Please note, this communication applies to Healthy Blue + MedicareSM (HMO D-SNP) offered by Blue Cross and Blue Shield of North Carolina (Blue Cross NC).
Effective May 1, 2024, prior authorization (PA) requirements will change for the following code(s). The medical code(s) listed below will require PA by Blue Cross NC for Medicare members. Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines, including definitions and specific contract provisions/exclusions take precedence over these precertification rules and must be considered first when determining coverage. Non-compliance with new requirements may result in denied claims.
Prior authorization requirements will be added for the following code(s):
Code | Description |
|---|---|
0738T | Treatment planning for magnetic field induction ablation of malignant prostate tissue, using data from previously performed magnetic resonance imaging (MRI) examination |
| 0739T | Ablation of malignant prostate tissue by magnetic field induction, including all intraprocedural, transperineal needle/catheter placement for nanoparticle installation and intraprocedural temperature monitoring, thermal dosimetry, bladder irrigation, and magnetic field nanoparticle activation |
Code | Description |
|---|---|
| Q4272 | Esano a, per square centimeter |
| Q4273 | Esano aaa, per square centimeter |
| Q4274 | Esano ac, per square centimeter |
| Q4275 | Esano aca, per square centimeter |
| Q4276 | Orion, per square centimeter |
Q4277 | Woundplus membrane or e-graft, per square centimeter |
| Q4278 | Epieffect, per square centimeter |
Q4280 | Xcell amnio matrix, per square centimeter |
Q4281 | Barrera sl or barrera dl, per square centimeter |
Q4282 | Cygnus dual, per square centimeter |
Q4283 | Biovance tri-layer or biovance 3l, per square centimeter |
Q4284 | Dermabind sl, per square centimeter |
Code | Description |
|---|---|
E0761 | Non-Thermal Pulsed High Frequency Radiowaves, High Peak Power Electrom |
Not all PA requirements are listed here. Detailed PA requirements are available to providers on bluecrossnc.com/providers/networks-programs/blue-medicare/healthy-blue-medicare on the Resources tab or for contracted providers by accessing Availity.com. Providers may also call Provider Services at 833-540-2106 for assistance with PA requirements.
Blue Cross and Blue Shield of North Carolina does not discriminate on the basis of race, color, national origin, sex, age or disability in its health programs and activities. Learn more about our non-discrimination policy and no-cost services available to you.
Information in other languages: Español 中文 Tiếng Việt 한국어 Français العَرَبِيَّة Hmoob ру́сский Tagalog ગુજરાતી ភាសាខ្មែរ Deutsch हिन्दी ລາວ 日本語
© 2025 Blue Cross and Blue Shield of North Carolina. ®, SM Marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. All other marks and names are property of their respective owners. Blue Cross and Blue Shield of North Carolina is an independent licensee of the Blue Cross and Blue Shield Association.