This program applies to migrated members only. Review other authorization requirements for non-migrated members.

Commercial Migrated Member Prior Authorization List

This Prior Authorization List includes services and supplies that require prior authorization or notification for migrated Group, Individual and Administrative Services Only (ASO) members.

Expedited requests

Submit requests via Availity Essentials when the member or provider believes waiting for a decision under the standard time frame could place the member's life, health or ability to regain maximum function in serious jeopardy. Read the information carefully to ensure your request meets the qualifications, then check the box on the form to attest that it is an expedited request.

Medical services

All medical services prior authorization requests and supporting clinical documentation should be submitted electronically via Availity Essentials: Patient Registration>Authorizations & Referrals>Authorizations.

Request forms will be available by Dec. 1, 2026. Do not submit via fax unless they meet fax exception criteria as defined on the request form.

Medical Services Request Form
Intensity modulated radiotherapy (IMRT) Pre-authorization Request Supplement Form

Physical Medicine program

The Physical Medicine program includes joint management and spine-related services.
Sign in to the EviCore by Evernorth (EviCore) portal or route from Availity’s electronic authorization tool via single sign on.

DME and facilities

The following forms will be available by Dec. 1, 2026:

Durable Medical Equipment (DME) Form
Hospital Admit and Discharge Notification Form (out-of-state and non-contracted providers)
NICU/PICU Notification of Admission Form (out-of-state providers)
Skilled Nursing Facility (SNF), Long Term Acute Care (LTAC) and Inpatient Rehabilitation Form

Behavioral health facilities

The following forms will be available by Dec. 1, 2026:

Initial Request Form (can be added to an Availity Essentials submission)
Concurrent Request Form
Stepdown Request Form

Request status

Check the status of your requests using the same platform you used to submit the request:

Requests submitted through EviCore are updated on EviCore’s portal.
Requests submitted through Availity Essentials are updated in Availity.

Direct clinical information reviews (MCG Health)

For select CPT codes, Availity's electronic authorization tool automatically routes you to MCG Health's website where you can document specific clinical criteria for your patient. If all criteria are met, you will see the approval on the Auth/Referral Dashboard soon after you click submit. Once all criteria are documented, you will then be routed back to Availity Essentials to attach supporting documentation and submit the request. Documenting complete and accurate clinical information for your patients helps to reduce the overall time it takes to review a request. View the services that may receive automated approval.

Prior authorization request submission

Type of service or request

Online

Phone

Fax (only if unable to submit online)

Skilled nursing facility only

Submit an electronic prior authorization request through Availity Essentials

1‑844‑600‑4376

1‑833‑847‑6601

Long term acute care and inpatient rehabilitation

1‑800‑423‑6884

1‑833‑847‑6601

Chemical dependency and mental health

1‑800‑780‑7881

1‑833‑847‑6601

Transplants

1‑800‑423‑6884

1‑833‑847‑6601

Professional services and DME

1‑800‑423‑6884

1‑833‑847‑6601

Expedited requests

1‑800‑423‑6884

1‑833‑847‑6601

Concurrent review notification for:

Skilled nursing facilities (SNF)
Inpatient hospital continued stay
Inpatient rehabilitation (IPR)
Long‑term acute care hospitalizations (LTACH)

1‑800‑351‑2370

1‑833‑847‑6601

Admission or discharge notifications for inpatient hospital

1‑833‑847‑6601

Admission or discharge notifications for SNF/IPRL/LTACH

1‑800‑423‑6884

1‑833‑847‑6601

Clinical records for:

SNF stays
LTACH stays
IPR stays

1‑800‑423‑6884

1‑833‑847‑6601

Physical Medicine program

Codes requiring authorization are listed in the Physical Medicine section below. Determine whether your patient's plan participates in this program by using the Electronic Authorization application on Availity Essentials. View EviCore's clinical guidelines.

Obtain or verify an authorization with EviCore by Evernorth (EviCore):

Sign in to EviCore's portal or route to EviCore from Availity's electronic authorization tool via single sign on
Phone 1-855-252-1115 or fax 1-855-774-1319

Members of some group health plans may have terms of coverage or benefits that are different from this information. Refer to the Important Prior Authorization Reminders section for details. To verify coverage or benefits or determine pre-certification or prior authorization requirements for a particular member, call 1-800-676-BLUE (2583) or send an electronic inquiry through your established connection with your local Blue plan.

Online

Use the Electronic Provider Access (EPA) tool available in Availity Essentials. With EPA, you can gain access to an out-of-area member's Home Plan provider portal, through a secure routing mechanism and have access to electronic pre-service review capabilities.
Use our online tool to be automatically routed to the home plan's prior authorization / pre-certification requirements. Launch the tool.

Phone

Call BlueCard Eligibility at 1-800-676-BLUE (2583). You will be asked for the member's prefix and the type of service for which you are calling:

Medical/surgical
Behavioral health
Diagnostic imaging/radiology
Durable medical equipment (DME)

Upon making your selection, you will be connected to the appropriate Blue plan.

Electronic inquiry

Submit an ANSI 278 transaction (referral/authorization) to BCBSND.

Prior authorization must be requested before providing services. The current practice of pre-claim review will not continue for migrated members. Contracted providers may receive administrative denials if prior authorization is not obtained before the service.
Failure to authorize services subject to prior authorization requirements or follow concurrent review requirements may result in an administrative denial, claim non-payment, and provider and facility write-off. Members may not be balance billed.
Before requesting prior authorization, verify member eligibility and benefits via Availity Essentials as the member contract determines the covered benefits.
Verify that you are an in-network provider for each member to help reduce his or her out-of-pocket expense.
If services are to be rendered in a facility, the prior authorization request submitted should designate the facility where the treatment will occur to ensure proper reconciliation with related inpatient claims.
Medical policies and other criteria may be used as the basis for service coverage determinations, including length of stay and level of care, including:

MCG criteria: Visit MCG's website for information on purchasing their criteria, or call the Provider Contact Center at 1‑800‑368‑2312 for guidelines for specific services.

Behavioral health policies and criteria, including:
Behavioral health medical policies
Level of Care Utilization System (LOCUS)
Child and Adolescent Level of Care/Service Intensity Utilization System (CALOCUS)

EviCore by Evernorth: Contact EviCore at 1-855-252-1115 for criteria used for our Physical Medicine Program.
Some member contracts have specific prior authorization requirements. The member's contract language will apply.
Emergency services do not require prior authorization but are subject to hospital admission notification and concurrent review requirements (see below).
Please note that prior authorization does not guarantee payment for requested services. (See No. 2 above). Our reimbursement policies may affect how claims are reimbursed. Payment of benefits is subject to pre-payment and/or post-payment review, and all plan provisions, including, but not limited to, eligibility for benefits and our Coding Toolkit clinical edits.
Investigational and cosmetic services and supplies are typically contract exclusions and are ineligible for payment. Unlisted codes may be used for potentially investigational services and are subject to review. Please refer to the Clinical Edits by Code list for additional information. View a sample non-covered member consent form.
All CPT and HCPCS codes listed on our prior authorization lists require prior authorization. View list below for complete requirements.

Authorization review timeframes

Type of review

Standard turnaround timeframe for decisions

Additional time allowed for review if additional information is needed:

Urgent prior authorization

72 hours

The plan must notify providers within 24 hours what additional information is needed.
Provider has no less than 48 hours to provide needed information.
Plan decision is due within 48 hours of receiving additional information.

Standard initial prior authorization

Seven calendar days
ASO groups: 15 calendar days

The plan must notify within seven calendar days what additional information is needed.
Provider has 45 calendar days to provide needed information from date of request.
Decision is due within the time remaining in the original seven calendar day review period, which resumes once the requested information is received or the response deadline has passed.

ASO groups:

The plan must notify provider within 15 calendar days of receipt of request what additional information is needed.
Provider has 45 calendar days to provide needed information from date of request.
Plan decision is due 15 calendar days from additional information received date or additional information due date, whichever is sooner.

Concurrent review

24 hours
Provider must notify and submit records within two business days for all non-elective acute inpatient hospital admissions, including newborn intensive care unit (NICU) or pediatric intensive care unit (PICU) admission. Exception: Maternity delivery notifications are required on day six if the member has not discharged.

The plan must notify provider within 24 hours what additional information is needed.
Decision is due within 72 hours of receipt of the initial request.
All clinical records necessary to complete medical necessity reviews must also be submitted within 24 hours of acute inpatient hospital medical admissions. Exception: Normal maternity and normal newborn.
All clinical records necessary to complete medical necessity reviews must also be submitted within 24 hours of behavioral health admissions for fully insured members.

*Note that additional timeframes for review are after receipt of the requested documentation or after the timeframe for submission of the requested information has expired - whichever comes first.

Urgent/expedited criteria is defined as one or more of the following:

The member’s life, health or ability to regain maximum function is in serious jeopardy.
The member’s psychological state is putting the life, health or safety of the member or others in serious jeopardy.
The member is subjected to severe pain that cannot be adequately managed without the service.

Note: If a prior authorization request is received requesting urgent/expedited review, and the documentation provided does not meet the urgent/expedited criteria, the review will be reclassified to a standard review and standard timeframes will apply.

Failure to secure approval for services subject to prior authorization or concurrent review authorization before providing services may result in claim non-payment and provider write-off. Our members must be held harmless and cannot be balance billed.

Please note the following:

Hospital claims for elective services that require prior authorization are reimbursed based upon the member's contract only when the physician or other healthcare professional has completed and received approval of the prior authorization for the services. We therefore strongly suggest that facilities develop a method to ensure that required prior authorization requests have been submitted and approved before the patient is admitted.
If the physician or other healthcare professional follows our prior authorization requirements, they will not be subject to penalties for failure to provide the required inpatient admission and discharge notification. Stays that extend beyond the prior authorized number of days require admission notification and concurrent review. If a facility fails to receive authorization for additional days, the additional days are a provider liability.
A prior authorization does not guarantee payment for requested services. Health plan reimbursement policies may affect how claims are reimbursed, and payment of benefits is subject to all plan provisions, including eligibility for benefits. Services must always be covered benefits and medically necessary.
If an elective service that requires prior authorization needs to occur during the course of an inpatient admission, and that need could not be foreseen before admission, the facility or provider can request prior authorization for the service while the member is inpatient (before the service occurs). If prior authorization does not occur during the stay, services are subject to review post-service for medical

See the mental health and substance use disorder section for information about inpatient admissions for chemical dependency and mental health.

