CurrentBaylor Scott & White Health PlanPolicy N/A

Self-funded ASO Prior Authorization/Notification

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Governance of prior authorization and notification requirements for Baylor Scott & White Health Plan acting as third‑party administrator for self‑funded (ASO) employer-sponsored plans, including how providers submit requests and that benefits vary by member plan.

Policy Summary

PayerBaylor Scott & White Health Plan

PolicySelf-funded ASO Prior Authorization/Notification

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateMay 1, 2026

Next Review DateN/A

Key ActionVerify member benefits and submit electronic preauthorization requests via the secure provider portal or call the number on the member ID card.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

20+CPT codes in excerpt

MultipleSpecialties represented

MultipleCodes effective 1/1/2023

Part 4–15Document part

Key Definitions

Prior Authorization — overview

DefinitionPrior Authorization is a payer determination process that does not guarantee benefits or payment at the time of service; reimbursement of authorized services depends on member eligibility and benefit limitations/exclusions.

VerificationBenefits vary by plan; providers must verify coverage via the member benefit booklet or contact customer service.

SubmissionRegistered users may submit electronic preauthorization requests via the Baylor Scott & White Health Plan secure provider portal or call the number on the member ID card.

Self-funded ASO — third‑party administrator

RoleScott and White Health Plan serves as a third-party administrator for self-funded employer-sponsored plans (Administrative Services Only - ASO).

ScopeApplies to self-funded ASO employer-sponsored plans administered by Scott and White Health Plan; related subsidiaries serve insured products separately.

ResponsibilityPlan acts as the ASO administrator and maintains the prior authorization/notification listing for self-funded accounts.

ASO prior authorization/notification — label

Short labelASO Prior Authorization/Notification

Alternate useIncludes both prior authorization and requested notifications to support discharge planning and care coordination.

Applies toProcedure and service codes (CPT/HCPCS/U/T) listed in the ASO code listing maintained by the plan.

CPT — code system

Code systemCurrent Procedural Terminology (CPT) codes

UsageCPT codes are used to identify procedural services in the ASO prior authorization/notification listing.

Cross-referenceCPT entries in the listing include short descriptors and administrative/effective dates for routing authorizations.

CPT mapping lines — examples with effective dates

00170Anesthesia for intraoral procedures, including biopsy — Effective Date = 1/2/2020

29867-29871Knee arthroscopy/arthroplasty related procedures — Effective Date = 10/1/2018 (per entries)

43770-43775, 43648Gastric restrictive and related procedures — Effective Dates include 1/2/2020 (mapping lines show dates)

Administrative date — meaning

MeaningDate shown after code entries represents an administrative/effective date related to the ASO prior authorization/notification listing.

Example62325, 2 = 10/1/2018 (injection with imaging guidance) — the trailing date denotes the listed effective/administrative date.

ImplicationProviders should use the effective date in the listing when determining whether a code currently requires ASO prior authorization/notification.

ASO prior authorization/notification — alternate phrasing

Alternate phrasingASO Prior Authorization / Notification (self-funded Administrative Services Only listing)

Short formASO prior auth/notification listing — payer-maintained code roster requiring authorization or notification.

IncludesCPT/HCPCS/U/T codes and effective dates mapped for ASO account processing.

ASO prior authorization/notification list — description

DescriptionA payer-maintained listing of procedure and service codes (CPT/HCPCS/U/T) and their effective dates that require prior authorization or notification under self-funded ASO arrangements.

PurposeUsed by providers and the plan to route and process preauthorization and notification requests for self-funded accounts.

AccessThe current list and instructions for online authorization submission are available on the Baylor Scott & White Health Plan secure provider portal.

Administrative Services Only (ASO) — short label

Short labelASO (Administrative Services Only)

DefinitionAdministrative Services Only arrangements where the plan serves as third‑party administrator for self‑funded employer plans.

ContextASO designation indicates the listing and authorization rules apply to self‑funded accounts administered by the plan.

SPECT — definition

DefinitionSingle Photon Emission Computed Tomography (SPECT) — tomographic nuclear medicine imaging modality; listing notes SPECT with concurrently acquired CT for anatomical localization.

Example entry78832, 8/1/2018 = 2/1/2020 — tomographic (SPECT) with concurrently acquired CT noted in listing.

UseSPECT imaging entries are included in the ASO code listing and may require prior authorization/notification.

U/M/T codes — proprietary molecular test codes

ExplanationProprietary U/M/T codes (e.g., 0001U, 0011M) represent specific molecular/genomic laboratory tests and algorithms reported as risk/likelihood/score outputs or other analytic results.

Examples0001U = Red blood cell antigen typing, DNA; 0011M = Prostate cancer mRNA expression assay of 12 genes (RT-PCR).

Reported outputsThese codes often correspond to algorithmic or scored results (eg, risk scores, likelihood categories) and are listed with effective dates in the ASO listing.

U-code — temporary HCPCS/CPT Category codes

LabelU-code (temporary HCPCS/CPT Category or proprietary code) — used to identify new or emerging tests/services (eg, 0080U, 0326U).

FunctionDenotes temporary or category-specific codes for novel tests and services that may be listed for ASO prior authorization/notification.

Example0326U = Targeted genomic panel, cfDNA, 83+ genes; listed with effective date in ASO listing.

U/T codes — Category III / Proprietary codes

DescriptionU/T codes encompass CPT Category III (T) and proprietary U-codes used to identify emerging, specialized, or advanced procedures and molecular tests (eg, ctDNA NGS panels, genomic profiling).

ExamplesT-codes: 0201T, 0329T; U-codes: 0250U, 0530U — used for device procedures and oncology/genomic tests in the ASO listing.

ImplicationThese codes often include specific gene counts, algorithmic outputs, or device descriptors and are included with effective/review dates for ASO processing.

U-code — Medicare/HCPCS temporary codes

ExplanationMedicare/HCPCS temporary U-codes designate new tests and services and are used here to identify novel genomic and diagnostic assays pending permanent coding; entries show effective dates in the ASO listing.

Example0314U, 0315U, 0326U, 0329U appear in the listing with effective dates and descriptors for test type and specimen.

Usage noteProviders should reference the ASO listing effective date when submitting authorization requests for U-coded services.

FFPE — formalin‑fixed paraffin‑embedded tissue

DefinitionFormalin-fixed paraffin-embedded (FFPE) tissue — tissue preservation method commonly specified as the specimen type for molecular assays and genomic testing in the listing.

Examples0295U, 0296U, 0297U entries reference FFPE tissue for algorithmic or sequencing-based oncology tests.

ImplicationWhen a code entry specifies FFPE, providers should ensure submitted specimens match the listed tissue type for authorization and processing.

Cardiac contractility modulation system — definition

DefinitionCardiac contractility modulation system — permanent implantable system including pulse generator with transvenous electrodes used to deliver contractility modulation therapy; listed with CPT Category III codes (eg, 0408T).

Coding0408T, 0409T, 0410T series correspond to insertion or replacement of permanent cardiac contractility modulation systems and components.

Listing implicationThese device implantation and management codes are included in the ASO prior authorization listing with effective dates (eg, 1/1/2023).

Interrogation/device evaluation — definition

DefinitionInterrogation/device evaluation — in-person or remote device interrogation with analysis, review and report for implantable cardiac systems; entries include specific codes for in-person and programmed evaluations (eg, 0418U, 0522T).

Examples0418U = Interrogation device evaluation (in person) for implantable cardiac contractility modulation system; 0522T = Programming device evaluation (in person) for wireless cardiac stimulator.

UseThese codes link device evaluation procedures to related oncology or laboratory test code descriptors in the ASO listing where applicable.

FFPE — definition (duplicate)

DefinitionFormalin-fixed paraffin-embedded (FFPE) tissue — preserved tissue specimen frequently cited as the required input for many listed molecular and oncology assays.

ContextMultiple U-code entries and genomic test listings specify FFPE as the specimen type for sequencing or algorithmic analysis.

ImplicationAuthorization requests and lab submissions should indicate FFPE when the code description and listing require that specimen type.

ctDNA/NGS — circulating tumor DNA by NGS

DefinitionCirculating tumor DNA analyzed by next‑generation sequencing (ctDNA/NGS) — plasma-based cfDNA NGS assays used for tumor profiling, MRD, or therapy response assessment, listed under U-codes (eg, 0530U, 0326U).

Examples0530U = ctDNA NGS of 77 genes with fusions, MSI, and TMB from plasma; 0326U = targeted cfDNA panel of 83+ genes including MSI and TMB.

SpecimenThese entries specify plasma/cell-free DNA (cfDNA) as the specimen type for ctDNA testing.

T-code listing section — label

Section labelT-code listing (partial) — CPT Category III (T) codes enumerated in the ASO prior authorization/notification listing.

ContentIncludes imaging, monitoring, device implantation and novel procedure T-codes with effective dates (examples: 0639T, 0644T, 0645T).

PurposeUsed by providers to identify T-coded services that may require ASO prior authorization/notification.

Coverage Review Criteria and Code-Based Rules

COVERAGE CRITERIA — General coverage and claim review rules

General coverage and claim review rules:

All services must be medically necessary and appropriate and meet Texas Medicaid Provider Procedures Manual / BSWHP coverage criteria where applicable.

Claims will be reviewed to determine member eligibility at the time of service, benefit availability, evidence of coverage provisions, and claims payment agreements.

Prior authorization is not a guarantee of benefits or payment at the time of service; reimbursement of authorized services is dependent upon eligibility and benefit limitations/exclusions.

There are services and procedures that are never covered and therefore are not listed on the prior authorization list; verify benefits by consulting the member benefit booklet or contacting customer service.

Newly published/assigned codes and new/emerging therapy services or technology not listed may require prior authorization to determine medical necessity; check with Baylor Scott & White Health Plan before providing these services.

Procedure codes referenced

Codes listed (with short descriptors and date annotations) that are referenced for administrative prior authorization/notification.

The document enumerates CPT, HCPCS T-codes, and proprietary U-codes that are referenced for ASO prior authorization/notification; entries include short descriptors and administrative/effective dates.

Examples include

Spine and vertebral augmentation codes (e.g., 22515 with date 10/1/2018).
Selected genetic/molecular test codes (e.g., 81162 BRCA analysis with date 1/2/2020).
U/T codes for device and oncology-related tests (examples in the 0200–0525 range with various effective dates).

Providers should reference the code-specific line entries for the exact descriptor and effective/administrative date when preparing prior authorization or notification requests.

Procedure code lists

Listed CPT codes and their referenced effective dates — use for prior authorization/notification routing.

Orthopedics — arthroscopy/arthroplasty examples

29867, 29868, 29870, 29871 (knee arthroscopy/arthroplasty) — entries show 10/1/2018 effective dates for many lines.
29914–29916 (hip arthroscopy with listed 10/1/2018 dates).

Spine and neurostimulator/intrathecal examples

22515 and related arthrodesis codes (spine), with dates such as 10/1/2018 and 1/2/2020 as shown on listed lines.
62325–62362 (injection and intrathecal pump/device implantation codes) — many entries list 10/1/2018 as administrative date.

Cardiac, thoracic, transplant and vascular examples

33340, 33361–33366 and related transcatheter valve and transplant procedure codes with dates (examples include 5/1/2023 and 1/2/2020).
33975–33991 ventricular assist device and related codes with 1/2/2020 administrative dates in the listing.

Vascular and venous procedures

36474–36483 endovenous ablation and AV fistula creation codes with dates (eg, 3/1/2023, 1/2/2020, 5/1/2023).

Procedure code entries (excerpts)

Code list with administrative dates (partial)

62325 — Injection(s) including indwelling catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance — listed with administrative date 10/1/2018.

62326 — Injection(s) including indwelling catheter placement, lumbar or sacral (caudal); without imaging guidance — listed with administrative date 10/1/2018.

62327 — Injection(s) including indwelling catheter placement, lumbar or sacral (caudal); with imaging guidance — listed with administrative date 10/1/2018.

62350–62362 — Implantation/revision of tunneled intrathecal/epidural catheters and intrathecal pump devices — entries shown with administrative dates (many 10/1/2018).

CPT code listing and effective dates (informational)

This excerpt provides CPT code equivalencies and effective dates used for ASO prior authorization/notification processing; it does not include utilization criteria or medical necessity rules in this segment.

Selected imaging groups (MRI/CT/MRA) are listed with their effective dates (examples include 71550-71555, 72125-72133 with 8/1/2018 dates noted).

Cardiac CT/MR codes (75557–75577) and related entries show effective date annotations (example: 75577 entry shows 5/1/2026 for one line).

Breast MRI and therapeutic radiology planning/delivery CPT groups (77047–77049, 77261–77435) are included with effective dates for routing and authorization processing.

Code inclusion (informational)

Codes shown in this excerpt are included in the ASO prior authorization/notification listing.

Radiation therapy and related device/management CPT/HCPCS codes (e.g., 77387, 77402, 77407, 77520 series) are listed with administrative dates (many 10/1/2021 and 9/1/2021 entries).

Proton therapy, hyperthermia, brachytherapy, and intracavitary radiation application codes are enumerated for ASO prior authorization consideration with effective dates noted.

Nuclear medicine and PET/SPECT imaging CPT codes (e.g., 78430 series, 78812–78816) are part of the listing to inform ASO imaging prior authorization and notification workflows.

ASO Prior Auth/Notification Code List (partial)

Codes and brief descriptors requiring ASO prior authorization/notification (partial list from chunks 126–145).

Radiopharmaceutical tomographic (SPECT) imaging with concurrently acquired CT is included and subject to prior authorization/notification (example reference: 78832 with dates).

Molecular and genetic testing examples

Single-gene and hereditary testing codes (e.g., 81161–81167 BRCA/DMD entries) with their listed administrative dates are included for ASO processing.
Multi-gene panels and molecular pathology codes (e.g., 81410, 81442, 81443) include gene-count requirements and listed dates and are part of the ASO molecular/genetic testing listing.

Entries in this segment should be referenced directly for the exact test descriptor and effective/administrative date when submitting authorization requests.

Listed codes (informational)

Codes listed in this document segment are included in the ASO prior authorization/notification listing; many entries include brief descriptors and effective dates.

Selected laboratory, pathology and algorithmic tests

81551 — Promoter methylation profiling for prostate detection, FFPE tissue — listed with date 7/1/2025.
81554 — IPF mRNA gene expression (190 genes) with administrative date 1/1/2023.
0001U — Red blood cell antigen typing, DNA (35 antigens) — listed with date 1/1/2023.

Laboratory and serology codes (e.g., 82523 collagen cross links; 86015, 86036, 86037 immunology tests) include administrative dates for authorization routing.

Code listing (informational)

Code listing and effective dates (excerpt). No explicit coverage criteria present in this segment.

Several proprietary and U-code entries have mapping lines showing earlier administrative entries updated to 1/1/2023 (examples in this chunk).

This excerpt summarizes administrative date mappings (e.g., 4/1/2021 mapped to 1/1/2023) for use in ASO authorization workflows; clinical criteria are not provided in this excerpt.

ASO code entries (part 11)

Code listing for ASO prior authorization/notification

Selected U/T code examples (section part 11)

0201T/0201U series — red cell antigen genotyping mappings with administrative dates (examples include 1/1/2023 and 4/1/2021 references).
0314U–0321U and related U-codes — hematology, oncology, infectious disease and transplant-related genomic/algorithmic tests with 5/1/2023 effective dates on many entries.

Each listed U/T code and its descriptor are subject to ASO prior authorization/notification per plan provisions; clinical criteria are provided in separate policy sections when applicable.

Code listing — informational for authorization

Code listings and short descriptors (service type, specimen, and algorithm/reporting style) provided for payer processing and prior authorization workflow.

0334U — Sequence analysis of FFPE tumor tissue, DNA analysis of 84+ genes, includes MSI and TMB interrogation — listed with administrative annotation (1/1/2023).

0335U — Whole genome sequence analysis for rare/heritable disorders with detailed variant interrogation — listed with administrative date 1/1/2023.

Providers should use the exact code descriptor and administrative date when preparing ASO prior authorization/notification requests for these advanced genomic tests.

Coverage stance and mappings (excerpt)

This excerpt provides mappings of CPT/Category III codes to device and laboratory procedures and lists effective/review dates; it does not itself state utilization or medical necessity criteria in this window.

Device and Category III code examples

0408T–0411T — Insertion/replacement of permanent cardiac contractility modulation system (pulse generator, electrodes) — listed with effective date 1/1/2023.
0418U, 0420U, 0422U — Interrogation and oncology molecular test mappings linking device evaluation codes to oncology test descriptors with dates often showing 1/1/2023 and 7/1/2025 for U-codes.

Category III and U-code mappings are included for ASO routing; clinical utilization criteria are addressed elsewhere in the plan or through case-by-case review.

Partial code listing — no coverage criteria in excerpt

Code listings and effective dates included in this excerpt (partial). No explicit coverage rules or criteria are present in these chunks.

0512U, 0513U, 0515T and related entries — oncology molecular U-codes and T-codes for wireless cardiac stimulator insertion and MSI/HRD analyses with administrative dates (examples include 1/1/2023 and 7/1/2025).

Additional procedure/T-code examples

0522T — Programming device evaluation (in person) for wireless cardiac stimulator — administrative date 1/1/2023.
0525T/0525U — Intracardiac ischemia monitoring system insertion and oncology spheroid cell culture 11-drug response panel with listed administrative dates; U-code entries show future review dates (7/1/2025) for some tests.

Use the full listing when determining whether an ASO prior authorization or notification is required for the procedure or test; this excerpt alone does not define clinical eligibility.

T-code descriptors

Enumerated list of T-codes and effective dates (no decision criteria in this excerpt).

Selected T-code examples from Part 15

0639T–0649T — Magnetic resonance spectroscopy and transcatheter intracardiac and valve-related T-codes with administrative dates (many 1/1/2023 and 10/1/2021).
0650T–0773T — Programming device evaluation (remote), capsule endoscopy, transperineal focal laser ablation, VR procedural dissociation services, and other novel procedure T-codes with listed effective dates for ASO routing.

These T-code listings are for administrative routing and do not in themselves specify medical necessity criteria; consult the full policy or the plan for clinical requirements.

