CurrentBlue Cross Blue Shield - New MexicoPolicy N/A

2023 NM Commercial Outpatient Benefit Prior Authorization Fully Insured Medical Surgical Procedure Code List

This document lists outpatient medical and surgical CPT/diagnostic procedure codes that require prior authorization for fully insured commercial members of Blue Cross Blue Shield New Mexico and explains how to request authorization via Availity or Carelon.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyOutpatient prior authorization procedure code list (medical/surgical)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2023

Next Review DateN/A

Key ActionInitiate prior authorization online via Availity Authorizations (278) or the Carelon web portal, or call the number on the member's ID card.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

multiple hundredsprocedure codes listed (partial)

Carelonprior authorization vendor

24/7Carelon portal availability

1-866-745-1789Carelon phone

Carelon / BCBSNMauthorization attribution

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Prior Authorization Coverage Criteria and Code Listings

inv-01: Prior authorization requirements

Prior authorization is required for the outpatient procedure codes listed in this document for fully insured commercial members; categories requiring review are managed through Carelon.

Prior authorization is required for the outpatient procedure codes listed in this document for fully insured commercial outpatient medical/surgical services.

Certain outpatient care categories require prior authorization through Carelon Medical Benefits Management (formerly AIM) for all commercial members (examples include: Molecular Genetic Lab Testing; Radiation Therapy/Radiation Oncology; Advanced Imaging/Radiology; Musculoskeletal - Pain; Musculoskeletal - Joint, Spine Surgery).

Providers must verify member eligibility and benefits and obtain required prior authorization via Availity (278) or the Carelon web portal or by phone; presence of a code on this list does not guarantee coverage under the member's contract.

inv-02: Code list (partial)

Representative entries from the code list; each line shows: code — clinical category/description — reviewer (Carelon or BCBSNM).

78315 — Advanced Imaging / Radiology: Bone Imaging 3 Phase — Carelon

78445 — Advanced Imaging / Radiology: Vascular Flow Imaging — Carelon

81233 — Molecular Genetic Lab Testing: Btk Gene Common Variants — Carelon

81234 — Molecular Genetic Lab Testing: DMPK Gene Detection Abnormal Allele — Carelon

0007M — Molecular Genetic Lab Testing: Onc Gastro 51 Gene Nomogram — Carelon

inv-03: Code-only prior authorization listing (molecular/genetic tests)

Molecular/genetic and proprietary laboratory test codes — prior authorization required; entries present code and brief descriptor only.

Examples: 81233-81355, 81400-81595, 0001U-0031U — CPT and proprietary molecular/genetic testing codes; listed with short descriptors and Carelon as reviewer.

0306U — Molecular Genetic Lab Testing: Oncology (Minimal Residual Disease), Next-Generation Targeted Sequencing Analysis, Cell-Free DNA, Initial Assessment — Carelon

0313U — Molecular Genetic Lab Testing: Oncology (Pancreas), DNA and mRNA Next-Generation Sequencing Analysis of 74 genes; pancreatic cyst fluid algorithm result — Carelon

inv-04: Prior authorization stance for listed codes

Stance on prior authorization for listed codes.

Prior authorization required and managed by Carelon for the listed codes (Carelon indicated alongside many entries).

This portion of the file provides code identifiers and short descriptions only; clinical coverage criteria are not included in these chunks.

inv-05: Prior-authorization stance for listed CPTs

Prior-authorization routing and vendor attribution for listed CPTs.

Musculoskeletal/joint and spine surgical CPTs shown in the list are subject to prior authorization and are routed to Carelon as the reviewer.

Example: 27412 (Autochondrocyte Implant Knee) explicitly notes: 'Prior Authorization required through Carelon.'

inv-06: Procedure code list fragment

Procedure code list fragment — CPT/HCPCS examples with high-level category and administrative reviewer.

63056 — Musculoskeletal_Joint, Spine Surgery: Decompress Spinal Cord Lumbar — Carelon

63075 — Musculoskeletal_Joint, Spine Surgery: Neck Spine Disk Surgery — Carelon

77295 — Radiation Therapy / Radiation Oncology: 3-D Radiotherapy Plan — Carelon

inv-07: Code listing — coverage/management stance

Codes grouped with their associated program or management entity as listed in this portion of the code list.

Radiation therapy CPT/HCPCS (sample): 77295, 77301, 77373 — attributed to Carelon for prior-authorization review.

Radiopharmaceutical HCPCS (sample): A9606 (Radium Ra223 Dichloride), A9607 (Lutetium Lu 177 Vipivotide Tetraxetan) — Carelon; A9607 noted as added effective 01/01/2023.

