The following types of Durable Medical Equipment (DME) and Prostheses or the rental of such equipment require prior authorization.
Blood Glucose Monitor with Special Features
E2100, E2101
Cochlear Device
L8614, L8619
Hospital Beds, Specialized
E0193, E0194, E0270, E0301, E0302, E0303, E0304
Infusion Pumps, Implantable
E0782, E0783, E0785, E0786
Insulin Pump, Implantable
E0784
Download a Prior Authorization/Predetermination Form
Mattresses, Pressure Pads, Overlays
E0277, E0371, E0372, E0373, E0180, E0181
Myo-Electric Prostheses
L7010, L7015, L7020, L7025, L7030, L7035, L7040, L7170, L7180, L7185, L7186, L7190, L7191, L7260, L7261, L7272, L7274
Orthotic Seating System
K0115, K0016
Power Operated Vehicle or Power Wheelchair
E1230, K0010, K0011, K0012
Prostheses
L2039, L3902, L3904, L5050, L5060, L5100, L5105, L5150, L5160, L5200, L5210, L5220, L5250, L5270, L5280, L5320, L5540, L5560, L5570, L5580, L5585, L5590, L5595, L5600, L5610, L5613, L5700, L5701, L5702, L5726, L5728, L5814, L5826, L5828, L5830, L5840, L5846, L5930, L5968, L5979, L5980, L5981, L5987, L5988, L6050, L6055, L6100, L6110, L6120, L6130, L6200, L6205, L6250, L6300, L6310, L6320, L6350, L6360, L6370, L6400, L6500, L6550, L6570, L6584, L6588, L6590, L6693, L6920, L6925, L6930, L6935, L6940, L6945, L6950, L6955, L6960, L6965, L6970, L6975, L8035, L8042, L8043, L8044, V2623, V2627
Speech Generating Device
E2351, E2500, E2502, E2504, E2506, E2508, E2510, E2511, E2512
Specially Sized or Constructed Wheelchair, Custom Chair
E1220
To submit a prior authorization request for one of these types of DME, download a request form. For the most timely response, fax the request to 816-502-4910. Requests may also be mailed to:
Blue Cross and Blue Shield of Kansas City
Attention: Prior Authorization, Mail Stop B5A1
P.O. Box 411878
Kansas City, MO 64141-1878
Please include any supporting medical information in your fax. Please allow at least two business days from the date of receipt of all necessary information for a determination. To check the status of a prior authorization, call the Customer Service number listed on the member ID card.