Preauthorization required for unspecified laboratory/genetic testing

Preauthorization is required for genetic and other laboratory tests not addressed elsewhere; requests must meet the policy’s clinical criteria for the test type (familial variant, carrier screening, single‑gene/multigene panels, prenatal diagnosis, or other laboratory tests).

• Request prior authorization before performing tests covered by this policy.

Preauthorization required for listed PLA codes

The listed proprietary PLA/unique laboratory procedure codes require prior authorization; providers must submit a procedure plus diagnosis code pair (use Quick Code Search to add code pairs) when requesting authorization.

• Include both the procedure (PLA) code and the associated diagnosis code in the authorization request via Quick Code Search.

Preauthorization required for listed tests

Preauthorization is required for the tests enumerated by code in the policy; providers must request prior authorization using the exact test code and descriptor shown in the code list when seeking coverage.

• Order and submit the exact CPT/PLA code and test descriptor from the policy when requesting authorization.

Preauthorization required — listed laboratory tests governed by preauthorization

The laboratory tests enumerated in this document are governed by the policy’s preauthorization process and require review prior to service; do not assume inclusion in the code list guarantees coverage without authorization.

• Obtain preauthorization per Policy M.89 before performing listed laboratory tests.

Prior authorization required for listed molecular/genetic tests

Prior authorization is required for the molecular and genetic CPT/HCPCS codes listed in the policy; providers must request authorization referencing the exact CPT or PLA code(s).

• Reference the specific CPT/HCPCS code(s) (e.g., 81177–81182 and others listed) in prior authorization requests.

Preauthorization required for listed codes

Preauthorization is required for the molecular pathology and genetic/cytogenomic procedure codes enumerated in this section; providers must request authorization referencing the exact CPT/PLA code(s) listed.

• Submit the precise CPT/PLA code(s) from the policy when requesting prior authorization for molecular pathology procedures.

Prior authorization required — exome/genome and multianalyte assay codes

Prior authorization is required for exome/genome sequence analysis and multianalyte assay codes (examples include exome/genome and multianalyte assay CPT codes listed); obtain authorization before testing.

• Reference exome/genome and multianalyte CPT codes (e.g., 81415–81427, 815xx codes) in authorization requests.

Preauthorization requirement — medical policies determine scientific validity and coverage

BCBSN uses its medical policies to determine scientific validity and to administer plan benefits; certain laboratory tests require preauthorization per this policy and benefits are determined by the applicable contract terms.

• Follow BCBSN preauthorization processes; the medical policy determines scientific validity but does not itself guarantee benefits.

Prefer targeted familial variant testing when possible

When a known pathogenic familial variant exists, ordering targeted familial variant analysis is preferred over broader single‑gene or multigene panel testing.

• If a familial pathogenic/likely pathogenic variant is known, submit a request for targeted variant analysis rather than a broad panel.

Required documentation to support medical necessity

Document the member’s clinical features, prior evaluations (labs/imaging), familial variant status (if known), and evidence of the test’s clinical validity and utility to support medical necessity for authorization and claims.

• Include relevant clinical signs/symptoms and prior diagnostic workup.
• Indicate known familial variant status when applicable.
• Provide rationale showing clinical validity/utility for the requested test.

Pre-test counseling documentation

Provide documentation of pre‑test genetic counseling (discussion of test performance, limitations, benefits, and alternatives) prior to ordering genetic tests, particularly for prenatal or predictive testing.

• Document counseling content including benefits, limitations, sensitivity/specificity, and potential outcomes.
• Recommend counseling by a genetic counselor or genetics‑expert clinician.

Documentation to support preauthorization

When requesting preauthorization, include the exact test code and the appropriate clinical documentation demonstrating how the request meets the policy’s clinical criteria.

• Submit the precise CPT/PLA code and supporting clinical notes demonstrating medical necessity.
• Use Quick Code Search to verify procedure+diagnosis code pairing for authorization.

Required billing/test documentation

Use the billing code and full test description listed in the policy for preauthorization and claims documentation; each listed test entry includes the billing code and description to be used.

• Ensure claims and authorization requests use the exact code/description from the policy’s code list.

Submission should cite listed test codes

Submit preauthorization requests referencing the specific test code(s) listed in the policy (for example, gene analysis codes 81177, 81178, etc.) to obtain prior authorization.

• Reference the exact CPT or PLA code(s) from the policy in the authorization submission.

Use code-level descriptors for authorization

When requesting authorization, reference the molecular pathology procedure level and code‑level descriptors (Levels 1–7 and examples) as shown in the policy to clarify analytic scope and match the requested service.

• Include the molecular pathology procedure level (e.g., 81400–81406, or higher-level codes) and examples of gene/exon scope when applicable.

Documentation and references

Follow the policy references and disclaimers and provide any cited professional guideline support when submitting authorization requests; adhere to BCBSN preauthorization procedures.

• Cite relevant professional guidance (NSGC, ACOG, AAP/ACMG) and include policy disclaimers as applicable in submissions.

Provider responsibility and benefits determination

Providers remain responsible for clinical decision‑making and patient care; benefits for a particular service are determined by the terms and conditions of the member’s benefit contract, not the policy alone.

• Obtain benefit determination from the member’s contract even if the test meets policy criteria.

Denial for VUS familial variant testing

Targeted mutation analysis for a known familial variant of uncertain significance (VUS) is considered not reasonable and necessary and would be denied.

