FEP Blue Focus®

Precertification is required for inpatient hospital admissions, inpatient and outpatient residential treatment center admissions, and skilled nursing facility admissions.

Emergency inpatient admissions require notification within two business days following the day of emergency admission to avoid penalty.

Maternity admissions for routine delivery do NOT require precertification; unless the medical condition requires a stay more than 48 hours after a vaginal delivery or 96 hours after a cesarean section. Newborn stays after the mother is discharged require precertification of additional days.

Contact the Federal Employee Program® (855.395.2583 for postal employee members and 800.344.5446 for all other federal employee members) for questions related to member eligiblity, benefits, and preauthorization requirements.

 

Service type category

Procedure code(s)

Comments

Applied Behavior Analysis (ABA) services

0362T, 0373T, 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158

Preauth required for Autism Spectrum Disorder diagnosis code(s) F840, F843, F845, F848, F849.

Gender affirming services

(Gender Affirming Surgery Procedure Codes) 11920, 11921, 11922, 11970, 15771, 15772, 15877, 19303, 19318, 19325, 19350, 19357, 53410, 53430, 54125, 54400, 54401, 54405, 54660, 54520, 54690, 55175, 55180, 55899, 55970, 55980, 56625, 56805, 57110, 57291, 57292, 57335, 58150, 58180, 58260, 58262, 58275, 58290, 58291, 58541, 58542, 58543, 58544, 58550, 58552, 58553, 58554, 58570, 58571, 58572, 58573, 58661, 58720, 58999, C1789, C1813, C2622, L8600

(Gender Affirming Facial Surgery) 11950, 11951, 11952, 11954, 15770, 15769, 15773, 15774, 15775, 15776, 15780, 15781, 15782, 15783, 15788, 15789, 15792, 15793, 15820, 15821, 15822, 15823, 15824, 15825, 15826, 15828, 15829, 15876, 17380, 21025, 21120, 21121, 21122, 21123, 21125, 21127, 21137, 21138, 21139, 21141, 21142, 21143, 21145, 21146, 21147, 21150, 21151, 21154, 21155, 21159, 21160, 21172, 21175, 21179, 21180, 21188, 21193, 21194, 21195, 21196, 21208, 21209, 21210, 21215, 21230, 21235, 21244, 21245, 21246, 21248, 21249, 21270, 21899, 30400, 30410, 30420, 30430, 30435, 30450, 31599, 40799, 67900, 69300

Preauth required for Gender Dysphoria diagnoses.

Gene therapy and cellular immunotherapy

C9172, J1411, J1412, J1413, J1414, J3392, J3393, J3394, J3398, J3399, J3401, J9029, J9325, J9380, Q2041, Q2042, Q2043, Q2053, Q2054, Q2055, Q2056, S2107, 38225, 38226, 38227, 38228

 

Transplants - artificial heart

33927, 33928, 33929

Benefits for certain transplants are limited to Blue Distinction Centers for Transplants.

Transplants - blood or marrow stem cell transplants

(Transplant) 38240, 38241, S2142, S2150

(Donor) 38205, 38206, 38207, 38230, 38232, S2140

Benefits for certain transplants are limited to Blue Distinction Centers for Transplants.

Transplants - organ/tissue

(Transplant) 32851, 32852, 32853, 32854, 33935, 33945, 44135, 44136, 47135, 48160, 48554, 0584T, 0585T, 0586T, G0341, G0342, G0343, S2053, S2054, S2060, S2065, S2152

(Donor) 0494T, 0495T, 0496T, 0894T, 0895T, 0896T, 32850, 33930, 33940, 44132, 44133, 47133, 47140, 47141, 47142, 48550, S2055, S2061

(Backbench) 32855, 32856, 33933, 33944, 44715, 44720, 44721, 47143, 47144, 47145, 47146, 47147, 48551, 48552

Benefits for certain transplants are limited to Blue Distinction Centers for Transplants.

Transplants - travel benefits

S9992, S9994

Benefits for certain transplants are limited to Blue Distinction Centers for Transplants.

