Prior Approval Database

For Blue Cross VT and IBEW

Refer to individual listing items under the Cosmetic and Reconstructive Services Category (use the Search by Category box above) for more details on specific codes/listings (list is not all-inclusive).

When benefits apply

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

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)

Prior approval is required when the purchase price is over the following dollar thresholds:

• Blue Cross VT: $1,000 or more
• IBEW: $3,500 or more
• State of VT (including SOV Total Choice): $1,000 or more

Exception: No PA required for urinary catheters and supplies, ostomy supplies, oxygen and oxygen-related supplies, insulin pump supplies, certain breast prosthetics for patients with a diagnosis of breast cancer, and cranial/scalp/wig prostheses.

Exception: No PA required for the following hand splints: L3702, L3760, L3763, L3764, L3808, L3921

Exception: When benefits apply, hearing aids do not require PA regardless of purchase price.

State of VT (including SOV Total Choice): Additional coverage applies for the following shoe insert orthotics, and prior approval is required when the purchase price is $1,000 or more: A5501, A5513, L3000, L3001, L3002, L3003, L3010, L3020, L3030, L3031, L3070, L3080, L3090, L3201, L3202, L3203, L3204, L3206, L3207, L3215, L3216, L3217, L3219, L3221, L3222, L3224, L3225, L3230, L3250, L3251, L3252, L3253

State of VT Total Choice (FVT): Prior approval required for durable medical equipment and supplies as indicated within this list.

See separate listings in this database for additional prior approval needs for:

• Continuous Glucose Monitoring Systems
• Continuous Passive Motion Equipment
• Electrical and Ultrasound Stimulation
• Enteral Formulae and Total Parenteral Nutrition
• Home Infusion Therapy
• Hospital Beds and Accessories
• Medical Nutrition for Inherited Metabolic Diseases
• Miscellaneous DME, Orthotics and Prosthetics
• Positive Airway Pressure Devices (APAP, BiPAP, CPAP)
• Vision Services and Medical Coverage for Ocular Disease
• Wheelchairs

IBEW: PA required for electrical bone growth stimulation, neuromuscular electrical stimulation, and transcutaneous electrical nerve stimulation regardless of purchase price. Prior approval required for other electrical and ultrasound stimulation services when the purchase price meets the dollar threshold indicated in the durable medical equipment section above.

State of VT: No PA required for bone growth and spinal electrical stimulation (marked with * regardless of purchase price).

State of VT Total Choice (FVT): Prior approval required, except for bone growth and spinal electrical stimulation (marked with * regardless of purchase price).