Obtain precertification and verify eligibility

Providers must verify member eligibility and benefits and obtain precertification when required; except in emergencies, failure to obtain preapproval prior to rendering designated services may result in denial of reimbursement. Preapproval submission instructions (Carelon portal and phone) are available on Anthem's provider website or the member ID card.

• Verify eligibility/benefits prior to service.
• Obtain precertification when required; exceptions: emergencies.
• Submit requests via Carelon provider portal (select GA) or call 866-714-1103; see member ID card for phone.

Precertification review: anterior cervical fusion codes

Anterior cervical arthrodesis CPT codes (e.g., 22548, 22551, 22552) are reviewed by Carelon Medical Benefits Management and mapped to Carelon Level of Care for Surgical Procedures and MCG Spine Surgery guidance for prior authorization.

• Codes cited: 22548, 22551, 22552 (anterior cervical arthrodesis).
• Requests reviewed against Carelon Level of Care for Surgical Procedures and MCG guidelines.

Precertification review: anterior interbody arthrodesis

Additional anterior interbody arthrodesis CPT codes (22554, 22556, 22558, 22585) must be submitted for review to Carelon Medical Benefits Management and are evaluated using Carelon Spine Surgery guidance and MCG Spine Surgery criteria for prior authorization.

• Codes cited: 22554, 22556, 22558, 22585.
• Reviewed per Carelon Spine Surgery and MCG guidelines.

Precertification review: posterior fusion codes

Posterior fusion and arthrodesis procedure codes (e.g., 22590, 22595, 22600, 22612, 22614, 22630) require prior authorization review by Carelon Medical Benefits Management using Carelon Spine Surgery criteria and applicable MCG guidelines.

• Examples: 22590, 22595, 22600, 22610, 22612, 22614, 22630.
• Evaluate per Carelon Spine Surgery and referenced MCG criteria.

Precertification mapping: interbody devices & disc arthroplasty

Interbody device insertion and total disc arthroplasty codes (e.g., 22853, 22854, 22856, 22857, 22864, 22865) are subject to Carelon review and mapped to Carelon Level of Care for Surgical Procedures and MCG guidance for authorization.

• Codes cited include 22853, 22854, 22856, 22857, 22864, 22865.
• Requests evaluated against Carelon Level of Care for Surgical Procedures and MCG guidelines.

Precertification mapping: joint surgery (shoulder/hip)

Joint surgery CPT codes for shoulder and hip (examples: 23105, 23130, 23410, 27130) are reviewed by Carelon Medical Benefits Management under Joint Surgery and Level of Care for Surgical Procedures guidance (MCG) for prior authorization.

• Representative codes: 23105 (arthrotomy/glenohumeral), 23410 (rotator cuff repair), 27130 (total hip arthroplasty).
• Follow Carelon Joint Surgery / MCG Level of Care criteria when requesting authorization.

Submit requests to designated responsible reviewer

The document lists CPT codes mapped to their responsible reviewer and applicable criteria/guideline (Carelon MBM as responsible party for many entries); providers must submit authorization requests to the designated responsible party and follow the referenced criteria.

• Carelon Medical Benefits Management is the responsible reviewer for listed codes.
• Provider submissions should reference the code-level criteria/guideline noted in the code line item.

Arthroscopy and arthroplasty: prior authorization required

Multiple arthroscopy and arthroplasty CPT codes (shoulder, hip, knee) are reviewed by Carelon and linked to Joint Surgery, Level of Care for Surgical Procedures and MCG guidelines; submit prior authorization to Carelon for these codes.

• Shoulder arthroscopy codes (e.g., 29805–29828) and hip/knee arthroscopy codes (e.g., 29860–29916) require Carelon review.
• Follow the Joint Surgery / MCG guidance listed per code when requesting authorization.

Arthroscopy (shoulder) — obtain Carelon review

Shoulder arthroscopy codes (e.g., 29823–29828, 29805) are reviewed by Carelon Medical Benefits Management and evaluated under Carelon Joint Surgery criteria and MCG Guidelines; obtain prior authorization as applicable.

• Codes include 29823–29828 and 29805.
• Requests evaluated per Carelon Joint Surgery, Level of Care for Surgical Procedures, and MCG criteria.

