First Priority Health Authorizations (Self Funded)
Effective date November 1, 2011
CT Scans Requiring Precertification:
Proc Code
75571
75572
1-800-962-5353
Fax # (570) 200-6799
Description
Proc Code
Computed tomography, heart, without contrast material, with
quantitative evaluation of coronary calcium
Computed tomography, heart, with contrast material, for
evaluation of cardiac structure and morphology (including
3D image post processing, assessment or cardiac function,
and evaluation of venous structures, if performed )
MRI’s Requiring Precertification
1-800-962-5353
75574
Computed tomographic angiography, heart, coronary
arteries and bypass grafts (when present), with contrast
material, including 3D image post processing (including
evaluation of cardiac structure and morphology,
assessment or cardiac function, and evaluation of venous
structures, if performed )
Fax # (570) 200-6799
Proc Code
Description
Proc Code
70540
MRI Orbit, face and/or neck w/o dye
72157
70542
MRI Orbit, face and/or neck w/ dye
72158
70543
MRI Orbit, face and/or neck w/ and w/o dye
73218
70544
MRA Angiography Head w/o Dye
73221
70545
73222
MRA, head; w/dye
70546
73223
MRA, head; w/o dye and w/dye
70551
MRI Brain w/o Dye
73718
70552
MRI Brain w/ Dye
73721
70553
MRI Brain w/ and w/o Dye
73722
72141
MRI Neck Spine w/o Dye
73723
72142
MRI Neck Spine w/Dye
74181
72146
MRI Thoracic Spine w/o Dye
74182
72147
MRI Thoracic Spine w/ Dye
74183
72148
MRI Lumbar Spine w/o Dye
76390
72149
MRI Lumbar Spine w/ Dye
77058
72156
MRI Neck Spine w/ and w/o Dye
77059
The following additional Breast MRI HCPCS codes also require precertification: C8903,
Revised August 1, 2011
Description
Description
MRI Thoracic Spine w/ and w/o Dye
MRI Lumbar Spine w/ and w/o Dye
MRI Upper extremity, other than joint w/o dye
MRI Joint Upper Extremity w/o Dye (Shoulder requires notes*)
MRI Joint Upper Extremity w/Dye
(Shoulder requires notes*)
MRI Joint Upper Extremity w/and w/o Dye
MRI Lower extremity other than joint w/o dye
MRI Joint Lower Extremity w/o Dye
(Knee requires notes*)
MRI Joint Lower Extremity w/Dye
MRI Joint Lower Extremity w/ and w/o Dye
MRI Abdomen, w/o dye
MRI Abdomen, w/ dye
MRI Abdomen w/ and w/o dye
Magnetic Resonance Spectroscopy
MRI Breast w/ and w/o dye, unilateral (See addt’l breast MRI codes below)
MRI Breast w/ and w/o dye, bilateral (See addt’l breast MRI codes below)
C8904, C8905, C8906, C8907, C8908
**FOCUS Outpatient Procedure Precertification List 1-800-962-5353
Regardless of the setting - physician office, outpatient facility, or SPU
0075T
15830
TRNSCATH XTRACRAN
VERTB OR INTRATHOR ART
STNT PERQ; INITIAL
VESSEL
EXCISION, EXCESSIVE
SKIN AND SUBCUTANEOUS
TISSUE (INCLUDES
LIPECTOMY); ABDOMEN,
INFRAUMBILICAL
PANNICULECTOMY
Fax # (570) 200-6799
43845
GASTRIC RESTRICTIVE PROCEDURE WITH
PARTIAL GASTRECTOMY, PYLORUSPRESERVING DUODENOILEOSTOMY AND
ILEOILEOSTOMY
27415
OSTEOCHONDRAL
ALLOGRAFT, KNEE, OPEN
43846
GASTRIC RESTRICTIVE PROCEDURE, WITH
GASTRIC BYPASS FOR MORBID OBESITY;
WITH SHORT LIMB (150 CM OR LESS) ROUXEN-Y GASTROENTEROSTOMY
27599
UNLISTED PROCEDURE,
FEMUR OR KNEE (E.G.,
MENISCAL ALLOGRAFT
TRANSPLANTATION)
43847
WITH SMALL INTESTINE RECONSTRUCTION TO
LIMIT ABSORPTION
43848
43886
27412
AUTOLOGOUS CHONDROCYTE
IMPLANTATION, KNEE
21137
REDUCTION FOREHEAD;
CONTOURING ONLY
21138
REDUCTION FOREHEAD;
CONTOUR&APPLIC
PROSTH MATL/BN GFT
29866
SCOPE KNEE SURG IMPL
OSTEOCHONDRAL GFT;
AUTOGFT
21139
REDUCTION FOREHEAD;
CONTOUR&SETBACK
FRNTL SINUS WALL
29867
OSTEOCHONDRAL ALLOGRAFT
(E.G. MOSAICPLASTY)
21175
RECON BIFRONTAL ORBIT
RIMS&LO FOREHEAD W/WO
GFTS
29868
21179
RECON MAJORITY
FOREHEAD/SUPRAORBITAL
RIMS; W/GFT
30400
21180
RECON MAJORITY
FOREHEAD/SUPRAORB
RIMS; W/AUTOGFT
30410
21181
21182
21183
RECON CONTOUR BEN
TUMOR CRANIAL BONES
XTRACRAN
RECNSTR ORB FLW EXC
BEN TUMR; BN GFT < 40 SQ
CM
RECNSTR ORB FLW EXC
TUMR;BN GFT > 40 BUT<80
SQ CM
Revised August 1, 2011
