CurrentBlue Cross Blue Shield - NevadaPolicy N/A

Prior authorization processes and Carelon-managed service review list

Explains eligibility and prior authorization verification, provider responsibilities and notification timelines, and lists services reviewed by Carelon Medical Benefits Management on behalf of the plan (Virginia plan referenced). Affects ordering/rendering providers and facilities interacting with the plan.

Policy Summary

PayerBlue Cross Blue Shield - Nevada

PolicyPrior authorization processes and Carelon-managed service review list

Policy CodePolicy N/A

Change TypeInformational / no material change

Effective DateN/A

Next Review DateN/A

Key ActionOrdering or rendering provider must verify eligibility and complete prior authorization via Availity or the Carelon provider portal.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Availitywebsite to verify eligibility and submit authorizations

866-789-0158Carelon contact center phone

14 daysrecommended lead time for non-urgent submissions

48 hrs / next bdfacility notification timeframe for admissions

Many

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entries referencing Carelon as responsible party

Carelon-managed Coverage Criteria and Code Mappings

Carelon-managed programs and reviewed codes (partial list)

Carelon Medical Benefits Management provides benefits management and reviews for the following programs and associated codes:

Carelon Medical Benefits Management provides benefits management and utilization review for the named programs and associated codes as listed below.

Programs

Advanced Imaging (Carelon-managed review).
Bariatrics (Carelon-managed review).
Base Surgical (Carelon-managed review).
Cancer Care Quality Program (Carelon-managed review).
Cardiovascular Services (Carelon-managed review).
Certain Outpatient Utilization Management Services (Carelon-managed review).
Diagnostic Imaging Management (Carelon-managed review).
Fertility (Carelon-managed review).
Genetic Testing (Carelon-managed review; HMO excluded).
Imaging Level of Care (Carelon-managed review).
Musculoskeletal (MSK) Program (Carelon-managed review).
Oncology Drugs (Carelon-managed review).
Outpatient Sleep Testing and Therapy Services (Carelon-managed review).
Rehabilitative Services (Carelon-managed review).
Radiation Therapy Services (Carelon-managed review).
Sleep Therapy (Carelon-managed review).
Upper Gastrointestinal Endoscopy in Adults, and Site of Care for Certain Surgical Services (Carelon-managed review).
Vascular Services (Carelon-managed review).

Reviewed code entries with links to criteria

Codes reviewed with associated criteria/guidelines and responsible party assignments.

0118U — Transplantation medicine, quantification of donor-derived cell-free DNA using whole genome; Responsible party = Carelon Medical Benefits Management or Anthem; Criteria/Guideline = Carelon Medical Benefits Management Genetic Testing.

0152U — Infectious disease microbial cell-free DNA, plasma, untargeted NGS; Responsible party = Carelon Medical Benefits Management or Anthem; Criteria/Guideline = Carelon Medical Benefits Management or Anthem LAB.00050.

0238U — Oncology (Lynch syndrome), genomic DNA sequence analysis of MLH1, MSH2, MSH6, PMS2, and EPCAM; Responsible party = Carelon Medical Benefits Management or Anthem; Criteria/Guideline = Carelon Medical Benefits Management Genetic Testing.

0323U — Infectious agent detection by nucleic acid, CNS pathogen, metagenomic NGS, CSF; Responsible party = Carelon Medical Benefits Management or Anthem; Criteria/Guideline = Carelon Medical Benefits Management or Anthem LAB.00050.

Code-to-guideline mappings

Codes and their assigned review guidelines

0314U, 0315U, 0318U, 0319U — Genetic testing/molecular diagnostic panels listed with responsible party and mapped to Carelon Genetic Testing criteria or Carelon/Anthem where noted; apply the referenced genetic testing guideline for coverage review.

Code-to-guideline mapping

Codes listed with associated Criteria/Guideline references (Carelon Medical Benefits Management: Genetic Testing; Base Surgical; Vascular; Musculoskeletal; MED.00111; SURG.00045 etc.)