Cochlear implants/Prosthetic devices/Specialty DME

(Cochlear Implants) 69930, L8614, L8627, L8628, L8615, L8616, L8617, L8618, L8619

(Prosthetic Devices) E0738, E0739, L5000, L5010, L5020, L5050, L5060, L5100, L5105, L5150, L5160, L5200, L5210, L5220, L5230, L5250, L5270, L5280, L5301, L5312, L5321, L5331, L5341, L5500, L5505, L5510, L5520, L5530, L5535, L5540, L5560, L5570, L5580, L5585, L5590, L5595, L5600, L5610, L5611, L5613, L5614, L5615, L5616, L5617, L5618, L5620, L5622, L5624, L5626, L5628, L5629, L5630, L5631, L5632, L5634, L5636, L5637, L5638, L5639, L5640, L5642, L5643, L5644, L5645, L5646, L5647, L5648, L5649, L5650, L5651, L5652, L5653, L5654, L5655, L5656, L5658, L5661, L5665, L5666, L5668, L5670, L5671, L5672, L5673, L5676, L5677, L5678, L5679, L5680, L5681, L5682, L5683, L5684, L5685, L5686, L5688, L5690, L5692, L5694, L5695, L5696, L5697, L5698, L5699, L5700, L5701, L5702, L5703, L5704, L5705, L5706, L5707, L5710, L5711, L5712, L5714, L5716, L5718, L5722, L5724, L5726, L5728, L5780, L5781, L5782, L5783, L5785, L5790, L5795, L5810, L5811, L5812, L5814, L5816, L5818, L5822, L5824, L5826, L5828, L5830, L5840, L5841, L5845, L5848, L5850, L5855, L5856, L5857, L5858, L5859, L5910, L5920, L5925, L5926, L5930, L5940, L5950, L5960, L5961, L5962, L5964, L5966, L5968, L5969, L5970, L5971, L5972, L5973, L5974, L5975, L5976, L5978, L5979, L5980, L5981, L5982, L5984, L5985, L5986, L5987, L5988, L5990, L5991, L5999, L6000, L6010, L6020, L6026, L6050, L6055, L6100, L6110, L6120, L6130, L6200, L6205, L6250, L6300, L6310, L6320, L6350, L6360, L6370, L6380, L6382, L6384, L6386, L6388, L6400, L6450, L6500, L6550, L6570, L6580, L6582, L6584, L6586, L6588, L6590, L6600, L6605, L6610, L6611, L6615, L6616, L6620, L6621, L6623, L6624, L6625, L6628, L6629, L6630, L6632, L6635, L6637, L6638, L6640, L6641, L6642, L6645, L6646, L6647, L6648, L6650, L6655, L6660, L6665, L6670, L6672, L6675, L6676, L6677, L6680, L6682, L6684, L6686, L6687, L6688, L6689, L6690, L6691, L6692, L6693, L6694, L6695, L6696, L6697, L6698, L6703, L6704, L6706, L6707, L6708, L6709, L6711, L6712, L6713, L6714, L6715, L6721, L6722, L6805, L6810, L6880, L6881, L6882, L6883, L6884, L6885, L6890, L6895, L6900, L6905, L6910, L6915, L6920, L6925, L6930, L6935, L6940, L6945, L6950, L6955, L6960, L6965, L6970, L6975, L7007, L7008, L7009, L7040, L7045, L7170, L7180, L7181, L7185, L7186, L7190, L7191, L7259, L7400, L7401, L7402, L7403, L7404, L7405, L7499, L7510, L7520, L7600, L7700, L8000, L8001, L8002, L8010, L8015, L8020, L8030, L8031, L8032, L8033, L8035, L8039, L8040, L8041, L8042, L8043, L8044, L8045, L8046, L8047, L8048, L8049, L8608, L8701, L8702, L8720, L8721

