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
KEY

New Code Added

Listing of Prior Approval itens

  1. 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): $500 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