Habilitative inpatient services

Prior authorization is required prior to patient admission.

Hospital admissions

Prior authorization is required for elective, non-emergent (medical or surgical procedure scheduled in advance) inpatient admissions.
Notification of inpatient hospital admission and discharge are required within two business days, regardless of federal holidays or day of the week.
Submit notification of hospital admissions through Availity Essentials. If Availity is unavailable, fax our Hospital Admit and Discharge Notification Form (available by Dec. 1, 2026). Providers should not call Customer Service to notify of patient admissions or discharge.
All admissions and requests for concurrent review must include diagnosis and clinical information regarding the member’s current inpatient stay. Upon receipt of initial admission notification, we will provide the date clinical information is due. Clinical information demonstrating the medical necessity for admission, as well as continued stay, must be submitted through Availity Essentials. Failure to provide required records may result in a reduction in or denial of benefits.
All clinical records necessary to complete medical necessity reviews must also be submitted within:
- ASO: One calendar day, regardless of federal holidays or day of the week.
- Commercial: Two business days of acute inpatient hospital medical admissions.

Inpatient hospice

Notification of admission or discharge is necessary within 24 hours of admission or discharge (or one business day, if the admission or discharge occurs on a weekend or a federal holiday). Notification of inpatient hospice admission and discharge required within 24 hours, regardless of federal holidays or day of the week.
Notification is required via fax 1-833-847-6601.

Long-Term Acute Care Facility (LTAC)

Prior authorization is required prior to patient admission.

Rehabilitation

Prior authorization is required prior to patient admission.

Skilled Nursing Facility (SNF)

Prior authorization is required prior to patient admission.

Prior authorization or notification is required for the services listed below. For select CPT codes, including transcranial magnetic stimulation services, Availity Essential's electronic authorization tool automatically connects to MCG Health's website where specific clinical criteria can be documented for your patient. If all criteria are met, approval will be received on the Auth/Referral Dashboard.

Inpatient: Psychiatric, eating disorder or ASAM 4.0 detoxification
- Notification is required as soon as possible after admission, with clinical information submitted with notification.
- Timely concurrent review will be required if additional days are requested after an initial prior authorization is issued. Concurrent review records are due on the last covered date of prior authorization. Failure to follow concurrent review requirements may result in an administrative denial, claim non-payment and provider and facility write-off. Members may not be balance billed. All clinical records necessary to complete medical necessity reviews must also be submitted within two business days of behavioral health admissions for fully insured members.
Residential levels of care (LOC)
- Prior authorization is required prior to patient admission for chemical dependency (ASAM 3.7and ASAM 3.5) residential, mental health residential and eating disorder residential requests.

Behavioral health criteria:

Prior Authorization List

Administrative Guidelines to Determine Dental vs Medical Services

21245, 21246, 21248, 21249

Custom-Fitted Intra-Oral Appliances for Obstructive Sleep Apnea (Medical policy will be published here by Oct. 1, 2026)

Effective Jan. 1, 2027, prior authorization will be required on codes 0964T, 0965T, 0966T, E0486, K1027

Dental and orthodontic services for the treatment of craniofacial anomalies (PDF)

D5999, D7999, D8999

Enteral and Oral Nutrition Therapy in the Home Setting (PDF)

B4034, B4035, B4036, B4081, B4082, B4083, B4087, B4088, B4105, B4148, B4149, B4150, B4152, B4153, B4154, B4155, B4157, B4158, B4159, B4160, B4161, B4162, B9002, B9998, S9434, S9435
Note: Prior authorization is not required for select inborn errors of metabolism. Use the Availity Essentials Authorization application to determine whether prior authorization is required for a member.

Bone Growth Stimulators, Electrical (Osteogenic Stimulation)

E0747, E0748, E0749
- Requests for E0747 require prior authorization through BCBSND.
- Requests for E0748 and E0749 are detailed in the "Physical Medicine" section below, and requests for prior authorization are submitted directly to EviCore

Ultrasonic Bone Growth Stimulators (Osteogenic Stimulation)

E0760, 20979

Definitive Lower Limb Prostheses

L5010, L5020, L5050, L5060, L5100, L5105, L5150, L5160, L5200, L5210, L5220, L5230, L5250, L5270, L5280, L5301, L5312, L5321, L5331, L5341, L5610, L5611, L5613, L5614, L5616, L5700, L5701, L5702, L5703, L5710, L5711, L5712, L5714, L5716, L5718. L5722, L5724, L5726, L5728, L5780, L5810, L5811, L5812, L5814, L5816, L5818, L5822, L5824, L5826, L5828, L5830, L5840, L5841, L5848, L5930, L5968, L5970, L5972, L5974, L5976, L5978, L5979, L5980, L5981, L5982, L5984. L5985, L5986, L5987

