Scope and medical necessity linkage

The following CPT and HCPCS codes are in-scope under the Carelon High Technology Radiology program for Commercial products. For medical necessity criteria, providers must refer to the Carelon Medical Benefits Management Clinical Guidelines for Advanced Imaging/Radiology.

• Commercial products: CPT and HCPCS codes in-scope under Carelon High Technology Radiology — follow Carelon medical necessity criteria.

Scope and medical necessity linkage (Medicare Advantage)

The following CPT and HCPCS codes are in-scope under the Carelon Advanced Imaging/Radiology Management Program for Medicare Advantage (HMO and PPO). For medical necessity criteria, providers must refer to Carelon Medical Benefits Management Clinical Guidelines for Advanced Imaging/Radiology.

• Medicare Advantage products: CPT and HCPCS codes in-scope under Carelon Advanced Imaging/Radiology Management Program — follow Carelon medical necessity criteria.

Prior authorization exceptions and radiotracer PA requirements

The duplex/vascular study codes listed in Blue Cross Blue Shield of Massachusetts Medical Policy #691 (Non‑Invasive Vascular Studies — Duplex Scans) do not require prior authorization through Carelon Medical Benefits Management when the policy criteria are met. Additionally, specified radiotracer HCPCS codes have prior authorization requirements as noted in policy history.

• Codes exempt from Carelon prior authorization when policy criteria are met: 93880, 93882, 93922, 93923, 93924, 93925, 93926, 93930, 93931, 93978, 93979 (see BCBSMA Medical Policy #691).
• Radiotracer prior authorization notes: A9596, A9601, A9602, A9800 were added in policy history and require prior authorization through AIM Specialty Health/Carelon as indicated by effective dates in Policy History.