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May 2025
We’ve made changes to prior authorization for select services
Action item
Review the changes we’ve recently made to prior authorization for select services, which also affect some questionnaires in the e-referral system.
On March 23, Blue Cross Blue Shield of Michigan and Blue Care Network changed prior authorization requirements for some services.
We’ve updated the document Preview questionnaires and medical necessity criteria, previously titled Authorization criteria and preview questionnaires, on ereferrals.bcbsm.com to reflect any questionnaire changes.
Changes to prior authorization requirements and questionnaires
Service |
Affected lines of business |
What changed |
Abdominoplasty
|
- BCN commercial
- BCN Advantage℠
|
Procedure code *15847 no longer requires prior authorization.
The Abdominoplasty questionnaire continues to open for procedure code *15830. |
Blepharoplasty |
- Medicare Plus Blue℠
- BCN commercial
- BCN Advantage
|
Select cases will automatically approve when prior authorization requests include an appropriate diagnosis code.
The Blepharoplasty and repair of brow ptosis questionnaire opens only when prior authorization requests don’t include an appropriate diagnosis code.
This change affects procedure codes *15822, *15823, *67900, *67901, *67902, *67903, *67904, *67906 and *67908. |
Gastric pacing/stimulation |
- Medicare Plus Blue
- BCN commercial
- BCN Advantage
|
Procedure codes *43882 and *64595 no longer require prior authorization.
The Gastric stimulation questionnaire in the e-referral system:
- No longer opens for procedure code *64590. However, this code continues to require prior authorization.
- Continues to open for procedure codes *43647, *43648, *43881, *95980, *95981 and *95982.
|
Temporomandibular joint surgery |
- BCN commercial
- BCN Advantage
|
The Temporomandibular joint surgery questionnaire no longer opens for BCN Advantage members. However, procedure codes *20605, *20606, *21010, *21050, *21060, *21070, *21240, *21242, *21243, *21490 and *29804 continue to require prior authorization.
Note: Most Medicare Advantage plans no longer cover temporomandibular joint disorders or dysfunction services and treatments. Affected procedure codes include *20605, *20606, *21010, *21050, *21060, *21070, *21240, *21242, *21243, *21490 and *29804. |
Various |
- BCN commercial
- BCN Advantage
|
For BCN commercial:
- Procedure codes *92517 and *92519 no longer require prior authorization.
- We won’t accept prior authorization for the following procedure codes because the subscriber contracts will no longer cover the services: G0019, G0022, G0023, G0024, G0316, G0317 and G0318.
For BCN commercial and BCN Advantage:
- Procedure code G0463 no longer requires prior authorization.
|
Preview questionnaires and medical necessity criteria
For some of the above services, health care providers are prompted to complete questionnaires in the e-referral system. Refer to the Preview questionnaires and medical necessity criteria for:
- Links to preview questionnaires that show the questions you’ll need to answer in the
e-referral system so you can prepare your answers ahead of time
- Information about how to access medical necessity criteria and the criteria source for each service
As a reminder, we use the pertinent medical necessity criteria and your answers to the questionnaires in the e-referral system when making utilization management determinations on your prior authorization requests. |
