Pre-authorizations

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.

Some services that require pre-authorization

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

How to find out if a procedure requires pre-authorization

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.

Inpatient admissions

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

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

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

Extracorporeal Circulation Membrane Oxygenation (ECMO) for the Treatment of Respiratory Failure in Adults (PDF)

  • We require the facility to notify us when ECMO is initiated on a Regence member. We will initiate concurrent review upon this notification.

Home health care

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

Chemical dependency and mental health

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.
  • 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 trials, Investigational Device Exemption (IDE) studies, and Coverage with Evidence Development (CED) studies and registries

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)

Allied health

Dental Services (PDF)

  • 21245, 21246, 21248, 21249

Durable medical equipment

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

Powered and Microprocessor-Controlled Knee and Ankle-Foot Prostheses and Microprocessor-Controlled Knee-Ankle Foot Orthoses (PDF)

  • 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

Genetic testing

Genetic and Molecular Diagnostics - Next Generation Sequencing and Genetic Panel Testing and Biomarker Testing (PDF)

  • 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

Genetic and Molecular Diagnostics - Testing for Cancer Diagnosis, Prognosis, and Treatment Selection (PDF)

  • 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

Medicine

Autologous Blood-Derived Growth Factors as a Treatment for Wound Healing and Other Miscellaneous Conditions (PDF)

  • 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

Cardiac Hemodynamic and Thoracic Fluid Index Monitoring for the Management of Heart Failure in the Outpatient Setting (PDF)

  • 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

Intensity Modulated Radiotherapy (IMRT) of the Central Nervous System (CNS), Head, Neck, and Thyroid (PDF)

  • 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

Investigational (Experimental) Services, New and Emerging Medical Technologies and Procedures, and Other Non-Covered Services (PDF)

  • 0888T, 0893T, 0898T

In Vivo Analysis of Colorectal Lesions (PDF)

  • 88375

Laser Interstitial Thermal Therapy (PDF)

  • 61736, 61737

Low-Level Laser Therapy (PDF)

  • 0552T, 97037

Measurement of Exhaled Breath Condensate in the Diagnosis and Management of Respiratory Disorders (PDF)

  • 83987

Myocardial Strain Imaging (PDF)

  • C9762, C9763

Orthopedic Applications of Stem-Cell Therapy, Including Bone Substitutes Used with Autologous Bone Marrow (PDF)

  • 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

Sleep Medicine

  • View the Sleep Medicine Program for notification or authorization requirements
  • Review the codes requiring authorization or notification in the Sleep medicine section.

Physical Medicine

  1. Review this entire page for similar services that require pre-authorization
  2. Verify member benefits, eligibility and pre-authorization requirements on Availity Essentials
  3. Determine whether a member's plan participates in this program by using the electronic authorization tool on Availity Essentials
  4. Obtain or verify an authorization with eviCore:

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

Radiology

Contact Regence for pre-authorization for the following codes:

Carelon Medical Benefits Management (Carelon)

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.

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.

Sleep Medicine

We partner with Carelon to administer our Sleep Medicine program.

Contact Carelon to request pre-authorization for the following codes:

  • 95782, 95783, 95805, 95807, 95808, 95810, 95811, E0470, E0471, E0561, E0562, E0601

Cardiology

We partner with Carelon to administer our cardiology program.

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.

Surgery

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.

Decompression of Intervertebral Discs Using Laser Energy (Laser Discectomy) or Radiofrequency Energy (Nucleoplasty) (PDF)

  • 62287, 62292

Deep Brain Stimulation (PDF)

  • 61850, 61860, 61863, 61864, 61867, 61868, 61885, 61886

Dual Chamber Leadless Pacemakers (PDF)

  • 0795T, 0796T, 0797T, 0798T, 0799T, 0800T, 0801T, 0802T, 0803T, 0804T

Extracorporeal Circulation Membrane Oxygenation (ECMO) for the Treatment of Respiratory Failure in Adults (PDF)

  • 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

Magnetic Resonance (MR) Guided Focused Ultrasound (MRgFUS), and High Intensity Focused Ultrasound (HIFU) Ablation, and Transurethral Ultrasound Ablation (TULSA) (PDF)

  • 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

Orthognathic Surgery (PDF)

  • 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

Radiofrequency and Ultrasound Ablation of the Renal Sympathetic Nerves as a Treatment for Uncontrolled Hypertension (PDF)

  • 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

Sacroiliac Joint Fusion (PDF)

  • 27278, 27279, 27280, C1737

Subacromial Balloon Placement (PDF)

  • C9781

Subcutaneous Tibial Nerve Stimulation (PDF)

  • 0816T, 0817T, 0818T, 0819T

Subtalar Arthroereisis (PDF)

  • 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

Devices for Treatment of Benign Prostatic Hyperplasia, Urethral Stricture, and Urethral Stenosis (PDF)

  • 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

Varicose Vein Treatment (PDF)

  • 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.

Transplants and ventricular assist devices

Ventricular Assist Devices and Total Artificial Hearts (PDF)

  • 33927, 33975, 33976, 33979, 33990, 33991, 33993, 33995, 33997, L8698

Heart Transplants (PDF)

  • 33945

Heart-Lung Transplants (PDF)

  • 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

Liver Transplants (PDF)

  • 47135

Lung Transplants (PDF)

  • 32851, 32852, 32853, 32854

Pancreas Transplants (PDF)

  • 48554

Stem Cell and Bone Marrow Transplantation (PDF)

  • 38205, 38206, 38232, 38240, 38241, 38242, C9782

Uterus Transplant (PDF)

  • 0664T, 0665T, 0666T, 0667T, 0668T, 0669T, 0670T

Utilization management

Air Ambulance Transport (PDF)

  • 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.