Procedure Code List for Preauthorization for Blue Cross and Blue Shield of New Mexico Medicare Advantage Members Only Beginning Jan.1, 2018, providers will be required to obtain preauthorization through Blue Cross and Blue Shield of New Mexico (BCBSNM), DaVita Medical Group (DMG) or eviCore for certain procedures for Blue Cross Medicare Advantage members as noted below. Services performed without benefit preauthorization may be denied for payment and in whole or in part, you may not seek reimbursement from members. Member eligibility and benefits should be checked prior to every scheduled appointment. Eligibility and benefit quotes include membership status, coverage status and other important information, such as applicable copayment, coinsurance and deductible amounts. It is strongly recommended that providers ask to see the member's ID card for current information and a photo ID to guard against medical identity theft. When services may not be covered, members should be notified that they may be billed directly. A referral to an out-of-plan or out-of-network provider which is necessary due to network inadequacy or continuity of care must be reviewed by the BCBSNM Utilization Management or DMG (if the member is attributed to DMG this information will be reflected on the ID card) prior to a BCBSNM patient receiving care. To obtain benefit preauthorization through BCBSNM for the procedures noted below, you may continue to use iExchange®. This online tool is accessible to physicians, professional providers and facilities contracted with BCBSNM. For more information or to set up a new account, refer to the iExchange page in the Provider Tools section of our Provider website. Procedure codes highlighted in green denote preauthorization through eviCore. Our goal is to provide our members with access to quality, cost-effective health care. If you have any questions, please contact your Network Management Consultant . 1 Dec. 6, 2017 Procedure Description of procedure Code Medical Medical Records Request information required codes that Review require Category authorization 11970 Replacement of tissue expander with Cosmetic - Pre-Operative Evaluation, History and Physical permanent prosthesis Potential including functional impairment, and Operative Contract report. Exclusion 15002 Surgical preparation or creation of recipient site Cosmetic - Pre-operative evaluation, history and physical by excision of open wounds, burn eschar, or Potential including functional impairment, and operative scar (including subcutaneous tissues), or Contract report. incisional release of scar contracture, trunk, Exclusion arms, legs; first 100 sq cm or 1% of body area of infants and children 15003 Surgical preparation or creation of recipient site Cosmetic - Pre-operative evaluation, history and physical by excision of open wounds, burn eschar, or Potential including functional impairment, and operative scar (including subcutaneous tissues), or Contract report. incisional release of scar contracture, trunk, Exclusion arms, legs; each additional 100 sq cm, or part thereof, or each additional 1% of body area of infants and children (List separately in addition to code for primary procedure 15004 Surgical preparation or creation of recipient site Cosmetic - Pre-operative evaluation, history and physical by excision of open wounds, burn eschar, or Potential including functional impairment, and operative scar (including subcutaneous tissues), or Contract report. incisional release of scar contracture, face, Exclusion scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; first 100 sq cm or 1% of body area of infants and children 15005 Surgical preparation or creation of recipient site Cosmetic - Pre-operative evaluation, history and physical by excision of open wounds, burn eschar, or Potential including functional impairment, and operative scar (including subcutaneous tissues), or Contract report. incisional release of scar contracture, face, Exclusion scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet and/or multiple digits; each additional 100 sq cm, or part thereof, or each additional 1% of body area of infants and children (List separately in addition to code for primary procedure) 15220 Full thickness graft, free, including direct Cosmetic - Pre Operative Evaluation, History and Physical closure of donor site, scalp, arms, and/or legs; Potential including functional impairment, and Operative 20 sq cm or less Contract report Exclusion 15775 Punch graft for hair transplant; 1 to 15 punch Cosmetic - Pre Operative Evaluation, History and Physical grafts Potential including functional impairment, and Operative Contract report Exclusion 15776 Punch graft for hair transplant; more than 15 Cosmetic - Pre Operative