services requiring prior authorization - Premera Blue Cross

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 RequestK0858K0859K0860K0861K0862K0863K0864Power wheelchair, group 3 heavy‐duty, single power option, sling/solidseat/back, patient weight 301 to 450 poundsPower wheelchair, group 3 heavy‐duty, single power option, captain's chair,patient weight capacity 301 to 450 poundsPower wheelchair, group 3 very heavy‐duty, single power option, sling/solidseat/back, patient weight capacity 451 to 600 poundsPower wheelchair, group 3 standard, multiple power option, sling/solidseat/back, patient weight capacity up to and including 300 poundsPower wheelchair, group 3 heavy‐duty, multiple power option, sling/solidseat/back, patient weight capacity 301 to 450 poundsPower wheelchair, group 3 very heavy‐duty, multiple power option,sling/solid seat/back, patient weight capacity 451 to 600 poundsPower wheelchair, group 3 extra heavy‐duty, multiple power option,sling/solid seat/back, patient weight capacity 601 pounds or moreHCPCHCPCHCPCHCPCHCPCHCPCHCPCHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthHistory and Physical to Include the following: diagnosis; abilities and limitations asthey relate to the equipment (e.g., degree of independence/ dependence,frequency and nature of the activities the patient performs, duration of medicalcondition, Past experience if any using similar equipment, Evaluation of upperextremity strengthCPT codes, descriptions and material are copyrighted by the American Medical Association. Page 53 of 58 027236 (10‐2014)