Prior Authorization Documentation Standards

BCBSRI is working to align applicable prior authorization documentation requirements with nationally standardized clinical documentation standards developed through AHIP and BCBSA. These standards are intended to promote consistency, improve transparency, and help providers understand what clinical information is needed when submitting prior authorization requests.

Please note the standards below only define the clinical documentation that may be requested to support prior authorization decision-making. BCBSRI Medical Policies, clinical review criteria and coverage determinations still apply. Prior authorization requirements can be found here.

Varicose Veins

Procedure Codes: 36465, 36466, 36468, 36470, 36471, 36473-36476, 36478, 36479, 36482, 36483, 37700, 37718, 37722, 37735, 37760, 37761, 37765, 37766, 37780, 37785

ID	Clinical Data Type	Clinical Documentation
1	Requested Procedure Code(s)	Requested procedure codes
2	Laterality	Body part being treated; include laterality if relevant (left, right, or bilateral)
3	Primary Diagnosis	Diagnosis codes of the condition or concern targeted by requested service
4	State-Specific Documentation	State-specific documentation applicable to the requested service, if any (e.g., regulatory, coverage, or program-specific criteria)
5	Functional Impairment	Functional impairment, related to the condition targeted by requested service, and interference with ADLs
6	Medical History	Relevant history related to the target condition for which the service is requested; symptoms and function should be measured and reported using standardized tools, if any tools are listed below
7	Comorbidities	Documentation of comorbidities relevant to the condition targeted by the requested service; provide severity and duration of each
8	Conservative Treatment: Non-Rx	Other than medications, list relevant prior therapies, treatments, or conservative management tried and/or contraindicated or not tolerated; include the dates and duration, reason for discontinuation (if stopped), and therapeutic response
9	Conservative Treatment: Rx	List of medications (OTC and Rx) that have been tried, contraindicated, or not tolerated and the therapeutic response; include duration of use
10	Prior Imaging Performed	Imaging reports (e.g., x-rays, CT, MRI, nuclear scans): include dates and reports demonstrating pathology that justifies the requested service (e.g., ACR-RADS)
11	Other Diagnostics	Results of relevant tests (e.g., laboratory studies, tests, procedures)
12	Photographic Documentation	Include high-quality color photographs
13	Physical Examination	Physical examination and relevant findings
14	Treatment Plan	Details of the plan for treating the current condition

Vascular Embolization

Procedure Codes: 37241-37244

ID	Clinical Data Type	Clinical Documentation
1	Requested Procedure Code(s)	Requested procedure codes
2	Procedure Type	Procedure being requested is diagnostic or postoperative
3	Laterality	Body part being treated; include laterality if relevant (left, right, or bilateral)
4	Imaging Special Considerations	Documentation of imaging related special considerations relevant to the condition targeted by requested service; provide severity and duration of each (e.g., pregnancy status, renal function, allergy to contrast, metal/indwelling devices)
5	Primary Diagnosis	Diagnosis codes of the condition or concern targeted by requested service
6	State-Specific Documentation	State-specific documentation applicable to the requested service, if any (e.g., regulatory, coverage, or program-specific criteria)
7	Repeat Examinations	Reason for repeat, if performed in the past or additional services, provide dates and results
8	Medical History	Relevant history related to the target condition for which the service is requested; symptoms and function should be measured and reported using standardized tools, if any tools are listed below
9	History of Malignancy	History of malignancy (Y/N) if yes, include specific diagnosis, date of diagnosis, and phase of treatment
10	Comorbidities	Documentation of comorbidities relevant to the condition targeted by the requested service; provide severity and duration of each
11	Conservative Treatment: Non-Rx	Other than medications, list relevant prior therapies, treatments, or conservative management tried and/or contraindicated or not tolerated; include the dates and duration, reason for discontinuation (if stopped), and therapeutic response
12	Conservative Treatment: Rx	List of medications (OTC and Rx) that have been tried, contraindicated, or not tolerated and the therapeutic response; include duration of use
13	Prior Imaging Performed	Imaging reports (e.g., x-rays, CT, MRI, nuclear scans): include dates and reports demonstrating pathology that justifies the requested service (e.g., ACR-RADS)
14	Physical Examination	Physical examination and relevant findings
15	Treatment Plan	Details of the plan for treating the current condition

