Some medical procedures need to be approved by your health plan before you receive treatment. This is called pre-authorization.
Pre-authorization allows us to review your treatment within the context of any other health issues you may have and to consider the latest scientific research available to manage your condition. Some conditions have a wide range of treatment choices, and some treatments work better than others. Checking in on your progress after a series of treatments helps us make sure your treatment is effective, medically necessary and right for you.
Pre-authorization helps you:
- Understand your treatment options and any related risks
- Ensure that you'll have insurance coverage for a procedure, treatment or service
- Avoid inappropriate or unnecessary medical treatment
Save unnecessary out-of-pocket costs by guiding you to the approved service or vendor
Your doctor should know which procedures require pre-authorization. If a doctor does not get pre-authorization before treating you, your health plan will not cover those costs and the doctor may bill you for that treatment.
Doctors may contact our clinical partner to get pre-authorization online, by fax or by phone. If they seek pre-authorization online, they get an immediate response. They can also get pre-authorization before you arrive for your scheduled service or procedure to avoid delay.
If you use an in-network doctor, you don't need to do anything. Our clinical partner evaluates your treatment plan to make sure it is the most effective treatment based on published research. Our partner also ensures that it is medically necessary and covered by your health plan.
If you use an out-of-network doctor, contact us about your options. Using an out-of-network doctor may mean higher out-of-pocket costs for you.
Treatment, services and equipment that may require pre-authorization:
- Some surgeries and reconstructive surgery
- Planned admission into hospitals or skilled nursing facilities
- Transplant and donor services
- Specialized imaging such as MRIs, CT scans and cardiac imaging
- Non-emergency air ambulance transport
- Prosthetics and some orthotics
- Home medical equipment
- Interventional pain procedures
- Physical medicine services such as physical therapy and chiropractic care
Sleep studies
Prescription medications that may require pre-authorization:
- Some high-cost injectable medications
Specialty drugs
For complete information about your plan's pre-authorization requirements, call the Member Services number listed on the back of your member ID card. Because some plans have different pre-authorization requirements, it's important for you to contact us if you have any questions about your coverage.
See below for chemical dependency and mental health admissions.
Hospital admissions
- Pre-authorization is required for elective inpatient admissions.
- Notification of hospital admission and discharge required within 1 calendar day, regardless of federal holidays or day of the week.
Notification should be provided via electronic medical record, if available. If electronic medical records are not available, notifications should be provided via fax or by calling 1 (800) 423-6884. Providers should not call Customer Service to notify of patient admissions or discharge. Learn more about this requirement in the Facility Guidelines section of our Administrative Manual.
Inpatient hospice
- Notification of admission or discharge is necessary within 24 hours of admission or discharge (or one business day, if the admission or discharge occurs on a weekend or a federal holiday). Notification of inpatient hospice admission and discharge required within 24 hours, regardless of federal holidays or day of the week.
Notification should be provided via electronic medical record, if available. If electronic medical records are not available, notifications should be provided via fax or by calling 1 (800) 423-6884. Providers should not call Customer Service to notify of patient admissions or discharge. Learn more about this requirement in the Facility Guidelines section of our Administrative Manual.
Long Term Acute Care Facility (LTAC)
- Pre-authorization required prior to patient admission.
Request pre-authorization with Carelon prior to patient admission for dates of service on or after February 1, 2024
- Sign in to Carelon's ProviderPortal or phone 1 (844) 411-9622
Acute Rehabilitation
- Pre-authorization required prior to patient admission.
Request pre-authorization with Carelon prior to patient admission for dates of service on or after February 1, 2024
- Sign in to Carelon's ProviderPortal or phone 1 (844) 411-9622
Skilled Nursing Facility (SNF)
- Sometimes referred to as "sub-acute rehabilitation"
- Pre-authorization required prior to patient admission
- SNF is required to fax the Notice of Medicare Non-Coverage (NOMNC) on discharge from services.
Request pre-authorization with Carelon prior to patient admission for dates of service on or after February 1, 2024
- Sign in to Carelon's ProviderPortal or phone 1 (844) 411-9622
We require the facility to notify us when ECMO is initiated on a Regence member. We will initiate concurrent review upon this notification.
Contact Carelon for:
- Concurrent review
- All visits in excess of the authorized number of visits or authorization period will require a subsequent pre-authorization request.
- Providers must include visit notes and an updated treatment plan to demonstrate the member’s status at the time of the pre-authorization request—not their status upon admission to home health services.
- The Outcome and Assessment Information Set (OASIS) is only required every 60 days.
- Initial notification submitted within 24-48 hours of the first home visit. Notification must include:
- The original OASIS and the completed medication reconciliation form, both signed by the physician
- A signed physician’s order for home health services and the plan of care; non-physician practitioner-signed documentation will be accepted where allowed by law
- G0151, G0152, G0153, G0155, G0156, G0157, G0158, G0159, G0160, G0161, G0162, G0299, G0300, G0493, G0494, G0495, G0496
- Sign in to Carelon's ProviderPortal or phone 1 (844) 411-9622
Pre-authorization is required for the services listed below.
- Inpatient: Psychiatric, eating disorder, ASAM 4.0 or ASAM 3.7 in a hospital setting
- Authorization requests should be submitted as soon as possible and are accepted if they are within 3 business days of admission.
- Timely concurrent review will be required if additional days are requested after an initial authorization is issued. Concurrent review records are due on the last covered date of an authorization. Failure to follow concurrent review requirements may result in an administrative denial, claim non-payment and provider and facility write-off. Members may not be balance billed.
- Partial Hospitalization & Intensive Outpatient Treatment
- Includes mental health, eating disorder and chemical dependency (ASAM 2.5, ASAM 2.1)
- Request for authorization is required within 7 calendar days of start date.
