2018 Additional Codes for BCBSTX Preauthorization 2-23-18

1 February 2018 Procedure CodeDescriptionNotes15824 RHYTIDECTOMY; FOREHEAD 15826 RHYTIDECTOMY; GLABELLAR FROWN LINES 19316 MASTOPEXY 19318 REDUCTION MAMMAPLASTY 20930 ALLOGRAFT FOR SPINE SURGERY ONLY.

2 MORSELIZED 20931 ALLOGRAFT FOR SPINE SURGERY ONLY; STRUCTURAL 20936 AUTOGRAFT FOR SPINE SURGERY ONLY (INCLUDES HARVESTING THE GRAFT); LOCAL (EG, RIBS, SPINOUS PROCESS, OR LAMINAR FRAGMENTS) OBTAINED FROM SAME INCISION 20937 AUTOGRAFT FOR SPINE SURGERY ONLY (INCLUDES HARVESTING THE GRAFT); MORSELIZED (THROUGH SEPARATE SKIN OR FASCIAL INCISION) 20938 AUTOGRAFT FOR SPINE SURGERY ONLY (INCLUDES HARVESTING THE GRAFT); STRUCTURAL, BICORTICAL OR TRICORTICAL (THROUGH SEPARATE SKIN OR FASCIAL INCISION) 21085 IMPRESSION AND CUSTOM PREPARATION.

3 ORAL SURGICAL SPLINT 21110 APPLICATION OF INTERDENTAL FIXATION DEVICE FOR CONDITIONS OTHER THAN FRACTURE OR DISLOCATION, INCLUDES REMOVAL 21125 AUGMENTATION, MANDIBULAR BODY OR ANGLE; PROSTHETIC MATERIAL 21127 AUGMENTATION, MANDIBULAR BODY OR ANGLE; WITH BONE GRAFT, ONLAY OR INTERPOSITIONAL (INCLUDES OBTAINING AUTOGRAFT) 21141 RECONSTRUCTION MIDFACE, LEFORT I; SINGLE PIECE, SEGMENT MOVEMENT IN ANY DIRECTION (EG, FOR LONG FACE SYNDROME), WITHOUT BONE GRAFT 21142 RECONSTRUCTION MIDFACE, LEFORT I; TWO PIECES, SEGMENT MOVEMENT IN ANY DIRECTION, WITHOUT BONE GRAFT 21143 RECONSTRUCTION MIDFACE, LEFORT I.

4 THREE OR MORE PIECES, SEGMENT MOVEMENT IN ANY DIRECTION, WITHOUT BONE GRAFT Updates to the list are announced routinely in the News and Updates section of the : This list contains the Additional Codes requiring benefit Preauthorization effective Jan. 1, 2018 only. Services which began requiring benefit Preauthorization prior to Jan. 1, 2018 are not included in this list, but are still in effect. To confirm if benefit Preauthorization is needed, check eligibility and benefits through AvailityTM or your preferred vendor portal or call the customer service number on the member's ID card. Codes notated in red on this list are Codes that will no longer require Preauthorization effective as of the date indicated. Blue Advantage HMOSM and Blue Advantage PlusSM HMO (BAV)Blue Choice PPOSM (BCA)Blue EssentialsSM and Blue Essentials AccessSM (HMO)Blue PremierSM and Blue Premier AccessSM (HMH)This list includes procedure Codes related to Additional care categories for which benefit Preauthorization through Blue Cross and Blue Shield of Texas ( BCBSTX ) are required for fully insured members effective Jan.

5 1, 2018 for the products listed below:2018 Blue Cross and Blue Shield of Texas Newly Effective Preauthorization Codes For Fully Insured Commercial PlansBlue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association 1 February 2018 Procedure CodeDescriptionNotesUpdates to the list are announced routinely in the News and Updates section of the : This list contains the Additional Codes requiring benefit Preauthorization effective Jan. 1, 2018 only. Services which began requiring benefit Preauthorization prior to Jan. 1, 2018 are not included in this list, but are still in effect. To confirm if benefit Preauthorization is needed, check eligibility and benefits through AvailityTM or your preferred vendor portal or call the customer service number on the member's ID card. Codes notated in red on this list are Codes that will no longer require Preauthorization effective as of the date indicated.

