View Blue Shield Authorization list Form

Prior Authorization List for Blue Shield

              Effective May 1, 2026 
      (is List is updated monthly)

Page 1 of 7

Policy Name/Program Procedure Code (To search, Press Ctrl + F) To access our most up-to-date prior authorization list, please use AuthAccel - Blue Shield’s online authorization system. You can check if a service requires authorization, submit a request, attach documentation, track status, and receive determinations for both medical and pharmacy authorizations. Visit Provider Connection (www.blueshieldca.com/provider) and click the Authorizations tab to get started. Administrative-Medical - Air Ambulance A0430 Administrative-Medical - Bone Marrow Transplant 38204, 38205, 38206, 38207, 38230, 38240, 38241, 38242, 86813, 86817 Administrative-Medical - Clinical Trials S9988, S9990, S9991, S9992, S9994, S9996 Administrative-Medical - Continuous Home Hospice T2043 Administrative-Medical - Enteral/Parenteral B4034, B4035, B4036, B4081, B4082, B4083, B4087, B4088, B4100, B4102, B4103, B4104, B4149, B4150, B4152, B4153, B4154, B4155, B4157, B4158, B4159, B4160, B4161, B4162, B4164, B4168, B4172, B4176, B4178, B4180, B4185, B4189, B4193, B4197, B4199, B4216, B4220, B4222, B4224, B5000, B5100, B5200, B9002, B9004, B9006 Administrative-Medical - Heart Lung Transplant 33935 Administrative-Medical - Heart Transplant 33945 Administrative-Medical - Home Hospice Q5010, S9126, T2042 Administrative-Medical - Home Infusion S9379 Administrative-Medical - Hospice Care (Assisted Living Facility) Q5002 Administrative-Medical - Hospice Care (Hospice Inpatient Facility) Q5006 Administrative-Medical - Hospice Care (Inpatient Hospital) Q5005 Administrative-Medical - Hospice Care (Inpatient Psych Facility) Q5008 Administrative-Medical - Hospice Care (Long-Term Care Facility) Q5007 Administrative-Medical - Hospice Care (Skilled Nursing Facility) Q5004 Administrative-Medical - Inpatient Injectable/Infusion 96413, 96415, 96416, 96417, 96440, 96446, 96450, 96542, 96549 Administrative-Medical - Intestine/Bowel Transplant 44135, 44136 Administrative-Medical - Liver Transplant 47135 Administrative-Medical - Lung Transplant 32852, 32854

Prior Authorization List for Blue Shield

              Effective May 1, 2026 
      (is List is updated monthly)

Page 2 of 7

Policy Name/Program Procedure Code (To search, Press Ctrl + F) Administrative-Medical - Nursing/Shift Care S9123, S9124 Administrative-Medical - Pancreas Transplant 48554 Administrative-Medical - Solid Organ Transplant Q0508, S9975 Administrative-Medical--Home Hospice Q5001 Administrative-Pharmacy S9560 Administrative-Unlisted Pharmacy J3490, J3590, J9999 Adjustable Cranial Orthoses for Positional Plagiocephaly and Craniosynostoses 97799 Ambulatory Event Monitors and Mobile Cardiac Outpatient Telemetry 0937T, 0938T, 0939T, 0940T, 33285, 93241, 93242, 93243, 93244, 93245, 93246, 93247, 93248, 93268, 93270, 93271, 93272 Balloon Ostial Dilation for Treatment of Chronic and Recurrent Acute Rhinosinusitis 31295, 31296, 31297, 31298 Bariatric Surgery 0813T, 43632, 43644, 43645, 43659, 43770, 43771, 43772, 43773, 43774, 43775, 43842, 43843, 43845, 43846, 43847, 43848, 43860, 43865, 43886, 43887, 43888, 43999 Behavioral Health1 00104, 0362T, 0373T, 0889T, 0890T, 0891T, 0892T, 90867, 90868, 90869, 90870, 90889, 96116, 96121, 96132, 96133, 96136, 96137, 96138, 96139, 96146, 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, G0137, G0410, G0411, G2000, G8539, H0008, H0009, H0010, H0011, H0012, H0013, H0014, H0015, H0017, H0018, H0019, H0031, H0032, H0035, H2012, H2014, H2019, H2020, H2034, S0201, S5108, S5110, S5111, S9475, S9480 Bioengineered Skin and Soft Tissue Substitutes Q4101, Q4102, Q4105, Q4107, Q4114, Q4116, Q4122, Q4124, Q4128 Blepharoplasty, Blepharoptosis Repair (Levator Resection) and Brow Lift (Repair of Brow Ptosis) 15820, 15821, 15822, 15823, 67900, 67901, 67902, 67903, 67904, 67906, 67908, 67909 Carrier Screening for Genetic Diseases 81406, 81479 Catheter Ablation as Treatment for Atrial Fibrillation 93656

1 Only Inpatient and Residential Treatment Center (RTC) services require prior authorization for members in Department of Insurance/California Department of Insurance plans. All other BH services listed do not require prior authorization.

