Commercial
Advanced Search

​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​Services that require precertification for Independence Commercial Members (Effective 10/01/2025)​​​

Services that Require Precertification 


​As of October 1, 2025, this list applies to all Independence Blue Cross HMO, PPO, and POS products, including Flex products.  For Federal Employee Program (FEP) precertification requirements, please see the separate FEP precertification list. 

This applies to services performed on an elective, nonemergency basis 

Because a service or item is subject to precertification, it does not guarantee coverage. The terms and conditions of your benefit plan must be reviewed to determine if any of these services or items are excluded. 

You can find additional information regarding preapproval/precertification, member cost-sharing and prescription drug coverage on the Independence Preapproval/Precertification Requirements, Member Cost-Sharing, and Prescription Drug Formulary Lists page.


​All Home-Care Services (including Infusion Therapy in the Home) 


Inpatient Services 


  • Acute rehabilitation admissions 
  • Elective surgical and nonsurgical inpatient admissions 
  • Inpatient hospice admissions 
  • Long term acute care (LTAC) facility admissions 
  • Skilled nursing facility admissions 

Cardiology Procedures


Precertification is performed by Carelon Medical Benefits Management. Precertification review only applies to members for whom the Program is applicable.  For additional information, refer to the current version of Medical Policy 11.02.27, Percutaneous Coronary Intervention, Coronary Angiography and Arterial Ultrasound. 

Arterial Ultrasound 
93978, 93979, 93880, 93882, 93922, 93923, 93924, 93925, 93926, 93930, 93931​

Diagnostic Coronary Angiography
93454, 93455, 93456, 93457, 93458, 93459, 93460, 93461, C7516, C7517, C7518, C7519, C7520, C7521, C7522, C7523, C7524, C7525, C7526, C7527, C7528, C7529, C7552, C7553, C7557, C7562

Percutaneous Coronary Intervention 
92920,​ 92924, 92928, 92933, 92937, 92943, C9600, C9602, C9604, C9607​

Procedures​ 


  • Cochlear Implant Surgery and Associated Supplies/Bone-Anchored (Osseointegrated) Hearing Aids, Implantable Bone Conduction Hearing Aids

    69714, 69715, 6971​7, 69718, 69930, L8614, L8619, L8627, L8628, L8629, L8690, L8691, L8692, L8693
     
  • Obesity Surgery

    43644, 43645, 43659, 43770, 43771, 43772, 43773, 43774, 43775, 43843, 43845, 43846, 43847, 43848, 43886, 43887, 43888, 43999
     

Musculoskeletal Procedures


Precertification is performed by Carelon Medical Benefits Management. Precertification review only applies to members for whom the Program is applicable. For additional information, refer to the current version of Medical Policy 00.01.66, Musculoskeletal Services.​

​

Allograft
​​​​29032, 29033, 29034

Bone Grafts
20930, 20931, 20932, 20933, 20934, 20936, 20937, 20938

Bone Growth Stimulator
E0748

Cervical Spine Surgery - Anterior Decompression with Fusion
22551, 22552, 22554, 22830, 22585, 63081, 63082

Cervical Spine Surgery - Anterior Decompression without Fusion
63075, 63076

Cervical Spine Surgery - Posterior Decompression with Fusion
22600, 22614, 22632, 22634, 22830, 22864

Cervical Spine Surgery - Posterior Decompression without Fusion
63001, 63015, 63020, 63035, 63040, 63043, 63045, 63048, 63050, 63051, 63052, 63053

Cervical Total Disc Replacement (Arthroplasty)
0095T, 0098T, 22856, 22858, 22861, 22864

Hip Arthroscopy
27120, 27122, 29860, 29861, 29862, 29863, 29914, 29915, 29916

Hip Replacement
27125, 27130, 27132, 27134, 27137, 27138, S2118

Knee Arthroscopy
29866, 29867, 29868, 29870, 29871, 29873, 29874, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889 

Knee Open
27331, 27332, 27333, 27334, 27335, 27345, 27403, 27405, 27407, 27409, 27412, 27415, 27416, 27427, 27428, 27429

Knee Replacement
27437, 27438, 27440, 27441, 27442, 27443, 27445, 27446, 27447, 27486, 27487, 27488, J7330, S2112

​Lumbar Decompression (Laminotomy/Laminectomy/Discectomy/Formanitomy)
63005, 63012, 63017, 63030, 63035, 63042, 63044, 63047, 63048, 63056, 63057, S2350, S2351

Lumbar Disc Replacement (Arthroplasty
0164T, 0165T, 22857, 22860, 22862, 22865

Lumbar Fusion
22533, 22534, 22558, 22585, 22612, 22614, 22630, 22632, 22633, 22634, 22830

​​Sacroiliac Joint Fusion​
27279, 27280, C1737​

​Shoulder - Arthroscopic and Open Procedures
23105, 23107, 23120, 23130, 23410, 23412, 23415, 23420, 23430, 23440, 23450, 23455, 23460, 23462, 23465, 23466, 29805, 29806, 29807, 29819, 29820, 29821, 29822, 29823, 29824, 29825, 29826, 29827, 29828

Shoulder Replacement
23470, 23472, 23473, 23474

Spinal Deformity (Scoliosis/Kyphosis)
22206, 22207, 22208, 22210, 22212, 22214, 22216, 22220, 22222, 22224, 22226, 22610, 22800, 22802, 22804, 22808, 22810, 22812, 22818, 22819, 63085, 63086, 63087, 63088, 63090, 63091, 63101, 63102, 63103, 63300, 63301, 63302, 63303, 63304, 63305, 63306, 63307, 63308

Spinal Instrumentation
22840, 22841, 22842, 22843, 22844, 22845, 22846, 22847, 22848, 22849, 22853, 22854, 22859

Vertebroplasty, Kyphoplasty
22510, 22511, 22512, 22513, 22514, 22515, C7504, C7505, C7507, C7508


Interventional Pain Management Services


Precertification is performed by Carelon Medical Benefits Management. Precertification review only applies to members for whom the Program is applicable. For additional information, refer to the current version of Medical Policy 00.01.66, Musculoskeletal Services.

Epidural Injection Procedures and Diagnostic Selective Nerve Root Blocks

  • Cervical or Thoracic Epidural Steroid Injection

62320, 62321, 64479, 64480

  • Lumbar or Sacral Epidural Steroid Injection

62322, 62323, 64483, 64484

Paravertebral Facet Injection/Nerve Block/Neurolysis

  • Cervical or Thoracic Facet Injection

64490, 64491, 64492

  • Cervical Radiofrequency Ablation

64633, 64634

  • Lumbar or Sacral Facet Injection

64493, 64494, 64495

  • Lumbar Radiofrequency Ablation

64635, 64636

​Sacroiliac Joint injections
27096, G0260

Spinal Cord and Nerve Root Stimulators

  • Implantation of Spinal Cord Stimulators

63650, 63655, 63663, 63664, 63685, 63688


Regional Sympathetic Nerve Blocks
​64510, 64520


Reconstructive Procedures and Potentially Cosmetic Procedures​​ 


  • Blepharoplasty/Ptosis Repair

    15820, 15821, 15822, 15823, 67900, 67901, 67902, 67903, 67904, 67906, 67908, 67909​
     
  • Bone Graft, Genioplasty and Mentoplasty

    21120, 21121, 21122, 21123
     
  • Breast Reconstruction

    11920, 11921, 11922, 11970, 11971, 15271, 15272, 15769, 15771, 15772, 15773, 15774, 15777, 19300, 19350, 19355, 19357, 19361, 19364, 19367, 19368, 19369, 19380, Q4100, Q4107, Q4116, Q4130, Q4142, Q4143, S2066, S2067, S2068
     
