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

Medical Policy Procedure Codes
Actigraphy 95803
Autologous Chondrocyte Implantation and Other Cell-based Treatments of Focal Articular Cartilage Lesions 27412, J7330
S2112
Balloon Sinuplasty for Treatment of Chronic Sinusitis 31295
31296
31297
Bariatric Surgery 43659* 43999*
Bariatric Surgery 43644, 43645
*43659, 43770
43771, 43772
43773, 43774
43775, 43842
43843, 43845
43846, 43847
43848, 43886
43887, 43888
*43999
Behavioral Health Treatment for Pervasive Developmental Disorders (BHT) *a.k.a., Applied Behavioral Analysis Therapy [ABA] ALL BHT/ABA related codes when requested with any of the following diagnoses:
Biofeedback Prior authorization is recommended for the following procedure codes when requested with any of the following diagnoses:
E0746
Biofeedback 90901
90911
Blepharoplasty, Blepharoptosis Repair, and Brow Lift 67900 67904 67901 67906
67902 67908
67903 67909
15820 15821
15822 15823 
Brachytherapy for Oncologic Indications 0182T 19296
19297 19298
20555 31643
41019 67218
77326 77327
77328 77750
77761 77762
77763 77776
77777 77778 
77785 77786 77787
C9725 C9726
Breast Duct Cytology and Endoscopy Prior authorization is recommended for the following procedure codes when requested with any of the following diagnoses:

88199
19499
Cancer Clinical Trial All codes requested as part of a Cancer Clinical Trial
Carotid Intima-Media Thickness Measurement 0126T
Charged-Particle (Proton or Helium) Radiation Therapy 77520 77522 77523 77525
Cochlear and Auditory Brainstem Implants 69930 L8614 L8615 L8616 L8617 L8618 L8619 L8627 L8628S2235
Cognitive Rehabilitation 97532
Congenital Anomalies
(FEP Members Only)
33813, 33814, 40700, 40701, 40702, 40720
40761, 42200, 42225, 50070, 50135, 50405
61680, 61682, 61684, 61686, 61690, 61692, 61710, 63250, 63251, 63252, C8921
Cryosurgical Ablation of Miscellaneous Solid Tumors 50250
50542
50593
19105
Cryosurgical Ablation of Prostate Cancer 55873
CT Colonography (Virtual Colonoscopy) 74261
74262
74263
Deep Brain Stimulation 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
Electrical Bone Growth Stimulation E0747
E0748
E0749
20974
20975
Endoscopic Injection 51715
External Insulin Infusion Pump E0784
Extracorporeal Shock Wave Therapy for Musculoskeletal Conditions 28890, 0101T, 0019T, 0102T, 0299T, 0300T
Factor for the Treatment of Hemophilia J7184, J7185, J7193 J7186, J7194 J7187, J7195 J7189, J7197 J7190, J7198 J7191, J7192
Gastrointestinal Motility and Manometry Testing 0240T
0241T
91010
91013
91020
91022
91117
91120
91122
Gene Expression Profiling for Managing Breast Cancer Treatment S3854
General anesthesia for routine dental procedures performed in an outpatient surgery center or facility 00170
Genetic Testing for Hereditary Breast and Ovarian Cancer 81211, 81212 81213, 81214 81215, 81216 81217, 81479
Genetic Testing for Colorectal Cancer 81201 81202 81203 81292
81293
81294
81295
81296
81297
81298
81299
81300
81301
81317
81318
81319
Genetic Testing for Hereditary Breast and Ovarian Cancer 81211
81212
81213
81214
81215
81216
81217
81479
83898
83909
83912
Gynecomastia Prior authorization is recommended for the following procedure codes when requested with any of the following diagnoses: 19301
19303
19304
Gynecomastia Note: Prior authorization is required for the following procedure codes when requested with the following diagnoses.

