, spinal implants) for Administrative Services Only (ASO), HMO Direct Contracting, and PPO plans. Review requests for services are performed by TRIAD Healthcare, a musculoskeletal health services company. Visit triadhealthcareinc.com/bsc to use this service or call (877) 282-2510.

Federal Employee Program

Members of the Federal Employee Blue Cross/Blue Shield Service Benefit Plan (FEP) are subject to different prior authorization requirements and generally do not require written prior authorization for the procedures and services listed below. However, for treatment requiring an inpatient stay, call (800) 633-4581 to obtain an authorization.

Out-of-Area Providers

If you are an Out-of-Area provider treating a Blue Shield of California member, refer to the Authorization List below or prior authorization requirements.

Prior Authorization List

Procedure
Codes
DescriptionDiagnosis
Codes
Criteria
95803ActigraphyAny DxNo records required. This procedure is considered investigational in all instances. If you would like to submit additional information, please forward to the Prior Aurthorization Department.

27412, J7330
S2112

Autologous Chondrocyte Implantation and Other Cell-based Treatments of Focal Articular Cartilage Lesions Any DX

FEP: Send FEP FEP Autologous Chondrocyte Implantation Fax Form with the documentation requested.

All other requests: Send Autologous Chondrocyte Implantation Fax Form with the documentation requested.

31295
31296
31297
S2344
Baloon Sinuplasty for Treatment of Chronic Sinusitis473.0
473.1
473.2
473.3
473.8
473.9

No clinical documentation required with request.

43999*Bariatric Surgery*Note: Prior Authorization is recommended when the requested with any of the following diagnoses:

278-278.02
278.8
V85.35-V85.39
V85.4

FEP: Send FEP Bariatric Surgery Fax Form with the documentation requested.

All other requests: Send Bariatric Surgery Fax Form with the documentation requested.
43644, 43645
*43659,43770
43771, 43772
43773, 43774
43775, 43842
43843, 43845
43846, 43847
43848, 43886
43887, 43888
*43999
Bariatric Surgery

Any DX

FEP: Send FEP Bariatric Surgery Fax Form with the documentation requested.

All other requests: Send Bariatric Surgery Fax Form with the documentation requested.

ALL BHT/ABA related codes when requested with any of the following diagnoses:Behavioral Health Treatment for Pervasive Developmental Disorders (BHT) *a.k.a., Applied Behavioral Analysis Therapy [ABA]299
299.0
299.00
299.01
299.1
299.10
299.11
299.8
299.80
299.81
299.9
299.90
299.91
 

BHT/ABA is covered under the Mental Health benefit.

For IN STATE requests:

Contact MHSA for authorization at 877-263-9952

For Out of State requests: BSC will review. Specific clinical will be requested by the reviewer, if needed.

Prior authorization is recommended for the following procedure codes when requested with any of the following diagnoses:
E0746

Biofeedback Any DX

FEP: Send FEP Biofeedback Fax Form with the documentation requested.

All other requests: Send Biofeedback Fax Form with the documentation requested.

90901
90911

Biofeedback595.1 
596.5-596.59
599.0-599.82
599.82
625.6
788.2-788.99

FEP: Send FEP Biofeedback Fax Form with the documentation requested.

All other requests: Send Biofeedback Fax Form with the documentation requested.

67900 67904 67901 67906
67902 67908
67903 67909
15820
15821
15822
Blepharoplasty, Blepharoptosis Repair, and Brow Lift Any DX

FEP: Send FEP Blepharoplasty Fax Form with the documentation requested.

All other requests: Send Blepharoplasty Fax Form with the documentation requested.

Prior authorization is recommended for the following procedure codes when requested with any of the following diagnoses:

83891
83898
83909
83912

BRAC Analysis Rearrangement Test (BART)174.0 - 174.9
V16.3
V16.41
V10 - V10.9
No records required. This procedure is considered investigational in all instances. If you would like to submit additional information, please forward to the Prior Authorization Department.

0182T 19296
19297 19298
20555 31643
41019 67218
77326 77327
77328 77750
77761 77762
77763 77776
77777 77778
77785 77785
77786 77787
C9725 C9726

Brachytherapy for Oncologic Indications
 Any DX

FEP: Send FEP Brachytherapy Fax Form with the documentation requested.

All other requests: Send Brachytherapy Fax Form with the documentation requested.

Prior authorization is recommended for the following procedure codes when requested with any of the following diagnoses:

88199
19499
Breast Duct Cytology and Endoscopy174.0 - 174.9
175.0
175.9
233.0
No records required. This procedure is considered investigational in all instances. If you would like to submit additional information, please forward to the Prior Authorization Department.
All codes requested as part of a Cancer Clinical TrialCancer Clinical Trial Any DX

FEP: Send FEP Cancer Clinical Trial Fax Form with the documentation requested.

All other requests: Send Cancer Clinical Trial Fax Form with the documentation requested.

