Medical Authorization Table | Wellmark Blue Cross and Blue Shield

Medical Authorization Table

The medical Authorization Table is your best resource for viewing medical policies and criteria used by Wellmark. It is also your first stop in learning whether an authorization is required.

 

Obtain approval in advance to help prevent delays and unexpected costs.

 

Beginning April 1, 2020, Part 2 providers will need to follow the steps when requesting a pre-service review for SUD (Substance Use Disorder) related services:

 

Providers must obtain authorized consent from the member or member's guardian for disclosure of patient identifying information to be released to Wellmark for:

  1. Treatment
  2. Payment of claims
  3. Health care operations
  4. Wellmark to re-disclose information with current and future treating entities related to this episode of care

If you don't have a consent form, we have created a template pdf you may use.

 

To view authorizations and quantity limits for drugs and medications, please view the drug authorization list or the FEP drug authorization list pdf.

 

View important details about authorization

Use the search box and/or pre-service filter criteria below to narrow your search results.
Click on the row header in the grid to sort your search results.
Pre Service Review Type:

Code - CPT/HCPCSTitle (Service/Description)Pre Service Review RequiredType of Pre Service Review RequiredSubmit UsingPolicy or Criteria Link(s)Comments
0001URed blood cell antigen typing, DNA, human erythrocyte antigen gene analysis of 35 antigens from 11 blood groups, utilizing whole blood, common RBC alleles reportedYesPrior ApprovalUtilization Management Tool- Procedures and DME Molecular Testing Vendor Policies  
0002MLiver disease, ten biochemical assays (ALT, A2-macroglobulin, apolipoprotein A-1, total bilirubin, GGT, haptoglobin, AST, glucose, total cholesterol and triglycerides) utilizing serum, prognostic algorithm reported as quantitative scores for fibrosis, steatosis and alcoholic steatohepatitis (ASH)YesPrior ApprovalUtilization Management Tool- Procedures and DME Molecular Testing Vendor Policies  
0003MLiver disease, ten biochemical assays (ALT, A2-macroglobulin, apolipoprotein A-1, total bilirubin, GGT, haptoglobin, AST, glucose, total cholesterol and triglycerides) utilizing serum, prognostic algorithm reported as quantitative scores for fibrosis, steatosis and nonalcoholic steatohepatitis (NASH)YesPrior ApprovalUtilization Management Tool- Procedures and DME Molecular Testing Vendor Policies  
0004MScoliosis, DNA analysis of 53 single nucleotide polymorphisms (SNPs), using saliva, prognostic algorithm reported as a risk scoreYesPrior ApprovalUtilization Management Tool- Procedures and DME Molecular Testing Vendor Policies  
0005UOncology (prostate) gene expression profile by real-time RT-PCR of 3 genes (ERG, PCA3, and SPDEF), urine, algorithm reported as risk scoreYesPrior ApprovalUtilization Management Tool- Procedures and DME Molecular Testing Vendor Policies  
0006MOncology (hepatic), mRNA expression levels of 161 genes, utilizing fresh hepatocellular carcinoma tumor tissue, with alpha-fetoprotein level, algorithm reported as a risk classifierYesPrior ApprovalUtilization Management Tool- Procedures and DME Molecular Testing Vendor Policies  
0007MOncology (gastrointestinal neuroendocrine tumors), real-time PCR expression analysis of 51 genes, utilizing whole peripheral blood, algorithm reported as a nomogram of tumor disease indexYesPrior ApprovalUtilization Management Tool- Procedures and DME Molecular Testing Vendor Policies  
0007UDrug test(s), presumptive, with definitive confirmation of positive results, any number of drug classes, urine, includes specimen verification including DNA authentication in comparison to buccal DNA, per date of serviceNoN/AN/A Drug Testing in Pain Management and Substance Use Disorder Treatment  
0008UHelicobacter pylori detection and antibiotic resistance, DNA, 16S and 23S rRNA, gyrA, pbp1, rdxA and rpoB, next-generation sequencing, formalin-fixed paraffin embedded or fresh tissue or fecal sample, predictive, reported as positive or negative for resistance to clarithromycin, fluoroquinolones, metronidazole, amoxicillin, tetracycline, and rifabutinNoN/AN/A Molecular Testing Vendor Policies  
0008UHelicobacter pylori detection and antibiotic resistance, DNA, 16S and 23S rRNA, gyrA, pbp1, rdxA and rpoB, next-generation sequencing, formalin-fixed paraffin embedded or fresh tissue or fecal sample, predictive, reported as positive or negative for resistance to clarithromycin, fluoroquinolones, metronidazole, amoxicillin, tetracycline, and rifabutinNoN/AN/A Plasma-Based Proteomic Screening in the Management of Pulmonary Nodules  