Insulin Infusion Pumps, Automated Insulin Delivery and Artificial Pancreas Device Systems

S1034

Myoelectric and Microprocessor Prosthetic and Orthotic Components for the Upper Limb

L6026, L6693, L6700, L6715, L6880, L6881, L6882, L6925, L6935, L6945, L6955, L6965, L6975, L7007, L7008, L7009, L7045, L7180, L7181, L7190, L7191

Noninvasive Ventilators in the Home Setting

E0466

Power Wheelchairs: Group 2 and Group 3

K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855, K0856, K0857, K0858, K0859, K0860, K0861, K0862, K0863, K0864

Powered and Microprocessor-Controlled Knee and Ankle-Foot Prostheses and Microprocessor-Controlled Knee-Ankle-Foot Orthoses

L5615, L5856, L5857, L5858

Tumor Treatment Field Therapy (PDF)

E0766

Genetic Testing for Alzheimer's Disease - GT01

81401, 81405, 81406

Genetic Testing for Hereditary Breast, Ovarian, Pancreatic and Prostate Cancer and Li-Fraumeni Syndrome - GT02

81162, 81163, 81164, 81165, 81166, 81167, 81212, 81215, 81216, 81217, 81307, 81308, 81321, 81322, 81323, 81351, 81352, 81404, 81405, 81406, 81432

Apolipoprotein E for Risk Assessment and Management of Cardiovascular Disease - GT05

81401

Genetic Testing for Lynch Syndrome and APC-associated and MUTYH-associated Polyposis Syndromes - GT06

81201, 81202, 81203, 81210, 81288, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81317, 81318, 81319, 81401, 81406, 81435

Genetic Testing for Cutaneous Malignant Melanoma - GT08

81404

Cytochrome p450 and VKORC1 Genotyping for Treatment Selection and Dosing - GT10

81225, 81227, 81401, 81402, 81404, 81405

Familial Hypercholesterolemia - GT11

81401, 81405, 81406, 81407

KRAS, NRAS and BRAF Variant Analysis and MicroRNA Expression Testing for Colorectal Cancer - GT13

81210, 81275,81276, 81311, 81403, 81404

Preimplantation Genetic Testing of Embryos - GT18

89290, 89291, 81228, 81229, 81349, 0552U

IDH1 and IDH2 Genetic Testing for Conditions Other Than Myeloid Neoplasms or Leukemia - GT19

81120, 81121

Genetic and Molecular Diagnostic Testing - GT20

81201, 81202, 81203, 81210, 81212, 81215, 81216, 81217, 81225, 81227, 81228, 81229, 81235, 81243, 81244, 81250, 81252, 81253, 81254, 81257, 81275, 81276, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81302, 81303, 81304, 81311, 81314, 81317, 81318, 81319, 81321, 81322, 81323, 81324, 81325, 81326, 81341, 81349, 81350, 81351, 81352, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81419, 81441, 81470, 81471, S3800, S3840, S3844, S3845, S3846, S3849, S3850, S3853, S3865, S3866

Biallelic RPE65 Variant-Associated Retinal Dystrophy - GT21

81406

Gene Expression Profiling for Melanoma - GT29

81552

BRAF Genetic Testing to Select Melanoma or Glioma Patients for Targeted Therapy - GT41

81210

Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer - GT42

81518, 81519, 81521, 81522, 81523, S3854

Diagnostic Genetic Testing for FMR1 and AFF2 Variants (Including Fragile X and Fragile XE Syndromes - GT43

81243, 81244

Noninvasive Prenatal Testing to Determine Fetal Aneuploidies, Microdeletions, Single-Gene Disorders, and Twin Zygosity - GT44

81408, 81243

Genetic Testing for CADASIL Syndrome - GT51

81406

Diagnostic Genetic Testing for α-Thalassemia - GT52

81257, 81258, 81259, 81269, 81404

Primary Mitochondrial Disorders - GT54

0417U, 81401, 81403, 81404, 81405, 81406, 81440, 81460, 81465

Targeted Genetic Testing for Selection of Therapy for Non-Small Cell Lung Cancer (NSCLC) - GT56

81210, 81235, 81275, 81276, 81404, 81405, 81406

Chromosomal Microarray Analysis (CMA) or Copy Number Analysis for the Genetic Evaluation of Patients with Developmental Delay Intellectual Disability, Autism Spectrum Disorder or Congenital Anomalies - GT58

81228, 81229, 81349, S3870

Myeloid Neoplasms and Leukemia - GT59

81120, 81121, 81351, 81352, 81401, 81402, 81403, 81450, 81451, 81455, 81456

PTEN Hamartoma Tumor Syndrome - GT63

81321, 81322, 81323

Evaluating the Utility of Genetic Panels - GT64

81201, 81202, 81203, 81210, 81225, 81227, 81228, 81229, 81235, 81243, 81244, 81250, 81252, 81253, 81254, 81257, 81275, 81276, 81288, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81302, 81303, 81304, 81311, 81314, 81317, 81318, 81319, 81321, 81322, 81323, 81324, 81325, 81326, 81349, 81350, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81412, 81432, 81434, 81437, 81440, 81441, 81443, 81450, 81451, 81455, 81456, 81460, 81465, 81470, 81471