Transplant service codes (sample): 47135 (Liver allotransplantation), 50360 (Renal allotransplantation), 0584T (Islet cell transplant) — attributed to BCBSNM as the reviewer/administrator in the list segment.

Sample Code Tables and Coding Notes

Selected Advanced Imaging / Radiology CPT codes (partial list)CPTCovered

70450	CT Head/Brain without contrast
70460	CT Head/Brain with contrast
71250	CT Thorax diagnostic without contrast
72131	CT Lumbar Spine without contrast

Sample codes from list (Advanced Imaging; Molecular Genetic Lab Testing; ENT)mixedCovered

78315	Bone Imaging 3 Phase (Advanced Imaging / Radiology)
78445	Vascular Flow Imaging (Advanced Imaging / Radiology)
81120	IDH1 common variants (Molecular Genetic Lab Testing)
81223	CFTR gene full sequence (Molecular Genetic Lab Testing)
69930	Implant Cochlear Device (Ear, Nose, and Throat)

Molecular/genetic and molecular pathology codes (segment)mixed

81233-81355, 81400-81595, 0001U-0031U

Examples of CPT and proprietary molecular/genetic testing codes included in this document segment (many individual codes listed).

Molecular genetic lab testing (U/M codes)mixedCovered

0007M	Onc Gastro 51 Gene Nomogram
0011M	Molecular Genetic Lab Testing - Onc Prst8 Ca Mrna 12 Gen Alg
0036U	Xome Tum & Nml Spec Seq Alys

Musculoskeletal / spine surgery CPTsCPTCovered

20930	Sp Bone Algrft Morsel Add-On (musculoskeletal/joint, spine)
20939	Bone Marrow Aspir Bone Grfg
22206	Incis Spine 3 Column Thorac

Selected bone graft/add-on CPTsCPT

20931	Sp Bone Algrft Struct Add-On
20932	Osteoart Algrft W/Surf & B2

Selected spine incision CPTsCPT

22206	Incis Spine 3 Column Thorac
22207	Incis Spine 3 Column Lumbar

Selected joint replacement and implant CPTsCPT

27130	Total Hip Arthroplasty
27412	Autochondrocyte Implant Knee

Procedure code groups appearing in this partmixed

63055-63308 (selected examples shown)	Spine surgery and vertebral body procedures listed with Carelon attribution
0095T-0165T, C9359-C9362, J7330, E0748-E0749, J7330	Miscellaneous musculoskeletal and device/prosthesis codes with Carelon attribution
61850-61868, 64561, 64581, A4290, E0745	Neurology/neurostimulation related codes with BCBSNM attribution
19294-19298, 77295, 77301-77385	Radiation therapy / radiation oncology codes with Carelon attribution

Radiation therapy CPT codes (sample)CPTCovered

77295	3-D Radiotherapy Plan
77301	Radiotherapy Dose Plan IMRT
77373	SBRT Delivery

Radiopharmaceutical HCPCS codes (sample)HCPCSCovered

A9606	Radium Ra223 Dichloride Ther
A9607	Lutetium Lu 177 Vipivotide Tetraxetan, Therapeutic

Transplant service codes (sample)mixedCovered

47135	Liver allotransplantation, orthotopic
50360	Renal allotransplantation, implantation of graft; without recipient nephrectomy
0584T	Islet cell transplant, percutaneous

List completeness note

ScopeThis list is not exhaustive; codes may be updated throughout the year and presence on this list does not necessarily indicate coverage under the member benefits contract.

ActionVerify member benefits against the member benefit booklet or contact customer service to determine coverage for a specific service.

Update frequencyCodes may be updated throughout the year.

Document scope

How to Request Prior Authorization and Provider Notices

Prior Authorization

How to request prior authorization

Online: Registered Availity users may submit prior authorization requests to BCBSNM through Availity's Authorizations tool (HIPAA-standard 278 transaction). Refer to the Availity Authorizations User Guide for instructions. By phone: Call the prior authorization number on the member's ID card for requests handled by BCBSNM. Carelon (formerly AIM) portal: For prior authorization requests managed by Carelon Medical Benefits Management, use the Carelon web portal to initiate cases, check status, review guidelines, view authorization/eligibility, and more. The web portal is available 24/7 at https://www.careloninsights.com/medical-benefits-management/specialty-care or call toll-free 1-866-745-1789 (7 a.m. to 7 p.m. Monday–Friday, except holidays).

Prior Authorization

Prior authorization required care categories

The following care categories require prior authorization through Carelon for all Commercial members: Molecular Genetic Lab Testing; Radiation Therapy / Radiation Oncology; Advanced Imaging / Radiology; Musculoskeletal - Pain; Musculoskeletal - Joint, Spine Surgery. Additional outpatient care categories that may require prior authorization (and the vendor indicated) include: Select Outpatient Procedures (see code list), Cardiology - Lipid Apheresis, Ear/Nose/Throat, Gastroenterology, Neurology, Outpatient Surgery (breast, deactivation of headache triggers, jaw), Pain Management, Sleep, and Wound Care. Providers must check member eligibility and product-specific requirements (PPO, EPO, HMO, etc.) and verify preauthorization requirements through Availity.

