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
0003UOncology (ovarian) biochemical assays of five proteins (apolipoprotein A-1, CA 125 II, follicle stimulating hormone, human epididymis protein 4, transferrin), utilizing serum, algorithm reported as a likelihood score NoN/AN/A Multimarker Serum Testing Related to Ovarian Cancer  
0004MScoliosis, DNA analysis of 53 single nucleotide polymorphisms (SNPs), using saliva, prognostic algorithm reported as a risk scoreNoN/AN/A DNA-Based Testing for Adolescent Idiopathic Scoliosis  
0005UOncology (prostate) gene expression profile by real time RT-PCR of 3 genes (ERG, PCA3, and SPDEF), urine algorithm reported as risk score NoN/AN/A Genetic and Protein Biomarkers for the Diagnosis and Cancer Risk Assessment of Prostate Cancer  
0006UPrescription drug monitoring, 120 or more drugs and substances, definitive tandem mass spectrometry with chromatography, urine, qualitative report of presence (including quantitative levels, when detected) or absence of each drug or substance with description and severity of potential interactions, with identified substances, per date of serviceNoN/AN/A Drug Testing  
0007UDrug test(s), presumptive, with definitive confirmation of positive results, any number of drug classes, urine, includes specimen verification including DNA authentication in comparison to buccal DNA, per date of serviceNoN/AN/A Drug Testing  
0008MOncology (breast), mRNA analysis of 58 genes using hybrid capture, on formalin-fixed paraffin-embedded (FFPE) tissue, prognostic algorithm reported as a risk score NoN/AN/A Gene Expression Profiling for the Management of Breast Cancer  
0009MFetal aneuploidy (trisomy 21 and 18) DNA sequence analysis of selected regions using maternal plasma, algorithm reported as risk score for each trisomy NoN/AN/A Noninvasive Prenatal Screening for Fetal Aneuploidies Using Cell - Free Fetal DNA in Maternal Plasma  
0011MOncology, prostate cancer, mRNA expression assay of 12 genes (10 content and 2 housekeeping), RT-PCR test utilizing blood plasma and/or urine, algorithms to predict high-grade prostate cancer risk NoN/AN/A Genetic and Protein Biomarkers for the Diagnosis and Cancer Risk Assessment of Prostate Cancer  
0012UGermline disorders, gene rearrangement detection by whole genome next-generation sequencing, DNA, whole blood, report of specific gene rearrangement(s)NoN/AN/A Whole Exome and Whole Genome Sequencing for Diagnosis of Genetic Disorders  
0013UOncology (solid organ neoplasia), gene rearrangement detection by whole genome next-generation sequencing, DNA, fresh or frozen tissue or cells, report of specific gene rearrangement(s)NoN/AN/A Whole Exome and Whole Genome Sequencing for Diagnosis of Genetic Disorders  
0014UHematology (hematolymphoid neoplasia), gene rearrangement detection by whole genome next-generation sequencing, DNA, whole blood or bone marrow, report of specific gene rearrangement(s)NoN/AN/A Whole Exome and Whole Genome Sequencing for Diagnosis of Genetic Disorders  
0016UOncology (hematolymphoid neoplasia), RNA, BCR/ABL1 major and minor breakpoint fusion transcripts, quantitative PCR amplification, blood or bone marrow, report of fusion not detected or detected with quantitationNoN/AN/A Genetic Testing for BCR-ABL Fusion Gene  
0017UOncology (hematolymphoid neoplasia), JAK2 mutation, DNA, PCR amplification of exons 12-14 and sequence analysis, blood or bone marrow, report of JAK2 mutation not detected or detectedNoN/AN/A Genetic Testing in Myeloproliferative Disorders





 
0018UOncology (thyroid), microRNA profiling by RT-PCR of 10 microRNA sequences, utilizing fine needle aspirate, algorithm reported as a positive or negative result for moderate to high risk of malignancy NoN/AN/A Molecular Markers in Fine Needle Aspirates of the Thyroid  
0021UOncology (prostate), detection of 8 autoantibodies (ARF 6, NKX3-1, 5-UTR-BMI1, CEP 164, 3-UTR-Ropporin, Desmocollin, AURKAIP-1, CSNK2A2), multiplexed immunoassay and flow cytometry serum, algorithm reported as risk scoreNoN/AN/A Genetic and Protein Biomarkers for the Diagnosis and Cancer Risk Assessment of Prostate Cancer





 
0022UDrug test(s), presumptive, with definitive confirmation of positive results, any number of drug classes, urine, with specimen verification including DNA authentication in comparison to buccal DNA, per date of service NoN/AN/A Epidermal Growth Factor Receptor (EGFR) testing  
0023UOncology (acute myelogenous leukemia), DNA, genotyping of internal tandem duplication, p.D835, p.I836, using mononuclear cells, reported as detection or non-detection of FLT3 mutation and indication for or against the use of midostaurin NoN/AN/A Genetic Testing for Variants Found in Leukemia  
0026UOncology (thyroid), DNA and mRNA of 112 genes, next-generation sequencing, fine needle aspirate of thyroid nodule, algorithmic analysis reported as a categorical result ("Positive, high probability of malignancy" or "Negative, low probability of malignancy") NoN/AN/A Molecular Markers in Fine Needle Aspirates of the Thyroid  
0027UJAK2 (Janus kinase 2) (eg, myeloproliferative disorder) gene analysis, targeted sequence analysis exons 12-15NoN/AN/A Genetic Testing in Myeloproliferative Disorders  
0029UDrug metabolism (adverse drug reactions and drug response), targeted sequence analysis (ie, CYP1A2, CYP2C19, CYP2C9, CYP2D6, CYP3A4, CYP3A5, CYP4F2, SLCO1B1, VKORC1 and rs12777823) NoN/AN/A Pharmacogenomic Testing for Drug Metabolism  
0030UDrug metabolism (warfarin drug response), targeted sequence analysis (ie, CYP2C9, CYP4F2, VKORC1, rs12777823) NoN/AN/A Pharmacogenomic Testing for Drug Metabolism  
0031U CYP1A2 (cytochrome P450 family 1, subfamily A, member 2)(eg, drug metabolism) gene analysis, common variants (ie, *1F, *1K, *6, *7) NoN/AN/A Pharmacogenomic Testing for Drug Metabolism  
0032UCOMT (catechol-O-methyltransferase)(drug metabolism) gene analysis, c.472G>A (rs4680) variant NoN/AN/A Pharmacogenomic Testing for Drug Metabolism  
0036UExome (ie, somatic mutations), paired formalin-fixed paraffin-embedded tumor tissue and normal specimen, sequence analysesNoN/AN/A Whole Exome and Whole Genome Sequencing for Diagnosis of Genetic Disorders  
0038UVitamin D, 25 hydroxy D2 and D3, by LC-MS/MS, serum microsample, quantitativeNoN/AN/A Vitamin D Testing

Cardiovascular Disease Risk Tests
 
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