Providers | Blue Shield of California Promise Health Plan

Prior Authorization List

The “Prior Authorization List” is a list of designated medical and surgical services and select prescription Drugs that require prior authorization under the medical benefit. The list below includes specific equipment, services, drugs, and procedures requiring review and/or supplemental documentation prior to payment authorization.

Members and providers are encouraged to obtain prior authorization and may call Member Services to inquire about the need for prior authorization. While the list below covers the medical services, drugs, and procedures that require authorization prior to rendering; Blue Shield of California Promise Health Plan may require additional information after the service is provided.

If further information is required to process the payment Blue Shield of California Promise Health Plan’s Claims department will reach out and will request the specific information at that time. Before providing service please contact Member Services or access the provider website to verify the service is a covered benefit.

Blue Shield of California Promise Health Plan Providers

Prior authorization for the services listed below is highly recommended. Refer to your provider manual for more information on obtaining prior authorization review. If authorization was not obtained prior to the service being rendered, the service will likely be reviewed for medical necessity at the point of claim.

Please include medical records when you are ready to submit for claim payment, review our medical policies, and verify the service is a covered benefit online through our provider connection website or contact Member Services. If prior authorization was obtained and you are submitting an offline (i.e. paper) claim, remember to attach a copy of the prior authorization letter.

