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

Description

Diagnosis
Codes

Criteria

95803

Actigraphy

Any Dx

No 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

Baloon Sinuplasty for Treatment of Chronic Sinusitis

473.0
473.1
473.2
473.3
473.8
473.9

No clinical documentation required with request.

43659* 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

Biofeedback

595.1 
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 15823 

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.

0182T 19296
19297 19298
20555 31643
41019 67218
77326 77327
77328 77750
77761 77762
77763 77776
77777 77778 
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 Endoscopy

174.0 - 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 Trial

Cancer 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.

0126T

Carotid Intima-Media Thickness Measurement

 Any DX

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.

77520 77522

77523 77525

Charged-Particle (Proton or Helium) Radiation Therapy

Any DX

Send Charged-Particle (proton or Helium) Radiation Therapy Fax Form

69930 L8614

L8615 L8616 L8617 L8618 L8619 L8627

L8628S2235

Cochlear and Auditory Brainstem Implants

 Any DX

FEP:Send FEP Cochlear Implant Fax Form with the documentation requested.

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

97532

Cognitive Rehabilitation

 Any DX

FEP: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 ofTraumatic 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 DX

FEP: Send FEP Congenital Anomalies Fax Form with the documentation requested.

All other requests: No prior authorization recommended.

50250
50542
50593
19105

Cryosurgical Ablation of Miscellaneous Solid Tumors

 Any DX

FEP: 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 DX

FEP: 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 DX

FEP: 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 DX

FEP: 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 DX

FEP: 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 DX

FEP: Send FEP Endoscopic Injection Fax Form with the documentation requested.

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

E0784

External Insulin Infusion Pump

 Any DX

FEP: 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, 0300T

Extracorporeal Shock Wave Therapy for Musculoskeletal Conditions

 Any DX

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.

J7184, J7185, J7193 J7186, J7194 J7187, J7195 J7189, J7197 J7190, J7198 J7191, J7192

Factor for the Treatment of Hemophilia

 Any DX

FEP: 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 Walgreenswill 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 DX

FEP: 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.

S3854

Gene Expression Profiling for Managing Breast Cancer Treatment

 Any DX

FEP: Send FEP Gene Expression Profiling Fax Form with the documentation requested.

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

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.

81211, 81212 81213, 81214 81215, 81216 81217, 81479

Genetic Testing for Hereditary Breast and Ovarian Cancer

Any DX

Send Genetic Testing for Hereditary Breast and Ovarian Cancer Fax Form

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.

81211
81212
81213
81214
81215
81216
81217
81479
83898
83909
83912

Genetic Testing for Hereditary Breast and Ovarian Cancer

 Any DX

FEP: 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

E0446

Hyperbaric Oxygen Therapy (HBOT)

 Any DX

FEP: 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  L8691 L8693 S2230 V5095

Implantable Middle Ear and Bone-Anchored Hearing Aids

 Any DX

FEP: 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.

0099T

Implantation of Intrastromal Corneal Ring Segments)

 Any DX

FEP: 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.

E0740 64566 97014 97032 G0283

Incontinence Treatment System

 Any DX

FEP: 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
L1844

Knee braces

 Any DX

FEP: 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 DX

FEP: Send FEP Lower Limb Prostheses Fax Form with the documentation requested.

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

L5856,L5857 L5858,L5859 L5973

Microprocessor-Controlled Lower Limb Prostheses

Any DX

SendMicroprocessor-Controlled Lower Limb Prostheses Fax Form

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 DX

FEP: Send FEP MRI of Breast Fax Form with the documentation requested.

All other requests: Send MRI of Breast 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 DX

FEP: 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 DX

FEP: 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 DX

FEP: 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 DX

FEP: 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 DX

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

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

92065

Orthoptic Training

 Any DX

FEP: 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 for 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 Diseases

000.00-276.99
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 Recti

Any 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 DX

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.

E1016  E1018  
E2300  E2301
E2310  E2311
E2351  E2358 E2360  E2362 E2364  E2367  
E2372  E2609 E2610  E2617
K0669  K0806
K0807  K0808
K0830  K0831
K0868  K0869 K0870  K0871 K0877  K0878 K0879  K0880 K0884  K0885 K0886

Power Wheelchair

 Any DX

FEP: 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, 44721

Preparation/reconstruction on a cadaver or living donor intestine allograft prior to transplantation

 Any DX

FEP: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:

37204  75894
77399  77778 79445  C2616 S2095

Radioembolization for Primary and Metastatic Tumors of the Liver

 153.0-153.8
155.0-155.2
157.4
193

194.0-194.9

197.7
209.00-209.79
230.8
259.2
570

572.4

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 DX

FEP: 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 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.

63650-63688, 64581, 95970-95973

 Spinal Implants
(Neurostimulator)

 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.

  

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-0231T

Spinal 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-0218T

Spinal 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.

62287

Spinal 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, 22527

Spinal 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.

 M0076

Spinal Injections (Prolotherapy)

 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.

64622-64627, 64633-64636

Spinal Injections (Radiofrequency Neurotomy of Facet Joints)

 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.

64510, 64520

Spinal 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, G0260

Spinal Injections (Sacroiliac Joint 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.

22520-22525, 72291, 72292, 0200T, 0201T, S2360, S2361

Spinal Injections (Vertebroplasty and Sacroplasty)

  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.

20930, 20931, 21120

Spinal 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, 0055T

Spinal 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-E0749

Spinal 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, 0209T

Spinal 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–G0047

The 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.

90867 90868 90869

Transcranical Magnetic Stimulation (TMS)

Any DX

Send Transcranical Magnetic Stimulation Fax Form

0193T

Transurethral Radiofrequency

 Any DX

FEP: Send FEP Transurethral Radiofrequency Fax Form with the documentation requested.

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

42145

 UVPP UPPP
(Uvulopalatopharyngoplasty, Uvulopharyngoplasty)

 Any DX

FEP: 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 DX

FEP: 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 DX

FEP: 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 DX

FEP: Send FEP Wireless Capsule Endoscopy Fax Form with the documentation requested.

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