Defined Terms and Administrative Names

Carelon

TermCarelon Medical Benefits Management (formerly AIM Specialty Health)

RoleProvides utilization management and prior-authorization review for designated care categories and procedure codes.

PortalCarelon web portal available 24/7 for initiating and managing cases.

Availity

ToolAvaility Authorizations tool (HIPAA-standard 278 transaction)

UsersRegistered Availity users may use the Authorizations tool to initiate prior authorization requests for BCBSNM-handled cases.

Note

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyOutpatient prior authorization procedure code list (medical/surgical)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2023

Next Review DateN/A

Key ActionInitiate prior authorization online via Availity Authorizations (278) or the Carelon web portal, or call the number on the member's ID card.

SourceLink

On This Page

Product scopeApplies to fully insured commercial outpatient medical/surgical services for Blue Cross Blue Shield of New Mexico.

RequirementProcedure codes listed require prior authorization for fully insured commercial outpatient services.

Provider verificationProviders must check eligibility and benefits and verify preauthorization requirements through Availity.

A9607 effective date note

CodeA9607

DescriptionLutetium Lu 177 Vipivotide Tetraxetan, Therapeutic, 1 Millicurie.

Effective dateAdded effective 01/01/2023.

Prior Authorization

Procedure code prior-authorization list (partial)

The following is a partial list of procedure codes requiring prior authorization for fully insured commercial outpatient services. Codes shown below include CPT, HCPCS, proprietary (M/U/Z) codes and are grouped by clinical category. Codes listed indicate the administrative reviewer — Carelon or BCBSNM — responsible for the prior authorization review for that code/group.

Prior Authorization

Molecular/genetic testing codes requiring prior authorization

Molecular and genetic testing codes (CPT, M/001–099, U-codes) appearing on the prior authorization list require prior authorization review by Carelon for fully insured commercial outpatient benefits. Examples from the list include (partial): - 81233, 81234, 81235, 81236, 81237, 81238, 81239, 81240, 81242, 81244, 81245, 81246, 81247 - Proprietary and molecular codes: 0007M, 0011M, 0012M, 0012U, 0013M, 0013U, 0014U, 0016M, 0016U, 0017M, 0017U, 0018U, 0019U, 0022U, 0023U, 0026U, 0027U, 0029U, 0030U, 0031U, ... - Later U-codes and molecular panels: 0306U, 0307U, 0313U, 0314U, 0315U, etc. All molecular/genetic codes on the full list are routed to Carelon for review; check the full published code list for specific codes and updates.

Prior Authorization

Prior authorization vendor responsibility

Codes on this list are assigned to an administrative reviewer for prior authorization. Many categories (Advanced Imaging, Radiation Therapy, Musculoskeletal, Molecular Genetic Lab Testing, etc.) are routed to Carelon Medical Benefits Management for review. Certain services within Transplant, Wound Care and selected complex procedures are routed to BCBSNM for prior authorization review as indicated in the code list. Providers should follow the routing indicated for each CPT/HCPCS/U-code when submitting prior authorization requests.

Prior Authorization

Prior authorization routing for listed CPT codes

Outpatient surgical CPT codes for musculoskeletal (joint and spine) procedures on the list are routed to Carelon. Examples include (partial): 20931, 20932, 20933, 20934, 20936, 20937, 20938, 20939, 20974, 27138, 27279, 27332–27335, 27345, 27403, 27412 (note: 27412 explicitly requires prior authorization through Carelon), 27415, 63055–63057, 63075–63088, and many other spine/joint CPTs in the list. Verify routing and prior authorization requirements for each CPT on the full code list before scheduling or performing services.

Denial Risk

Payment disclaimer and authorization note

Please note: Checking eligibility and benefits and/or the fact that a service has been prior authorized/pre-notified is not a guarantee of payment. Benefits will be determined when a claim is received and will be based upon the member's eligibility and the terms of the member's certificate of coverage on the date services were rendered. CPT copyright 2022 AMA. Availity is a separate company; Carelon is an independent vendor contracted to provide utilization management services. BCBSNM makes no endorsement or warranty regarding third-party vendors.

Prior Authorization

Prior authorization code listings (Radiation, Transplant, Wound Care, etc.)

