2018 BCBSTX Newly Effective Preauthorization …

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

2 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 noted in red on this list will no longer require Preauthorization Effective 2/23/2018. 2018 Blue Cross and Blue Shield of Texas Newly Effective Preauthorization Codesfor Health Advocacy Solutions Premier PackageThis list includes procedure codes related to additional care categories for which benefit Preauthorization through Blue Cross and Blue Shield of Texas ( BCBSTX ) will be required Effective Jan. 1, 2018 for the product listed below:Blue Choice PPOSM (BCA) with Health Advocacy Solutions Premier PackageBlue 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.

3 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 noted in red on this list will no longer require Preauthorization Effective 2/23/2018. 2018 Blue Cross and Blue Shield of Texas Newly Effective Preauthorization Codesfor Health Advocacy Solutions Premier PackageThis list includes procedure codes related to additional care categories for which benefit Preauthorization through Blue Cross and Blue Shield of Texas ( BCBSTX ) will be required Effective Jan. 1, 2018 for the product listed below:Blue Choice PPOSM (BCA) with Health Advocacy Solutions Premier Package21145 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.

4 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).

5 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.

6 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.

7 Codes noted in red on this list will no longer require Preauthorization Effective 2/23/2018. 2018 Blue Cross and Blue Shield of Texas Newly Effective Preauthorization Codesfor Health Advocacy Solutions Premier PackageThis list includes procedure codes related to additional care categories for which benefit Preauthorization through Blue Cross and Blue Shield of Texas ( BCBSTX ) will be required Effective Jan. 1, 2018 for the product listed below:Blue Choice PPOSM (BCA) with Health Advocacy Solutions Premier Package21195 RECONSTRUCTION OF MANDIBULAR RAMI AND/OR BODY, SAGITTAL SPLIT; WITHOUT INTERNAL RIGID FIXATION 21196 RECONSTRUCTION OF MANDIBULAR RAMUS AND/OR BODY, SAGITTAL SPLIT; WITH INTERNAL RIGID FIXATION 21198 OSTEOTOMY, MANDIBLE, SEGMENTAL 21199 OSTEOTOMY, MANDIBLE, SEGMENTAL.

8 WITH GENIOGLOSSUS ADVANCEMENT 21206 OSTEOTOMY, MAXILLA, SEGMENTAL (EG, WASSMUND OR SCHUCHARD) 21208 OSTEOPLASTY, FACIAL BONES; AUGMENTATION (AUTOGRAFT, ALLOGRAFT, OR PROSTHETIC IMPLANT) 21209 OSTEOPLASTY, FACIAL BONES; reduction 21210 GRAFT, BONE; NASAL, MAXILLARY OR MALAR AREAS (INCLUDES OBTAINING GRAFT) 21215 GRAFT, BONE; MANDIBLE (INCLUDES OBTAINING GRAFT) 21230 GRAFT.

9 RIB CARTILAGE, AUTOGENOUS, TO FACE, CHIN, NOSE OR EAR (INCLUDES OBTAINING GRAFT) 22533 ARTHRODESIS LATERAL EXTRACAVITARY TECHNIQUE, INCLUDING MINIMAL DISKECTOMY TO PREPARE INTERSPACE (OTHER THAN FO RDECOMPRESSION); LUMBAR 22534 ARTHRODESIS, LATERAL EXTRACAVITARY TECHNIQUE, INCLUDING MINIMAL DISKECTOMYTO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); THORACIC OR LUMBAR, EACH ADDITONAL VERTEBRAL SEGMENT (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY 22558 ARTHRODESIS, ANTERIOR INTERBODY TECHNIQUE, INCLUDING MINIMAL DISKECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION); LUMBAR 22585 ARTHRODESIS, ANTERIOR INTERBODY TECHNIQUE, INCLUDING MINIMAL DISKECTOMY TO PREPARE INTERSPACE (OTHER THAN FOR DECOMPRESSION).)

10 EACH ADDITIONAL INTERSPACE (LIST SEPARATE FROM PRIMARY PROC) 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 3 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.