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Authorization Table | Wellmark Blue Cross and Blue Shield

Authorization Table

The Wellmark Authorization Table is your best resource to view medical policies and criteria used by Wellmark. It is also your first stop in learning whether pre-service review is required. Note:

  • If a medical service, procedure or durable medical equipment (DME) item is not listed, Wellmark does not maintain a medical policy or criteria for it. Pre-service review is not required and will not be completed. Payment will be based on eligibility and plan coverage when the service is provided.
  • If a medical service, procedure or DME item is listed but “No” appears in the “Pre-service Review Required“ column, Wellmark maintains a medical policy that outlines the criteria which will be applied to the claim when it is received. Pre-service review will not be completed.
  • Pre-service review will be completed only if a medical service, procedure or DME item is listed on the Authorization Table and “Yes” appears under “Pre-service Review Required.”

If a required pre-service review request is not approved or not completed prior to the service being provided, the claim(s) will be denied.

 

If you receive a denial for services that require prior approval (PA), you may follow Wellmark's member and provider inquiry and appeals secure image process. If the 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. Also remember:

  • Some groups have specific authorization requirements. Always verify benefits secure image first.
  • Servicing providers (i.e., facilities or providers listed as the “servicing facility” who did not originate the request may check its status.
  • Learn more if you are a Non-contracted providers or a contracted DME provider.

Pharmacy

Prescribing certain medications for Wellmark members is also subject to approval. Visit the Pharmacy Prior Authorization page to access a complete list of these medications, the policy associated with each and a form for making your 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 UsingPolicy or Criteria Link(s)Comments
0009MFetal aneuploidy (trisomy 21, and 18) DNA sequence analysis of selected regions using maternal plasma, algorithm reported as a risk score for each trisomyNoN/AN/A Noninvasive Prenatal Testing (NIPT) for Fetal Aneuploidies Using Cell - Free Fetal DNA in Maternal Plasma  
0010MOncology (High-Grade Prostate Cancer), biochemical assay of four proteins (Total PSA, Free PSA, Intact PSA and human kallikrein 2 [hK2]) plus patient age, digital rectal examination status, and no history of positive prostate biopsy, utilizing plasma, prognostic algorithm reported as a probability score NoN/AN/A Genetic and Protein Biomarkers for the Diagnosis and Cancer Risk Assessment of Prostate Cancer  
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  
00640Anesthesia for manipulation of the spine or for closed procedures on the cervical, thoracic or lumbar spine NoN/AN/A Manipulation under Anesthesia  
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  
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  
00740Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum NoN/AN/A Anesthesia Services for Gastrointestinal Endoscopic Procedures  
00810Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum NoN/AN/A Anesthesia Services for Gastrointestinal Endoscopic Procedures  
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  
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 and Interspinous Fixation (Fusion) Devices  
0172TInsertion of posterior spinous process distraction device (including necessary removal of bone or ligament for insertion and imaging guidance), lumbar; each additional level (List separately in addition to code for primary procedure)NoN/AN/A Interspinous Distraction Devices and Interspinous Fixation (Fusion) Devices  
0195TArthrodesis, pre-sacral interbody technique, including instrumentation, imaging (when performed), and discectomy to prepare interspace, lumbar; single interspace YesPrior ApprovalUtilization Management Tool- Procedures and DME Fusion_Lumbar_Spine  
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