(Specialty DME) E0265, E0266, E0270, E0277, E0296, E0297, E0300, E0301, E0302, E0303, E0304, E0316, E0328, E0329, E0371, E0372, E0373, E0983, E0984, E0985, E0986, E1002, E1003, E1004, E1005, E1006, E1007, E1008, E1009, E1010, E1012, E1230, E1239, E2310, E2311, E2312, E2313, E2321, E2322, E2323, E2324, E2325, E2326, E2327, E2328, E2329, E2330, E2331, E2340, E2341, E2342, E2343, E2351, E2358, E2359, E2360, E2361, E2362, E2363, E2364, E2365, E2366, E2367, E2368, E2369, E2370, E2371, E2372, E2373, E2374, E2375, E2376, E2377, E2378, E2381, E2382, E2383, E2384, E2385, E2386, E2387, E2388, E2389, E2390, E2391, E2392, E2394, E2395, E2396, E2397, E2398, K0010, K0011, K0012, K0013, K0014, K0108, K0733, K0800, K0801, K0802, K0806, K0807, K0808, K0812, K0813, K0814, K0815, K0816, K0820, K0821, K0822, K0823, K0824, K0825, K0826, K0827, K0828, K0829, K0830, K0831, K0835, K0836, K0837, K0838, K0839, K0840, K0841, K0842, K0843, K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855, K0856, K0857, K0858, K0859, K0860, K0861, K0862, K0863, K0864, K0868, K0869, K0870, K0871, K0877, K0878, K0879, K0880, K0884, K0885, K0886, K0890, K0891, K0898 or K0899

 

Bariatric surgery

0813T, 43290, 43291, 43644, 43645, 43770, 43771, 43773, 43775, 43842, 43843, 43845, 43846, 43847, 43848, 43886, 43888, C9784, C9785

Must be performed at a Blue Distinction Center (BDC) for Comprehensive Bariatric Surgery.

Oral/Maxillofacial surgery

21010, 21050, 21060, 21070, 21073, 21193, 21194, 21195, 21196, 21198, 21199, 21206, 21210, 21215, 21240, 21242, 21243, 21244, 21245, 21246, 21247, 21248, 21249, 21345, 21346, 21347, 21348, 21355, 21356, 21360, 21365, 21366, 21421, 21422, 21423, 21431, 21432, 21433, 21435, 21436, 21440, 21445, 21452, 21454, 21461, 21462, 21465, 21470, 21480, 21485, 21490, 21497,  21450, 21451, 21453, 29804, 40510, 40520, 40525, 40527, 40530, 40650, 40652, 40654, 40800, 40801, 40804, 40805, 40830, 40831, 41000, 41005, 41006, 41007, 41008, 41009, 41015, 41016, 41017, 41018, 41250, 41251, 41252, 42180, 42182, D7220, D7230, D7240, D7241, D7251, D7260, D7261, D7270**, D7272**, D7282, D7285, D7286, D7290**, D7291**, D7310**, D7311**, D7320**, D7321**, D7340**, D7350**, D7410, D7411, D7412, D7413, D7414, D7415, D7440, D7441, D7460, D7461, D7465, D7471, D7472, D7473, D7485, D7490, D7509, D7510, D7511, D7520, D7521, D7530**, D7540**, D7550**, D7560**, D7610**, D7620**, D7630**, D7640**, D7650**, D7660**, D7670**, D7671, D7680**, D7710**, D7720**, D7730**, D7740**, D7750**, D7760**, D7770**, D7771, D7780**, D7810, D7820, D7830, D7840, D7850, D7852, D7854, D7856, D7858, D7860, D7865, D7870, D7871**, D7872, D7873, D7874, D7875, D7876, D7877, D7910, D7911, D7912, D7920, D7922**, D7940**, D7941**, D7943, D7944**, D7945**, D7946**, D7947**, D7948**, D7949**, D7950**, D7951**, D7952**, D7953**, D7955**, D7956**, D7957**, D7963, D7972, D7980, D7981, D7982, D7983, D7993**, D7994**, D7995**, D7996**, D7997**

Preauth is required except when care is provided within 72 hrs of an accidental injury.

Procedure Codes marked with double asterisk (**) when billed with Cancer Diagnosis Codes require Prior Approval

