Services Requiring Prior Authorization
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1 Blue Cross and Blue Shield of Texas Effective September 1, 2015 Services Requiring Prior Authorization The services listed below require authorization prior to providing services to STAR and CHIP Members. Blue Cross and Blue Shield of Texas (BCBSTX) also applies this Prior Authorization (PA) list when BCBSTX is the secondary coverage for Medicaid members. This list will be updated as needed. Contact BCBSTX to verify benefits by calling the Customer Care Center at All Providers are responsible for verifying eligibility and obtaining authorization for non-emergent services provided to a BCBSTX Member by out-of-network Providers prior to rendering services. The exception to this rule is services for which Members can self-refer with no authorization needed, such as family planning. For benefits to be paid, the Member must be eligible on the date of service and the service must be a covered benefit. Failure to obtain prior authorization for the designated services below may result in a denial for reimbursement, (except in the case of an emergency). BCBSTX offers a variety of forms to use to obtain authorization prior to rendering services. You will find this toolkit on the Provider Resources webpage under Prior Authorization Requirements at: Here are some tips for getting the fastest response to your authorization request: Please print out forms and complete legibly prior to faxing. Unreadable forms result in mistakes and delays. Fill forms out completely. Unanswered questions typically result in delays. Access forms online when you need one, rather than pre-printing and storing them. We revise forms periodically, and outdated forms can delay your request. To Request Prior Authorization To request Prior Authorization (PA), report a medical admission, or ask questions regarding PA, please contact Utilization Air Ambulance Ambulance Ground Behavioral/Mental Health Biofeedback Non-emergent transport from facility to facility requires authorization prior to services rendered. Please contact Magellan Behavioral Health Services at for referrals and authorizations. Blue Cross and Blue Shield of Texas is a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association. CHIP and Medicaid managed care administered by WellPoint Partnership Plan, LLC. an independent company. TXW
2 Blue Cross and Blue Shield of Texas Page 3 of 11 Dental Services Durable Medical Equipment (DME) and Disposable Supplies For DME not listed above or any other questions regarding DME, please contact Utilization Dental coverage through the medical plan is limited to emergency needs only. Facility services and dental anesthesia services provided in an inpatient or outpatient facility require PA from BCBSTX. For more detail, please call the member s selected dental plan: STAR DentaQuest MCNA Dental CHIP DentaQuest MCNA Dental Rental of DME and purchase of custom equipment will require PA request. Providers are required to get Prior Authorization for the following: Altered Auditory Feedback (AAF) Devices for the Treatment of Stuttering Augmentative and Alternative Communication (AAC) Devices/Speech Generating Devices (SGD) Automated External Defibrillators for Home Use Bone-Anchored Hearing Aids Continuous Local Delivery of Analgesia to Operative Sites using an Elastomeric Infusion Pump during the Post-Operative Period Custom Durable Medical Equipment Electrical Bone Growth Stimulation Electrical Stimulation as a Treatment for Pain and Related Conditions: Surface and Percutaneous Devices External (Portable) Continuous Insulin Infusion Pump Functional Electrical Stimulation (FES); Threshold Electrical Stimulation (TES) Hospital Beds Implantable Cardioverter-Defibrillator (ICD) Implantable Infusion Pumps Implantable Left Atrial Hemodynamic (LAH) Monitor Implantable Middle Ear Hearing Aids Implanted Devices for Spinal Stenosis Implanted Spinal Cord Stimulators (SCS) Lifts Microprocessor Controlled Lower Limb Prosthesis Myoelectric Upper Extremity Prosthetic Devices Oscillatory Devices for Airway Clearance including High Frequency Chest Compression (Vest Airway Clearance System) and Intrapulmonary Percussive Ventilation (IPV)
