Prior authorization required; verify benefits and submit via portal

Prior authorization is required for services and procedures that appear on the current ASO prior authorization list; authorization does not guarantee payment. Verify member benefits and eligibility before providing services and submit electronic preauthorization requests via the secure provider portal (or call the number on the member ID card).

• Prior authorization required for services on the current list; authorization is not a guarantee of payment.
• Verify benefits and eligibility using the member benefit booklet or contact customer service.
• Registered users may submit electronic preauthorization requests via the secure provider portal; call the number on the member ID card or Provider Relations for help.

Notification (not PA) requested for care coordination

For certain services the plan requests notification (not prior authorization) to support discharge planning, care coordination, and case management; these notifications do not replace medical necessity review and are used for operational coordination.

• Notification is requested for some services to assist providers and members with discharge planning, care coordination, and case management.
• All services must still be medically necessary and eligibility/benefit limits apply.

Partial CPT code listing provided for ASO PA/notification

This document includes a partial CPT listing used to identify procedures subject to ASO prior authorization/notification; reference the listed codes when submitting requests.

• Excerpt includes vertebral augmentation, arthrodesis, instrumentation and other spine procedures and continues into shoulder and joint procedures (see code list in policy).

Reference knee arthroscopy / arthroplasty CPT mappings (29867–29871)

Knee arthroscopy and knee arthroplasty/meniscal procedure mappings are listed and must be referenced for ASO processing; examples include 29867, 29868, 29870, and 29871 with effective dates noted.

• 29867 — Arthroscopy, knee, surgical; osteochondral allograft (eg, mosaicplasty).
• 29868 — Arthroplasty, knee, condyle and plateau; medial AND lateral compartments (mapping to meniscal transplantation).
• 29870, 29871 — mappings to diagnostic or infection-related arthroscopy entries; effective 10/1/2018 noted.

Knee and hip arthroscopy code mappings (29874–29889; 29914–29916)

Additional knee and hip arthroscopy CPT mappings are listed and should be used when requesting prior authorization; examples include codes 29874–29889 and hip arthroscopy codes 29914–29916.

• 29874–29889 — multiple knee arthroscopy surgical mappings (synovectomy, meniscectomy, repairs, ACL/PCL procedures) with effective dates 10/1/2018.
• 29914–29916 — hip arthroscopy mappings (femoroplasty, acetabuloplasty, labral repair) with effective dates 10/1/2018.

ENT and airway procedure CPT mappings (rhinoplasty, nasal valve, bronchial thermoplasty)

ENT and airway procedure code mappings (including rhinoplasty, nasal valve repair, and bronchial thermoplasty cross-maps) are included in the ASO listing and must be referenced for authorization requests.

• 30400–30468 — rhinoplasty and nasal valve procedure mappings (effective dates shown).
• 31660–31661 — bronchial thermoplasty cross-maps (31660/31661 effective 5/1/2023 = 1/1/2023).
• 31660/31661 cross-mapped to nasal valve repair and bronchial thermoplasty entries (see policy).

Thoracic and cardiac procedure code mappings (lung transplant, thoracoscopy, cardiac devices)

Thoracic and cardiac procedure mappings (including lung transplant, thoracoscopy, and multiple cardiac device and valve procedure cross-maps) are listed and must be used for ASO prior authorization.

• 32851–32854 — lung transplant single/double mappings (effective 5/1/2023 = 1/2/2020).
• 33267–33275, 33289 — left atrial appendage exclusion, leadless pacemaker and implanted sensor mappings (effective dates shown).
• 33340, 33361–33366 and related TAVR/TAVI mappings and effective dates included.

Cardiac and venous procedure CPT mappings (transplant, VAD, TAVR, venous procedures)

Cardiac transplant, VAD, TAVR and venous procedure code mappings are enumerated for authorization reference; providers must reference these codes (examples: 33365–33366, 33927–33983, 34839 and venous mapping codes).