Watchman Procedure

Procedure Codes: 33340

ID	Clinical Data Type	Clinical Documentation
1	Requested Procedure Code(s)	Requested procedure codes
2	Procedure Type	Procedure being requested is diagnostic or postoperative
3	Imaging Special Considerations	Documentation of imaging related special considerations relevant to the condition targeted by requested service; provide severity and duration of each (e.g., pregnancy status, renal function, allergy to contrast, metal/indwelling devices)
4	Primary Diagnosis	Diagnosis codes of the condition or concern targeted by requested service
5	State-Specific Documentation	State-specific documentation applicable to the requested service, if any (e.g., regulatory, coverage, or program-specific criteria)
6	Medical History	Relevant history related to the target condition for which the service is requested; symptoms and function should be measured and reported using standardized tools, if any tools are listed below
7	ECG Report	ECG report: include dates and findings demonstrating pathology that justifies the requested service
8	Stroke Risk	CHA2DS2 clinical risk score (>2)
9	Contraindication to Anticoagulation	List any/all contraindications to or previous complications from long-term anticoagulation
10	Treatment Plan	Documentation of performing physician specialty and experience with interventional cardiac procedures involving transeptal puncture through an intact septum.
11	Multidisciplinary Heart Team Evaluation	Documentation of Heart Team evaluation for the requested LAAC procedure, including participating provider specialties, clinical recommendation, and facility structural heart program qualifications or credentials, as applicable.
12	Shared Decision-Making	Documentation of shared decision-making between the patient and treating clinician, including treatment options discussed, risks and benefits reviewed, patient preferences, and rationale for the requested service.
13	Treatment Plan	Specific plan, including the type of implant and/or graft and pre- and post-service care to optimize outcomes
14	Other Diagnostics	Results of relevant tests (e.g., laboratory studies, tests, procedures)
15	Physical Examination	Physical examination and relevant findings

Cosmetic & Reconstructive

Breast Reconstruction

Procedure Codes: 11920-11922, 11970, 11971, 13100-13102, 15271, 15272, 15734, 15769, 15771-15773, 15777, 15877, 19316, 19325, 19328, 19330, 19340, 19342, 19350, 19355, 19357, 19361, 19364, 19367-19371, 19380, 19396, 19499, S2066-S2068, S8950

ID	Clinical Data Type	Clinical Documentation
1	Requested Procedure Code(s)	Requested procedure codes
2	Laterality	Body part being treated; include laterality if relevant (left, right, or bilateral)
3	Primary Diagnosis	Diagnosis codes of the condition or concern targeted by requested service
4	State-Specific Documentation	State-specific documentation applicable to the requested service, if any (e.g., regulatory, coverage, or program-specific criteria)
5	Functional Impairment	Functional impairment, related to the condition targeted by requested service, and interference with ADLs
6	Photographic Documentation	Include high-quality color photographs
7	Medical History	Relevant history related to the target condition for which the service is requested; symptoms and function should be measured and reported using standardized tools, if any tools are listed below
8	Comorbidities	Documentation of comorbidities relevant to the condition targeted by the requested service; provide severity and duration of each
9	Nicotine Use	Nicotine history and status, including nicotine cessation, if applicable (e.g., smoking pack year history)
10	Surgical History	Relevant surgical history related to the target condition for which service is requested; include surgeries and dates performed
11	History of Malignancy	History of malignancy (Y/N) if yes, include specific diagnosis, date of diagnosis, and phase of treatment
12	Conservative Treatment: Non-Rx	Other than medications, list relevant prior therapies, treatments, or conservative management tried and/or contraindicated or not tolerated; include the dates and duration, reason for discontinuation (if stopped), and therapeutic response
13	Conservative Treatment: Rx	List of medications (OTC and Rx) that have been tried, contraindicated, or not tolerated and the therapeutic response; include duration of use
14	Prior Imaging Performed	Imaging reports (e.g., x-rays, CT, MRI, nuclear scans): include dates and reports demonstrating pathology that justifies the requested service (e.g., ACR-RADS)
15	Other Diagnostics	Results of relevant tests (e.g., laboratory studies, tests, procedures)
16	Physical Examination	Physical examination and relevant findings
17	Treatment Plan	Specific plan, including the type of implant and/or graft and pre- and post-service care to optimize outcomes

