Prior Authorization Guidelines - Blue Cross NC

1 ~ Prior Authorization Guidelines ~Services marked by a bullet in the columns to the left require Prior Authorization for the designated line of business. For Specific Codes Requiring PA, please go to: Procedures (or those potentially cosmetic), such as but not limited to:ggAbdominoplasty ggBlepharoplasty ggBreast ReductiongDental ServicesgDiagnostic TestingggNeuropsychological TestingggPsychological Evaluations for medical conditionsggDurable Medical Equipment (See Prosthetics listed separately below) ggAll Rental Items ggItems > $ (Purchase) ggDME Maintenance or Repair ggHome Health ServicesggInpatient AdmissionsggScheduled admissions, including acute hospital, acute to acute hospital transfers, rehabilitation facility, hospice and skilled nursing facility : For urgent/emergency admits (including obstetric admits), Prior Authorization is NOT required.

2 However, notification of urgent/emergency admits (including obstetric admits) within 24 hours or the first business day after the admission is Procedures (or those potentially investigational) such as, but not limited to Codes 0001T-0391 TgNonparticipating Providers and ServicesggPharmaceuticals (See formulary)ggProsthetics (Such as artificial limbs and components) gRehabilitation/TherapyggCardiac Rehab: The Initial program of 36 sessions is covered without PA. Additional Cardiac Rehab requires PAgPulmonary Rehab: The Initial Program of 36 sessions is covered without PA. Additional Pulm. Rehab requires PAgSpeech Therapy SurgerygRefractive Surgical Procedures (LASIK, PRK, etc.)ggSacral Neurostimulators ggSpinal NeurostimulatorsggDeep Brain StimulatorsggNeuromuscular StimulatorsggPenile ImplantsggVagal Nerve Stimulators for EpilepsyggSurgical Treatment of Morbid Obesity ggSurgical Treatment of Sleep Apnea (UPPP, somnoplasty, uvulectomy, etc.)

3 GTemporomandibular Joint Surgery ggTransplants, Bone Marrow/Stem Cell and OrganggVaricose Vein Treatment ggVertebroplasty and Kyphoplasty, PercutaneousggTransportation (non-emergency) ggUnlisted/Miscellaneous CPT and HCPCS CodesEffective 1/1/2018An independent licensee of the Blue Cross and Blue Shield Association. , SM Marks of the Blue Cross and Blue Shield Association.