  • Breast Reduction

    15877, 19318
     
  • Breast Augmentation/Mammoplasty

    19325
     
  • Breast Mastopexy

    19316
     
  • Insertion of Breast Implants

    19340, 19342, 19396
     
  • Removal of Breast Implants

    19328, 19330, 19370, 19371
     
  • Canthopexy/Canthoplasty

    21280, 21282, 67950

  • Cervicoplasty

    17999​

  • Chemical Peels

    15788, 15789, 15792, 15793​

  • Dermabrasion

    15780, 15781, 15782, 15783
     
  • Excision of Excessive Skin and/or Subcutaneous Tissue

    15830, 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839
     
  • Gender Affirming Interventions 

    11920, 11921, 11922, 11960, 15877, 17380, 19303, 53430, 54125, 54400, 54401, 54405, 54520, 54660, 54690, 55175, 55180, 57106, 57110, 58150, 58180, 58260, 58262, 58275, 58290, 58291, 58541, 58542, 58543, 58544, 58550, 58552, 58553, 58554, 58570, 58571, 58572, 58573, 58720
     
  • Genetically and Bio-Engineered Skin Substitutes for Wound Care​​​

​​​​​​A2001, A2002, A2004, A2007, A2008, A2009, A2010, A2011, A2012, A2013, A2014, A2015, A2016, A2018, A2019, A2021, ​​​A2022, A2023, A2024, A2025, A2026, A2027, A2028, A2030, A2031, A2032, A2033, A2034, A2035, A2036, A2037, A2038, A2039,​ Q4100, Q4101, Q4102, Q4103, Q4104, Q4105, Q4106, Q4107, Q4108, ​Q4110, Q4111, Q4113, Q4114, Q4115, Q4117, Q4118, Q4121, Q4122, Q4123, ​Q​4124, Q4126, Q4127, Q4128, Q4132, Q4133, ​Q4134, Q4135, Q4136, Q4137,​ Q4139, Q4140, Q4141, Q4145, Q4146, Q4147, Q4148, Q4149, Q4151, Q4152, Q4153, Q4154, Q4155, Q4156, Q4157, Q4158, Q4159, Q4160, Q4161, Q4162, Q4163, Q4164, Q4165, Q4166, Q4167, Q4168, Q4169, Q4170, Q4171, Q4173, Q4174, Q4175, Q4176, Q4177, Q4178, Q4179, Q4180, Q4181, Q4182, Q4199, ​Q4205, Q4206, Q4208, Q4209, Q4211, Q4214, Q4215, Q4216, Q4217, Q4218, Q4219, Q4220, Q4221, Q4222, Q4224, Q4225, Q4227, Q4228, Q4229, Q4230, Q4232, Q4233, Q4234, Q4235, Q4236, Q4237, Q4238, Q4239, Q4245, Q4246, Q4247, Q4248, Q4249, Q4250, Q4251, Q4252, Q4253, Q4254, Q4255, Q4256, Q4257, Q4258, Q4259, Q4260, Q4261, ​Q4262, Q4263, Q4264, Q4265, Q4266, Q4267, Q4268, Q4269, Q4270,​ Q4271, Q4272, Q4273, Q4274, Q4275, Q4276, Q4278, Q4279, Q4280, Q4281, Q4282, Q4283, Q4284, Q4287, Q4288, Q4289, Q4290, Q4291, Q4292, Q4293, Q4294, Q4295, Q4296, Q4297, Q4298, Q4299, Q4300, Q4301, Q4302, Q4303, Q4304, Q4305, Q4306, Q4307, Q4308, Q4309, Q4310, Q4311, Q4312, Q4314, Q4317, Q4318, Q4319, Q4320, Q4321, Q4322, Q4325, Q4326, Q4327, Q4328, Q4329, Q4330, Q4331, Q4332, Q4333, Q4336, Q4337, Q4338, Q4339, Q4340, Q4341, Q4342, Q4344, Q4345, Q4354, Q4355, Q4356, Q4357, Q4358, Q4359, Q4361, Q4362, Q4363, Q4364, Q4365, Q4366, Q4367, Q4368, Q4370, Q4371, Q4372, Q4373, Q4375, Q4376, Q4377, Q4378, Q4379, Q4380, Q4382, Q4383, Q4384, Q4385, Q4386, Q4387, Q4388, Q4389, Q4390, Q4392, Q4393, Q4394, Q4395, Q4396, Q4396, Q4397​

  • Gynecomastia

​19300​

  • Hair Transplant

15775, 15776 

  • Injectable Dermal Fillers

    Effective 07/01/2023, procedure codes that represent Injectable Dermal Fillers (11950, 11951, 11952, 11954, Q2026, and Q2028) no longer require precertification for Independence Commercial Lines of Business.

  • ​​​​Keloid Removal

13100, 13101, 13102, 13120, 13121, 13122, 13131, 13132, 13133, 13151, 13152, 13153, 14000, 14001, 14020, 14021, 14040, 14041, 14060, 14061, 14301, 14302, 15002, 15003, 15004, 15005, 15040, 15050, 15100, 15101, 15110, 15111, 15115, 15116, 15120, 15121, 15130, 15131, 15135, 15136, 15150, 15151, 15152, 15155, 15156, 15157, 15200, 15201, 15220, 15221, 15240, 15241, 15260, 15261, 15271, 15272, 15273, 15274, 15275, 15276, 15277, 15278, 15570, 15572, 15574, 15576, 15600, 15610, 15620, 15630, 15650, 15731, 15733, 15734, 15736, 15738, 15740, 15750, 15756, 15757, 15758, 15760, 15770, 15780, 15781, 15782, 15783, 15786, 15787, 31830

  • Lipectomy, Liposuction, or Any Other Excess Fat-Removal Procedure

15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, 15876, 15877, 15878, 15879

  • Otoplasty

13151, 13152, 13153, 14060, 14061, 15260, 15261, 21235, 69300, 69399

  • Rhinoplasty

30400, 30410, 30420, 30430, 30435, 30450

  • Rhytidectomy

15824, 15825, 15826, 15828, 15829, 15838, 15839, 15876

  • Scar Revision

13100, 13101, 13102, 13120, 13121, 13122, 13131, 13132, 13133, 13151, 13152, 13153, 14000, 14001, 14020, 14021, 14040, 14041, 14060, 14061, 14301, 14302, 15002, 15003, 15004, 15005, 15040, 15050, 15100, 15101, 15110, 15111, 15115, 15116, 15120, 15121, 15130, 15131, 15135, 15136, 15150, 15151, 15152, 15155, 15156, 15157, 15200, 15201, 15220, 15221, 15240, 15241, 15260, 15261, 15271, 15272, 15273, 15274, 15275, 15276, 15277, 15278, 15570, 15572, 15574, 15576, 15600, 15610, 15620, 15630, 15650, 15731, 15733, 15734, 15736, 15738, 15740, 15750, 15756, 15757, 15758, 15760, 15770, 15780, 15781, 15782, 15783, 15786, 15787, 31830

  • Skin Closures

13100, 13101, 13102, 13120, 13121, 13122, 13131, 13132, 13133, 13151, 13152, 13153, 14000, 14001, 14020, 14021, 14040, 14041, 14060, 14061, 14301, 14302, 15002, 15003, 15004, 15005, 15040, 15050, 15100, 15101, 15110, 15111, 15115, 15116, 15120, 15121, 15130, 15131, 15135, 15136, 15150, 15151, 15152, 15155, 15156, 15157, 15200, 15201, 15220, 15221, 15240, 15241, 15260, 15261, 15271, 15272, 15273, 15274, 15275, 15276, 15277, 15278, 15570, 15572, 15574, 15576, 15600, 15610, 15620, 15630, 15650, 15731, 15733, 15734, 15736, 15738, 15740, 15750, 15756, 15757, 15758, 15760, 15770