• 33365–33366 — TAVR approach mappings (effective 1/2/2020).
• 33927–33983 — heart transplant, VAD insertion/replacement mappings (effective dates shown).
• 34839 — physician planning of patient-specific fenestrated aortic endograft (effective 1/2/2020 = 4/1/2021).

Venous/vascular procedure CPT mappings (endovenous ablation, ligation/stripping)

Endovenous and vascular procedure mappings (including endovenous ablation, ligation/stripping and related vascular surgery codes) are listed and must be used when submitting prior authorization requests.

• 36465–36483 and 36470–36478 — sclerotherapy and endovenous ablation therapy mappings with effective dates (eg, 36483 effective 3/1/2023).
• 36836–36837 — percutaneous arteriovenous fistula creation mappings (noted 3/1/2023 = 5/1/2023).
• 37700–37799 series — ligation/stripping and unlisted vascular surgery mappings with dates.

Transplant preparation and bariatric procedure code mappings (38206–38241; 43210; 43644–43773)

Transplant preparation and bariatric/gastric procedure code mappings (including HPC preparation and bariatric device/balloon codes) are included and must be referenced for authorization.

• 38206–38214, 38240–38241 — hematopoietic progenitor cell (HPC) transplant preparation and related mappings (effective dates shown).
• 40799 — unlisted transplant-related procedure (effective date shown).
• 43210, 43290–43291, 43644–43773 — EGD with bariatric procedures and gastric restrictive procedure mappings (effective dates noted).

CPT and unlisted procedure mapping excerpt (reference codes and effective dates)

The CPT and unlisted procedure mapping excerpt lists specific CPTs and unlisted mappings used for ASO processing; providers should reference the listed code descriptions and effective dates when requesting authorization.

• Examples include 38240–38241 (HPC prep), 40799 (unlisted), and other mapped CPT entries with effective-date annotations.

Procedural CPT listing (partial) for ASO PA/notification

A partial procedural CPT listing is provided for ASO prior authorization/notification; use the code list in the policy when preparing authorization requests.

• Excerpt includes intrathecal/epidural device implantation codes (62350–62362), decompression and laminectomy codes (62380, 63001–63005) and other procedures with effective dates.

Head/neck CT and MRI CPT codes (70481–70498; 70540–70549)

Head and neck CT and MRI CPT codes (70481–70555 series and 70540–70549) and their contrast/non-contrast permutations are listed with effective dates and must be referenced for imaging authorizations.

• 70481–70498 — CT orbit/maxillofacial/neck series with contrast/noncontrast mappings (effective 8/1/2018).
• 70540–70549 — MRI orbit/face/neck series with contrast/noncontrast mappings (effective 8/1/2018).
• 70496 and 70498 include CTA/head and neck with image postprocessing entries.

Thorax and spine CT/MR codes and crosswalks

Thorax and spine CT/MR code mappings and CTA crosswalks are listed (e.g., 71275, 71550–71555, 72125–72133) and must be used when requesting authorization for thoracic or spinal imaging.

• 71275 — CT thorax crosswalk to CTA chest with image postprocessing (effective 8/1/2018).
• 71550–71552, 71555 — chest CT/MR crosswalks for mediastinal evaluation (effective 8/1/2018).
• 72125–72133, 72141–72142 — cervical/thoracic/lumbar spine CT/MR mappings (effective dates shown).

Pelvis and upper-extremity imaging codes (CTA/CT/MR and discography crosswalks)

Pelvis and upper extremity CT/MR/CTA codes—including discography crosswalks—are enumerated; reference codes such as 72192–72198 and 72285/72295 when requesting authorization for these studies.

• 72192–72198 — CTA pelvis and associated MRI/CT crosswalks (effective 8/1/2018).
• 72285/72295 — discography crosswalks to CTA with image postprocessing; effective 1/1/2023 noted for discography entries.

Lower extremity / abdomen / pelvis imaging CPT codes

Lower extremity, abdomen, pelvis and specialized CT/MR codes (e.g., 73700–73725, 74150–74187, 74261–74262) and CT colonography mappings are listed for ASO authorization reference.