0424U, 0425U, 0433U, 0437U, 0444U, 0493U, 0530U, 0516U — Refer to Carelon Medical Benefits Management: Genetic Testing criteria/guidelines noted next to each code for clinical review and coverage adjudication (see source mappings).

See chunk 54 for specific code descriptions and criteria references.

0449T, 0524T, 0525T, 0526T, 0527T — Surgical and device-related T-codes; refer to Carelon Base Surgical or Vascular criteria and Anthem surgical guidelines (e.g., MED.00111) as indicated for prior authorization and coverage determination.

See chunks 57–73 for assignment details.

Utilization review assignments

Codes are paired with responsible parties and guideline references to determine applicable review pathways.

0524T, 0525T, 0526T, 0527T — Assigned responsible party = Carelon Medical Benefits Management or Anthem; Criteria/Guideline = Carelon Medical Benefits Management Vascular or Anthem MED.00111 as specified.

Code-to-guideline mappings

Codes are associated with Carelon Medical Benefits Management and/or Anthem and reference internal criteria sets for review; coverage determinations are governed by those referenced criteria.

0717T, 0718T, 0736T, 0745T, 0746T, 0747T — Autologous ADRC therapies, colonic lavage, and cardiac focal ablation entries listed with Responsible party = Carelon Medical Benefits Management or Anthem; Criteria/Guideline = Carelon Base Surgical or MED.00132 / MED.00141 or Anthem equivalents per code.

15773–15793 series — Dermatologic and fat grafting procedures with Responsible party = Carelon Medical Benefits Management or Anthem; Criteria/Guideline = Carelon Base Surgical or Anthem ANC.00007 as referenced.

Code-to-guideline mapping for utilization review

Codes are associated with internal guideline references which determine coverage decisions; responsible party noted per code.

Examples: 15820 (Blepharoplasty) — Responsible party = Carelon Medical Benefits Management or Anthem; Criteria/Guideline = Carelon Base Surgical or Anthem CG-SURG-03.

Examples: 20979 (Low intensity ultrasound stimulation to aid bone healing) — Responsible party = Carelon Medical Benefits Management or Anthem; Criteria/Guideline = Musculoskeletal or related internal guidance.

Code-to-guideline mapping (partial)

Codes listed with their responsible party and associated criteria/guideline label (Musculoskeletal Carelon Medical Benefits Management).

22505, 22510, 22512, 22513, 27130, 27132, 27137, 27138, 27275, 27279, 27280 — Responsible party = Carelon Medical Benefits Management; Criteria/Guideline = Carelon Medical Benefits Management Musculoskeletal. Apply Musculoskeletal guideline for authorization determinations.

Administrative mapping

No explicit per-code coverage rules provided in this segment. Codes are linked to the Carelon Musculoskeletal criteria/guideline or Anthem surgical policies for coverage determinations.

Each listed musculoskeletal or surgical CPT code is mapped to a responsible reviewer (predominantly Carelon Medical Benefits Management) and a named criteria/guideline (primarily Carelon Musculoskeletal or Anthem surgical policies); specific coverage criteria are contained within those referenced guidelines.

Referenced criteria/guideline assignments

Codes are associated with named criteria/guidelines which govern coverage decisions; examples include Carelon Medical Benefits Management Base Surgical, Anthem CG-SURG-24, CG-MED-79, MCG Guidelines.

Carelon Medical Benefits Management Base Surgical — applies to listed ENT, sinus, and many reconstructive surgical codes (e.g., 31237 and related CPTs).

Anthem CG-SURG-24 — referenced where Anthem is responsible or co-responsible for select endoscopy and ENT procedures.

MCG Guidelines — referenced for venous and endovenous procedures (e.g., 36473, 36475, 36478).

Assigned review responsibilities and guideline cross-references

Codes listed include assigned responsible party and the internal criteria/guideline to be applied during review.