  • Surgery for Varicose Veins, Including Perforators and Sclerotherapy

36465, 36466, 36468, 36470, 36471, 36475, 36476, 36478, 36479, 36482, 36483​, 37500, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37785, 37799, S2202 ​


Day Rehabilitati​on Progra​​ms

​S9960, S9961 ​

​

Elective (Nonemergency) Ground, A​ir, and Sea Ambulance Transportation​


A0140, A0426, A0428, A0430, A0431, A0434, S9960, S9961 

Outpa​tient Private-Duty N​​ursing


S9123, S9124 

Outp​​atient Radiation Therapy


Precertification is performed by CareCore National, LLC d/b/a eviCore healthcare (eviCore). Precertification review only applies to members for whom the Program is applicable. For additional information, refer to the current version of Medical Policy 09.00.56, Radiation Therapy Services.​ 

Brachytherapy
0394T, 0395T, 77761, 77762, 77763, 77767, 77768, 77770, 77771, 77772, 77778, 77789, G0458

Cardiac Focal Ablation
0747T

Hyperthermia Treatment
​77600, 77605, 77610, 77615, 77620

​Image-Guided Radiation (IGRT)
77014, 77387, G6001, G6002, G6017

​Intensity Modulated Radiation Therapy (IMRT)
77385, 77386, G6015, G6016

​Intraoperative Radiation Therapy (IORT)
77424, 77425

​Neutron Beam Radiation Therapy
77423

​Proton Beam Radiation Therapy
77520, 77522, 77523, 77525

​Radiation Treatment Delivery
77401, 77402, 77407, 77412, A9609, G0563, G6003, G6004, G6005, G6006, G6007, G6008, G6009, G6010,, G6011, G6012, G6013, G6014

​Stereotactic Radiation Therapy
77371, 77372, 77373, G0339, G0340

Therapeutic Radiopharmaceuticals
​77750, 79005, 79101, 79403, A9513, A9543, A9590, A9606, A9607, A9699, C2616, S2095


Radiology


Precertification is performed by Carelon Medical Benefits Management. Precertification review only applies to members for whom the Program is applicable. For additional information, refer to the current version of Medical Policy 09.00.46, High-Technology Radiology Services.

Computed Tomography (CT)

  • ​Abdomen
​

74150, 74160, 74170


  • Abdomen and Pelvis

74176, 74177, 74178


  • Cervical Spine

72125, 72126, 72127


  • Chest

​71250, 71260, 71270


  • Head

0042T, 70450, 70460, 70470


  • Lower Extremity

73700, 73701, 73702

  • Lumbar Spine

72131, 72132, 72133

  • Lung

71271

  • Neck

70490, 70491, 70492

  • Orbit

70480, 70481, 70482

  • Pelvis

72192, 72193, 72194

  • Sinus

70486, 70487, 70488

  • Thoracic Spine

72128, 72129,72130

  • Upper Extremity

73700, 73701, 73702
 
Combined Positron Emission Tomography (PET) and Positron Emission Tomography (PET)/Computed Tomography (CT)
​
  • Computed Tomography (CT) Heart for Calcium Scoring

75771

  • Coronary Computed Tomography (CT) and Computed Tomography Angiography (CTA)

0503T, 75572, 75573, 75574, 75580

  • Tumor Imaging

78811, 78812​, 78813, 78814, 78815, 78816

 
Computed Tomography Angiography (CTA)

  • Abdomen

741​75

  • Abdomen and Pelvis

74174

  • Abdominal Arteries

75635

  • Chest

71275

  • Head

70496

  • Lower Extremity

73706

  • Lung

71271

  • Neck

70498

  • Pelvis

72191

  • Upper Extremity

73206

Diagnostic Computed Tomography (CT) Colonoscopy


74261, 74262

Fluorine-18 fluorodeoxyglucose (f-18 FDG)


S8085


Follow Up Study Computed Tomography (CT)


76380


Functional Magnetic Resonance Imaging (MRI) Brain


70554, 70555


Low-Field MRI


S8042

 
Magnetic Resonance Angiography (MRA)

  • Abdomen

74185, C8900, C8901, C8902

  • Chest

71555, C8909, C8910, C8911

  • Head

615, 70544, 70545, 70546

  • Lower Extremity

73725, C8912, C8913, C8914

  • Neck

615, 70547, 70548, 70549

  • Pelvis

72198, C8918, C8919, C8920

  • Spinal Canal

72159, C8931, C8932, C8933

  • Upper Extremity

73225, C8934, C8935, C8936


Magnetic Resonance Elastograhpy


7639​1


Magnetic Resonance Imaging (MRI)

  • Abdomen

74181, 74182, 74183, S8037

  • Brain

70551, 70552, 70553

  • Breast

77046, 77047, 77048, 77049, C8903, C8905, C8906, C8908

  • Cardiac

75557, 75559, 75561, 75563, 75565, C9762, C9763

  • Cervical Spine

72141, 72142, 72156

  • Chest

71550, 71551, 71552

  • Fetal

74712, 74713

  • Lower Extremity

73718, 73719, 73720, 73721, 73722, 73723

  • Lumbar Spine

72148, 72149, 72158

  • Orbit

70540, 70542, 70543

  • Pelvis

72195, 72196, 72197

  • Temporomandibular Joint (TMJ)

70336

  • Thoracic Spine

72146, 72147, 72157

  • Upper Extremity (Any Joint)

73221, 73222, 73223

  • Upper Extremity (Non-Joint)

73218, 73219, 73220


Magnetic Resonance Spectroscopy (MRS)

​​76390


Magnetic Resonance Technology (MRT)

616
 

Magnetoencephalography (MEG)​

Head


95965, 95966*

​

Nuclear Cardiology

  • Cardiac Blood Pool Imaging

78472, 78473, 78481, 78483, 78494, 78496

  • Infarct Imaging

0742T, 78451, 78452, 78453, 78454, 78466, 78468, 78469
 
Positron Emission Tomography (PET)

  • Brain Imaging

78608, 78609

  • Myocardial Imaging

78429, 78430, 78431 78432, 78433, 78434, 78459, 78491, 78492

  • Other Imaging Services

404

Quantitative Computed Tomography (QCT) Bone Densitometry


77078

​Resting Transthoracic Echocardiography (TTE)


93303, 93304, 93306, 93307, 93308


  • Echocardiography Add-On Codes

93319, 93320, 93321, 93325


​Screening Computed Tomography (CT) Colonoscopy


742​63

​​Stress Echocardiography


93350, 933​51

  • Echocardiography Add-On Codes

93320, 93321, 93325, 93352


​Transesophageal Echocardiography (TEE)

93312, 93313, 93314, 93315, 93316, 93317

  • Echocardiography Add-On Codes

93319, 93320, 93321, 93325

 
3-D Rendering

  • Computed Tomography (CT) or Magnetic Resonance Imaging (MRI) Grouping

76376, 76377

​* Precertification for these codes will become effective November 15, 2025.​


Prosthetics/Orthoses: 


