CurrentBlue Cross Blue Shield - MassachusettsPolicy 957

Carelon Genetic Testing Management Program CPT and HCPCS Codes

Lists CPT and HCPCS codes that are in-scope under the Carelon Genetic Testing Management Program for Blue Cross Blue Shield Massachusetts commercial and Medicare Advantage products and provides prior authorization and policy scope guidance.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyCarelon Genetic Testing Management Program CPT and HCPCS Codes

Policy CodePolicy 957

Change TypeNo material changes

Effective DateJanuary 1, 2019

Next Review Date

Key ActionRequest prior authorization via BCBSMA Provider Central or Carelon ProviderPortal (or by phone at 1-866-745-1783) for applicable commercial and Medicare Advantage products.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2019-01-01Commercial effective

2025-01-01Medicare Advantage effective

81400–81470CPT series described

multipleCPT codes listed

Coverage stance and scope

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Coverage stance and procedural notes

Codes listed are in‑scope under the Carelon Genetic Testing Management Program. For medical necessity and coverage criteria, refer to Carelon Medical Benefits Management Clinical Guidelines or the referenced BCBSMA medical policies where specified.

Codes in this document are managed under the Carelon Genetic Testing Management Program for Commercial products effective January 1, 2019; medical necessity determinations follow Carelon Medical Benefits Management Clinical Guidelines.

Carelon management excludes cytogenetics, HLA testing, and HPA testing; Preimplantation Genetic Testing (including codes 89290 and 89291) is governed by BCBSMA Medical Policy #088 and requires prior authorization through BCBSMA.

Molecular genetic/genomic testing that does not meet coverage criteria in the applicable Carelon guidelines or BCBSMA policies may be considered experimental/investigational or not medically necessary and may not be covered.

Coverage is subject to the member's benefit contract; member records must document medical necessity and BCBSMA may audit services and request documentation.

Coding reference (no coverage rules in this extract)

This extract provides coding descriptors only; no explicit coverage criteria or medical necessity rules are present in these chunks.

List of CPT and PLA codes with descriptors is provided for billing and reference; these entries do not state coverage stance or authorization criteria within these chunks.

Code list (informational)

Enumeration of molecular/genetic test codes and descriptions (informational). No explicit coverage criteria are included in these chunks.

Enumerated CPT and PLA/U codes with short assay descriptions (clinical area, analytes or gene counts, specimen types, and reporting format) are listed for informational purposes.

Examples include multi-gene oncology panels, tumor/normal matched assays, cfDNA panels, whole genome/exome entries, and drug metabolism/pharmacogenomic panels as described in the code listings.

Coding/descriptive guidance (no coverage rules present)

Code-to-assay mappings and descriptive guidance; no explicit coverage rules or approval criteria are provided in these sections.

Codes are mapped to assay types and key descriptors (for example: gene counts, DNA vs RNA analysis, specimen type such as FFPE, blood, plasma, urine, buccal swab, and algorithmic or score-based report outputs).

Specific CPT/PLA entries denote distinctions such as targeted panels (e.g., 5–50 genes), larger panels (51+ genes), exome/genome testing, or specialized analyses (methylation, optical genome mapping, ddPCR), as indicated in the code descriptions.

Coverage stance and operational notes

Policy history and operational notes affecting authorization and effective dates.

Policy history documents additions and removals of CPT/HCPCS/PLA codes across multiple effective dates (examples: codes added effective 1/1/2026, 10/1/2025, 7/1/2025, 4/1/2025).

Prior authorization requirement: Commercial products managed through Carelon effective 1/1/2019; effective 1/1/2025, prior authorization for Medicare Advantage was added to be required through Carelon. Preimplantation biopsy codes require BCBSMA authorization per Policy #088.

Coverage remains subject to applicable benefit contracts; member-specific benefits may vary and documentation must support medical necessity; BCBSMA may audit services and request records.