0126TCarotid Intima-Media Thickness Measurement Any DXNo records required. This procedure is considered investigational in all instances. If you would like to submit additional information, please forward to the Prior Authorization Department.
21076, D5933 D8020, D8080 21079, D5936 D8030, 21080 D5951, D8040 D5922, D5955 D8050, D5931 D5958, D8060
D5932, D8010 D8070
Cleft Palate - Dental Related Services Any DXFEP: Send FEP Cleft Palate Fax Form with the documentation requested.

All other requests: Send Cleft Palate Fax Form with the documentation requested.
69930 L8615
L8616 L8617
L8618 L8619
L8614 S2235
Cochlear and Auditory Brainstem Implants Any DXFEP: Send FEP Cochlear Implant Fax Form with the documentation requested.

All other requests:
Send Cochlear Implant Fax Form with the documentation requested.
97532Cognitive Rehabilitation Any DXFEP: For treatment of Traumatic Brain Injury (TBI), send FEP Cognitive Rehabilitation Fax Form with the documentation requested. All other diagnoses: No records required. This procedure is considered investigational in all instances. If you would like to submit additional information, please forward to the Prior Authorization Department.

All other requests: For treatment of Traumatic Brain Injury (TBI), send Cognitive Rehabilitation Fax Form with the documentation requested. All other diagnoses: No records required. This procedure is considered investigational in all instances. If you would like to submit additional information, please forward to the Prior Authorization Department.
33813, 33814, 40700, 40701, 40702, 40720
40761, 42200, 42225, 50070, 50135, 50405
61680, 61682, 61684, 61686, 61690, 61692, 61710, 63250, 63251, 63252, C8921
Congenital Anomalies
(FEP Members Only)
 Any DXFEP: Send FEP Congenital Anomalies Fax Form with the documentation requested.

All other requests: No prior authorization recommended.
95250, A9278
95251, S1030
A9276, S1031
A9277
Continuous Glucose Monitoring Systems Any DXFEP: Send FEP Continuous Glucose Monitoring Fax Form with the documentation requested.

All other requests: Send Continuous Glucose Monitoring Fax Form with the documentation requested.
L0112
L0113
S1040
Cranial Remodeling Orthosis Any DXFEP: Send FEP Cranial Remodeling Fax Form with the documentation requested.

All other requests: Send Cranial Remodeling Fax Form with the documentation requested.
50250
50542
50593
19105
Cryosurgical Ablation of Miscellaneous Solid Tumors Any DXFEP: Send FEP Cryosurgical Ablation of Miscellaneous Solid Tumors Fax Form with the documentation requested.

All other requests: Send Cryosurgical Ablation of Miscellaneous Solid Tumors Fax Form with the documentation requested.
 55873 Cryosurgical Ablation of Prostate Cancer Any DXFEP: Send FEP Cryosurgical Ablation of Prostate Cancer Fax Form with the documentation requested.

All other requests: Send Cryosurgical Ablation of Prostate Cancer Fax Form with the documentation requested.

74261
74262
74263

CT Colonography (Virtual Colonoscopy)Any DXFEP: Send  FEP CT Colonography Fax Form with the documentation requested.

All other requests: Send CT Colonography Fax Form with the documentation requested.

61850 61870
61860 61875
61863 61880
61864 61885
61867 61886
61868 61888
64553 64555
64575 64568
64590 95971
C1767 C1778
C1816 C1787
C1820 C1897
L8680 L8681
L8682 L8683
L8685 L8686
L8687 L8688
L8689 L8695

 Deep Brain Stimulation Any DXFEP: Send FEP Deep Brain Stimulation Fax Form with the documentation requested.

All other requests: Send Deep Brain Stimulation Fax Form with the documentation requested.
E0747
E0748
E0749
20974
20975

Electrical Bone Growth Stimulation

 Any DXFEP: Send FEP Electrical Bone Growth Stimulation Fax Form with the documentation requested.
All other requests: Send Electrical Bone Growth Stimulation Fax Form with the documentation requested.
51715 Endoscopic Injection Any DXFEP: Send FEP Endoscopic Injection Fax Form with the documentation requested.

All other requests: Send Endoscopic Injection Fax Form with the documentation requested.
E0784External Insulin Infusion Pump Any DXFEP: Send FEP External Insulin Pump Fax Form with the documentation requested.

All other requests: Send External Insulin Pump Fax Form with the documentation requested.
28890, 0101T, 0019T, 0102T, 0299T, 0300TExtracorporeal Shock Wave Therapy for Musculoskeletal Conditions Any DXNo records required. This procedure is considered investigational in all instances. If you would like to submit additional information, please forward to the Prior Authorization Department.
J7184,
J7185, J7193
J7186, J7194
J7187, J7195
J7189, J7197
J7190, J7198
J7191, J7199
J7192
Factor for the Treatment of Hemophilia Any DXFEP: No prior authorization recommended.

All other requests: Send Factor for Treatment of Hemophilia Fax Form with the documentation requested.
Note: There is a narrow network for the distribution of Factor: CVS/Caremark and Walgreens will be the only providers. Factor from any other provider will be considered not a benefit after the effective dates.
0240T
0241T
91010
91013
91020
91022
91117
91120
91122
Gastrointestinal Motility and Manometry Testing Any DXFEP: Send FEP Gastrointestinal Motility and Manometry Testing Fax Form with the documentation requested.

All other requests: Send Gastrointestinal Motility and Manometry Testing Fax Form with the documentation requested.
S3854Gene Expression Profiling for Managing Breast Cancer Treatment Any DXFEP: Send FEP Gene Expression Profiling Fax Form with the documentation requested.

All other requests: Send Gene Expression Profiling Fax Form with the documentation requested.

00100
00170

General anesthesia for routine dental procedures performed in an outpatient surgery center or facility Any DX

FEP: Send FEP General Anesthesia for a Dental Procedure Fax Form with the documentation requested.

All other requests: Send General Anesthesia for a Dental Procedure Fax Form with the documentation requested.

81201 81202 81203 81292
81293
81294
81295
81296
81297
81298
81299
81300
81301
81317
81318
81319
Genetic Testing for Colorectal Cancer Any DX FEP: Send FEP Genetic Testing for Colorectal Cancer Risk Fax Form with the documentation requested.

All other requests: Send Genetic Testing for Colorectal Cancer Risk Fax Form with the documentation requested.
Prior authorization is recommended for the following procedure codes when requested with any of the following diagnoses.

83901
83909
88387
S3828
S3829
S3830
S3831
Genetic Testing for Colorectal Cancer153.0
153.1
153.2
153.3
153.4
153.5
153.6
153.7
153.8
153.9 
154.0
154.1
154.2
154.3
154.8
211.3
211.4
230.3
230.4
230.5
230.6
235.2
239.0
V10.05
V10.06
V12.72
V16.0
V18.51
V26.31
V26.34
V26.39
V76.41
V76.50
V76.51
V82.71
V84.09
FEP: Send FEP Genetic Testing for Colorectal Cancer Risk Fax Form with the documentation requested.

All other requests: Send Genetic Testing for Colorectal Cancer Risk Fax Form with the documentation requested.
81211
81212
81213
81214
81215
81216
81217
81479
83898
83909
83912
Genetic Testing for Hereditary Breast and Ovarian Cancer Any DXFEP: Send FEP Genetic Testing for Hereditary Breast and Ovarian Cancer Fax Form with the documentation requested.

All other requests: Send Genetic Testing for Hereditary Breast and Ovarian Cancer Fax Form with the documentation requested.

Prior authorization is recommended for the following procedure codes when requested with any of the following diagnoses:

19301
19303
19304

Gynecomastia

000.00-174.99
175.91-198.80
198.82-232.99
233.01-999.99

FEP: Send FEP Gynecomastia Fax Form with the documentation requested.

All other requests: Send Gynecomastia Fax Form with the documentation requested.

Note: Prior authorization is required for the following procedure codes when requested with the following diagnoses.

19300
Gynecomastia Any DX

FEP: Send FEP Gynecomastia Fax Form with the documentation requested.

All other requests: Send Gynecomastia Fax Form with the documentation requested.

99183
A4575
C1300
Hyperbaric Oxygen Therapy (HBOT)
 Any DXFEP: Send FEP Hyperbaric Oxygen Therapy Fax Form with the documentation requested.

All other requests: Send Hyperbaric Oxygen Therapy Fax Form with the documentation requested.
69710
69711
69714
69715
69717
69718
L8690
Implantable Middle Ear and Bone-Anchored Hearing Aids Any DXFEP: Send FEP Implantable Middle Ear and Bone-Anchored Hearing Aids Fax Form with the documentation requested.

All other requests: Send Implantable Middle Ear and Bone-Anchored Hearing Aids Fax Form with the documentation requested.
0099TImplantation of Intrastromal Corneal Ring Segments)
 Any DXFEP: Send FEP Implantation of Intrastromal Corneal Ring Segments Fax Form with the documentation requested.

All other requests: Send Implantation of Intrastromal Corneal Ring Segments Fax Form with the documentation requested.
E0740Incontinence Treatment System Any DXFEP: Send FEP Incontinence Treatment System Fax Form with the documentation requested.

All other requests: Send Incontinence Treatment System Fax Form with the documentation requested.
L8603
L8606
Injectable Bulking Agent Any DX FEP: Send FEP Injectable Bulking Agent Fax Form with the documentation requested.

All other requests: Send Injectable Bulking Agent Fax Form with the documentation requested.