30420
MENISCAL TRANSPLANTATION
(INCLUDES ARTHROTOMY FOR
MENISCAL INSERTION), MEDIAL
OR LATERAL
RHINOPLASTY, PRIMARY;
LATERAL AND ALAR
CARTILAGES AND/OR
ELEVATION OF NASAL TIP
RHINOPLASTY, PRIMARY;
COMPLETE, EXTERNAL PARTS
INCLUDING BONY PYRAMID,
LATERAL AND ALAR
CARTILAGES, AND/OR
ELEVATION OF NASAL TIP
RHINOPLASTY, PRIMARY;
INCLUDING MAJOR SEPTAL
REPAIR
REVISION, OPEN, OF GASTRIC RESTRICTIVE
PROCEDURE FOR MORBID OBESITY, OTHER
THAN ADJUSTABLE GASTRIC RESTRICTIVE
DEVICE (SEPARATE PROCEDURE)
GASTRIC RESTRICTIVE PROCEDURE, OPEN;
REVISION OF SUBCUTANEOUS PORT
COMPONENT ONLY
43887
REMOVAL OF SUBCUTANEOUS PORT
COMPONENT ONLY
43888
REMOVAL AND REPLACEMENT OF
SUBCUTANEOUS PORT COMPONENT ONLY
47370
LAPARSCPY SURG ABLAT 1/MORE LIVR TUMR;
RADIOFREQ
47371
LAPARSCPY SURG ABLAT 1/MORE LIVER
TUMR; CRYOSURG
30620
SEPTAL OR OTHER
INTRANASAL DERMATOPLASTY
47380
ABLATION OPEN 1/MORE LIVER TUMOR;
RADIOFREQUENCY
36470
INJECTION OF SCLEROSING
SOLUTION ; SINGLE VEIN
47381
ABLATION OPEN 1/MORE LIVER TUMOR;
CRYOSURGICAL
21184
RECNSTR ORB FLW EXC
BEN TUMR; BN GFT > 80 SQ
CM
36471
21208
OSTEOPLASTY FACIAL
BONES; AUGMENTATION
37204
21209
OSTEOPLASTY FACIAL
BONES; REDUCTION
37500
21256
RECONSTRUCTION ORBIT
W/OSTEOTOMIES&W/BONE
GRAFTS
43644
21270
MALAR AUGMENTATION
PROSTHETIC MATERIAL
43645
21275
SEC REVISION
ORBITOCRANIOFACIAL
RECONSTRUCTION
43770
21280
MEDIAL CANTHOPEXY-SEP
PROC
43771
21282
LATERAL CANTHOPEXY
43772
22220
OSTEOT SPN W/DISKECT
ANT APPRCH 1 VERT SEG;
CERV
22224
OSTEOT SPN W/DISKECT
ANT APPRCH 1 VERT SEG;
LUMB
22520
PERQ VERTPLSTY 1 VERT
BODY UNI/BIL INJ;
THORACIC
Revised August 1, 2011
43773
43774
43775
INJESTION SCLEROSING
SOLUTION ; MX VEINS SAME
LEG
TRANSCATH
OCCLUD/EMBOLIZAT PERQ
NON CNS/HEAD
VASCULAR ENDOSCOPY,
SURGICAL WITH LIGATION OF
PERFORATOR VEINS,
SUBFASCIAL (SEPS)
LAPAROSCOPY, SURGICAL,
GASTRIC RESTRICTIVE
PROCEDURE ; WITH GASTRIC
BYPASS AND ROUX-EN-Y
GASTROENTEROSTOMY (ROUX
LIMB 150 CM OR LESS)
WITH GASTRIC BYPASS AND
SMALL INTESTINE
RECONSTRUCTION TO LIMIT
ABSORPTION
LAPAROSCOPY, SURGICAL,
GASTRIC RESTRICTIVE
PROCEDURE; PLACEMENT OF
ADJUSTABLE GASTRIC
RESTRICTIVE DEVICE
REVISION OF ADJUSTABLE
GASTRIC RESTRICTIVE DEVICE
COMPONENT ONLY
REMOVAL OF ADJUSTABLE
GASTRIC RESTRICTIVE DEVICE
COMPONENT ONLY
REMOVAL AND REPLACEMENT
OF ADJUSTABLE GASTRIC
RESTRICTIVE DEVICE
COMPONENT ONLY
REMOVAL OF ADJUSTABLE
GASTRIC RESTRICTIVE DEVICE
AND SUBCUTANEOUS PORT
COMPONENTS
LAPAROSCOPY , SURGICAL ,
GASTRIC RESTRICTIVE
PROCEDURE , LONGITUDINAL
GASTRECTOMY ( IE, SLEEVE
GASTRECTOMY)
47382
ABLAT 1/MORE LIVER TUMOR PERCUT
RADIOFREQUENCY
55873
CRYOSURGICAL ABLATION OF THE PROSTATE
67900
REPAIR OF BROW PTOSIS
67906
REPR BLEPHAROPT; SUP RECTUS TECH
W/FASCL SLING
67908
REPR BLEPHAROPTOSIS; CONJUNC-TARSOMULLER’S
67909
REDUCTION OF OVERCORRECTION OF PTOSIS
67911
CORRECTION OF LID RETRACTION
91110
GASTROINTESTINAL TRACT IMAGING,
INTRALUMINAL (E.G., CAPSULE ENDOSCOPY),
ESOPHAGUS THROUGH ILEUM, WITH
PHYSICIAN INTERPRETATION AND REPORT
92974
TRNSCATH PLCMT RAD DEL DEVC SUBSQT
COR BRACHYTX
D7230
REMOVAL OF IMPACTED TOOTH – PARTIALLY
BONY ( INPATIENT SPU/ASC Only)
D7240
REMOVAL OF IMPACTED TOOTH –
COMPLETELY BONY (INPATIENT SPU/ASC Only)
22521
PERQ VERTPLSTY 1 VERT
BODY UNI/BIL INJ; LUMBAR
43842
22522
PERQ VERTPLSTY 1 VERT
BODY UNI/BIL INJ; EA ADD
43843
GASTRIC RESTRICTIVE
PROCEDURE, WITOUT
GASTRIC BYPASS, FOR
MORBID OBESITY; VERTICALBANDED GASTROPLASTY
OTHER THAN VERTICALBANDED GASTROPLASTY
D7241
REMOVAL OF IMPACTED TOOTH –
COMPLETELY BONY WITH UNUSUAL
SURGICAL COMPLICATIONS (INPATIENT
SPU/ASC Only)
G0166
EXTERNAL COUNTERPULSATION PER
TREATMENT SESSION
Precertification is not a guarantee of payment. The Utilization Management Department is not responsible for member eligibility or benefit information.
Providers are encouraged to check member eligibility/benefits prior to rendering service.
First Priority Health Self Funded Authorizations