19300
Hyperbaric Oxygen Therapy (HBOT) 99183
A4575
C1300 E0446
Implantable Middle Ear and Bone-Anchored Hearing Aids 69710 69711
69714 69715
69717 69718
L8690  L8691 L8693 S2230 V5095
Implantation of Intrastromal Corneal Ring Segments) 0099T
Incontinence Treatment System E0740 64566 97014 97032 G0283
Injectable Bulking Agent L8603
L8606
Intensity Modulated Radiation Therapy (IMRT) 0073T
77301
77338
77418
Knee braces L1840 L1846
L1844
Lower Limb Prostheses L5100 L5230
L5105 L5250
L5150 L5270
L5160 L5280
L5301 L5311
L5321 L5331
L5341 L5617
L5700 L5701
L5702 L5930
L5990 L5312
Microprocessor-Controlled Lower Limb Prostheses L5856,L5857 L5858,L5859 L5973
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.
77058
77059
C8903
C8904
C8905
C8906
C8907
C8908
0159T
Negative Pressure Wound Therapy in the Outpatient Setting 97605
97606
A6550
A9272
E2402
G0456
G0457
K0743
K0744
K0745
K0746 codes in yellow require no review for Dx 998.83
Neuromuscular and Functional Electrical Stimulation) 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
Neuropsychological Testing 96116
96118
96119
96120
Oral/Maxillofacial Procedures
(FEP Members Only)
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 
Orthognathic Surgery 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
Orthoptic Training 92065
Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Diseases Prior authorization is  recommended for the following procedure codes when requested with any of the following diagnoses: E0481
E0483
E0484
A7025
A7026
S8185
Panniculectomy, Abdominoplasty and Surgical Management of Diastasis Recti 15830
15847
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.
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.
78459
78491
78492
Power Wheelchair E1018  
E2300  E2301
E2310  E2311
E2351  E2358 E2360  E2367  
E2372  E2609 E2610  E2617
K0669  K0806
K0807  K0808
K0830  K0831
K0868  K0885 K0886
Preparation/reconstruction on a cadaver or living donor intestine allograft prior to transplantation 44715, 44720, 44721
Radioembolization for Primary and Metastatic Tumors of the Liver Prior authorization is recommended for the following procedure codes when requested with any of the following diagnoses:   75894
77399  C2616 S2095
Radiofrequency Ablation of Solid Tumors Excluding Liver Tumors 20982
32998
50542
50592
76940
77013
77022
 Spinal Implants
(Continuous local infusion device)
A4305, A4306, E0779-E0781
Spinal Implants
(Neurostimulator)
63650-63688, 64581, 95970-95973
Spinal Implants
(Pain pump)
62318, 62319, 62350, 62351, 62352, 62353, 62354, 62355, 62356, 62357, 62358, 62359, 62360, 62361, 62362, 62363, 62364, 62365, 62366, 62368, 95990-95991
Spinal Injections (Discography) 62290-62292, 72275, 72285, 72295
Spinal Injections (Epidural Steroid Injections) 62310, 62311, 64479-64484, 0228T-0231T
Spinal Injections(Facet Joint Injections and Facet Joint Blocks) 64490-64495, 64470-64476, 0213T-0218T
Spinal Injections (Lysis of Epidural Adhesions) 62263, 62264,
62280
Spinal Injections (Percutaneous Decompression Procedure 62287
Spinal Injections (Percutaneous Intradiscal Electrothermal Annuloplasty) 22526, 22527
Spinal Injections (Prolotherapy) M0076
Spinal Injections (Radiofrequency Neurotomy of Facet Joints) 64622-64627, 64633-64636
Spinal Injections (Regional Sympathetic Blocks) 64510, 64520
Spinal Injections (Sacroiliac Joint Injections) 27096, G0259, G0260
Spinal Injections (Vertebroplasty and Sacroplasty) 22520-22525, 72291, 72292, 0200T, 0201T, S2360, S2361
Spinal Surgery (Bone Morphogenetic Protein) 20930, 20931, 21120
Spinal Surgery (Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedure) 20985, 0054T, 0055T
Spinal Surgery (Electrical Bone Growth) 20974, 20975, E0747-E0749
Spinal Surgery (Spinal Decompression, Laminectomy) 22100-22226, 63001-63308, S2348, S2350, S2351, S2090, 0274T, 22556, 22633, 22634,
Spinal Surgery (Spinal Fusion, Kyphectomy, Exploration of Spinal Fusion, Spinal Arthroplasty) 22532-22812, 0195T, 0196T, 22586, 22818, 22819, 22830, 22856-22865, 0092T-0098T, 0202T, 0209T
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). 70010-78999, G0235, G0030-G0047
Transcranical Magnetic Stimulation (TMS) 90867 90868 90869
Transurethral Radiofrequency 0193T
UVPP UPPP
(Uvulopalatopharyngoplasty, Uvulopharyngoplasty)
42145
Varicose Vein Treatments 36468, 36478
36469, 36479
36470, 37500
36471, 37765
36475, 37766
36476, S2202
Wearable Cardioverter Defibrillator 93292
93745
K0606
K0607
K0608 
K0609
Wireless Capsule Endoscopy 91110
91111