36903 — Responsible party = Carelon Medical Benefits Management; Criteria/Guideline = Carelon Medical Benefits Management Vascular.

37238 — Responsible party = Carelon Medical Benefits Management or Anthem; Criteria/Guideline = Carelon Medical Benefits Management Vascular or Anthem CG-SURG-106.

43290 — Responsible party = Carelon Medical Benefits Management or Anthem; Criteria/Guideline = Carelon Medical Benefits Management or Anthem CG-SURG-83.

Code-to-responsibility mapping

Mapping of CPT codes to review responsibility and guidance references; individual code coverage would be determined by applying the listed criteria/guideline during authorization or claim review.

55875, 55881, 55882 — Responsible party = Carelon Medical Benefits Management; Criteria/Guideline = Carelon Medical Benefits Management Radiation Therapy / Base Surgical as indicated.

57155 — Responsible party = Carelon Medical Benefits Management; Criteria/Guideline = Carelon Medical Benefits Management Radiation Therapy.

62360–62362 series (implantable infusion devices) — Responsible party = Carelon Medical Benefits Management or Anthem; Criteria/Guideline = Carelon Base Surgical or Anthem CG-SURG-79 per code.

Code-to-responsibility mappings

Codes listed are associated with internal criteria/guidelines; prior authorization and responsibility are assigned to the named entity.

63250, 63252, 63265, 63267, 63270, 63272 — Responsible party = Carelon Medical Benefits Management; Criteria/Guideline = Carelon Medical Benefits Management Musculoskeletal.

64405, 64415 (injection codes) — Responsible party = Carelon Medical Benefits Management or Anthem; Criteria/Guideline = Musculoskeletal or Anthem SURG.00140 as specified.

64628, 64629 (basivertebral nerve ablation) — Responsible party = Carelon Medical Benefits Management or Anthem; Criteria/Guideline = Carelon Medical Benefits Management Musculoskeletal.

Responsibility and criteria linkage

Codes are reviewed and associated with specific internal criteria/guidelines and responsible parties for adjudication; no explicit per-code coverage rules or clinical criteria text is present in this excerpt.

Assign Carelon Medical Benefits Management (or Anthem where noted) as the responsible party to apply referenced internal criteria/guidelines during benefit review for the listed CPT codes.

Code-to-responsible-party mappings

Codes and responsible parties with referenced internal criteria/guidelines

74150–74178 (Abdomen/pelvis CT/MRI series) — Responsible party = Carelon Medical Benefits Management; Criteria/Guideline = Carelon Medical Benefits Management Radiology.

77295–77525 (Radiation therapy planning and delivery codes) — Responsible party = Carelon Medical Benefits Management; Criteria/Guideline = Carelon Medical Benefits Management Radiation Therapy.

78429–78816 (Nuclear medicine / PET imaging codes) — Responsible party = Carelon Medical Benefits Management; Criteria/Guideline = Carelon Medical Benefits Management Radiology.

81162–81202 (Selected genetic testing codes, e.g., BRCA series, ASXL1, APC, optical genome mapping) — Responsible party = Carelon Medical Benefits Management or Anthem where noted; Criteria/Guideline = Carelon Medical Benefits Management Genetic Testing.

Reviewed Codes and Code Tables

How Providers Request Authorization and Operational Requirements

Prior Authorization

Prior Authorization Responsibility

The ordering or rendering provider is responsible for completing prior authorization. Verify member eligibility and benefits via Availity or the member ID card before requesting authorization. Note: NOC/unlisted codes may still require review at claims submission.

Provider responsibility: ordering or rendering provider must initiate prior authorization
Verify eligibility: https://Availity.com or member ID card

Note

Notification timelines

Submit non-urgent prior authorization requests with all required clinical information at least 14 calendar days before the proposed service when possible. For institutional admissions, notify the plan by the next business day or within 48 hours after admission, whichever is earlier. Failure to notify promptly may result in a financial penalty.