0073T
77301
77338
77418

Intensity Modulated Radiation Therapy (IMRT)Any DX
See Note in Criteria

FEP: Send FEP Intensity Modulated Radiation Fax Form with the documentation requested. Note: Prior authorization is not recommended for outpatient IMRT with one of the following diagnoses related to head, neck, breast, or prostate cancer:

  • 174.0-174.9

  • 175 .0-175.9

  • 185

Exception:
Prior Authorization is not required for outpatient IMRT with one of the following diagnoses:
140.0-149.9
• 154.2-154.3
• 160.0-161.9
• 190.0-190.9
• 195.0
• 230.0
• 230.5-230.6
• 235.6

All other requests: Send Intensity Modulated Radiation Fax Form with the documentation requested.

L1840 L1846
L1843 L1844
L2755 L2800
Knee braces
 Any DXFEP: Send FEP Knee Braces Fax Form with the documentation requested.

All other requests: Send Knee Braces Fax Form with the documentation requested
L5100 L5230
L5105 L5250
L5150 L5270
L5160 L5280
L5301 L5311
L5321 L5331
L5341 L5617
L5700 L5701
L5702 L5930
L5990 L5312
Lower Limb Prostheses Any DXFEP: Send FEP Lower Limb Prostheses Fax Form with the documentation requested.

All other requests: Send  Lower Limb Prostheses Fax Form with the documentation requested.
77058
77059
C8903
C8904
C8905
C8906
C8907
C8908
0159T
MRI of breast

Shared Advantage members within CA and any member receiving services out of state. Contact Blue Shield of California Prior Authorization Department. PPO underwritten, Direct Contract HMO and Administrative Services Only (ASO) members receiving services within California: Contact National Imaging Associates (NIA) for prior authorization.

MRI of the breast without the use of a breast coil, regardless of the clinical indication, is considered investigational.
 Any DXFEP: Send FEP MRI of Breast Fax Form with the documentation requested.

All other requests: Send MRI of Breast Fax Form with the documentation requested.
L6025
L6881
L6882
L6925
L6935
L6945
L6955
L6965
L6975
L7007
L7008
L7009
L7045
L7180
L7181
L7190
L7191
L6715
L6880
Myoelectric Upper Limb Prostheses Any DXFEP: Send FEP Myoelectric Upper Limb Prostheses Fax Form with the documentation requested.

All other requests: Send Myoelectric Upper Limb Prostheses Fax Form with the documentation requested.

97605
97606
A6550
A9272
E2402
G0456
G0457
K0743
K0744
K0745
K0746

codes in yellow require no review for Dx 998.83

Negative Pressure Wound Therapy in the Outpatient Setting Any DXFEP: Send FEP Negative Pressure Wound Therapy in the outpatient setting Fax Form with the documentation requested.

All other requests: Send Negative Pressure Wound Therapy in the outpatient setting Fax Form with the documentation requested
63185 C1787
63190 C1816
63650 C1820
63655 C1897
63663 E0747
63664 L8680
63685 L8681
63688 L8682
64555 L8683
64565 L8685
64575 L8686
64580 L8687
64585 L8688
64590 L8689
64595 L8695
C1767
C1778
Neuromuscular and Functional Electrical Stimulation) Any DXFEP: Send FEP Neuromuscular and Functional Electrical Stimulation Fax Form with the documentation requested.

All other requests: Send Neuromuscular and Functional Electrical Stimulation Fax Form with the documentation requested.
96116
96118
96119
96120
Neuropsychological Testing Any DXFEP: Send FEP FEP Neuropsychological Testing Fax Form with the documentation requested.

All other requests: Send Neuropsychological Testing Fax Form with the documentation requested.
20605, 21010, 21026, 21030, 21031, 21032, 21034, 21037, 21040, 21044, 21045, 21046
21047, 21048, 21049, 21050, 21060, 21070, 21073, 21116, 21240, 21241, 21242, 21243
21480, 21485, 21490, 29800, 29804, 40490, 40500, 40510, 40520, 40525, 40527, 40530
40650, 40800, 40801, 40804, 40805, 40806, 40808, 40810, 40812, 40814, 40816, 40819
40820, 40830, 40831, 40840, 40842, 40843, 40844, 40845, 41000, 41005, 41006, 41007
41008, 41009, 41010, 41015, 41016, 41017, 41018, 41100, 41105, 41108, 41110, 41112
41113, 41114, 41115, 41116, 41120, 41130, 41150, 41250, 41251, 41252, 41520, 42000
42100, 42104, 42106, 42107, 42120, 42140, 42160, 42300, 42305, 42310, 42320, 42330,
42335, 42340 
Oral/Maxillofacial Procedures
(FEP Members Only)
Any DXFEP: Send FEP FEP Oral/Maxillofacial Fax Form with the documentation requested.

All other requests: No prior authorization recommended.
21085, 21146, 21196,
21110, 21147, 21198
21120, 21150, 21199
21121, 21151, 21206
21122, 21154, 21208
21123, 21155, 21209
21125, 21159, 21210
21127, 21160, 21215
21141, 21188, 21230
21142, 21193, 21247
21143, 21194
21145, 21195
D7940, D7941, D7943
D7944, D7945, D7946
D7947, D7948, D7949
D7950, D7995, D7996
 Orthognathic Surgery Any DXFEP: Send FEP Orthognathic Surgery Fax Form with the documentation requested.

