Ask To See The Member's ID Card For Current Information
Procedure Code List Effective Jan. 1, 2020 forPreauthorization for Blue Cross and Blue Shield ofNew Mexico Medicare Advantage Members onlyBeginning Jan. 1, 2020, providers will be required to obtain preauthorization through Blue Cross andBlue Shield of New Mexico (BCBSNM), Optum, or eviCore for certain procedures for Blue CrossMedicare Advantage members as noted in the MAPD Benefit Preauthorization Procedure Code List,Effective 1/1/2020, below. For members NOT attributed to Optum, preauthorization should beobtained from BCBSNM unless the applicable entry in the MAPD Benefit Preauthorization ProcedureCode List references eviCore. For members attributed to Optum, preauthorization should be obtainedfrom Optum, even if the applicable entry in the MAPD Benefit Preauthorization Procedure Code Listreferences eviCore. Any entry that references eviCore should be preauthorized through eviCore exceptfor members attributed to Optum. The member's ID Card will indicate that the member is attributed toOptum.Services performed without benefit preauthorization may be denied for payment in whole or in part,and you may not seek reimbursement from members.Member eligibility and benefits should be checked prior to every scheduled appointment. Eligibilityand benefit quotes include membership status, coverage status and other important information, suchas applicable copayment, coinsurance and deductible amounts. It is strongly recommendedthat providers ask to see the member's ID card for current information and a photo ID to guard againstmedical identity theft.A referral to an out-of-plan or out-of-network provider which is necessary due to network inadequacyor continuity of care must be reviewed by the BCBSNM Utilization Management or DMG (if themember is attributed to DMG this information will be reflected on the ID card) prior to a BCBSNMpatient receiving care.To obtain benefit preauthorization through BCBSNM for the procedures noted below, you maycontinue to use iExchange . This online tool is accessible to physicians, professional providers andfacilities contracted with BCBSNM. For more information or to set up a new account, refer to theiExchange page in the Provider Tools section of our Provider website.Procedure codes highlighted in green denote preauthorization through eviCore.Our goal is to provide our members with access to quality, cost-effective health care. If you have anyQuestions regarding this communication, please contact your Provider Network Representative.Please note that verification of eligibility and benefits, and/or the fact that a service or treatment hasbeen preauthorized or predetermined for benefits is not a guarantee of payment. Benefits will bedetermined once a claim is received and will be based upon, among other things, the member’seligibility and the terms of the member’s certificate of coverage applicable on the date services wererendered. If you have questions regarding these preauthorization requirements, please contact thenumber on the member’s ID card.
MAPD Benefit Preauthorization Procedure Code ListEffective 1/1/2020(Updated 09/27/2019)This list is not exhaustive. The presence of codes on this list does not necessarilyindicate coverage under the member benefits contract. Member contracts differ intheir benefits. Consult the member benefit booklet, or contact a customer servicerepresentative to determine coverage for a specific medical service or supply.Green highlighted codes are managed by eviCore healthcare (eviCore).CPT and HCPCS Description of procedure Codecodes thatrequireauthorization11043DEB MUSC/FASCIA 20 SQ CM/ 11970REPLACE TISSUE EXPANDER15271SKIN SUB GRAFT TRNK/ARM/LEG15775HAIR TRNSPL 1-15 PUNCH GRFTS15776HAIR TRNSPL 15 PUNCH GRAFTS15777ACELLULAR DERM MATRIX IMPLT15780DERMABRASION TOTAL FACE15781DERMABRASION SEGMENTAL FACE15782DERMABRASION OTHER THAN FACE15783DERMABRASION SUPRFL ANY SITE15786ABRASION LESION SINGLE15787ABRASION LESIONS ADD-ONUtilization Management ProcessCPT Copyright 2018 American Medical Association. All rights reserved.CPT is a registered trademark of the American Medical Association.Medical Records Request information requiredRecent history and physical, plan of care, and documentation of medicalnecessity.Pre Operative Evaluation, History and Physical including functional impairment,and Operative report.Recent history and physical, plan of care, and documentation of medicalnecessity.Pre Operative Evaluation, History and Physical including functional impairment,and Operative reportPre Operative Evaluation, History and Physical including functional impairment,and Operative reportPre Operative Evaluation, History and Physical including functional impairment,and Operative reportPre-operative evaluation, history and physical including functional impairment,and operative report.Pre-operative evaluation, history and physical including functional impairment,and operative report.Pre-operative evaluation, history and physical including functional impairment,and operative report.Pre-operative evaluation, history and physical including functional impairment,and operative report.Pre-operative evaluation, history and physical including functional impairment,and operative report.Pre-operative evaluation, history and physical including functional impairment,and operative report.A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
2CPT and HCPCS Description of procedure Codecodes thatrequireauthorization15788CHEMICAL PEEL FACE EPIDERM15789CHEMICAL PEEL FACE DERMAL15792CHEMICAL PEEL NONFACIAL15793CHEMICAL PEEL NONFACIAL15819PLASTIC SURGERY NECK15820REVISION OF LOWER EYELID15821REVISION OF LOWER EYELID15822REVISION OF UPPER EYELID15823REVISION OF UPPER EYELID15824REMOVAL OF FOREHEAD WRINKLES15825REMOVAL OF NECK WRINKLES15826REMOVAL OF BROW WRINKLES15828REMOVAL OF FACE WRINKLES15829REMOVAL OF SKIN WRINKLES15830EXC SKIN ABD15832EXCISE EXCESSIVE SKIN THIGH15833EXCISE EXCESSIVE SKIN LEG15834EXCISE EXCESSIVE SKIN HIPUpdated 9/27/2019Medical Records Request information requiredPre-operative evaluation, history and physical including functional impairment,and operative report.Pre-operative evaluation, history and physical including functional impairment,and operative report.Pre-operative evaluation, history and physical including functional impairment,and operative report.Pre-operative evaluation, history and physical including functional impairment,and operative report.Pre-operative evaluation, history and physical including functional impairment,and operative report.Pre-operative Evaluation, history and physical including functional impairment,operative report and photographs of the affected eyes.Pre-operative Evaluation, history and physical including functional impairment,operative report and photographs of the affected eyes.Pre-operative Evaluation, history and physical including functional impairment,operative report and photographs of the affected eyes.Pre-operative Evaluation, history and physical including functional impairment,operative report and photographs of the affected eyes.Pre-operative evaluation, history and physical including functional impairment,and operative report.Pre-operative evaluation, history and physical including functional impairment,and operative report.Pre-operative evaluation, history and physical including functional impairment,and operative report.Pre-operative evaluation, history and physical including functional impairment,and operative report.Pre-operative evaluation, history and physical including functional impairment,and operative report.Pre-operative evaluation, history and physical including functional impairment,and operative report.Pre-operative evaluation, history and physical including functional impairment,and operative report.Pre-operative evaluation, history and physical including functional impairment,and operative report.Pre-operative evaluation, history and physical including functional impairment,and operative report.2
3CPT and HCPCS Description of procedure Codecodes thatrequireauthorization15835EXCISE EXCESSIVE SKIN BUTTCK15836EXCISE EXCESSIVE SKIN ARM15837EXCISE EXCESS SKIN ARM/HAND15838EXCISE EXCESS SKIN FAT PAD15839EXCISE EXCESS SKIN & TISSUE15847EXC SKIN ABD ADD-ON15876EXC SKIN ABD ADD-ON15877EXC SKIN ABD ADD-ON15878EXC SKIN ABD ADD-ON15879EXC SKIN ABD ADD-ON17340CRYOTHERAPY OF SKIN17360SKIN PEEL THERAPY17380HAIR REMOVAL BY ELECTROLYSIS19316SUSPENSION OF BREAST19318REDUCTION OF LARGE BREAST1932419325ENLARGE BREASTENLARGE BREAST WITH IMPLANT19328REMOVAL OF BREAST IMPLANTUpdated 9/27/2019Medical Records Request information requiredPre-operative evaluation, history and physical including functional impairment,and operative report.Pre-operative evaluation, history and