Prior Approval Database

Search by CPT® or HCPCS code, or the name of the item to find services, equipment and supplies that need prior approval. If the service and applicable CPT® or HCPCS code appears below, we require prior approval even if the plan is secondary to another carrier, including Medicare.

Unless otherwise indicated, the following health plans do not require prior approval for the services within this database:

  • The State of Vermont Total Choice Plan (prefix FVT) 
  • Vermont Blue65 and Vermont Medigap Blue supplement plans (prefix ZIB)

This database applies to the following health plans:

  • Blue Cross Vermont (Note: Blue Cross VT includes Access Blue New England (ABNE), New England Health Plan (NEHP), and The Vermont Health Plan)
  • International Brotherhood of Electrical Workers (IBEW Local 300)
  • The State of Vermont (Administrative Services Only)


Act 111 – Blueprint Primary Care Provider waiver of prior authorization: Effective for dates of service January 1, 2025 or after, prior authorization is waived for eligible primary care providers who order a qualifying service for a qualifying member. If you are not familiar with Act 111 and the waiver, please see Section 12 of our online Provider Handbook.
 

Prescription drugs: Please note that prescription drugs requiring prior approval are not listed in this database. Please refer the Vermont Blue Rx Center for drugs requiring prior approval. For State of Vermont plans, contact the pharmacy benefits manager for information.

Prior approval requirements and member benefits vary according to the member’s group or individual contract. Not all groups are required to follow the Vermont legislative mandates, and member contract language takes precedence over medical policies or the prior approval database when there is a conflict. Please verify member benefits prior to rendering services.

Clarifications

  • ABNE and NEHP members: requirements only apply when members have primary care providers (PCPs) located in Vermont. For members with Vermont PCPs, the member’s Home Plan may manage mental health and pharmacy/mail order prescription drugs requirements and reviews.
  • Federal Employee Program (FEP) members have separate prior approval or referral authorization
    requirements. Please see separate lists for details.

Not Reviewed Definition

‘Not Reviewed’ in the database listings denotes that prior approval is not reviewed. Please verify member benefits prior to rendering services. A 'Not Reviewed' notation does not indicate that the service is covered.

 

Additional Information

We supply this database as a quick reference only. Codes appearing in this database may not be all inclusive. AMA and CMS code updates may occur more frequently than policy updates.

Search the Prior Approval Database

Search by code or name, or select the name of the service, equipment of supplies that need prior approval

Search by Code

Enter the CPT® or HCPCS code you're looking for. If no results are found, search All to expand your results.

Search by Category

Select the category you’re looking for (i.e., Radiology). If no results are found, use the Search by Name area below.

Search by Name

Find the services, equipment, or supplies you’re looking for. Note that the name may not be the same as a CPT®/HCPCS descriptor.

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Updated on

Mar 1, 2025
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New Code Added

Listing of Prior Approval itens

  1. Dental Services

    Details

    See medical policy for Dental Services for Accidental Injury, Gross Deformity, Head and Neck Cancers, and Congenital/Genetic Disorders for more information.

    Even with prior approval, benefits are limited. Certain services may not be covered.

    Pediatric dental services are provided through CBA Blue, when applicable. See medical policy for Pediatric Dental Services or contact the customer service team for more information.

    Secure prior approvals

    Prior Authorization Portal (via Provider Resource Center)

    State of Vermont Uniform Medical Prior Authorization Form

    We review only the following dental services under the medical benefit:

    • Treatment for, or in connection with, an accidental injury to jaws, sound natural teeth, mouth or face, provided a continuous course of dental treatment begins within six months of the accident.
    • Surgery to correct gross deformity resulting from major disease or Surgery (Surgery must take place within six months of the onset of disease or within six months after Surgery, except as otherwise required by law).
    • Surgery related to head and neck cancer where sound natural teeth may be affected primarily or as a result of the chemotherapy or radiation treatment of that cancer.
    • Treatment for a congenital or genetic disorder. Treatment for a congenital or genetic disorder, such as but not limited to the absence of one or more teeth, up to the first molar, or abnormal enamel (example lateral peg).

    Facility and anesthesia charges for members who are:

    • with phobias or mental illness documented by a licensed physician or mental health professional; OR
    • with disabilities that preclude office-based dental care due to safety considerations; OR
    • who are developmentally unable to safely tolerate office-based dental care
    CPT/HCPCS Code
    • All

    Exception: No PA for bone-impacted wisdom teeth when benefits apply.

    No PA for the following:

    • Lesion excision/destruction (D7286, D7413, D7414, D7415, D7440, D7441)
    • Lesion excision/biopsy of lips (40490)
    • Lesion excision/biopsy of mucosa (40810, 40812, 40814, 40816)
    • Lesion excision/biopsy of vestibule of mouth (40808, 40818, 40820)
    • Lesion excision/biopsy of tongue (41100, 41105, 41110, 41112, 41113, 41114)
    • Lesion excision/biopsy of floor of mouth (41108, 41116)
    • Lesion excision/biopsy of dentoalveolar structures (41800, 41825, 41826, 41827)
    • Glossectomy (41120, 41130, 41135, 41155)
    • Frenectomy of uvula (40819)
    • Biopsy of the uvula (42100, 42104, 42106, 42107)
    • Biopsy of salivary glands (42400, 42405)

  2. Nasopharyngoscopy

    Secure prior approvals

    Prior Authorization Portal (via Provider Resource Center)

    State of Vermont Uniform Medical Prior Authorization Form

    CPT/HCPCS Code
    • 69705
    • 69706