All other requests: Send Orthognathic Surgery Fax Form with the documentation requested.
92065Orthoptic Training Any DXFEP: Send FEP Orthoptic Training Fax Form with the documentation requested.

All other requests: Send Orthoptic Training Fax Form with the documentation requested.
 

Prior authorization is  recommended fot the following procedure codes when requested with any of the following diagnoses:

E0481
E0483
E0484
A7025
A7026
S8185

Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Diseases000.00-276.99
277.10-999.99
 

FEP: Send FEP Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Diseases Fax Form with the documentation requested.

All other requests: Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Diseases Fax Form with the documentation requested.

15830
15847
Panniculectomy, Abdominoplasty and Surgical Management of Diastasis RectiAny DX

FEP: Send FEP Panniculectomy Abdominoplasty Fax Form with the documentation requested.

All other requests: Send Panniculectomy Abdominoplasty Fax Form with the documentation requested.

78608
78609
78811
78812
78813
78814
78815
78816

G0235
G0252
G0219
S8085

Positron Emission Tomography (PET)

Shared Advantage members within CA and any member receiving services out of state: Contact Blue Shield of California Prior Authorization Department. PPO underwritten, Direct Contract HMO and Administrative Services Only (ASO) members receiving services within California: Contact National Imaging Associates (NIA) for prior authorization.
000.00-139.99
149.81-149.99
150.91-151.99
152.91-152.99
153.91-153.99
154.81-160.19
160.51-160.99
161.91-182.99
183.01-190.99
191.91-194.99
195.01-199.99
200.89-200.99
201.99
202.99
730.20-999.99
FEP: Send FEP Positron Emission Tomography (PET) Fax Form with the documentation requested.

All other requests: Send Positron Emission Tomography (PET) Fax Form with the documentation requested.
78459
78491
78492
Positron Emission Tomography (PET)

Shared Advantage members within CA and any member receiving services out of state: Contact Blue Shield of California Prior Authorization Department. PPO underwritten, Direct Contract HMO and Administrative Services Only (ASO) members receiving services within California: Contact National Imaging Associates (NIA) for prior authorization.
 Any DXFEP: Send FEP Positron Emission Tomography (PET) Fax Form with the documentation requested.

All other requests: Send Positron Emission Tomography (PET) Fax Form with the documentation requested.

E1002  E1003
E1004  E1005
E1006  E1007
E1008  E1009
E1010  E1016
E1018  E1230
E2301  E2300
E2310  E2311
E2351  E2360 E2362  E2364
E2367  E2368
E2369  E2370
E2372  E2378
E2609  E2610
E2617
K0010 K0011
K0014 K0108
K0462 K0669
K0800 K0801
K0802 K0806
K0807 K0808
K0812 K0813
K0814 K0815
K0820 K0821
K0822 K0823
K0824 K0825
K0826 K0827
K0828 K0829
K0830 K0831
K0835 K0836
K0837 K0838
K0839 K0840
K0841 K0842
K0843 K0848
K0849 K0850
K0851 K0852
K0853 K0854
K0855 K0856
K0857 K0858
K0859 K0860
K0861 K0862
K0864 K0868
K0869 K0870
K0871 K0877
K0878 K0879
K0880 K0884
K0885 K0886
K0890 K0891

Power Wheelchair Any DXFEP: Send FEP FEP Power Wheelchair Fax Form with the documentation requested.

All other requests: Send Power Power Wheelchair Fax Form with the documentation requested.
44715, 44720, 44721Preparation/reconstruction on a cadaver or living donor intestine allograft prior to transplantation Any DXFEP: No prior authorization recommended.

All other requests: Send Preparation Reconstruction Fax Form with the documentation requested. For questions: Contact the Transplant Team-916 350 7708
Prior authorization is recommended for the following procedure codes when requested with any of the following diagnoses:

36245
37204
47370
47371
47380
47381
47382
75894
75896
77399
77778

Radioembolization for Primary and Metastatic Tumors of the Liver 153.0-153.9
154.0-154.8
155.0-155.2
157.4
190
190.6
190.8
197.6
197.7
209.00-209.30
230.8
251
251.1
251.2
251.4-251.9
259.2
V49.83
FEP: Send FEP Radioembolization of Liver Tumors (SIRT) Fax Form with the documentation requested.

All other requests: Send Radioembolization of Liver Tumors (SIRT) Fax Form with the documentation requested.
20982
32998
50542
50592
76940
77013
77022
Radiofrequency Ablation of Solid Tumors Excluding Liver Tumors Any DXFEP: Send FEP Radiofrequency Ablation of Solid Tumors Excluding Liver Tumors Fax Form with the documentation requested.