Breast Reduction

Procedure Codes: 19318

ID	Clinical Data Type	Clinical Documentation
1	Requested Procedure Code(s)	Requested procedure codes
2	Laterality	Body part being treated; include laterality if relevant (left, right, or bilateral)
3	Primary Diagnosis	Diagnosis codes of the condition or concern targeted by requested service
4	State-Specific Documentation	State-specific documentation applicable to the requested service, if any (e.g., regulatory, coverage, or program-specific criteria)
5	Photographic Documentation	Include high-quality color photographs
6	Medical History	Relevant history related to the target condition for which the service is requested; symptoms and function should be measured and reported using standardized tools, if any tools are listed below
7	Comorbidities	Documentation of comorbidities relevant to the condition targeted by the requested service; provide severity and duration of each
8	Nicotine Use	Nicotine history and status, including nicotine cessation, if applicable (e.g., smoking pack year history)
9	Surgical History	Relevant surgical history related to the target condition for which service is requested; include surgeries and dates performed
10	Conservative Treatment: Non-Rx	Other than medications, list relevant prior therapies, treatments, or conservative management tried and/or contraindicated or not tolerated; include the dates and duration, reason for discontinuation (if stopped), and therapeutic response
11	Conservative Treatment: Rx	List of medications (OTC and Rx) that have been tried, contraindicated, or not tolerated and the therapeutic response; include duration of use
12	Prior Imaging Performed	Imaging reports (e.g., x-rays, CT, MRI, nuclear scans): include dates and reports demonstrating pathology that justifies the requested service (e.g., ACR-RADS)
13	Other Diagnostics	Results of relevant tests (e.g., laboratory studies, tests, procedures)
14	Physical Examination	Physical examination and relevant findings
15	Treatment Plan	Specific plan, including the type of implant and/or graft and pre- and post-service care to optimize outcomes
16	For Revision - Indication	Reason for revision, including indication
17	For Revision - Treatment Plan	For revision, provide treatment plan

Cochlear Implants

Procedure Codes: 69930, L8614-L8619, L8627, L8628, V5273

ID	Clinical Data Type	Clinical Documentation
1	Requested Procedure Code(s)	Requested procedure codes
2	Procedure Type	Procedure being requested is diagnostic or postoperative
3	Laterality	Body part being treated; include laterality if relevant (left, right, or bilateral)
4	Primary Diagnosis	Diagnosis codes of the condition or concern targeted by requested service
5	Treatment Plan	Document: new, renewal, replacement, repair, modification or product change
6	Product Make And Model	Make and model of the product requested. Provide relevant codes (e.g., NDC codes), where applicable.
7	State-Specific Documentation	State-specific documentation applicable to the requested service, if any (e.g., regulatory, coverage, or program-specific criteria)
8	Medical History	Relevant history related to the target condition for which the service is requested; symptoms and function should be measured and reported using standardized tools, if any tools are listed below
9	Vaccine Status	Vaccine history related to the target condition for which service is requested
10	Diagnostic Testing	Include results of relevant tests (e.g., audiology reports, laboratory tests)
11	Conservative Treatment: Non-Rx	Other than medications, list relevant prior therapies, treatments, or conservative management tried and/or contraindicated or not tolerated; include the dates and duration, reason for discontinuation (if stopped), and therapeutic response
12	Prior Imaging Performed	Imaging reports (e.g., x-rays, CT, MRI, nuclear scans): include dates and reports demonstrating pathology that justifies the requested service (e.g., ACR-RADS)
13	Physical Examination	Physical examination and relevant findings
14	Cognitive Status	Ability to use auditory clues and a willingness to undergo an extended program of rehabilitation
15	Replacement or Upgrade	Documentation of the reason for replacement or upgrade, including device status, current functional limitations, impact on activities of daily living, and whether the existing device is no longer adequate, functional, or repairable.
16	Treatment Plan	Specific plan, including the type of implant and/or graft and pre- and post-service care to optimize outcomes