CPT / HCPCS / PLA code lists and coding details

Selected single-gene CPT codes (81120-81289)CPT

81120	IDH1 (isocitrate dehydrogenase 1) common variants
81121	IDH2 (isocitrate dehydrogenase 2) common variants
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
81167	BRCA2 duplication/deletion analysis
81168	CCND1/IGH translocation analysis

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Selected 812xx single-gene codes (examples)CPT

81216	BRCA2 full sequence analysis
81220	CFTR common variants
81275	KRAS exon 2 variants

Selected 814xx genomic and panel codes (selected)CPTCovered

81401	Molecular pathology procedure, Level 2
81402	Molecular pathology procedure, Level 3
81403	Molecular pathology procedure, Level 4
81404	Molecular pathology procedure, Level 5
81405	Molecular pathology procedure, Level 6
81406	Molecular pathology procedure, Level 7
81407	Molecular pathology procedure, Level 8
81408	Molecular pathology procedure, Level 9
81410	Aortic dysfunction or dilation panel (>=9 genes)
81415	Exome sequence analysis

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Selected molecular/genomic procedure codes (reference)CPT

81451	Targeted genomic sequence panel, hematolymphoid, 5-50 genes
81456	Targeted genomic sequence panel, 51+ genes (RNA analysis)
81457	Solid organ neoplasm panel, microsatellite instability
81458	Solid organ neoplasm panel, copy number variants and MSI
81459	Solid organ neoplasm panel, DNA/RNA analysis
81462	Cell-free solid organ neoplasm panel, cfDNA
81463	Cell-free solid organ neoplasm panel, cfDNA (copy number & MSI)
81464	Cell-free solid organ neoplasm panel with TMB and rearrangements

Selected representative CPT/PLA codes (examples)mixed

0204U	Oncology (thyroid) mRNA gene expression analysis (593 genes)
0212U	Rare diseases whole genome and mitochondrial DNA sequence analysis (proband)
0410U	Oncology (pancreatic) whole genome sequencing with 5hmC enrichment
0488U	Obstetrics fetal antigen noninvasive prenatal test (Rh/antigen)
0569U	Tumor methylation markers (>20,000 DMRs) in cfDNA

Selected molecular/genomic CPT entries and descriptionsCPT

81470	X-linked intellectual disability panel (>=60 genes)
81471	XLID duplication/deletion analysis (>=60 genes)
81493	Coronary artery disease mRNA gene expression profiling (23 genes)
81504	Oncology tissue of origin microarray (>2000 genes)
81507	Fetal aneuploidy cfDNA for trisomies 21/18/13

Additional CPT/HCPCS genetic testing codesmixed

0205U	Ophthalmology AMD analysis (3 variants)
0209U	Cytogenomic constitutional genome-wide analysis (PLA)
G9143	Warfarin responsiveness testing by genetic technique (HCPCS G-code)
S3870	CGH microarray testing for developmental delay/autism/intellectual disability (HCPCS S-code)

In-scope effective dates by productmixed

Commercial	Effective January 1, 2019
Medicare Advantage	Effective January 1, 2025

Panel gene count requirements (examples)CPT

81410	Must include sequencing of at least 9 genes
81430	Must include sequencing of at least 60 genes
81432	Genomic sequence panel, 5 or more genes; must include at least 10 genes for listing

Gene count thresholdsmixed

5-50 genes	Targeted panels (e.g., 5-50 genes)
51+ genes	Larger targeted panels (51 or greater genes)
60+ genes	Panels requiring 60 or more genes (hearing loss, XLID)
2000+ genes	Microarray or expression profiling (>2000 genes)

Gene/region counts examplesmixed

Single-gene	Single-gene CPT/812xx codes
Panel 5-50	Targeted tumor or inherited panels (5-50 genes)
Panel 51+	Comprehensive panels (51 or greater genes)
>20,000 DMRs	Large methylation assays (>20,000 DMRs)

Billing, prior authorization, and operational guidance

Prior Authorization

Prior authorization required

Providers must request prior authorization for molecular and genomic testing through the channels below for affected products. Follow the Blue Cross Blue Shield of Massachusetts Provider Central pathway to Carelon Medical Benefits Management or use Carelon ProviderPortal directly. For assistance, call Carelon at 1-866-745-1783 when applicable.