Prior Authorization List for Blue Shield

              Effective May 1, 2026 
      (is List is updated monthly)

Page 3 of 7

Policy Name/Program Procedure Code (To search, Press Ctrl + F) Circulating Tumor DNA and Circulating Tumor Cells for Cancer Management (Liquid Biopsy) 81406, 81479 Comprehensive Genetic Profiling for Selecting Targeted Cancer Therapies 81479 Continuous Glucose Monitoring 0446T, 0447T, 0448T, A4238, A4239, A9276, A9277, A9278, E2102, E2103, S1030, S1031 Dental Anesthesia 00170 Diagnosis of Obstructive Sleep Apnea Syndrome 95810, 95811 Elective Invasive Coronary Angiography (ICA) 93454, 93455, 93456, 93457, 93458, 93459, 93460, 93461 Elective Percutaneous Coronary Intervention (PCI) 92920, 92924, 92928, 92933, 92937, 92941, 92943, C1874, C9600, C9601, C9602, C9603, C9604, C9605, C9607, C9608 RadMD • Advanced Imaging • Spine Surgery • Interventional Pain Management

CarePro • Radiation Oncology • Medical Oncology (drugs paid under the medical benefit)

Advanced Imaging

Spine Surgery

Interventional Pain Management

Oncology

External Insulin Infusion Pump A9274, E0784, E0787, S1034, S1035, S1036, S1037 Functional Endoscopic Sinus Surgery for Chronic Rhinosinusitis* CalPERS ASO Only 31237, 31238, 31239, 31240, 31241, 31253, 31254, 31255, 31256, 31257, 31259, 31276, 31287, 31288, 31290, 31291, 31292, 31293, 31294, 31295, 31296, 31297, 31298 Gender Affirmation Surgery 11920, 11921, 11922, 11950, 11951, 11952, 11954, 11960, 11970, 11971, 15770, 15775, 15776, 15777, 15824, 15825, 15826, 15828, 15829, 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, 15876, 15877, 15878, 15879, 19300, 19301, 19303, 19318, 19325, 19340, 19342, 19357, 21087, 21088, 21089, 21120, 21121, 21122, 21123, 21125, 21127, 21137, 21138, 21193, 21194, 21195, 21196, 21208, 21209, 21210, 21270, 21299, 30400, 30410, 30420, 30430, 30435, 30450, 31587, 31599, 31750, 53410,

Prior Authorization List for Blue Shield

              Effective May 1, 2026 
      (is List is updated monthly)

Page 4 of 7

Policy Name/Program Procedure Code (To search, Press Ctrl + F) 53430, 54125, 54400, 54401, 54405, 54406, 54408, 54410, 54411, 54415, 54416, 54417, 54520, 54660, 54690, 55150, 55175, 55180, 55970, 55980, 56620, 56625, 56800, 56805, 56810, 57106, 57107, 57110, 57111, 57291, 57292, 57295, 57296, 57335, 57426, 57530, 58150, 58180, 58260, 58262, 58263, 58270, 58275, 58280, 58285, 58290, 58291, 58292, 58294, 58541, 58542, 58543, 58544, 58550, 58552, 58553, 58554, 58555, 58570, 58571, 58572, 58573, 58661, 58720, 58940, 92507, 92508, C1813, C2622 General Approach to Evaluating the Utility of Genetic Panels 81406, 81479 General Approach to Genetic Testing 81406, 81479 Genetic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment in Advanced Cancer 81162, 81479 Genetic Cancer Susceptibility Panels Using Next-Generation Sequencing 81406 Genetic Testing for Alzheimer Disease 81406 Genetic Testing for Cardiac Ion Channelopathies 81406 Genetic Testing for Diagnosis and Management of Mental Health Conditions 81479 Genetic Testing for Epilepsy 81406 Genetic Testing for Heterozygous Familial Hypercholesterolemia 81406 Genetic Testing for Idiopathic Dilated Cardiomyopathy 81406, 81479 Genetic Testing for Macular Degeneration 81479 Genetic Testing for Marfan Syndrome, Thoracic Aortic Aneurysms and Dissections, and Related Disorders 81479 Genetic Testing for Mitochondrial Disorders 81406 Genetic Testing for Predisposition to Inherited Hypertrophic Cardiomyopathy 81406, 81479 Genetic Testing for the Diagnosis of Inherited Peripheral Neuropathies 81406, 81479 Germline Genetic Testing for Hereditary Breast/Ovarian Cancer Syndrome and Other High-Risk Cancers (BRCA1, BRCA2, PALB2) 81162

Prior Authorization List for Blue Shield

              Effective May 1, 2026 
      (is List is updated monthly)

