Services and CPT codes

The PDF versions of the code lists have been removed. Please use the search tool to determine if the service requires prior authorization. You can also view the entire code lists as web pages:

• Avalon, Cover My Meds, and Blue Cross NC UM Prior Authorization Code List
• Carelon Medical Benefit Management Prior Authorization Code List
• All Prior Authorization Code List (Avalon, Cover My Meds, Blue Cross NC, and Carelon code lists combined)

AVALON = Avalon Lab

Blue Cross NC = Blue Cross Utilization Management (UM)

CMM = Cover My Meds

MHK

Oncology = Oncology

Sleep = Sleep Study

DIM = Diagnostic Imaging

Cardiology = Cardiology

MSK = Musculoskeletal

Rehab = Rehabilitation (PT/OT/ST)

Surg = Surgical

[i] = Investigational

* Prior authorization is required for all drugs listed regardless of the HCPCS code submitted on the claim. The requirement is based on the drug itself – not the code chosen to submit on the claim.

New to market drugs are defined as drugs that have only been available on the US market for 90 days or less from the FDA approval date. Individual drug names will be added to the prior authorization list as soon as possible but even if the drug is not listed by name and it is new to market prior authorization is required.

* Prior authorization is required for all drugs listed regardless of the HCPCS code submitted on the claim. The requirement is based on the drug itself – not the code chosen to submit on the claim.

New to market drugs are defined as drugs that have only been available on the US market for 90 days or less from the FDA approval date. Individual drug names will be added to the prior authorization list as soon as possible but even if the drug is not listed by name and it is new to market prior authorization is required.

• Notice Date: The listed date is when the notice of the existing code was added.
• Effective Date: The listed date is when the code will require prior authorization for correct claims processing. If there is no date in this field, the requirement is in effect.
• Ineffective Date: The listed date is when the code became invalid.
• What is a CPT® code? The Current Procedural Terminology (CPT®) codes offer doctors and health care professionals a uniform language for coding medical services and procedures to streamline reporting, increase accuracy and efficiency. CPT codes are also used for administrative management purposes such as claims processing and developing guidelines for medical care review.

Requirements for utilization of in-network and out-of-network facilities and professionals must be verified in conjunction with obtaining prior plan approval. Blue Medicare^℠ 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. Services not covered by Original Medicare are not covered by Blue Medicare.

Refer to either the CPT Code Search Tool or the Blue Medicare Prior Authorization Guidelines for other prior authorization requirements.

Enter CPT and HCPCS codes in the search to determine if they require prior authorization. Codes that require prior authorization will have a link to direct you to related requirements and instructions. The code list isn't an all-inclusive list. Please review the prior authorization guidelines for additional services that require prior authorization.

The PDF versions of the code lists have been removed. Please use the search tool to determine if the service requires prior authorization. You can also view the entire code lists as web pages:

• Blue Medicare Carelon Prior Authorization Code List
• Blue Medicare Carelon Oncology Prior Authorization Code List
• Medicare Part B Prior Authorization and Step Therapy Drug Codes
• All Blue Medicare Prior Authorization Code List (Blue Medicare Carelon, Blue Medicare Carelon Oncology, and Medicare Part B Prior Authorization and Step Therapy)

Listed services require prior authorization for both HMO and PPO members.

Services marked by a star (*) do not require prior authorization for PPO members.

• Cosmetic Procedures (or those potentially cosmetic), such as but not limited to:

  • Abdominoplasty
  • Blephroplasty
  • Breast Reduction

• Dental Services (coverage under the medical benefit) *

• Durable Medical Equipment (DME):

  • All rental items
  • Items greater than $1200.00
  • DME repair or maintenance

• Home Health Services and Home Infusion Services

• Inpatient Admissions

  • Scheduled admission to any of the following: acute hospital, long term hospitals, acute to acute hospital transfers, inpatient rehabilitation facilities, inpatient hospice,  skilled nursing facilities and religious non-medical healthcare services
  • Urgent/emergent inpatient admissions do not require prior authorization. However, notification of these admissions within 24 hours or the first business day after admission is required

• Inpatient Psychiatric and Chemical Dependency Treatment

  • Urgent/emergent inpatient admissions do not require prior authorization. However,  notification of these admissions within 24 hours or the first business day after admission is required

• Experimental/Investigational Procedures (or those potentially experimental/investigational)

• Nonparticipating Providers and Services *

• Pharmaceuticals (see formulary):

  • Aduhelm, Kisunia, and Leqembi

• Prosthetics (such as artificial limbs and components)

• Electroconvulsive Therapy (ECT)

• Facet Joint Intervention

• Therapeutic Repetitive Transcranial Magnetic Stimulation Treatment (TMS)

• Surgery

  • Refractive Surgical Procedures (Lasik, PRK, etc) *
  • Sacral Neurostimulators
  • Spinal Neurostimulators
  • Deep Brain Stimulators
  • Neuromuscular Stimulators
  • Bone Growth Stimulators (osteogenesis) *
  • Penile Implants
  • Vagal Nerve Stimulators for Epilepsy
  • Surgical Treatment of Morbid Obesity
  • Surgical Treatment of Sleep Apnea (UPP, somnoplasty, uvulectomy, etc)
  • Temporomandibular Joint Surgery *
  • Transplants: Bone Marrow/Stem Cell and Solid Organ
  • Varicose Vein Treatment
  • Vertebroplasty and Kyphoplasty, Percutaneous
  • Artificial Heart
  • Ventricular Assist Device

• Transportation (non-emergent)

• Unlisted/Miscellaneous CPT and HCPCs codes

HCPCS codes beginning with "S", other than those listed, will not be considered for coverage by Blue Medicare HMO/PPO.