What documentation does Blue Cross Blue Shield of Michigan require for CPT 72197?

Member benefit and eligibility verification; Clinical records supporting the requested service when requested by BCBSM/BCN or its delegated vendor

How much does Medicare pay for CPT 72197 in 2026?

In 2026, the national Medicare allowable for CPT 72197 is $334.34 in an office setting and $334.34 in a facility. Commercial allowables for Blue Cross Blue Shield of Michigan are typically negotiated against this benchmark.

What if Blue Cross Blue Shield of Michigan denies the PA for CPT 72197?

Appeal in writing within 60 days, citing the specific clinical policy criteria the case meets and attaching supporting documentation. Many denials are reversed on first-level appeal when the criteria language is mirrored.

Prior Authorization

Blue Cross Blue Shield of Michigan Prior Authorization for CPT 72197

CT and MRI of pelvis and CT/MR angiography of pelvis with various contrast protocols · Standard commercial plans

Prior authorization REQUIREDState-specific policyLast verified May 9, 2026 · Reviewed by the D3rx Clinical Billing Team

Source

Blue Cross Blue Shield of Michigan Procedure Codes Requiring Prior Authorization

Not medical advice. PA policies change frequently. Always confirm against the payer's current policy before submitting. d3rx pulls directly from publicly published policy PDFs and refreshes daily.

Clinical criteria

Blue Cross Blue Shield of Michigan public procedure-code table lists 72197 as requiring prior authorization for PPO/PPO* Blue Cross commercial members, managed by Carelon, table date May 1, 2026. Verify the member, group, benefits, and submission path in Availity or the payer portal; this listing is not a payment or medical-necessity approval guarantee.

Documentation checklist

✓Member benefit and eligibility verification
✓Clinical records supporting the requested service when requested by BCBSM/BCN or its delegated vendor

2026 Medicare rate for CPT 72197

Office (non-facility)

$334.34

Facility

$334.34

Total RVUs (office)

10.01

Conversion factor

$33.4009

National Medicare Physician Fee Schedule amounts (GPCI 1.0). Blue Cross Blue Shield of Michigan's commercial allowable is negotiated against this benchmark — see the full RVU and locality breakdown on the CPT 72197 code page.

How to submit the PA

1Verify the requirement against the current clinical policy linked above.
2Gather documentation: Member benefit and eligibility verification, Clinical records supporting the requested service when requested by BCBSM/BCN or its delegated vendor.
3Submit via the payer's provider portal or designated PA channel.
4Document the reference number and follow up within 5 business days if no determination is received.

FAQ

Does Blue Cross Blue Shield of Michigan require prior authorization for CPT 72197?: Yes. Blue Cross Blue Shield of Michigan requires prior authorization for CPT 72197 (CT and MRI of pelvis and CT/MR angiography of pelvis with various contrast protocols) under Standard commercial plans per its published clinical policy.
What documentation does Blue Cross Blue Shield of Michigan require for CPT 72197?: Member benefit and eligibility verification; Clinical records supporting the requested service when requested by BCBSM/BCN or its delegated vendor
How much does Medicare pay for CPT 72197 in 2026?: In 2026, the national Medicare allowable for CPT 72197 is $334.34 in an office setting and $334.34 in a facility. Commercial allowables for Blue Cross Blue Shield of Michigan are typically negotiated against this benchmark.
What if Blue Cross Blue Shield of Michigan denies the PA for CPT 72197?: Appeal in writing within 60 days, citing the specific clinical policy criteria the case meets and attaching supporting documentation. Many denials are reversed on first-level appeal when the criteria language is mirrored.

Other Blue Cross Blue Shield of Michigan PA lookups

CPT 70450 CPT 72148 CPT 73721 CPT 74177 CPT 73221 CPT 76641 CPT 76942 CPT 70551

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