Page 5 of 7

Policy Name/Program Procedure Code (To search, Press Ctrl + F) High Intensity Laser Therapy for Chronic Musculoskeletal Pain Conditions and Bell''s Palsy 97799 Hip Arthroplasty for Adults 27130 Hyperbaric Oxygen Therapy 99183, G0277 Hysterectomy Surgery for Benign Conditions 51925, 58150, 58152, 58180, 58200, 58210, 58240, 58260, 58262, 58263, 58267, 58270, 58275, 58280, 58285, 58290, 58291, 58292, 58294, 58541, 58542, 58543, 58544, 58548, 58550, 58552, 58553, 58554, 58570, 58571, 58572, 58573, 58951, 58953, 58954, 58956, 59525 Implantable Cardioverter Defibrillators 33216, 33217, 33230, 33231, 33240, 33249, 33262, 33263, 33264, 93287, C1721, C1722, C1777, C1882, C1895, C1896, G0448 Implantable Peripheral Nerve Stimulation for Chronic Pain Conditions C1767, C1778 Knee Arthroplasty for Adults 27447, 27486, 27487, 27488 Liposuction for Lipedema and Lymphedema 15877, 15878, 15879 Molecular Genomic Profiling for Cancers of Unknown Primary 81479 Monitored Anesthesia Care CalPERS ASO Only 00811, 00812, 00813 Nasal Septoplasty 30520, 30620 Non-emergency Ground Ambulance A0426, A0428 Noninvasive Prenatal Screening for Fetal Aneuploidies, Microdeletions, Single-Gene Disorders, and Twin Zygosity Using Cell- Free Fetal DNA 81479 Occupational Therapy CalPERS ASO Only 20560, 20561, 97010, 97012, 97014, 97016, 97018, 97022, 97024, 97028, 97032, 97033, 97034, 97035, 97036, 97110, 97112, 97113, 97116, 97124, 97140, 97165, 97166, 97167, 97168, 97169, 97170, 97171, 97172, 97530, 97535, 97537, 97542, 97545, 97546, 97761, 97763, G0129, G0158, G0160, G0237, G0238, G0239, S8940, S8948, S8990, S9117, S9129 Orthognathic Surgery 21085, 21110, 21120, 21121, 21122, 21123, 21125, 21127, 21141, 21142, 21143, 21145, 21146, 21147, 21150, 21151, 21154, 21155, 21159, 21160, 21188, 21193, 21194, 21195, 21196, 21198, 21199, 21206, 21208, 21209, 21210, 21215, 21230, 21247,

Prior Authorization List for Blue Shield

              Effective May 1, 2026 
      (is List is updated monthly)

Page 6 of 7

Policy Name/Program Procedure Code (To search, Press Ctrl + F) D7940, D7941, D7943, D7944, D7945, D7946, D7947, D7948, D7949, D7950, D7995, D7996 Outpatient Pulmonary Rehabilitation 97799 Paraspinal Surface Electromyography to Evaluate and Monitor Back Pain 97799 Personalized Breast Cancer Screening Clinical Trial 81162 Pharmacogenetic Testing for Pain Management 81479 Physical Therapy CalPERS ASO Only 97010, 97012, 97014, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036, 97039, 97110, 97112, 97113, 97116, 97124, 97139, 97140, 97150, 97530, 97533, 97535, 97597, 97598, 97602, 97750, 97799, G0281, G0283, G0329 Polysomnography for Non-Respiratory Sleep Disorders 95810, 95811 Preimplantation Genetic Testing 81162, 81223, 81406, 81479 Reconstructive Breast Surgery/Management of Breast Implants 19328, 19330, 19340, 19342, 19370, 19371, C1789, L8030, L8039, L8600 Reconstructive Services 11950, 11951, 11952, 11954, 15770, 15775, 15776, 15777, 15824, 15825, 15826, 15828, 15829, 15832, 15833, 15834, 15835, 15836, 15837, 15838, 15839, 15876, 15877, 15878, 15879, 19325, 19350, 19355, 19357, 19370, 21087, 21088, 21089, 21120, 21121, 21122, 21123, 21125, 21127, 21137, 21138, 21193, 21194, 21195, 21196, 21208, 21209, 21210, 21270, 21299, 30400, 30410, 30420, 30430, 30435, 30450, 31587, 31599, 31750, 57335, 92507, 92508 Reduction Mammaplasty for Breast- Related Symptoms 19318 Rib Remodeling and Clavicle Shortening 21600, 21899 Speech Therapy CalPERS ASO Only 92507, 92508, 92521, 92522, 92523, 92524, 92526, 92610, G0153, G0161, S9128, S9152 Spinal Cord and Dorsal Root Ganglion Stimulation C1767, C1778 Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome 21685, 41512, 41530, 42145, 42299, C1767, C1778 Synthetic Cartilage Implants for Joint Pain L8699 Total Artificial Hearts and Implantable Ventricular Assist Devices 33927, 33928, 33929

Prior Authorization List for Blue Shield

              Effective May 1, 2026 
      (is List is updated monthly)

Page 7 of 7

Policy Name/Program Procedure Code (To search, Press Ctrl + F) Treatment of Varicose Veins/Venous Insufficiency 36465, 36466, 36468, 36470, 36471, 36475, 36476, 36478, 36479, 36482, 36483, 37765, 37766, S2202 Vagus Nerve Stimulation C1767 Whole Exome and Whole Genome Sequencing for Diagnosis of Genetic Disorders 81415, 81416