Prior authorization and submission

Prior authorization is required for services and codes listed on this prior authorization/notification list. Providers must submit electronic preauthorization requests via the Baylor Scott & White Health Plan secure provider portal (call the number on the member’s ID card for portal access). Note that prior authorization is not a guarantee of payment; reimbursement depends on member eligibility, benefit limitations/exclusions, and plan-specific benefits.

• Submit requests through the secure provider portal; contact Provider Relations for assistance.
• Authorization does not guarantee payment; verify member benefits via the benefit booklet or customer service.

Notification requests

The plan requests notifications for certain services to support discharge planning, care coordination, and case management. Providers should submit requested notifications per the payer’s instructions to enable care coordination activities.

• Notifications are separate from prior authorization and are used for care coordination and discharge planning.
• Follow the payer’s notification process as listed on the provider portal or contact customer service for instructions.

Spine arthrodesis and related procedures

Spine arthrodesis and related spinal fusion/interbody instrumentation procedures listed on the prior authorization/notification list require provider submission per the payer’s process; codes and effective dates are shown in the list (examples include 22552, 22554, 22556, 22558, 22600, 22612, 22614, 22630, 22632).

• These procedures are included on the commercial prior authorization/notification list and have effective dates noted.
• Reference the code list when requesting authorization or submitting notifications.

Shoulder and interbody device procedures

Shoulder procedures and interbody device/instrumentation codes (examples: 23410–23473 series; interbody insertion codes 22853–22858) are on the prior authorization/notification list and require preauthorization/notification per the payer’s submission process.

• Shoulder repair and arthroplasty CPTs (eg, 23410, 23412, 23430, 23470, 23472) have effective dates shown.
• Insertion of interbody biomechanical devices (eg, 22853, 22854, 22856–22858) is listed with effective dates and requires authorization.

Hip and knee arthroplasty and injections

Hip and knee arthroplasty procedures and related injection procedures (examples: 27125–27138, 27332, 27428–27446, 27486, and arthroscopy/arthroplasty codes 29860–29883 series) are included on the list and require prior authorization or notification as shown alongside codes and dates.

• Sacroiliac/hip injection CPTs mapped to hip arthroplasty codes (eg, 27125, 27130, 27132, 27134) are listed with effective dates.
• Total knee and related arthroplasty/arthroscopy CPTs (eg, 29860–29883, 29874–29881) are listed and require authorization per the code list.

CPT code mappings and notes

The document provides CPT code mappings and notes showing mapped equivalents or descriptive titles and effective dates; providers should use these mappings and the dates to determine authorization applicability (examples include arthroscopy/arthroplasty mappings such as 29828, 29860 and other mapped entries).

• Many codes are shown with mapping notes and effective dates; use the list to identify mapped equivalents when submitting requests.
• Check the effective date shown next to a code to determine when the requirement applies.

CPT code listing (partial)

This excerpt includes many CPT procedure codes paired with effective/change dates that indicate prior authorization or notification requirements; providers must reference the listed codes and dates when requesting authorization.

• Examples in this fragment include 43210 (1/2/2020 = 4/1/2021), 43290 (1/2/2020 = 5/1/2023), and other CPT lines with dates.
• Use the payer’s secure provider portal and the code list to submit requests for these CPTs.

Epidural/interlaminar injections — prior auth/notification entries

Epidural and interlaminar injection procedures (CPTs 62321, 62322, 62323) and additional interlaminar injection entries (62324–62327) are listed with imaging-guidance distinctions and effective dates; these injection services require prior authorization or notification as shown.

• 62321 — interlaminar epidural/subarachnoid injection, cervical or thoracic; with imaging guidance (2 = 10/1/2018).
• 62322 — interlaminar epidural/subarachnoid injection, lumbar or sacral; without imaging guidance (2 = 1/2/2020).
• 62323 — interlaminar epidural/subarachnoid injection, lumbar or sacral; with imaging guidance (2 = 1/2/2020).
• 62324–62327 — injection(s) including indwelling catheter placement and continuous infusion entries with dates (10/1/2018).

Intrathecal/epidural catheter and pump procedures

Intrathecal/epidural catheter and pump implantation, revision, replacement and reservoir procedures (CPTs 62350–62362) are on the list and require prior authorization or notification; effective dates are shown alongside each code.