Code Tables and Effective Dates

Selected CPT codes from partial listCPT

00170	Anesthesia for intraoral procedures, including biopsy; not otherwise specified
11950	Subcutaneous injection of filling material; 1 cc or less
11951	Subcutaneous injection of filling material; 1.1 to 5.0 cc

Selected spine procedure CPTs in excerptCPT

22515	Percutaneous vertebral augmentation (eg, kyphoplasty), 1 vertebral body
22526	Percutaneous intradiscal electrothermal annuloplasty, single level
22630	Arthrodesis, posterior interbody technique, single interspace, lumbar

Additional spine and shoulder CPTsCPT

22856	Total disc arthroplasty, cervical, single interspace
22867	Insertion of interlaminar/interspinous stabilization device, lumbar; single level
23470	Arthroplasty, glenohumeral joint; hemiarthroplasty

Hip, knee, and arthroscopy CPTsCPT

27125	Hemiarthroplasty, hip, partial
27486	Arthroplasty, knee, condyle and plateau; medial AND lateral compartments (total knee arthroplasty)
29805	Arthroscopy, shoulder, diagnostic

Knee arthroscopy/arthroplastyCPT

29867	Knee arthroscopy; osteochondral allograft (mosaicplasty)
29868	Knee arthroplasty / meniscal transplantation (as listed)
29870	Knee arthroplasty / diagnostic arthroscopy
29871	Knee arthroplasty / infection lavage and drainage

Rhinoplasty / nasal proceduresCPT

30400	Rhinoplasty, primary
30410	Rhinoplasty, primary complete
30420	Rhinoplasty including major septal repair
30430	Rhinoplasty, secondary minor revision

Bariatric and gastric procedure codes (partial)CPT

43648	Laparoscopy, surgical; revision or removal of gastric neurostimulator electrodes, antrum (mapping present)
43770	Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device
43775	Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (sleeve gastrectomy)
43845	Gastric restrictive procedure with partial gastrectomy; biliopancreatic diversion with duodenal switch

Neurostimulator/intrathecal/spine procedure codes (partial)CPT

61863	Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array; first array
62362	Implantation or replacement of programmable intrathecal pump
63001	Laminectomy with exploration/decompression, cervical

laminotomy/laminectomy related codesCPT

63043	Laminotomy with decompression, reexploration, single interspace; lumbar
63044	Laminotomy with decompression, reexploration, single interspace; each additional lumbar interspace
63045	Laminotomy with decompression, reexploration, single interspace; cervical

Radiology and Radiation Therapy CPT groupsCPT

71550-71555, 72125-72133, 72141-72159	Multiple MRI and CT chest/spine/head related imaging codes referenced with effective dates
72191-72198, 72285, 72295	CT/MR pelvis and discography codes with effective dates
73200-73225, 73701-73725	CT/MR upper and lower extremity imaging and angiography codes
74150-74185, 74261-74262	Abdomen/pelvis CT and MR and CT colonography codes
75557-75577, 75635	Cardiac and related CT/MR codes including ones with 9/1/2018 and 5/1/2026 notes
76376-76498, 76873, 76979, 77021-77022	3D rendering, postprocessing, ultrasound and MR guidance codes
77047-77049, 77078, 77084	Breast MRI and related imaging and bone density cross-references
77261-77435, 77336-77399, 77402-77417, 77423-77435	Therapeutic radiology planning, dosimetry, treatment delivery and management CPT codes with effective dates

Representative codes in excerptCPTCovered

77387	Guidance for localization of target volume for delivery of radiation treatment, includes intrafraction tracking
77435	Stereotactic body radiation therapy, treatment management, per treatment course
77520	Proton treatment delivery; simple
77770	Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy; 1 channel
78430	Myocardial imaging, PET, perfusion study with CT transmission scan
78816	PET with concurrently acquired CT for attenuation correction and anatomical localization; whole body
81162	BRCA1/BRCA2 full sequence and duplication/deletion analysis

Selected single-gene molecular codes (examples)CPTCovered

81161	DMD deletion and duplication analysis
81162	BRCA1/BRCA2 full sequence and duplication/deletion analysis
81163	BRCA1/BRCA2 full sequence analysis
81164	BRCA1/BRCA2 duplication/deletion analysis
81165	BRCA1 full sequence analysis
81166	BRCA1 duplication/deletion analysis

Multi-gene panels and higher-level molecular pathology codes (examples)CPTCovered

81410	Aortic dysfunction/dilation genomic sequence panel (≥9 genes)
81416	Exome sequencing (comparator exomes listed separately)
81418	Drug metabolism (pharmacogenomics) panel including CYP2C19, CYP2D6
81442	Noonan spectrum disorders panel (≥12 genes)
81445	Solid organ neoplasm panel (5-50 genes)

Proprietary/molecular test codes (partial)mixed

0001U	Red blood cell antigen typing, DNA, erythrocyte antigen gene analysis
0005U	Oncology (ovarian) biochemical assays of five proteins, algorithm reported as a likelihood score
0011M	Prostate cancer mRNA expression assay of 12 genes, RT-PCR

Cardiology CPT codes (partial)CPT

93451-93461	Right/left heart catheterization and related coronary angiography procedures (range shown)
93590-93597	Percutaneous transcatheter closure and congenital heart catheterization codes

Selected hereditary cancer panelsCPT

0101U	Hereditary colon cancer disorders — genomic sequence analysis panel (15 genes)
0102U	Hereditary breast cancer-related disorders — genomic sequence analysis panel (17 genes)
0103U	Hereditary ovarian cancer — genomic sequence analysis panel (24 genes)

Infectious disease NGS panelsCPT

0153U	Microbial cell-free DNA, plasma, untargeted NGS — report for significant positive pathogens
0164U	Microbial cell-free DNA, plasma, untargeted NGS mapped to various clinical tests

Red cell antigen genotyping seriesCPT

0184U	Red cell antigen genotyping (Dombrock blood group)
0198U	Red cell antigen (RH blood group) genotyping (RHD and RHCE)

Selected codes in this chunk rangeCPT

0201T	Red cell antigen (Kx blood group) genotyping (XK), gene analysis
0232T	Injection(s), platelet rich plasma, any site, including image guidance
0246U	Red blood cell antigen typing, DNA, genotyping of at least 16 blood groups
0250U	Oncology (solid organ neoplasm), targeted genomic sequence DNA analysis of 505 genes
0306U	Oncology (minimal residual disease), next-generation targeted sequencing analysis, cell-free DNA
0321U	Infectious agent detection by nucleic acid, genitourinary pathogens, multiplex amplified probe technique

Selected genomic U-codesmixed

0326U	Targeted genomic sequence analysis panel, solid organ neoplasm, cfDNA, 83+ genes including MSI and TMB
0329U	Exome and transcriptome sequence analysis for neoplasia with normal subtraction
0332U	Genetic profiling of 8 DNA-regulatory markers by qPCR for immune checkpoint response (whole blood)

Additional diagnostic U-codesmixed

0398U	DNA methylation analysis for Barrett esophagus risk score (FFPE tissue)
0399U	Anti-folate receptor autoantibodies for cerebral folate deficiency (serum)

Cardiac contractility modulation codesCPTCovered

0408T	Insertion or replacement of permanent cardiac contractility modulation system; pulse generator with transvenous electrodes
0409T	Insertion or replacement of permanent cardiac contractility modulation system; pulse generator only
0410T	Insertion or replacement of permanent cardiac contractility modulation system; atrial electrode only
0411T	Insertion or replacement ... ventricular electrode only

Interrogation and oncology molecular test codesmixed

0418U	Interrogation device evaluation (in person) with analysis, review and report, implantable cardiac contractility modulation system
0422U	Oncology pan-solid tumor: cfDNA analysis for response to anti-cancer therapy
0444U	Targeted genomic sequence analysis panel of 361 genes

Wireless cardiac stimulator codesCPTCovered

0515T	Insertion of wireless cardiac stimulator for left ventricular pacing; complete system
0521T	Interrogation device evaluation (in person) with analysis... wireless cardiac stimulator

Oncology / molecular U-codes presentmixed

0512U	Oncology (solid tumor), MSI analysis on FFPE tissue; reported probability of MSI-high
0513U	Oncology (prostate), algorithmic analysis of whole-slide imaging for MSI and HRD on FFPE tissue
0523U	Oncology, ctDNA/NGS of 22 genes on FFPE tissue reporting SNVs/indels
0525U	Oncology, spheroid cell culture 11-drug response panel for ovarian/fallopian/peritoneal tumors
0530U	Oncology (pan-solid tumor), ctDNA NGS of 77 genes, fusions, MSI, TMB from plasma

Cardiac device T-codesCPT

0513T	Extracorporeal shock wave for integumentary wound healing; add-on for additional wound
0515T	Insertion of wireless cardiac stimulator for LV pacing; complete system
0516T	Insertion of wireless cardiac stimulator for LV pacing; electrode only
0517T	Insertion of wireless cardiac stimulator for LV pacing; generator components only

Selected T-codes from part 15CPT

0639T	Magnetic resonance spectroscopy; determination and localization of discogenic pain; interpretation and report
0640T	Magnetic resonance spectroscopy; determination and localization of discogenic pain; interpretation and report (alternate descriptor)
0643T	Magnetic resonance spectroscopy; determination and localization of discogenic pain; interpretation and report (alternate descriptor)
0644T	Transcatheter removal or debulking of intracardiac mass via suction device; percutaneous
0645T	Transcatheter implantation of coronary sinus reduction device
0646T	Transcatheter tricuspid valve implantation/replacement (TTVI)
0647T	Insertion of gastrostomy tube, percutaneous, with magnetic gastropexy
0650T	Programming device evaluation (remote) of subcutaneous cardiac rhythm monitor system
0651T	Magnetically controlled capsule endoscopy, esophagus through stomach
0652T	Esophagogastroduodenoscopy, flexible, transnasal; diagnostic

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Effective dates present — examples

Effective dates presentVarious effective/administrative dates are listed per code (examples include 1/2/2020, 10/1/2018, 1/1/2023, 7/1/2025).

Common examplesMany entries show 10/1/2018 and 1/1/2023 as effective dates for procedural and device codes.

Future-dated entriesSeveral U/T codes include future review/effective dates (eg, 7/1/2025 for many U-code entries).

Example administrative date

Example administrative date10/1/2018 appears frequently as an administrative/effective date following multiple CPT entries (eg, 62325, 29867 series).

Usage noteThis date is used in the listing to indicate when the code entry became effective for ASO prior authorization/notification processing.

VerificationProviders should check the listing for the applicable date when confirming whether a procedure requires authorization.

Panel gene-count requirements — examples

Gene‑count requirement examplesMany multi‑gene panels specify minimum gene counts (examples: 81412/81410-type panels require ≥9 genes; 81442 requires ≥12 genes; 81443 requires ≥15 genes; 81445 specifies 5–50 genes).

ImplicationAuthorization and lab reporting should confirm panel size meets the listed minimum gene-count requirement.

Examples in listing81412, 81442, 81443, 81445 entries include specific gene-count thresholds in their descriptors.

Effective date threshold — common 1/1/2023

Common effective date thresholdMany codes in the U/T listings show an effective date of 1/1/2023 for inclusion in the ASO prior authorization/notification roster.

ActionWhen a code shows 1/1/2023 as the effective date, providers should include that date in authorization references and checks.

