Prior Authorization

Always check benefits through the Voice Response Unit (VRU) or My Insurance ManagerSM to determine if prior authorization is required.

Prior authorization is a process used to determine if a requested service is medically necessary. Currently, Medicare Advantage requires prior authorization for the following services:

Durable medical equipment $250 or more (including powered mobility)
E0250 E0251 E0290 E0291 E0255
E0256 E0292 E0293 E0260 E0261
E0294 E0295 E0265 E0266 E0296
E0297 E0301 E0304 E0766 E2402
E0986 K0013 K0800 K0898 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 L0456 L0464 L0482 L0637
L0650 L0651 L0648 L2036 L0488
L0631 L1852 L0486 L1843 L0457
L1851 L1950 L1970 L1932 L1833
L1951 L1832 L2385 L0472 L1845
L1990 L0627 L0642 L2624 L1971
L1970 L1945 L1846 L1960 L2280
L2114 L1850 L2260 L2330 L5856
L5973  
All inpatient admissions

Note: Inpatient admissions also require review if a continued stay is necessary.

Dialysis treatment (initial)
Non-emergent transportation
Medications covered under Medicare Part B including, but not limited to visco-supplementation for knee osteoarthritis (hyaluronan), monoclonal antibody treatments and other biologicals for multiple sclerosis, rheumatoid arthritis, psoriasis, inflammatory bowel disease, or chronic migraines
J1756 - Iron Sucrose J0897 - Denosumab
J7323 - Euflexxa J7321 - Hyalgan/Supartz
J0885 - Epoetin alfa J7324 - Orthovisc
J1561 - Gamunex-c/Gammaked J1569 - Gammagard
J1459 - Privigen J1745 - Infliximab
Q5115 - Truxima J2916 - Na Ferric Gluconate
J0717 - Certolizumab Pegol J1750 - Iron Dextran
J7327 - Monovisc J7605 - Arformoterol
J0178 - Aflibercept J2778 - Ranibizumab
J1439 - Ferric Carboxymaltos J2274 - Morphine
J9312 - Rituximab Q0138 - Ferumoxytol
J7325 - Synvisc/Synvisc-one J0881 - Darbepoetin alfa
J1568 - Octagam J0517 - Benralizumab
J2350 - Ocrelizumab J2357 - Omalizumab
J2182 - Mepolizumab J1300 - Eculizumab
J7312 - Dexamethasone intra J9035 - Bevacizumab
J0585 - Onabotulinumtoxina J3489 - Zoledronic acid
J2278 - Ziconotide J1602 - Golimumab
J9204 - Mogamulizumab-kpkc J2323 - Natalizumab
J0129 - Abatacept  
Continuous glucose monitors
K0553 K0554
Facility-based polysomnography
95807 95808 95810 95811
Bariatric surgery
43644 43645 43770 43845 43846
43847 43775  
Inpatient level of care for non-emergency surgery
Behavioral health services

Note: Behavioral health services are managed by Companion Benefit Alternatives (CBA), a separate company that offers behavioral health benefits on behalf of BlueCross BlueShield of South Carolina.

Life Vest – external cardiac defibrillators
K0606 K0607 K0608 K0609 93745
Trans-catheter aortic valve replacement
Testosterone replacement
J1071 J3121 J3145 J3490 S0149
11980  
Pneumatic compression devices
E0650 E0651 E0652 E0655 E0656
E0657 E0660 E0665 E0666 E0667
E0668 E0669 E0670 E0671 E0672
E0673 E0675  
IV iron therapy
J1439 J1756 J2916 Q0138
Spinal cord stimulators for chronic pain
63650 63655 63661 63662 63663
63664 63685 63688 95970 95971
95972 L8680  
Left atrial appendage closure devices
33340 33267 33268 33269 33999
Electronic bone growth stimulators
20975 E0747 E0748 E0749 E0760

 

Beginning July 1, 2022, the following service will be included in the prior authorization requirements:

  • Recurring outpatient nerve stimulation treatments specifically including, but not limited to electrical nerve stimulation treatments carried out with or without injections of anesthetic agents and/or nutritional supplements or vitamins, like the RST Sanexas system

 

Beginning Aug. 1, 2022, the following service will be included in the prior authorization requirements:

  • Amniotic products for non-ophthalmic conditions
  • Pelvic floor stimulation
  • Transcutaneous electrical nerve stimulation (TENS) unit

 

You can view the medical policies for all the above-mentioned services here.

Laboratory Services

As of April 25, 2022, the following services require prior authorization for our Medicare Advantage plans through Avalon Healthcare Solutions.

81162 81163 81164 81165 81166
81167 81206 81207 81212 81215
81216 81217 81225 81226 81227
81231 81235 81236 81237 81272
81273 81275 81276 81292 81293
81294 81295 81296 81297 81298
81299 81300 81301 81307 81308
81310 81311 81314 81317 81318
81319 81321 81322 81323 81400
81401 81402 81403 81404 81405
81406 81407 81408  

Methods for requesting prior authorization

Medical services

Behavioral health services

Laboratory services

  • PAS Portal – Avalon's prior authorization system (PAS). If you do not have an account, request one here.
  • Phone: 844-227-5769
  • Fax: 813-751-3760 – Submit the Preauthorization Request Form along with supporting documentation.

Avalon’s Laboratory Network

Avalon also manages a network of labs. Our members pay less out of pocket when you use network labs than for non-network labs. So, we urge you to use participating laboratories, when possible. 

Interested in enrolling in our lab network? Go to the Avalon website to get started. This link leads to a third party site. That company is solely responsible for the contents and privacy policies on its site.

 

Avalon Healthcare Solutions is an independent company that manages lab benefits on behalf of BlueCross BlueShield of South Carolina and BlueChoice HealthPlan.

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