6 Blue Advantage HMOSM and Blue Advantage PlusSM HMO (BAV)Blue Choice PPOSM (BCA)Blue EssentialsSM and Blue Essentials AccessSM (HMO)Blue PremierSM and Blue Premier AccessSM (HMH)This list includes procedure Codes related to Additional care categories for which benefit Preauthorization through Blue Cross and Blue Shield of Texas ( BCBSTX ) are required for fully insured members effective Jan. 1, 2018 for the products listed below:2018 Blue Cross and Blue Shield of Texas Newly Effective Preauthorization Codes For Fully Insured Commercial Plans21145 RECONSTRUCTION MIDFACE, LEFORT I; SINGLE PIECE, SEGMENT MOVEMENT IN ANY DIRECTION, REQUIRING BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS) 21146 RECONSTRUCTION MIDFACE, LEFORT I; TWO PIECES, SEGMENT MOVEMENT IN ANY DIRECTION, REQUIRING BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS) (EG, UNGRAFTED UNILATERAL ALVEOLAR CLEFT) 21147 RECONSTRUCTION MIDFACE, LEFORT I.

7 3 OR MORE PIECES, SEGMENT MOVEMENT IN ANY DIRECTION, REQUIRING BONE GRAFTS (INCL OBTAINING AUTOGRAFTS) (EG, UNGRAFTED BILAT ALVEOLAR CLEFT OR MULT OSTEOTOMIES) 21150 RECONSTRUCTION MIDFACE, LEFORT II; ANTERIOR INTRUSION (EG, TREACHER-COLLINS SYNDROME) 21151 RECONSTRUCTION MIDFACE, LEFORT II; ANY DIRECTION, REQUIRING BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS) 21154 RECONSTRUCTION MIDFACE, LEFORT III (EXTRACRANIAL), ANY TYPE, REQUIRING BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS); WITHOUT LEFORT I 21155 RECONSTRUCTION MIDFACE, LEFORT III (EXTRACRANIAL), ANY TYPE, REQUIRING BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS).

8 WITH LEFORT I 21159 RECONSTRUCTION MIDFACE, LEFORT III (EXTRA AND INTRACRANIAL) WITH FOREHEAD ADVANCEMENT (EG, MONO BLOC), REQUIRING BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS); WITHOUT LEFORT I 21160 RECONSTRUCTION MIDFACE, LEFORT III (EXTRA AND INTRACRANIAL) WITH FOREHEAD ADVANCEMENT (EG, MONO BLOC), REQUIRING BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS); WITH LEFORT I 21188 RECONSTRUCTION MIDFACE, OSTEOTOMIES (OTHER THAN LEFORT TYPE) AND BONE GRAFTS (INCLUDES OBTAINING AUTOGRAFTS) 21193 RECONSTRUCTION OF MANDIBULAR RAMI, HORIZONTAL, VERTICAL, "C", OR "L" OSTEOTOMY; WITHOUT BONE GRAFT 21194 RECONSTRUCTION OF MANDIBULAR RAMUS, HORIZONTAL, VERTICAL, "C", OR "L" OSTEOTOMY.

9 WITH BONE GRAFT (INCLUDES OBTAINING GRAFT) Blue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association 2 February 2018 Procedure CodeDescriptionNotesUpdates to the list are announced routinely in the News and Updates section of the : This list contains the Additional Codes requiring benefit Preauthorization effective Jan. 1, 2018 only. Services which began requiring benefit Preauthorization prior to Jan. 1, 2018 are not included in this list, but are still in effect. To confirm if benefit Preauthorization is needed, check eligibility and benefits through AvailityTM or your preferred vendor portal or call the customer service number on the member's ID card.

10 Codes notated in red on this list are Codes that will no longer require Preauthorization effective as of the date indicated. Blue Advantage HMOSM and Blue Advantage PlusSM HMO (BAV)Blue Choice PPOSM (BCA)Blue EssentialsSM and Blue Essentials AccessSM (HMO)Blue PremierSM and Blue Premier AccessSM (HMH)This list includes procedure Codes related to Additional care categories for which benefit Preauthorization through Blue Cross and Blue Shield of Texas ( BCBSTX ) are required for fully insured members effective Jan. 1, 2018 for the products listed below:2018 Blue Cross and Blue Shield of Texas Newly Effective Preauthorization Codes For Fully Insured Commercial Plans21195 RECONSTRUCTION OF MANDIBULAR RAMI AND/OR BODY, SAGITTAL SPLIT; WITHOUT INTERNAL RIGID FIXATION 21196 RECONSTRUCTION OF MANDIBULAR RAMUS AND/OR BODY, SAGITTAL SPLIT.