A Prior Authorization, Non-participating Authorization, or Precertification is not a guarantee of payment by FPH. The authorization is for medical necessity
as long as it is a benefit for the member.
Prior Authorization is required for:


Emergency Room services if directed to the ER by the Primary Care Physician or BlueCare HMO in advance of service and the service could have been
provided at the PCP office.
All services by non-participating providers
Check member eligibility/benefits prior to any service by accessing NaviNet or by calling Provider Services Unit at 1-800-822-8752, Monday through Friday, 8:00
a.m. to 5:00 p.m.
Non-participating Authorizations are required for all services by non-participating specialists and/or facilities.




Medical Director approval is required prior to services being rendered. No authorizations will be approved retroactively.
Request may be made by either the network specialist or the PCP, using the appropriate form or by phone to 1-800-962-5353
All requests must contain complete information; You will be notified if additional information is required.
Please use only BlueCard providers (www.bcbs.com “Find doctors or hospitals nationwide”)
Fax completed forms & necessary documentation to (570) 200-6840
Precertification is required for:
Phone # 1-800-962-5353
Fax # (570) 200-6799

Inpatient admissions to: Acute Care, Rehab. and Skilled Nursing facilities

Home Health Visits

Home Health Therapy Services (Physical, Occupational, Speech Therapy) effective with group renewals beginning 07/01/2008
Revised August 1, 2011

All PET Scans

*MRI / MRA – (See procedure list)

**Select Surgical Procedures. (See procedure list)

Select CT Scans (See procedure list)

All transplant surgeries

Inpatient Behavioral Health Care Services for the following ICD-9 diagnosis codes: 290 – 319 require precertification. For Outpatient services please
verify precertification requirements by calling Community Behavioral Healthcare of Northeastern Pa (CBHNP) at 1-800-577-3742.
Managed Pharmacy Program:
1-800-722-4062
Fax #: (570) 200-6870

Home Infusion Services - TPN, IVIG, Enteral feedings, Neupogen given intravenously, and Rocephin for Lyme disease require approval through the FPH Pharmacy

Department via the Prior Authorization form.
Refer to formulary for the current list of drugs requiring prior authorization – www.bcnepa.com
Revised August 1, 2011