services requiring prior authorization - Premera Blue Cross

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Note: This list is searchable by typing CNTRL + F,or by selecting the Edit menu, then Find.Effective 01/01/2014List updated 11/01/2014Items on this list will require prior authorization (via pre‐service review) for medical necessity, contract limitations and exclusions,experimental or investigational services.Prior Authorization Code ListPre‐service review can be required or recommended. To check the status of a code against a member’s plan, use the Prospective Review Tool, then submit thereview and check the status of the review online. This list is not exhaustive, and the presence of codes on this list does not necessarily indicate coverage underthe member benefits contract, as member contracts differ in their benefits. This list does not include any drugs that are subject to the pharmacy priorauthorization program. Always use the Prospective Review Tool, consult the member benefit booklet, or contact a customer service representative to determinecoverage for a specific medical service or supply. Please note: For a list of services requiring medical necessity review, refer to the Clinical Review Code List onthe Prospective Review page on the provider portal.Code Name Code Description Code Type Records Request77520 Proton treatment delivery; simple, without compensation CPT‐4 History and Physical, treatment plan. Allow if group #9000000 Alyeska77522 Proton treatment delivery; simple, with compensation CPT‐4 History and Physical, treatment plan. Allow if group #9000000 Alyeska77523 Proton treatment delivery; intermediate CPT‐4 History and Physical, treatment plan. Allow if group #9000000 AlyeskaHistory and Physical indicating why treatment is being done. Allow if group#9000000 Alyeska77525 Proton treatment delivery; complex CPT‐4Myocardial perfusion imaging, tomographic (SPECT) (including attenuationcorrection, qualitative or quantitative wall motion, ejection fraction by firstpass or gated technique, additional quantification, when performed); single78451 study, at rest or stress (CPT‐4Myocardial perfusion imaging, tomographic (SPECT) (including attenuationcorrection, qualitative or quantitative wall motion, ejection fraction by firstpass or gated technique, additional quantification, when performed);78452 multiple studies, at rest and/orCPT‐4Myocardial perfusion imaging, planar (including qualitative or quantitativewall motion, ejection fraction by first pass or gated technique, additionalquantification, when performed); single study, at rest or stress (exercise or78453 pharmacologic)CPT‐4Myocardial perfusion imaging, planar (including qualitative or quantitativewall motion, ejection fraction by first pass or gated technique, additionalquantification, when performed); multiple studies, at rest and/or stress78454 (exercise or pharmacologic) anCPT‐4Myocardial imaging, positron emission tomography (PET), metabolic78459 evaluationCPT‐478466 Myocardial imaging, infarct avid, planar; qualitative or quantitative CPT‐47846878469784727847378481Myocardial imaging, infarct avid, planar; with ejection fraction by first passtechniqueMyocardial imaging, infarct avid, planar; tomographic SPECT with or withoutquantificationCardiac blood pool imaging, gated equilibrium; planar, single study at rest orstress (exercise and/or pharmacologic), wall motion study plus ejectionfraction, with or without additional quantitative processingCardiac blood pool imaging, gated equilibrium; multiple studies, wall motionstudy plus ejection fraction, at rest and stress (exercise and/orpharmacologic), with or without additional quantificationCardiac blood pool imaging (planar), first pass technique; single study, at restor with stress (exercise and/or pharmacologic), wall motion study plusejection fraction, with or without quantificationCPT‐4CPT‐4CPT‐4CPT‐4CPT‐4Online review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, results of previous diagnostic procedure reportOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical , results of previous diagnositic procedure reportOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, results of previous diagnostic procedure reportOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, results of previous diagnostic procedure reportOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, including prior testing, procedures reportOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, procedure report, prior cardiac imaging procedure performed andoutcomeOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, procedure report, prior cardiac imaging procedure performed andoutcomeOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, procedure report, prior cardiac imaging procedure performed andoutcomeOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, procedure report, prior cardiac imaging procedure performed andoutcomeOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, procedure report, prior cardiac imaging procedure performed andoutcomeOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, procedure report, prior cardiac imaging procedure performed andoutcomeCPT codes, descriptions and material are copyrighted by the American Medical Association. Page 19 of 58 027236 (10‐2014)