  • Custom Ankle-Foot Orthoses

    L1900, L1904, L1907, L1920, L1940, L1945, L1950, L1960, L1970, L1980, L1990, L2106, L2108, L4631
     
  • Custom Knee-Ankle-Foot Orthoses

    L2000, L2005, L2010, L2020, L2030, L2034, L2036, L2037, L2038, L2126, L2128
     
  • Custom Knee Braces

    L1834, L1840, L1844, L1846, L1860
     
  • Custom Limb Prosthetics Including Accessories/Components

    • L5010, L5020, L5050, L5060, L5100, L5105, L5150, L5160, L5200, L5210, L5220, L5230, L5250, L5270, L5280, L5301, L5312, L5321, L5331, L5341, L5510, L5520, L5530, L5535, L5540, L5560, L5570, L5580, L5585, L5590, L5595, L5600, L5610, L5611, L5613, L5614, L5615, L5616, L5617, L5618, L5620, L5622, L5624, L5626, L5628, L5629, L5630, L5631, L5632, L5634, L5636, L5637, L5638, L5639, L5640, L5642, L5643, L5644, L5645, L5646, L5647, L5648, L5649, L5650, L5651, L5652, L5653, L5654, L5655, L5656, L5658, L5661, L5665, L5666, L5668, L5670, L5671, L5672, L5673, L5676, L5677, L5678, L5679, L5680, L5681, L5682, L5683, L5684, L5685, L5686, L5688, L5690, L5692, L5694, L5695, L5696, L5697, L5698, L5699, L5700, L5701, L5702, L5703, L5704, L5705, L5706, L5707, L5710, L5711, L5712, L5714, L5716, L5718, L5722, L5724, L5726, L5728, L5780, L5781, L5782, L5783, L5785, L5790, L5795, L5810, L5811, L5812, L5814, L5816, L5818, L5822, L5824, L5826, L5827, L5828, L5830, L5840, L5841, L5845, L5848, L5850, L5855, L5856, L5857, L5858, L5859, L5910, L5920, L5925, L5926, L5930, L5940, L5950, L5960, L5962, L5964, L5966, L5968, L5970, L5971, L5972, L5973, L5974, L5975, L5976, L5978, L5979, L5980, L5981, L5982, L5984, L5985, L5986, L5987, L5988, L5990, L5999, L6000, L6010, L6020, L6028, L6029, L6030, L6031, L6032, L6033, L6037, L6050, L6055, L6100, L6110, L6120, L6130, L6320, L6350, L6360, L6370, L6400, L6450, L6500, L6550, L6570, L6580, L6582, L6584, L6586, L6588, L6590, L6600, L6605, L6610, L6611, L6615, L6616, L6620, L6621, L6623, L6624, L6625, L6628, L6629, L6630, L6632, L6635, L6637, L6638, L6640, L6641, L6642, L6645, L6646, L6647, L6648, L6650, L6655, L6660, L6665, L6670, L6672, L6675, L6676, L6677, L6680, L6682, L6684, L6686, L6687, L6688, L6689, L6690, L6691, L6692, L6693, L6694, L6695, L6696, L6697, L6698, L6700, L6703, L6704, L6706, L6707, L6708, L6709, L6711, L6712, L6713, L6714, L6715, L6721, L6722, L6805, L6810, L6880, L6881, L6882, L6883, L6884, L6885, L6890, L6895, L6900, L6905, L6910, L6915, L6920, L6925, L6930, L6935, L6940, L6945, L6950, L6955, L6960, L6965, L6970, L6975, L7007, L7008, L7009, L7040, L7045, L7170, L7180, L7181, L7185, L7186, L7190, L7191, L7260, L7400, L7401, L7402, L7403, L7404, L7405, L7406, ​L7499​, L5657, L6034, L6035, L6036, L6038

 Selected Durable Medical Equipment (DME) 

  • Bone Growth Stimulators

    Low-intensity ultrasound noninvasive bone growth stimulation
    E0760

    Other Than Spinal Noninvasive Electrical Bone Growth Stimulation
    E0747
     
    Spinal Noninvasive Electrical Bone Growth Stimulation
    E0748 

  • Bone-Anchored (Osseointegrated) Hearing Aids

    69716, 69719, 69726, 69727, L8690, L8691, L8692, L8693, L8694
     
  • ​Continuous Positive Airway Pressure (CPAP) Devices, Bi-Level (Bi-PAP) Devices, and All Supplies

Precertification is performed by Carelon Medical Benefits Management. Precertification review only applies to members for whom the Program is applicable. For additional information, refer to the current version of Medical Policy 07.03.05, Sleep Disorder Testing and Positive Airway Therapy Services and Supplies.​
 
A4604, A7027, A7028, A7029, A7030, A7031, A7032, A7033, A7034, A7035, A7036, A7037, A7038, A7039, A7046, E0470, E0471, E0561, E0562, E0601, E1399

  • Dynamic Adjustable and Static Progressive Stretching Devices (excludes CPMs)

    E1800, E1802, E1805, E1810, E1812, E1825, E1830
     
  • Electric, Power, and Motorized Wheelchairs Including Custom Accessories

    E1002, E1003, E1004, E1005, E1006, E1007, E1008, E1009, E1010, E1012, E1239, E2291, E2292, E2293, E2294 E2310, E2311, E2312, E2313, E2321, E2322, E2323, E2324, E2325, E2326, E2327, E2328, E2329, E2330, E2331 E2340, E2341, E2342, E2343, E2351, E2368, E2369, E2370, E2373, E2374, E2375, E2376, E2377, E2603, E2604, E2605, E2606, E2607, E2608, E2609, E2613 E2614, E2615, E2616, E2617, E2620, E2621, E2622, E2623, E2624, E2625, E2626, E2627, E2628, E2629, E2630, K0010, K0011, K0012, K0013, K0014, K0056, K0108, K0813, K0814, K0815, K0816, K0820, K0821, K0822, K0823, K0824, K0825, K0826, K0827, K0828, K0829, K0835, K0836, K0837, K0838, K0839, K0840, K0841, K0842, K0843 K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855, K0856, K0857, K0858, K0859, K0860, K0861, K0862 K0863, K0864, K0890, K0891, K0898
     
  • Insulin Pumps

    E0784, E0787, S1034
     
  • Manual Wheelchairs with the Exception of those that are Rented

    E0958, E1002, E1003, E1004, E1005, E1006, E1007, E1008, E1009, E1010, E1012, E1031, E1037, E1038, E1039 E1050, E1060, E1070, E1083, E1084, E1085, E1086, E1087, E1088, E1089, E1090, E1092, E1093, E1100, E1110  E1130, E1140, E1150, E1160, E1161, E1170, E1171, E1172, E1180, E1190, E1195, E1200, E1220, E1221, E1222  E1223, E1224, E1229, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, E1240, E1250, E1260, E1270  E1280, E1285, E1290, E1295, E2291, E2292, E2293, E2294, E2295, E2603, E2604, E2605, E2606, E2607, E2608  E2609, E2613, E2614, E2615, E2616, E2617, E2620, E2621, E2622, E2623, E2624, E2625, E2626, E2627, E2628  E2629, E2630, K0001, K0002, K0003, K0004, K0005, K0006, K0007, K0008, K0009, K0108
     
  • Negative Pressure Wound Therapy

    A6550, A9272, E2402, K0743, K0744, K0745, K0746
     
  • Neuromuscular Stimulators

    E0744, E0745, E0764, E0770
     
  • Power Operated Vehicles (POV)

    E1230, K0800, K0801, K0802, K0812
     
  • Pressure Reducing Support Surfaces Including: 

    • Air Fluidized Bed

      E0194
       
    • Non Powered Advanced Pressure Reducing Mattress

      E0371, E0373
       
    • Powered Air Flotation Bed (Low Air Loss Therapy)

      E0193, E0372
       
    • ​Powered Pressure Reducing Mattress

      E0277 

  • Push Rim Activated Power Assist Devices

    E0986
     
  • Repair or Replacement of All DME Ite​ms, as well as Orthoses and Prosthetics that Require Precertification
    ​See specific DME, orthoses, and prosthetics categories for Repair or Replacement codes that require precertification.

  • ​Speech Generating Devices
​
​E2500, E2502, E2504, E2506, E2508, E2510, E2511, E2599, V5336

Medical Foods


B4149, B4150, B4152, B4153, B4154, B4155, B4157, B4158, B4159, B4160, B4161, B4162, S9433, S9434, S9435

Hyperbaric Oxygen Therapy


0413, G0277 

In-Lab / Facility Sleep Studies


Precertification is performed by Carelon Medical Benefits Management. Precertification review only applies to members for whom the Program is applicable. For additional information, refer to the current version of Medical Policy 07.03.05, Sleep Disorder Testing and Positive Airway Therapy Services and Supplies.

