Services requiring prior plan approval

• Admissions, skilled nursing and private duty nursing
• Avalon Lab Services Prior Authorization Request Form (PDF) – Please fax the completed form to Avalon's Medical Management Department at 813-751-3760. If you have any questions, please call 844-227-5769.
• Diagnostic and Specialty Care – Log in to Blue e to use a group search to review policies for the below programs. You can also view clinical guidelines on the Carelon Medical Benefits Management website. 
  • Diagnostic Imaging Management (DIM) Program – requires medical necessity review of services such as MRIs, MRAs. CT Scans, PET Scans, and nuclear imaging.
  • Enhanced Cardiology Program – requires medical necessity review of services such as  echocardiology, diagnostic coronary angiography, arterial duplex, implantable defibrillators, and permanent pacemakers.
  • Medical Oncology Program – promotes optimal support for our members' cancer care needs, while reducing the costs for managing one of the most complex, expensive and prevalent diseases they can encounter.
  • Musculoskeletal (MSK) Program – requires medical necessity review for services such as spine surgery, joint surgery, and interventional pain management. 
  • Rehabilitation Program – requires medical necessity review for physical therapy, occupational therapy, and speech services. 
  • Sleep Management Program – considers the medical necessity of studies and the clinical appropriateness of a facility- or home-based test.
  • Surgical Program – requires medical necessity review of upper endoscopy procedures. 

• Commercial Prescription Drugs including medications to treat Hepatitis C, ADHD, weight loss, biologics for arthritis and psoriasis, and restricted access drugs
• Medicare Prescription Drugs
• Medicare Part B Step Therapy and Prior Authorization Drug List (PDF)

• Non-emergency ambulance services
• Home health, including nursing and certain home infusions
• Prosthetics (Commercial only)
• Behavioral health (mental health or substance use disorder) treatment
  • For Blue Medicare HMO/PPO: contact 800-266-6167
• 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

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.