3 Blue Cross and Blue Shield of Texas Page 4 of 11 Durable Medical Equipment (DME) and Disposable Supplies (continued) For DME not listed above or any other questions regarding DME, please contact Utilization Partial-Hand Myoelectric Prosthesis Patient-Operated Spinal Unloading Devices Certain Prosthetic and Orthotic Devices Self-Operated Spinal Unloading Devices Standing Frames Transtympanic Micropressure for the Treatment of Ménière s Disease Ultrasound Bone Growth Stimulation Ultraviolet Light Therapy Delivery Devices for Home Use Underpads Vacuum Assisted Wound Therapy in the Outpatient Setting Wearable Cardioverter Defibrillators Wheelchair / wheelchair accessories Wheeled Mobility Devices: Manual Wheelchairs-Ultra Lightweight Wheeled Mobility Devices: Wheelchairs-Powered, Motorized, With or Without Power Seating Systems and Power Operated Vehicles (POVs) Family Planning Alpha Hydroxyprogesterone Caproate (17P) Hydroxyprogesterone Caproate Injection (Makena) Gene Testing Home Health Care Services Injection Therapy and Specialty Medication (not covered under Pharmacy) Inpatient Hospital Services Newborn Stays Beyond Mother Inpatient Skilled Nursing Facility (SNF) Long Term acute Care Facility (LTAC) Rehabilitation Facility Admissions Laboratory Services Providers are required to get prior authorization for the following: All elective inpatient admissions. Notify BCBSTX of emergent admissions within 24 hours or the next business day of inpatient admission. Routine vaginal or cesarean section deliveries do not require medical necessity review; however, both delivery types require notification. All newborn deliveries require notification. Complete and send Newborn Enrollment Notification Report Form within three days of delivery. Providers are to utilize in-network hospitals/laboratories for all laboratory needs. Out-of-network lab services and tests that are potentially investigational require Prior
4 Blue Cross and Blue Shield of Texas Page 5 of 11 Pharmacy and/or Over-the-Counter (OTC) Products Physician Services Referrals to Specialists Prescription drugs are covered by BCBSTX through Express Scripts, Inc. (ESI). For details about pharmacy Prior Authorization requirements, please contact ESI at For information about the formulary and drugs requiring Prior Authorization, you may also visit Texas Medicaid Vendor Drug Program website at Required when referring Member to an out-of-network specialist. Radiology Services Prior Authorization is required for all PET/SPECT scans, CT, CTA, MRI, and MRA. PA also is required for the following: MR Spectroscopy QCT Bone Densitometry Myocardial Perfusion Imaging Infarct Imaging Intensity Modulated Radiation Therapy (IMRT) Cardiac Blood Pool Imaging PET/CT Fusion Screening CT colonoscopy Diagnostic CT Colonography Functional MRI Brain CT Heart for Calcium Scoring CT Heart for Structure & Morph CTA Heart Incl Structure & Morph MEG Add-on Procedures Radiology services that are potentially investigational
5 Blue Cross and Blue Shield of Texas Page 6 of 11 Inpatient & Outpatient Surgeries/ Procedures Surgeries/procedures that are for cosmetic purposes or considered investigational are not covered. Please contact Utilization for questions regarding Prior All elective inpatient procedures (excluding labor and delivery) and some outpatient procedures require Prior Surgeries/procedures that are potentially cosmetic and or investigational require Prior Outpatient procedures include: Ablative Techniques as a Treatment for Barrett's Esophagus Adoptive Immunotherapy and Cellular Therapy Anterior Segment Optical Coherence Tomography Antineoplaston Therapy Artificial Anal Sphincter for the Treatment of Severe Fecal Incontinence Artificial Retinal Devices Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting Autologous Cellular Immunotherapy for the Treatment of Prostate Cancer Automated Evacuation of Meibomian Gland Automated Nerve Conduction Testing Axial Lumbar Interbody Fusion Balloon Sinus Ostial Dilation Bariatric Surgeries Behavioral Health Treatments for Pervasive Developmental Disorders Bicompartmental Knee Arthroplasty Bioimpedance Spectroscopy Devices for the Detection and Management of Lymphedema Biomagnetic Therapy Blepharoplasty, Blepharoptosis Repair, and Brow Lift Breast Ductal Examination and Fluid Cytology Analysis Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures Bronchial Thermoplasty Cardiac Resynchronization Therapy (CRT) with or without an Implantable Cardioverter Defibrillator (CRT/ICD) for the Treatment of Heart Failure Carotid Sinus Baroreceptor Stimulation Devices Carotid, Vertebral and Intracranial Artery Angioplasty with or without Stent Placement Coblation Therapies for Musculoskeletal Conditions Cochlear Implants and Auditory Brainstem Implants Cognitive Rehabilitation