Other surgical services

0054T, 0055T, 0511T, 0524T, 0717T, 0718T, 0719T, 0775T, 15769, 15771, 15772, 15773, 15774, 19350, 19355, 19357, 19361, 19364, 19367, 19368, 19369, 19380, 19396, 20650, 20662, 20663, 20665, 20670, 20680, 20690, 20692, 20693, 20694, 20696, 20697, 20900, 20902, 20920, 20922, 20924, 20930, 20931, 20936, 20937, 20938, 20939, 20955, 20956, 20962, 20970, 20985, 21026, 21030, 21031, 21032, 21034, 21040, 21044, 21045, 21046, 21047, 21048, 21049, 21116, 21120, 21121, 21122, 21123, 21125, 21127, 21137, 21138, 21139, 21141, 21142, 21143, 21145, 21146, 21147, 21150, 21151, 21154, 21155, 21159, 21160, 21172, 21175, 21179, 21180, 21181, 21182, 21183, 21184, 21188, 21208, 21209, 21230, 21235, 21255, 21256, 21260, 21261, 21263, 21267, 21268, 21270, 21275, 21280, 21282, 21295, 21296, 21740, 21742, 21743, 22010, 22015, 22100, 22101, 22102, 22103, 22110, 22112, 22114, 22116, 22206, 22207, 22208, 22210, 22212, 22214, 22216, 22220, 22222, 22224, 22226, 22532, 22533, 22534, 22548, 22551, 22552, 22554, 22556, 22558, 22585, 22586, 22590, 22595, 22600, 22610, 22612, 22614, 22630, 22632, 22633, 22634, 22800, 22802, 22804, 22808, 22810, 22812, 22818, 22819, 22830, 22836, 22837, 22840, 22841, 22842, 22843, 22844, 22845, 22846, 22847, 22848, 22849, 22850, 22852, 22853, 22854, 22855, 22856, 22857, 22858, 22859, 22860, 22861, 22862, 22864, 22865, 22867, 22868, 22869, 22870, 23020, 23035, 23040, 23044, 23100, 23101, 23105, 23106, 23107, 23120, 23125, 23130, 23170, 23172, 23174, 23180, 23182, 23184, 23190, 23195, 23395, 23397, 23405, 23406, 23410, 23412, 23415, 23420, 23430, 23440, 23450, 23455, 23460, 23462, 23465, 23466, 23470, 23472, 23473, 23474, 23480, 23485, 23490, 23491, 23700, 23800, 23802, 23900, 23920, 23921, 24134, 24140, 24344, 24346, 24498, 26500, 26502, 26541, 26542, 26545, 26992, 27000, 27001, 27003, 27005, 27006, 27025, 27027, 27030, 27033, 27036, 27050, 27052, 27054, 27057, 27070, 27071, 27080, 27097, 27098, 27100, 27105, 27110, 27111, 27120, 27122, 27125, 27130, 27132, 27134, 27137, 27138, 27140, 27146, 27147, 27151, 27156, 27161, 27165, 27170, 27175, 27176, 27177, 27178, 27179, 27181, 27185, 27187, 27275, 27278, 27279, 27280, 27282, 27284, 27286, 27290, 27295, 27303, 27305, 27306, 27307, 27325, 27326, 27330, 27331, 27332, 27333, 27334, 27335, 27350, 27360, 27380, 27381, 27385, 27386, 27390, 27391, 27392, 27393, 27394, 27395, 27396, 27397, 27400, 27403, 27405, 27407, 27409, 27412, 27415, 27416, 27418, 27420, 27422, 27424, 27425, 27427, 27428, 27429, 27430, 27435, 27437, 27438, 27440, 27441, 27442, 27443, 27445, 27446, 27447, 27448, 27450, 27454, 27455, 27457, 27465, 27466, 27468, 27470, 27472, 27475, 27477, 27479, 27485, 27486, 27487, 27495, 27496, 27497, 27498, 27499, 27570, 27580, 27598, 27600, 27601, 27602, 27605, 27606, 27607, 27612, 27620, 27625, 27626, 27640, 27641, 27650, 27652, 27654, 27656, 27658, 27659, 27664, 27665, 27675, 27676, 27680, 27681, 27685, 27686, 27687, 27690, 27691, 27692, 27695, 27696, 27698, 27700, 27702, 27703, 27705, 27707, 27709, 27712, 27715, 27720, 27722, 27724, 27725, 27726, 27730, 27732, 27734, 27740, 27742, 27745, 27860, 27870, 27871, 27889, 27892, 27893, 27894, 27899, 28005, 28238, 29800, 29806, 29807, 29820, 29821, 29822, 29823, 29824, 29825, 29826, 29827, 29828, 29862, 29863, 29866, 29867, 29868, 29871, 29873, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889, 29891, 29895, 29897, 29898, 29899, 29914, 29915, 29916, 30400, 30410*, 30420*, 30430*, 30435*, 30450*, 30460, 30462, 30520, 36465, 36466, 36468, 36470, 36471, 36473, 36474, 36475, 36476, 36478, 36479, 36482, 36483, 37500, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37785, 40490, 40500, 40806, 40808, 40810, 40812, 40814, 40816, 40819, 40820, 41010, 41100, 41105, 41108, 41110, 41112, 41113, 41114, 41115, 41116, 41120, 41130, 41150, 41520, 42000, 42100, 42104, 42106, 42107, 42120, 42140, 42145, 42160, 42300, 42305, 42310, 42320, 42330, 42335, 42340, 63052, 63053, 67971, 67973, 67974, 67975, 69310, 69641, 69642, 69643, 69644, 69646, C8003, C9781

