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Prior plan approval

Other services and procedures

Prior plan approval code list:

This list is updated on a quarterly basis, within the first 10 days of January, April, July, and October. If there is no update within this time period, the list will remain unchanged until the following quarter. Unlisted and miscellaneous health services codes should only be used if a specific code has not been established by the American Medical Association.

 Prior plan approval code list
 Topical Negative Pressure Therapy for Wounds Request Form
 Topical Negative Pressure Therapy for Wounds Extension Request Form

Prior plan approval policies and procedures:

  • *Blue Care® plan: BCBSNC may authorize a service received out-of-network at the in-network benefit level if the service is not available in-network or if there is a transition of care issue.
  • Blue Advantage®, Blue Choice® and Blue OptionsSM plans: BCBSNC may authorize a service received out-of-network at the in-network benefit level if the service is not available in-network or if there is a transition of care issue.
  • **Blue Advantage plans: Prior plan approval is not required for mental health or substance abuse services.
  • ***Prior approval codes for DME are available from Customer Service, Utilization Management or your BCBSNC Network Management representative.
  • Requirements for utilization of in-network and out-of-network facilities and professionals must be verified in conjunction with obtaining prior plan approval.

Policies apply to members covered by:

Blue Advantage, Blue Care, Blue Choice and Blue Options. Prior approval for Classic Blue ®is also required for employees of Duke Energy, Morgan USA, Martin Marietta, Goodrich and U.S. Airways. US Airways requires PPA for DME greater than $500.00 for all lines of business.

Request prior plan approval:

For other services and procedures:

  • Online: Submit request 
  • By fax: Request form 
  • By phone: BCBSNC Utilization Management - 1-800-672-7897
    Monday - Friday, 8 a.m. - 5 p.m., Eastern time
  • Breast Brachytherapy - Mammosite: Request Form 
  • Oncotype DX™: Request Form 
  • Topical Negative Pressure Therapy for Wounds: Request Form 
  • Topical Negative Pressure Therapy for Wounds Extension: Request Form 

The following services and procedures received in a nonemergency situation on an outpatient basis require prior plan approval.

  • Blue Care: Any service received at an out-of-network provider*
  • Mental health or substance abuse treatment (except for Blue Advantage)**
  • Non-emergency air ambulance services
  • Certain durable medical equipment (DME)***
  • Home health, including nursing and home infusion
  • Surgery and/or outpatient procedures, including but not limited to:
    • Lung volume reduction surgery
    • Morbid obesity surgery
    • UPPP, surgical management of obstructive sleep apnea
    • Vertebroplasty and kyphoplasty
    • Percutaneous treatment of HNP
    • Orthotripsy
  • Procedures potentially cosmetic, including but not limited to:
    • Reconstructive surgery, including but not limited to rhitidectomy, dermabrasion, scar revision
    • Breast surgeries including insertion and removal of silicone breast implants (not resulting from mastectomy), reduction mammoplasty, and gynecomastia
    • Otoplasty
    • Blepharoplasty
    • Abdominoplasty
    • Therapy of superficial veins, such as varicose veins, telangiectasias
    • Home use of ultraviolet light box
    • Orthognathic surgery
    • Rhinoplasty

Please note: In addition to the services listed above, prior plan approval may be required for diagnostic imaging services. For instructions on requesting prior plan approval for diagnostic imaging, see diagnostic imaging procedures.