Eye Reconstructive

Procedure Codes: 15820-15823, 21280, 21282, 67900-67904, 67906, 67908, 67909, 67911, 67912, 67914-67917, 67921-67924, 67950, 67961, 67966

ID	Clinical Data Type	Clinical Documentation
1	Requested Procedure Code(s)	Requested procedure codes
2	Procedure Type	Procedure being requested is diagnostic or postoperative
3	Laterality	Body part being treated; include laterality if relevant (left, right, or bilateral)
4	Primary Diagnosis	Diagnosis codes of the condition or concern targeted by requested service
5	State-Specific Documentation	State-specific documentation applicable to the requested service, if any (e.g., regulatory, coverage, or program-specific criteria)
6	Medical History	Relevant history related to the target condition for which the service is requested; symptoms and function should be measured and reported using standardized tools, if any tools are listed below
7	Cause of Condition	Documentation of the condition etiology or circumstances, such as congenital, post-surgical, accident-related, injury-related, or other acquired cause.
8	Comorbidities	Documentation of comorbidities relevant to the condition targeted by the requested service; provide severity and duration of each
9	Nicotine Use	Nicotine history and status, including nicotine cessation, if applicable (e.g., smoking pack year history)
10	Symptoms and Duration	Relevant symptoms, duration, frequency, and severity
11	Functional Impairment	Functional impairment, related to the condition targeted by requested service, and interference with ADLs
12	Conservative Treatment: Non-Rx	Other than medications, list relevant prior therapies, treatments, or conservative management tried and/or contraindicated or not tolerated; include the dates and duration, reason for discontinuation (if stopped), and therapeutic response
13	Eye Exam Results	Results of relevant eye examination and vision testing (e.g., eye exam, visual acuity, visual field testing, marginal reflex distance)
14	Photographic Documentation	Include high-quality color photographs
15	Treatment Plan	Specific plan, including the type of implant and/or graft and pre- and post-service care to optimize outcomes

Musculoskeletal & Orthopedics

Artificial Disc Replacement - Cervical & Lumbar

Procedure Codes: 22856-22858, 22860-22862, 22865, 0095T, 0098T, 0164T, 0165T

ID	Clinical Data Type	Clinical Documentation
1	Requested Procedure Code(s)	Requested procedure codes
2	Primary Diagnosis	Diagnosis codes of the condition or concern targeted by requested service
3	Spinal Level(s)	Include the number of spine levels being treated and their location
4	State-Specific Documentation	State-specific documentation applicable to the requested service, if any (e.g., regulatory, coverage, or program-specific criteria)
5	Symptoms and Duration	Relevant symptoms, duration, frequency, and severity
6	Functional Impairment	Functional impairment, related to the condition targeted by requested service, and interference with ADLs
7	Medical History	Relevant history related to the target condition for which the service is requested; symptoms and function should be measured and reported using standardized tools, if any tools are listed below
8	Surgical History	Relevant surgical history related to the target condition for which service is requested; include surgeries and dates performed
9	Conservative Treatment: Non-Rx	Other than medications, list relevant prior therapies, treatments, or conservative management tried and/or contraindicated or not tolerated; include the dates and duration, reason for discontinuation (if stopped), and therapeutic response
10	Conservative Treatment: Rx	List of medications (OTC and Rx) that have been tried, contraindicated, or not tolerated and the therapeutic response; include duration of use
11	Comorbidities	Documentation of comorbidities relevant to the condition targeted by the requested service; provide severity and duration of each
12	Nicotine Use	Nicotine history and status, including nicotine cessation, if applicable (e.g., smoking pack year history)
13	Behavioral Health Disorder or Substance Use Disorder	Validated assessment and results for a behavioral health disorder and substance use disorder
14	Prior Imaging Performed	Imaging reports (e.g., x-rays, CT, MRI, nuclear scans): include dates and reports demonstrating pathology that justifies the requested service (e.g., ACR-RADS)
15	Other Diagnostics	Results of relevant tests (e.g., laboratory studies, tests, procedures)
16	Physical Examination	Physical examination and relevant findings
17	Treatment Plan	Specific plan, including the type of implant and/or graft and pre- and post-service care to optimize outcomes