Prior authorization code listings by category (examples, partial): - Radiation Therapy / Radiation Oncology: extensive list of CPT/HCPCS and Q/A/G codes routed to Carelon (e.g., 61798–61800, 63620–63621, 67218, 76873, 76965, 77014, 77295, 77301, 77316–77318, 77338, 77370–77373, 77385–77387, 77402, 77407, 77412, 77424, 77425, 77432, 77435, 77469–77470, 77520–77525, 77750, 77761–77763, 77767–77778, 77790, 79005, 79101, 79403, 0394T–0395T, A9508–A9607, G0339–G0340, G0458, G6001–G6017, Q3001, etc.) - Transplant Services / Transplant Evaluations and Transplants: selected surgical and procedure codes routed to BCBSNM (examples: 32851–32854, 33935, 33945, 38204–38207, 38230–38243, 44135–44136, 47135, 48160, 48554, 50360–50365, 50380, 0584T–0586T, G0341–G0343, S2053–S2065, S2102, S2140–S2150, etc.) - Wound Care / Hyperbaric Oxygen Therapy: examples routed to BCBSNM include 99183, G0277. This is a partial representation; consult the full code list for the complete, product-updated roster of codes and their assigned reviewer.

Availity is an administrative health information network providing services to BCBSNM.

Carelon (named reviewer)

Named reviewerCarelon is the named reviewer/authorization vendor referenced alongside many listed codes.

Attribution examplesMany molecular genetic, radiology, and musculoskeletal codes show 'Carelon' as the reviewer in the code list entries.

ResponsibilityCarelon handles prior-authorization review for the codes and categories assigned to it.

BCBSNM

TermBCBSNM (Blue Cross Blue Shield of New Mexico)

RoleListed as the reviewer/administrator for some procedure codes in the code list (e.g., certain outpatient surgery and air ambulance codes).

Provider actionFor PA requests handled by BCBSNM, providers may initiate via Availity or by calling the number on the member's ID card.

Named utilization management reviewer/administrator (Carelon)

Administrator nameCarelon

ContextAppears repeatedly as the utilization management reviewer/administrator associated with listed codes (molecular genetic, radiation, musculoskeletal segments).

FunctionPerforms prior-authorization reviews and guideline application for codes attributed to Carelon.

Descriptor: Molecular Genetic Lab Testing / Molecular Pathology

DescriptorMolecular Genetic Lab Testing / Molecular Pathology

UsageUsed throughout the list to categorize molecular/genetic testing codes (includes U- and M-series and some S/G/G9 codes).

ExamplesEntries such as 81233–81246 and numerous U-codes are grouped under this descriptor with Carelon attribution.

Carelon (designated PA reviewer/vendor)

Prior-authorization reviewerCarelon (designated as the prior authorization reviewer/vendor for the listed procedure codes).

Document instancesMultiple code lines across molecular genetic, radiation, and musculoskeletal sections list Carelon as the reviewer.

Provider resourcesUse the Carelon portal or phone line to initiate or check authorization status for Carelon-attributed codes.

Molecular Genetic Lab Testing (category header)

Category headerMolecular Genetic Lab Testing

ScopeGroups molecular/genetic testing codes including U-codes, proprietary codes, and certain CPT ranges.

AttributionEntries under this header commonly indicate Carelon as the reviewer.

Prior-authorization vendor identified for listed procedure codes

Prior-authorization vendorCarelon is identified as the prior-authorization vendor for many procedure codes in this document portion.

Per-code attributionSome codes show BCBSNM as administrator while many others list Carelon; each code entry indicates the responsible reviewer.

ImplicationProviders should route PA requests to the vendor shown next to the procedure code (Carelon or BCBSNM).

Administrator attribution (Carelon or BCBSNM)

Administrator attributionCarelon or BCBSNM — the named administrator/reviewer shown alongside each procedure code entry.

ExamplesCodes such as 0095T list Carelon; codes like 19316 list BCBSNM as the reviewer.

UseAttribution determines where providers submit prior-authorization requests (Carelon web portal/phone or BCBSNM via Availity/phone).

Code status note

Code statusSome entries note code terminations and replacements (example: 0163T termed 12/31/2022 and replaced by 22860).

Provider noteCheck code status and crosswalks when a CPT/temporary code shows a termination or replacement annotation.

Source examples0163T annotated as termed 12/31/2022 and replaced by 22860 in the list.

Carelon (formal name)

CarelonCarelon Medical Benefits Management (formerly AIM Specialty Health)

Alternate nameAIM Specialty Health (former name).

RoleIndependent company contracted to provide utilization management services for BCBSNM members.

Availity (service description)

AvailityAvaility (third-party health information network) provides the Authorizations tool for initiating prior authorization requests (278 transaction).

FunctionProvides electronic information exchange services and administrative services to BCBSNM.

Provider requirementRegistered users should refer to the Availity Authorizations User Guide for instructions.