• 73700–73725 — lower extremity CT/MR and CTA mappings (effective 8/1/2018).
• 74150–74187 — abdominal and pelvic CT/MR, CT angiography and postprocessing codes (effective 8/1/2018).
• 74261–74262 — CT colonography with image postprocessing (effective 8/1/2018).

Cardiac imaging, CTA and postprocessing codes (75557–75577; 76376–76391)

Cardiac CT/MRI and advanced postprocessing/3D rendering codes are included (e.g., 75557–75577, 75635, 76376–76391); note 75577's mapping date update to 5/1/2026.

• 75557–75563, 75571–75577 — cardiac MRI/CT and CTA codes including 3D postprocessing; 75577 mapping date updated to 5/1/2026.
• 75635, 76376–76377 — CTA abdominal/iliac runoff and 3D rendering/postprocessing descriptors with effective dates.
• 76380–76391, 76497–76498 — additional cardiac CT/MR postprocessing and unlisted imaging procedure codes.

Ancillary imaging and therapeutic radiology CPT codes

Ancillary imaging and therapeutic radiology codes (ultrasound guidance, MRI guidance, breast MRI, bone density, and therapeutic radiology planning/simulation) are listed and must be used for ASO processing.

• 76873, 76979 — ultrasound and contrast characterization entries with effective dates.
• 77021–77049 — MRI guidance and breast MRI codes (effective dates shown).
• 77262–77299, 77300–77338, 77372–77425 — therapeutic radiology planning, simulation, treatment delivery and management codes with 10/1/2021 date notes.

ASO prior authorization/notification listing — Part 7

This section is the ASO Prior Authorization/Notification listing (part 7) and identifies codes subject to ASO prior authorization/notification for self-funded clients; providers must reference the ASO list when initiating requests.

• Part 7 header indicates the codes that follow are within the Self-funded ASO prior authorization/notification catalog.

Procedure and nuclear medicine CPT listings (partial)

Procedure and nuclear medicine code listings (e.g., 78494–78499, 78579–78598 and related series) are provided for ASO consideration and must be referenced for authorization/notification.

• 78494–78499 — myocardial PET perfusion imaging and cardiac blood pool imaging equivalencies (effective 9/1/2018).
• 78579–78598 — PET perfusion equivalency mappings and pulmonary imaging crosswalks (effective dates noted).
• 78430–78432 and other nuclear medicine cardiac imaging codes are included in the listing.

Molecular pathology / genetic test CPT listings (partial)

Molecular pathology and genetic test CPT codes (for example 81161–81351 and the 81408–81430 series) and their panel descriptions and effective dates are enumerated — providers must include the specific CPT when requesting authorization.

• 81162, 81163, 81164, 81175, 81194 and other genetic test codes with effective dates.
• 81408–81411, 81412–81416 and related Level 8/9 molecular pathology codes with panel descriptors and required gene inclusions.

Molecular pathology / genomic panels — required gene lists and minimum gene counts

Selected molecular pathology/genomic sequence analysis panels are specified with required gene lists or minimum gene counts (examples include 81410 requiring at least 9 specified genes and 81412 requiring sequencing of at least 9 genes).

• 81410 — aortic dysfunction/dilation panel must include sequencing of at least 9 genes including FBN1, TGFBR1, TGFBR2, COL3A1, MYH11, ACTA2, SLC2A10, SMAD3, and MYLK.
• 81412 — Ashkenazi Jewish associated disorders panel must include sequencing of at least 9 genes (ASPA, BLM, CFTR, FANCC, GBA, HEXA, IKBKAP, MCOLN1, SMPD1).
• 81413–81416 — cardiac ion channelopathies and exome/comparator descriptors with minimum gene counts noted.

Expanded genomic panels (81430–81456) — gene-count thresholds and requirements

Expanded genomic panels and duplication/deletion panels (e.g., 81430, 81431, 81439, 81442, 81448–81451, 81455) are listed with required gene-count thresholds or specific gene inclusions and effective dates; reference these entries for authorization.