physical including functional impairment,and operative report.Pre-operative evaluation, history and physical including functional impairment,and operative report.Pre-operative evaluation, history and physical including functional impairment,and operative report.Pre-operative evaluation, history and physical including functional impairment,and operative report.Pre-operative evaluation, history and physical including functional impairment,and operative report.Pre-operative evaluation, history and physical including functional impairment,and operative report.Pre-operative evaluation, history and physical including functional impairment,and operative report.Pre-operative evaluation, history and physical including functional impairment,and operative report.Pre-operative evaluation, history and physical including functional impairment,and operative report.Pre-operative evaluation, history and physical including functional impairment,and operative report.Pre-operative evaluation, history and physical including functional impairment,and operative report.Pre-operative evaluation, history and physical including functional impairment,and operative report.Pre-operative evaluation, history and physical including functional impairment andoperative report.Pre-operative evaluation, height/ weight, previous conservative treatment tried,pathology report, operative report, number of grams of tissue removed.Pre-operative evaluation, history and physical including functional impairment,Pre-operative evaluation, history and physical including functional impairment,and operative report.Pre-operative evaluation, history and physical including functional impairment,and operative report.3
4CPT and HCPCS Description of procedure Codecodes thatrequireauthorization19330REMOVAL OF IMPLANT MATERIAL19340IMMEDIATE BREAST PROSTHESIS19342DELAYED BREAST PROSTHESIS19350BREAST RECONSTRUCTION19355CORRECT INVERTED P BONE ALGRFT MORSEL ADD-ONSP BONE ALGRFT STRUCT ADD-ONSP BONE AGRFT LOCAL ADD-ONSP BONE AGRFT MORSEL ADD-ONSP BONE AGRFT STRUCT ADD-ONELECTRICAL BONE STIMULATIONELECTRICAL BONE STIMULATIONPREPARE FACE/ORAL PROSTHESIS21085PREPARE FACE/ORAL PROSTHESIS21120RECONSTRUCTION OF CHIN21121RECONSTRUCTION OF CHIN21122RECONSTRUCTION OF CHIN21123RECONSTRUCTION OF CHIN21125AUGMENTATION LOWER JAW BONE21127AUGMENTATION LOWER JAW BONE21138REDUCTION OF FOREHEADUpdated 9/27/2019Medical Records Request information requiredPre-operative evaluation, history and physical including functional impairment,and operative report.Pre-operative evaluation, history and physical including functional impairment,and operative report.Pre-operative evaluation, history and physical including functional impairment,and operative report.Pre-operative evaluation, history and physical including functional impairment,and operative report.Pre Operative evaluation, History and Physical including functional impairment,and operative report.eviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or ve evaluation, history and physical including functional impairment,and operative report.Submit chart notes including type of appliance, history of re- occurring TMJ, andcopy of diagnostic sleep studies.Submit chart notes including type of appliance, history of re- occurring TMJ, andcopy of diagnostic sleep studies.Submit chart notes including type of appliance, history of re- occurring TMJ, andcopy of diagnostic sleep studies.Submit chart notes including type of appliance, history of re- occurring TMJ, andcopy of diagnostic sleep studies.Submit chart notes including type of appliance, history of re- occurring TMJ, andcopy of diagnostic sleep studies.Submit chart notes including type of appliance, history of re- occurring TMJ, andcopy of diagnostic sleep studies.Submit chart notes including type of appliance, history of re- occurring TMJ, andcopy of diagnostic sleep studies.History and physical, documentation of medical necessity and previous stages ofreconstruction if done.4
