Prior Approval

Prior approval is the process by which the member or the member's health care provider provides information to BCBSND to establish the medical appropriateness and necessity of specified services, prior to receiving care, in order to receive benefits for the service. Benefits will be denied if the member is not eligible for coverage under the benefit plan on the date services are provided or if services received are not medically appropriate and necessary.

To request prior approval, the member or the health care provider must notify BCBSND, in writing, of the member's intent to receive services requiring prior approval.

Policy/Criteria
Members must consult their applicable benefit plans or contact Member Services for specific coverage information. Contact information is located on the back of the member's ID card.

Procedures Requiring Written Prior Approval
The list below is a standard prior approval list. Some benefit plans have variations to the list. You may verify if prior approval is required for a service by contacting Provider Services at 800-368-2312.

  • Artificial intervertebral cervical disc (effective 1/1/2016)
  • Assisted reproductive technology for GIFT, ZIFT, ICSI and IVF
  • Autologous chondrocyte implantation (effective 1/1/2016)
  • Blepharoplasty (effective 1/1/2016)
  • Bone growth stimulator (electrical or ultrasound) (effective 1/1/2016)
  • Chronic pain management program
  • Cochlear implant
  • Cosmetic surgeries
  • Deep brain stimulator (effective 1/1/2016)
  • Dental anesthesia and hospitalization for all Members age 9 and older
  • Electric wheelchairs
  • Growth hormone therapy/treatment
  • Human organ and tissue transplants, except kidney and cornea transplants
  • Insulin infusion pump
  • Mastectomy for gynecomastia (effective 1/1/2016)
  • Morbid obesity surgery
  • Negative pressure wound therapy in an outpatient setting (effective 1/1/2016)
  • Obstructive sleep apnea treatment, except for continuous positive airway pressure (CPAP)
  • Oscillatory devices for respiratory conditions (effective 1/1/2016)
  • Osseointegrated implants
  • Programmable lymphedema pumps (effective 1/1/2016)
  • Prosthetic Limbs controlled by microprocessors and any Prosthetic Limb replacement within 5 years
  • Restricted Use Drugs
  • Rhinoplasty (effective 1/1/2016)
  • Sacral nerve stimulator (effective 1/1/2016)
  • Spinal cord stimulator (effective 1/1/2016)
  • Total ankle replacement (effective 1/1/2016)
  • Vagus nerve stimulator (effective 1/1/2016)
  • Wearable cardioverter defibrillators (effective 1/1/2016)
  • Wireless capsule endoscopy (effective 1/1/2016) 

Note: No prior approval is required when BCBSND is secondary to other insurance, unless other insurance benefits have been exhausted. This list does not apply to the Federal Employee Program (FEP).

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