• 62350–62351 — implantation/revision/repositioning of tunneled intrathecal or epidural catheter (10/1/2018).
• 62360–62362 — implantation/replacement of intrathecal/epidural infusion devices and pumps (10/1/2018).

Spinal decompression and laminectomy

Spinal decompression, laminectomy, laminotomy and related decompressive procedures (CPTs 62380, 63001, 63003, 63005, 63012, 63015, 63017, etc.) are listed with effective dates and require prior authorization/notification per the payer list.

• 62380 — endoscopic decompression of spinal cord/nerve root(s), lumbar (10/1/2018).
• 63001, 63003, 63005, 63012, 63015, 63017 — laminectomy and decompression CPTs with dates indicating authorization requirement.

Laminotomy/laminoplasty and reexploration

Laminotomy/laminoplasty and re-exploration procedure codes (CPTs 63020, 63030, 63035, 63042–63050, 63082, etc.) are included on the prior authorization/notification list and have effective dates; providers must reference these when requesting authorization.

• 63020–63035 — laminotomy/hemilaminectomy entries with effective dates (10/1/2018).
• 63042–63050, 63082 — reexploration and additional laminotomy/laminoplasty codes with dates (10/1/2018).

Neurostimulation and related injections

Neurostimulation services and related injection procedures (examples: CPTs 63650, 63685, 64454, 64479–64484) are listed on the prior authorization/notification list; imaging-guidance distinctions and effective dates are shown.

• 63650 — percutaneous implantation of neurostimulator electrode array, epidural (10/1/2018).
• 63685 — laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural (10/1/2018).
• 64454 — genicular nerve injections with imaging guidance, effective 1/1/2023; 64479–64484 — transforaminal epidural injections with guidance (10/1/2018).

Peripheral and cranial nerve injections and stimulators

Peripheral and cranial nerve injection and stimulator procedures (CPTs 64490–64590 series including paravertebral facet injections, stellate ganglion, sacral nerve, cranial nerve neurostimulator implantation and peripheral pulse generator procedures) are included on the list and require authorization/notification as indicated.

• 64490–64495 — paravertebral facet/paraspinal injections with imaging guidance (10/1/2018).
• 64510, 64520, 64553, 64561, 64568, 64581–64583, 64590 — peripheral and cranial nerve stimulator and generator implantation/replacement codes with dates.

Neurolytic and radiofrequency ablation procedures

Neurolytic and radiofrequency ablation procedures including basivertebral nerve destruction (CPTs 64624–64636 and related entries) are listed with effective dates; providers must obtain prior authorization/notification for these services per the code list.

• 64624 — neurolytic destruction, genicular nerve branches (1/1/2023).
• 64628–64629 — thermal destruction of intraosseous basivertebral nerve including imaging guidance (1/1/2023).
• 64633–64636 — neurolytic ablation of facet joint nerves with imaging guidance (10/1/2018).

Oculoplastic and otoplasty / ENT and hearing device procedures

Oculoplastic, otoplasty, ENT and osseointegrated hearing device procedures (examples: CPTs 67900–67909, 69300, 69705–69730) are included on the list with effective dates and require prior authorization/notification per the payer’s list.

• 67900–67909 — oculoplastic procedures listed with dates (1/2/2020).
• 69705–69706 — nasopharyngoscopy with Eustachian tube balloon dilation (5/1/2023).
• 69710–69730 — osseointegrated implant and replacement codes listed with dates (2022–2023).

CT and MRI imaging procedures

A wide range of CT and MRI imaging CPT codes (head/brain, orbit/face/neck, CT angiography, thorax, spine and extremity MR/CT codes) are on the prior authorization/notification list; providers must reference the list and effective dates when seeking authorizations.

• Examples include CT head codes 70450–70470 and MRI brain codes 70551, 70553–70555 (effective dates 8/1/2018).
• CT/MR extremity and abdominal/pelvis codes (eg, 73702, 73706, 74150–74178) are listed with dates and mapping notes.
• Cardiac MRI CPTs (75559–75577 series) are listed with effective dates (9/1/2018 and others).

Imaging CPT codes requiring prior authorization/notification (examples)

Imaging CPT codes requiring prior authorization/notification include numerous MRI and CT codes mapped in the list (examples: 70551, 70553, 70554, 70555, 71250–71275, 71550–71555). Providers should consult the code list and effective dates when submitting authorization requests.

• 70551 — MRI brain without contrast (8/1/2018).
• 70553–70555 — MRI brain with contrast/functional MRI entries (8/1/2018).
• 71250–71275 and 71550–71555 — CT/MR thorax and chest mappings listed with dates (8/1/2018).

CT/MR extremity and abdominal CPT codes

CT and MR extremity and abdominal/pelvic CPT codes (examples: 73700–73725 series for extremities; 74150–74178 series for abdomen/pelvis) are included on the prior authorization/notification list with effective dates; use the list when requesting authorization.

• 73702, 73706, 73718–73725 — CT/MR lower extremity mappings (8/1/2018).
• 74150–74178 — CT abdomen/pelvis and angiography mappings (8/1/2018).

Cardiac MRI CPT codes

Cardiac MRI and related CPTs (examples: 75559, 75561, 75563, 75571–75574, 75577) are on the list and require prior authorization/notification; effective dates are shown alongside these codes.

• 75559–75563 — cardiac MRI morphology and function CPTs with effective dates (9/1/2018).
• 75571–75574, 75577 — other cardiac MR/CT and postprocessing entries listed with dates (9/1/2018; 5/1/2026 for 75577).

Radiation therapy/medical physics codes

Radiation oncology delivery/management and medical physics CPT codes (examples: 77334, 77336, 77338, 77370–77373, 77387, 77402, 77407, 77412, 77417, 77423–77427) are included on the prior authorization/notification list; providers must obtain authorization per the payer’s process.

• 77336 — continuing medical physics consultation, reported per week (effective 10/1/2021).
• 77371–77373 — stereotactic radiosurgery and SBRT delivery codes (10/1/2021).
• 77402, 77407, 77412 — radiation treatment delivery level codes with effective dates (10/1/2021).

Brachytherapy, proton therapy, hyperthermia

Brachytherapy, proton therapy and hyperthermia CPT codes (examples: 77520–77525 for proton therapy; 77750–77799 series for brachytherapy; 77600–77620 for hyperthermia) are included on the list and require prior authorization/notification as indicated.

• 77523–77525 — proton treatment delivery (intermediate/complex) listed with dates (9/1/2021).
• 77600–77620 — hyperthermia therapy CPTs listed (10/1/2021).
• 77761–77772, 77767–77768 — brachytherapy entries with effective dates (10/1/2021).

Diagnostic nuclear medicine and radiopharmaceutical codes

Extensive diagnostic nuclear medicine and radiopharmaceutical CPT codes (examples: 78012–78499, 78600–78816 series, 78709, 78800–78816) are listed and require prior authorization/notification per the payer list; effective dates are shown for many entries.

• 78012–78020 — thyroid uptake and imaging codes (effective 8/1/2018).
• 78071–78075, 78102–78104 — parathyroid and bone marrow imaging series (8/1/2018).
• 78800–78816 — radiopharmaceutical localization and PET/SPECT imaging codes (8/1/2018; 4/1/2020 for select PET codes).

Prior authorization/notification requirement listing (partial)

This excerpt enumerates imaging, genetic and laboratory procedure codes that are subject to the payer’s prior authorization/notification requirements; providers must reference the list and effective dates when requesting authorization or submitting notifications.

• The listing includes imaging CPTs (eg, 78709, 78800–78804, 78811–78816) and genomic/genetic test codes.
• Providers must use the payer’s code list to determine which services require prior authorization/notification and the effective date applicable.

Genomic/molecular oncology panels

Genomic and molecular oncology panels (examples: CPTs 81451, 81455, 81456, 81458, 81459, 81462–81464) are listed and require prior authorization/notification; many entries include panel gene-count groupings and effective/revision dates.

• 81451 — hematolymphoid neoplasm panel, 5–50 genes, RNA analysis (effective 7/1/2023).
• 81455–81456 — solid organ/hematolymphoid panels with ≥51 genes (effective 9/1/2021 and 7/1/2023 respectively).
• Entries specify panel sizes (eg, 5–50 genes, ≥51 genes) and effective dates; use the list when requesting authorization.

Oncology molecular tests and expression panels

Oncology molecular tests and gene expression panels (examples: CPTs 81471, 81479, 81493, 81503–81523, 81525–81551) are listed with indications and effective dates; prior authorization/notification is required per the code list.