Genetic Testing for Methionine Metabolism Enzymes, including MTHFR - GT65

81401, 81403, 81404, 81405, 81406

Diagnosis of Inherited Peripheral Neuropathies - GT66

81403, 81404, 81405, 81406, 81324, 81325, 81326, 81448

Genetic Testing for Rett Syndrome - GT68

81302, 81303, 81304, 81404, 81405, 81406

Duchenne and Becker Muscular Dystrophy - GT69

81161, 81408

Fetal Red Blood Cell Antigen Genotyping Using Maternal Plasma - GT74

81403

Genetic Testing for Macular Degeneration - GT75

81401, 81405, 81408

Whole Exome and Whole Genome Sequencing - GT76

0214U, 0215U, 0672U, 0673U, 81415, 81416

Genetic Testing for Heritable Disorders of Connective Tissue - GT77

81405, 81408

Invasive Prenatal Fetal Diagnostic Testing for Chromosomal Abnormalities - GT78

81228, 81229, 81349, 81405

Genetic Testing for the Evaluation of Products of Conception and Pregnancy Loss - GT79

81228, 81229, 81349

Genetic Testing for Epilepsy - GT80

81188, 81189, 81190, 81401, 81403, 81404, 81405, 81406, 81407, 81419

Reproductive Carrier Screening for Genetic Diseases - GT81

81161, 81243, 81244, 81250, 81252, 81253, 81254, 81257, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81412, 81434, 81443, S3844, S3845, S3846, S3849, S3850, S3853

Expanded Molecular Panel Testing of Cancers to Select Targeted Therapies - GT83

0037U, 0048U, 0211U, 0250U, 0334U, 0379U, 0473U, 0523U, 0538U, 0543U, 0648U, 0696U, 81120, 81121, 81162, 81210, 81235, 81275, 81276, 81292, 81295, 81298, 81311, 81314, 81319, 81321, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81445, 81449, 81455, 81456, 81457, 81458, 81459, Q4223

Genetic Testing for Neurofibromatosis Type 1 or 2 - GT84

81405, 81406, 81408

ClonoSEQ® Testing for the Assessment of Measurable Residual Disease (MRD) - GT88

0364U

Visit MCG's website for information on buying their criteria or contact the Provider Contact Center at 1-800-368-2312 and we will be happy to provide you with a copy of the specific guideline.

G0151, G0152, G0153, G0155, G0156, G0157, G0158, G0159, G0160, G0162, G0299, G0300, G0490, G0493, G0494, G0495, G0496, Q5001, Q5009, S9097, S9122, S9128, S9129, S9131, T1021, T1022 – GRG-MED-HC, GRG-SUR-HC
S9123, S9124, T1030 – GRG-MED-HC, GRG-SUR-HC, PDN-2001

Assisted Reproductive Technologies (Medical policy will be published here by Oct. 1, 2026)

55870, 58321, 58322, 58323, 58970, 58974, 58976, 76830, 76948, 82670, 83001, 83002, 84144, 84702, 89240, 89250, 89251, 89253, 89254, 89255, 89257, 89258, 89259, 89260, 89261, 89264, 89268, 89272, 89280, 89281, 89290, 89291, 89335, 89337, 89342, 89343, 89344, 89346, 89352, 89353, 89354, 89356, 89398, 90283, S4011, S4013, S4014, S4015, S4016, S4017, S4018, S4020, S4021, S4022, S4023, S4024, S4025, S4026, S4027, S4028, S4030, S4031, S4037, S4040, S4042, S9977, S9986

Bioengineered Skin and Soft Tissue Substitutes and Amniotic Products

A4100, A6460, A6461, G0681, G0682, G0683, G0684, Q4101, Q4102, Q4105, Q4107, Q4114, Q4116, Q4121, Q4122, Q4128, Q4132, Q4133, Q4151, Q4154, Q4159, Q4160, Q4186, Q4187, Q4391, Q4431, Q4432, Q4433

Charged-Particle (Proton) Radiotherapy

32701, 61796, 61797, 61798, 61799, 61800, 63620, 63621, 77301, 77338, 77371, 77372, 77373, 77432, 77435, 77520, 77522, 77523, 77525, G0339, G0340

Confocal Laser Endomicroscopy

43206, 43252, 88375

Digital Therapeutic Products

98978, A9291, A9292, A9294, E1905, G0552, G0553, G0554

Digital Therapeutic Products for Attention Deficit Hyperactivity Disorder

98978, A9291, G0552, G0553, G0554

Digital Therapeutic Products for Chronic Low Back Pain

98978, A9291, E1905, G0552, G0553, G0554

Digital Therapeutic Products for Substance Use Disorders

98978, A9291, G0552, G0553, G0554

Digital Therapeutic Products for Amblyopia

A9292

Digital Therapeutic Products for Post-traumatic Stress Disorder and Panic Disorder