95782, 95783, 95805, 95807, 95808, 95810, 95811

All Transplant Procedures, with the Exception of Corneal Transplants


0584T, 0585T, 0586T, 15775, 15776, 27415, 27416, 29866, 29867, 32851, 32852, 32853, 32854, 33935, 33945, 38205, 38206, 38207, 38208, 38209, 38210, 38211, 38212, 38213, 38214, 38215, 38230, 38232, 38240, 38241, 38242, 38243, 44133, 44135, 44136, 44137, 47135, 47140, 47141, 47142, 47399, 48160, 48554, 48556, 50320, 50340, 50360, 50365, 50370, 50380, 50547, G0341, G0342, G0343, S2053, S2054, S2060, S2061, S2065, S2103, S2140, S2142, S2150
 

Mental Health/Serious Mental Illness/Substance Abuse


  • Mental health and serious mental illness treatment (inpatient/partial hospitalization programs/intensive outpatient programs) 

  • Repetitive transcranial magnetic stimulation (rTMS) 

0889T, 0890T, 0891T, 0892T, 90867, 90868, 90869
​
  • ​Substance abuse treatment (inpatient/partial hospitalization programs/intensive outpatient programs)
 

Autism Spectrum Disorders 


  • Applied behavioral analysis

​0362T, 0373T, 971​51, 97152, 97153, 97154, 97155, 97156, 97157, 97158​


Genetic and ​Genomic Tests Requiring Precertification


Precertification is performed by CareCore National, LLC d/b/a eviCore healthcare (eviCore). Precertification review only applies to members for whom the Program is applicable. For additional information, refer to the current version of Medical Policy 06.02.52, eviCore Lab Management Program.

The following list is a guide to the types of genetic and genomic tests that require precertification. 

Hereditary Cancer Syndromes 


  • BRCA gene testing (breast and ovarian cancer syndrome) 
  • Lynch syndrome gene testing 
  • Familial adenomatous polyposis gene testing 
  • PTEN gene testing (Cowden syndrome) 
  • General cancer type panels (such as colon, breast, or neuroendocrine cancers)​​ 

​Hereditary Heart Disease​s


  • Long QT syndrome gene testing 
  • ​Aortic dilation or aneurysm syndrome testing (includes Marfan syndrome) 

Other Full Gene Analysis Testing 


  • Cystic fibrosis full gene sequencing and deletion/duplication analysis 
  • ​PMP22 full gene sequencing and deletion/duplication analysis (Charcot-Marie-Tooth, hereditary neuropathy) 

Tests for m​any Genetic Disorders Simulta​​​neously 


  • Expanded carrier screening panels (such as Carrier Status DNA Insight®, Counsyl Family Prep Screen, Pan-Ethnic Carrier Screening) 
  • Hearing loss panels 
  • Intellectual disability panels 
  • Noonan spectrum disorders panels
 
Specialty Oncology Tests 
  • Cancer gene expression or protein signature tests (such as OncotypeDX®, MammaPrint®, Afirma®, Prosigna®, HeproDX™) 
  • Tumor molecular profiling (such as FoundationOne®, neoTYPE™, OncoPlexDx®, and many others) 
  • Tissue of origin testing (for cancer of unknown primary) 
  • ​​PCA3 testing for prostate cancer

Pharmacogenomic Tests 


  • Cytochrome P450 metabolism gene testing (CYP2D6, CYP2C9, CYP2C19) 
  • Specialized drug response gene panels (such as Assurex GeneSight®, GeneTrait, Genecept®, Millennium PGTSM) 
  • Warfarin response testing 
  • MGMT methylation analysis for glioblastoma 

Other spec​​ialty Tests 


  • Coronary artery disease risk testing (such as CorusCAD®, CardioIQ®, APOE, ACE, KIF6) 
  • ​Heart disease risk testing (such as CorusCAD®, CardioIQ®, APOE, ACE, KIF6, MTHFR) 

Genome-Wide Te​​​​​​sts 


  • Microarray studies 
  • Whole exome testing 
  • Whole genome testing 
  • ​Mitochondrial genome or nuclear testing 

ANY genetic test for more than one gene or condition (often includes words like “panel" or “comprehensive" in the nam​e) 


ANY genetic test th​at will be billed with a N​​​on-Specific Procedure Code 


  • Billed with CPT® codes 81400-81408 
  • ​Billed with an unlisted code: 81479, 81599, 84999


The following are the specific CPT and HCPCS codes for genetic and genomic tests that require pre-service reviews by CareCore National, LLC d/b/a eviCore he​althcare (eviCore).

  • Molecular Pathology

0001U, 0005U, 0016U, 0017U, 0018U, 0019U, 0022U, 0026U, 0029U, 0030U, 0031U, 0032U, 0033U, 0034U, 0036U, 0037U, 0045U, 0047U, 0048U, 0050U, 0055U, 0060U, 0067U, 0069U, 0070U, 0071U, 0072U, 0073U, 0074U, 0075U, 0076U, 0078U, 0079U, 0084U, 0087U, 0088U, 0089U, 0090U, 0094U, 0101U, 0102U, 0103U, 0111U, 0113U, 0114U, 0118U, 0120U, 0129U, 0130U, 0131U, 0132U, 0133U, 0134U, 0135U, 0136U, 0137U, 0138U, 0153U, 0156U, 0​​157U, 0158U, 0159U, 0160U, 0161U, 0162U, 0169U, 0170U, 0171U, 0172U, 0173U, 0175U, 0179U, 0229U, 0230U,0231U, 0232U, 0233U, 0234U, 0235U, 0236U, 0237U, 0238U, 0239U, 0242U, 0244U, 0245U, 0246U, 0250U, 0252U, 0253U, 0254U, 0258U, 0260U, 0262U, 0264U, 0265U, 0266U, 0267U, 0268U, 0269U, 0270U, 0271U, 0272U, 0273U, 0274U, 0276U, 0277U, 0278U, 0282U, 0285U, 0286U, 0297U, 0298U, 0299U, 0300U, 0332U, 0333U, 0334U, 0335U, 0336U, 0339U, 0340U, 0341U, 0343U, 0345U, 0347U, 0348U, 0349U, 0350U, 0355U, 0356U, 0362U, 0363U,0364U, 0368U, 0379U, 0388U, 0389U, 0391U, 0392U, 0395U, 0396U, 0398U, 0400U, 0401U, 0403U, 0405U, 0409U, 0410U, 0411U, 0413U, 0414U, 0417U, 0418U, 0419U, 0420U, 0421U, 0422U, 0423U, 0424U, 0425U, 0426U, 0433U, 0434U, 0437U, 0438U, 0439U, 0440U, 0449U, 0452U, 0453U, 0454U, 0460U, 0461U, 0465U, 0466U, 0467U, 0469U, 0470U, 0473U, 0474U, 0475U, 0476U, 0477U, 0478U, 0481U, 0485U, 0486U, 0487U, 0488U, 0489U, 0493U, 0494U, 0495U, 0496U, 0497U, 0498U, 0499U, 0501U, 0506U, 0507U, 0508U, 0509U, 0510U, 0516U, 0532U, 0533U, 0534U, 0536U, 0537U, 0538U, 0539U, 0540U, 0543U, 0544U, 0549U, 81162, 81163, 81164, 81165, 81166, 81167, 81173, 81174, 81185, 81186, 81189, 81190, 81201, 81202, 81203, 81212, 81215, 81216, 81217, 81221, 81222, 81223, 81225, 81226 81227, 81228, 81229, 81230, 81231, 81232, 81238, 81248, 81249, 81252, 81253, 81257, 81258, 81259, 81269, 81277, 81283, 81286, 81289, 81291, 81292, 81293, 81294, 81295, 81296, 81297, 81298, 81299, 81300, 81302, 81303, 81304, 81306, 81307, 81308, 81313, 81317, 81318, 81319, 81321, 81322, 81323, 81325, 81326, 81327, 81328, 81335, 81336, 81337, 81346, 81349, 81350, 81351, 81353, 81355, 81361, 81362, 81363, 81364, 81400, 81401, 81402, 81403, 81404, 81405, 81406, 81407, 81408, 81410, 81411, 81412, 81413, 81414, 81415, 81416, 81417, 81418, 81419, 81422, 81425, 81426, 81427, 81430, 81431, 81432, 81433, 81434, 81435, 81436, 81437, 81438, 81439, 81440, 81441, 81442, 81443, 81445, 81448, 81449, 81450, 81451, 81455, 81456, 81457, 81458, 81459, 81460, 81462, 81463, 81464, 81465, 81470, 81471, 81493, 81518,​ 81522, 81523, 81542, 81552