Bone Stimulators

Procedure Codes: 20974, 20975, 20979, E0747-E0749, E0760

ID	Clinical Data Type	Clinical Documentation
1	Requested procedure code(s)	Requested procedure codes
2	Primary Diagnosis	Diagnosis codes of the condition or concern targeted by requested service
3	Anatomic Area	Detail specific anatomic area(s) being evaluated/treated
4	State-Specific Documentation	State-specific documentation applicable to the requested service, if any (e.g., regulatory, coverage, or program-specific criteria)
5	Medical History	Relevant history related to the target condition for which the service is requested; symptoms and function should be measured and reported using standardized tools, if any tools are listed below
6	History of Trauma and/or Accident	Reports of past injury relevant to the current service requested
7	Surgical History	Relevant surgical history related to the target condition for which service is requested; include surgeries and dates performed
8	Functional Impairment	Functional impairment, related to the condition targeted by requested service, and interference with ADLs
9	Comorbidities	Documentation of comorbidities relevant to the condition targeted by the requested service; provide severity and duration of each
10	Nicotine Use	Nicotine history and status, including nicotine cessation, if applicable (e.g., smoking pack year history)
11	Behavioral Health Disorder or Substance Use Disorder	Validated assessment and results for a behavioral health disorder and substance use disorder
12	Conservative Treatment: Non-Rx	Other than medications, list relevant prior therapies, treatments, or conservative management tried and/or contraindicated or not tolerated; include the dates and duration, reason for discontinuation (if stopped), and therapeutic response
13	Conservative Treatment: Rx	List of medications (OTC and Rx) that have been tried, contraindicated, or not tolerated and the therapeutic response; include duration of use
14	Prior Imaging Performed	Imaging reports (e.g., x-rays, CT, MRI, nuclear scans): include dates and reports demonstrating pathology that justifies the requested service (e.g., ACR-RADS)
15	Other Diagnostics	Results of relevant tests (e.g., laboratory studies, tests, procedures)
16	Physical Examination	Physical examination and relevant findings
17	Treatment Plan	Specific plan, including the type of implant and/or graft and pre- and post-service care to optimize outcomes
18	For Revision or Removal - Indication	Reason for revision or removal, including indication
19	For Revision or Removal - Treatment Plan	For revision or removal, provide treatment plan

Hip Arthroscopy

Procedure Codes: 29860-29863, 29914-29916

ID	Clinical Data Type	Clinical Documentation
1	Requested procedure code(s)	Requested procedure codes
2	Primary Diagnosis	Diagnosis codes of the condition or concern targeted by requested service
3	Laterality	Body part being treated; include laterality if relevant (left, right, or bilateral)
4	State-Specific Documentation	State-specific documentation applicable to the requested service, if any (e.g., regulatory, coverage, or program-specific criteria)
5	Functional Impairment	Functional impairment, related to the condition targeted by requested service, and interference with ADLs
6	Symptoms and Duration	Relevant symptoms, duration, frequency, and severity
7	Comorbidities	Documentation of comorbidities relevant to the condition targeted by the requested service; provide severity and duration of each
8	Nicotine Use	Nicotine history and status, including nicotine cessation, if applicable (e.g., smoking pack year history)
9	Surgical History	Relevant surgical history related to the target condition for which service is requested; include surgeries and dates performed
10	Conservative Treatment: Rx	List of medications (OTC and Rx) that have been tried, contraindicated, or not tolerated and the therapeutic response; include duration of use
11	Conservative Treatment: Non-Rx	Other than medications, list relevant prior therapies, treatments, or conservative management tried and/or contraindicated or not tolerated; include the dates