All other requests: Send Radiofrequency Ablation of Solid Tumors Excluding Liver Tumors  Fax Form with the documentation requested.
A4305, A4306, E0779-E0781 Spinal Implants
(Continuous local infusion device)
  Any DXThe prior authorization process is applicable to the following Blue Shield of California members:
  1. Fully-Insured PPO
  2. Self-Insured PPO
  3. Direct Contracting HMO – Members who have an HMO benefit and have selected a Blue Shield administered Direct Contract HMO (DCHMO) network option, or members using their point-of-service option (POS).

Please note: Any Blue Shield HMO members who have selected IPA/medical groups that are delegated for prior authorization as their provider network are not included in the new prior authorization process.

Send Spinal Surgery/Injections/Implants/Devices TRIAD fax form with the documentation requested.
63650-63688, 64581, 95970-95973 Spinal Implants
(Neurostimulator)
 Any DXThe prior authorization process is applicable to the following Blue Shield of California members:
  1. Fully-Insured PPO
  2. Self-Insured PPO
  3. Direct Contracting HMO – Members who have an HMO benefit and have selected a Blue Shield administered Direct Contract HMO (DCHMO) network option, or members using their point-of-service option (POS).

Please note: Any Blue Shield HMO members who have selected IPA/medical groups that are delegated for prior authorization as their provider network are not included in the new prior authorization process.

Send Spinal Surgery/Injections/Implants/Devices TRIAD fax form with the documentation requested.
  

62318, 62319, 62350, 62351, 62352, 62353, 62354, 62355, 62356, 62357, 62358, 62359, 62360, 62361, 62362, 62363, 62364, 62365, 62366, 62368, 95990-95991

 Spinal Implants
(Pain pump)
 Any DX The prior authorization process is applicable to the following Blue Shield of California members:
  1. Fully-Insured PPO
  2. Self-Insured PPO
  3. Direct Contracting HMO – Members who have an HMO benefit and have selected a Blue Shield administered Direct Contract HMO (DCHMO) network option, or members using their point-of-service option (POS).

Please note: Any Blue Shield HMO members who have selected IPA/medical groups that are delegated for prior authorization as their provider network are not included in the new prior authorization process.

Send Spinal Surgery/Injections/Implants/Devices TRIAD fax form with the documentation requested.
62290-62292, 72275, 72285, 72295 Spinal Injections (Discography) Any DX The prior authorization process is applicable to the following Blue Shield of California members:
  1. Fully-Insured PPO
  2. Self-Insured PPO
  3. Direct Contracting HMO – Members who have an HMO benefit and have selected a Blue Shield administered Direct Contract HMO (DCHMO) network option, or members using their point-of-service option (POS).

Please note: Any Blue Shield HMO members who have selected IPA/medical groups that are delegated for prior authorization as their provider network are not included in the new prior authorization process.

Send Spinal Surgery/Injections/Implants/Devices TRIAD fax form with the documentation requested.
62310, 62311, 64479-64484, 0228T-0231TSpinal Injections (Epidural Steroid Injections) Any DX The prior authorization process is applicable to the following Blue Shield of California members:
  1. Fully-Insured PPO
  2. Self-Insured PPO
  3. Direct Contracting HMO – Members who have an HMO benefit and have selected a Blue Shield administered Direct Contract HMO (DCHMO) network option, or members using their point-of-service option (POS).

Please note: Any Blue Shield HMO members who have selected IPA/medical groups that are delegated for prior authorization as their provider network are not included in the new prior authorization process.

Send Spinal Surgery/Injections/Implants/Devices TRIAD fax form with the documentation requested.
64490-64495, 64470-64476, 0213T-0218TSpinal Injections(Facet Joint Injections and Facet Joint Blocks) Any DX The prior authorization process is applicable to the following Blue Shield of California members:
  1. Fully-Insured PPO
  2. Self-Insured PPO
  3. Direct Contracting HMO – Members who have an HMO benefit and have selected a Blue Shield administered Direct Contract HMO (DCHMO) network option, or members using their point-of-service option (POS).

Please note: Any Blue Shield HMO members who have selected IPA/medical groups that are delegated for prior authorization as their provider network are not included in the new prior authorization process.

Send Spinal Surgery/Injections/Implants/Devices TRIAD fax form with the documentation requested.
 

62263, 62264,
62280

Spinal Injections (Lysis of Epidural Adhesions) Any DX The prior authorization process is applicable to the following Blue Shield of California members:
  1. Fully-Insured PPO
  2. Self-Insured PPO
  3. Direct Contracting HMO – Members who have an HMO benefit and have selected a Blue Shield administered Direct Contract HMO (DCHMO) network option, or members using their point-of-service option (POS).

Please note: Any Blue Shield HMO members who have selected IPA/medical groups that are delegated for prior authorization as their provider network are not included in the new prior authorization process.

Send Spinal Surgery/Injections/Implants/Devices TRIAD fax form with the documentation requested.
62287Spinal Injections (Percutaneous Decompression Procedure Any DX The prior authorization process is applicable to the following Blue Shield of California members:
  1. Fully-Insured PPO
  2. Self-Insured PPO
  3. Direct Contracting HMO – Members who have an HMO benefit and have selected a Blue Shield administered Direct Contract HMO (DCHMO) network option, or members using their point-of-service option (POS).