Arthroscopy (hip/knee & joint surgery) — Carelon review

Hip and knee arthroscopy and related joint surgery codes (e.g., 29860–29916, 29870–29889 series) are subject to Carelon review and must meet the Carelon Joint Surgery and MCG guideline criteria for prior authorization.

• Representative codes: 29860–29916 series for hip/knee arthroscopy.
• Submit to Carelon and reference the Joint Surgery / MCG guidelines listed per code.

Hip arthroscopy and selected thoracic/radiation procedures

Selected hip arthroscopy and thoracic/radiation procedure codes (e.g., 29914–29916, 31643, 32994) are reviewed by Carelon and mapped to Radiation Therapy or Joint Surgery/MCG guidance; obtain precertification as indicated.

• Examples: 29914–29916 (hip arthroscopy), 31643 (bronchoscopy with catheter placement for intracavitary radioelement), 32994 (pulmonary tumor ablation).
• Follow the referenced Radiation Therapy or Joint Surgery/MCG guidance when submitting.

Cardiac implantable devices & phrenic nerve stimulators — Carelon review

Cardiovascular implantable device and phrenic nerve stimulator procedure codes (e.g., 33206–33288, 33276–33288) are reviewed by Carelon MBM and linked to Carelon device/MCG criteria; submit prior authorization to Carelon.

• Representative codes: 33206–33288 series (pacemaker/ICD/phrenic nerve stimulator).
• Evaluation references include Permanent Implantable Pacemakers, Implantable Cardioverter Defibrillators, and CG-MED-79/MCG guidance.

Venous procedures and vascular embolization — prior review

Venous and vascular embolization procedures (e.g., 36465–36482; 37241–37244) require Carelon review and are evaluated against Treatment of Varicose Veins, Vascular Embolization and MCG criteria; submit for prior authorization.

• Codes include 36465–36482 and 37241–37244 (vascular embolization/occlusion).
• Carelon criteria referenced: Treatment of Varicose Veins / Vascular Embolization and MCG guidelines.

Head/neck interstitial placement & upper GI endoscopy — Carelon review

Head/neck interstitial placement and upper GI endoscopy procedure codes (e.g., 41019, 43229–43270) are reviewed by Carelon and referenced to Radiation Therapy or CG‑MED/CG‑SURG/MCG guidance; obtain precertification as indicated.

• Examples: 41019 (placement of needles/catheters into head/neck for interstitial radioelement) and 43229–43270 (EGD/EGD with dilation/ablation/biopsy series).
• Follow the Carelon Radiation Therapy, CG‑MED, CG‑SURG, and MCG references listed per code.

Sample codes and responsible party (Carelon)

Sample codes such as 37244 (vascular embolization) and 41019 (interstitial radioelement placement) have Carelon listed as the responsible party; submit prior authorization requests to Carelon and follow the referenced Carelon/MCG guidelines.

• Example responsible party: Carelon MBM for codes 37244 and 41019.
• Requests routed to and reviewed by Carelon per code-level guideline references.

Upper GI endoscopy codes — Carelon review required

Upper GI endoscopy codes (e.g., 43229, 43233, 43235, 43239–43255, 43266, 43270) require review by Carelon Medical Benefits Management and reference CG‑MED‑59, CG‑SURG‑101 and MCG Guidelines for authorization decisions.

• Codes include 43229, 43233, 43235, 43239–43255, 43266, 43270.
• Criteria referenced: CG‑MED‑59, CG‑SURG‑101 and MCG Guidelines.

Urologic & gynecologic procedures — submit to Carelon

Urologic and gynecologic procedure codes (e.g., 55706, 55862–55882, 55920, 57155–57156, 58145, 58346, 58545–58546) are assigned to Carelon for prior authorization and reference Radiation Therapy (excludes Proton), CG‑MED‑81, or MCG guidance as noted.

• Representative codes: 55706, 55862–55882, 55920, 57155–57156, 58145, 58346, 58545–58546.
• Follow the listed Carelon Radiation Therapy, CG‑MED‑81, or MCG references when submitting.

Mixed surgical & interventional codes — Carelon review

A mixed range of surgical, radiosurgery, spine and injection procedure codes are reviewed by Carelon and tied to MCG, Proton Beam Therapy, CG‑SURG‑61, and interventional pain management guidance; providers must submit prior authorization to Carelon per code.