Non-urgent submission timeline: 14 calendar days prior when possible
Facility admissions: notify by next business day or within 48 hours

Terminology and Responsible Parties

Carelon Medical Benefits Management

DefinitionCarelon Medical Benefits Management is a separate company providing specialty benefits management and utilization management services on behalf of the health plan, with its own portals and contact center.

PortalsOnline access via providerportal.com and Availity.com (providerportal.com referenced as Carelon site).

Contact centerCarelon Medical Benefits Management Contact Center: 866-789-0158 (Mon-Fri 8 a.m. to 5 p.m. ET).

Eligibility and benefits / prior authorization

How to verify eligibilityVerify eligibility and benefits via Availity (https://Availity.com) or by calling the number on the back of the member's ID card.

Preapproval depends on planService preapproval is based on the member's benefit plan/eligibility at the time of review; benefit plans vary and may change by contract effective date.

Policy Summary

PayerBlue Cross Blue Shield - Nevada

PolicyPrior authorization processes and Carelon-managed service review list

Policy CodePolicy N/A

Change TypeInformational / no material change

Effective DateN/A

Next Review DateN/A

Key ActionOrdering or rendering provider must verify eligibility and complete prior authorization via Availity or the Carelon provider portal.

SourceLink

On This Page

Prior Authorization

How to request prior authorization

Providers may request prior authorization through the plan’s point-of-care portal or by phone. Use Availity (https://Availity.com) or the Carelon provider portal (https://providerportal.com) for real-time online requests. For services reviewed by Carelon Medical Benefits Management, call the Carelon Contact Center at 866-789-0158 (M–F, 8 a.m.–5 p.m. ET). For mental health and substance use disorder prior authorizations, call 800-755-0851. Follow program-specific submission instructions (imaging, MSK, genetic testing, radiation, etc.) and include all required documentation to avoid delays.

Online (preferred): Availity or Carelon provider portal — fastest method
Carelon phone: 866-789-0158, M–F 8 a.m.–5 p.m. ET
Mental health/substance use: 800-755-0851
Include full clinical documentation and relevant program identifiers (eg, Genetic Testing, Advanced Imaging, Musculoskeletal)

Note

Third-party UM vendor interactions

Carelon Medical Benefits Management is a third-party UM vendor that manages prior authorization for many service categories on behalf of the health plan. When Carelon is listed as the responsible reviewer, follow Carelon submission routes and criteria. Linking to Carelon/third‑party sites subjects users to the external site terms and privacy policies.

Carelon programs include: Advanced Imaging, Musculoskeletal, Genetic Testing, Radiation Therapy, Oncology Drugs, Vascular Services, Bariatrics, Fertility, Sleep Testing/Therapy, Rehabilitative Services, Diagnostic Imaging Management, and select outpatient UM services

Documentation Required

Code responsibility and guideline references (sample)

The policy maps many CPT/HCPCS/PLA codes to an assigned responsible reviewer (Carelon Medical Benefits Management or Anthem) and to applicable guideline sets. When a code lists Carelon or Anthem as the responsible party, prior authorization and medical necessity review will follow the named guideline (for example: Carelon Medical Benefits Management Genetic Testing, Carelon Medical Benefits Management Radiology, Carelon Musculoskeletal, Anthem SURG/CG guidelines, MCG where noted). Always check the code-level entry for the cited guideline before submitting.

