Prior Approval Database

Search by CPT® or HCPCS code, or the name of the item to find services, equipment and supplies that need prior approval. If the service and applicable CPT® or HCPCS code appears below, we require prior approval even if the plan is secondary to another carrier, including Medicare.

Unless otherwise indicated, the following health plans do not require prior approval for the services within this database:

  • The State of Vermont Total Choice Plan (prefix FVT) 
  • Vermont Blue65 and Vermont Medigap Blue supplement plans (prefix ZIB)

This database applies to the following health plans:

  • Blue Cross Vermont (Note: Blue Cross VT includes Access Blue New England (ABNE), New England Health Plan (NEHP), and The Vermont Health Plan)
  • International Brotherhood of Electrical Workers (IBEW Local 300)
  • The State of Vermont (Administrative Services Only)

Prescription drugs: Please note that prescription drugs requiring prior approval are not listed in this database. Please refer the Vermont Blue Rx Center for drugs requiring prior approval. For State of Vermont plans, contact the pharmacy benefits manager for information.

Prior approval requirements and member benefits vary according to the member’s group or individual contract. Not all groups are required to follow the Vermont legislative mandates, and member contract language takes precedence over medical policies or the prior approval database when there is a conflict. Please verify member benefits prior to rendering services.

Clarifications

  • ABNE and NEHP members: requirements only apply when members have primary care providers (PCPs) located in Vermont. For members with Vermont PCPs, the member’s Home Plan may manage mental health and pharmacy/mail order prescription drugs requirements and reviews.
  • Federal Employee Program (FEP) members have separate prior approval or referral authorization
    requirements. Please see separate lists for details.

Not Reviewed Definition

‘Not Reviewed’ in the database listings denotes that prior approval is not reviewed. Please verify member benefits prior to rendering services. A 'Not Reviewed' notation does not indicate that the service is covered.

 

Additional Information

We supply this database as a quick reference only. Codes appearing in this database may not be all inclusive. AMA and CMS code updates may occur more frequently than policy updates.

Search the Prior Approval Database

Search by code or name, or select the name of the service, equipment of supplies that need prior approval

Search by Code

Enter the CPT® or HCPCS code you're looking for. If no results are found, search All to expand your results.

Search by Category

Select the category you’re looking for (i.e., Radiology). If no results are found, use the Search by Name area below.

Search by Name

Find the services, equipment, or supplies you’re looking for. Note that the name may not be the same as a CPT®/HCPCS descriptor.

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Updated on

May 1, 2024
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New Code Added

Listing of Prior Approval itens

  1. Autism-Spectrum-Disorder-Related Occupational, Physical, and Speech Therapy

    For additional visits beyond the defined benefit limit.

    Details

    See medical policies for Occupational Therapy, Physical Therapy Medicine, and Speech Language Pathology/Therapy Services for more details.

    Secure prior approvals

    Prior Authorization Portal (via Provider Resource Center)

    State of Vermont Uniform Medical Prior Authorization Form

    When benefits apply

     

    CPT/HCPCS Code
    • All

    New England Health Plan / Access Blue New England: Prior approval not reviewed.

  2. Chiropractic Services

    After 12 initial visits

    Details

    See medical policy for Chiropractic Services for more information.

    Secure prior approvals

    Prior Authorization Portal (via Provider Resource Center)

    State of Vermont Uniform Medical Prior Authorization Form

    CPT/HCPCS Code
    • All

    New England Health Plan / Access Blue New England: Prior approval not reviewed.

  3. Cosmetic and Reconstructive Services

    Cosmetic and Reconstructive Services

    Details

    See medical policy for Cosmetic and Reconstructive Procedures for more information.

    Secure prior approvals

    Prior Authorization Portal (via Provider Resource Center)

    State of Vermont Uniform Medical Prior Authorization Form

    CPT/HCPCS Code
    • All

    Refer to individual listing items under the Cosmetic and Reconstructive Services Category (use the Search by Category box above) for more details on specific codes/listings (list is not all-inclusive).

    When benefits apply

  4. Dental Services

    Details

    See medical policy for Dental Services for Accidental Injury, Gross Deformity, Head and Neck Cancers, and Congenital/Genetic Disorders for more information.

    Even with prior approval, benefits are limited. Certain services may not be covered.

    Pediatric dental services are provided through CBA Blue, when applicable. See medical policy for Pediatric Dental Services or contact the customer service team for more information.

    Secure prior approvals

    Prior Authorization Portal (via Provider Resource Center)

    State of Vermont Uniform Medical Prior Authorization Form

    We review only the following dental services under the medical benefit:

    • Treatment for, or in connection with, an accidental injury to jaws, sound natural teeth, mouth or face, provided a continuous course of dental treatment begins within six months of the accident.
    • Surgery to correct gross deformity resulting from major disease or Surgery (Surgery must take place within six months of the onset of disease or within six months after Surgery, except as otherwise required by law).
    • Surgery related to head and neck cancer where sound natural teeth may be affected primarily or as a result of the chemotherapy or radiation treatment of that cancer.
    • Treatment for a congenital or genetic disorder. Treatment for a congenital or genetic disorder, such as but not limited to the absence of one or more teeth, up to the first molar, or abnormal enamel (example lateral peg).

    Facility and anesthesia charges for members who are:

    • with phobias or mental illness documented by a licensed physician or mental health professional; OR
    • with disabilities that preclude office-based dental care due to safety considerations; OR
    • who are developmentally unable to safely tolerate office-based dental care
    CPT/HCPCS Code
    • All

    Exception: No PA for bone-impacted wisdom teeth when benefits apply.