ExamplesMultiple U/T and T-code entries (eg, 0326U, 0329T/0329U, 0408T series) list 1/1/2023 as an effective date.

Gene panel size thresholds — examples

Gene panel size thresholdsSome U-codes represent very large panels (examples: 0242U = 55–74 genes; 0244U = 257 genes; 0239U = 311+ genes; 0250U = 505 genes).

ImplicationLarge panel gene counts affect test complexity, reporting, and potential authorization review requirements.

Provider noteReference the ASO listing descriptor for exact gene counts when submitting prior authorization for multi‑gene panels.

Gene count threshold examples

Gene count examplesMultiple genomic U-codes specify panel sizes such as 83+, 311+, 437, 505 genes depending on the test (examples appear across 0326U, 0250U, and related entries).

Listing implicationAuthorization requests should reference the specific code and stated gene-count to ensure correct routing and review.

VerificationCheck the ASO code descriptor for the panel size requirement before submission.

U-code future effective date examples

Future effective date examplesSeveral U-code entries include future effective or review dates of 7/1/2025 (examples: 0250U, many 04xx–05xx U-codes list 7/1/2025).

ActionProviders should note future review dates when planning authorizations for emerging tests that may change coverage stance on that date.

Examples0250U (1 = 505-gene panel) shows 7/1/2025; multiple 04xx–05xx U-code entries also show 7/1/2025 in the listing.

Provider Submission and Authorization Instructions

Prior Authorization

Prior Authorization and Notification overview — Verify benefits and submit requests

Prior Authorization is not a guarantee of benefits or payment at time of service. Verify member eligibility and benefits prior to rendering services. Use the secure provider portal to submit electronic preauthorization requests. Call the number on the member ID card or contact your Provider Relations Representative for assistance. Note: Notification is requested for certain services to support discharge planning, care coordination, and case management.

Prior authorization does not ensure payment — benefits vary by plan; verify member benefits.
Submit preauthorization electronically via the secure provider portal; phone number on member ID for portal assistance.
Notification is requested for some services to assist coordination and discharge planning.

Note

Authorization submission pathway — Secure provider portal and contact info

Use the Baylor Scott & White Health Plan secure provider portal to submit prior authorization requests and receive status updates. Registered providers may also contact Provider Relations for help. Always include accurate CPT/HCPCS codes, clinical rationale, and pertinent medical records.

Submit via secure provider portal (registered users).
If you cannot access the portal, call the number on the member's ID card or contact your Provider Relations Representative.

Note

Code list (partial) — overview and submission guidance

The ASO prior authorization/notification code list includes a broad set of CPT, HCPCS, T-, U-, and proprietary lab/test codes across clinical areas. The following highlights consolidate required-procedure groups and examples that require prior authorization or notification.

Comprehensive code lists include ENT, thoracic, cardiac, neuro/spine, orthopedic, vascular/venous, transplant preparation, bariatric, radiation therapy, nuclear medicine, PET/SPECT, and molecular/genetic tests.
Providers must include the specific CPT/HCPCS/T/U/code when requesting authorization; newly published codes may also require review.

Prior Authorization

Provider action: ENT / thoracic / cardiac codes

ENT, thoracic, and cardiac procedure codes on the ASO list require prior authorization or notification. Examples include advanced nasal valve procedures, bronchoscopy with bronchial thermoplasty, tracheoplasty, lung volume reduction resections, thoracoscopy for emphysema, and lung and heart transplant procedures. Also included are left atrial appendage closure and transcatheter valve procedures.

30400, 30410, 30420, 30430, 30435, 30450, 30460 (rhinoplasty variants) — effective dates vary (eg, 1/2/2020).
31660, 31661 (nasal valve repair) — effective 5/1/2023 = 1/1/2023.
Bronchoscopy with bronchial thermoplasty and related codes (e.g., 31660 series).
32491, 32672 (lung volume reduction procedures) — effective dates noted in plan.
32851 (lung transplant, single) and other transplant CPTs — see transplant code group.

Prior Authorization

Provider action: Cardiac / vascular / endovenous codes

Cardiac, vascular and endovenous procedural codes requiring authorization/notification include transcatheter valve procedures, TAVR/TAVI variants, percutaneous transcatheter left atrial appendage closure, VAD and artificial heart implantation/replacement, endovenous ablation therapies, injections/sclerosant procedures, and arteriovenous fistula creation.

33340 (left atrial appendage closure) — 5/1/2023.
33361–33366 (TAVR/TAVI approaches) — various effective dates.
33418, 33477 (transcatheter mitral/pulmonary interventions) — effective dates per list.
33927–33991 (heart replacement, transplant, VAD insertion/replacement) — 1/2/2020 onward.
36465–36483, 36474, 36475, 36478, 36482–36483 (sclerotherapy, endovenous ablation, chemical adhesive) — effective dates include 1/2/2020 and 3/1/2023.
36836–36837 (percutaneous AV fistula creation) — effective 5/1/2023.

Prior Authorization

Provider action: Venous / vascular / transplant prep codes

Venous/vascular and transplant preparation codes on the ASO listing include endovenous ablation therapy, varicose vein surgery, AV fistula creation, and hematopoietic progenitor cell collection and processing. Transplant prep CPTs (collection, cryopreservation, cell depletion, thawing) are included and require prior authorization.

36474, 36475, 36478, 36482, 36483 (endovenous ablation and adhesive closure) — 1/2/2020 and 3/1/2023 effective dates.
37700–37785 (ligation/stripping, phlebectomy, varicose vein procedures) — effective dates noted (eg, 1/2/2020).
36836–36837 (percutaneous AV fistula creation) — effective 5/1/2023.
38206–38215, 38240–38241, 38207–38209, 38211–38215 (hematopoietic progenitor cell harvest/processing/cryopreservation/thawing and specific cell depletion procedures) — effective dates 1/2/2020 and related.

Note

Provider action: CPT mapping entries (partial)

Selected CPT mapping examples and other CPT entries are explicitly listed for authorization review. Providers must reference the exact CPT code and effective date when submitting requests.

Examples: 43648 (laparoscopy; revision/removal gastric neurostimulator) — 1/2/2020.
43770–43775 (laparoscopic bariatric procedures including adjustable band and sleeve gastrectomy) — 1/2/2020.
29867–29916 series (knee and hip arthroscopy/arthroplasty mapping) — effective 10/1/2018 and later.
0201T–0207T, 0408T–0411T, 0515T–0519T (selected T-codes for devices, genotyping, and implantable systems) — effective dates in listing.

Prior Authorization

Provider action: Neuro/spine/injection CPT entries

Neuro, spine, and injection-related CPT codes that require authorization/notification include spinal arthrodesis and vertebral augmentation, intradiscal procedures, neurostimulator implantation and programming, intrathecal/intraspinal catheter and pump implantation, epidural/nerve injections, adhesiolysis, and percutaneous disc decompression and injections.

22515, 22526–22534 series (vertebral augmentation, intradiscal electrothermal annuloplasty, lateral extracavitary arthrodesis) — effective dates vary (e.g., 10/1/2018, 1/2/2020).
61863, 61867, 61885–61886 (neurostimulator electrode array implantation and pulse generator insertion/replacement) — 1/2/2020.
62263–62264 (percutaneous lysis of epidural adhesions) — 1/1/2023.
62280–62292 series and 62320–62351, 62360–62361 (neurolytic injections, discography, intrathecal/epidural injections, pump/catheter implantation, intrathecal drug delivery devices) — effective dates include 10/1/2018 and 4/1/2021.

Prior Authorization

Provider action: Nuclear medicine, diagnostic imaging, PET/SPECT, and genetic test codes

Nuclear medicine, diagnostic imaging, PET/SPECT, and genetic/molecular test codes are included in the ASO list and require prior authorization or notification. This includes planar and tomographic nuclear studies, PET/CT, SPECT/CT, cardiac nuclear studies, and a range of molecular and genomic test CPTs and U/T codes.

78018–78899 range covers thyroid, parathyroid, salivary, hepatobiliary, bone and joint, myocardial perfusion, cardiac blood pool, pulmonary ventilation/perfusion, PET imaging (e.g., 78811–78816), SPECT/CT (e.g., 78831–78832) — effective dates noted (8/1/2018 and updates).
78430–78432, 78451–78454 (myocardial PET and SPECT perfusion) — effective dates include 4/1/2020 and 9/1/2018.
78811–78816 (PET limited/skull-base/whole body and PET/CT variants) — effective 8/1/2018.
Molecular/genetic codes (e.g., 80145, 80230; 81161–81167 BRCA panels; 81349, 81351, 81407–81412; 81410–81411 gene panels; T/U codes 0080U–0099U, 0201T–0207T, 0408T–0469T, 0444U, 0460U–0471U, 0512U–0513U, 0515T etc.) — effective dates and code-specific requirements vary; many have 2020–2025 effective dates.
Providers must submit clinical indication, prior imaging/testing results, and specific assay/panel requested for molecular/genetic tests.

Prior Authorization

Provider action: Cardiac contractility modulation & device codes (examples)

Cardiac contractility modulation systems, device insertion/replacement, and associated device interrogation codes are included and require prior authorization. Device interrogation, programming, and remote monitoring services (including implantable cardiac contractility modulation system and wireless cardiac stimulators) are captured, as are procedure and device codes for implantation and component replacements.

0408T, 0409T, 0410T, 0411T (permanent cardiac contractility modulation system insertion and components) — 1/1/2023.
0515T–0519T (wireless cardiac stimulator insertion and related device management) — 1/1/2023.
93264 (remote monitoring of wireless pulmonary artery pressure sensor) — 4/1/2021.
0418U, 0419T, 0420T (interrogation and device evaluation codes) — effective dates per listing.

Note

Provider action: Device interrogation and oncology test mappings

Device interrogation and oncology test mapping codes (Category III, proprietary U-codes, and device/programming CPTs) appear on the listing. Examples include in-person interrogation and analysis with report for implanted devices, and many oncology genomic panels and algorithmic tests that require prior authorization.