- Includes mental health, eating disorder and chemical dependency (ASAM 2.5, ASAM 2.1)
- Transcranial magnetic stimulation (TMS) & applied behavior analysis (ABA)
- Request for authorization is required within 7 calendar days of start date.
- ABA services require authorization for all members regardless of age.
View our resources and forms for behavioral health facilities and our behavioral health medical policies.
Clinical trial, registry or study | Contact and coverage summary |
---|---|
IMPORTANT NOTE: Services in the following categories that are not listed as requiring pre-authorization elsewhere on this page do not require pre-authorization. In addition, the following guidelines may apply to these services, and should be fully reviewed. We recommend confirming coverage with Medicare and/or the health plan. Providers are expected to only submit claims for medically reasonable and necessary services per Title XVIII of the Social Security Act §1862(a)(1)(A). | |
Category A and Category B Investigational Device Exemption (IDE) studies | Coverage for CMS-approved Category A and B IDE studies includes routine care items and services. Category B IDE devices are also reimbursable, but reimbursement for Category A devices under investigation is statutorily excluded. View the Medicare Advantage medical policy for Category A and Category B Investigational Device Exemption (IDE) Studies (PDF) |
Coverage with Evidence Development (CED) studies and registries | Medicare determines coverage requirements and restrictions for services covered under the CED provision. These services generally have a national coverage determination (NCD) available, and approved studies and registries are added to the CMS clinical trials/registry web site. View the Medicare Advantage medical policy for Coverage with Evidence Development (CED) Studies and Registries (PDF) |
Clinical trials or registries (not otherwise specified) | Medicare determines coverage for clinical trials, including for Medicare Advantage beneficiaries. We recommend providers call Medicare directly at 1-800-MEDICARE to determine Medicare approval status of the requested clinical trial/registry. View the Medicare Advantage medical policy for Clinical Trials/Registries (PDF) |
21245, 21246, 21248, 21249
Amplitude-Modulated Radiofrequency Electromagnetic Fields (AM RF-EMF) for Cancer Treatment (PDF)
E0767
Bone Growth Stimulators (Osteogenic Stimulation) (PDF)
20979, E0747, E0760
Commode Chairs with Seat Lift Mechanism (PDF)
E0170, E0171
Electrical Stimulation and Electromagnetic Therapy Devices (PDF)
- 0278T, 0882T, 0883T, 0906T, 0907T, A4542, A4544, A4560, A4596, E0731, E0732, E0733, E0734, E0743, E0745, E0761, E0764, E0770, G0329
Lower Extremity Sensory Prostheses (PDF)
L8720, L8721
Multi-Positional Patient Transfer System (PDF)
E0636, E1035, E1036
Myoelectric Prosthetic and Orthotic Components for the Upper Limb (PDF)
L6026, L6693, L6715, L6880, L6881, L6882, L6925, L6935, L6945, L6955, L6965, L6975, L7007, L7008, L7009, L7045, L7180, L7181, L7190, L7191, L8701, L8702
Definitive Lower Limb Prostheses (PDF)
- L5000, L5010, L5020, L5050, L5060, L5100, L5105, L5150, L5160, L5200, L5210, L5220, L5230, L5250, L5270, L5280, L5301, L5312, L5321, L5331, L5341, L5610, L5611, L5613, L5614, L5616, L5700, L5701, L5702, L5703, L5710, L5711, L5712, L5714, L5716, L5718, L5722, L5724, L5726, L5728, L5780, L5783, L5810, L5811, L5812, L5814, L5816, L5818, L5822, L5824, L5826, L5828, L5830, L5840, L5841, L5848, L5930, L5968, L5970, L5972, L5974, L5976, L5978, L5979, L5980, L5981, L5982, L5984, L5985, L5986, L5987
Negative Pressure Wound Therapy in the Outpatient Setting (PDF)
- 97605, 97606, 97607, 97608, A6550, A7000, E2402, K0743
The policy requires an initial pre-authorization for a 1-month therapeutic trial and then after one month, another pre-authorization for continuation is required demonstrating improvement in the wound.
Noninvasive Ventilators in the Home Setting (PDF)
E0466, E0468
Pneumatic Compression Devices (PDF)
E0650, E0651, E0652, E0655, E0656, E0657, E0660, E0665, E0666, E0667, E0668, E0669, E0670, E0671, E0672, E0673
Power Wheelchairs - Group 2 and Group 3 (PDF)
- E2298, 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, K0863, K0864
Effective February 1, 2025: E1002, E1003, E1004, E1005, E1006, E1007, E1008, E1009, E1010, E1012
Powered Exoskeleton for Ambulation (PDF)
E0739, K1007
L2006, L5615, L5859, L5973 L5856, L5857, L5858
Sleep Medicine
- View the Sleep Medicine Program for notification or authorization requirements
Review the codes requiring authorization or notification in the sleep medicine section on this list.
Tumor Treatment Field Therapy (TTFT) (PDF)
- E0766
Upper Extremity Rehabilitation System with Brain-Computer Interface (PDF)
- E0738
- 0029U, 0030U, 0031U, 0032U, 0033U, 0034U, 0039U, 0068U, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076U, 0086U, 0105U, 0109U, 0112U, 0115U, 0118U, 0140U, 0141U, 0142U, 0156U, 0169U, 0202U, 0218U, 0223U, 0225U, 0230U, 0231U, 0232U, 0233U, 0234U, 0236U, 0237U, 0311U, 0323U, 0327U, 0330U, 0345U, 0352U, 0355U, 0371U, 0372U, 0377U, 0378U, 0389U, 0393U, 0399U, 0402U, 0407U, 0411U, 0419U, 0423U, 0441U, 0442U, 0446U, 0447U, 0455U, 0456U, 0457U, 0480U, 0483U, 0484U, 0493U, 0500U, 0502U, 0504U, 0505U, 0508U, 0509U, 0516U, 0527U, 0528U, 81105, 81106, 81107, 81108, 81109, 81110, 81111, 81112, 81161, 81171, 81172, 81173, 81174, 81177, 81178, 81179, 81180, 81181, 81182, 81183, 81184, 81185, 81186, 81187, 81188, 81189, 81190, 81200, 81204, 81205, 81209, 81220, 81221, 81222, 81223, 81224, 81225, 81226, 81227, 81228, 81229, 81230, 81231, 81234, 81238, 81239, 81242, 81243, 81244, 81247, 81248, 81249, 81250, 81251, 81252, 81253, 81254, 81255, 81256, 81257, 81258, 81259, 81260, 81265, 81266, 81267, 81268, 81269, 81271, 81274, 81283, 81284, 81285, 81286, 81289, 81290, 81302, 81303, 81304, 81306, 81312, 81324, 81325, 81326, 81328, 81329, 81330, 81331, 81332, 81333, 81335, 81336, 81337, 81343, 81344, 81349, 81350, 81355, 81361, 81362, 81363, 81364, 81370, 81371, 81372, 81373, 81374, 81375, 81376, 81377, 81378, 81379, 81380, 81381, 81382, 81383, 81400, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81410, 81411, 81412, 81413, 81414, 81415, 81416, 81417, 81418, 81419, 81420, 81422, 81425, 81426, 81427, 81430, 81431, 81434, 81439, 81440, 81441, 81442, 81443, 81448, 81460, 81465, 81470, 81471, 81493, 81507, 81513, 81514, 81554, 87523, G9143
- 0011M, 0017M, 0020M, 0005U, 0009U, 0016U, 0017U, 0018U, 0019U, 0022U, 0023U, 0026U, 0027U, 0037U, 0045U, 0046U, 0047U, 0048U, 0049U, 0069U, 0080U, 0089U, 0090U, 0111U, 0154U, 0155U, 0171U, 0172U, 0177U, 0179U, 0229U, 0239U, 0242U, 0244U, 0245U, 0250U, 0288U, 0306U, 0307U, 0314U, 0326U, 0329U, 0331U, 0334U, 0338U, 0339U, 0340U, 0343U, 0356U, 0360U, 0362U, 0364U, 0375U, 0376U, 0379U, 0387U, 0388U, 0391U, 0395U, 0398U, 0403U, 0404U, 0405U, 0406U, 0409U, 0410U, 0413U, 0414U, 0418U, 0420U, 0422U, 0424U, 0433U, 0436U, 0444U, 0450U, 0451U, 0467U, 0470U, 0471U, 0473U, 0478U, 0481U, 0485U, 0486U, 0487U, 0490U, 0491U, 0492U, 0495U, 0497U, 0498U, 0499U, 0502U, 0506U, 0507U, 0510U, 0512U, 0513U, 0523U, 0530U, 81120, 81121, 81162, 81163, 81164, 81165, 81166, 81167, 81168, 81170, 81175, 81176, 81191, 81192, 81193, 81194, 81206, 81207, 81208, 81210, 81212, 81216, 81218, 81219, 81233, 81235, 81236, 81237, 81245, 81246, 81261, 81262, 81263, 81264, 81270, 81272, 81273, 81275, 81276, 81277, 81278, 81279, 81287, 81301, 81305, 81309, 81310, 81311, 81313, 81314, 81315, 81316, 81320, 81327, 81334, 81338, 81339, 81340, 81341, 81342, 81345, 81347, 81348, 81351, 81352, 81357, 81360, 81400, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81445, 81449, 81450, 81451, 81455, 81456, 81457, 81458, 81459, 81462, 81463, 81464, 81504, 81518, 81519, 81520, 81521, 81522, 81523, 81525, 81529, 81538, 81539, 81540, 81541, 81542, 81546, 81551, 81552, G0327
Genetic and Molecular Diagnostics - Testing for Inherited Cancer Risk (PDF)
- 0101U, 0129U, 0130U, 0131U, 0133U, 0134U, 0162U, 0235U, 0238U, 0474U, 0475U, 81162, 81163, 81164, 81165, 81166, 81167, 81201, 81202, 81203, 81212, 81215, 81216, 81217, 81288, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81307, 81308, 81317, 81318, 81319, 81321, 81322, 81323, 81351, 81352, 81353, 81400, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81432, 81435, 81436, 81437, 81438
Allergy and Sensitivity Tests of Uncertain Efficacy (PDF)