• Codes include radiosurgery (61796, 61798), spine injections (62320–62323, 62350–62351), and others listed in the mixed section.
• Refer to the specific code line for the Carelon criteria/guideline to apply.

Spine surgery codes subject to Carelon review

Extensive spine surgery codes (e.g., 62380, 63001–63056, 63075–63091, 63047–63052, 63050–63052) are subject to prior authorization review by Carelon Medical Benefits Management and are governed by Carelon Level of Care for Surgical Procedures and MCG Spine Surgery guidance.

• Examples: 62380, 63001–63056, 63047–63052, 63050–63051, 63052.
• Evaluate and submit per Carelon Spine Surgery criteria and MCG guidelines.

Spine surgery codes requiring review (examples)

Specific spine surgery procedure codes (e.g., 63047, 63048, 63050) are reviewed by Carelon and require precertification/prior authorization under the referenced Carelon/MCG Spine Surgery guidelines.

• Codes highlighted: 63047 (lumbar laminectomy single segment), 63048 (additional segment), 63050 (cervical laminoplasty).
• Submit prior authorization to Carelon and reference the Carelon/MCG Spine Surgery criteria.

Neurostimulation procedures — Carelon prior authorization

Spinal neurostimulator implantation and related revision/removal procedures (e.g., 63650, 63655, 63663, 63685, 63688) are reviewed by Carelon Medical Benefits Management and evaluated using Interventional Pain Management and MCG guidance for authorization.

• Representative codes: 63650, 63655, 63663, 63685, 63688.
• Requests reviewed per Carelon Interventional Pain Management and MCG criteria.

Interventional pain injection codes — submit for review

Interventional pain injection codes (epidural, transforaminal, facet) such as 64479, 64480, 64483, 64490, 64491–64495 are subject to Carelon review and are evaluated using Interventional Pain Management and Site of Care for Surgical Procedures guidance (MCG) for prior authorization.

• Examples: 64479 (transforaminal cervical/thoracic), 64483 (lumbar/sacral), 64490–64495 (facet/paravertebral injections).
• Follow Carelon Interventional Pain Management and MCG Site of Care criteria when submitting.

Facet/paravertebral injections — Carelon review

Facet/paravertebral joint injections with image guidance (codes 64490–64495) are specifically mapped to Carelon Interventional Pain Management and Site of Care for Surgical Procedures (MCG) and require prior authorization as indicated.

• Codes include 64490–64495 (paravertebral/facet injections, various levels).
• Carelon evaluates these per Site of Care and Interventional Pain Management criteria.

Neurostimulation procedures — prior authorization required

Neurostimulator procedures including posterior tibial neurostimulation and peripheral neurostimulator implantation/revision (e.g., 64561, 64566, 64581, 64585) are reviewed by Carelon with CG‑SURG and MCG guideline references; obtain authorization from Carelon for these services.

• Representative codes: 64561, 64566, 64581, 64585.
• Criteria referenced include CG‑SURG‑95 and CG‑SURG‑126 and MCG guidelines.

Neurolytic/ablation procedures — Carelon review

Neurolytic and ablation procedures (radiofrequency and similar destruction) such as 64625, 64629, 64633–64636 are reviewed by Carelon under Interventional Pain Management and MCG guidance and require prior authorization.

• Examples: 64625 (sacroiliac joint RFA), 64629 (basivertebral nerve thermal destruction), 64633–64636 (neurolytic facet procedures).
• Submit requests to Carelon and reference Interventional Pain Management/MCG criteria.

Advanced imaging, radiation & surgical procedures — Carelon review

A broad set of advanced imaging, radiation therapy, CT/MR, angiography and other surgical procedure codes (examples listed across chunks 112–127) are reviewed by Carelon and cross‑referenced to specific Carelon criteria/guidelines (Imaging of the Brain/Heart/Abdomen, Radiation Therapy, Site of Care for Advanced Imaging); obtain prior authorization where indicated.

• Includes CT/MR/CTA, angiography, advanced imaging and radiation therapy codes listed in the referenced sections.
• Follow the code-level Carelon criteria/guideline (Imaging of the Heart/Brain/Abdomen, Radiation Therapy, Site of Care) when requesting authorization.