  • Molecular HCPCS Codes

G9143, S3800, S3840, S3841, S3842, S3844, S3845, S3846, S3850, S3852, S3854, S38​​61, S3865, S3866, S3870

  • Multianalyte Assays with Algorithmic Analyses (MAAA)

0004M, 0006M, 0007M, 0011M, 0012M, 0013M, 0016M, 0017M, 0020M, 0203U, 0205U, 0209U, 0211U, 0212U, 0213U, 0214U, 0215U, 0216U, 0217U, 0218U, 0220U, 0228U, ​0287U, 0288U, 0289U, 0290U, 0291U, 0292U, 0293U, 0294U, 0296U, 0306U, 0307U, 0313U, 0314U, 0315U, 0317U, 0318U, 0319U, 0320U, 0326U, 0329U, 0331U, 0363U, 0444U, 0523U, 0529U, 0530U, 0552U, 0553U, 0554U, 0555U, 0560U, 0561U, 0562U, 0565U, 0566U, 0567U, 0569U, 0571U, 0572U, 81195, 81504, 81519, 81520, 81521, 81525, 81529, 81540, 81541, 81546, 81551, 81554, 81558, 81595

  • Unlisted Molecular Codes (When Reported With Genetic/Genomic Testing)

81479, 81599, 84999


Specialty Drugs Requi​​​ring Precert​​ification


All listed brands and their generic equivalents or biosimilars require precertification. This list is subject to change. 

Amyotrophic Lateral Sclerosis Agents​​​

​

  • NurOwn® - J3490, J3590, and C9399​


Antineoplastic Agen​​ts

  • Abraxane® - J9264
  • Adstiladrin® - J9029​
  • Adcetris® - J9042
  • Anktiva® - J9028
  • Alymsys® - Q5126 (Note: Ophthalmologic use of Alymsys does not require precertification.)
  • Avastin® - C9257, J9035, and Q5129 (Note: Ophthalmologic use of Avastin does not require precertification. Precertification requirements apply to all FDA-approved biosimilars to this reference product.)
  • ​Avzivi® - J3490, J3590, and C9399​
  • Azedra - A9590
  • ​Bizengri® - J9382​
  • Blincyto™ - J9039
  • Columvi™ - J9286​
  • Cyramza® - J9308
  • Darzalex™ - J9145
  • Darzalex Faspro™ - J9144
  • Datroway® - J9011
  • Elahere™ - J9063
  • Elrexfio™ - J1323
  • Emrelist™ - C9306 and J3590​
  • Enhertu® - J9358
  • ​Epkinly™ - J9321​
  • Erbitux® - J9055
  • Herceptin® - J9355 (Precertification requirements apply to all FDA-approved biosimilars to this originator product.)
  • Herceptin® Hylecta - J9356
  • Herzuma® - Q5113
  • Imjudo® - J9347
  • Kadcyla® - J9354
  • Kimmtrak® - J9274
  • Kyprolis® - J9047
  • Lunsumio™ - J9350
  • Margenza™ - J9353
  • Monjuvi® - J9349
  • Ogivri™ - Q5114
  • Ontruzant®- Q5112
  • Opdualag™ - J9298
  • Padcev™-J9177
  • ​Patritumab Deruxtecan - J3490, J3590, and C9399​
  • Pemfexy™ - J9304​
  • Perjeta® - J9306
  • Phesgo™ - J9316
  • Pluvicto™* - J3490 and C9399​
  • Polivy™ - J9309
  • Poteligeo® - J9204
  • Provenge® - Q2043
  • Riabni™ - J3490, J3590, and C9399
  • Rituxan® - J9312 (Precertification requirements apply to all FDA-approved biosimilars to this originator product.)
  • Rituxan Hycela™ - J9311
  • Rybrevant™ - J9061 
  • Rylaze™ - J9021​
  • ​Rytelo™ - J0870​
  • Sarclisa® - J9227
  • Taclantis (pending FDA approval) - J3490 and C9399
  • Talvey™ - ​J3055
  • Tecvayli™ - J9380​
  • Tivdak™ - J9273
  • Trodelvy® - J9317
  • Vyloy® - J1326​
  • Xofigo®* - A9606
  • Yervoy™ - J9228
  • Zepzelca™ - J9223
  • Zevalin®* - A9543
  • ​​Ziihera® - J9276​
  • Zynlonta™ - J9359

* Precertification review is provided by CareCore National, LLC d/b/a eviCore healthcare (eviCore). Precertification review only applies to members for whom the Program is applicable.
​​
​​ Anti PD-1/PD-L1 Human Monoclonal Antibodies

All drugs that can be classified under this header require precertification. This includes any unlisted brand or generic names, or biosimilars, as well as new drugs that are approved by the FDA in that class during the course of the benefit year. 
  • Bavencio® - J9023
  • ​Camrelizumab (pending FDA approval) - J3490, J3590, and C9399
  • Imfinzi™ - J9173
  • Jemperli™ - J9272
  • Keytruda™ - J9271
  • Libtayo® - J9119
  • Loqtorzi™ - J3263​
  • Opdivo® - J9299
  • Opdivo Qvantig™ - J9289​​
  • ​Tecentriq™ - J9022
  • Tecentriq Hybreza™ - J9024​
  • Tevimbra® - J9329
  • Unloxcyt™ - J9275​
  • Zynyz™ - J9345​

​​​​Bone-Modifying Agents

  • Bomyntra® and Conexxance® - Q5158​
  • Evenity™ - J3111
  • Jubbonti® - Q5136
  • ​Ospomyv™ and Xbryk - Q5159​
  • Prolia® - J0897
  • Stoboclo® and Osenvelt® - Q5157​
  • Wyost® - Q5136
  • Xgeva® - J0897
    •  

Botulinum Toxin Agen​​ts 


  • ​Botox® - J0585 

Chimeric Antigen Recept​​or (CAR-T) Therapies


All drugs that can be classified under this header require precertification. This includes any unlisted brand or generic names, or biosimilars, as well as new drugs that are approved by the FDA in that class during the course of the benefit year. 
  • Abecma® - Q2055
  • Aucatzyl® - Q2058​​
  • Breyanzi® - Q2054
  • Carvykti™ - Q2056
  • Kymriah™ - Q2042​
  • Tecartus™ - Q2053
  • ​Yescarta™ - Q2041
  • Chimeric antigen receptor t-cell (car-t) therapy; car-t cell administration, autologous - 38228


Endocrine/Metabolic Agents


  • Acthar® Gel - J0801 and J0802​
  • Lanreotide - J1932
  • Lutathera®* - A9513 and A9699
  • Sandostatin® LAR - J2353
  • Somatuline® depot - J1930 
  • Xenpozyme™ - J0218​
​
* Precertification review is provided by CareCore National, LLC d/b/a eviCore healthcare (eviCore). Precertification review only applies to members for whom the Program is applicable.
​​

