New and updated preview questionnaires and medical necessity criteria for the prior authorization program expansion, which begins Jan. 1

In preparation for the upcoming expansion of the prior authorization program for Medicare Plus Blue^SM, BCN commercial and BCN Advantage^SM members, we've added and updated preview questionnaires, authorization criteria and medical policies on this website. These documents apply to authorization requests submitted for dates of service on or after Jan. 1, 2022.

The preview questionnaires show:

• The procedure codes and, if applicable, the diagnosis codes for which each questionnaire will open in the e-referral system
• The questions you'll need to answer in the questionnaires that open in the e-referral system

We're publishing these documents now to help you prepare for the changes.

Note: To view the procedure codes that are affected by the expansion, see the preview questionnaires on this website or see the provider alert titled Prior authorization requirements expanding for Medicare Plus Blue, BCN commercial and BCN Advantage members (PDF), which we posted on Sept. 30, 2021.

New preview questionnaires

We added the following preview questionnaires for the members specified below.

• Blepharoplasty, lower lid repair — For pediatric and adult Medicare Plus Blue, BCN commercial and BCN Advantage members
• Endovenous ablation for the treatment of varicose veins — For adult Medicare Plus Blue, BCN commercial and BCN Advantage members
• Implantable ambulatory event monitors — For pediatric and adult Medicare Plus Blue, BCN commercial and BCN Advantage members
• Left atrial appendage closure — For adult BCN commercial members
• Left atrial appendage closure — For adult Medicare Plus Blue and BCN Advantage members
• Radiofrequency ablation (RFA), cardiac, trigger — For adult Medicare Plus Blue, BCN commercial and BCN Advantage members
• Radiofrequency ablation (RFA), cardiac atrial fibrillation or atrial flutter — For adult Medicare Plus Blue, BCN commercial and BCN Advantage members
• Radiofrequency ablation (RFA), cardiac frequent monomorphic premature ventricular contractions — For adult Medicare Plus Blue, BCN commercial and BCN Advantage members
• Radiofrequency ablation (RFA), cardiac nonsustained ventricular tachycardia — For adult Medicare Plus Blue, BCN commercial and BCN Advantage members
• Radiofrequency ablation (RFA), cardiac suspected AVNRT, AVRT or focal atrial tachycardia — For adult Medicare Plus Blue, BCN commercial and BCN Advantage members
• Radiofrequency ablation (RFA), cardiac sustained (more than 30 seconds) ventricular tachycardia — For adult Medicare Plus Blue, BCN commercial and BCN Advantage members
• Radiofrequency ablation (RFA), cardiac treatment for preexcitation syndrome or WPW syndrome — For adult Medicare Plus Blue, BCN commercial and BCN Advantage members
• Septoplasty — For adult Medicare Plus Blue, BCN commercial and BCN Advantage members
• Thyroidectomy, partial — For adult Medicare Plus Blue, BCN commercial and BCN Advantage members
• Thyroidectomy, total — For adult Medicare Plus Blue, BCN commercial and BCN Advantage members

Updated preview questionnaires

We updated the following preview questionnaires to reflect that they'll apply to Medicare Plus Blue members. (They already apply to BCN commercial and BCN Advantage members.)

• Blepharoplasty
• Cosmetic or reconstructive surgery — The list of procedure codes for which the questionnaire will open differs depending on whether the member has Medicare Plus Blue or BCN coverage.
• Rhinoplasty — The list of procedure codes for which the questionnaire will open differs depending on whether the member has Medicare Plus Blue or BCN coverage.

Accessing preview questionnaires, authorization criteria and medical policies

You can access the preview questionnaires, authorization criteria and medical policies on the following pages of this website:

• Blue Cross Authorization Requirements & Criteria
• BCN Authorization Requirements & Criteria

As a reminder, we use our authorization criteria, our medical policies and your answers to the questionnaires in the e-referral system when making utilization management determinations on your authorization requests.

Posted: December 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network