86001, 86343, 95065
Biochemical and Cellular Markers of Alzheimer’s Disease (PDF)
0206U, 0207U, 0358U, 0412U, 0445U, 0459U, 0479U, 0503U, 82233, 82234, 84393, 84394
Chemoresistance and Chemosensitivity Assays (PDF)
81535, 81536, 0083U
0202U, 0223U, 0225U
Measurement of Serum Antibodies to Selected Biologic Agents (PDF)
80145, 80230, 80280
81232, 81346
81596, 0002M, 0003M, 0014M, 0166U, 81517
Multimarker and Proteomics-based Testing Related to Ovarian Cancer (PDF)
- 81500, 81503
0232T, G0460, G0465, P9020
Bioengineered Skin and Soft Tissue Substitutes and Amniotic Products (PDF)
15011, 15012, 15013, 15014, 15015, 15016, 15017, 15018, A2001, A2002, A2004, A2005, A2006, A2007, A2008, A2009, A2010, A2022, A2023, A2024, A2025, A2026, A2027, A2028, A2029, A6460, A6461, C8002, C9356, C9358, C9360, C9363, C9364,Q4100, Q4101, Q4102, Q4103, Q4104, Q4105, Q4106, Q4107, Q4108, Q4110, Q4111, Q4112, Q4113, Q4114, Q4115, Q4116, Q4117, Q4118, Q4121, Q4122, Q4123, Q4124, Q4125, Q4126, Q4127, Q4128, Q4130, Q4132, Q4133, Q4134, Q4135, Q4136, Q4137, Q4138, Q4139, Q4140, Q4141, Q4142, Q4143, Q4145, Q4146, Q4147, Q4148, Q4149, Q4150, Q4151, Q4152, Q4153, Q4154, Q4155, Q4156, Q4157, Q4158, Q4159, Q4160, Q4161, Q4162, Q4163, Q4164, Q4165, Q4166, Q4167, Q4168, Q4169, Q4170, Q4171, Q4173, Q4174, Q4175, Q4176, Q4177, Q4178, Q4179, Q4180, Q4181, Q4182, Q4183, Q4184, Q4185, Q4186, Q4187, Q4188, Q4189, Q4190, Q4191, Q4192, Q4193, Q4194, Q4195, Q4196, Q4197, Q4198, Q4199, Q4200, Q4201, Q4202, Q4203, Q4204, Q4205, Q4206, Q4208, Q4209, Q4211, Q4212, Q4213, Q4214, Q4215, Q4216, Q4217, Q4218, Q4219, Q4220, Q4221, Q4222, Q4226, Q4227, Q4229, Q4230, Q4231, Q4232, Q4233, Q4234, Q4235, Q4237, Q4238, Q4239, Q4240, Q4241, Q4242, Q4245, Q4246, Q4247, Q4248, Q4249, Q4250, Q4251, Q4252, Q4253, Q4254, Q4255, Q4272, Q4273, Q4274, Q4275, Q4276, Q4278, Q4279, Q4280, Q4281, Q4282, Q4283, Q4284, Q4285, Q4286, Q4287, Q4288, Q4289, Q4290, Q4291, Q4292, Q4293, Q4294, Q4295, Q4296, Q4297, Q4298, Q4299, Q4300, Q4301, Q4302, Q4303, Q4304, Q4305, Q4306, Q4307, Q4308, Q4309, Q4310, Q4311, Q4312, Q4313, Q4314, Q4315, Q4316, Q4317, Q4318, Q4319, Q4320, Q4321, Q4322, Q4323, Q4324, Q4325, Q4326, Q4327, Q4328, Q4329, Q4330, Q4331, Q4332, Q4333, Q4336, Q4337, Q4338, Q4339, Q4340, Q4341, Q4342, Q4343, Q4344, Q4345, Q4346, Q4347, Q4348, Q4349, Q4350, Q4351, Q4352, Q4353
0607T, 0608T, 33289, 93264, 93701 C2624
Cell Therapy for Peripheral Arterial Disease (PDF)
0263T, 0264T, 0265T
Charged-Particle (Proton) Radiotherapy (PDF)
77301, 77338, 77520, 77522, 77523, 77525
Digital Therapeutic Products for Attention Deficit Hyperactivity Disorder (PDF)
- G0552, G0553, G0554
Digital Therapeutic Products for Chronic Low Back Pain
- E1905, G0552, G0553, G0554
Digital Therapeutic Products for Post-traumatic Stress Disorder and Panic Disorder (PDF)
- G0552, G0553, G0554
Digital Therapeutic Products for Substance Use Disorders (PDF)
- G0552, G0553, G0554
Extracorporeal Shock Wave Therapy (ESWT) (PDF)
28890, 0101T, 0102T, 0512T, 0513T
Gender Affirming Interventions for Gender Dysphoria (PDF)
- 11920, 11921, 11950, 15769, 15771, 15772, 15773, 15774, 15775, 15776, 15825, 15828, 15829, 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, 17380, 17999, 19303, 19316, 19318, 19325, 19350, 21125, 21127, 21137, 21139, 21141, 21142, 21143, 21145, 21146, 21147, 21188, 21193, 21194, 21195, 21196, 21208, 53400, 53405, 53410, 53415, 53420, 53425, 53430, 54125, 54400, 54401, 54405, 54520, 54660, 54690, 55175, 55180, 55970, 55980, 56625, 56800, 57106, 57110, 57291, 57292, 57295, 57296, 57335, 57426, C1813, C2622, L8600
- Codes 55970 and 55980 are non-specific. The specific procedure code(s) must be requested in place of these non-specific codes.
- Use code 17999 to request laser hair removal.
Gender affirming surgical interventions for gender dysphoria require pre-authorization. Codes for specific procedures might also be listed as requiring pre-authorization in other medical policies, including but not limited to:
- Abdominoplasty - 15830
- Adipose-derived Stem Cell Enrichment in Autologous Fat Grafting to the Breast - 15771
- Breast Reconstruction - 19316, 19318, 19325, 19350, L8600
- Blepharoplasty and Brow Lift - 15820, 15821, 15822, 15823, 67900, 67901, 67902, 67903, 67904, 67906, 67908, 67909, 67950
- Chin Implants - 21120, 21121, 21122, 21123, 21209
- Collagen Injections - 11950, 11951, 11952, 11954
- Cosmetic and Reconstructive Procedures - 15771, 15773
- Panniculectomy - 15830
- Reconstructive Breast Surgery, Mastopexy, and Management of Breast Implants - 15771
- Rhinoplasty - 30400, 30410, 30420, 30430, 30435, 30450
Hyperoxemic Reperfusion Therapy (PDF)
- 0659T
Immunological Cellular Therapies and Gene Therapies (PDF)
36511
Intensity Modulated Radiotherapy (IMRT) for Breast Cancer (PDF)
- 77301, 77338, G6015, G6016
- 77301, 77338, G6015, G6016
Intensity Modulated Radiotherapy (IMRT) of the Thorax, Abdomen, Pelvis, and Extremities (PDF)
- 77301, 77338, G6015, G6016
Intensity Modulated Radiotherapy (IMRT) for Tumors in Close Proximity to Organs at Risk (PDF)
- 77301, 77338, G6015, G6016
- 0888T, 0893T, 0898T
In Vivo Analysis of Colorectal Lesions (PDF)
88375
Laser Interstitial Thermal Therapy (PDF)
61736, 61737
0552T, 97037
83987
Myocardial Strain Imaging (PDF)
C9762, C9763
38206, 38232, 38241, 0565T, 0566T, C9782
Periurethral Transperineal Adjustable Balloon Continence Device (PDF)
- 53451, 53452, 53453, 53454
Progenitor Cell Therapy for the Treatment of Damaged Myocardium Due to Ischemia (PDF)
38205, 38206, 38240, 38241
Quantitative Sensory Testing (PDF)
0106T, 0107T, 0108T, 0109T, 0110T
Skin Lesion Imaging and Spectroscopy (PDF)
0658T, 96931, 96932, 96933, 96934, 96935, 96936
Signal-Averaged Electrocardiography (SAECG) (PDF)
93278
Surface Electromyography (SEMG) Including Paraspinal SEMG (PDF)
96002, 96004
- View the Sleep Medicine Program for notification or authorization requirements
- Review the codes requiring authorization or notification in the Sleep medicine section.
- Review this entire page for similar services that require pre-authorization
- Verify member benefits, eligibility and pre-authorization requirements on Availity Essentials
- Determine whether a member's plan participates in this program by using the electronic authorization tool on Availity Essentials
Obtain or verify an authorization with eviCore:
- Login to eviCore's portal
- Phone (855) 252-1115
- Fax (855) 774-1319
Physical therapy, speech therapy, occupational therapy (PT,ST,OT); complementary and alternative medicine
- Determine whether a member's plan participates in this program by using the electronic authorization tool on Availity Essentials.
- Members aged 17 and younger: Select pediatric diagnosis codes are excluded from the program (PDF) for enrolled dependents aged 17 and younger.
We require authorization from eviCore for these codes: 92507, 92508, 92521, 92522, 92523, 92524, 92526, 92597, 92607, 92608, 92609, 92610, 92626, 92627, 95851, 95852, 96105, 97012, 97016, 97018, 97022, 97024, 97028, 97032, 97034, 97035, 97036, 97110, 97112, 97113, 97116, 97129, 97130, 97140, 97150, 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 97530, 97542, 97750, 97755, 97760, 97761, 97763, 97799, G0283, S9152
Pain management
- Determine whether a member's plan participates in this program by using the electronic authorization tool on Availity Essentials.
We require authorization from eviCore for these codes: 00640, 22510, 22511, 22512, 22513, 22514, 22515, 27096, 61790, 61791, 62290, 62291, 62320, 62321, 62322, 62323, 62324, 62325, 62326, 62327, 62350, 62351, 62360, 62361, 62362, 63650, 63655, 63663, 63664, 63685, 63688, 64405, 64479, 64480, 64483, 64484, 64490, 64491, 64492, 64493, 64494, 64495, 64510, 64520, 64633, 64634, 64635, 64636, 72285, 72295, G0259, G0260
Joint management
- To determine whether a member's plan participates in this program, use the electronic authorization tool on Availity Essentials
We require authorization from eviCore for these codes: 23000, 23020, 23120, 23130, 23410, 23412, 23420, 23430, 23440, 23455, 23462, 23466, 23470, 23472, 23473, 23474, 23700, 27125, 27132, 27134, 27137, 27138, 27130, 27332, 27333, 27334, 27403, 27405, 27415, 27416, 27418, 27420, 27422, 27425, 27427, 27428, 27429, 27430, 27438, 27440, 27441, 27442, 27443, 27445, 27446, 27447, 27486, 27487, 27488, 27570, 27580, 29805, 29806, 29807, 29819, 29820, 29821, 29822, 29823, 29824, 29825, 29826, 29827, 29828, 29860, 29861, 29862, 29863, 29866, 29867, 29868, 29870, 29871, 29873, 29874, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889, 29891, 29892, 29893, 29894, 29895, 29897, 29898, 29899, 29904, 29905, 29906, 29907, 29914, 29915, 29916
Spine
- To determine whether a member's plan participates in this program, use the electronic authorization tool on Availity Essentials
- We require authorization from eviCore for these codes: 20931, 20937, 20938, 22100, 22101, 22102, 22103, 22110, 22112, 22114, 22116, 22206, 22207, 22208, 22210, 22212, 22214, 22216, 22220, 22222, 22224, 22226, 22325, 22326, 22327, 22328, 22510, 22511, 22512, 22513, 22514, 22515, 22532, 22533, 22534, 22548, 22551, 22552, 22554, 22556, 22558, 22585, 22590, 22595, 22600, 22610, 22612, 22614, 22630, 22632, 22633, 22634, 22800, 22802, 22804, 22808, 22810, 22812, 22818, 22819, 22830, 22840, 22842, 22843, 22844, 22845, 22846, 22847, 22848, 22849, 22850, 22852, 22853, 22854, 22855, 22856, 22858, 22859, 63001, 63003, 63005, 63011, 63012, 63015, 63016, 63017, 63020, 63030, 63035, 63040, 63042, 63043, 63044, 63045, 63046, 63047, 63048, 63050, 63051, 63055, 63056, 63057, 63064, 63066, 63075, 63076, 63077, 63078, 63081, 63082, 63085, 63086, 63087, 63088, 63090, 63091, 63101, 63102, 63103, 63170, 63172, 63173, 63185, 63190, 63191, 63197, 63200, 63250, 63251, 63252, 63265, 63266, 63267, 63268, 63270, 63271, 63272, 63273, 63275, 63276, 63277, 63278, 63280, 63281, 63282, 63283, 63285, 63286, 63287, 63290, 63295, 63300, 63301, 63302, 63303, 63304, 63305, 63306, 63307, 63308, E0748, E0749
Contact Regence for pre-authorization for the following codes:
- Cone Beam Computed Tomography of the Breast (PDF)
- 0633T, 0634T, 0635T, 0636T, 0637T, 0638T
- Magnetic Resonance Spectroscopy
- 0609T, 0610T, 0611T, 0612T, 76390
- Opto-acoustic Imaging of the Breast
- 0857T
- 93895
We partner with Carelon to administer our radiology program. Determine whether your patient's plan participates in this program by using the Electronic Authorization application on Availity Essentials.