A9291, A9294, G0552, G0553, G0554

Electromagnetic Navigation Bronchoscopy

31626, 31627, C7509, C7510, C7511, C7567, C8005

Gender Affirming Interventions for Gender Dysphoria

11920, 11921, 15769, 15771, 15772, 15773, 15774, 15775, 15776, 15825, 15828, 15829, 15839, 17380, 17999, 19303, 19316, 19318, 19325, 19350, 21125, 21127, 21137, 21139, 21141, 21142, 21143, 21145, 21146, 21147, 21188, 21193, 21194, 21195, 21196, 21208, 21270, 53400, 53405, 53410, 53415, 53420, 53425, 53430, 54125, 54400, 54401, 54405, 54520, 54660, 54690, 55175, 55180, 55970, 55980, 56625, 56800, 56805, 57106, 57110, 57291, 57292, 57295, 57296, 57335, 57426, 58353, 58356, 58563, C1813, C2622, L8600
Codes 55970 and 55980 are non-specific. The specific procedure code(s) must be requested in place of these non-specific codes.
Use code 17999 to request laser hair removal.
Gender affirming surgical interventions for gender dysphoria require prior authorization. Codes for specific procedures might also be listed as requiring prior authorization in other medical policies, including but not limited to:
- Abdominoplasty - 15830
- Adipose-derived Stem Cell Enrichment in Autologous Fat Grafting to the Breast - 15771
- Breast Reconstruction - 19316, 19318, 19325, 19350, L8600
- Blepharoplasty and Brow Lift - 15820, 15821, 15822, 15823, 67900, 67901, 67902, 67903, 67904, 67906, 67908, 67909, 67950
- Chin Implants - 21120, 21121, 21122, 21123, 21209
- Collagen Injections - 11950, 11951, 11952, 11954
- Cosmetic and Reconstructive Procedures - 15771, 15773
- Endometrial Ablation - 58353, 58356, 58563
- Panniculectomy - 15830
- Reconstructive Breast Surgery, Mastopexy, and Management of Breast Implants - 15771
- Rhinoplasty - 30400, 30410, 30420, 30430, 30435, 30450

Hyperbaric Oxygen Therapy

99183, G0277

Intensity Modulated Radiotherapy (IMRT)

Submit the IMRT Prior Authorization Request Supplement Form (form will be available Dec. 1, 2026) when requesting prior authorization for these services. This form will help determine when the Dose Volume Summary Analysis is required.
When required, color dose volume histograms must be in color
- 77301, 77338
Please reference the following Medical Policies for further information:

Orthopedic Applications of Stem-Cell Therapy, Including Bone Substitutes Used with Autologous Bone Marrow

38206, 38232, 38241

Progenitor Cell Therapy for the Treatment of Damaged Myocardium Due to Ischemia

38205, 38206, 38240, 38241

Proton Beam (Medical policy will be published by Oct. 1)

77520, 77522, 77523, 77525, S8030

In Vivo Analysis of Colorectal Lesions

88375

We partner with EviCore by Evernorth (EviCore) to administer our Physical Medicine program.

How to submit an authorization

Review this entire prior authorization list for similar services that require prior authorization.
Verify member benefits, eligibility and prior authorization requirements on Availity Essentials
Determine whether a member's plan participates in this program by using the Electronic Authorization application on Availity Essentials
Obtain or verify an authorization with EviCore:

Online: Use EviCore's portal for the fastest submission option
Phone: Call 1-855-252-1115
Fax: 1-855-774-1319

If one submission option is unavailable, use the next available option. If all submission options are unavailable, submit affected authorization requests within two days after systems are restored.

Retroactive authorization requests are accepted for dates affected by the outage. Retroactive requests are still subject to member eligibility and medical necessity review.

Joint management

To determine which program a member participates in, use the Electronic Authorization application on Availity Essentials.
We require prior authorization from EviCore for these codes: 23000, 23020, 23120, 23130, 23410, 23412, 23420, 23430, 23440, 23455, 23462, 23466, 23470, 23472, 23473, 23474, 23700, 27125, 27130, 27132, 27134, 27137, 27138, 27332, 27333, 27334, 27403, 27405, 27415, 27416, 27418, 27420, 27422, 27425, 27427, 27428, 27429, 27430, 27438, 27440, 27441, 27442, 27443, 27446, 27447, 27486, 27487, 27570, 27580, 29805, 29806, 29807, 29819, 29820, 29821, 29822, 29823, 29824, 29825, 29826, 29827, 29828, 29860, 29861, 29862, 29863, 29866, 29867, 29868, 29870, 29871, 29873, 29874, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889, 29914, 29915, 29916