0418U, 0419T, 0420T (interrogation and device evaluation for cardiac contractility modulation systems) — dates 1/1/2023 to 7/1/2025 for related U-codes.
0444U, 0445T, 0461U, 0467U (targeted genomic panels, implantable sensor creation/removal, oncology pharmacogenomics) — referenced with effective dates through 7/1/2025.
0472T–0473T (device evaluation and interrogation of intraocular retinal electrode arrays) — effective dates noted in list.

Prior Authorization

Provider action: Ophthalmology/device and oncology genomic codes

Ophthalmology device procedures and oncology genomic testing codes are included. Examples include retinal device evaluation/interrogation, insertion/removal of ocular inserts, optical coherence tomography remote monitoring services, and multiple U/T codes for oncology genomic panels and molecular assays.

0445T (placement of drug-eluting ocular insert) — 4/1/2021.
0472T, 0473T (device evaluation/interrogation of intraocular retinal electrode arrays) — 4/1/2021.
0604T–0606T (remote OCT retina device provision and monitoring) — 1/1/2023.
Numerous oncology genomic U-codes (e.g., 0444U, 0460U, 0461U, 0467U, 0512U, 0513U) — effective through 7/1/2025; provide test name, specimen, and clinical indication with requests.

Prior Authorization

Provider action: Code list excerpt — additional procedures

Additional procedure and novel-technology code excerpts across specialties require prior authorization/notification. This includes T-codes for novel interventions (e.g., intracardiac devices, percutaneous interatrial shunt, transcatheter tricuspid/left ventricular devices), advanced imaging (CT breast 3D, MR spectroscopy discogenic pain), biologic injections, cellular therapies, and other emerging services. Always reference the exact code and effective date from the ASO list.

0613T (transcatheter interatrial septal shunt device) — 1/1/2023.
0632T (pulmonary artery nerve ablation) — 1/1/2023.
0633T–0638T (CT breast with 3D rendering variants) — 1/1/2023.
0586T (islet cell transplant) and 0627T–0630T (percutaneous injection of allogeneic cellular/tissue products to intervertebral disc) — 1/1/2023.
Multiple T-codes (0600T–0650T and others) and U-codes for innovative diagnostics and therapeutics — check the ASO code listing for exact effective dates and submission requirements.

Background and Scope Notes

This policy governs prior authorization and notification requirements when Baylor Scott & White Health Plan is acting as a third‑party administrator for self‑funded employer (ASO) plans. Prior authorization is a payer determination process and is not a guarantee of benefits or payment at the time of service; reimbursement of any authorized service remains subject to member eligibility, plan benefit limitations or exclusions, and applicable claims payment agreements. Benefits vary by employer plan, so providers must verify eligibility and coverage by consulting the member benefit booklet or contacting customer service.

Providers serving ASO members should submit preauthorization requests through the Baylor Scott & White Health Plan secure provider portal (registered users log in to submit electronic requests) or call the number on the member ID card for assistance. Provider Relations can also be contacted for additional help. The Plan additionally requests notification for certain services to support discharge planning, care coordination, and case management.

The Plan maintains a listing of procedure and service codes (CPT/HCPCS/T/U codes) with administrative effective dates that are subject to ASO prior authorization or notification. The listing is used to route requests and identify services that require review; newly published codes or emerging therapies not yet listed may also require prior authorization and providers should check with Baylor Scott & White Health Plan before providing such services.

Revision History

2026-05-01Policy Effective DateLatest

Policy effective date published as May 01, 2026; establishes the ASO prior authorization/notification listing and submission instructions.

Policy Summary

PayerBaylor Scott & White Health Plan

PolicySelf-funded ASO Prior Authorization/Notification

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateMay 1, 2026

Next Review DateN/A

Key ActionVerify member benefits and submit electronic preauthorization requests via the secure provider portal or call the number on the member ID card.

SourceLink

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Self-funded ASO Prior Authorization/Notification

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Key Definitions

Prior Authorization — overview

VerificationBenefits vary by plan; providers must verify coverage via the member benefit booklet or contact customer service.

SubmissionRegistered users may submit electronic preauthorization requests via the Baylor Scott & White Health Plan secure provider portal or call the number on the member ID card.

Self-funded ASO — third‑party administrator

RoleScott and White Health Plan serves as a third-party administrator for self-funded employer-sponsored plans (Administrative Services Only - ASO).

ScopeApplies to self-funded ASO employer-sponsored plans administered by Scott and White Health Plan; related subsidiaries serve insured products separately.

ResponsibilityPlan acts as the ASO administrator and maintains the prior authorization/notification listing for self-funded accounts.

ASO prior authorization/notification — label

Short labelASO Prior Authorization/Notification

Alternate useIncludes both prior authorization and requested notifications to support discharge planning and care coordination.

Applies toProcedure and service codes (CPT/HCPCS/U/T) listed in the ASO code listing maintained by the plan.

CPT — code system

Code systemCurrent Procedural Terminology (CPT) codes

UsageCPT codes are used to identify procedural services in the ASO prior authorization/notification listing.

Cross-referenceCPT entries in the listing include short descriptors and administrative/effective dates for routing authorizations.

CPT mapping lines — examples with effective dates

00170Anesthesia for intraoral procedures, including biopsy — Effective Date = 1/2/2020

29867-29871Knee arthroscopy/arthroplasty related procedures — Effective Date = 10/1/2018 (per entries)

43770-43775, 43648Gastric restrictive and related procedures — Effective Dates include 1/2/2020 (mapping lines show dates)

Administrative date — meaning

MeaningDate shown after code entries represents an administrative/effective date related to the ASO prior authorization/notification listing.

Example62325, 2 = 10/1/2018 (injection with imaging guidance) — the trailing date denotes the listed effective/administrative date.

ImplicationProviders should use the effective date in the listing when determining whether a code currently requires ASO prior authorization/notification.

ASO prior authorization/notification — alternate phrasing

Alternate phrasingASO Prior Authorization / Notification (self-funded Administrative Services Only listing)

Short formASO prior auth/notification listing — payer-maintained code roster requiring authorization or notification.

IncludesCPT/HCPCS/U/T codes and effective dates mapped for ASO account processing.

ASO prior authorization/notification list — description

DescriptionA payer-maintained listing of procedure and service codes (CPT/HCPCS/U/T) and their effective dates that require prior authorization or notification under self-funded ASO arrangements.

PurposeUsed by providers and the plan to route and process preauthorization and notification requests for self-funded accounts.

AccessThe current list and instructions for online authorization submission are available on the Baylor Scott & White Health Plan secure provider portal.

Administrative Services Only (ASO) — short label

Short labelASO (Administrative Services Only)

DefinitionAdministrative Services Only arrangements where the plan serves as third‑party administrator for self‑funded employer plans.

ContextASO designation indicates the listing and authorization rules apply to self‑funded accounts administered by the plan.

SPECT — definition

DefinitionSingle Photon Emission Computed Tomography (SPECT) — tomographic nuclear medicine imaging modality; listing notes SPECT with concurrently acquired CT for anatomical localization.

Example entry78832, 8/1/2018 = 2/1/2020 — tomographic (SPECT) with concurrently acquired CT noted in listing.

UseSPECT imaging entries are included in the ASO code listing and may require prior authorization/notification.

U/M/T codes — proprietary molecular test codes

ExplanationProprietary U/M/T codes (e.g., 0001U, 0011M) represent specific molecular/genomic laboratory tests and algorithms reported as risk/likelihood/score outputs or other analytic results.

Examples0001U = Red blood cell antigen typing, DNA; 0011M = Prostate cancer mRNA expression assay of 12 genes (RT-PCR).

Reported outputsThese codes often correspond to algorithmic or scored results (eg, risk scores, likelihood categories) and are listed with effective dates in the ASO listing.

U-code — temporary HCPCS/CPT Category codes

LabelU-code (temporary HCPCS/CPT Category or proprietary code) — used to identify new or emerging tests/services (eg, 0080U, 0326U).

FunctionDenotes temporary or category-specific codes for novel tests and services that may be listed for ASO prior authorization/notification.

Example0326U = Targeted genomic panel, cfDNA, 83+ genes; listed with effective date in ASO listing.

U/T codes — Category III / Proprietary codes

ExamplesT-codes: 0201T, 0329T; U-codes: 0250U, 0530U — used for device procedures and oncology/genomic tests in the ASO listing.

ImplicationThese codes often include specific gene counts, algorithmic outputs, or device descriptors and are included with effective/review dates for ASO processing.

U-code — Medicare/HCPCS temporary codes

Example0314U, 0315U, 0326U, 0329U appear in the listing with effective dates and descriptors for test type and specimen.

Usage noteProviders should reference the ASO listing effective date when submitting authorization requests for U-coded services.

FFPE — formalin‑fixed paraffin‑embedded tissue

DefinitionFormalin-fixed paraffin-embedded (FFPE) tissue — tissue preservation method commonly specified as the specimen type for molecular assays and genomic testing in the listing.

Examples0295U, 0296U, 0297U entries reference FFPE tissue for algorithmic or sequencing-based oncology tests.

ImplicationWhen a code entry specifies FFPE, providers should ensure submitted specimens match the listed tissue type for authorization and processing.

Cardiac contractility modulation system — definition

Coding0408T, 0409T, 0410T series correspond to insertion or replacement of permanent cardiac contractility modulation systems and components.

Listing implicationThese device implantation and management codes are included in the ASO prior authorization listing with effective dates (eg, 1/1/2023).

Interrogation/device evaluation — definition

Examples0418U = Interrogation device evaluation (in person) for implantable cardiac contractility modulation system; 0522T = Programming device evaluation (in person) for wireless cardiac stimulator.

UseThese codes link device evaluation procedures to related oncology or laboratory test code descriptors in the ASO listing where applicable.