Pelvic MRI/MRA — Carelon review required

Magnetic resonance imaging of the pelvis (72195–72198) is reviewed by Carelon Medical Benefits Management and governed by Imaging of the Abdomen and Pelvis, Oncologic Imaging, Site of Care for Advanced Imaging, and Vascular Imaging criteria.

• Codes: 72195–72198 (pelvic MRI/MRA variants).
• Submit authorization requests to Carelon using Imaging of the Abdomen and Pelvis / Oncologic Imaging criteria.

Extremity imaging — submit to Carelon for review

Upper and lower extremity CT/MR/angiography imaging codes (e.g., 72295, 73200–73223, 73700–73725) are reviewed by Carelon under Imaging of the Extremities, Oncologic Imaging and Site of Care for Advanced Imaging; obtain prior authorization when applicable.

• Representative codes: 73200, 73206, 73218–73223, 73700–73718.
• Follow Imaging of the Extremities and Site of Care guidance when submitting to Carelon.

Abdomen & pelvis imaging — Carelon prior authorization

Abdomen and pelvis CT/MR/CTA and CT colonography codes (e.g., 74150–74183, 74174, 74261–74263) are reviewed by Carelon Medical Benefits Management and governed by Imaging of the Abdomen and Pelvis, Oncologic Imaging and Site of Care for Advanced Imaging criteria.

• Examples: 74150–74183 series, 74174 (CTA abdomen/pelvis), 74261–74263 (CT colonography).
• Submit prior authorization to Carelon per the Imaging of the Abdomen and Pelvis / Oncologic Imaging criteria.

Cardiac & fetal imaging — Carelon review

Fetal MRI and advanced cardiac imaging codes (e.g., 74712, 75557–75574, 75571–75574) are reviewed by Carelon and governed by Imaging of the Abdomen and Pelvis and Imaging of the Heart criteria; submit requests to Carelon for prior authorization.

• Representative codes: 74712 (fetal MRI), 75557–75574 (cardiac MRI/CT/CTA).
• Follow Carelon Imaging of the Heart and related criteria when submitting.

Breast, ultrasound & bone imaging — submit for Carelon review

Breast imaging (MRI), ultrasound and bone imaging codes (e.g., 77046–77049, 77078, 77084) are assigned to Carelon Medical Benefits Management and governed by Radiation Therapy guidance and Imaging of the Chest/Spine criteria; obtain prior authorization as required.

• Representative codes: 77046–77049 (breast MRI), 77078 (bone density), 77084 (bone marrow imaging).
• Submit to Carelon per the listed imaging and radiation therapy criteria.

Radiation, proton & brachytherapy procedures — Carelon prior auth

Radiation therapy planning, delivery, proton therapy and brachytherapy procedure codes (e.g., 77295, 77301, 77316, 77370, 77371–77373, 77402–77435, 77520–77525, 77761–77772) are reviewed by Carelon and governed by Radiation Therapy (excludes Proton), Proton Beam Therapy and related MCG/GRG oncology guidance; obtain prior authorization as indicated.

• Includes radiation planning/delivery codes (77295, 77301, 77316, 77370, 77371–77373), treatment delivery (77402–77435) and proton therapy (77520–77525).
• Carelon is the responsible party; follow Radiation Therapy / Proton Beam Therapy criteria for authorization.

Radiation / Proton therapy prior authorization responsibility

Carelon Medical Benefits Management is the responsible party for listed radiation and proton therapy delivery and intraoperative/special radiation procedure codes; follow the associated Carelon criteria (Radiation Therapy; Proton Beam Therapy) when submitting for prior authorization.

• Representative codes: 77435, 77469, 77520, 77522–77525 and related intraoperative radiation codes.
• Submit authorization requests to Carelon and reference the Radiation Therapy or Proton Beam Therapy criteria.

Cardiac imaging prior authorization (PET/SPECT)

Myocardial and cardiac imaging (PET/SPECT/planner) codes (e.g., 78429–78433, 78491–78494) are reviewed by Carelon Medical Benefits Management under Imaging of the Heart criteria; prior authorization must be submitted to Carelon.

• Examples: 78429–78433 (myocardial PET) and 78491–78494 (myocardial PET perfusion).
• Follow Carelon Imaging of the Heart criteria for authorization requirements.