Breast reduction/Augmentation

15777, 19316, 19318, 19325, 19328, 19330, 19340, 19342

Preauth is NOT required for treatment of breast cancer.

Hospice services

Q5001, Q5002, Q5003, Q5004, Q5005, Q5006, Q5007, Q5008, Q5009, Q5010, S0255, S0271, S9126

Preauth is required for home hospice, continuous home hospice, or inpatient hospice care services.

CT scan/MRI/PET scan

0042T, 0332T, 0588T,0609T, 0610T, 0611T, 0612T, 0633T, 0634T, 0635T, 0636T, 0637T, 0638T, 0648T, 0649T, 0697T, 0698T, 0742T, 0808T, 0865T, 0866T, 0899T, 0900T, 0946T, 0947T, 61715, 70336, 70450, 70460, 70470, 70480, 70481, 70482, 70486, 70487, 70488, 70490, 70491, 70492, 70496, 70498, 70540, 70542, 70543, 70544, 70545, 70546, 70547, 70548, 70549, 70551, 70552, 70553, 70554, 70555, 70557, 70558, 70559, 71250, 71260, 71270, 71271, 71275, 71550, 71551, 71552, 71555, 72125, 72126, 72127, 72128, 72129, 72130, 72131, 72132, 72133, 72141, 72142, 72146, 72147, 72148, 72149, 72156, 72157, 72158, 72159, 72195, 72196, 72197, 72198, 72191, 72192, 72193, 72194, 73200, 73201, 73202, 73206, 73218, 73219, 73220, 73221, 73222, 73223, 73225, 73700, 73701, 73702, 73706, 73718, 73719, 73720, 73721, 73722, 73723, 73725, 74150, 74160, 74170, 74174, 74175, 74176, 74177, 74178, 74181, 74182, 74183, 74185, 74261, 74262, 75571, 75572, 75573, 75574, 75580, 75635, 76014, 76015, 76016, 76017, 76018, 76019, 76376, 76377, 76380, 76390, 76391, 76497, 77011, 77012, 77013, 77014, 77078, 78072, 74712, 74713, 75557, 75559, 75561, 75563, 75565, 76498, 77021, 77022, 77046, 77047, 77048, 77049, 77084, 78071, 78429, 78430, 78431, 78432, 78433, 78434, 78451, 78452, 78459, 78469, 78491, 78492, 78494, 78608, 78609, 78811, 78812, 78813, 78814, 78815, 78816, 78830, 78831, 78832, 78835, 78803, C8903, C8905, C8906, C8908, C9762, C9763, C9791, G0219, G0235, G0252, G0288, S8092