Note: The Radiology Quality Initiative (RQI) component of this program was phased out in 2023.
- Sign in to Carelon's ProviderPortal
- Phone 1 (877) 291-0509
Contact Carelon to request pre-authorization for the following codes:
- 70336, 70450, 70460, 70470, 70480, 70481, 70482, 70486, 70487, 70488, 70490, 70491, 70492, 70496, 70498, 70540, 70542, 70543, 70544, 70545, 70546, 70547, 70548, 70549, 70551, 70552, 70553, 70554, 70555, 71250, 71260, 71270, 71271, 71275, 71550, 71551, 71552, 71555, 72125, 72126, 72127, 72128, 72129, 72130, 72131, 72132, 72133, 72141, 72142, 72146, 72147, 72148, 72149, 72156, 72157, 72158, 72159, 72191, 72192, 72193, 72194, 72195, 72196, 72197, 72198, 73200, 73201, 73202, 73206, 73218, 73219, 73220, 73221, 73222, 73223, 73225, 73700, 73701, 73702, 73706, 73718, 73719, 73720, 73721, 73722, 73723, 73725, 74150, 74160, 74170, 74174, 74175, 74176, 74177, 74178, 74181, 74182, 74183, 74185, 74712, 75557, 75559, 75561, 75563, 75572, 75573, 75574, 75635, 76391, 77046, 77047, 77048, 77049, 77078, 77084, 78012, 78013, 78014, 78015, 78016, 78018, 78070, 78071, 78072, 78075, 78102, 78103, 78104, 78185, 78195, 78201, 78202, 78215, 78216, 78226, 78227, 78230, 78231, 78232, 78258, 78261, 78262, 78264, 78265, 78266, 78278, 78290, 78291, 78300, 78305, 78306, 78315, 78429, 78430, 78431, 78432, 78433, 78445, 78451, 78452, 78453, 78454, 78456, 78457, 78458, 78459, 78466, 78468, 78469, 78472, 78473, 78481, 78483, 78491, 78492, 78494, 78579, 78580, 78582, 78597, 78598, 78600, 78601, 78605, 78606, 78608, 78609, 78610, 78630, 78635, 78645, 78650, 78660, 78700, 78701, 78707, 78708, 78709, 78725, 78740, 78761, 78800, 78801, 78802, 78803, 78804, 78811, 78812, 78813, 78814, 78815, 78816, 78830, 78831, 78832, 93303, 93304, 93306, 93307, 93308, 93312, 93313, 93314, 93315, 93316, 93317, 93350, 93351, 0042T, 0648T, 0649T
- Procedures performed in an inpatient setting or on an emergent basis do not require pre-authorization from Carelon. Inpatient stays are subject to review by Regence for determining the appropriate length of stay.
We partner with Carelon to administer our Sleep Medicine program.
- Sign in to Carelon's ProviderPortal
- Phone 1 (877) 291-0509
Contact Carelon to request pre-authorization for the following codes:
95782, 95783, 95805, 95807, 95808, 95810, 95811, E0470, E0471, E0561, E0562, E0601
We partner with Carelon to administer our cardiology program.
- Sign in to Carelon's ProviderPortal
- Phone 1 (877) 291-0509
Contact Carelon to request pre-authorization for the following codes: 33206, 33207, 33208, 33212, 33213, 33214, 33221, 33227, 33228, 33229, 33230, 33231, 33240, 33249, 33270, 33271, 33274, 33285, 36901, 36902, 36903, 36904, 36905, 36906, 37220, 37221, 37224, 37225, 37226, 37227, 37228, 37229, 37230, 37231, 37241, 37242, 37243, 37244, 92920, 92924, 92928, 92933, 92937, 92943, 93228, 93229, 93454, 93455, 93456, 93457, 93458, 93459, 93460, 93461, 93580, 93600, 93602, 93603, 93610, 93612, 93618, 93619, 93620, 93624, 93642, 93644, 93650, 93653, 93654, 93656, 93978, 93979, 93880, 93882, 93922, 93923, 93924, 93925, 93926, 93930, 93931, 0823T, 0825T, C1721, C1722, C1764, C1777, C1785, C1786, C1882, C1895, C1896, C1899, C2619, C2620, C2621, C7513, C7514, C7515, C7530, E0616, G0448
- Procedures performed in an inpatient setting or on an emergent basis do not require pre-authorization from Carelon. Inpatient stays are subject to review by Regence for determining the appropriate length of stay.
- Retrospective review is not allowed for cardiac rhythm monitors (93228 and 33285). Retrospective review is allowed for cardiac ablation and wearable and cardioverter defibrillators if records are received within 10 business days of the date of service.