Affected products: Commercial Managed Care (HMO and POS), Commercial PPO/EPO (PA effective 1/1/2019), Medicare HMO Blue and Medicare PPO Blue (PA requirement effective 1/1/2025).
How to request via BCBSMA Provider Central: Log in at www.bluecrossma.com/provider → eTools → Carelon Medical Benefits Management → Go Now.
How to request via Carelon ProviderPortal: Register and log in at www.providerportal.com, or call 1-866-745-1783.

Prior Authorization

Preimplantation biopsy prior authorization

Prior authorization is required for preimplantation biopsy procedure codes listed below. If the biopsy authorization is approved, no additional authorization is required for the subsequent genetic testing associated with Medical Policy #088 Preimplantation Genetic Testing.

Prior authorization required for biopsy codes: 89290 (Biopsy, oocyte polar body or embryo blastomere, microtechnique; ≤ 5 embryos) and 89291 (Biopsy, oocyte polar body or embryo blastomere, microtechnique; > 5 embryos).
Affected products: Commercial Managed Care (HMO and POS), Commercial PPO and Indemnity, Medicare HMO Blue and Medicare PPO Blue.
Request authorization via BCBSMA Provider Central following the steps above.

Prior Authorization

Exome and genome testing codes

Exome and genome testing CPT codes are included in the policy’s code listings and may require prior authorization per the processes above. Codes describe primary procedures and related services such as comparator genome sequencing and re-evaluation of previously obtained genome data.

Relevant CPT codes: 81415–81417 (exome testing variants) and 81425–81427 (genome testing, including 81426 each comparator genome, 81427 re-evaluation).
Prior authorization applies per payer product and the Carelon/BCBSMA instructions in this section.

Note

Code listing — molecular/genomic tests

The policy includes comprehensive CPT and PLA/Category I/III (U) code listings for molecular and genomic tests used for billing and prior authorization. Use these codes when submitting authorization requests and claims.

Molecular pathology procedure levels (examples): 81400–81408 (Levels 1–7 descriptions and analytic examples).
Targeted and panel genomic CPT codes: examples include 81430–81432, 81451, 81455–81457 and many others describing targeted genomic panels, sequence analysis, and RNA/DNA analyses.
Category III / PLA and other U-codes: examples include 0204U, 0205U, 0209U, 0211U, 0212U, 0410U, 0411U, 0413U, 0414U, 0417U, 0419U, 0420U (see full policy code list for complete enumerations).
Refer to the policy’s full CPT/PLA code tables for the complete list of covered, experimental, or neutral codes and for current effective dates (policy history notes additions through 2026).

Definitions and exclusions

Exclusions — tests not included in Carelon management

Tests excluded from Carelon managementCytogenetics, Human Leukocyte Antigen (HLA) testing, and Human Platelet Antigen (HPA) testing are not included in Carelon management

Preimplantation Genetic TestingPreimplantation Genetic Testing is governed by BCBSMA Medical Policy #088 and prior authorization is required through BCBSMA

Use appropriate policy for PGT codesDo not use BCBSMA Policy #957 to look up codes for Preimplantation Genetic Testing; see Policy #088

Coverage determination note

Non-covered designationMolecular genetic/genomic testing that does not meet Carelon or BCBSMA coverage criteria may be considered experimental/investigational or not medically necessary and therefore not covered

Coverage conditional on guideline criteriaGenetic testing is covered only when the patient meets coverage criteria outlined in the corresponding guideline or BCBSMA Medical Policy

Documentation requirementMember medical records must document that services are medically necessary

81400–81408 — molecular pathology procedure levels

81400–81408 — molecular pathology levelsThese CPT codes represent molecular pathology procedure levels (81401 level 2 through 81406 level 7) with examples of analytic complexity such as number of SNPs, methylated variants, exon analysis, and cytogenomic array analysis