6 Blue Cross and Blue Shield of Texas Page 7 of 11 Inpatient & Outpatient Surgeries/ Procedures (continued) Surgeries/procedures that are for cosmetic purposes or considered investigational are not covered. Please contact Utilization for questions regarding Prior Computer Analysis and Probability Assessment of Electrocardiographic-Derived Data Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedures Convection Enhanced Delivery of Therapeutic Agents to the Brain Cooling Devices and Combined Cooling/Heating Devices Cosmetic and Reconstructive Services of the Head and Neck Cosmetic and Reconstructive Services of the Trunk and Groin Cosmetic and Reconstructive Services: Skin Related Cryoablation for Plantar Fasciitis and Plantar Fibroma Cryopreservation of Oocytes or Ovarian Tissue Cryosurgical Ablation of Solid Tumors Outside the Liver Deep Brain Stimulation Diaphragmatic/Phrenic Nerve Stimulation and Diaphragm Pacing Systems Electric Tumor Treatment Field (TTF) Electroencephalography (EEG) Testing: Ambulatory and Video Electromagnetic Navigational Bronchoscopy Electrothermal Shrinkage of Joint Capsules, Ligaments, and Tendons Endobronchial Valve Devices Endothelial Keratoplasty Endovascular/Endoluminal Repair of Aortic Aneurysms Epidural Steroid Injections Epiduroscopy Extracorporeal Shock Wave Therapy for Orthopedic Conditions Facet Joint Allograft Implants for Facet Disease Fetal Surgery for Prenatally Diagnosed Malformations Functional Endoscopic Sinus Surgery (FESS) Gastric Electrical Stimulation Growth Factors, Silver-based Products and Autologous Tissues for Wound Treatment and Soft Tissue Grafting Hepatic Activation Therapy High Intensity Focused Ultrasound (HIFU) for the Treatment of Prostate Cancer High Resolution Anoscopy Screening Hip Resurfacing Hippotherapy Hyperbaric Oxygen Therapy (Systemic/Topical) Hyperoxemic Reperfusion Therapy Hyperthermia for Cancer Therapy Idiopathic Environmental Illness (IEI) Imaging Techniques for Screening and Identification of Cervical Cancer Injection Treatment for Morton s Neuroma In Vivo Analysis of Gastrointestinal Lesions
7 Blue Cross and Blue Shield of Texas Page 8 of 11 Inpatient & Outpatient Surgeries/ Procedures (continued) Surgeries/procedures that are for cosmetic purposes or considered investigational are not covered. Please contact Utilization for questions regarding Prior Inhaled Nitric Oxide for the Treatment of Respiratory Failure Intervertebral Stabilization Devices Intracardiac Ischemia Monitoring Intradiscal Annuloplasty Procedures (Percutaneous Intradiscal Electrothermal Therapy [IDET] Intraocular Anterior Segment Aqueous Drainage Devices Intraocular Epiretinal Brachytherapy Intraocular Telescope Intravitreal Corticosteroid Implants Keratoprosthesis Laparoscopic and Percutaneous MRI-Image Guided Techniques for Myolysis as a Treatment of Uterine Fibroids Locally Ablative Techniques for Treating Primary and Metastatic Liver Malignancies Low-Frequency Ultrasound Therapy for Wound Management Lung Volume Reduction Surgery Lysis of Epidural Adhesions Mandibular/Maxillary (Orthognathic) Surgery Manipulation Under Anesthesia of the Spine and Joints other than the Knee Mastectomy for Gynecomastia Maze Procedure Mechanical Embolectomy for Treatment of Acute Stroke Mechanized Spinal Distraction Therapy for Low Back Pain Melanoma Vaccines Microvolt T-Wave Alternans MRI Guided High Intensity Focused Ultrasound Ablation of Uterine Fibroids Nasal Surgery for the Treatment of Obstructive Sleep Apnea Nasal Valve Suspension Nerve Graft after Prostatectomy Neural Therapy Non-Invasive Measurement of Left Ventricular End Diastolic Pressure (LVEDP) in the Outpatient Setting Occipital Nerve Stimulation Open Treatment of Rib Fracture(s) Requiring Internal Fixation Ophthalmologic Techniques for Evaluating Glaucoma Oral, Pharyngeal and Maxillofacial Surgical Treatment for Obstructive Sleep Apnea Ovarian and Internal Iliac Vein Embolization as a Treatment of Pelvic Congestion Syndrome
8 Blue Cross and Blue Shield of Texas Page 9 of 11 Inpatient & Outpatient Surgeries/ Procedures (continued) Surgeries/procedures that are for cosmetic purposes or considered investigational are not covered. Please contact Utilization for questions regarding Prior Panniculectomy and Abdominoplasty Pain Management Injections and Procedures Partial Left Ventriculectomy Penile Prosthesis Implantation Percutaneous and Endoscopic Spinal Surgery Percutaneous Neurolysis for Chronic Back Pain Percutaneous (Vertebroplasty, Kyphoplasty and Sacroplasty) Photocoagulation of Macular Drusen Presbyopia and Astigmatism-Correcting Intraocular Lenses Prolotherapy for Joint and Ligamentous Conditions Prostate Saturation Biopsy Quantitative Muscle Testing Devices Quantitative Sensory