Authorization Requirements & Criteria

This page provides Blue Cross Blue Shield of Michigan's authorization requirements, including information that applies to:

For Blue Cross PPO (commercial) members

Information on requesting authorization – Blue Cross PPO (commercial)

Utilization management criteria – Blue Cross PPO (commercial)

Forms – Blue Cross PPO (commercial)

Air ambulance authorization requests – Blue Cross PPO (commercial)

Blue Cross PPO (commercial) Provider Manual

To access the manual, complete these steps:

  1. Visit bcbsm.com/providers
  2. Log in to Provider Secured Services.
  3. Click Provider Manuals.
  4. Click Blue Cross PPO Provider Manual.

For Medicare Plus Blue PPO members

Services that require authorization – Medicare Plus Blue PPO

Utilization management criteria – Medicare Plus Blue PPO

Forms – Medicare Plus Blue PPO

Authorization criteria and preview questionnaires – Medicare Plus Blue PPO

Surgery, joint replacement and revision
Hip replacement surgery procedure, initial Authorization criteria (PDF)
Preview questionnaire (PDF)
Hip arthroplasty, total, revision Authorization criteria (PDF)
Preview questionnaire (PDF)
Knee replacement surgery, nonunicondylar, initial Authorization criteria (PDF)
Preview questionnaire (PDF)
Knee replacement surgery, unicondylar, initial Authorization criteria (PDF)
Preview questionnaire (PDF)
Knee arthroplasty, total, revision Authorization criteria (PDF)
Preview questionnaire (PDF)
Shoulder replacement surgery procedure, initial Authorization criteria (PDF)
Preview questionnaire (PDF)
Various procedures
Deep brain stimulation Refer to the medical policy on Deep Brain Stimulation (PDF)
Preview questionnaire (PDF)
Endovascular intervention, peripheral artery Authorization criteria (PDF)
Preview questionnaire (PDF)
Ethmoidectomy, endoscopic Authorization criteria (PDF)
Preview questionnaire (PDF)
Gastric pacing / stimulation Refer to the medical policy on Gastric Electrical Stimulation (PDF)
Preview questionnaire (PDF)
Hammertoe correction surgery Authorization criteria (PDF)
Preview questionnaire (PDF)
Noncoronary vascular stents Authorization criteria (PDF)
Preview questionnaire (PDF)
Sacral nerve neuromodulation/stimulation Refer to the medical policy on Sacral Nerve Neuromodulation / Stimulation (PDF)
Preview questionnaire (PDF)
Sinusotomy, frontal, endoscopic Authorization criteria (PDF)
Preview questionnaire (PDF)
Spinal cord stimulator or epidural or intrathecal catheter (trial or permanent placement) Authorization criteria (PDF)
Preview questionnaire (PDF)
Vascular embolization or occlusion of hepatic tumors (TACE/RFA) Refer to the medical policy on:
  • Transcatheter Arterial Chemoembolization of Hepatic Tumors (TACE) (PDF)
  • Radioembolization for Primary and Metastatic Tumors of the Liver (PDF)
  • Preview questionnaire (PDF)

    For related information on: