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Authorization Table | Wellmark Blue Cross and Blue Shield

Authorization Table

The Wellmark Authorization Table is the definitive resource for utilization management requirements for prior approval (PA) of a medical procedure, equipment or hospital admission. PA is required for all designated services and procedures listed on the Authorization Table. If a service or procedure is not listed on the Authorization Table, Wellmark does not maintain a policy on the service or procedure. In this case, pre-service review is not necessary; no member or provider action is needed.

 

If the PA request is not approved or not completed prior to the service being provided, all claims for the procedure will be denied. This includes hospital, practitioner, and ancillary claims. In the case of a denial, please follow Wellmark’s member and provider inquiry and appeals process. If the PA request is approved, the accompanying authorization number must be submitted on all claims associated with the procedure. An authorization number is not a guarantee of member benefits. Payment is based on the member's eligibility and plan coverage when the service is provided. Other important information includes:

  • Some groups have specific authorization requirements. Always verify current member benefits secure image first.
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  • If you are a contracted durable medical equipment provider or a non-contracted provider, click here.
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  • Servicing providers (i.e., facilities or providers listed as the “servicing facility” on the PA request) who did not originate the request may check the status of a request.

 


Use the search box and/or pre-service filter criteria below to narrow your search results.
Click on the row header in the grid to sort your search results.
Pre Service Review Type:

Code - CPT/HCPCTitle (Service/Description)Pre Service Review RequiredType of Pre Service Review RequiredSubmit UsingMedical Policy or Criteria Link(s)Comments
0051TImplantation of a total replacement heart system (artificial heart) with recipient cardiectomy NoN/AN/A Ventricular Assist Devices and Artificial Hearts  
0052TReplacement or repair of thoracic unit of a total replacement heart systemNoN/AN/A Ventricular Assist Devices and Artificial Hearts  
0053TReplacement or repair of implantable component or components of total replacement heart system, excluding thoracic unit NoN/AN/A Ventricular Assist Devices and Artificial Hearts  
0054TComputer-assisted musculoskeletal surgical navigational orthopedic procedure, with image-guidance based on fluoroscopic images (List separately in addition to code for primary procedure) NoN/AN/A Computer-assisted Navigation Systems for Orthopedic Surgery  
0055TComputer-assisted musculoskeletal surgical navigational orthopedic procedure, with image-guidance based on CT/MRI images (List separately in addition to code for primary procedure)NoN/AN/A Computer-assisted Navigation Systems for Orthopedic Surgery  
0071TFocused ultrasound ablation of uterine leiomyomata, including MR guidance; total leiomyomata volume less than 200 cc of tissueNoN/AN/A MRI-Guided High-Intensity Focused Ultrasound Ablation of Uterine Fibroids and Other Tumors  
0072TFocused ultrasound ablation of uterine leiomyomata, including MR guidance; total leiomyomata volume greater or equal to 200 cc of tissue NoN/AN/A MRI-Guided High-Intensity Focused Ultrasound Ablation of Uterine Fibroids and Other Tumors  
0092TTotal disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompression and microdissection), each additional interspace, cervical (List separately in addition to code for primary procedure)NoN/AN/A Artificial Intervertebral Disc  
0095TRemoval of total disc arthroplasty (artificial disc), anterior approach, each additional interspace, cervical (List separately in addition to code for primary procedure)NoN/AN/A Artificial Intervertebral Disc  
0098TRevision including replacement of total disc arthroplasty (artificial disc), anterior approach, each additional interspace, cervical (List separately in addition to code for primary procedure)NoN/AN/A Artificial Intervertebral Disc  
0106TQuantitative sensory testing (QST), testing and interpretation per extremity; using touch pressure stimuli to assess large diameter sensationNoN/AN/A Quantitative Sensory Testing  
0107TQuantitative sensory testing (QST), testing and interpretation per extremity; using vibration stimuli to assess large diameter fiber sensationNoN/AN/A Quantitative Sensory Testing  
0108TQuantitative sensory testing (QST), testing and interpretation per extremity; using cooling stimuli to assess small nerve fiber sensation and hyperlgesia.NoN/AN/A Quantitative Sensory Testing  
0109TQuantitative sensory testing (QST), testing and interpretation per extremity; using heat-pain stimuli to assess small nerve fiber sensation and hyperalgesiaNoN/AN/A Quantitative Sensory Testing  
0110TQuantitative sensory testing (QST), testing and interpretation per extremity; using other stimuli to assess sensation.NoN/AN/A Quantitative Sensory Testing  
0111TLong-chain (C20-22) omega-3 fatty acids in red blood cell (RBC) membranes NoN/AN/A Cardiovascular Disease Risk Tests  
0126TCommon carotid intima-media thicknessNoN/AN/A Measurement of Carotid Intima-Medial Thickness as an Assessment of Subclinical Atherosclerosis Using Ultrasound  
0141TPancreatic islet cell transplantation through portal vein, percutaneous NoN/AN/A Pancreatic Islet Cell Transplant  
0142TPancreatic islet cell transplantation through portal vein, open NoN/AN/A Pancreatic Islet Cell Transplant  
0143TLaparoscopy, surgical, pancreatic islet cell transplantation through portal vein NoN/AN/A Pancreatic Islet Cell Transplant  
0159TComputer-aided detection, including computer algorithm analysis of MRI image data for lesion detection/characterization, pharmacokinetic analysis, with further physician review for interpretation, breast MRI (List separately in addition to code for primary procedure) NoN/AN/A Computer-aided Detection (CAD)/Computer-aided Evaluation (CAE) of Malignancy with MRI of the Breast  
0163TTotal disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), lumbar, each additional interspaceNoN/AN/A Artificial Intervertebral Disc  
0164TRemoval of total disc arthroplasty, anterior approach, lumbar, each additional interspace NoN/AN/A Artificial Intervertebral Disc  
0165TRevision of total disc arthroplasty, anterior approach, lumbar, each additional interspace NoN/AN/A Artificial Intervertebral Disc  
0171TInsertion of posterior spinous process distraction device (including necessary removal of bone or ligament for insertion and imaging guidance), lumbar; single levelNoN/AN/A Interspinous Distraction Devices  
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Tips

» Know when to expect a response.
» Learn about FEP requirements.
» Review important terminology.
» Do not submit for out-of-area diagnostic imaging.
 
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