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.

Updated on

May 1, 2024
KEY

New Code Added

Listing of Prior Approval itens

  1. Continuous Passive Motion (CPM) Equipment

    Details

    See medical policy for Continuous Passive Motion (CPM) for more information.

    Secure prior approvals

    Prior Authorization Portal (via Provider Resource Center)

    State of Vermont Uniform Medical Prior Authorization Form

    CPT/HCPCS Code
    • E0935
    • E0936

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

    IBEW: Prior approval required for continuous passive motion equipment when the purchase price meets the dollar threshold indicated in the durable medical equipment listing.

  2. Radiology (Advanced Imaging)

    Coronary Fractional Flow Reserve (FFR)

    Secure prior approvals

    Carelon Medical Benefits Management (formerly AIM Specialty Health) reviews advanced imaging services. The ordering physician must submit the request through Carelon by phone at (800) 701-0080 or via their online portal.

    For Blue Cross VT and IBEW

     

    CPT/HCPCS Code
    • 75580
  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. Cosmetic and Reconstructive Services

    Cryotherapy for Acne

    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
    • 17340
  5. Genetic Testing & Other Pathology Services

    Cytogenetic Studies

    Details

    See medical policies for Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer, Cytochrome P450 Genotype-Guided Treatment Strategy

    Secure prior approvals

    Prior Authorization Portal (via Provider Resource Center)

    State of Vermont Uniform Medical Prior Authorization Form

    CPT/HCPCS Code
    • 88230
    • 88233
    • 88235
    • 88237
    • 88239
    • 88240
    • 88241
    • 88245
    • 88248
    • 88249
    • 88261
    • 88262
    • 88263
    • 88264
    • 88267
    • 88269
    • 88271
    • 88272
    • 88273
    • 88274
    • 88275
    • 88280
    • 88283
    • 88285
    • 88289
    • 88291
    • 88299

  6. 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)
  7. Cosmetic and Reconstructive Services

    Dermatologic Application of Photodynamic Therapy

    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
    • 96567
    • 96573
    • 96574
  8. Surgery

    Disc Arthroplasty

    Secure prior approvals

    Prior Authorization Portal (via Provider Resource Center)

    State of Vermont Uniform Medical Prior Authorization Form

    CPT/HCPCS Code
    • 22856
    • 22858
    • 22861
    • 22864
    • C9757
  9. Genetic Testing & Other Pathology Services

    Diseases and Other Medical Conditions

    Details

    See medical policies for Assays of Genetic Expression in Tumor Tissue as a Technique to Determine Prognosis in Patients with Breast Cancer, Cytochrome P450 Genotype-Guided Treatment Strategy

    Secure prior approvals

    Prior Authorization Portal (via Provider Resource Center)

    State of Vermont Uniform Medical Prior Authorization Form

    CPT/HCPCS Code
    • 0002M
    • 0003M
    • 0006M
    • 0007M

  10. 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