Spine

To determine which program a member participates in, use the Electronic Authorization application on Availity Essentials.
We require prior authorization from EviCore for these codes: 20931, 20937, 20938, 22100, 22101, 22102, 22103, 22110, 22112, 22114, 22116, 22206, 22207, 22208, 22210, 22212, 22214, 22216, 22220, 22222, 22224, 22226, 22325, 22326, 22327, 22328, 22510, 22511, 22512, 22513, 22514, 22515, 22532, 22533, 22534, 22548, 22551, 22552, 22554, 22556, 22558, 22585, 22590, 22595, 22600, 22610, 22612, 22614, 22630, 22632, 22633, 22634, 22800, 22802, 22804, 22808, 22810, 22812, 22818, 22819, 22830, 22840, 22842, 22843, 22844, 22845, 22846, 22847, 22848, 22849, 22850, 22852, 22853, 22854, 22855, 22856, 22858, 22859, 22867, 22868, 63001, 63003, 63005, 63011, 63012, 63015, 63016, 63017, 63020, 63030, 63035, 63040, 63042, 63043, 63044, 63045, 63046, 63047, 63048, 63050, 63051, 63055, 63056, 63057, 63064, 63066, 63075, 63076, 63077, 63078, 63081, 63082, 63085, 63086, 63087, 63088, 63090, 63091, 63101, 63102, 63103, 63170, 63172, 63173, 63185, 63190, 63191, 63197, 63200, 63250, 63251, 63252, 63265, 63266, 63267, 63268, 63270, 63271, 63272, 63273, 63275, 63276, 63277, 63278, 63280, 63281, 63282, 63283, 63285, 63286, 63287, 63290, 63295, 63300, 63301, 63302, 63303, 63304, 63305, 63306, 63307, 63308, E0748, E0749, S2350, S2351

Adipose-derived Stem Cell Enrichment in Autologous Fat Grafting to the Breast

15769, 15771, 15772, 11950, 11951, 11952, 11954
Note: Codes 19380 and 19499 do not require prior authorization but are considered, and will deny as, investigational when used for autologous fat grafting with adipose-derived stem cell enrichment for augmentation or reconstruction of the breast.

Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions

27412, J7330, S2112

Balloon Ostial Dilation for Treatment of Sinusitis

31295, 31296, 31297, 31298

Bariatric surgery

43644, 43771, 43772, 43773, 43774, 43775, 43820, 43845, 43846, 43848, 43860, 43886, 43887, 43888

Blepharoplasty, Repair of Blepharoptosis, and Brow Ptosis Repair

15820, 15821, 15822, 15823, 67900, 67901, 67902, 67903, 67904, 67906, 67908, 67909, 67950

Bone Lengthening (Distraction Osteogenesis) (Medical policy will be published by Oct. 1)

0594T, 20690, 20692, 20693, 20694, 20696, 20697, 24420, 25391, 25393, 27458, 27466, 27713, 27715

Chemical Peels

15788, 15789, 15792, 15793, 17360

Cochlear Implant

69930, L8614, L8619, L8627, L8628

Cosmetic and Reconstructive Procedures

11920, 11921, 11922, 11950, 11951, 11952, 11954, 15769, 15771, 15772, 15773, 15774, 17106, 17107, 17108, 19355, 21230, 21244, 21245, 21246, 21248, 21249, 21295, 21296, 41510, 49250, 54360, 67950, 69300, G0429
Prior authorization is required EXCEPT when services are rendered in association with breast reconstruction and nipple/areola reconstruction following mastectomy for breast cancer.
Note: Codes 19380 and 19499 do not require prior authorization but are considered, and will deny as, investigational when used for autologous fat grafting with adipose-derived stem cell enrichment for augmentation or reconstruction of the breast.

Corneal Cross-Linking

J2789
Visit MCG's website for information on purchasing their criteria or contact the Provider Contact Center at 1-800-368-2312 and we will be happy to provide you with a copy of the specific guideline.
Code J2789 does not require prior authorization but is considered and will deny as investigational if the diagnosis code is not for Progressive Keratoconus or Corneal Ectasia.

Deep Brain Stimulation

61850, 61860, 61863, 61867, 61868, 61885, 61886

Devices for Treatment of Benign Prostatic Hyperplasia, Urethral Stricture, and Urethral Stenosis

52284, 52443, 83855, 53865, 53866, 0941T, 0942T, 0943T

Gastric Electrical Stimulation

43647, 43881, 64590, E0765

Hypoglossal Nerve Stimulation

64568, 64582, 64583, C8007, C8008, C8011, C8012

Interspinous and Interlaminar Stabilization and Distraction Devices (Spacers)

22867, 22868
We require prior authorization for these codes for ASO groups that do not participate in the Physical Medicine program (EviCore) above. For fully insured groups and Individual plans, please review the Physical Medicine section above.

Implantable Peripheral Nerve Stimulation and Peripheral Subcutaneous Field Stimulation

64590, 64596, 64597, 64598

Laser Treatment for Port Wine Stains

17106, 17107, 17108

Left-Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation

33340

Mastectomy as a Treatment of Gynecomastia

19300

Occipital Nerve Stimulation

61885, 61886, 64553, 64568, 64590, 64596, 64597, 64598
Occipital Nerve Stimulation is considered investigational for all indications, including but not limited to headaches.
NOTE: These codes may overlap with the codes in the Vagus Nerve Stimulation Medical Policy. To ensure proper adjudication of your claim, please contact BCBSND for prior authorization on all of the above codes.