• 81430 — hearing loss genomic sequence analysis panel example must include sequencing of at least 60 genes (effective dates shown).
• 81439 — hereditary cardiomyopathy panel must include sequencing of at least 5 cardiomyopathy-related genes.
• 81442 — Noonan spectrum disorders panel must include sequencing of at least 12 specified genes.

Gene expression / algorithmic assay CPT codes (examples 81503–81541)

Gene expression and algorithmic assays (CPT codes such as 81503, 81504, 81518, 81519 and others) are enumerated with sample type and algorithm output descriptors; providers must include the specific code when requesting prior authorization.

• 81503 — mRNA gene expression profiling (coronary artery disease mapping to oncology examples), effective 1/1/2023 = 7/1/2025.
• 81518, 81519, 81520–81525 — breast and other oncology expression profiling codes with effective dates and algorithmic output descriptors.
• Providers must reference the exact CPT for algorithmic assays when submitting authorization requests.

Laboratory / immunology / vaccine code listings (selected)

Laboratory, immunology and vaccine CPT/HCPCS codes (e.g., 81560, 81595, 82523, 84999, 86015, 86036–86037, 88267–88269, 90378–90381) are listed with effective dates; use the listed codes in notifications or prior authorization submissions.

• 81560, 81595 — transplant and cardiac transplant gene expression/rejection risk assays with effective dates.
• 90378–90381 — RSV monoclonal antibody dosing codes and effective dates.
• 86015, 86036–86037 — immunology antibody testing entries and dates.

Imaging / monitoring / cardiac catheterization CPT codes

Imaging, monitoring and cardiac catheterization codes (e.g., 91110–91113, 92065, 92145, 92548, 92970, 93264, 93451–93461) are enumerated with effective dates and must be used when seeking authorization for related services.

• 93451–93461 — right and left heart catheterization and related combined procedures with effective date notes (11/1/2024 for many entries).
• 93264 — remote monitoring of pulmonary artery pressure sensor for up to 30 days (effective 4/1/2021).
• 91110–91113 — capsule endoscopy and gastrointestinal tract imaging codes with effective dates.

Interventional / congenital catheterization CPT codes (93590–93597)

Interventional and congenital catheterization procedure codes (e.g., 93590–93597 series) are included with effective dates; reference these codes for ASO prior authorization.

• 93590–93592 — percutaneous transcatheter closure of paravalvular leak mappings (effective 1/1/2023 for some entries).
• 93593–93597 — right/left heart catheterization codes for congenital defects with effective dates through 11/1/2024.

Unlisted and miscellaneous CPT/U-code listings (selected)

Unlisted and miscellaneous procedure codes (including unlisted cardiovascular, neurophysiology, psychological testing, home visit, and proprietary genomic assay codes such as 0001U, 0003U, 0005U) are listed with descriptors and effective dates — providers must reference these when applicable.

• 95905, 95940–95941 — neurophysiology monitoring and unlisted cardiovascular service mappings with dates.
• 96130–96139 — psychological testing and administration codes with effective dates.
• 0001U, 0003U and other U-codes — proprietary genomic/laboratory codes listed with effective dates.

Use ASO code & test listing when requesting PA/notification

Providers must reference the ASO code and test listing when requesting prior authorization/notification; the listing contains CPT/HCPCS and proprietary codes with descriptors and effective dates used to determine ASO requirements.

• The ASO list is the authoritative code catalog for self-funded prior authorization/notification requirements; providers must reference the specific code(s) when submitting requests.

Partial listing of temporary/proprietary U/T codes for ASO processing

A partial listing of temporary/proprietary U-codes and T-codes (examples: 0152U, 0153U, 0142U) is provided for ASO prior authorization/notification workflows; include these codes exactly when applicable.