Genetic testing

G0452, G9143, S3800, S3840, S3841, S3842, S3844, S3845, S3846, S3849, S3850, S3852, S3853, S3854, S3861, S3865, S3866, S3870, 0001U, 0004M, 0005U, 0006M, 0007M, 0008U, 0009U, 0010U, 0011M, 0012M, 0013M, 0016M, 0017M, 0016U, 0017U, 0018U, 0019U, 0022U, 0023U, 0026U, 0027U, 0029U, 0030U, 0031U, 0032U, 0033U, 0034U, 0036U, 0037U, 0039U, 0040U, 0045U, 0046U, 0047U, 0048U, 0049U, 0050U, 0055U, 0060U, 0069U, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076U, 0078U, 0079U, 0087U, 0088U, 0089U, 0090U, 0091U, 0094U, 0101U, 0102U, 0103U, 0111U, 0112U, 0113U, 0114U, 0118U, 0120U, 0129U, 0130U, 0131U, 0132U, 0133U, 0134U, 0135U, 0136U, 0137U, 0153U, 0154U, 0155U, 0156U, 0157U, 0158U, 0159U, 0160U, 0161U, 0162U, 0169U, 0170U, 0171U, 0172U, 0173U, 0175U, 0177U, 0179U, 0180U, 0181U, 0182U, 0183U, 0184U, 0185U, 0186U, 0187U, 0188U, 0189U, 0190U, 0191U, 0192U, 0193U, 0194U, 0195U, 0196U, 0197U, 0198U, 0199U, 0200U, 0201U, 0203U, 0205U, 0209U, 0211U, 0212U, 0213U, 0214U, 0215U, 0216U, 0217U, 0218U, 0221U, 0229U, 0230U, 0231U, 0232U, 0233U, 0234U, 0235U, 0236U, 0237U, 0238U, 0239U, 0242U, 0244U, 0245U, 0249U, 0250U, 0252U, 0258U, 0260U, 0262U, 0264U, 0265U, 0266U, 0267U, 0268U, 0269U, 0270U, 0271U, 0272U, 0273U, 0274U, 0276U, 0277U, 0278U, 0282U, 0285U, 0286U, 0287U, 0288U, 0289U, 0290U, 0291U, 0292U, 0293U, 0294U, 0295U, 0296U, 0297U, 0298U, 0299U, 0300U, 0306U, 0307U, 0313U, 0314U, 0315U, 0317U, 0318U, 0319U, 0320U, 0326U, 0327U, 0329U, 0331U, 0332U, 0333U, 0334U, 0335U, 0336U, 0339U, 0340U, 0341U, 0343U, 0345U, 0347U, 0348U, 0349U, 0350U, 0356U, 0362U, 0363U, 0364U, 0368U, 0378U, 0379U, 0388U, 0391U, 0392U, 0395U, 0396U, 0398U, 0400U, 0401U, 0403U, 0405U, 0409U, 0410U, 0411U, 0413U, 0414U, 0417U, 0419U, 0420U, 0421U, 0422U, 0423U, 0424U, 0425U, 0426U, 0433U, 0434U, 0437U, 0438U, 0439U, 0440U, 0444U, 0449U, 0452U, 0453U, 0454U, 0460U, 0461U, 0463U, 0464U, 0465U, 0466U, 0467U, 0469U, 0470U, 0471U, 0473U, 0474U, 0475U, 0488U, 0489U, 0495U, 0496U, 0498U, 0499U, 0500U, 0501U, 0506U, 0507U, 0523U, 0529U, 0530U

81120, 81121, 81161, 81168, 81170, 81171, 81172, 81173, 81174, 81175, 81176, 81177, 81178, 81179, 81180, 81181, 81182, 81183, 81184, 81185, 81186, 81187, 81188, 81189, 81190, 81191, 81192, 81193, 81194, 81195, 81200, 81201, 81202, 81203, 81204, 81205, 81206, 81207, 81208, 81209, 81210, 81218, 81219, 81220, 81221, 81222, 81223, 81224, 81225, 81226, 81227, 81228, 81229, 81230, 81231, 81232, 81233, 81234, 81235, 81236, 81237, 81238, 81239, 81240, 81241, 81242, 81243, 81244, 81245, 81246, 81247, 81248, 81249, 81250, 81251, 81252, 81253, 81254, 81255, 81257, 81258, 81259, 81260, 81261, 81262, 81263, 81264, 81269, 81270, 81271, 81272, 81273, 81274, 81275, 81276, 81277, 81278, 81279, 81283, 81284, 81285, 81286, 81287, 81288, 81289, 81290, 81291, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81301, 81302, 81303, 81304, 81305, 81306, 81307, 81308, 81309, 81310, 81311, 81312, 81313, 81314, 81315, 81316, 81317, 81318, 81319, 81320, 81321, 81322, 81323, 81324, 81325, 81326, 81327, 81328, 81329, 81330, 81331, 81332, 81333, 81334, 81335, 81336, 81337, 81338, 81339, 81340, 81341, 81342, 81343, 81344, 81345, 81346, 81347, 81348, 81349, 81350, 81351, 81352, 81353, 81355, 81357, 81360, 81361, 81362, 81363, 81364, 81400, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81410, 81411, 81412, 81413, 81414, 81415, 81416, 81417, 81418, 81419, 81425, 81426, 81427, 81430, 81431, 81432, 81434, 81435, 81436, 81437, 81439, 81440, 81441, 81442, 81443, 81445, 81448, 81449, 81450, 81451, 81455, 81456, 81457, 81458, 81459, 81460, 81462, 81463, 81464, 81465, 81470, 81471, 81479, 81493, 81504, 81518, 81519, 81520, 81521, 81522, 81523, 81525, 81528, 81529, 81540, 81541, 81542, 81546, 81551, 81552, 81554, 81558, 81595, 81599, 88245, 88248, 88249, 88283, 88285, 88289 or 88291