Enzyme Replacement Agents


All drugs that can be classified under this header require precertification. This includes any unlisted brand or generic names, or biosimilars, as well as new drugs that are approved by the FDA in that class during the course of the benefit year.
  • Aldurazyme® - J1931
  • Adzynma - J7171​
  • Brineura™ - J0567
  • Cerezyme® - J1786
  • Cinaxadamtase Alfa (pending FDA approval) - J3490, J3590, and C9399​
  • ​Cipaglucosidase Alfa (pending FDA approval) - J3490, J3590, and C9399​
  • Elaprase® - J1743
  • Elelyso® - J3060
  • Elfabrio® - J2508​
  • Fabrazyme® - J0180
  • Kanuma® - J2840
  • Lamzede® - J0217​
  • Lumizyme® - J0221
  • Mepsevii™ - J3397
  • Naglazyme® - J1458
  • ​Nexviazyme™ - J0219
  • ​Pombiliti™ - J1203​
  • Replagal® (pending FDA approval) - J3490
  • Revcovi™ - J3590 and C9399
  • Vimizim™ - J1322​
  • Vpriv® - J3385​
  • Xenpozyme® - J3590 and C9399


​Gene Replacement / Gene Editing Therapies


All drugs that can be classified under this header require precertification. This includes any unlisted brand or generic names, or biosimilars, as well as new drugs that are approved by the FDA in that class during the course of the benefit year. 

  • Casgevy™ - J3392
  • Eladocagene exuparvovec - J3490, J3590, and C9399​
  • Elevidys® - J1413
  • ​Hemgenix® - J1411​
  • Lenmeldy™ - J3391​
  • Luxturna™ - J3398
  • Lyfgenia™ - J3394
  • Marnetegragen​​e aututemcel - J3490, J3590, and C9399
  • Roctavian® - J1412​
  • Skysona® - J3590 and C9399​
  • Vvjuvek™ - J3401​
  • Zevaskyn™ - C9399 and J3590​
  • Zolgensma® - J3399
  • Zynteglo® - J3393

Hemophil​ia/Coagulation Factors


All drugs that can be classified under this header require precertification. This includes any unlisted brand or generic names, or biosimilars, as well as new drugs that are approved by the FDA in that class during the course of the benefit year. 

  • Advate® - J7192
  • Adynovate® - J7207
  • Afstyla® - J7210
  • Alhemo® - J7173​
  • Alphanate® - J7186
  • Alphanine SD® - J7193
  • Alprolix® - J7201
  • Altuviiio® - J7214
  • Bebulin VH® - J7194
  • Benefix® - J7195
  • Coagadex® - J7175
  • Corifact® - J7180
  • Eloctate® - J7205
  • Esperoct® - J7204
  • Feiba NF® - J7198
  • Feiba VH® - J7198
  • Fibryga® - J7177
  • Helixate FS® - J7192
  • Hemlibra® - J7170
  • Hemofil-M® - J7190
  • Humate-P® - J7187​
  • ​Hympavzi™ - J7172
  • Idelvion® - J7202
  • Ixinity® - J7213
  • Jivi® - J7199 and J7208
  • Koate-DVI® - J7190
  • Kogenate FS® - J7192
  • Kovaltry® - J7207 and J7211
  • Monarc® - J7190
  • Mononine® - J7193
  • Novoeight® - J7182
  • Novoseven RT® - J7189
  • Novoseven® - J7189
  • Nuwiq® - J7209
  • Obizur® - J7188
  • Profilnine SD® - J7194
  • Qfitlia™ - J7174​
  • Rebinyn® - J7203
  • Recombinate® - J7192
  • RiaSTAP® - J7178
  • Rixubis® - J7195 and J7200
  • Sevenfact® - J7212
  • Tretten® - J7181
  • Vonvendi® - J7179 and J7199
  • Wilate® - J7183
  • ​Xyntha® - J7185 

Hyaluronate Acid Pro​​​ducts


  • Cingal (pending FDA approval) - J3490
  • Durolane® - J7318
  • Euflexxa™ - J7323
  • Gel-One® - J7326
  • Gelsyn-3™ - J7328
  • GenVisc 850® - J7320
  • Hyalgan® - J7321
  • Hymovis® - J7322
  • Supartz® - J7321
  • Synojoynt™ - J7331
  • Triluron™​ - J7332
  • TriVisc™ - J7329
  • ​VISCO-3® - J7321

Immunological ​Agents


  • Actemra®- J3262 (See note below.)
  • Avtozma® - Q5156​
  • Benlysta® IV - J0490
  • Cosentyx® IV - J3247​
  • Entyvio™ - J3380 (See note below.)
  • Ilumya™ - J3245
  • Imuldosa® - Q5098​
  • Omvoh™ - J2267
  • Orencia® IV - J0129
  • Otulfi® - Q9999​
  • Pyzchiva® - Q9996 and Q9997
  • Saphnelo™ - J0491
  • Selarsdi™ - Q9998
  • Simponi® Aria - J1602
  • Skyrizi® IV - J2327
  • Spevigo® - J1747​
  • Stelara®- J3357 and J3358  
  • Steqeyma® - Q5099​
  • Tofidence™ - Q5133​​
  • Tremfya® IV - J1628
  • Tyenne® - Q5135​
  • Wezlana -  Q5137, Q5138​
  • Yesintek™ - Q5100​

​​​​HCPCS codes J3362 and J3380 will only require precertification when not reported with the JB modifier.​

Intrave​​​nous Immune Globulin/Sub​​​cutaneous Immune Globulin (IVIG/SCIG)


All drugs that can be classified under this header require precertification. This includes any unlisted brand or generic names, or biosimilars, as well as new drugs that are approved by the FDA in that class during the course of the benefit year.
 
  • Intravenous Immune Globulin (IVIG)
    • Alyglo™ - J1552
    • Asceniv® - J1554
    • Bivigam® - J1556
    • Flebogamma® - J1572
    • Flebogamma-Dif® - J1572
    • Gammagard Liquid® - J1569
    • Gammagard S/D® - J1566
    • Gammaked® - J1561
    • Gammaplex® - J1557
    • Gamunex-C® - J1561
    • Octagam® - J1568
    • Panzyga® - J1576
    • Privigen® - J1459 
  • Subcutaneous Immune Globulin (SCIG)
    • Cutaquig® - J1551
    • Cuvitru® - J1555
    • Hizentra® - J1559
    • Hyqvia® - J1575
    • Xembi​​fy®​ - J1558

 Multiple Sclero​sis A​​gents


All drugs that can be classified under this header require precertification. This includes any unlisted brand or generic names, or biosimilars, as well as new drugs that are approved by the FDA in that class during the course of the benefit year. 

  • ​Briumvi™ - J2329
  • Lemtrada® - J0202
  • Ocrevus™ - J2350
  • Ocrevus Zunovo® - J2351​
  • ​Tyruko® - Q5134​
  • Tysabri® - J2323 ​

 Myasthenia Gravis Agents


All drugs that can be classified under this header require precertification. This includes any unlisted brand or generic names, or biosimilars, as well as new drugs that are approved by the FDA in that class during the course of the benefit year.