Example code responsibility & guideline references (sample):
- Genetic testing PLA/CPT (e.g., 0118U, 0120U, 0136U, 0138U, 0314U, 0315U): Responsible = Carelon; Guideline = Carelon Medical Benefits Management Genetic Testing
- Radiology/imaging codes (e.g., 0331T, 0329T, various CT/MRI/PET codes 70450–78816): Responsible = Carelon Radiology; Guideline = Carelon Medical Benefits Management Radiology or specified Anthem radiology guideline
- Cosmetic/derm procedures (e.g., 15773, 15780, 15781, 15782): Responsible = Carelon or Anthem; Guideline = Carelon Base Surgical or Anthem ANC.00007/CG-SURG-123
- Musculoskeletal/spine codes (eg, shoulder arthroscopy 29823–29827, vertebroplasty 22510–22515, spinal fusion/arthrodesis 22600–22612, neurostimulation 63650): Responsible = Carelon Musculoskeletal; Guideline = Carelon Musculoskeletal or Anthem SURG/CG codes

Documentation Required

Radiology / Utilization management responsibilities

Radiology services listed in the code tables (CT, MRI, PET, nuclear medicine, CT angiography, and radiation therapy delivery codes) are subject to radiology/utilization management review. Use the Carelon radiology program rules and the referenced Radiology criteria when requesting authorization. Imaging level-of-care and site-of-service rules may apply (eg, outpatient vs inpatient, advanced imaging prior‑authorization programs).

Radiology codes (selected): CT (70450–70487 series), CT pelvis/abdomen (72191–72197; 74150–74178), PET (78811–78816), specialized PET/brain (78608–78609) — Responsible = Carelon Medical Benefits Management; Guideline = Carelon Radiology
Radiation therapy delivery/planning codes (77338, 77370–77432, 77407, 77412, 77423–77425, 77373, 77387) — Responsible = Carelon Medical Benefits Management Radiation Therapy; Guideline = Carelon Radiation Therapy or Anthem THER‑RAD policies
Operational note: verify imaging level-of-care program (eg, Advanced Imaging, Imaging Level of Care) and submit clinical indication and prior imaging when requested

Billing Rule

Codes and responsible reviewer mapping (cosmetic/derm procedures)

Certain cosmetic and dermatologic procedure codes require preauthorization and map to either Carelon or Anthem surgical/ancillary cosmetic guidelines. When a code is identified as cosmetic or not covered under the applicable guideline, expect review and possible denial if criteria are not met.

Cosmetic/derm examples: 15773 (small-area liposuction technique to face/neck/genitalia/hands/feet), 15780–15782 (dermabrasion) — Responsible = Carelon or Anthem; Guideline = Carelon Base Surgical or Anthem ANC.00007/CG-SURG-123
Action: Provide clinical justification showing medical necessity (eg, scarring, functional impairment) and reference applicable surgical/cosmetic guideline

Documentation Required

Codes and responsible reviewer mapping (musculoskeletal/spine)

Musculoskeletal and spine procedure codes are mapped to Carelon Musculoskeletal review or Anthem surgical guidelines. Prior authorization is often required for major spine surgeries, arthroplasties, vertebral augmentation, advanced orthopedics, implantable devices, and many interventional pain procedures. Include supporting imaging, prior conservative therapy documentation, and specialist notes as applicable.

Selected MSK/Spine examples and responsible party:
- Arthroscopy/shoulder codes (29822–29827): Carelon Musculoskeletal; Guideline = Carelon Musculoskeletal
- Vertebroplasty/vertebral augmentation (22510–22515, 22527): Carelon Musculoskeletal; Guideline = Carelon Musculoskeletal
- Spine fusion/arthrodesis (22600–22612, 22532–22534, 22586, 22590, 22610): Carelon Musculoskeletal; Guideline = Carelon Musculoskeletal or Anthem SURG.00111
- Neurostimulation and implantable pain device codes (e.g., 63650, 64581, 64590, 64596, 33206–33249 series pacemaker/ICD device management): Responsible = Carelon; Guideline = Carelon Base Surgical / Vascular or Anthem CG-MED-79

Documentation Required

Code responsibility and guideline reference (partial)

Code-level entries include assigned responsible party and the guideline to use for clinical review. Always reference the specific code line to determine whether Carelon or Anthem is responsible and which guideline applies (examples below). When a code shows dual responsibility (Carelon or Anthem), follow the instructions provided in the code entry at time of submission.