FFPE — definition (duplicate)

DefinitionFormalin-fixed paraffin-embedded (FFPE) tissue — preserved tissue specimen frequently cited as the required input for many listed molecular and oncology assays.

ContextMultiple U-code entries and genomic test listings specify FFPE as the specimen type for sequencing or algorithmic analysis.

ImplicationAuthorization requests and lab submissions should indicate FFPE when the code description and listing require that specimen type.

ctDNA/NGS — circulating tumor DNA by NGS

Examples0530U = ctDNA NGS of 77 genes with fusions, MSI, and TMB from plasma; 0326U = targeted cfDNA panel of 83+ genes including MSI and TMB.

SpecimenThese entries specify plasma/cell-free DNA (cfDNA) as the specimen type for ctDNA testing.

T-code listing section — label

Section labelT-code listing (partial) — CPT Category III (T) codes enumerated in the ASO prior authorization/notification listing.

ContentIncludes imaging, monitoring, device implantation and novel procedure T-codes with effective dates (examples: 0639T, 0644T, 0645T).

PurposeUsed by providers to identify T-coded services that may require ASO prior authorization/notification.

Coverage Review Criteria and Code-Based Rules

COVERAGE CRITERIA — General coverage and claim review rules

General coverage and claim review rules:

All services must be medically necessary and appropriate and meet Texas Medicaid Provider Procedures Manual / BSWHP coverage criteria where applicable.

Claims will be reviewed to determine member eligibility at the time of service, benefit availability, evidence of coverage provisions, and claims payment agreements.

Prior authorization is not a guarantee of benefits or payment at the time of service; reimbursement of authorized services is dependent upon eligibility and benefit limitations/exclusions.

Procedure codes referenced

Codes listed (with short descriptors and date annotations) that are referenced for administrative prior authorization/notification.

The document enumerates CPT, HCPCS T-codes, and proprietary U-codes that are referenced for ASO prior authorization/notification; entries include short descriptors and administrative/effective dates.

Examples include

Spine and vertebral augmentation codes (e.g., 22515 with date 10/1/2018).
Selected genetic/molecular test codes (e.g., 81162 BRCA analysis with date 1/2/2020).
U/T codes for device and oncology-related tests (examples in the 0200–0525 range with various effective dates).

Providers should reference the code-specific line entries for the exact descriptor and effective/administrative date when preparing prior authorization or notification requests.

Procedure code lists

Listed CPT codes and their referenced effective dates — use for prior authorization/notification routing.

Orthopedics — arthroscopy/arthroplasty examples

29867, 29868, 29870, 29871 (knee arthroscopy/arthroplasty) — entries show 10/1/2018 effective dates for many lines.
29914–29916 (hip arthroscopy with listed 10/1/2018 dates).

Spine and neurostimulator/intrathecal examples

22515 and related arthrodesis codes (spine), with dates such as 10/1/2018 and 1/2/2020 as shown on listed lines.
62325–62362 (injection and intrathecal pump/device implantation codes) — many entries list 10/1/2018 as administrative date.

Cardiac, thoracic, transplant and vascular examples

33340, 33361–33366 and related transcatheter valve and transplant procedure codes with dates (examples include 5/1/2023 and 1/2/2020).
33975–33991 ventricular assist device and related codes with 1/2/2020 administrative dates in the listing.

Vascular and venous procedures

36474–36483 endovenous ablation and AV fistula creation codes with dates (eg, 3/1/2023, 1/2/2020, 5/1/2023).

Procedure code entries (excerpts)

Code list with administrative dates (partial)

62325 — Injection(s) including indwelling catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance — listed with administrative date 10/1/2018.

62326 — Injection(s) including indwelling catheter placement, lumbar or sacral (caudal); without imaging guidance — listed with administrative date 10/1/2018.

62327 — Injection(s) including indwelling catheter placement, lumbar or sacral (caudal); with imaging guidance — listed with administrative date 10/1/2018.

62350–62362 — Implantation/revision of tunneled intrathecal/epidural catheters and intrathecal pump devices — entries shown with administrative dates (many 10/1/2018).

CPT code listing and effective dates (informational)

Selected imaging groups (MRI/CT/MRA) are listed with their effective dates (examples include 71550-71555, 72125-72133 with 8/1/2018 dates noted).

Cardiac CT/MR codes (75557–75577) and related entries show effective date annotations (example: 75577 entry shows 5/1/2026 for one line).

Breast MRI and therapeutic radiology planning/delivery CPT groups (77047–77049, 77261–77435) are included with effective dates for routing and authorization processing.

Code inclusion (informational)

Codes shown in this excerpt are included in the ASO prior authorization/notification listing.

Radiation therapy and related device/management CPT/HCPCS codes (e.g., 77387, 77402, 77407, 77520 series) are listed with administrative dates (many 10/1/2021 and 9/1/2021 entries).

Proton therapy, hyperthermia, brachytherapy, and intracavitary radiation application codes are enumerated for ASO prior authorization consideration with effective dates noted.

Nuclear medicine and PET/SPECT imaging CPT codes (e.g., 78430 series, 78812–78816) are part of the listing to inform ASO imaging prior authorization and notification workflows.

ASO Prior Auth/Notification Code List (partial)

Codes and brief descriptors requiring ASO prior authorization/notification (partial list from chunks 126–145).

Radiopharmaceutical tomographic (SPECT) imaging with concurrently acquired CT is included and subject to prior authorization/notification (example reference: 78832 with dates).

Molecular and genetic testing examples

Single-gene and hereditary testing codes (e.g., 81161–81167 BRCA/DMD entries) with their listed administrative dates are included for ASO processing.
Multi-gene panels and molecular pathology codes (e.g., 81410, 81442, 81443) include gene-count requirements and listed dates and are part of the ASO molecular/genetic testing listing.

Entries in this segment should be referenced directly for the exact test descriptor and effective/administrative date when submitting authorization requests.

Listed codes (informational)

Codes listed in this document segment are included in the ASO prior authorization/notification listing; many entries include brief descriptors and effective dates.

Selected laboratory, pathology and algorithmic tests

81551 — Promoter methylation profiling for prostate detection, FFPE tissue — listed with date 7/1/2025.
81554 — IPF mRNA gene expression (190 genes) with administrative date 1/1/2023.
0001U — Red blood cell antigen typing, DNA (35 antigens) — listed with date 1/1/2023.

Laboratory and serology codes (e.g., 82523 collagen cross links; 86015, 86036, 86037 immunology tests) include administrative dates for authorization routing.

Code listing (informational)

Code listing and effective dates (excerpt). No explicit coverage criteria present in this segment.

Several proprietary and U-code entries have mapping lines showing earlier administrative entries updated to 1/1/2023 (examples in this chunk).

This excerpt summarizes administrative date mappings (e.g., 4/1/2021 mapped to 1/1/2023) for use in ASO authorization workflows; clinical criteria are not provided in this excerpt.

ASO code entries (part 11)

Code listing for ASO prior authorization/notification

Selected U/T code examples (section part 11)

0201T/0201U series — red cell antigen genotyping mappings with administrative dates (examples include 1/1/2023 and 4/1/2021 references).
0314U–0321U and related U-codes — hematology, oncology, infectious disease and transplant-related genomic/algorithmic tests with 5/1/2023 effective dates on many entries.

Each listed U/T code and its descriptor are subject to ASO prior authorization/notification per plan provisions; clinical criteria are provided in separate policy sections when applicable.

Code listing — informational for authorization

Code listings and short descriptors (service type, specimen, and algorithm/reporting style) provided for payer processing and prior authorization workflow.

0334U — Sequence analysis of FFPE tumor tissue, DNA analysis of 84+ genes, includes MSI and TMB interrogation — listed with administrative annotation (1/1/2023).

0335U — Whole genome sequence analysis for rare/heritable disorders with detailed variant interrogation — listed with administrative date 1/1/2023.

Providers should use the exact code descriptor and administrative date when preparing ASO prior authorization/notification requests for these advanced genomic tests.

Coverage stance and mappings (excerpt)

Device and Category III code examples

0408T–0411T — Insertion/replacement of permanent cardiac contractility modulation system (pulse generator, electrodes) — listed with effective date 1/1/2023.
0418U, 0420U, 0422U — Interrogation and oncology molecular test mappings linking device evaluation codes to oncology test descriptors with dates often showing 1/1/2023 and 7/1/2025 for U-codes.

Category III and U-code mappings are included for ASO routing; clinical utilization criteria are addressed elsewhere in the plan or through case-by-case review.

Partial code listing — no coverage criteria in excerpt

Code listings and effective dates included in this excerpt (partial). No explicit coverage rules or criteria are present in these chunks.

Additional procedure/T-code examples

0522T — Programming device evaluation (in person) for wireless cardiac stimulator — administrative date 1/1/2023.
0525T/0525U — Intracardiac ischemia monitoring system insertion and oncology spheroid cell culture 11-drug response panel with listed administrative dates; U-code entries show future review dates (7/1/2025) for some tests.

Use the full listing when determining whether an ASO prior authorization or notification is required for the procedure or test; this excerpt alone does not define clinical eligibility.

T-code descriptors

Enumerated list of T-codes and effective dates (no decision criteria in this excerpt).

Selected T-code examples from Part 15

0639T–0649T — Magnetic resonance spectroscopy and transcatheter intracardiac and valve-related T-codes with administrative dates (many 1/1/2023 and 10/1/2021).
0650T–0773T — Programming device evaluation (remote), capsule endoscopy, transperineal focal laser ablation, VR procedural dissociation services, and other novel procedure T-codes with listed effective dates for ASO routing.

These T-code listings are for administrative routing and do not in themselves specify medical necessity criteria; consult the full policy or the plan for clinical requirements.