5CPT and HCPCS Description of procedure Codecodes thatrequireauthorization21141LEFORT I-1 PIECE W/O GRAFT21142LEFORT I-2 PIECE W/O GRAFT21143LEFORT I-3/ PIECE W/O GRAFT21145LEFORT I-1 PIECE W/ GRAFT21146LEFORT I-2 PIECE W/ GRAFT21147LEFORT I-3/ PIECE W/ GRAFT21150LEFORT II ANTERIOR INTRUSION21151LEFORT II W/BONE GRAFTS21154LEFORT III W/O LEFORT I21155LEFORT III W/ LEFORT I21159LEFORT III W/FHDW/O LEFORT I21160LEFORT III W/FHD W/ LEFORT I21188RECONSTRUCTION OF MIDFACE21193RECONST LWR JAW W/O GRAFT21194RECONST LWR JAW W/GRAFT21195RECONST LWR JAW W/O FIXATION21196RECONST LWR JAW W/FIXATION21198RECONSTR LWR JAW SEGMENTUpdated 9/27/2019Medical Records Request information requiredSubmit chart notes including type of appliance, history of re- occurring TMJ, andcopy of diagnostic sleep studies.Submit chart notes including type of appliance, history of re- occurring TMJ, andcopy of diagnostic sleep studies.Submit chart notes including type of appliance, history of re- occurring TMJ, andcopy of diagnostic sleep studies.Submit chart notes including type of appliance, history of re- occurring TMJ, andcopy of diagnostic sleep studies.Submit chart notes including type of appliance, history of re- occurring TMJ, andcopy of diagnostic sleep studies.Submit chart notes including type of appliance, history of re- occurring TMJ, andcopy of diagnostic sleep studies.Submit chart notes including type of appliance, history of re- occurring TMJ, andcopy of diagnostic sleep studies.Submit chart notes including type of appliance, history of re- occurring TMJ, andcopy of diagnostic sleep studies.Submit chart notes including type of appliance, history of re- occurring TMJ, andcopy of diagnostic sleep studies.Submit chart notes including type of appliance, history of re- occurring TMJ, andcopy of diagnostic sleep studies.Submit chart notes including type of appliance, history of re- occurring TMJ, andcopy of diagnostic sleep studies.Submit chart notes including type of appliance, history of re- occurring TMJ, andcopy of diagnostic sleep studies.Submit chart notes including type of appliance, history of re- occurring TMJ, andcopy of diagnostic sleep studies.Submit chart notes including type of appliance, history of re- occurring TMJ, andcopy of diagnostic sleep studies.Submit chart notes including type of appliance, history of re- occurring TMJ, andcopy of diagnostic sleep studies.Submit chart notes including type of appliance, history of re- occurring TMJ, andcopy of diagnostic sleep studies.Submit chart notes including type of appliance, history of re- occurring TMJ, andcopy of diagnostic sleep studies.Submit chart notes including type of appliance, history of re- occurring TMJ, andcopy of diagnostic sleep studies.5
6CPT and HCPCS Description of procedure Codecodes thatrequireauthorization21199RECONSTR LWR JAW W/ADVANCE21206RECONSTRUCT UPPER JAW BONE21208AUGMENTATION OF FACIAL BONES21209REDUCTION OF FACIAL BONES21210FACE BONE GRAFT21215LOWER JAW BONE GRAFT21230RIB CARTILAGE GRAFT21244RECONSTRUCTION OF LOWER JAW21245RECONSTRUCTION OF JAW21246RECONSTRUCTION OF JAW21270PT TALK EVAL HLTHWKR RE MDD21685HYOID MYOTOMY & SUSPENSION21740RECONSTRUCTION OF STERNUM21742REPAIR STERN/NUSS W/O SCOPE21743REPAIR STERNUM/NUSS W/SCOPE22505MANIPULATION OF SPINE22510225112251222513PERQ CERVICOTHORACIC INJECTPERQ LUMBOSACRAL INJECTIONVERTEBROPLASTY ADDL INJECTPERQ VERTEBRAL AUGMENTATIONUpdated 9/27/2019Medical Records Request information requiredSubmit chart notes including type of appliance, history of re- occurring TMJ, andcopy of diagnostic sleep studies.Submit chart notes including type of appliance, history of re- occurring TMJ, andcopy of diagnostic sleep studies.Submit chart notes including type of appliance, history of re- occurring TMJ, andcopy of diagnostic sleep studies.Submit chart notes including type of appliance, history of re- occurring TMJ, andcopy of diagnostic sleep studies.Submit history and physical, documentation of medical necessity includingoperative report.Submit history and physical, documentation of medical necessity includingoperative report.Submit history and physical, documentation of medical necessity includingoperative report.Submit history and physical, documentation of medical necessity includingoperative report.Submit history and physical, documentation of medical necessity includingoperative report.Submit history and physical, documentation of medical necessity includingoperative report.Submit history and physical, documentation of medical necessity includingoperative report.Submit history and physical, documentation of medical necessity includingoperative report.Submit history and physical, documentation of medical necessity includingoperative report.Submit History and Physical, documentation of medical necessity includingoperative report.Submit History and Physical, documentation of medical necessity includingoperative report.Submit history and physical, documentation of medical necessity includingoperative report.eviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbs6