SpecialtyServicesProcedure (CPT) Code
Consult99203, 99204, 99205, 99243, 99244, 99245, 99215
Supplies99070
Spirometry94010, 94060
Anesthesia (Dental)Anesthesia services for dental proceduresANES, Z7500
Consultation99203, 99204, 99205, 99243, 99244
Follow up visits up to x 399213-99214, 99215
Hearing Testing92550, 92553, 92555, 92556, 92557, 92565, 92582, 92587, 92588
Tympanometry92567, 92568, 92550
Visual Reinforcement Audiometry (VRA)92579
Evoked Auditory Test92587, 92558
Nerve Conduction Test95908
Pure Tone Audiometry92552
Hearin Quality Analysis92524
Consults99203, 99204, 99205, 99243, 99244
Stress Test and Holter Monitors93015/93234
EKG93000, 93005, 93010
Echocardiogram93306, 93000, 93325, 93303, 93320
TTE93351
Follow up visits up to x 399213-99214, 99215
Breathing Capacity94010
Evaluation of Wheezing94060
Heart Cath93451, 93453, 93456, 93457, 93460, 93461
pm device program eval93279, 93280. 93288, 93283, 93289, 93290
Pacemaker Checks93732
Oxygen Saturation94760
Doppler Studies93880, 93926, 93971
DietaryConsultAll Codes
Consult
Exclusions: Nurse
MUST review:
1. Dx of: Acne, Alopecia, Keloid scars
2. Dermatology referral requests from Antelope Valley
99203, 99204, 99205, 99243, 99244
Follow up visits up to x 399213, 99214, 99215
Destruction of skin lesions17111, 17108, 17999
Removal of skin tags11200, 11201
Shave Lesion, Tray11310, 11301, A4550, 11302, 11306, 11307
Inject Skin Lesions11901, J3301, 11900
Biopsy11100, 11101, 19802, 19802, A4215, A4550, A4649, 20206, 60100, 38505, 42400
Wound debridements11056, 11055, 11042, 97568, 97597
Consult99203, 99204, 99205, 99243, 99244
Follow up visits up to x 399213, 99214, 99215
Blood Glucose Test82948, 82962
Consult99203, 99204, 99205, 99243, 99244
Follow up visits up to x 399213, 99214, 92557, 99215
Tympanometry92567, 92550
Ear Microscopy92504
Hearing Testing92557
Diagnostic Laryngoscopy31575
Nasal Endoscopy31231
Hearing Exam Codes92553, 92555, 92556, 92557, 92565, 92568, 92579, 92582, 92587, X4500
Control of Nose Bleed30901, 30902, 30903
Evaluation of Speech92521, 92522, 92523, 92506, 99354, 99355
Consult99203, 99204, 99205, 99243, 99244, 99245
Follow up visits up to x 399213, 99214, 99215
Colonoscopy45381, 45384, 43450, 48385
Abdominal Paracentesis49080
Consult99203, 99204, 99205, 99243, 99244, 99245
Follow up visits up to x 399213, 99214, 99215
Circumcision54150, 54160, 54161
Colonoscopy45378 to 45380 (Biopsy single or more)
Endoscopy43235 to 43239 (Biopsy single or more)
POH WITH APPROVAL FROM IPAZ7500
Surgical Procedures:(e.g. Lap chole, hysterectomy, hernia repair, etc.)
Infectious DiseaseConsult99203, 99204, 99205, 99243, 99244, 99245
Follow Up visits up to x399213, 99214, 99215
GentamicinJ1580
PICC Line Insertion36569
Chemotherapy (Outpatient)
Injectables
Consult99203, 99204, 99205, 99243, 99244
Follow up visits UP TO x899213, 99214, 99215
CBC85025
Home HealthSkilled ServicesG0162, G0154, G0299, G0300, G0151, G0159, G0152, G0160, G0153, G0156, G0155, S9123, S9124, Z5834, Z5835
Home Infusion MedicationInitial & Follow Ups x 3 monthsALL MEDICATIONS CODES ONLY
Home Infusion Per Diem SuppliesInitial & Follow Ups x 3 monthsS5035, S5036, S5108, S5109, S5110, S5111, S5115, S5116, S5180, S5181, S5497, S5498, S5501, S5502 S5517, S5518, S5520, S5521, S5522, S5523, S9061, S9097 S9098, S9122, S9123 S9124, S9127, S9128, S9129, S9131, S9208, S9209, S9211, S9212, S9213, S9214, S9325, S9326, S9327, S9328, S9329, S9330, S9331, S9335, S9336, S9338, S9339 S9340, S9341, S9342, S9343, S9345, S9346, S9347, S9348, S9351, S9353 S9355, S9357, S9359, S9361, S9363, S9364, S9365, S9366, S9367, S9368, S9370, S9372, S9373, S9374, S9375, S9376, S9377, S9379, S9474, S9490, S9494, S9497, S9500, S9501, S9502, S9503, S9504, S9537, S9538, S9542, S9559, S9560, S9562, S9590 99601 99602
Wound Care SuppliesInitial & Follow Ups x 3 monthsA4217, A4927, A6452, A4406, A4407, A4385, A4409, A4411, A4412, A4413, A4415, A4416, A4417,A4418, A4419, A4420, A6010, A6021, A6022, A6154, A6196, A6197, A6199, A6203, A6204, A6205, A6206, A6207, A6208, A6209, A6210, A6211, A6212,A6213, A6214, A6215, A6216, A6217, A6218, A6219, A6220, A6221, A6222,A6223, A6224, A6228, A6229, A6230,A6231, A6232, A6237, A6238, A6239, A6240, A6241, A6243, A6244, A6245, A6246, A6247, A6248, A6251, A6252,A6253, A6254, A6255, A6256, A6257, A6258, A6259, A6261, A6262, A6266,A6402, A6403, A6404, A6407, A6410,A6411, A6442, A6443, A6444, A6445, A6446, A6447, A6449 A6453, A6455, A6457
Medical SuppliesInitial & Follow Ups x 3 monthsA4216, A4310, A4314, A4322, A4326, A4332, A4338, A4351, A4353, A4354, A4358, A4367, A4371, A4385, A4394, A4406, A4409, A4419, A4425, A4450, A4452, A4456, A4554, A5061, A5120, A5051, A5052, A5053, A5054, A5055, A5056, A5057, A5061, A5062, A5062, A5063, A5071, A5072, A5073, A5081, A5082, A5083, A5093, A5105, A5112, A5113, A5200,
Hospice Room & BoardInitial & Follow Up x 6 Months658
NephrologyConsult99203, 99204, 99205, 99243, 99244
Follow up visits99213, 99214, 99215
Dialysis
NeurologyConsult99203, 99204, 99205, 99243, 99244, 99245
Follow up visits99213, 99214, 99215
All Diagnostic Testing
Nutritional Counselling (New) Z5020
OB High Risk or perinatalTotal Care (non-high risk OB visits 4x or more until delivery plus 6 weeks post partum)59400, 59401, 59402, 59403, 59404, 59405, 59406, 59407, 59408, 59409, 76825, 59025, Z codes; CPSP