Examples of code-to-guideline mapping (partial):
- 0118U, 0120U, 0136U, 0138U: Responsible = Carelon; Guideline = Carelon Genetic Testing
- 0314U, 0315U: Responsible = Carelon or Anthem; Guideline = Carelon Genetic Testing
- 22586: Responsible = Carelon or Anthem; Guideline = Carelon Musculoskeletal or Anthem SURG.00111
- 33230–33240 series (pacemaker/ICD): Responsible = Carelon Vascular or Anthem; Guideline = Carelon Vascular or Anthem device management

Documentation Required

Procedure codes and assigned review responsibility

For many procedures the code table explicitly assigns review responsibility and the guideline to apply — follow that mapping when submitting authorization requests. Include the code, clinical indication, prior conservative care, imaging reports, device specifics, and operative notes as required by the cited guideline to support medical necessity determinations.

Procedure codes and assigned review responsibility (selected examples):
- Radiation/therapeutic procedures (55875, 55881–55882; brachytherapy 57155–57156): Responsible = Carelon Radiation Therapy; Guideline = Carelon Radiation Therapy or Anthem THER‑RAD.
- Spine injections and device implantation (62287, 62290–62323, 62362, 62380): Responsible = Carelon Musculoskeletal; Guideline = Carelon Radiology or Musculoskeletal criteria.
- Neurolytic and neurostimulation procedures (64600–64640, 64581, 64590): Responsible = Carelon Musculoskeletal; Guideline = Carelon Musculoskeletal or Anthem SURG/ANC guidance

Submission portalsSubmit prior authorization via Availity or the Carelon provider portal (https://providerportal.com); phone submission options available via Carelon contact center.

Responsible party assigned for review

Assigned reviewerResponsible party is designated per code entry (Carelon Medical Benefits Management or Anthem) to perform clinical review and apply the listed criteria/guideline.

Examples of responsible party entriesMany genetic testing and sequencing codes list Responsible party = Carelon Medical Benefits Management or Anthem (eg, 0118U, 0152U, 0314U).

Guideline linkageEach responsible party entry is paired with a Criteria/Guideline identifier (eg, Carelon Medical Benefits Management Genetic Testing or Anthem LAB.00050).

Referenced laboratory criteria/guideline

Referenced lab guidelineSome infectious disease metagenomic sequencing codes reference Anthem LAB.00050 as the criteria/guideline for laboratory review (eg, entries in the 0152U/0323U group).

Applicable codesInfectious disease microbial cell-free DNA and CNS pathogen metagenomic NGS codes reference Anthem LAB.00050 where noted (eg, 0152U, 0323U).

Co-responsibilityThese entries may list Carelon or Anthem as responsible party depending on the code and context.

Responsible party

Responsible party notation'Responsible party' entries indicate which organization (Carelon Medical Benefits Management or Anthem) is assigned to review or manage utilization for the listed code.

Common pairingGenetic testing codes frequently pair Responsible party = Carelon Medical Benefits Management or Anthem in the document's code list.

Use in adjudicationThe named responsible party applies the referenced internal criteria/guideline during prior authorization and claim review.

Criteria/Guideline

Criteria/Guideline entry meaningCriteria/Guideline entries (eg, MED.00131, Carelon Genetic Testing, Musculoskeletal) reference the internal Carelon or Anthem policy/guideline that governs coverage decisions for the code.

ExamplesMED.00131 (Additional Outpatient Utilization Management Services), Carelon Genetic Testing, Carelon Musculoskeletal are cited against specific codes in the list.

ApplicationReviewers use the referenced Criteria/Guideline to determine medical necessity and authorization requirements for the listed procedure or test.

Responsible party noted for review

Reviewed codes responsibilityCarelon Medical Benefits Management is the responsible party noted for review of many listed codes (genetic, surgical, vascular, etc.), with Anthem noted on selected entries.

ExamplesCodes such as 0424U, 0524T, 0525T list Carelon Medical Benefits Management (or Anthem) as the responsible party for utilization review.