7CPT and HCPCScodes thatrequireauthorization225142251522520Description of procedure CodeMedical Records Request information requiredPERQ VERTEBRAL AUGMENTATIONPERQ VERTEBRAL AUGMENTATIONPERQ VERTEBRAL AUGMENTATION22521PERQ VERTEBRAL AUGMENTATION22523PERQ VERTEBRAL AUGMENTATION22524PERQ VERTEBRAL T SINGLE LEVELIDET 1 OR MORE LEVELSLAT LUMBAR SPINE FUSIONLAT THOR/LUMB ADDL SEGNECK SPINE FUSE&REMOV BEL C2ADDL NECK SPINE FUSIONNECK SPINE FUSIONLUMBAR SPINE FUSIONADDITIONAL SPINAL FUSIONNECK SPINE FUSIONLUMBAR SPINE FUSIONSPINE FUSION EXTRA SEGMENTLUMBAR SPINE FUSIONSPINE FUSION EXTRA SEGMENTLUMBAR SPINE FUSION COMBINEDSPINE FUSION EXTRA SEGMENTPOST FUSION /6 VERT SEG22802POST FUSION 7-12 VERT SEG22804POST FUSION 13/ VERT SEGeviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbsSubmit history and physical, documentation of medical necessity includingoperative report.Submit history and physical, documentation of medical necessity includingoperative report.Submit history and physical, documentation of medical necessity includingoperative report.Submit history and physical, documentation of medical necessity includingoperative report.eviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbsSubmit history and physical, operative report, documentation of conservativemeasures.Submit history and physical, operative report, documentation of conservativemeasures.Submit history and physical, operative report, documentation of conservativemeasures.Updated 9/27/20197
8CPT and HCPCS Description of procedure Codecodes thatrequireauthorization22808ANT FUSION 2-3 VERT SEGMedical Records Request information required22810ANT FUSION 4-7 VERT SEG22812ANT FUSION 8/ VERT 85422856228572285822859228612286222864INSERT SPINE FIXATION DEVICEINSERT SPINE FIXATION DEVICEINSERT SPINE FIXATION DEVICEINSERT SPINE FIXATION DEVICEINSERT SPINE FIXATION DEVICEINSERT SPINE FIXATION DEVICEINSERT SPINE FIXATION DEVICEINSERT PELV FIXATION DEVICEINSJ BIOMECHANICAL DEVICEINSJ BIOMECHANICAL DEVICECERV ARTIFIC DISKECTOMYCERV ARTIFIC DISKECTOMYSECOND LEVEL CER DISKECTOMYINSJ BIOMECHANICAL DEVICEREVISE CERV ARTIFIC DISCREVISE LUMBAR ARTIF DISCREMOVE CERV ARTIF DISC22865REMOVE LUMB ARTIF DISC2286722868228692287022999INSJ STABLJ DEV W/DCMPRNINSJ STABLJ DEV W/DCMPRNINSJ STABLJ DEV W/O DCMPRNINSJ STABLJ DEV W/O DCMPRNABDOMEN SURGERY PROCEDURESubmit history and physical, operative report, documentation of conservativemeasures.Submit history and physical, operative report, documentation of conservativemeasures.Submit history and physical, operative report, documentation of conservativemeasures.eviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbsRecent history and physical, plan of care, and documentation of medicalnecessity.Recent history and physical, plan of care, and documentation of medicalnecessity.eviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbsRecent history and physical, plan of care, and documentation of medical necessity.23000REMOVAL OF CALCIUM DEPOSITSeviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbsUpdated 9/27/20198
9CPT and HCPCScodes 347023472234732347427096Description of procedure CodeMedical Records Request information requiredRELEASE SHOULDER JOINTPARTIAL REMOVAL COLLAR BONEREMOVE SHOULDER BONE PARTREPAIR ROTATOR CUFF ACUTEREPAIR ROTATOR CUFF CHRONICRELEASE OF SHOULDER LIGAMENTREPAIR OF SHOULDERREPAIR BICEPS TENDONREMOVE/TRANSPLANT TENDONREPAIR SHOULDER CAPSULEREPAIR SHOULDER CAPSULEREPAIR SHOULDER CAPSULEREPAIR SHOULDER CAPSULEREPAIR SHOULDER CAPSULEREPAIR SHOULDER CAPSULERECONSTRUCT SHOULDER JOINTRECONSTRUCT SHOULDER JOINTREVIS RECONST SHOULDER JOINTREVIS RECONST SHOULDER JOINTINJECT SACROILIAC JOINTeviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 orhttps://www.evicore.com/healthplan/bcbsNo Prior Auth required for MT Medicare Advantage Plan effective L HIP REPLACEMENTTOTAL HIP ARTHROPLASTYTOTAL HIP ARTHROPLASTYREVISE HIP JOINT REPLACEMENTREVISE HIP JOINT REPLACEMENTREVISE HIP JOINT REPLACEMENTARTHRODESIS SACROILIAC JOINT27332EXC THIGH/KNEE TUM DEEP 5CMeviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbsPre Operative Evaluation, History and Physical including functional impairment,and Operative reporteviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbsUpdated 9/27/20199
