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Services requiring prior plan approval

Some services require prior plan approval (PPA) and instructions on how to request prior review.

Health management programs and procedures

Diagnostic imaging utilization management, Cardiology and Sleep Study

Log in to Blue e to use a group search to review policies for diagnostic imaging including CT/CTA, PET and MRI/MRA scans and nuclear cardiology studies. You can also view clinical guidelines on the Carelon Medical Benefits Management website. 

Pharmacy and prescription drugs

Non-emergency/outpatient services and procedures

  • Non-emergency ambulance services
  • Home health, including nursing and certain home infusions
  • Prosthetics (Commercial only)
  • Behavioral health (mental health or substance use disorder) treatment
  • Certain durable medical equipment (DME)
    • Blue Medicare HMO/PPO DME and Experience Health Medicare Advantage (HMO) DME: Prior approval codes for DME are available from Customer Service, Utilization Management or your Blue Cross NC Network Management representative.
  • Surgery and/or outpatient procedures, including but not limited to:
    • Lung volume reduction surgery
    • Morbid obesity surgery
    • UPPP, surgical management of obstructive sleep apnea
    • Vertebroplasty and kyphoplasty (Commercial only)
    • Percutaneous treatment of HNP (Commercial only)
    • Orthotripsy (Commercial only)
  • Procedures potentially cosmetic, including but not limited to:
    • Reconstructive surgery, including but not limited to dermabrasion
    • Reconstructive surgery (Commercial only), including but not limited to rhitidectomy or scar revision
    • Breast surgeries including insertion and removal of silicone breast implants, reduction mammoplasty, and gynecomastia
    • Blepharoplasty
    • Abdominoplasty
    • Therapy of superficial veins, such as varicose veins
    • Orthognathic surgery
    • Otoplasty (Commercial only)
    • Telangiectasias (Commercial only)
    • Rhinoplasty (Commercial only)
  • Investigational and Experimental Services (Medicare)
  • Blue Care: Any service received at an out-of-network provider1

Notice of mastectomy benefits

As required by the Women's Health and Cancer Rights Act of 1998, your health insurance policy provides benefits for mastectomy-related services, including all stages of reconstruction and surgery to achieve symmetry between the breasts, prostheses and complications resulting from a mastectomy, including lymphedema. This coverage is subject to the same deductibles, copayments, coinsurance or limitations as applied to other medical and surgical benefits provided under the member's policy. If you have questions, please check the member benefit booklet or call the Customer Service number on the member ID card for more information.

Looking for Prior Authorization fax forms?

PDFs of most authorizations, requests and review forms are available.