PET / oncologic imaging & radiopharmaceutical therapy — Carelon review

PET/oncologic imaging and radiopharmaceutical therapy codes (e.g., 78608–78609, 78811–78815, 79403) are the responsibility of Carelon and are evaluated using Imaging of the Brain/Chest/Extremities/Spine and related Carelon criteria for prior authorization.

• Representative codes: 78608–78609 (brain PET), 78811–78815 (PET limited/skull base/whole body), some radiopharmaceutical therapy codes.
• Submit to Carelon and reference Imaging of the Brain/Chest/Spine and associated Carelon criteria.

Genetic testing prior authorization responsibility (somatic/hereditary/carrier)

Genetic testing codes for somatic tumor testing, hereditary cancer testing and carrier screening (examples: 81120–81174 series, 81200–81209, 81400–81408) are reviewed by Carelon Medical Benefits Management and require prior authorization per the referenced Carelon genetic testing criteria.

• Representative codes: 81162 (BRCA full sequence), 81200–81209 (various gene analyses), 81400–81408 (molecular pathology levels).
• Follow Carelon Somatic Tumor Testing, Hereditary Cancer Testing, Carrier Screening and molecular pathology criteria when requesting authorization.

Additional genetic testing prior authorization responsibility

Additional genetic testing and cytogenomic codes (e.g., 81200–81204, 81205–81217, 81228–81237) are assigned to Carelon for review and are governed by Carrier Screening, Hereditary Cancer Testing and Somatic Tumor Testing criteria; submit prior authorization to Carelon.

• Codes include 81200–81209 (inherited/carrier variants), 81228–81229 (cytogenomic CGH microarray), 81230–81237 (pharmacogenetic/somatic testing).
• Carelon criteria: Carrier Screening in the Reproductive Setting, Genetic Testing for Inherited Conditions, Somatic Tumor Testing, Pharmacogenetic Testing.

Genetic test codes (sample) — Carelon responsible

Sample genetic test codes (81200–81204) are reviewed by Carelon Medical Benefits Management; providers should submit authorization requests to Carelon and reference the listed Carrier Screening and Hereditary Cancer Testing criteria.

• Codes: 81200–81204 (examples of inherited/carrier testing).
• Refer to Carelon Carrier Screening and Hereditary Cancer Testing guidance when submitting.

Upper GI endoscopy codes requiring Carelon review

Upper GI endoscopy codes requiring review (see list: 43229, 43233–43251, 43254–43270) must be submitted to Carelon Medical Benefits Management and are evaluated using CG‑MED‑59, CG‑SURG‑101 and MCG Guidelines for authorization.

• Full list includes 43229, 43233–43251, 43254–43270 as enumerated in the document.
• Apply CG‑MED‑59 / CG‑SURG‑101 / MCG criteria in requests to Carelon.

Urologic & gynecologic codes — Carelon review & criteria

Urologic and gynecologic procedure codes (e.g., prostate brachytherapy, interstitial radioelement placement, HIFU) are assigned to Carelon and reference Radiation Therapy (excludes Proton), CG‑MED‑81 and MCG guidance; obtain prior authorization from Carelon.

• Examples: 51721, 55706, 55875–55882, 55920, 57155–57156.
• Follow Carelon Radiation Therapy and CG‑MED‑81 / MCG references when submitting.

Mixed surgical & interventional codes — follow Carelon criteria

A mixed set of surgical and interventional codes (including injective, radiosurgery, spine procedures) listed are subject to Carelon review; submit prior authorization to Carelon and follow the code-level MCG/CG criteria referenced.

• Includes codes across surgical, radiosurgery, spine and injection groups (see code lines for specifics).
• Requests evaluated per MCG, CG‑SURG and other Carelon guidance shown per code.

Spine surgery codes — Carelon prior authorization required

Spine surgery codes throughout the document are subject to prior authorization review by Carelon and are governed by Carelon Level of Care for Surgical Procedures and MCG Spine Surgery guidance; providers must submit authorization requests to Carelon.

• Numerous spine codes (laminectomy, laminoplasty, fusion, decompression) are listed across the spine sections.
• Apply Carelon Spine Surgery / MCG criteria when requesting authorization.