10CPT and HCPCScodes 7430274382744027441274422744327445Description of procedure CodeMedical Records Request information requiredEXC THIGH/KNEE LES SC 3 CMREMOVE KNEE JOINT LININGEXC THIGH/KNEE LES SC 3 CMREPAIR OF KNEE CARTILAGEAUTOCHONDROCYTE IMPLANT KNEEOSTEOCHONDRAL KNEE ALLOGRAFTOSTEOCHONDRAL KNEE AUTOGRAFTREPAIR DEGENERATED KNEECAPREVISION OF UNSTABLE KNEECAPREVISION OF UNSTABLE KNEECAPREVISION/REMOVAL OF KNEECAPLAT RETINACULAR RELEASE OPENRECONSTRUCTION KNEERECONSTRUCTION KNEERECONSTRUCTION KNEEREVISION OF THIGH MUSCLESREVISE KNEECAP WITH IMPLANTREVISION OF KNEE JOINTREVISION OF KNEE JOINTREVISION OF KNEE JOINTREVISION OF KNEE JOINTREVISION OF KNEE JOINT2744627447274862748727557REVISION OF KNEE JOINTTOTAL KNEE ARTHROPLASTYREVISE/REPLACE KNEE JOINTREVISE/REPLACE KNEE JOINTTREAT KNEE DISLOCATION27558TREAT KNEE DISLOCATIONeviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or ve evaluation, history and physical including functional impairment,and operative report.eviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or https://www.evicore.com/healthplan/bcbseviCore - 1-855-252-1117 or ve evaluation, history and physical including functional impairment,and operative report.Pre-operative evaluation, history and physical including functional impairment,and operative report.Updated 9/27/201910 page
Code List references eviCore. For members attributed to Optum, preauthorization should be obtained from Optum, even if the applicable entry in the MAPD Benefit Preauthorization Procedure Code List references eviCore. Any entry that references eviCore should be preauthorized through eviCore except for members attributed to Optum.
May 02, 2018 · D. Program Evaluation ͟The organization has provided a description of the framework for how each program will be evaluated. The framework should include all the elements below: ͟The evaluation methods are cost-effective for the organization ͟Quantitative and qualitative data is being collected (at Basics tier, data collection must have begun)
Silat is a combative art of self-defense and survival rooted from Matay archipelago. It was traced at thé early of Langkasuka Kingdom (2nd century CE) till thé reign of Melaka (Malaysia) Sultanate era (13th century). Silat has now evolved to become part of social culture and tradition with thé appearance of a fine physical and spiritual .
On an exceptional basis, Member States may request UNESCO to provide thé candidates with access to thé platform so they can complète thé form by themselves. Thèse requests must be addressed to esd rize unesco. or by 15 A ril 2021 UNESCO will provide thé nomineewith accessto thé platform via their émail address.
̶The leading indicator of employee engagement is based on the quality of the relationship between employee and supervisor Empower your managers! ̶Help them understand the impact on the organization ̶Share important changes, plan options, tasks, and deadlines ̶Provide key messages and talking points ̶Prepare them to answer employee questions
Dr. Sunita Bharatwal** Dr. Pawan Garga*** Abstract Customer satisfaction is derived from thè functionalities and values, a product or Service can provide. The current study aims to segregate thè dimensions of ordine Service quality and gather insights on its impact on web shopping. The trends of purchases have
Chính Văn.- Còn đức Thế tôn thì tuệ giác cực kỳ trong sạch 8: hiện hành bất nhị 9, đạt đến vô tướng 10, đứng vào chỗ đứng của các đức Thế tôn 11, thể hiện tính bình đẳng của các Ngài, đến chỗ không còn chướng ngại 12, giáo pháp không thể khuynh đảo, tâm thức không bị cản trở, cái được
Le genou de Lucy. Odile Jacob. 1999. Coppens Y. Pré-textes. L’homme préhistorique en morceaux. Eds Odile Jacob. 2011. Costentin J., Delaveau P. Café, thé, chocolat, les bons effets sur le cerveau et pour le corps. Editions Odile Jacob. 2010. Crawford M., Marsh D. The driving force : food in human evolution and the future.
Le genou de Lucy. Odile Jacob. 1999. Coppens Y. Pré-textes. L’homme préhistorique en morceaux. Eds Odile Jacob. 2011. Costentin J., Delaveau P. Café, thé, chocolat, les bons effets sur le cerveau et pour le corps. Editions Odile Jacob. 2010. 3 Crawford M., Marsh D. The driving force : food in human evolution and the future.