    No PA for the following:

    • Lesion excision/destruction (D7286, D7413, D7414, D7415, D7440, D7441)
    • Lesion excision/biopsy of lips (40490)
    • Lesion excision/biopsy of mucosa (40810, 40812, 40814, 40816)
    • Lesion excision/biopsy of vestibule of mouth (40808, 40818, 40820)
    • Lesion excision/biopsy of tongue (41100, 41105, 41110, 41112, 41113, 41114)
    • Lesion excision/biopsy of floor of mouth (41108, 41116)
    • Lesion excision/biopsy of dentoalveolar structures (41800, 41825, 41826, 41827)
    • Glossectomy (41120, 41130, 41135, 41155)
    • Frenectomy of uvula (40819)
    • Biopsy of the uvula (42100, 42104, 42106, 42107)
    • Biopsy of salivary glands (42400, 42405)

  5. Durable Medical Equipment (DME), Medical Supplies (including rentals), Orthotics and Prosthetics

    Details

    See corporate medical policies on Medical Equipment and Supplies – Durable Medical Equipment (DMEPOS) and Supplies or Medical Equipment and Supplies – Prosthetics and Orthotics for more information.

    Additionally, see service-specific medical policies when appropriate.

    Secure prior approvals

    Prior Authorization Portal (via Provider Resource Center)

    State of Vermont Uniform Medical Prior Authorization Form

    Prior approval is required when the purchase price is over the following dollar thresholds:

    • Blue Cross VT: $500 or more
    • IBEW: $3,500 or more
    • State of VT (including SOV Total Choice): $250 or more

     

    CPT/HCPCS Code
    • All

    Exception: No PA required for urinary catheters and supplies, ostomy supplies, oxygen and oxygen-related supplies, insulin pump supplies, certain breast prosthetics for patients with a diagnosis of breast cancer, and cranial/scalp/wig prostheses.

    Exception: No PA required for the following hand splints: L3702, L3760, L3763, L3764, L3808, L3921

    Exception: When benefits apply, hearing aids do not require PA regardless of purchase price.

    State of VT (including SOV Total Choice): Additional coverage applies for the following shoe insert orthotics, and prior approval is required when the purchase price is $500 or more: A5501, A5513, L3000, L3001, L3002, L3003, L3010, L3020, L3030, L3031, L3070, L3080, L3090, L3201, L3202, L3203, L3204, L3206, L3207, L3215, L3216, L3217, L3219, L3221, L3222, L3224, L3225, L3230, L3250, L3251, L3252, L3253

    State of VT Total Choice (FVT): Prior approval required for durable medical equipment and supplies as indicated within this list.

    See separate listings in this database for additional prior approval needs for:

    • Continuous Glucose Monitoring Systems
    • Continuous Passive Motion Equipment
    • Electrical and Ultrasound Stimulation
    • Enteral Formulae and Total Parenteral Nutrition
    • Home Infusion Therapy
    • Hospital Beds and Accessories
    • Medical Nutrition for Inherited Metabolic Diseases
    • Miscellaneous DME, Orthotics and Prosthetics
    • Positive Airway Pressure Devices (APAP, BiPAP, CPAP)
    • Vision Services and Medical Coverage for Ocular Disease
    • Wheelchairs

  6. Gender Affirming Services

    Details

    See medical policy for Gender Affirming Services for more information.

    Secure prior approvals

    Prior Authorization Portal (via Provider Resource Center)

    State of Vermont Uniform Medical Prior Authorization Form

    CPT/HCPCS Code
    • All

    Exception: No PA required for orchiectomy, hysterectomy, or salpingo-oophorectomy.

  7. Hospital Beds and Accessories

    Secure prior approvals

    Prior Authorization Portal (via Provider Resource Center)

    State of Vermont Uniform Medical Prior Authorization Form

    PA required for hospital bed accessories when the purchase price meets the dollar threshold indicated in the durable medical equipment section.

     

    CPT/HCPCS Code
    • All

    State of VT Total Choice (FVT): Prior approval required.

    IBEW: Prior approval required for hospital beds when the purchase price meets the dollar threshold indicated in the durable medical equipment section.

  8. Intensive Outpatient Services (IOP)

    For mental health and substance use disorder

    Secure prior approvals

    Prior Authorization Portal (via Provider Resource Center)

    State of Vermont Uniform Medical Prior Authorization Form

    Prior approval will be waived if the rendering provider/facility is contracted with Blue Cross VT.

    Non-emergency, as noted

     

    CPT/HCPCS Code
    • All

    New England Health Plan / Access Blue New England: Prior approval not reviewed.

  9. Out of Network Providers and Facilities

    Details

    See medical policy for Out-of-Network Services Claims Processing Policy and Procedure for more information.

    Secure prior approvals

    Prior Authorization Portal (via Provider Resource Center)

    State of Vermont Uniform Medical Prior Authorization Form

    CPT/HCPCS Code
    • All

    You may only request prior approval for the following:

    • There is not a network provider with appropriate training and experience to provide the medically necessary services needed to meet the particular health care needs of a member; or
    • When a member already temporarily lives, works, or attends school or otherwise already temporarily lives outside of the service area at the time of the request and treatment cannot be delayed.

    All other out-of-network services are not covered or are subject to the out-of-network or non-preferred benefit in effect at the time of service based on the member’s benefit plan. Prior approval requirements remain in effect for all other services on this list.

    New England Health Plan: Referral required for services outside the state of Vermont but within New England. For services outside of New England, prior approval is required.

     

  10. Out of State Inpatient Care

    For facilities that are not contracted with Vermont

    Secure prior approvals

    Prior Authorization Portal (via Provider Resource Center)

    State of Vermont Uniform Medical Prior Authorization Form

    CPT/HCPCS Code
    • All

    Exception: No review required for services when another carrier is primary, unless the service is found elsewhere on this list.

    New England Health Plan: Prior approval required for all inpatient services outside of Vermont.