Baylor Scott & White Prior Auth Code List

Coverage Determination and Medical Necessity

Covered when the member is eligible and the service is medically necessary; reimbursement depends on plan benefits and limitations.

ALL of the following

The requested service must be medically necessary and appropriate.
The member must be eligible and coverage must be available under the member's specific plan; verify benefits in the member benefit booklet or with customer service prior to service.
Reimbursement of authorized services is dependent upon eligibility, benefit limitations and exclusions, evidence of coverage provisions, and any claims payment agreements.
Prior authorization is not a guarantee of benefits or payment at the time of service; authorization only determines medical necessity.
Newly published or emerging codes/therapies not listed may still require prior authorization to determine medical necessity; check with Baylor Scott & White Health Plan before providing these services.
Operational: Providers should submit electronic preauthorization requests via the secure provider portal or call the number on the member's ID card; contact Provider Relations for assistance.

Non-covered Services

Services or procedures that are never covered are not included on the prior authorization list.

ALL of the following

There are services and procedures which are not covered by Baylor Scott & White Health Plan / FirstCare or its subsidiaries.
These never-covered services are intentionally not listed on the prior authorization code list.
Always verify plan benefits and exclusions prior to providing services to confirm whether a service is excluded from coverage.

Code mapping list (partial)

Partial code mapping list with associated reference/effective dates (examples).

ALL of the following

21247 — Reconstruction superior-lateral orbital rim and lower forehead; reference dates shown (e.g., 1/1/2024 = 1/2/2020).
21248 — Reconstruction superior-lateral orbital rim and lower forehead; descriptor and reference date shown (1/1/2024 = 1/2/2020).
21249 — Reconstruction superior-lateral orbital rim and lower forehead; descriptor and reference date shown (1/1/2024 = 1/2/2020).
Additional listed CPT codes mapped to short descriptors with cross-reference dates are included in this partial mapping (see source chunk for examples).

Billing/coding list

Coding list excerpt; contains code descriptors and effective/reference dates for billing reference only.

ALL of the following

58720 — Salpingo-oophorectomy complete/partial uni/bi; reference date 1/1/2023 = 1/2/2020.
58970 — Follicle puncture for oocyte retrieval; code mapped and reference date shown (1/1/2023 = 1/1/2024).
59897 — Unlisted fetal invasive procedure with ultrasound; reference date shown (1/1/2023 = 12/1/2019).
Operational: This excerpt lists codes and dates for billing reference; no medical necessity or coverage rules are provided in this segment.

Codes-only section

Codes-only section: enumerated CPT/HCPCS codes with short descriptors and reference dates (informational).

ALL of the following

75571, 75572, 75573, 75574 — CT cardiac imaging codes with descriptor and prior reference dates (examples shown).
Multiple PET, radiopharmaceutical and genetic test codes listed with descriptions and dates (see source chunks).
Informational: This section provides code descriptions and dates only; it does not contain coverage or payment determinations.

Code listing (informational)

Informational code listing with descriptors and referenced effective dates; no explicit medical necessity criteria included in this excerpt.

ALL of the following

89261, 89264, 89320, 89337 — Examples of oncology and reproductive laboratory codes listed with effective/reference dates (see chunk).
0007U–0012M and related U/M/T codes — Examples of proprietary and temporary codes with dates included for billing reference.
These listings are for coding and billing reference only; they do not state approval criteria or coverage rules in this segment.

Coverage — informational only

Coverage — informational only: lists U-/T-code descriptors and associated dates; no coverage determinations provided here.

ALL of the following

0087U, 0088U, 0089U, etc. — Sample U-code entries with descriptors and reference/effective dates provided for billing.
No prior authorization guidance or medical necessity rules are included in this excerpt; content is limited to code descriptors and dates.

Code entries (excerpt)

Code entries (excerpt) enumerating U/T codes and example effective/revision dates (informational).

ALL of the following

0351U–0359U, 0352T–0354T — Sample U- and T-code entries with short descriptors and noted dates (examples include APOL1 testing and MRD assays).
0355U — APOL1 risk variants (G1, G2) example; reference date 1/2/2020 = 4/1/2023 shown.
These are code entries with dates for reference; no per-code medical necessity criteria are asserted in this excerpt.

Examples

Examples of code descriptors and their effective dates (informational).

ALL of the following

0487U — Oncology (pan-solid tumor) NGS analysis of tumor methylation markers in cell-free circulating tumor DNA; effective date 7/1/2025 noted.
Related U/T code examples include descriptors mapping to effective dates for billing reference.
This example lists a code and effective date for reference; it does not provide coverage rules or medical necessity criteria in this excerpt.

Billing/coding information only

Billing/coding information only: procedure and Category III codes with descriptors and dates; no coverage criteria are provided here.

ALL of the following

0570T–0572T — Intraprocedural coronary functional mapping and related device/procedure T-codes with effective date 1/1/2023.
0697T–0714T and others — Category III and other T/T-like codes listed with descriptors and reference dates (examples include quantitative MRI, remote amblyopia treatment, noninvasive arterial plaque analysis).
Informational: Codes and dates are provided for billing; medical necessity requirements are not specified in these code-only excerpts.

Enumerated codes only

Enumerated codes (partial): Category III, T-codes and related procedure codes with short descriptors and effective/reference dates.

ALL of the following

0697T–0704T — Category III imaging and remote therapy codes with descriptors and dates (examples: quantitative MRI, remote amblyopia treatment).
0705T–0714T — Additional Category III codes for remote therapy, plaque analysis, transperineal laser ablation, cardiac acoustic waveform recording, etc., with reference dates (mostly 5/1/2023 or 10/1/2022 as shown).
This block enumerates codes and dates for provider/billing reference; it does not establish per-code medical necessity criteria in the excerpt.

Coverage — informational (codes and dates)

Coverage stance from excerpt (informational): lists HCPCS/C CPT/C-code entries with effective dates for billing reference.

ALL of the following

C9361, C9364, C9399, C9734, C9739, C9751, C9756, C9758, C9759, C9762, C9763, C9764, C9765, C9766 — sample C-code entries with descriptors and effective dates for billing reference.
These entries provide code descriptors and dates; the excerpt does not specify coverage determinations or payment rules per code.

Code-to-description entries

Code-to-description entries: selected J-code mappings and drug HCPCS entries with associated effective dates (informational).

ALL of the following

J0172 — Aducanumab-avwa; mapping and effective/reference date provided (J0172, 9/1/2020 = 3/1/2022).
J0174 — Lecanemab-irmb, 1 mg; mapping and effective/reference date provided (J0174, 9/1/2020 = 11/1/2023).
Selected J-codes (J0600, J0614, J0638, J0641, etc.) are listed with short descriptors and varied effective/reference dates for billing reference.
These mappings are informational; consult coverage rules and benefit limitations to determine payment eligibility for drug administrations.

Prior Authorization, Notification and Billing Guidance

Prior Authorization

Prior Authorization Submission and Notice

Prior Authorization is not a guarantee of benefits or payment at the time of service. Reimbursement of authorized services is dependent upon eligibility, benefit limitations, and exclusions. Benefits vary between plans; always verify member benefits by consulting the member benefit booklet or contacting Customer Service. The current list of prior authorization codes, specific code requirements, and online authorization submission are available on the Baylor Scott & White Health Plan provider portal. Registered users of the secure provider portal can log in and submit an electronic preauthorization request. Call the number on the member's ID card for portal assistance or contact your Provider Relations Representative.

PA is not a guarantee of payment; benefits and coverage determined at claim adjudication
Electronic PA submission available via secure provider portal for registered users
Verify member eligibility and benefits prior to service

Note

Notification and Discharge Planning

Notification is requested for certain services to assist with discharge planning, care coordination, and case management. Providers should notify Baylor Scott & White Health Plan when these services are scheduled or provided so the plan can assist with transitions of care. All services must be medically necessary and appropriate and meet applicable coverage criteria. Claims will be reviewed for member eligibility at the time of service, benefit availability, evidence of coverage provisions, and payment agreements. Newly published codes or new/emerging therapies may require prior authorization—check with the plan before providing such services.

Notification assists with discharge planning, care coordination, and case management
All services remain subject to medical necessity and plan benefit rules
Check with Baylor Scott & White Health Plan for new codes or emerging therapies

Billing Rule

Code listing — no authorization guidance

This policy includes a code listing for provider billing reference. The list contains CPT, HCPCS, Category III, temporary (U/T) and other codes with descriptors and effective/reference dates. The presence of a code in this listing is for coding and billing reference only and does not, by itself, indicate coverage or prior authorization requirements. Providers must verify coverage, medical necessity, and any authorization requirements prior to rendering services.

Comprehensive code listings (CPT/HCPCS/U/T/Category III) included for billing reference with effective dates
Inclusion in the code list is not authorization or coverage determination
Verify plan coverage and prior authorization requirements before providing services

OpenPayer

Prior Authorization / Prior Authorization Code List

Coverage Determinations and Code Listings

Code Tables and Selected Code Examples

Prior Authorization, Notification and Billing Guidance

Definitions and Terminology