Evaluation, History and Physical punch grafts Potential including functional impairment, and Operative Contract report Exclusion 2 Dec. 6, 2017 15777 Implantation of biologic implant (eg, acellular Cosmetic - Pre Operative Evaluation, History and Physical dermal matrix) for soft tissue reinforcement (ie, Potential including functional impairment, and Operative breast, trunk) (List separately in addition to Contract report code for primary procedure) Exclusion 15780 Dermabrasion; Total Face Cosmetic - Pre - operative evaluation, history and physical Potential including functional impairment, and operative Contract report. Exclusion 15781 Dermabrasion; Segmental, Face Cosmetic - Pre - operative evaluation, history and physical Potential including functional impairment, and operative Contract report. Exclusion 15782 Dermabrasion; Regional, Other Than Face Cosmetic - Pre - operative evaluation, history and physical Potential including functional impairment, and operative Contract report. Exclusion 15783 Dermabrasion; Superficial, Any Site Cosmetic - Pre - operative evaluation, history and physical Potential including functional impairment, and operative Contract report. Exclusion 15786 Abrasion; Single Lesion Cosmetic - Pre - operative evaluation, history and physical Potential including functional impairment, and operative Contract report. Exclusion 15787 Abrasion; Add'l 4 Lesions/< Cosmetic - Pre - operative evaluation, history and physical Potential including functional impairment, and operative Contract report. Exclusion 15788 Chemical Peel, Facial; Epidermal Cosmetic - Pre - operative evaluation, history and physical Potential including functional impairment, and operative Contract report. Exclusion 15789 Chemical Peel, Facial; Dermal Cosmetic - Pre - operative evaluation, history and physical Potential including functional impairment, and operative Contract report. Exclusion 15792 Chemical Peel, Nonfacial; Epidermal Cosmetic - Pre - operative evaluation, history and physical Potential including functional impairment, and operative Contract report. Exclusion 15793 Chemical Peel, Nonfacial; Dermal Cosmetic - Pre - operative evaluation, history and physical Potential including functional impairment, and operative Contract report. Exclusion 15819 Cervicoplasty Cosmetic - Pre-operative evaluation, history and physical Potential including functional impairment, and operative Contract report. Exclusion 15820 Blepharoplasty, Lower Eyelid Medical Pre - operative Evaluation, history and physical Necessity including functional impairment, operative report and photographs of the affected eyes. 3 Dec. 6, 2017 15821 Blepharoplasty, Lower Eyelid; W/Extensive Medical Pre-operative Evaluation, history and physical Herniated Fat Pad Necessity including functional impairment, operative report and photographs of the affected eyes. 15822 Blepharoplasty, Upper Eyelid Medical Pre - operative Evaluation, history and physical Necessity including functional impairment, operative report and photographs of the affected eyes. 15823 Blepharoplasty, Upper Eyelid; W/Excessive Skin Medical Pre-operative Evaluation, history and physical Weighting Down Lid Necessity including functional impairment, operative report and photographs of the affected eyes. 15824 Rhytidectomy; Forehead Cosmetic - Pre - operative evaluation, history and physical Potential including functional impairment, and operative Contract report. Exclusion 15825 Rhytidectomy; Neck W/Platysmal Tightening Cosmetic - Pre-operative evaluation, history and physical (Platysmal Flap, P-Flap) Potential including functional impairment, and operative Contract report. Exclusion 15826 Rhytidectomy; Glabellar Frown Lines Cosmetic - Pre - operative evaluation, history and physical Potential including functional impairment, and operative Contract report. Exclusion 15828 Rhytidectomy; Cheek, Chin, & Neck Cosmetic - Pre - operative evaluation, history and physical Potential including functional impairment, and operative Contract report. Exclusion 15829 Rhytidectomy; superficial musculoaponeurotic Cosmetic - Pre-operative evaluation, history and physical system (SMAS) flap Potential including functional impairment, and operative Contract report. Exclusion 15830 Excision, excessive skin and subcutaneous tissue Medical Pre-operative evaluation, history and physical (includes lipectomy); abdomen, infraumbilical Necessity including functional impairment, and operative panniculectomy report. 15832 Excision, Excessive Skin & Subq Tissue Cosmetic - Pre-operative evaluation, history and physical (W/Lipectomy); Thigh Potential including functional impairment, and operative Contract report. Exclusion 15833 Excision, Excessive Skin & Subq Tissue Cosmetic - Pre-operative evaluation, history