Neurostimulation codes — submit to Carelon

Selected spinal neurostimulation and peripheral neurostimulation codes (e.g., 63650, 63655, 63685, 64561, 64581) are reviewed by Carelon using Interventional Pain Management and CG‑SURG criteria; obtain prior authorization from Carelon.

• Examples: 63650, 63655, 63685 (spinal), 64561, 64581 (sacral).
• Follow Carelon Interventional Pain Management and CG‑SURG references in submissions.

Interventional pain injection codes — Carelon review & site-of-care mapping

Interventional pain injection codes (transforaminal, epidural, facet) such as 64479, 64483, 64490–64495 are subject to Carelon review and mapped to Interventional Pain Management and Site of Care for Surgical Procedures (MCG) guidance; prior authorization required when indicated.

• Representative codes: 64479, 64480, 64483, 64490–64495.
• Carelon applies Site of Care and MCG Minor Procedure GRG guidance in authorization decisions.

Neurostimulation procedures — Carelon authorization required

Neurostimulation procedures including posterior tibial neurostimulation and related revisions/removals (e.g., 64561, 64566, 64585) are managed by Carelon and reference CG‑SURG and MCG guidelines; submit prior authorization to Carelon.

• Codes include 64561, 64566, 64581, 64585.
• Carelon references CG‑SURG‑95 / CG‑SURG‑126 and MCG guidance for review.

Neurolytic & ablation procedures — Carelon review

Neurolytic/ablation procedures (e.g., 64625, 64629, 64633–64636) are reviewed by Carelon under Interventional Pain Management and MCG guidance and require prior authorization per the listed criteria.

• Representative codes: 64625 (sacroiliac RFA), 64629 (basivertebral nerve thermal destruction), 64633–64636 (neurolytic facet nerve destruction).
• Refer to Carelon Interventional Pain Management and MCG criteria for authorization.

Advanced imaging, radiation & surgical codes — follow Carelon criteria

Listed advanced imaging, radiation and surgical procedure codes (comprehensive code lists provided) are reviewed by Carelon and cross‑referenced to Carelon criteria such as Imaging of the Brain/Abdomen/Heart, Site of Care for Advanced Imaging, Radiation Therapy and Oncologic Imaging; providers must submit prior authorization to Carelon.

• Examples include CT/MR codes (70450–70498, 70540–70555, 71250–71275, 72125–72199, etc.) and radiation planning/delivery codes.
• Follow the specific Carelon imaging/radiation criteria listed for each code when requesting authorization.

Pelvic MRI/MRA — Carelon prior authorization

Pelvic MRI/MRA codes (72195–72198) are reviewed by Carelon and governed by Imaging of the Abdomen and Pelvis, Oncologic Imaging, Site of Care for Advanced Imaging and Vascular Imaging criteria; submit for prior authorization to Carelon.

• Codes: 72195–72198.
• Carelon criteria: Imaging of the Abdomen and Pelvis, Oncologic Imaging, Site of Care for Advanced Imaging, Vascular Imaging.

Extremity imaging review — Carelon responsible

Extremity imaging codes (upper/lower CT/MR/angiography; e.g., 73200–73223, 73700–73718) are reviewed by Carelon under Imaging of the Extremities, Oncologic Imaging and Site of Care for Advanced Imaging criteria; obtain authorization from Carelon as required.

• Representative codes: 73200, 73206, 73218–73223, 73700–73718.
• Submit requests to Carelon and reference the Imaging of the Extremities / Oncologic Imaging guidance.

Abdomen & pelvis imaging — Carelon prior authorization

Abdomen and pelvis imaging (CT/MR/CTA and CT colonography codes such as 74150–74183, 74174, 74261–74263) are reviewed by Carelon and require prior authorization per Imaging of the Abdomen and Pelvis, Oncologic Imaging and Site of Care for Advanced Imaging criteria.

• Examples: 74150, 74174, 74176, 74181–74183, 74261–74263.
• Carelon is responsible for authorization and applies the named imaging criteria.

Cardiac & fetal imaging — submit to Carelon

Cardiac and fetal imaging codes (e.g., 74712 fetal MRI, 75557–75574 cardiac MRI/CT/CTA) are reviewed by Carelon under Imaging of the Abdomen/Pelvis and Imaging of the Heart criteria; submit prior authorization to Carelon for these services.

