Procedure Code List for Preauthorization for Blue …

1 1 Dec. 6, 2017 Procedure code List for Preauthorization for Blue Cross and Blue Shield of New mexico medicare advantage members only Beginning , 2018, providers will be required to obtain Preauthorization through Blue Cross and Blue Shield of New mexico (BCBSNM), DaVita Medical Group (DMG) or eviCore for certain procedures for Blue Cross medicare advantage members as noted below. Services performed without benefit Preauthorization may be denied for payment and in whole or in part, you may not seek reimbursement from members . Member eligibility and benefits should be checked prior to every scheduled appointment. Eligibility and benefit quotes include membership status, coverage status and other important information, such as applicable copayment, coinsurance and deductible amounts. It is strongly recommended that providers ask to see the member's ID card for current information and a photo ID to guard against medical identity theft.

2 When services may not be covered, members should be notified that they may be billed directly. A referral to an out-of-plan or out-of-network provider which is necessary due to network inadequacy or continuity of care must be reviewed by the BCBSNM Utilization Management or DMG (if the member is attributed to DMG this information will be reflected on the ID card) prior to a BCBSNM patient receiving care. To obtain benefit Preauthorization through BCBSNM for the procedures noted below, you may continue to use iExchange . This online tool is accessible to physicians, professional providers and facilities contracted with BCBSNM. For more information or to set up a new account, refer to the iExchange page in the Provider Tools section of our Provider website. Procedure codes highlighted in green denote Preauthorization through eviCore. Our goal is to provide our members with access to quality, cost-effective health care. If you have any questions, please contact your Network Management Consultant.

3 2 Dec. 6, 2017 Procedure codes that require authorization Description of Procedure code Medical Review Category Medical Records Request information required 11970 Replacement of tissue expander with permanent prosthesis Cosmetic - Potential Contract Exclusion Pre-Operative Evaluation, History and Physical including functional impairment, and Operative report. 15002 Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, trunk, arms, legs; first 100 sq cm or 1% of body area of infants and children Cosmetic - Potential Contract Exclusion Pre-operative evaluation, history and physical including functional impairment, and operative report. 15003 Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, trunk, arms, legs; each additional 100 sq cm, or part thereof, or each additional 1% of body area of infants and children (List separately in addition to code for primary Procedure Cosmetic - Potential Contract Exclusion Pre-operative evaluation, history and physical including functional impairment, and operative report.)

4 15004 Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first 100 sq cm or 1% of body area of infants and children Cosmetic - Potential Contract Exclusion Pre-operative evaluation, history and physical including functional impairment, and operative report. 15005 Surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; each additional 100 sq cm, or part thereof, or each additional 1% of body area of infants and children (List separately in addition to code for primary Procedure ) Cosmetic - Potential Contract Exclusion Pre-operative evaluation, history and physical including functional impairment, and operative report.

5 15220 Full thickness graft, free, including direct closure of donor site, scalp, arms, and/or legs; 20 sq cm or less Cosmetic - Potential Contract Exclusion Pre Operative Evaluation, History and Physical including functional impairment, and Operative report 15775 Punch graft for hair transplant; 1 to 15 punch grafts Cosmetic - Potential Contract Exclusion Pre Operative Evaluation, History and Physical including functional impairment, and Operative report 15776 Punch graft for hair transplant; more than 15 punch grafts Cosmetic - Potential Contract Exclusion Pre Operative Evaluation, History and Physical including functional impairment, and Operative report 3 Dec. 6, 2017 15777 Implantation of biologic implant (eg, acellular dermal matrix) for soft tissue reinforcement (ie, breast, trunk) (List separately in addition to code for primary Procedure ) Cosmetic - Potential Contract Exclusion Pre Operative Evaluation, History and Physical including functional impairment, and Operative report 15780 Dermabrasion; Total Face Cosmetic - Potential Contract Exclusion Pre-operative evaluation, history and physical including functional impairment, and operative report.

6 15781 Dermabrasion; Segmental, Face Cosmetic - Potential Contract Exclusion Pre-operative evaluation, history and physical including functional impairment, and operative report. 15782 Dermabrasion; Regional, Other Than Face Cosmetic - Potential Contract Exclusion Pre-operative evaluation, history and physical including functional impairment, and operative report. 15783 Dermabrasion; Superficial, Any Site Cosmetic - Potential Contract Exclusion Pre-operative evaluation, history and physical including functional impairment, and operative report. 15786 Abrasion; Single Lesion Cosmetic - Potential Contract Exclusion Pre-operative evaluation, history and physical including functional impairment, and operative report.

7 15787 Abrasion; Add'l 4 Lesions/< Cosmetic - Potential Contract Exclusion Pre-operative evaluation, history and physical including functional impairment, and operative report. 15788 Chemical Peel, Facial; Epidermal Cosmetic - Potential Contract Exclusion Pre-operative evaluation, history and physical including functional impairment, and operative report. 15789 Chemical Peel, Facial; Dermal Cosmetic - Potential Contract Exclusion Pre-operative evaluation, history and physical including functional impairment, and operative report. 15792 Chemical Peel, Nonfacial; Epidermal Cosmetic - Potential Contract Exclusion Pre-operative evaluation, history and physical including functional impairment, and operative report.

8 15793 Chemical Peel, Nonfacial; Dermal Cosmetic - Potential Contract Exclusion Pre-operative evaluation, history and physical including functional impairment, and operative report. 15819 Cervicoplasty Cosmetic - Potential Contract Exclusion Pre-operative evaluation, history and physical including functional impairment, and operative report. 15820 Blepharoplasty, Lower Eyelid Medical Necessity Pre-operative Evaluation, history and physical including functional impairment, operative report and photographs of the affected eyes. 4 Dec. 6, 2017 15821 Blepharoplasty, Lower Eyelid; W/Extensive Herniated Fat Pad Medical Necessity Pre-operative Evaluation, history and physical including functional impairment, operative report and photographs of the affected eyes.

9 15822 Blepharoplasty, Upper Eyelid Medical Necessity Pre-operative Evaluation, history and physical including functional impairment, operative report and photographs of the affected eyes. 15823 Blepharoplasty, Upper Eyelid; W/Excessive Skin Weighting Down Lid Medical Necessity Pre-operative Evaluation, history and physical including functional impairment, operative report and photographs of the affected eyes. 15824 Rhytidectomy; Forehead Cosmetic - Potential Contract Exclusion Pre-operative evaluation, history and physical including functional impairment, and operative report. 15825 Rhytidectomy; Neck W/Platysmal Tightening (Platysmal Flap, P-Flap) Cosmetic - Potential Contract Exclusion Pre-operative evaluation, history and physical including functional impairment, and operative report.

10 15826 Rhytidectomy; Glabellar Frown Lines Cosmetic - Potential Contract Exclusion Pre-operative evaluation, history and physical including functional impairment, and operative report. 15828 Rhytidectomy; Cheek, Chin, & Neck Cosmetic - Potential Contract Exclusion Pre-operative evaluation, history and physical including functional impairment, and operative report. 15829 Rhytidectomy; superficial musculoaponeurotic system (SMAS) flap Cosmetic - Potential Contract Exclusion Pre-operative evaluation, history and physical including functional impairment, and operative report. 15830 Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomy Medical Necessity Pre-operative evaluation, history and physical including functional impairment, and operative report.