Code Tables and Effective Dates

Selected CPT codes from partial listCPT

00170	Anesthesia for intraoral procedures, including biopsy; not otherwise specified
11950	Subcutaneous injection of filling material; 1 cc or less
11951	Subcutaneous injection of filling material; 1.1 to 5.0 cc

Selected spine procedure CPTs in excerptCPT

22515	Percutaneous vertebral augmentation (eg, kyphoplasty), 1 vertebral body
22526	Percutaneous intradiscal electrothermal annuloplasty, single level
22630	Arthrodesis, posterior interbody technique, single interspace, lumbar

Additional spine and shoulder CPTsCPT

22856	Total disc arthroplasty, cervical, single interspace
22867	Insertion of interlaminar/interspinous stabilization device, lumbar; single level
23470	Arthroplasty, glenohumeral joint; hemiarthroplasty

Hip, knee, and arthroscopy CPTsCPT

27125	Hemiarthroplasty, hip, partial
27486	Arthroplasty, knee, condyle and plateau; medial AND lateral compartments (total knee arthroplasty)
29805	Arthroscopy, shoulder, diagnostic

Knee arthroscopy/arthroplastyCPT

29867	Knee arthroscopy; osteochondral allograft (mosaicplasty)
29868	Knee arthroplasty / meniscal transplantation (as listed)
29870	Knee arthroplasty / diagnostic arthroscopy
29871	Knee arthroplasty / infection lavage and drainage

Rhinoplasty / nasal proceduresCPT

30400	Rhinoplasty, primary
30410	Rhinoplasty, primary complete
30420	Rhinoplasty including major septal repair
30430	Rhinoplasty, secondary minor revision

Bariatric and gastric procedure codes (partial)CPT

43648	Laparoscopy, surgical; revision or removal of gastric neurostimulator electrodes, antrum (mapping present)
43770	Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device
43775	Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (sleeve gastrectomy)
43845	Gastric restrictive procedure with partial gastrectomy; biliopancreatic diversion with duodenal switch

Neurostimulator/intrathecal/spine procedure codes (partial)CPT

61863	Twist drill, burr hole, craniotomy, or craniectomy with stereotactic implantation of neurostimulator electrode array; first array
62362	Implantation or replacement of programmable intrathecal pump
63001	Laminectomy with exploration/decompression, cervical

laminotomy/laminectomy related codesCPT

63043	Laminotomy with decompression, reexploration, single interspace; lumbar
63044	Laminotomy with decompression, reexploration, single interspace; each additional lumbar interspace
63045	Laminotomy with decompression, reexploration, single interspace; cervical

Radiology and Radiation Therapy CPT groupsCPT

71550-71555, 72125-72133, 72141-72159	Multiple MRI and CT chest/spine/head related imaging codes referenced with effective dates
72191-72198, 72285, 72295	CT/MR pelvis and discography codes with effective dates
73200-73225, 73701-73725	CT/MR upper and lower extremity imaging and angiography codes
74150-74185, 74261-74262	Abdomen/pelvis CT and MR and CT colonography codes
75557-75577, 75635	Cardiac and related CT/MR codes including ones with 9/1/2018 and 5/1/2026 notes
76376-76498, 76873, 76979, 77021-77022	3D rendering, postprocessing, ultrasound and MR guidance codes
77047-77049, 77078, 77084	Breast MRI and related imaging and bone density cross-references
77261-77435, 77336-77399, 77402-77417, 77423-77435	Therapeutic radiology planning, dosimetry, treatment delivery and management CPT codes with effective dates

Representative codes in excerptCPTCovered

77387	Guidance for localization of target volume for delivery of radiation treatment, includes intrafraction tracking
77435	Stereotactic body radiation therapy, treatment management, per treatment course
77520	Proton treatment delivery; simple
77770	Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy; 1 channel
78430	Myocardial imaging, PET, perfusion study with CT transmission scan
78816	PET with concurrently acquired CT for attenuation correction and anatomical localization; whole body
81162	BRCA1/BRCA2 full sequence and duplication/deletion analysis

Selected single-gene molecular codes (examples)CPTCovered

81161	DMD deletion and duplication analysis
81162	BRCA1/BRCA2 full sequence and duplication/deletion analysis
81163	BRCA1/BRCA2 full sequence analysis
81164	BRCA1/BRCA2 duplication/deletion analysis
81165	BRCA1 full sequence analysis
81166	BRCA1 duplication/deletion analysis

Multi-gene panels and higher-level molecular pathology codes (examples)CPTCovered

81410	Aortic dysfunction/dilation genomic sequence panel (≥9 genes)
81416	Exome sequencing (comparator exomes listed separately)
81418	Drug metabolism (pharmacogenomics) panel including CYP2C19, CYP2D6
81442	Noonan spectrum disorders panel (≥12 genes)
81445	Solid organ neoplasm panel (5-50 genes)

Proprietary/molecular test codes (partial)mixed

0001U	Red blood cell antigen typing, DNA, erythrocyte antigen gene analysis
0005U	Oncology (ovarian) biochemical assays of five proteins, algorithm reported as a likelihood score
0011M	Prostate cancer mRNA expression assay of 12 genes, RT-PCR

Cardiology CPT codes (partial)CPT

93451-93461	Right/left heart catheterization and related coronary angiography procedures (range shown)
93590-93597	Percutaneous transcatheter closure and congenital heart catheterization codes

Selected hereditary cancer panelsCPT

0101U	Hereditary colon cancer disorders — genomic sequence analysis panel (15 genes)
0102U	Hereditary breast cancer-related disorders — genomic sequence analysis panel (17 genes)
0103U	Hereditary ovarian cancer — genomic sequence analysis panel (24 genes)

Infectious disease NGS panelsCPT

0153U	Microbial cell-free DNA, plasma, untargeted NGS — report for significant positive pathogens
0164U	Microbial cell-free DNA, plasma, untargeted NGS mapped to various clinical tests

Red cell antigen genotyping seriesCPT

0184U	Red cell antigen genotyping (Dombrock blood group)
0198U	Red cell antigen (RH blood group) genotyping (RHD and RHCE)

Selected codes in this chunk rangeCPT

0201T	Red cell antigen (Kx blood group) genotyping (XK), gene analysis
0232T	Injection(s), platelet rich plasma, any site, including image guidance
0246U	Red blood cell antigen typing, DNA, genotyping of at least 16 blood groups
0250U	Oncology (solid organ neoplasm), targeted genomic sequence DNA analysis of 505 genes
0306U	Oncology (minimal residual disease), next-generation targeted sequencing analysis, cell-free DNA
0321U	Infectious agent detection by nucleic acid, genitourinary pathogens, multiplex amplified probe technique

Selected genomic U-codesmixed

0326U	Targeted genomic sequence analysis panel, solid organ neoplasm, cfDNA, 83+ genes including MSI and TMB
0329U	Exome and transcriptome sequence analysis for neoplasia with normal subtraction
0332U	Genetic profiling of 8 DNA-regulatory markers by qPCR for immune checkpoint response (whole blood)

Additional diagnostic U-codesmixed

0398U	DNA methylation analysis for Barrett esophagus risk score (FFPE tissue)
0399U	Anti-folate receptor autoantibodies for cerebral folate deficiency (serum)

Cardiac contractility modulation codesCPTCovered

0408T	Insertion or replacement of permanent cardiac contractility modulation system; pulse generator with transvenous electrodes
0409T	Insertion or replacement of permanent cardiac contractility modulation system; pulse generator only
0410T	Insertion or replacement of permanent cardiac contractility modulation system; atrial electrode only
0411T	Insertion or replacement ... ventricular electrode only

Interrogation and oncology molecular test codesmixed

0418U	Interrogation device evaluation (in person) with analysis, review and report, implantable cardiac contractility modulation system
0422U	Oncology pan-solid tumor: cfDNA analysis for response to anti-cancer therapy
0444U	Targeted genomic sequence analysis panel of 361 genes

Wireless cardiac stimulator codesCPTCovered

0515T	Insertion of wireless cardiac stimulator for left ventricular pacing; complete system
0521T	Interrogation device evaluation (in person) with analysis... wireless cardiac stimulator

Oncology / molecular U-codes presentmixed

0512U	Oncology (solid tumor), MSI analysis on FFPE tissue; reported probability of MSI-high
0513U	Oncology (prostate), algorithmic analysis of whole-slide imaging for MSI and HRD on FFPE tissue
0523U	Oncology, ctDNA/NGS of 22 genes on FFPE tissue reporting SNVs/indels
0525U	Oncology, spheroid cell culture 11-drug response panel for ovarian/fallopian/peritoneal tumors
0530U	Oncology (pan-solid tumor), ctDNA NGS of 77 genes, fusions, MSI, TMB from plasma

Cardiac device T-codesCPT

0513T	Extracorporeal shock wave for integumentary wound healing; add-on for additional wound
0515T	Insertion of wireless cardiac stimulator for LV pacing; complete system
0516T	Insertion of wireless cardiac stimulator for LV pacing; electrode only
0517T	Insertion of wireless cardiac stimulator for LV pacing; generator components only

Selected T-codes from part 15CPT

0639T	Magnetic resonance spectroscopy; determination and localization of discogenic pain; interpretation and report
0640T	Magnetic resonance spectroscopy; determination and localization of discogenic pain; interpretation and report (alternate descriptor)
0643T	Magnetic resonance spectroscopy; determination and localization of discogenic pain; interpretation and report (alternate descriptor)
0644T	Transcatheter removal or debulking of intracardiac mass via suction device; percutaneous
0645T	Transcatheter implantation of coronary sinus reduction device
0646T	Transcatheter tricuspid valve implantation/replacement (TTVI)
0647T	Insertion of gastrostomy tube, percutaneous, with magnetic gastropexy
0650T	Programming device evaluation (remote) of subcutaneous cardiac rhythm monitor system
0651T	Magnetically controlled capsule endoscopy, esophagus through stomach
0652T	Esophagogastroduodenoscopy, flexible, transnasal; diagnostic

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Effective dates present — examples

Effective dates presentVarious effective/administrative dates are listed per code (examples include 1/2/2020, 10/1/2018, 1/1/2023, 7/1/2025).