• Do not request targeted familial testing for variants classified as VUS; such requests will be considered not reasonable and necessary.

Denial for prenatal testing for adult-onset single-gene disorders

Prenatal diagnostic testing for adult‑onset single‑gene disorders (e.g., BRCA1/2) is considered not reasonable and necessary and would be denied.

• Do not submit prenatal diagnostic testing requests for known adult‑onset single‑gene disorders if pregnancy/childhood management will not be affected.

Denial for non-CLIA laboratory testing

Tests performed outside a CLIA‑approved laboratory are considered not reasonable and necessary and will be denied; ensure testing is performed in a CLIA‑approved laboratory.

• Confirm the performing laboratory is CLIA‑approved before submitting authorization or claims.

Code-pair entry requirement

Use the Quick Code Search to submit both the procedure and diagnosis code pair; failure to enter the required procedure+diagnosis code pair or mismatched pairing may result in denial or hold for review.

• Enter the procedure code first, then the diagnosis code, and click 'Add Code Pair' in Quick Code Search.
• Ensure the diagnosis code aligns with the policy’s clinical criteria for the procedure.

Preauthorization requirement (implied)

Submitting requests without prior authorization for tests covered under the policy’s General Criteria for Other Laboratory Tests may trigger denial; obtain authorization before service.

• Do not perform or bill for listed tests without first obtaining required prior authorization.

Preauthorization requirement — tests listed are subject to preauthorization per Policy M.89

Tests listed in this document are subject to preauthorization per Policy M.89; lack of preauthorization may trigger denial under the policy.

• Obtain prior authorization per Policy M.89 for listed tests to avoid denial.

Preauthorization required — document header indicates 'Preauthorization Required'

The document header and policy text indicate 'Preauthorization Required' for laboratory testing under this policy; ordering providers must obtain authorization prior to service.

• Ordering providers must request and receive preauthorization before performing tests covered by this policy.

Preauthorization requirement (general) — tests part of payer’s general preauthorization approach

The tests enumerated throughout the policy are part of BCBSN’s general approach requiring preauthorization; failure to obtain authorization may result in denial or hold for review.

• Verify authorization requirements for each listed CPT/PLA code prior to ordering.

Preauthorization required — molecular pathology and other listed laboratory tests

Molecular pathology and other listed laboratory tests require prior authorization; ordering providers must obtain preauthorization and reference the listed CPT/PLA code when requesting authorization.

• Include the exact code and test descriptor from the policy when submitting authorization requests for molecular pathology tests.

Denial risk from lack of authorization

Services may be denied if not authorized per the terms and conditions of the applicable benefit contract; the medical policy does not itself constitute authorization or guarantee coverage.

• Obtain explicit authorization per member benefit contract; policies do not replace contractual benefit determinations.

ORDERING REQUIREMENTS — genetic counseling involvement recommended; ordering guided by clinical evaluation and family history

Ordering should be guided by clinical evaluation and family history; consider involving genetic counseling and ensure carrier screening is performed when appropriate (ideally preconception) with counseling documented.

• Consider referral to a genetic counselor or genetics‑expert clinician for pre‑test counseling.
• Document family history and clinical evaluation supporting the test request.

Pre-test genetic counseling recommended

Pre‑test genetic counseling by a genetic counselor or genetics‑expert clinician is recommended prior to prenatal or predictive testing; document counseling and informed consent discussions.

• Document that the patient received pre‑test counseling including risks, benefits, limitations, and possible outcomes.
• Recommend counseling especially for prenatal and predictive testing.

Code-pair submission required for Quick Code Search/prior authorization

Submission of both procedure and diagnosis code pairs is required for the Quick Code Search/prior authorization process; enter the procedure code then the diagnosis code to add the pair for review.

• Use Quick Code Search: enter the procedure code, then the diagnosis code, and click 'Add Code Pair' to submit for review.

Ordering provider must request preauthorization and use the exact test code when ordering

The ordering provider must request preauthorization and use the exact test code and descriptor from the policy when ordering to ensure the authorization matches the service.

• Reference the exact CPT/PLA code and descriptor in the authorization request.

Preauthorization required for listed tests under Policy M.89 — ordering provider responsibilities implied

Preauthorization is required for the tests listed under Policy M.89; ordering provider responsibilities are implied (obtain authorization, submit required documentation) though specific permitted ordering provider types are not detailed in the excerpt.

• Ordering providers must obtain prior authorization and supply clinical documentation per the policy.

Authorization requests should reference specific CPT code(s)

Authorization requests should reference the specific CPT code(s) being ordered; the policy emphasizes citing the exact code(s) though ordering provider qualifications are not specified in the excerpt.

• Include specific CPT code(s) (for example, 81177, 81178, 814xx codes) in authorization requests.

Preauthorization must be obtained — reference specific CPT/PLA code and descriptor

Preauthorization must be obtained and the ordering provider should reference the specific CPT/PLA code and test descriptor when requesting authorization.

• Ensure the authorization request cites the exact CPT/PLA code and the test descriptor from the policy’s code list.

Prior authorization required — ordering providers must obtain preauthorization

Ordering providers must obtain prior authorization for listed tests; the excerpt indicates prior authorization is required though specific provider types allowed to order are not listed.

• Obtain prior authorization before ordering listed molecular/genomic tests.