Examples of level definitionsLevel descriptions include: Level 2 (2–10 SNPs or 1 methylated variant), Level 3 (>10 SNPs or 2–10 methylated variants), Level 4 (single exon by sequence or >10 amplicons), Level 5 (2–5 exons by sequence), Level 6 (6–10 exons by sequence), Level 7 (11–25 exons by sequence)

Unlisted procedure81479 is listed as unlisted molecular pathology procedure

81415–81417; 81425–81427 — exome/genome analysis and comparator/re-evaluation

81415–81417 — Exome services81415 = Exome sequence analysis; 81416 = comparator exome(s) listed separately; 81417 = re-evaluation of previously obtained exome sequence

81425–81427 — Genome services81425 = Genome sequence analysis; 81426 = comparator genome(s) listed separately; 81427 = re-evaluation of previously obtained genome sequence

Comparator and re-evaluation notesComparator codes (listed separately) apply to parental/sibling comparator analyses and re-evaluation codes apply when previously obtained data are reanalyzed

PLA/U-code — definition and examples

PLA/U-code definitionPLA/U-codes (Category III/Proprietary Laboratory Analyses) are proprietary/temporary codes assigned to specific molecular tests (examples in policy include 0211U, 0204U, 0434U)

Examples of PLA/U entriesExamples listed include 0211U (pan-tumor DNA and RNA NGS interpretative report), 0204U (thyroid mRNA gene expression of 593 genes), and many other U-codes in the 0204U–0613U range

Use in billing and PA listsPLA/U-codes are enumerated alongside CPT codes for billing and prior authorization reference in the policy

Specimen and analysis descriptors — examples

Plasma cfDNA specimensSeveral codes reference cell‑free DNA (cfDNA) from plasma (eg, circulating tumor DNA assays, noninvasive prenatal tests, transplant donor‑derived cfDNA) in their descriptors

FFPE tissue and tumor specimensMultiple entries specify FFPE tumor tissue as specimen type for DNA/RNA NGS and expression assays (eg, 0211U, 0543U, 0473U)

RNA, methylation and digital PCR modalitiesDescriptors include RNA analysis, mRNA expression profiling, methylation region analysis, and digital PCR modalities (examples include expression profiling, methylation assays, and digital PCR entries)

Other specimen typesExamples also include whole blood, urine, buccal/saliva, fine needle aspirate (FNA), and trophectoderm biopsy depending on the test code

CPT/PLA code descriptions — brief test descriptors

CPT/PLA code short descriptionsPolicy lists CPT and PLA codes with brief descriptors including clinical area, genes/analytes assayed, specimen type, and reportable result format (eg, algorithmic score, detected/not detected)

Examples with clinical area and genesExamples: 0204U (thyroid mRNA 593 genes, FNA, detected/not detected), 0211U (pan‑tumor DNA/RNA NGS, FFPE, SNVs/CNAs/TMB/MSI with therapy association), 0417U (mitochondrial genome + 335 nuclear genes)

Assay output typesReported outputs vary by code and include binary detected/not detected, quantitative scores, algorithmic risk/recurrence scores, and lists of actionable variants

CPT molecular/genomic assay listing — summary

Category I and III assays listedEntries correspond to Category I CPT codes and Category III/PLA (U) codes with short assay descriptions across oncology, hereditary disease, psychiatry, transplant, and other clinical areas

Assay modalities includedIncludes NGS, cfDNA, digital PCR, methylation analysis, expression profiling, optical genome mapping, and whole genome or mitochondrial sequencing

Representative code rangesRepresentative U-code and CPT entries span many specific tests (examples include 0410U–0613U and CPT 81400–81479 series) with short assay descriptors

Disclaimer and coverage limits

Coverage subject to benefit contractCoverage is subject to the applicable member benefit contract; specific benefits may vary by product or employer group

Medical necessity documentation requirementMember medical records must document that services are medically necessary; BCBSMA may audit services and require records

Potential denial or retraction of paymentFailure to produce requested documentation may result in denial or retraction of payment