Air ambulance transport (non-emergent)

(Revenue Code) 0540, 0541, 0542, 0543, 0544, 0546, 0547, 0548, 0549

(Procedure Code) A0430, A0431, A0435, A0436

Preauth is NOT required for air ambulance transport related to immediate care of a medical emergency or accidental injury.

BRCA testing

0138U, 81162, 81163, 81164, 81165, 81166, 81167, 81212, 81215, 81216, 81217

Cardiac rehabilitation services

(Revenue Code) 0943 or any covered non-Room and Board revenue code

(Procedure Code) 93797, 93798, S9472, G0422, G0423

Pulmonary rehabilitation services

(Revenue Code) 0948 or any covered non-Room and Board revenue code

(Procedure Code) 94625, 94626, S9473, G0237, G0238, G0239

Proton beam therapy

(Revenue Code) 0333

(Procedure Code) 77520, 77522, 77523, 77525, G0563

Preauth is NOT required for patients 21 years of age and younger, or when related to the treatment of neoplasms of the nervous system including the brain and spinal cord; malignant neoplasms of the thymus; Hodgkin and non-Hodgkin lymphomas.

Stereotactic body radiation therapy

(Revenue Code) 0333

(Procedure Code) 77373, 77435, G0563

Stereotactic radiosurgery

(Revenue Code) 0333

(Procedure Code) 77371, 77372, 77432

Preauth is required for all stereotactic radiosurgery except when related to the treatment of malignant neoplasms of the brain and of the eye specific to the choroid and ciliary body; benign neoplasms of the cranial nerves, pituitary gland, aortic body, or paraganglia; neoplasms of the craniopharyngeal duct and glomus jugular tumors; trigeminal neuralgias, temporal sclerosis, certain epilepsy conditions, or arteriovenous malformations.

Medical benefit drugs

C9173, C9257, J0222, J0223, J0224, J0177, J0178, J0179, J0225, J0885, J1300, J1303, J1442, J1447, J1449, J1602, J1745, J1748, J2327, J2350, J2506, J2777, J2778, J3357, J3358, J9035, J9311, J9312, J9332, J9334, J9355, J9356, Q5101, Q5103, Q5104, Q5106, Q5107, Q5108, Q5109, Q5110, Q5111, Q5112, Q5113, Q5114, Q5115, Q5116, Q5117, Q5118, Q5119, Q5120, Q5121, Q5122, Q5123, Q5124, Q5125, Q5126, Q5127, Q5128, Q5129, Q5130, Q5137, Q5138, Q5139, Q5146, Q9996, Q9997, Q9998

OR

Unclassified drug code(s) C9399, J3490, J3590, J3591, J7699, J7799, J8498, J8499, J8597, J8999, J9999, or Q0181 ONLY when NDC is:

72126000701, 72126000702, 71336100001, 71336100101, 71336100201, 25682000101 or 73475304105

Sperm or egg storage

89343, 89344, 89346

Preauth is required for the storage of sperm and eggs for individuals facing iatrogenic infertility.

Artificial insemination (AI) drugs

J0725, J1675, J1950, J1951, J1952, J2675, J3315, J3316, J9155, J9202, J9217, J9218, J9225, J9226, S0122, S0126, S0128, S0132

OR

Unclassified drug code(s) C9399, J3490, J3590, J3591, J7699, J7799, J8498, J8499, J8597, J8999, J9999, Q0181, S5000, or S5001 ONLY with an applicable (AI drug) NDC

Artificial insemination services

58321, 58322, 58323, 89257, 89260, 89261, 89264, 89353, 89354, S4028, S4035, S4042