• Representative codes: 74712, 75557–75574, 75571–75574.
• Follow Carelon Imaging of the Heart and related criteria when requesting authorization.

Breast, ultrasound & bone imaging — Carelon review

Breast MRI, ultrasound and bone imaging (e.g., 77046–77049, 77078, 77084) are reviewed by Carelon and governed by Radiation Therapy and Imaging of the Chest/Spine criteria; obtain prior authorization from Carelon when required.

• Representative codes: 77046–77049 (breast MRI), 77078 (bone density), 77084 (bone marrow imaging).
• Submit to Carelon and reference the appropriate imaging/radiation criteria.

Radiation & proton therapy codes — Carelon prior authorization

Radiation therapy and proton/brachytherapy codes (e.g., 77295, 77301, 77316, 77371–77373, 77402–77435, 77520–77525, 77761–77772) are the responsibility of Carelon and require prior authorization per Radiation Therapy (excludes Proton) or Proton Beam Therapy criteria.

• Includes planning (77295, 77301), delivery (77402–77435), brachytherapy (77316, 77371–77373) and proton therapy (77520–77525).
• Carelon applies Radiation Therapy or Proton Beam Therapy criteria for authorization decisions.

Carelon is the responsible reviewer for listed codes

Carelon Medical Benefits Management reviews the listed codes (including genetic, imaging, interventional and surgical services); providers must follow the referenced Carelon criteria/guidelines for prior authorization or clinical review when submitting these services.

• Large code set across specialties assigned to Carelon for review.
• Always reference the specific Carelon criteria/MCG/CG guidance listed in each code line when requesting authorization.

Coronary angiography & catheterization — Carelon review

Catheter angiography and coronary angiography codes (e.g., 93457–93461) are reviewed by Carelon Medical Benefits Management per Diagnostic Coronary Angiography and MCG Guidelines; submit prior authorization to Carelon.

• Codes include 93457–93461 for coronary angiography/catheter placement with various catheterization combinations.
• Carelon applies Diagnostic Coronary Angiography and MCG guidelines for authorization.

Electrophysiology studies & ablation — Carelon prior review

Electrophysiology study and ablation procedure codes (e.g., 93600–93624, 93650, 93653, 93654, 93619, 93613) are reviewed by Carelon under Electrophysiological Studies and Transcatheter Ablation MCG guidelines; prior authorization submission to Carelon is required.

• Representative codes: 93600, 93602–93624, 93613, 93619, 93653–93654 series.
• Carelon evaluates per Electrophysiological Studies / Transcatheter Ablation MCG guidance.

Vascular imaging prior review — submit to Carelon

Vascular imaging and physiologic study codes (e.g., 93880, 93882, 93922–93926, 93930–93931) are reviewed by Carelon Medical Benefits Management under Vascular Imaging criteria; submit prior authorization to Carelon when indicated.

• Examples: 93880 (duplex extracranial arteries), 93922–93926 (physiologic studies), 93930–93931.
• Requests are evaluated per Carelon Vascular Imaging criteria.

Sleep & respiratory procedures — Carelon review

Sleep and respiratory procedure codes (e.g., 94667–94668, 95782–95783, 95800–95811) are reviewed by Carelon Medical Benefits Management under Sleep Disorder Management and related therapy guidelines; obtain prior authorization from Carelon when required.

• Representative codes: 95782–95783 (pediatric polysomnography), 95800–95811 (sleep studies), 94667–94668 (chest wall manipulation).
• Carelon evaluates these under Sleep Disorder Management criteria.

Neurodiagnostic, imaging & therapy services — Carelon prior review

Neurodiagnostic, specialized imaging, and broad therapy service codes (autonomic testing, MEG, reflectance confocal microscopy, PT/OT/SLP modalities and evaluations) are reviewed by Carelon and referenced to MED and therapy/site‑of‑care guidelines; submit prior authorization to Carelon as indicated.

• Includes codes such as 95921–95923 (autonomic), 95965–95967 (MEG), 96934–96936 (RCM), and many PT/OT/SLP codes (97010, 97110, 97129–97168, etc.).
• Follow the specific MED or therapy/site‑of‑care criteria listed per code when requesting authorization.