PCP requesting multiple ultrasounds (Normal OB)
Rhogam shots (part of total OB care) Automatic approval for all Rh negative momsG8809, G8810
Routine US and NST's (part of total OB care)76801, 76805, 76813, 76816; 76817, 76820, 59025
Nucal Translucent (7-14 weeks gestation) 1st trimester screening (State Mandated) This is not High Risk and will be done by Perinatologist.76801, 76813, 99243, 99203
Consult99244, 99215
Breath Recording Infant94772
Alpha-Fetoprotein82105
Post Partum CheckZ1038
OB High RiskPerinatology (HROB only) initial consult: HTN, Diabetes, GDM, PIH, Hyper/Hypo thyroidism, cardiac, seizure disorder99243 or 99203
Perinatology (HROB only) follow-up visits:
BPP (76818 & 76819), AFI (82143)BPP (76818 & 76819) AFI (82143)
Multi -NSTs, US
Genetc Testing
Members in CM w/ HROB
Fetal Echo93325
Fetal Ultrasound76805, 76811
Advanced Maternal Age
Fetal MRI
Occupational TherapyOT EvaluationAll Codes
OT Therapeutic Exercise Initial up to 12All Codes
OT Therapeutic Exercise Additional Treatments after 12All Codes
OptometryComprehensive eye exam/glasses ( EOC per County)92004, V2020, 92340, 92341
OphthalmologyFollow up visits up to x 392020, 99213, 99214, 99215
Echo Exam of Eye76512, 76514, 76519
Visual Field Exam92083
Computerized Scanning92133, 92134
Refraction Determination92015 (mcal only)
Special Eye Eval92060, 92225, 92226
Eye Exam with Photos92235, 92250
Serial Tonometry92100
Injection65800
OrthopedicEMGAll Codes
Cast Removal29705
Pain ManagementFollow up visits x 699212, 99213, 99214, 99215
Drug test x 6g0477
Drug Testing Mult ClassesG0431
Physical TherapyPT Therapeutic Exercise Initial up to 12All Codes
PT Therapeutic Exercise Additional Treatments after 12All Codes
Aquatic TherapyAll Codes
PodiatryConsult x 2 f/u (other Dx)99202, 99203, 99204, 99205, 99244, 99245
Psychology/Psychiatry: /Medicare- to BEACON Medi- Cal -San DiegoCOUNTY OR LA County Mental HealthConsult/Therapy, ABAMust Be sent Beacon
PulmonologyConsult99202, 99203, 99204, 99205, 99244, 99245
Follow up visits up to x 399213, 99214, 99215
Sleep Study95810
PFT'S94060, 94664, 94726, 94729, 95831
Pulse Oximetry94760
Breathing Capacity94375, 94010
Pulmonary Stress Test94621, 63300
Blood Gases82810
Hempglobin85018
Radiation Therapy ALL
RheumatologyConsult99202, 99203, 99204, 99205, 99244, 99245
Follow up visits up to x 399213, 99214, 99215
Radiology/ Imaging/ ScansArterial Doppler93925
Bone Scan78300, 78306, 77080
Carotid Duplex93880
CT Scans
Dexa Scan (Above 65)77080, 77081
Doppler93971
ECHO GIUDE FOR BX76942
Echocardiogram93306, 9332, 93303, 93320
EXTREMITY ULTRASOUND93970
Mammogram77051, 77055, 77056, 77057, 76642, g0206
Computer Dx Mammogram77051
Diagnostic Mammo Produc DirG0204
MRIany codes for mri
MUGA78472
PET ScanALL
Plain films (1 to 3 views)70110, 70140, 70160, 70360, 70200, 70210, 70220, 70260, 71010, 71020, 71030, 71101, 71111, 71120, 71030, 72040, 72050, 72070, 72100, 72110, 72190, 72202, 72220, 72072, 72090, 73000, 73030 73060, 73090, 73092, 73110, 73130, 73140, 74455, 73510, 72520, 73562, 73590, 73552, 73564, 73565, 74000, 73610, 73630, 73650, 74220, 74230, 76080, 77057
Radiation TherapyALL
Ultrasound Soft Tissue76999
Speech TherapyPediatric (Also refer for Linked Services)All Codes
AdultAll Codes
UltrasoundsAbdominal Ultrasound - RUQ pain74290, 74291, 76700, 76705
Breast Ultrasound- breast massG0206, 77641, 76645, 76642, 76641
Pelvic Ultrasound - pelvic pain76856, 76857, 76830
Scrotal Ultrasound for mass/pain76870
Head/neck Ultrasound76536
Extremity Study76775, 93970
Venous Doppler93970, 93923, 93925
Thyroid76700, 76705, 78006
Extracranial study93880
Retroperitoneal76770
Renal Ultrasound76770
2D Echo93306
Transrectal Ultrasound76872
Soft Tissue Ultrasound76999
UrologyConsult99202, 99203, 99204, 99205, 99244, 99245
Follow up visits up to x 399213, 99214, 99215
VasectomyZ9780
Bladder scan (ultrasound)51798
Electro-Uroflowmetry51741
Bladder Irrigation51700
Bladder Catheter Insertion51703
Bladder Catheter Change51703
URINE CAPACITY51703
Urinalysis51703
Vascular SurgeryConsult99202, 99203, 99204, 99205, 99244, 99245
Follow up visits up to x 399213, 99214, 99215
Durable Medical EquipmentNew Request ($150 and below)
Extension or Renewal
CaneE0100
CPAP Supplies Per AllowableAll codes
**WHEN CPAP APPROVED
Incontinent Supplies Per AllowableA4332, A6250, A7927
Diapers & Liners Per AllowableT4525, T4526, T4527, T4535, T4536, T4537, T4541
Indwelling Catheter Per AllowableA3353, A4351
Diabetic ShoesL3030,L3221,L2999, L3215, A5500 x2
Shoe InsertsA5512 x 6 /year
Special Formula - Premature Infants
Glucometers/Lancets & Test Strips (Advanced Diabetic Supply)Glucometer - E0607 / Lancets - A4259
Hearing AidMEDICAL ONLY
Hearing Aid RepairV5014 UP TO X4-MEDICAL ONLY
Medical Supplies
Nebulizer (Asthma) J44 CODESE0570
Ostomy Skin Barrier Per AllowableA4371
Ostomy Supplies Per AllowableAll codes
Orthoticany "L" code
Wrist BraceL3908
Procrit-Epogen Injections
Prosthetic
Synagis InjectionsX7441, X7439
CrutchesE0114
Walker, Walker with SeatE0135, E0143, E0156
Wheelchair (Manual)K0001
Wheelchair (Power)
Scooter
Wound Vac
All Extension for CPAP/BiPAP, Manual Wheelchairs (if initial auth reviewed and approved)


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