Obtain prior authorization and submit via portal

Prior Authorization is required for services listed on the Commercial Prior Authorization/Notification List. Submit requests via the secure provider portal (registered users can log in to submit an electronic preauthorization request). For help, call the number on the member's ID card or contact your Provider Relations Representative. Note: prior authorization is not a guarantee of payment; verify member benefits, eligibility, and plan limits.

• Prior authorization required for listed services.
• Submit via secure provider portal; phone number on member ID card for assistance.
• Prior authorization does not guarantee payment; verify benefits and eligibility.

Provide notification for requested services

For certain services the plan requests notification (notification-only) to assist with discharge planning, care coordination, and case management; providers should notify the plan per payer procedures.

• Notification is requested (notification-only) for certain services to support discharge planning, care coordination, and case management.
• Refer to payer procedures for how to provide notifications.

Check list for CPT codes requiring prior authorization/notification

The list includes many CPT procedure codes that require prior authorization or notification; examples shown include spine codes 22515, 22526, 22527, 22532, 22533. Providers must check the full list and obtain prior authorization where indicated.

• Example codes requiring prior authorization/notification: 22515, 22526, 22527, 22532, 22533.
• Always reference the full Commercial Prior Authorization/Notification List for complete codes and effective dates.

Obtain prior authorization for listed hip procedures

Hip and related arthroplasty CPT codes are included on the list (examples: 27125, 27130, 27132, 27134, 27137, 27138); prior authorization must be obtained when these codes are being billed per the list.

• Hip-related codes listed: 27125, 27130, 27132, 27134, 27137, 27138.
• Obtain prior authorization when performing these hip procedures per the Commercial PA/Notification List.

Prior authorize knee arthroscopy/arthroplasty codes

Knee arthroscopy and arthroplasty procedure codes such as 29867, 29868, 29870, and 29871 are included on the prior authorization/notification list; obtain prior authorization as required.

• Knee codes on the list include: 29867, 29868, 29870, 29871.
• Prior authorization required for listed knee arthroscopy/arthroplasty services.

Secure prior authorization for knee/hip arthroscopy codes

Additional knee and hip arthroscopy codes (eg, 29874–29889 and 29914–29916) appear on the list with effective dates; providers must secure prior authorization when these codes apply.

• Included arthroscopy codes: 29874–29889 (knee) and 29914–29916 (hip).
• Effective dates are shown inline on the list; consult the list for date-specific mappings.

Obtain prior authorization for rhinoplasty/nasal procedures

Rhinoplasty and nasal surgery CPT codes (examples: 30400, 30410, 30420, 30430, 30435, 30450, 30460, 30468) are on the PA/notification list; obtain prior authorization per the list when billing these procedures.

• Rhinoplasty/nasal valve repair codes on the list include 30400, 30410, 30420, 30430, 30435, 30450, 30460, 30468.
• Check effective/mapping dates on the list when submitting authorization requests.

Prior authorization for thoracic, transplant and related cardiac procedures

Various thoracic, bronchial, lung transplant and cardiac procedure codes are included on the list (examples include bronchial procedures and transplant-related codes); providers must obtain prior authorization per the code entries and effective dates.

• Examples of included codes relate to bronchoscopy with bronchial thermoplasty and lung transplant mappings.
• Refer to the list for specific cardiac and transplant procedure codes and their effective dates.

Prior authorization for cardiac, transplant, and VAD procedures

Cardiac procedures and ventricular assist device (VAD) related codes (examples listed in the document) require prior authorization or notification as indicated on the list; verify the exact code and effective date before submission.

• Cardiac/transplant/VAD procedure codes are listed with effective dates (see list entries).
• Verify the specific CPT and effective date on the Commercial PA/Notification List before requesting authorization.

Obtain prior authorization for venous and vascular procedures

Venous and vascular procedures (including sclerotherapy and endovenous ablation) such as 36465, 36466, 36473, 36474, 36475, 36478, 36483, 36836, 36837, 37700 and related codes are listed; obtain prior authorization per the list.

• Examples of venous/vascular codes on the list: 36465–36471, 36473–36483, 36836–36837, 37700, 37718, 37722.
• Prior authorization required for listed venous and endovenous ablation services; check effective dates.

Prior authorization for transplant, HPC and bariatric/gastric procedures

Transplant preparation and hematopoietic progenitor cell (HPC) codes (examples: 38206–38214, 38240–38241) and bariatric/gastric procedure codes (eg, 43210, 43290–43291, 43644–43648, 43770–43773) are included on the list; prior authorization must be obtained when these services are provided.

• HPC/transplant codes listed include 38206–38214 and 38240–38241.
• Bariatric/gastric procedure codes listed include 43210, 43290–43291, 43644–43648, 43770–43773.
• Obtain prior authorization per the Commercial PA/Notification List for these transplant and bariatric services.

Reference the PA/notification code list when requesting authorization

The PA/notification list contains numerous CPT, category III (T), and proprietary (U) codes used for prior authorization/notification processing; providers must reference the list when submitting requests.

• The list enumerates CPT and unlisted procedure codes that are part of the commercial prior authorization/notification list.
• Providers must reference the list for correct codes and any mapping or effective dates when submitting authorizations.

Use exact code and effective date when requesting authorization

The document excerpt lists CPT procedure codes that require prior authorization or notification and often shows an associated effective or mapping date; providers should use the listed code and date when submitting authorization requests.

• Many code entries include an effective/mapping date shown inline (eg, 10/1/2018, 1/2/2020, 4/1/2020, 10/1/2021).
• Use the exact code and associated date from the list when initiating a prior authorization or notification.

Prior authorization for therapeutic radiology planning and devices

Therapeutic radiology planning and device codes (examples: 77306, 77307, 77316–77318, 77321, 77331–77332) are included on the list; prior authorization is required for listed treatment planning and device design services.

• Therapeutic radiology planning codes on the list include 77306, 77307, 77316–77318, 77321, 77331, 77332.
• Obtain prior authorization for listed radiotherapy planning and treatment device services per the list.

Prior authorization for radiation treatment delivery and management

Radiation treatment delivery and management CPTs (examples: 77372–77373, 77402, 77407, 77412, 77425–77435 and treatment management codes) are included; prior authorization is required for these radiation delivery and management services per the list.

• Radiation delivery codes on the list include stereotactic radiosurgery, SBRT, and Level 1–3 delivery codes (eg, 77372, 77373, 77402, 77407, 77412).
• Treatment management and course-level codes (eg, 77425–77435) are listed and require authorization.

Obtain prior authorization for brachytherapy and hyperthermia codes

Brachytherapy, hyperthermia, and related procedure codes (examples: 77610, 77750, 77761–77763, 77767–77772, 77778–77790) are listed and require prior authorization when billed as indicated.

• Brachytherapy/hyperthermia codes listed include 77610, 77750, 77761–77763, 77767–77772, 77778–77790, 77799.
• Obtain prior authorization for listed brachytherapy and hyperthermia services per the list.

Prior authorization for nuclear medicine and PET/SPECT studies

Extensive nuclear medicine and PET/SPECT codes (eg, 78012–78020, 78103–78104, 78430–78432, 78451–78452, 78605–78610, 78630) are included on the list; prior authorization or notification is required for these studies per the list.

• Nuclear medicine/myocardial PET and SPECT codes listed include 78430–78432, 78451–78452 and multiple 780xx/781xx/786xx codes.
• Check the list for the specific nuclear medicine CPT and associated effective date when submitting authorization.

Verify prior authorization for nuclear medicine/radiopharmaceutical codes

Numerous nuclear medicine codes across 786xx–788xx ranges and related radiopharmaceutical procedures are on the authorization/notification list; providers must obtain prior authorization or provide notification as specified.

• Nuclear medicine/radiopharmaceutical code ranges on the list include 78605–78660, 78700–78730, 78800–78832.
• Refer to the list for the exact CPT and effective/mapping date when requesting authorization.

Prior authorization for molecular pathology and genetic tests

Molecular pathology and genetic testing CPTs (811xx, 812xx, 813xx, 814xx series) are included on the PA/notification list; providers must request prior authorization or notification for listed genetic tests and observe any test-specific requirements.

• Genetic test codes listed include BRCA analyses (81162–81167, etc.) and molecular pathology procedure levels (81408–81412 and others).
• Obtain prior authorization per the list and note any effective dates for specific genetic tests.

Ensure genomic panels meet listed gene-content requirements before authorization

Genomic panels and molecular pathology entries specify minimum gene content or analysis requirements for certain panels (examples: aortic dysfunction panels must include sequencing of at least 9 named genes; hearing loss panels require copy number analyses for STRC and DFNB1/GJB2/GJB6; XLID panels must include at least 60 genes). Ensure ordered panels meet the listed panel content requirements when seeking authorization.

• 81410 requires sequencing of at least 9 genes including FBN1, TGFBR1, TGFBR2, COL3A1, MYH11, ACTA2, SLC2A10, SMAD3, MYLK.
• 81431 hearing loss panels must include copy number analyses for STRC and DFNB1 deletions in GJB2 and GJB6.
• 81470 XLID panel must include sequencing of at least 60 specified genes.

Confirm panel size, analytes, and sample type for expanded genomic panels

Expanded genomic sequence analysis panels and related molecular pathology CPTs (eg, 81455–81464 and others) appear on the list with gene-count thresholds and specimen-type notes (including cell-free/plasma); confirm panel size, analytes (DNA/RNA), and sample type when submitting prior authorization.

• Examples include 81456 (solid organ neoplasm panels ≥51 genes), 81462–81464 (cell-free/plasma panels with various analytes).
• Confirm DNA vs combined DNA/RNA testing and cell-free/plasma sample applicability per the list before requesting authorization.

Prior authorization for gene expression and assay-based tests

Gene expression and algorithmic/assay-based tests (examples: 81503, 81504, 81518, 81519, 81520, 81521, 81522, 81523, 81525, 81529, 81535, 81541, 81560, 81595) are listed; these often report algorithmic risk scores or categorical results and require prior authorization per the list.

• Listed assay codes include oncology and transplant gene expression profiling tests (eg, 81519 – 21-gene breast recurrence score; 81541 – prostate 46-gene profile).
• Authorization requests should reference the listed code and note that algorithmic/risk score outputs are typical for these tests.

Verify authorization/notification for laboratory, reproductive and immunology codes

Assorted laboratory, reproductive, immunology, vaccine and related CPTs (eg, 82523, 84999, 86015, 86036, 86037, 88267, 89250–89264, 90378–90381) are listed for notification or authorization; follow the list and effective dates when submitting.

• Examples include reproductive medicine and cryopreservation codes (89250–89264) and immunology/vaccine codes (90378–90381).
• Use the Commercial PA/Notification List to determine whether prior authorization or notification is required for these lab/reproductive codes.

Obtain authorization for imaging, ophthalmology, vestibular and cardiac codes

Imaging, ophthalmology, vestibular, and numerous cardiac catheterization CPTs (examples: 91110–91113 capsule endoscopy, 92065 orthoptic training, 92549 CDP-SOT, 93451–93461 cardiac catheterization codes) are included on the list; obtain prior authorization or provide notification as indicated.

• Imaging and cardiac catheterization codes listed include 93451–93461 and related procedural codes with effective dates.
• Vestibular and ophthalmology services (eg, 92549, 92065) are listed—check the list before scheduling services.

Prior authorization for interventional, neurophysiology, psychological, and home health services

Interventional cardiology, neurophysiology, neurodiagnostic, psychological testing, and home health supervision CPTs (examples: 93590–93597, 95905, 95940–95941, 96130–96131, 99374) are on the list; prior authorization or notification is required per the list entries and effective dates.

• Interventional and neurophysiology codes on the list include 93590–93597, 95905, 95940–95941.
• Psychological testing and home health supervision codes (96130–96131, 99374) are listed — follow the PA/notification process.

Use the official PA/Notification list as the authorization reference

Providers must reference the Commercial Prior Authorization/Notification List when seeking prior authorization or providing notification; the list contains code descriptions and effective/mapping dates used by the plan for authorization decisions.

• Segment lists codes and descriptions that are part of the commercial PA/Notification List; providers must reference these.
• The full, current list and submission instructions are available on the Baylor Scott & White Health Plan Service Portal.

Confirm authorization requirements for U/T proprietary and temporary codes

The document includes many U- and T- proprietary codes and temporary tracking codes (eg, 0122U, 0350T, 0473U, 0474U, 0355U, 0395U, 0473T) used to identify molecular/genomic tests and emerging technologies; check the list for exact U/T code entries and effective dates before submitting authorization requests.

• Examples of U/T codes in the list: 0122U, 0350T, 0355U, 0473U, 0474U, 0395U.
• Confirm the exact U/T code and effective/mapping date on the Commercial PA/Notification List when requesting authorization.

Include test/panel details and gene-count requirements in authorization requests

When requesting authorization for molecular/genomic tests and procedural T-codes, include test details (panel name, gene count, specimen type) and reference any gene-content or panel-size requirements noted in the list to facilitate review.

• Provide panel name, gene count, and specimen type (eg, FFPE tissue or plasma cell-free) when submitting authorization for genomic panels.
• Reference the list's gene-content requirements (eg, minimum gene counts for specific panels) in the request.

Demonstrate panels meet minimum gene-content thresholds

Some listed molecular/genomic tests specify minimum gene-content thresholds (examples: 81439 requires sequencing of at least 5 cardiomyopathy-related genes; 81442 requires at least 12 genes for Noonan spectrum panels; 81470 requires sequencing of at least 60 genes for XLID). Ensure authorization requests demonstrate the panel meets these minimums.

• 81439 (hereditary cardiomyopathy) must include sequencing of at least 5 genes (eg, DSG2, MYBPC3, MYH7, PKP2, TTN).
• 81442 (Noonan spectrum) must include sequencing of at least 12 genes (eg, BRAF, CBL, HRAS, KRAS, MAP2K1, MAP2K2, NRAS, PTPN11, RAF1, RIT1, SHOC2, SOS1).
• 81470 (XLID) must include sequencing of at least 60 specified genes.

Include exact CPT and effective date for radiation/nuclear medicine authorization

For radiation and nuclear medicine services listed, use the exact CPT and effective date from the list (e.g., therapeutic radiology planning codes 77306, 77307, and radiation delivery codes 77402, 77407, 77412 show effective date 10/1/2021) when submitting prior authorization to avoid processing delays.

• Examples of codes with 10/1/2021 effective dates: 77306, 77307, 77316–77318, 77402, 77407, 77412.
• Include the listed effective/mapping date with the CPT when submitting authorization requests.

Verify member eligibility and benefits before services

Claims will be reviewed to determine member eligibility at time of service and benefit availability; prior authorization does not guarantee payment—providers must verify member benefits and eligibility before providing services.

• Prior authorization is not a guarantee of payment; reimbursement depends on eligibility, benefit limits and exclusions.
• Verify benefits via the member benefit booklet or customer service before providing services.

Confirm authorization for newly published or emerging codes

Newly published or assigned codes and emerging therapy services not listed may still require prior authorization; check with Baylor Scott & White Health Plan before providing these services.

• New or emerging codes/services may require prior authorization even if not yet listed.
• Contact Baylor Scott & White Health Plan to confirm authorization requirements for new codes/technologies.