Note: This list is searchable by typing CNTRL + F,or by selecting the Edit menu, then Find.Effective 01/01/2014List updated 11/01/2014Items on this list will require prior authorization (via pre‐service review) for medical necessity, contract limitations and exclusions,experimental or investigational services.Prior Authorization Code ListPre‐service review can be required or recommended. To check the status of a code against a member’s plan, use the Prospective Review Tool, then submit thereview and check the status of the review online. This list is not exhaustive, and the presence of codes on this list does not necessarily indicate coverage underthe member benefits contract, as member contracts differ in their benefits. This list does not include any drugs that are subject to the pharmacy priorauthorization program. Always use the Prospective Review Tool, consult the member benefit booklet, or contact a customer service representative to determinecoverage for a specific medical service or supply. Please note: For a list of services requiring medical necessity review, refer to the Clinical Review Code List onthe Prospective Review page on the provider portal.Code Name Code Description Code Type Records RequestCardiac blood pool imaging (planar), first pass technique; multiple studies, atOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andrest and with stress (exercise and/ or pharmacologic), wall motion study plusPhysical, procedure report, prior cardiac imaging procedure performed and78483 ejection fraction, with or without quantificationCPT‐4 outcomeMyocardial imaging, positron emission tomography (PET), perfusion; singleOnline review at www.aimspecialtyhealth.com For Prior Authorization: History and784917849278494study at rest or stressMyocardial imaging, positron emission tomography (PET), perfusion;multiple studies at rest and/or stressCardiac blood pool imaging, gated equilibrium, SPECT, at rest, wall motionstudy plus ejection fraction, with or without quantitative processingCPT‐4CPT‐4CPT‐478608 Brain imaging, positron emission tomography (PET); metabolic evaluation CPT‐478609 Brain imaging, positron emission tomography (PET); perfusion evaluation CPT‐478811Tumor imaging, positron emission tomography (PET); limited area (e.g., leg,chest, head/neck)CPT‐478812 Tumor imaging, positron emission tomography (PET); skull base to mid‐thigh CPT‐478813 Tumor imaging, positron emission tomography (PET); whole body CPT‐4788147881578816Tumor imaging, positron emission tomography (PET) with concurrentlyacquired computed tomography (CT) for attenuation correction andanatomical localization: limited areas (e.g., leg, chest, head/neck)Tumor imaging, positron emission tomography (PET) with concurrentlyacquired computed tomography (CT) for attenuation correction andanatomical localization: skull base to mid‐thighTumor imaging, positron emission tomography (PET) with concurrentlyacquired computed tomography (CT) for attenuation correction andanatomical localization: whole bodyCPT‐4CPT‐4CPT‐488241 Thawing and expansion of frozen cells, each aliquot CPT‐4Physical, including prior testing, procedures reportOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, including prior testing, procedures reportOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, procedure report, prior cardiac imaging procedure performed andoutcomeOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, Office Notes from ordering Physician for visits related to the billed serviceand results of testing performedOnline review at www.aimspecialtyhealth.com For Prior Authorization: History andPhysical, Office Notes from ordering Physician for visits related to the billed serviceand results of testing performedOnline review at www.aimspecialtyhealth.com For Prior Authorization: If diagnosisis Cancer/Malignancy ‐ Allow, no records are required. For all other diagnosis billedrequest History and Physical, Office Notes from ordering Physician for visits relatedto the billed service and results of testing performedOnline review at www.aimspecialtyhealth.com For Prior Authorization: If diagnosisis Cancer/Malignancy ‐ Allow, no records are required. For all other diagnosis billedrequest History and Physical, Office Notes from ordering Physician for visits relatedto the billed service and results of testing performedOnline review at www.aimspecialtyhealth.com For Prior Authorization: If diagnosisis Cancer/Malignancy ‐ Allow, no records are required. For all other diagnosis billedrequest History and Physical, Office Notes from ordering Physician for visits relatedto the billed service and results of testing performedOnline review at www.aimspecialtyhealth.com For Prior Authorization: If diagnosisis Cancer/Malignancy ‐ Allow, no records are required. For all other diagnosis billedrequest History and Physical, Office Notes from ordering Physician for visits relatedto the billed service and results of testing performedOnline review at www.aimspecialtyhealth.com For Prior Authorization: If diagnosisis Cancer/Malignancy ‐ Allow, no records are required. For all other diagnosis billedrequest History and Physical, Office Notes from ordering Physician for visits relatedto the billed service and results of testing performedOnline review at www.aimspecialtyhealth.com For Prior Authorization: If diagnosisis Cancer/Malignancy ‐ Allow, no records are required. For all other diagnosis billedrequest History and Physical, Office Notes from ordering Physician for visits relatedto the billed service and results of testing performedIf transplant approval on record: Date of Transplant If no Transplant approval:History and Physical, Transplant evaluation, and date of transplantCPT codes, descriptions and material are copyrighted by the American Medical Association. Page 20 of 58 027236 (10‐2014)
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