Testing Radiofrequency Ablation Radiofrequency and Pulsed Radiofrequency Radiofrequency Pallidotomy Neurolysis for Trigeminal Neuralgia (TGN) Real-Time Remote Heart Monitors Recombinant Human Bone Morphogenetic Protein Reduction Mammaplasty Refractive Surgery Rhinophototherapy Sacral Nerve Stimulation as a Treatment of Neurogenic Bladder Secondary to Spinal Cord Injury Sacral Nerve Stimulation (SNS) and Percutaneous Tibial Nerve Stimulation (PTNS) for Urinary and Fecal Incontinence; Urinary Retention Sensory Stimulation for Brain-Injured Patients in a Coma or Vegetative State Selected Sleep Testing Services Septoplasty Sleep Studies Stereotactic Radiofrequency Pallidotomy Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiotherapy (SBRT) Subtalar Arthroereisis Suprachoroidal Injection of a Pharmacologic Agent Surgery for Clinically Severe Obesity Surgical and Minimally Invasive Treatments for Benign Prostatic Hyperplasia (BPH) and Other Genitourinary Surgical Treatment of Femoroacetabular Impingement Syndrome Surgical and Ablative Treatments for Chronic Headaches Technologies for the Evaluation of Skin Lesions
9 Blue Cross and Blue Shield of Texas Page 10 of 11 Inpatient & Outpatient Surgeries/ Procedures (continued) Surgeries/procedures that are for cosmetic purposes or considered investigational are not covered. Please contact Utilization for questions regarding Prior Procedures Related to Temporomandibular Disorders Tonsillectomy and Adenoidectomy Total Ankle Replacement Transanal Endoscopic Microsurgical (TEM) Excision of Rectal Lesions Transanal Radiofrequency Treatment of Fecal Incontinence Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins as a Treatment of Atrial Fibrillation Transcatheter Closure of Patent Foramen Ovale and Left Atrial Appendage for Stroke Prevention Transcatheter Heart Valves Transcatheter Uterine Artery Embolization Transcranial Magnetic Stimulation for Behavioral and Non-Behavioral Health Indications Transendoscopic Therapy for Gastroesophageal Reflux Disease Transmyocardial Revascularization Treatment for Obstructive Sleep Apnea in Adults Treatment of Hyperhidrosis Treatment of Osteochondral Defects of the Knee and Ankle Treatment of Varicose Veins (Lower Extremities) Treatments for Urinary Incontinence and Urinary Retention Unicondylar Interpositional Spacer Vagus Nerve Stimulation Viscocanalostomy and Canaloplasty Venous Angioplasty with or without Stent Placement for the Treatment of Multiple Sclerosis Vertebral Body Stapling for the Treatment of Scoliosis Wearable Cardioverter Defibrillators Wireless Capsule for the Evaluation of Suspected Gastric and Intestinal Motility Disorders Surgeries/procedures that are for cosmetic purposes or considered investigational are not covered. Please contact the Utilization Management department at for information regarding PA. Therapy Services Physical, Occupational or Speech Therapies Transplant Services Initial evaluation for Therapy Services does not require prior authorization. Therapy visits following the initial evaluation and continuation of services must be authorized prior to services being rendered. Re-evaluations of therapy must be authorized prior to services being rendedred. Vision Services Vision services for routine eye care: Contact Davis Vision at for vision benefits.
10 Blue Cross and Blue Shield of Texas Page 11 of 11 The services listed below DO NOT require Prior Authorization (PA) for in-network Providers: Chiropractic Services Limited to 12 visits per benefit period Dialysis Emergency Services Notify BCBSTX of admissions within 24 hours or the next business day of inpatient admission Formulary glucometers and nebulizers Family Planning/Well Woman Check Up Member may self-refer to any Medicaid Provider for the following services: Pelvic and breast examinations Lab work Birth Control Genetic counseling FDA approved devices and supplies related to family planning (such as IUD) HIV/STD screening Obstetrical Care: No authorization is required for in-network physician visits and routine testing. Pregnancy and newborn deliveries require notification. Please notify BCBSTX of Member pregnancies using the Notification of Pregnancy Report. Please complete and submit this form online or print and complete the form legibly before faxing to BCBSTX at Notify BCBSTX of newborn enrollments within three days of delivery by calling No PA required for physician referrals if referring member to an in-network specialist for consultation or a nonsurgical course of treatment Standard x-rays and ultrasounds
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