  • Imaavy™ - C9305 and J3590​
  • Rystiggo® - J9333
  • Vyvgart™ - J9332
  • Vyygart® Hytrulo - J9334​


Neutropenia

​

  • Efbemalenograstim Alfa (pending FDA approval) - J3490, J3590, and C9399
  • Fulphila™ - Q5108
  • Fylnetra® - Q5130
  • ​Granix® - J1447​
  • Lapelga (pending FDA approval) - J3490, J3590, and C9399
  • Neupogen® - J1442
  • Nypozi® - Q5148​
  • Releuko™ - Q5125
  • Rolvedon™ - J1449
  • ​Ryzneuta® - J9361
  • Stimufend® - Q5127
  • Udenyca™ - Q5111
  • Ziextenzo® - Q5120​


Ophthalm​ic Agents 

​

  • Ahzantive® - Q5150​
  • Beovu® - J0179
  • ​​Byooviz™ - Q5124
  • Cimerli™ - Q5128​
  • Encelto™ - J3403​
  • Enzeevu™ - Q5149​
  • Eylea® - J1078 (Precertification requirements apply to all FDA-approved biosimilars to this reference product.)
  • ​Eylea® HD - J1077 (Precertification requirements apply to all FDA-approved biosimilars to this reference product.)
  • Lucentis® - J2778 ​(Precertification requirements apply to all FDA-approved biosimilars to this reference product.)​
  • Opuviz - Q5153
  • Pavblu™ - Q5147​
  • ​Susvimo™- J2779
  • ​Tepe​zza® - J3241 
  • Vabysmo® ​- J2777
  • Yesafili™ - Q5155​


Pulmonary Arterial ​Hypertension


All drugs that can be classified under this header require precertification. This includes any unlisted brand or generic names, or biosimilars, as well as new drugs that are approved by the FDA in that class during the course of the benefit year.
  • Flolan® - J1325
  • Remodulin® - J3285
  • Revatio® - J3490 and C9399
  • Tyvaso® - J7686
  • ​Uptravi® IV - J3490 and C9399​
  • Veletri® - J1325
  • ​Ventavis® - Q4074 

Respirato​​ry Agents​


  • Cinqair® - J2786
  • ​Omlyclo® - Q5154​
  • Synagis® - 90378
  • ​Xolair® - J2357 

Respiratory Enzymes (Alpha-1​Antitrypsin)


All drugs that can be classified under this header require precertification. This includes any unlisted brand or generic names, or biosimilars, as well as new drugs that are approved by the FDA in that class during the course of the benefit year. 

  • Aralast - J0256
  • Glassia™ - J0257
  • Prolastin® - J0256
  • ​Zemaira® - J0256 

Tumor Infiltrating Lymphocyte (TIL) Therapy


All drugs that can be classified under this header require precertification. This includes any unlisted brand or generic names, or biosimilars, as well as new drugs that are approved by the FDA in that class during the course of the benefit year.​

  • Amtagvi™ – J3590, and C9399​​
  • Imdelltra™- J9026
  • Lynozyfic™ ​ - ​C9399 and J3590​
  • Tecelra® - Q2057​


Miscellaneous Therapeutic A​​​gents 


  • Adakveo® - J0791
  • Ampligen® (pending FDA approval) - J3490
  • Amvuttra™ - J0225​
  • Bkemv™ - Q5152​
  • Cosela® - J1448
  • Crysvita® - J0584
  • Enjaymo™ - J1302
  • Epysqli® - Q5151​​​
  • Evkeeza™ - J1305
  • Exenatide sustained-release ITCA 650 (pending FDA approval) - J3490
  • Gamifant® - J9210
  • Givlaari® - J0223
  • Ilaris® - J0638
  • Injectafar® - J1439​
  • Krystexxa®​ - J2507
  • ​​Lantidra® - J3490, J3590, and C9399​
  • Leqvio® - J1306​
  • Monoferric® - J1437​
  • Narsoplimab (pending FDA approval) - C9399 and J3590​
  • Niktimvo™ - J9038​
  • Onpattro® - J0222
  • Oxlumo™ - J0224​
  • Panhemitin® - J1640​
  • PiaSky® - J1307​
  • Reblozyl® - J0896
  • Remune - J3490
  • Rethymic™ - J3590 and C9399​
  • ​​Soliris® - J1299​
  • Spinraza™  -J2326
  • ​Tzield™ - J9381​
  • Ultomiris™ - J1303
  • Uplizna - J1823
  • Veopoz™ - J9376​
  • ​Vyepti™ - J3032
  • ​Xiaflex® - J0775
​

Revisio​ns​

​

October 1, 2025

 
The following revisions were incorporated into the October​ 1, 2025 update.​

Additions​

Genetically and Bio-Engineered Skin Substitutes for Wound Care

A2036 Cohealyx collagen dermal matrix, per square centimeter
A2037 G4derm plus, per milliliter
A2038 Marigen pacto, per square centimeter
A2039 Innovamatrix fd, per square centimeter
Q4383 Axolotl graft ultra, per square centimeter
Q4384 Axolotl dualgraft ultra, per square centimeter
Q4385 Apollo ft, per square centimeter
Q4386 Acesso trifaca, per square centimeter
Q4387 Neothelium ft, per square centimeter
Q4388 Neothelium ft, per square centimeter
Q4389 Neothelium 4l+, per square centimeter
Q4390 Ascendion, per square centimeter
Q4392 Grafix duo, per square centimeter
Q4393 Surgraft ac, per square centimeter
Q4394 Surgraft aca, per square centimeter
Q4395 Acelagraft, per square centimeter
Q4396 Natalin, per square centimeter
Q4397 Summit aaa, per square centimeter

Custom Limb Prosthetics Including Accessories/Components

L5657 Addition to lower extremity prosthesis, manual/automated adjustable air, fluid, gel or equal socket insert for limb volume management, any materials

L6034 Partial hand, finger, and thumb prosthesis without prosthetic digit(s)/thumb, amputation at transmetacarpal level, including flexible or non-flexible interface, molded to patient model, for use without external power and/or passive prosthetic digit/thumb, not including inserts described by L6692

L6035 Single prosthetic digit, mechanical, can include metacarpophalangeal (mcp), proximal interphalangeal (pip), and/or distal interphalangeal (dip) joint(s), with or without locking mechanism, can include flexion or extension assist, any material, attachment, initial issue or replacement

L6036 Prosthetic thumb, mechanical, can include metacarpophalangeal (mcp), interphalangeal (ip) joint(s), with or without locking mechanism, can include flexion or extension assist, any material, attachment, initial issue or replacement

L6038 Addition to single prosthetic digit or thumb, mechanical, attachment, multiaxial and/or internal/external rotation/abduction/adduction mechanism, with or without locking feature, any material

Radiology

Magnetoencephalography (MEG)

Head
95965, 95966

Antineoplastic Agents

Datroway® - J9011
Emrelist™ - C9306 and J3590

Bone-Modifying Agents

Bomyntra® and Conexxance® - Q5158
Ospomyv™ and Xbryk - Q5159
Stoboclo® and Osenvelt® - Q5157

Gene Replacement / Gene Editing Therapies

Zevaskyn™ - C9399 and J3590

Hemophilia/Coagulation Factors

Alhemo® - J7173
Qfitlia™ - J7174

Immunological Agents

Avtozma® - Q5156

Myasthenia Gravis Agents

Imaavy™ - C9305 and J3590

Ophthalmic Agents

Encelto™- J3403
Yesafili™ - Q5155

Respiratory Agents  

Omlyclo® - Q5154

Tumor Infiltrating Lymphocyte (TIL) Therapy

Lynozyfic™ - C9399 and J3590

_______________________________________________________________________


Deletions

Antineoplastic Agents

Datroway® - C9174

Gene Replacement / Gene Editing Therapies

Prademagene zamikeracel - J3490, J3590, and C9399

Ophthalmic Agents

Yesafili™ - J3490, J3590, and C9399

Tumor Infiltrating Lymphocyte (TIL) Therapy

Linvoseltamab - J3490, J3590, and C9399

​

​CPT Copyright 2025​​ American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association.  

Independence Blue Cross offers products through its subsidiaries Independence Hospital Indemnity Plan, Keystone Health Plan East and QCC Insurance Company, and with Highmark Blue Shield — independent licensees of the Blue Cross and Blue Shield Association.



​​​
​
​
Connect with Us

2025 Independence Blue Cross

Independence Blue Cross is a subsidiary of Independence Health Group, Inc. — independent licensees of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.