Panniculectomy

15830

Pectus Excavatum and Carinatum Surgery

21740, 21742, 21743

Phrenic Nerve Stimulation for Central Sleep Apnea

C1823

Radiofrequency and Ultrasound Ablation of the Renal Sympathetic Nerves as a Treatment for Uncontrolled Hypertension

0338T, 0339T, 0935T, C1735, C1736

Reconstructive Breast Surgery/Mastopexy, and Management of Breast Implants

11920, 11921, 15769, 15771, 15772, 19316, 19318, 19325, 19328, 19330, 19340, 19342, 19350, 19355, 19370, 19371, L8600
Prior authorization is required EXCEPT when services are rendered in association with breast reconstruction and nipple/areola reconstruction following mastectomy for breast cancer. However, if autologous fat grafting with adipose-derived stem cell enrichment is used for augmentation or reconstruction of the breast it would be considered investigational.
Note: Codes 19380 and 19499 do not require prior authorization but are considered, and will deny as, investigational when used for autologous fat grafting with adipose-derived stem cell enrichment for augmentation or reconstruction of the breast.

Reduction Mammaplasty

19318

Responsive Neurostimulation

61850, 61860, 61863, 61885, 61886, 61889, 61891

Rhinoplasty

30120, 30400, 30410, 30420, 30430, 30435, 30450

Sacral Nerve Neuromodulation (Stimulation) for Pelvic Floor Dysfunction

0786T, 0787T, 64561, 64581, 64590, 64596, 64597, 64598
NOTE: Please submit your prior authorization request for the temporary trial period of sacral nerve neuromodulation AND the permanent placement at the same time, as these are treated as one combined episode.

Sacroiliac Joint Fusion

27278, 27279, 27280, C1737

Spinal Cord and Dorsal Root Ganglion Stimulation

0784T, 0785T, 63650, 63655, 63685
NOTE: Please submit your prior authorization request for the temporary trial AND the permanent placement at the same time.

Spinal Surgery - Cervical Fusion

Visit MCG's website for information on purchasing their criteria or contact the Provider Contact Center at 1-800-368-2312 and we will be happy to provide you with a copy of the specific guideline.
22551, 22552, 22554, 22853, 22854, 22859 - MCG ORG S-320
22600 - MCG ORG S-330
We require prior authorization for these codes for ASO groups that do not participate in the Physical Medicine (EviCore) above. For fully insured groups and Individual plans, please review the "Physical Medicine" section above.

Spinal Surgery - Lumbar Fusion

22533, 22853, 22854, 22558, 22859, 22612, 22630, 22633

Spinal Surgery - Percutaneous Vertebroplasty, Kyphoplasty, Sacroplasty, and Coccygeoplasty

22510, 22511, 22512, 22513, 22514, 22515
We require prior authorization for these codes for ASO groups that do not participate in the Physical Medicine program (EviCore) above. For fully insured groups and Individual plans, please review the "Physical Medicine" section above.

Spinal Surgery - Artificial Intervertebral Disc

0164T, 0165T, 0719T, 22856, 22857, 22858, 22860, 22862, 22865
BCBSND requires prior authorization for the following codes: 0164T, 0165T, 0719T, 22856, 22857, 22858, 22860, 22862, 22865.
Codes 22856 and 22858 also require prior authorization through the Physical Medicine program (EviCore). If a group participates in the Physical Medicine program, please reference the “Physical Medicine” section above. Groups that are not participating in the Physical Medicine program require prior authorization through BCBSND.

Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy

32701, 61796, 61797, 61798, 61799, 61800, 63620, 63621, 77301, 77338, 77371, 77372, 77373, 77432, 77435, G0339, G0340, G0563
Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy of Intracranial, Skull Base, and Orbital Sites
Stereotactic Radiosurgery and Stereotactic Body Radiation Therapy for Tumors Outside of Intracranial, Skull Base, or Orbital Sites

Surgical Treatment for Lymphedema and Lipedema

Codes 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, 15876, 15877, 15878, 15879 require prior authorization for Lipedema only with diagnosis codes Q82.0, R60.0, R60.9

Surgeries for Snoring, Obstructive Sleep Apnea Syndrome, and Upper Airway Resistance

21121, 21122, 21141, 21145, 21196, 21198, 21199, 21685, 41120, 42140, 42145, 42160
Codes 21145, 21196, 21198, 41120, 42160 do not require prior authorization when the procedure is performed for oral cancer diagnosis codes: C01, C02-C02.9, C03-C03.9, C04-C04.9, C05-C05.9, C06, C06.2-C06.9, C09-C09.9, C10-C10.0, C41-C41.1. C46.2, D00-D00.00, D10, D10.1-D10.9, D16.4-D16.5, D37-D37.0, D49-D49.0

Transcatheter Heart Valve Procedures for Mitral or Tricuspid Valve Disorders

0483T, 0484T, 0569T, 0570T, 0646T

Transcutaneous Bone Conduction and Bone-Anchored Hearing Aids

69714, 69710, 69716, 69717, 69719, 69726, 69729, 69730, L8690, L8691, L8692, L8694

Vagus Nerve Stimulation

61885, 61886, 64553, 64568, E0735

Varicose Vein Treatment

0524T, 36465, 36466, 36470, 36471, 36475, 36476, 36478, 36479, 36482, 36483, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37785, S2202
Note: Code 37241 is not appropriate to use in the coding of varicose vein treatment.

Transplants - Stem Cell