Ablation of Peripheral Nerves to Treat Pain (PDF)
- C9808, C9809
- Effective February 1, 2025: 0440T, 0441T, 0442T, 64624, 64640
Ablation for the Treatment of Chronic Rhinitis (PDF)
- 31242, 31243
Adipose-derived Stem Cell Enrichment in Autologous Fat Grafting to the Breast (PDF)
- 15769, 15771, 15772, 19380
Notes:
- Codes 11950, 11951, 11952, 11954, 15769, 15771, 15772 and 19380 require pre-authorization (see other sections of this pre-authorization list) except when used for autologous fat grafting with adipose-derived stem cell enrichment for augmentation or reconstruction of the breast, where it is considered, and will deny as, not medically necessary.
- Code 19499 does not require pre-authorization but is considered, and will deny as, not medically necessary when used for autologous fat grafting and adipose-derived stem cell enrichment for augmentation or reconstruction of the breast.
Automated Percutaneous and Percutaneous Endoscopic Discectomy (PDF)
62287, 62380, C2614
Balloon Dilation of the Eustachian Tube (PDF)
69705, 69706
Balloon Ostial Dilation for Treatment of Sinusitis (PDF)
31295, 31296, 31297, 31298
Baroreflex Stimulation Devices (PDF)
0266T, 0267T, 0268T, 0272T, 0273T, C1825
Benign Prostatic Hyperplasia Surgical Treatments (PDF)
- 53854, 0421T, 0867T, C2596
Blepharoplasty, Eyelid Surgery, and Brow Lift (PDF)
- 15820, 15821, 15822, 15823, 67900, 67901, 67902, 67903, 67904, 67906, 67908, 67909
Coronary Intravascular Lithotripsy (PDF)
- 92972, C1761
Cosmetic and Reconstructive Procedures (PDF)
11920, 11921, 11922, 11950, 11951, 11952, 11954, 15769, 15771, 15772, 15773, 15774, 15780, 15781, 15782, 15783, 15786, 15787, 15788, 15789, 15792, 15793, 15830, 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, 15847, 15876, 15877, 15878, 15879, 17106, 17107, 17108, 17360, 19300, 19355, 21244, 21245, 21246, 21248, 21249, 21280, 21282, 21295, 21296, 21740, 21742, 21743, 30120, 30400, 30410, 30420, 30430, 30435, 30450, 41510, 49250, 54360, 67950, G0429
- Codes 11950, 11951, 11952, 11954, 15769, 15771 and 15772 always require pre-authorization (see other sections of this pre-authorization list, including the Adipose-derived Stem Cell Enrichment in Autologous Fat Grafting to the Breast section).
- Code 19499 does not require pre-authorization but is considered, and will deny as, not medically necessary when used for autologous fat grafting and adipose-derived stem cell enrichment for augmentation or reconstruction of the breast
- Pre-authorization is not required for breast reconstruction and nipple/areola reconstruction following mastectomy for breast cancer.
- Codes 21245, 21246, 21248 and 21249 are also found in the Medicare Dental Services Medical Policy.
62287, 62292
61850, 61860, 61863, 61864, 61867, 61868, 61885, 61886
Dual Chamber Leadless Pacemakers (PDF)
- 0795T, 0796T, 0797T, 0798T, 0799T, 0800T, 0801T, 0802T, 0803T, 0804T
Please see the Inpatient Admission section for further information.
Focal Laser Ablation of Prostate Cancer (PDF)
0655T
Gastric Electrical Stimulation (PDF)
- 43647, 43881, 64590, 64595, C1767, C1778, C1883, C1897
E0765
Gastroesophageal Reflux Surgery (PDF)
43279, 43280, 43281, 43282, 43325, 43327, 43328, 43332, 43333, 43334, 43335, 43336, 43337
Hypoglossal Nerve Stimulation (PDF)
64568, 64582, 64583, C1767
Image-Guided Minimally Invasive Decompression (IG-MSD) for Spinal Stenosis (PDF)
0274T
Interspinous and Interlaminar Stabilization/Distraction Devices (Spacers) (PDF)
22867, 22868, 22869, 22870, C1821
Intracardiac Ischemia Monitoring (PDF)
0525T, 0526T, 0527T, 0528T, 0529T
Intraosseous Radiofrequency Ablation of the Basivertebral Nerve (PDF)
- 64628, 64629
Lung Volume Reduction Surgery (LVRS, or Reduction Pneumoplasty) (PDF)
32491, 32672, G0302, G0303, G0304, G0305
Magnetic Esophageal Ring to Treat Gastroesophageal Reflux Disease (GERD) (PDF)
43284, 43285
51721, 55880, 55881, 55882, 61715, C9734, 0398T, 0071T, 0072T, 0947T
Micro-Invasive Glaucoma Surgery (MIGS) and Laser Trabeculectomy and Trabeculostomy (PDF)
- 0449T, 66989, 66991
Minimally Invasive Treatments of Nasal Valve Collapse (PDF)
- 30469
Occipital Nerve Stimulation (ONS) (PDF)
61885, 61886, 64553, 64555, 64568, 64569, 64575, 64585, 64590, 64595, 64596, 64597, 64598
- 21085, 21110, 21120, 21121, 21122, 21123, 21125, 21127, 21141, 21142, 21143, 21145, 21146, 21147, 21150, 21151, 21154, 21155, 21159, 21160, 21188, 21193, 21194, 21195, 21196, 21198, 21206, 21208, 21209, 21210, 21230, 21215, 21295, 21296
Codes 21145, 21196, 21198 do not require pre-authorization when the procedure is performed for oral cancer diagnosis codes: C01, C02-C02.9, C03-C03.9, C04-C04.9, C05-C05.9, C06, C06.2, C06.9, C09-C09.9, C10-C10.0, C41-C41.1, C46.2, D00-D00.00, D10, D10.1-D10.9, D16.4-D16.5, D37-D37.0, D49-D49.0
Percutaneous Axial Lumbosacral Interbody Fusion (LIF) (PDF)
22586
Percutaneous Transluminal Angioplasty (PTA) and Stenting (PDF)
37215, 37217, 37238, 37239, 37246, 37247, 37248, 37249, 61635, C7563
Peripheral Nerve Stimulation (PNS) and Peripheral Nerve Field Stimulation (PNFS) (PDF)
64555, 64575, 64585, 64590, 64595, 64596, 64597, 64598, C1778
Phrenic Nerve Stimulation for Central Sleep Apnea (PDF)
33276, 33277, 33278, 33279, 33280, 33281, 33287, 33288, 93150, 93151, 93152, 93153, C1823
Plugs for Enteric and Anorectal Fistula Repair (PDF)
46707
Pressure Ulcer Treatment by Musculocutaneous or Free Flap (PDF)
15734, 15738, 15756, 15757, 15758
- 0338T, 0339T, 0935T, C1735, C1736
Radiofrequency Ablation (RFA) of Tumors Other Than the Liver (PDF)
- 20982, 31641, 32998, 50542, 50592, 58580, 60660, 60661
Reconstructive Breast Surgery, Mastopexy, and Management of Breast Implants (PDF)
- 11920, 11921, 19316, 15769, 15771, 15772, 19318, 19325, 19328, 19330, 19340, 19342, 19350, 19355, 19357, 19361, 19364, 19367, 19368, 19369, 19370, 19371, 19380, 19396, L8600
- Pre-authorization is not required for breast reconstruction and nipple/areola reconstruction following mastectomy for breast cancer.
