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Predeterminations/Medical Necessity

Predeterminations are not required. They are performed as a courtesy to the member and provider. If a predetermination is not submitted the procedure(s) will be subject to a post service review for medical necessity.

All predeterminations must include the following:

  • Contract Number.
  • Patient's name and age.
  • Proposed procedure code.
  • Provider's plan code.
  • Provider number.

Predeterminations may be submitted to Blue Cross Blue Shield of Alabama by faxing to 1-205-220-9560 or mailing to:

Blue Cross Blue Shield of Alabama
Medical Review/Predeterminations
PO Box 362025
Birmingham, AL 35236

The following procedures are eligible for predeterminations:

  • Air-Fluidized Bed
  • Amevive
  • Autologous Chondrocyte Implantation
  • Blepharoplasty/Brow Lift/Ptosis Repair
  • Bone Growth Stimulators: Electrical (Invasive,Semi-invasive, and non-invasive), Ultrasound
  • Boniva (IV only; oral medication is reviewed by pharmacy)
  • Botox
  • Breast Reconstruction and Reduction (Predeterminations are not necessary for women who fall under The Women's Health and Cancer Rights Act of 1998.)
  • Cardioverter Defibrillators: Implantable, Wearable or External
  • Chelation Therapy
  • Cochlear Device Implantation
  • Colonoscopy (for non-routine screening)
  • Continuous or Intermittent Monitoring of Glucose in the Interstitial Fluid
  • CPAP
  • DME ($3000 or greater per line item)
  • Dermabrasion/Chemical Peel
  • Destruction of Cutaneous Vascular Proliferative Lesions
  • Dynamic Orthotic Cranioplasty
  • Electrical Spinal Cord Stimulators
  • Enhanced External Counter Pulsation (EECP)
  • Extracranial Carotid Angioplasty/Stenting
  • Gastric Restrictive Procedures (Alabama providers participating in the Bariatric Network are required to enter these procedures through the online system.)
  • Gastric Electrical Stimulator
  • Genetic Testing
  • Growth Hormone
  • Gynecomastia Surgery
  • Hospital Admission with General Anesthesia for Dental Treatment
  • Implantable Bone Conduction Hearing Aids (BAHA)
  • Infertility (When required by group)
  • Intrathecal Pump
  • Insulin Pump
  • IVIG
  • Laser Procedures
  • Lung Volume Reduction
  • Lymphedema Pumps/Pneumatic Compression Devices
  • Magnetic Resonance Choliangiopancreatography MRCP
  • Management of Obstructive Sleep Apnea and equipment
  • Motorized/Power Wheelchairs
  • Motorized Scooter
  • Nutritional Supplements and Formulas
  • Orthognathic Surgery
  • Oscillatory Devices for Airway Clearance (The Vest, Intrapulmonary Percussive Ventilation (IPV), Flutter Device)
  • Otoplasty
  • Penile Prosthesis
  • PET Scans (out-of-state providers only; in-state PMD should send to Care Core)
  • Pressure Reducing Support Surfaces
  • Prosthetics
  • Remicade
  • Rituxan
  • Rosacea Treatment
  • Sacral Nerve Stimulator (Interstim)
  • Scar Revisions
  • Septophinoplasty
  • Synagis
  • Uterine Artery Embolization
  • Vagus Nerve Stimulator
  • Varicose Veins
  • Vertebroplasty, Kyphoplasty and Sacroplasty
  • Wireless Capsule Endoscopy
  • Xolair

This courtesy predetermination indicates only that your patient's condition meets the medical policy criteria for the proposed procedure(s). This courtesy predetermination is not a guarantee of payment or the existence of coverage under the plan. The availability of benefits for eligible services is always subject to existence of coverage under the plan and the terms and limitations of the plan in effect at the time the services are provided. A loss of coverage (including a retroactive contract termination) can occur automatically under certain circumstances. There will be no benefits available if such circumstances occur.

The availability of benefits is also subject to whether the provider is an in-network or out-of-network provider for the proposed procedure(s) under the terms of the plan at the time the services are provided. This courtesy predetermination does not make any determination about whether the provider is or will continue to be an in-network or out-of-network provider for the proposed procedure(s). Benefits may be denied or reduced if the provider is out-of-network for the proposed procedure(s) at the time the services are provided.

Under the terms of this contract, Preadmission Certification (PAC) is required prior to an inpatient hospital admission for elective surgery. If the services cannot be provided in the following 12 months, the proposed treatment plan should be resubmitted to our medical staff to verify if the medical criteria would still be met.