Please note: Any Blue Shield HMO members who have selected IPA/medical groups that are delegated for prior authorization as their provider network are not included in the new prior authorization process.

Send Spinal Surgery/Injections/Implants/Devices TRIAD fax form with the documentation requested.
22526, 22527Spinal Injections (Percutaneous Intradiscal Electrothermal Annuloplasty) Any DX The prior authorization process is applicable to the following Blue Shield of California members:
  1. Fully-Insured PPO
  2. Self-Insured PPO
  3. Direct Contracting HMO – Members who have an HMO benefit and have selected a Blue Shield administered Direct Contract HMO (DCHMO) network option, or members using their point-of-service option (POS).

Please note: Any Blue Shield HMO members who have selected IPA/medical groups that are delegated for prior authorization as their provider network are not included in the new prior authorization process.

Send Spinal Surgery/Injections/Implants/Devices TRIAD fax form with the documentation requested.
 M0076Spinal Injections (Prolotherapy) Any DXThe prior authorization process is applicable to the following Blue Shield of California members:
  1. Fully-Insured PPO
  2. Self-Insured PPO
  3. Direct Contracting HMO – Members who have an HMO benefit and have selected a Blue Shield administered Direct Contract HMO (DCHMO) network option, or members using their point-of-service option (POS).

Please note: Any Blue Shield HMO members who have selected IPA/medical groups that are delegated for prior authorization as their provider network are not included in the new prior authorization process.

Send Spinal Surgery/Injections/Implants/Devices TRIAD fax form with the documentation requested.
64622-64627, 64633-64636Spinal Injections (Radiofrequency Neurotomy of Facet Joints) Any DXThe prior authorization process is applicable to the following Blue Shield of California members:
  1. Fully-Insured PPO
  2. Self-Insured PPO
  3. Direct Contracting HMO – Members who have an HMO benefit and have selected a Blue Shield administered Direct Contract HMO (DCHMO) network option, or members using their point-of-service option (POS).

Please note: Any Blue Shield HMO members who have selected IPA/medical groups that are delegated for prior authorization as their provider network are not included in the new prior authorization process.

Send Spinal Surgery/Injections/Implants/Devices TRIAD fax form with the documentation requested.
64510, 64520Spinal Injections (Regional Sympathetic Blocks)  Any DX The prior authorization process is applicable to the following Blue Shield of California members:
  1. Fully-Insured PPO
  2. Self-Insured PPO
  3. Direct Contracting HMO – Members who have an HMO benefit and have selected a Blue Shield administered Direct Contract HMO (DCHMO) network option, or members using their point-of-service option (POS).

Please note: Any Blue Shield HMO members who have selected IPA/medical groups that are delegated for prior authorization as their provider network are not included in the new prior authorization process.

Send Spinal Surgery/Injections/Implants/Devices TRIAD fax form with the documentation requested.
27096, G0259, G0260Spinal Injections (Sacroiliac Joint Injections)  Any DXThe prior authorization process is applicable to the following Blue Shield of California members:
  1. Fully-Insured PPO
  2. Self-Insured PPO
  3. Direct Contracting HMO – Members who have an HMO benefit and have selected a Blue Shield administered Direct Contract HMO (DCHMO) network option, or members using their point-of-service option (POS).

Please note: Any Blue Shield HMO members who have selected IPA/medical groups that are delegated for prior authorization as their provider network are not included in the new prior authorization process.

Send Spinal Surgery/Injections/Implants/Devices TRIAD fax form with the documentation requested.
22520-22525, 72291, 72292, 0200T, 0201T, S2360, S2361Spinal Injections (Vertebroplasty and Sacroplasty)  Any DXThe prior authorization process is applicable to the following Blue Shield of California members:
  1. Fully-Insured PPO
  2. Self-Insured PPO
  3. Direct Contracting HMO – Members who have an HMO benefit and have selected a Blue Shield administered Direct Contract HMO (DCHMO) network option, or members using their point-of-service option (POS).

Please note: Any Blue Shield HMO members who have selected IPA/medical groups that are delegated for prior authorization as their provider network are not included in the new prior authorization process.

Send Spinal Surgery/Injections/Implants/Devices TRIAD fax form with the documentation requested.
20930, 20931, 21120Spinal Surgery (Bone Morphogenetic Protein) Any DX The prior authorization process is applicable to the following Blue Shield of California members:
  1. Fully-Insured PPO
  2. Self-Insured PPO
  3. Direct Contracting HMO – Members who have an HMO benefit and have selected a Blue Shield administered Direct Contract HMO (DCHMO) network option, or members using their point-of-service option (POS).

Please note: Any Blue Shield HMO members who have selected IPA/medical groups that are delegated for prior authorization as their provider network are not included in the new prior authorization process.