• 0152U — microbial cell-free DNA, untargeted NGS (infectious disease), effective 1/1/2023.
• 0153U — oncology (breast) mRNA NGS gene expression profiling (101 genes), effective 1/1/2023.
• 0142U and other U/T entries appear in the partial list with effective date annotations.

Code list and descriptors (Part 12) — molecular/genomic and specialized lab services

Part 12 code list enumerates CPT/HCPCS molecular/genomic and specialized laboratory services (0265U–0352T range entries) with descriptors and effective dates; include the exact CPT/U/T code when seeking authorizations.

• 0265U–0268U — genomic and whole-transcriptome test entries with effective dates (eg, 0265U effective 1/1/2022).
• 0266U–0268U — whole-transcriptome and hematology genomic panels described for ASO consideration.

Enumerated T-code and U-code listings (Part 13) for ASO authorization

Part 13 enumerates CPT T-codes and proprietary U-codes with descriptors and effective dates for ASO prior authorization/notification; providers must use these specific codes in requests.

• 0347T/0348T and 0347U/0348U — radiostereometric analysis and drug metabolism U-codes with 1/1/2023 effective dates.
• 0478U and other U/T codes — oncology genomic panels and device/procedure codes with effective/expiration dates (eg, 0478U effective 7/1/2025).

Code listing — authorization reference (selected T- and U-codes)

Specific T- and U-code authorization reference entries (examples: 0478U, 0479T, 0480T, 0481T/0481U, 0483T–0485T/0485U) are listed with descriptors and effective/expiration dates; use the exact code and descriptor when requesting authorization.

• 0478U — Oncology (NSCLC) DNA/RNA digital PCR panel of 9 genes (effective 7/1/2025).
• 0481T/0481U — autologous white blood cell concentrate injection and IDH1/IDH2/TERT NGS descriptors with dates.
• 0483T–0485T series — transcatheter mitral valve implantation and related T-code entries (effective 1/1/2023).

Oncology and advanced diagnostic code entries (selected U-codes)

Additional oncology and novel diagnostic codes (e.g., 0525U spheroid cell culture drug panel, 0530U ctDNA NGS panel) are included for authorization consideration; include the listed code and descriptor when submitting requests.

• 0525U — oncology spheroid cell culture 11-drug panel for ovarian response prediction (effective 7/1/2025).
• 0530U — oncology pan-solid tumor ctDNA NGS panel (77 genes + fusions, MSI, TMB) with interpretative report (effective 7/1/2025).

Category III CPT codes (selection) — reference T-code list

A selection of Category III CPT (T) codes are listed for ASO prior authorization/notification (examples: 0580T–0600T series); providers must reference the specific T-code when applicable.

• 0580T–0600T series — Category III codes including removal of defibrillator pulse generator, anatomic model 3D printing, irreversible electroporation ablation (effective 1/1/2023 for many).
• Sample entries include 0580T (removal of substernal ICD generator) and 0600T (irreversible electroporation ablation).

Category III CPT codes (additional) — T-code examples

Additional Category III CPT (T) codes are listed (0620T–0640T range examples) with effective dates; include the exact T-code when requesting authorization for emerging technologies or procedures.

• 0620T, 0621T, 0627T–0635T — includes ablation and device/programming-related T-codes (effective 1/1/2023).
• 0627T–0630T — percutaneous injection of allogeneic cellular/tissue products for intervertebral disc and other interventions (effective 1/1/2023).

Category III CPT codes (May 2023 batch) — T-code listings

The May 2023 batch of Category III CPT codes (0673T–0697T and related entries) is enumerated with effective dates (many effective 5/1/2023); providers must reference these T-codes exactly for ASO prior authorization/notification.

• 0673T–0677T and 0683T–0694T — includes ablation, device programming, histotripsy, and 3D imaging/reconstruction codes with effective dates 5/1/2023.
• 0690T–0694T — quantitative ultrasound, automated CT vertebral fracture analysis, therapeutic ultrafiltration and 3D specimen imaging codes (effective 5/1/2023).