Notes:
- Codes 11950, 11951, 11952, 11954, 15769, 15771, 15772 and 19380 require pre-authorization (see other sections of this pre-authorization list) except when used for autologous fat grafting and adipose-derived stem cell enrichment for augmentation or reconstruction of the breast, where it is considered, and will deny as, not medically necessary
- Code 19499 does not require pre-authorization but is considered, and will deny as, not medically necessary when used for autologous fat grafting and adipose-derived stem cell enrichment for augmentation or reconstruction of the breast
Reduction Mammaplasty (Mammoplasty) (PDF)
- 15877, 19318
Pre-authorization is not required for breast reconstruction and nipple/areola reconstruction following mastectomy for breast cancer.
Responsive Neurostimulation (PDF)
61850, 61860, 61863, 61864, 61885, 61886. 61889, 61891
Sacral Nerve Stimulation (Neuromodulation) for Pelvic Floor Dysfunction (PDF)
0786T, 0787T, 64561, 64581, 64585, 64590, 64595, 64596, 64597, 64598, C1767
27278, 27279, 27280, C1737
Subacromial Balloon Placement (PDF)
- C9781
Subcutaneous Tibial Nerve Stimulation (PDF)
- 0816T, 0817T, 0818T, 0819T
0335T, 0510T, 0511T
Surgeries for Snoring, Obstructive Sleep Apnea Syndrome, and Upper Airway Resistance Syndrome (PDF)
- 21121, 21122, 21141, 21145, 21196, 21198, 21199, 21685, 41120, 41512, 41530, 42140, 42145, 42160
- Codes 21145, 21196, 21198, 41120, 42160 do not require pre-authorization when the procedure is performed for oral cancer diagnosis codes: C01, C02-C02.9, C03-C03.9, C04-C04.9, C05-C05.9, C06, C06.2-C06.9, C09-C09.9, C10-C10.0, C41-C41.1. C46.2, D00-D00.00, D10, D10.1-D10.9, D16.4-D16.5, D37-D37.0, D49-D49.0
Surgical Treatments for Lymphedema and Lipedema (PDF)
15876, 15877, 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, 15878, 15879
Surgical Ventricular Restoration (PDF)
33548, 0643T
- 52284, 53865, 53866, 0941T, 0942T, 0943T
Total Facet Arthroplasty (PDF)
0202T
Transcatheter Heart Valve Procedure (PDF)
0483T, 0484T, 0805T, 0806T, 33361, 33362, 33363, 33364, 33365, 33366, 33418, 33419, 0345T
Transesophageal Endoscopic Therapies for Gastroesophageal Reflux Disease (GERD) (PDF)
43192, 43201, 43236, 43257
Vagus Nerve Stimulation (VNS) (PDF)
0908T, 0909T, 0911T, 0912T, 61885, 61886, 64553, 64568, 64569, E0735
- 36465, 36466, 36470, 36471, 36473, 36474, 36475, 36476, 36478, 36479, 36482, 36483, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37785, 0524T
Note: Code 37241 is not appropriate to use in the coding of varicose vein treatment
Vertebral Body Tethering and Stapling (PDF)
- 0790T, 22836, 22837, 22838
Physical Medicine Program
- View Physical Medicine Program for notification or authorization requirements through eviCore
- Review the codes requiring authorization or notification in the Physical medicine section.
Ventricular Assist Devices and Total Artificial Hearts (PDF)
33927, 33975, 33976, 33979, 33990, 33991, 33993, 33995, 33997, L8698
33945
33935
Intestinal and Multi-Visceral Transplants (PDF)
44132, 44133, 44135, 44136, 44715, 44720, 44721, 47135, 48554
Islet Cell Transplantation (PDF)
0584T, 0585T, 0586T, G0343, G0341, G0342
47135
32851, 32852, 32853, 32854
48554
Stem Cell and Bone Marrow Transplantation (PDF)
38205, 38206, 38232, 38240, 38241, 38242, C9782
- 0664T, 0665T, 0666T, 0667T, 0668T, 0669T, 0670T
- A0430, A0435
- Pre-authorization is required prior to elective fixed wing air ambulance transport.
- Emergency air ambulance transports may be reviewed retrospectively for medical necessity.