Send Spinal Surgery/Injections/Implants/Devices TRIAD fax form with the documentation requested.
20985, 0054T, 0055TSpinal Surgery (Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedure) Any DX The prior authorization process is applicable to the following Blue Shield of California members:
  1. Fully-Insured PPO
  2. Self-Insured PPO
  3. Direct Contracting HMO – Members who have an HMO benefit and have selected a Blue Shield administered Direct Contract HMO (DCHMO) network option, or members using their point-of-service option (POS).

Please note: Any Blue Shield HMO members who have selected IPA/medical groups that are delegated for prior authorization as their provider network are not included in the new prior authorization process.

Send Spinal Surgery/Injections/Implants/Devices TRIAD fax form with the documentation requested.
20974, 20975, E0747-E0749Spinal Surgery (Electrical Bone Growth)
 Any DX The prior authorization process is applicable to the following Blue Shield of California members:
  1. Fully-Insured PPO
  2. Self-Insured PPO
  3. Direct Contracting HMO – Members who have an HMO benefit and have selected a Blue Shield administered Direct Contract HMO (DCHMO) network option, or members using their point-of-service option (POS).

Please note: Any Blue Shield HMO members who have selected IPA/medical groups that are delegated for prior authorization as their provider network are not included in the new prior authorization process.

Send Spinal Surgery/Injections/Implants/Devices TRIAD fax form with the documentation requested.
22100-22226, 63001-63308, S2348, S2350, S2351, S2090, 0274T, 22556, 22633, 22634,Spinal Surgery (Spinal Decompression, Laminectomy) Any DX The prior authorization process is applicable to the following Blue Shield of California members:
  1. Fully-Insured PPO
  2. Self-Insured PPO
  3. Direct Contracting HMO – Members who have an HMO benefit and have selected a Blue Shield administered Direct Contract HMO (DCHMO) network option, or members using their point-of-service option (POS).

Please note: Any Blue Shield HMO members who have selected IPA/medical groups that are delegated for prior authorization as their provider network are not included in the new prior authorization process.

Send Spinal Surgery/Injections/Implants/Devices TRIAD fax form with the documentation requested.
22532-22812, 0195T, 0196T, 22586, 22818, 22819, 22830, 22856-22865, 0092T-0098T, 0202T, 0209TSpinal Surgery (Spinal Fusion, Kyphectomy, Exploration of Spinal Fusion, Spinal Arthroplasty) Any DX The prior authorization process is applicable to the following Blue Shield of California members:
  1. Fully-Insured PPO
  2. Self-Insured PPO
  3. Direct Contracting HMO – Members who have an HMO benefit and have selected a Blue Shield administered Direct Contract HMO (DCHMO) network option, or members using their point-of-service option (POS).

Please note: Any Blue Shield HMO members who have selected IPA/medical groups that are delegated for prior authorization as their provider network are not included in the new prior authorization process.

Send Spinal Surgery/Injections/Implants/Devices TRIAD fax form with the documentation requested.
70010–78999, G0235, G0030–G0047The following should be referred to National Imaging Associates (NIA) for authorization: All non-emergency, outpatient CT, MRI, MRA, PET studies for PPO underwritten members , Direct Contract network HMO, and Administrative Services Only (ASO) members who reside in CA and receiving services within CA. (Related temporary codes: 0144T, 0148T, 0150T, S8037, 0042T, 0066T, 0067T). Any DX Submit supporting clinical indications for service.
0193TTransurethral Radiofrequency Any DXFEP: Send FEP Transurethral Radiofrequency Fax Form with the documentation requested.

All other requests: Send Transurethral Radiofrequency Fax Form with the documentation requested.

20979
E0760
Ultrasound Bone Growth Stimulation Any DXFEP: Send FEP FEP Ultrasound Bone Growth Stimulation Fax Form with the documentation requested.

All other requests: Send Ultrasound Bone Growth Stimulation Fax Form with the documentation requested.
42145 UVPP UPPP
(Uvulopalatopharyngoplasty, Uvulopharyngoplasty)
 Any DXFEP: Send FEP UVPP UPPP Fax Form with the documentation requested.

All other requests: Send UVPP UPPP Fax Form with the documentation requested.
36468, 36478
36469, 36479
36470, 37500
36471, 37765
36475, 37766
36476, S2202
 Varicose Vein Treatments Any DXFEP: Send FEP Varicose Vein Treatments Fax Form with the documentation requested.

All other requests: Send Varicose Vein Treatments Fax Form with the documentation requested.
 

93292
93745
K0606
K0607
K0608 
K0609

Wearable Cardioverter Defibrillator Any DXFEP: Send FEP Wearable Cardioverter Defibrillator Fax Form with the documentation requested.

All other requests: Send Wearable Cardioverter Defibrillator Fax Form with the documentation requested.
91110
91111
Wireless Capsule Endoscopy Any DXFEP: Send FEP Wireless Capsule Endoscopy Fax Form with the documentation requested.

All other requests: Send Wireless Capsule Endoscopy Fax Form with the documentation requested.