0009UOncology (breast cancer), ERBB2 (HER2) copy number by FISH, tumor cells from formalin fixed paraffin embedded tissue isolated using image-based dielectrophoresis (DEP) sorting, reported as ERBB2 gene amplified or non-amplifiedNoN/AN/A Molecular Testing Vendor Policies  
0010UInfectious disease (bacterial), strain typing by whole genome sequencing, phylogenetic-based report of strain relatedness, per submitted isolateNoN/AN/A Molecular Testing Vendor Policies  
0011MOncology, prostate cancer, mRNA expression assay of 12 genes (10 content and 2 housekeeping), RT-PCR test utilizing blood plasma and urine, algorithms to predict high-grade prostate cancer riskYesPrior ApprovalUtilization Management Tool- Procedures and DME Molecular Testing Vendor Policies  
0011UPrescription drug monitoring, evaluation of drugs present by LC-MS/MS, using oral fluid, reported as a comparison to an estimated steady-state range, per date of service including all drug compounds and metabolitesNoN/AN/A Drug Testing in Pain Management and Substance Use Disorder Treatment  
0012MOncology (urothelial), mRNA, gene expression profiling by real-time quantitative PCR of five genes (MDK, HOXA13, CDC2 [CDK1], IGFBP5, and CXCR2), utilizing urine, algorithm reported as a risk score for having urothelial carcinomaYesPrior ApprovalUtilization Management Tool- Procedures and DME Molecular Testing Vendor Policies  
0013MOncology (urothelial), mRNA, gene expression profiling by real-time quantitative PCR of five genes (MDK, HOXA13, CDC2 [CDK1], IGFBP5, and CXCR2), utilizing urine, algorithm reported as a risk score for having recurrent urothelial carcinomaYesPrior ApprovalUtilization Management Tool- Procedures and DME Molecular Testing Vendor Policies  
0016MOncology (bladder), mRNA, microarray gene expression profiling of 219 genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as molecular subtype (luminal, luminal infiltrated, basal, basal claudin-low, neuroendocrine-like)YesPrior ApprovalUtilization Management Tool- Procedures and DME Molecular Testing Vendor Policies  
0016UOncology (hematolymphoid neoplasia), RNA, BCR/ABL1 major and minor breakpoint fusion transcripts, quantitative PCR amplification, blood or bone marrow, report of fusion not detected or detected with quantitationNoN/AN/A Molecular Testing Vendor Policies  
0017MOncology (diffuse large B-cell lymphoma [DLBCL]), mRNA, gene expression profiling by fluorescent probe hybridization of 20 genes, formalin-fixed paraffinembedded tissue, algorithm reported as cell of originYesPrior ApprovalUtilization Management Tool- Procedures and DME Molecular Testing Vendor Policies  
0017UOncology (hematolymphoid neoplasia), JAK2 mutation, DNA, PCR amplification of exons 12-14 and sequence analysis, blood or bone marrow, report of JAK2 mutation not detected or detectedNoN/AN/A Molecular Testing Vendor Policies  
0018UOncology (thyroid), microRNA profiling by RT-PCR of 10 microRNA sequences, utilizing fine needle aspirate, algorithm reported as a positive or negative result for moderate to high risk of malignancyYesPrior ApprovalUtilization Management Tool- Procedures and DME Molecular Testing Vendor Policies  
0019UOncology, RNA, gene expression by whole transcriptome sequencing, formalin-fixed paraffin embedded tissue or fresh frozen tissue, predictive algorithm reported as potential targets for therapeutic agentsYesPrior ApprovalUtilization Management Tool- Procedures and DME Molecular Testing Vendor Policies  
0020M"Oncology (central nervous system), analysis of 30000 DNA methylation loci by methylation array, utilizing DNA extracted from tumor tissue, diagnostic algorithm reported as probability of matching a reference tumor subclass"YesPrior ApprovalUtilization Management Tool- Procedures and DME Molecular Testing Vendor Policies  
0021UOncology (prostate), detection of 8 autoantibodies (ARF 6, NKX3-1, 5-UTR-BMI1, CEP 164, 3-UTR-Ropporin, Desmocollin, AURKAIP-1, CSNK2A2), multiplexed immunoassay and flow cytometry serum, algorithm reported as risk scoreNoN/AN/A Genetic and Protein Biomarkers for the Diagnosis and Cancer Risk Assessment of Prostate Cancer  
0022UTargeted genomic sequence analysis panel, non-small cell lung neoplasia, DNA and RNA analysis, 23 genes, interrogation for sequence variants and rearrangements, reported as presence or absence of variants and associated therapy(ies) to considerYesPrior ApprovalUtilization Management Tool- Procedures and DME Molecular Testing Vendor Policies  
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