Guideline referencesThese responsible party assignments are paired with Carelon or Anthem guideline identifiers (eg, Carelon Genetic Testing; Anthem MED.00111).

Responsible party (Anthem)

Anthem as alternate reviewerSome codes indicate Anthem (instead of or alongside Carelon) as the responsible party, implying alternate reviewer or guideline application (examples: select surgical and musculoskeletal codes).

Example codesEntries such as 22586, and various surgical CPTs list Carelon or Anthem as responsible party with Anthem surgical guideline references (eg, SURG.00111).

ImplicationWhen Anthem is listed, Anthem policies/guidelines (eg, SURG.00092, SURG.00111) may govern the review instead of Carelon's internal guideline.

Entity assigned to review/approve utilization

Entities assigned to review/approveCodes are assigned to Carelon Medical Benefits Management or Anthem to perform utilization review and prior authorization (responsible party varies by code).

Vascular example0524T–0527T (intracardiac ischemia monitoring / endovenous chemical ablation) list Carelon or Anthem as responsible party with Carelon Vascular or Anthem MED.00111 guidance.

Genetic exampleSelected U-codes for ctDNA and genomic panels list Carelon as responsible party for Genetic Testing criteria application.

Internal clinical or utilization guideline references

Named internal guideline examplesInternal clinical/utilization guideline references cited include MED.00132, DME.00011, CG-SURG-123, MED.00141 and others used to govern review of specific codes.

Where appliedThese guideline identifiers are attached in the code list next to responsible party entries to indicate the policy basis for coverage review (eg, 0717T references MED.00132).

Reviewer actionReviewers apply the named guideline during prior authorization and claims medical necessity evaluations for the associated codes.

Responsible party (Carelon for musculoskeletal/surgical review)

Assigned reviewer (Carelon)Carelon Medical Benefits Management is frequently identified as the entity assigned to perform clinical review for many musculoskeletal and surgical CPT codes.

Musculoskeletal guidelineCarelon Musculoskeletal criteria/guideline is repeatedly referenced for spine, arthroplasty, and related procedure codes (eg, 22510, 27130).

Operational noteWhen Carelon is listed, prior authorization requests for the code should be submitted through Carelon portals for adjudication under the referenced guideline.

Entity accountable for review/authorization

Entity accountabilityEntries identify Carelon Medical Benefits Management or Anthem as accountable for review/authorization of specific procedure codes (responsible party tied to each code).

Vascular examplesCodes such as 36903, 37238, 37248 list Carelon (or Anthem) as responsible party with Carelon Vascular or Anthem CG-SURG-106 guidance.

Genetic examplesGenetic testing codes (eg, BRCA series) are listed with Carelon or Carelon/Anthem as responsible party and paired with Carelon Genetic Testing criteria.

Internal clinical or surgical guideline references cited

Internal guideline citation examplesInternal guidelines cited include 'Carelon Medical Benefits Management Radiology', 'Carelon Medical Benefits Management Radiation Therapy', and various Carelon Surgical or Musculoskeletal guidelines used as the policy basis for review.

Radiology applicationRadiology CPT ranges (eg, 74150–74178, 70450–70487) reference Carelon Medical Benefits Management Radiology as the Criteria/Guideline.

Radiation therapy applicationRadiation therapy codes (eg, 77371–77373, 77402–77407) reference Carelon Radiation Therapy guideline for review and authorization.

Entity assigned to manage criteria/guideline oversight

Assigned internal entity examplesThe internal entity assigned to manage criteria and oversight for listed codes is usually Carelon Medical Benefits Management; Anthem is noted where indicated.

Genetic testing oversightGenetic testing codes (eg, 81162–81167) list Carelon or Carelon/Anthem as responsible and reference Carelon Genetic Testing criteria.

How to route requestsSubmit prior authorization requests to the responsible entity noted for the code (Carelon portal or Availity) for review under the referenced guideline.