Common examplesMany entries show 10/1/2018 and 1/1/2023 as effective dates for procedural and device codes.

Future-dated entriesSeveral U/T codes include future review/effective dates (eg, 7/1/2025 for many U-code entries).

Example administrative date

Example administrative date10/1/2018 appears frequently as an administrative/effective date following multiple CPT entries (eg, 62325, 29867 series).

Usage noteThis date is used in the listing to indicate when the code entry became effective for ASO prior authorization/notification processing.

VerificationProviders should check the listing for the applicable date when confirming whether a procedure requires authorization.

Panel gene-count requirements — examples

ImplicationAuthorization and lab reporting should confirm panel size meets the listed minimum gene-count requirement.

Examples in listing81412, 81442, 81443, 81445 entries include specific gene-count thresholds in their descriptors.

Effective date threshold — common 1/1/2023

Common effective date thresholdMany codes in the U/T listings show an effective date of 1/1/2023 for inclusion in the ASO prior authorization/notification roster.

ActionWhen a code shows 1/1/2023 as the effective date, providers should include that date in authorization references and checks.

ExamplesMultiple U/T and T-code entries (eg, 0326U, 0329T/0329U, 0408T series) list 1/1/2023 as an effective date.

Gene panel size thresholds — examples

Gene panel size thresholdsSome U-codes represent very large panels (examples: 0242U = 55–74 genes; 0244U = 257 genes; 0239U = 311+ genes; 0250U = 505 genes).

ImplicationLarge panel gene counts affect test complexity, reporting, and potential authorization review requirements.

Provider noteReference the ASO listing descriptor for exact gene counts when submitting prior authorization for multi‑gene panels.

Gene count threshold examples

Gene count examplesMultiple genomic U-codes specify panel sizes such as 83+, 311+, 437, 505 genes depending on the test (examples appear across 0326U, 0250U, and related entries).

Listing implicationAuthorization requests should reference the specific code and stated gene-count to ensure correct routing and review.

VerificationCheck the ASO code descriptor for the panel size requirement before submission.

U-code future effective date examples

Future effective date examplesSeveral U-code entries include future effective or review dates of 7/1/2025 (examples: 0250U, many 04xx–05xx U-codes list 7/1/2025).

ActionProviders should note future review dates when planning authorizations for emerging tests that may change coverage stance on that date.

Examples0250U (1 = 505-gene panel) shows 7/1/2025; multiple 04xx–05xx U-code entries also show 7/1/2025 in the listing.

Provider Submission and Authorization Instructions

Prior Authorization

Prior Authorization and Notification overview — Verify benefits and submit requests

Prior authorization does not ensure payment — benefits vary by plan; verify member benefits.
Submit preauthorization electronically via the secure provider portal; phone number on member ID for portal assistance.
Notification is requested for some services to assist coordination and discharge planning.

Note

Authorization submission pathway — Secure provider portal and contact info

Submit via secure provider portal (registered users).
If you cannot access the portal, call the number on the member's ID card or contact your Provider Relations Representative.

Note

Code list (partial) — overview and submission guidance

Comprehensive code lists include ENT, thoracic, cardiac, neuro/spine, orthopedic, vascular/venous, transplant preparation, bariatric, radiation therapy, nuclear medicine, PET/SPECT, and molecular/genetic tests.
Providers must include the specific CPT/HCPCS/T/U/code when requesting authorization; newly published codes may also require review.

Prior Authorization

Provider action: ENT / thoracic / cardiac codes

30400, 30410, 30420, 30430, 30435, 30450, 30460 (rhinoplasty variants) — effective dates vary (eg, 1/2/2020).
31660, 31661 (nasal valve repair) — effective 5/1/2023 = 1/1/2023.
Bronchoscopy with bronchial thermoplasty and related codes (e.g., 31660 series).
32491, 32672 (lung volume reduction procedures) — effective dates noted in plan.
32851 (lung transplant, single) and other transplant CPTs — see transplant code group.

Prior Authorization

Provider action: Cardiac / vascular / endovenous codes

33340 (left atrial appendage closure) — 5/1/2023.
33361–33366 (TAVR/TAVI approaches) — various effective dates.
33418, 33477 (transcatheter mitral/pulmonary interventions) — effective dates per list.
33927–33991 (heart replacement, transplant, VAD insertion/replacement) — 1/2/2020 onward.
36465–36483, 36474, 36475, 36478, 36482–36483 (sclerotherapy, endovenous ablation, chemical adhesive) — effective dates include 1/2/2020 and 3/1/2023.
36836–36837 (percutaneous AV fistula creation) — effective 5/1/2023.

Prior Authorization

Provider action: Venous / vascular / transplant prep codes

36474, 36475, 36478, 36482, 36483 (endovenous ablation and adhesive closure) — 1/2/2020 and 3/1/2023 effective dates.
37700–37785 (ligation/stripping, phlebectomy, varicose vein procedures) — effective dates noted (eg, 1/2/2020).
36836–36837 (percutaneous AV fistula creation) — effective 5/1/2023.
38206–38215, 38240–38241, 38207–38209, 38211–38215 (hematopoietic progenitor cell harvest/processing/cryopreservation/thawing and specific cell depletion procedures) — effective dates 1/2/2020 and related.

Note

Provider action: CPT mapping entries (partial)

Selected CPT mapping examples and other CPT entries are explicitly listed for authorization review. Providers must reference the exact CPT code and effective date when submitting requests.

Examples: 43648 (laparoscopy; revision/removal gastric neurostimulator) — 1/2/2020.
43770–43775 (laparoscopic bariatric procedures including adjustable band and sleeve gastrectomy) — 1/2/2020.
29867–29916 series (knee and hip arthroscopy/arthroplasty mapping) — effective 10/1/2018 and later.
0201T–0207T, 0408T–0411T, 0515T–0519T (selected T-codes for devices, genotyping, and implantable systems) — effective dates in listing.

Prior Authorization

Provider action: Neuro/spine/injection CPT entries

22515, 22526–22534 series (vertebral augmentation, intradiscal electrothermal annuloplasty, lateral extracavitary arthrodesis) — effective dates vary (e.g., 10/1/2018, 1/2/2020).
61863, 61867, 61885–61886 (neurostimulator electrode array implantation and pulse generator insertion/replacement) — 1/2/2020.
62263–62264 (percutaneous lysis of epidural adhesions) — 1/1/2023.
62280–62292 series and 62320–62351, 62360–62361 (neurolytic injections, discography, intrathecal/epidural injections, pump/catheter implantation, intrathecal drug delivery devices) — effective dates include 10/1/2018 and 4/1/2021.

Prior Authorization

Provider action: Nuclear medicine, diagnostic imaging, PET/SPECT, and genetic test codes

78018–78899 range covers thyroid, parathyroid, salivary, hepatobiliary, bone and joint, myocardial perfusion, cardiac blood pool, pulmonary ventilation/perfusion, PET imaging (e.g., 78811–78816), SPECT/CT (e.g., 78831–78832) — effective dates noted (8/1/2018 and updates).
78430–78432, 78451–78454 (myocardial PET and SPECT perfusion) — effective dates include 4/1/2020 and 9/1/2018.
78811–78816 (PET limited/skull-base/whole body and PET/CT variants) — effective 8/1/2018.
Molecular/genetic codes (e.g., 80145, 80230; 81161–81167 BRCA panels; 81349, 81351, 81407–81412; 81410–81411 gene panels; T/U codes 0080U–0099U, 0201T–0207T, 0408T–0469T, 0444U, 0460U–0471U, 0512U–0513U, 0515T etc.) — effective dates and code-specific requirements vary; many have 2020–2025 effective dates.
Providers must submit clinical indication, prior imaging/testing results, and specific assay/panel requested for molecular/genetic tests.

Prior Authorization

Provider action: Cardiac contractility modulation & device codes (examples)

0408T, 0409T, 0410T, 0411T (permanent cardiac contractility modulation system insertion and components) — 1/1/2023.
0515T–0519T (wireless cardiac stimulator insertion and related device management) — 1/1/2023.
93264 (remote monitoring of wireless pulmonary artery pressure sensor) — 4/1/2021.
0418U, 0419T, 0420T (interrogation and device evaluation codes) — effective dates per listing.

Note

Provider action: Device interrogation and oncology test mappings

0418U, 0419T, 0420T (interrogation and device evaluation for cardiac contractility modulation systems) — dates 1/1/2023 to 7/1/2025 for related U-codes.
0444U, 0445T, 0461U, 0467U (targeted genomic panels, implantable sensor creation/removal, oncology pharmacogenomics) — referenced with effective dates through 7/1/2025.
0472T–0473T (device evaluation and interrogation of intraocular retinal electrode arrays) — effective dates noted in list.

Prior Authorization

Provider action: Ophthalmology/device and oncology genomic codes

0445T (placement of drug-eluting ocular insert) — 4/1/2021.
0472T, 0473T (device evaluation/interrogation of intraocular retinal electrode arrays) — 4/1/2021.
0604T–0606T (remote OCT retina device provision and monitoring) — 1/1/2023.
Numerous oncology genomic U-codes (e.g., 0444U, 0460U, 0461U, 0467U, 0512U, 0513U) — effective through 7/1/2025; provide test name, specimen, and clinical indication with requests.

Prior Authorization

Provider action: Code list excerpt — additional procedures

0613T (transcatheter interatrial septal shunt device) — 1/1/2023.
0632T (pulmonary artery nerve ablation) — 1/1/2023.
0633T–0638T (CT breast with 3D rendering variants) — 1/1/2023.
0586T (islet cell transplant) and 0627T–0630T (percutaneous injection of allogeneic cellular/tissue products to intervertebral disc) — 1/1/2023.
Multiple T-codes (0600T–0650T and others) and U-codes for innovative diagnostics and therapeutics — check the ASO code listing for exact effective dates and submission requirements.

Background and Scope Notes