• 81471 — duplication/deletion gene analysis for XLID, must include analysis of at least 60 genes (effective 1/1/2023).
• 81518, 81519, 81520 — breast oncology gene expression profiling entries with effective dates (various 2021–2025 dates).
• 81560 — IPF 190-gene expression assay listed with dates (1/1/2023 = 5/1/2023).

Pulmonary disease (IPF) gene expression and related codes

mRNA gene expression assays for pulmonary disease (IPF) and related CPTs (examples: 81560, 81595, and linked ancillary CPTs 82523, 84999, 86015–86037, 88267–88269, 89250) are listed and require prior authorization/notification per the payer list; effective dates are shown.

• 81560 — IPF 190-gene expression assay (1/1/2023 = 5/1/2023).
• 81595 and related lab/test CPTs are cross-listed with effective dates; providers must reference these codes when requesting authorization.

Category I/III and PLA laboratory codes

Category I/III and PLA laboratory codes (examples: 0001U, 0003U, 0005U, 0007U, 0008U, 0010U, 0011M/0011U, 0012M, etc.) are included on the list; providers must request prior authorization/notification for these molecular, infectious disease, pharmacologic and transplant-related tests as indicated.

• 0001U — red blood cell antigen typing DNA, 35 antigens (effective 1/1/2023).
• 0010U — infectious disease strain typing by whole genome sequencing (effective 1/1/2023).
• 0011M/0011U, 0012M, 0013M and other M/U codes for oncology and transplant tests have dates and require authorization.

Code list (partial)

This excerpt contains a partial code list of laboratory, diagnostic and procedural codes (including proprietary U/T codes and temporary T-codes) that are subject to prior authorization/notification; providers must reference the payer’s full list when submitting authorization or notification requests.

• Representative U/T codes are included (eg, 0120U, 0247U, 0250U, 0334U) with service descriptions and effective dates.
• T-code examples (eg, 0335T, 0441T, 0546T) are present; many entries include implementation dates to determine applicability.

Prior authorization/notification listing (excerpts)

Excerpts of the prior authorization/notification listing include many U/T proprietary codes for genomic, oncology, obstetrics, and other advanced diagnostics (examples: 0247U, 0250U, 0334U, 0335U); providers must request prior authorization/notify per the listed effective dates and descriptors.

• 0247U — IBP4/SHBG preterm birth predictive-risk stratification (10/1/2021).
• 0250U — targeted genomic DNA analysis of 505 genes (effective 7/1/2025).
• 0334U — oncology targeted genomic analysis of ≥84 genes (1/1/2023).

Code list – lab and procedure items requiring authorization/notification

The payer’s code list identifies lab and procedure items requiring authorization/notification, including numerous U-codes and T-codes; providers must consult the list and include effective dates when submitting authorization requests.

• Examples include 0247U (IBP4/SHBG), 0250U (505-gene panel), and 0334U (84+ gene panel) with effective dates.
• Providers should reference the code descriptor and effective date from the list when preparing prior authorization requests.

Code list excerpt — provider notification/prior auth

The document provides a provider-oriented code list excerpt that includes procedure and laboratory codes with descriptors and effective dates; when seeking prior authorization or submitting notifications, providers must reference these entries.

• Representative entries include 0334U (84+ gene oncology panel), 0335T (sinus tarsi implant insertion), and 0441T–0444T T-code examples with dates.
• Many entries show the effective date for the authorization/notification requirement; use that date to determine applicability.

T-code list (excerpt)

A partial T-code list (examples: 0546T, 0552T, 0559T, 0565T, 0566T, 0569T, 0570T, 0632T–0635T, 0650T–0655T) is included; these temporary/proprietary CPT T-codes require prior authorization or notification per the payer’s list and effective dates.

• 0546T — intraoperative radiofrequency spectroscopy margin assessment at partial mastectomy (1/1/2023).
• 0565T/0566T — autologous cellular implant for knee osteoarthritis (1/1/2023).
• 0633T–0635T, 0650T–0655T — CT breast and other T-code examples with effective dates (1/1/2023; earlier mapping dates noted).

Effective date guidance (implicit)

Many entries in the code lists include effective or implementation dates indicating when the prior authorization/notification requirement began or changed; providers must use these dates to determine whether a code is currently subject to authorization/notification.

• Effective dates are shown alongside most CPT/U/T entries (examples: 8/1/2018, 10/1/2018, 1/1/2023, 7/1/2025).
• Check the effective date next to a code on the list to determine applicability before submitting an authorization or notification.