Advanced Imaging/Radiology prior authorization code list (site-of-care updates)
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List of CPT/HCPCS procedure codes related to advanced imaging/radiology for which prior authorization may be required for BCBSNM networks; indicates management by Carelon and an effective change adding site-of-care to medical necessity criteria as of 01/01/2025. Affects providers submitting claims for listed codes under BCBSNM networks noted.
Addition of site of care to the medical necessity criteria for numerous advanced imaging CPT codes.
Addition of site of care to the medical necessity criteria for multiple advanced imaging CPT codes effective 01/01/2025.
Multiple CPT panel codes (e.g., 81433, 81436, 81438) are marked as 'Retire Effective 04/01/2025.'
Multiple Category III codes (e.g., 0476U–0508U and others) are listed with 'Add effective' dates of 07/01/2025 or various 04/01/2025 retirements.
Some Category III codes are marked 'Retire Effective' with specified dates (e.g., 0396U retire 07/01/2025; 0428U and 0448U retire 04/01/2025).
Coverage Criteria and Medical Necessity
Site-of-care addition to medical necessity criteria
Codes listed are subject to management and have updated medical necessity criteria.
Managed by Carelon for prior authorization determinations.
Panel gene-content criteria
Panels are defined as covered when they include the required minimum gene set as specified for the condition/panel.
Exact gene lists and minimum counts are provided in the CPT code descriptions in the document.
The provided excerpt does not include explicit clinical exclusion lists. For specific medical necessity rules, coverage determinations, or exclusions that apply to individual procedure codes, providers must refer to the BCBSNM Medical Policy Website or follow Carelon Medical Benefits Management processes as indicated in the file. Contact information for Carelon is provided for services they handle.
The document identifies specific coding conflicts for home infusion services that may cause claim denials if billed together. Do not use S9214 with any home infusion per diem code; do not use S9325 with S9326–S9328; do not use S9810 with any per diem code; and do not use S9494 with hourly dosing schedule codes S9497–S9504. These restrictions are listed alongside the S‑codes and the entries note that drugs and nursing visits are billed separately from the S‑per‑diem codes.
Several molecular genetic panel CPT codes are scheduled for retirement. Notably, duplication/deletion or panel codes such as 81433, 81436, and 81438 are marked 'Retire Effective 04/01/2025' in the code listings; providers should avoid submitting these codes after the stated retirement date and follow updated code guidance from BCBSNM/Carelon.
The chunks in this section are primarily a managed-code catalog and do not state explicit coverage determinations, medical necessity criteria, or exclusions. They list molecular genetic and related codes with management assignments; specific coverage rules must be confirmed through the payer's medical policy or Carelon's utilization management processes.
Some Category III and other temporary molecular codes include retire/transition notes. Examples in the catalog show 0380U is marked 'Retire Effective 04/01/2025' and 0396U is marked 'Retire Effective 07/01/2025'. These retirements indicate the codes will be removed or superseded on the effective dates and may affect authorization/claim processing after those dates.
Additional specific codes in the Category III listings carry retirement dates in-line with their entries. For example, 0428U and 0448U are listed 'Retire Effective 04/01/2025'. Providers should track these retire dates when preparing prior authorization requests or claims for services associated with these temporary codes.
This segment is a code/service catalog with management assignments and does not provide explicit coverage criteria, medical necessity statements, or exclusions. It lists U‑codes and related entries that are 'Managed By = Carelon' and includes administrative notes such as planned add/retire effective dates for selected codes.
The listed procedure CPT codes in this section are presented as administrative code listings with a 'Managed By = Carelon' assignment. The excerpt does not provide detailed medical necessity rule text for these surgical/procedure codes; providers should follow Carelon's utilization management instructions for prior authorization and documentation requirements.
The provided text does not specify items that are explicitly 'not medically necessary.' No not‑medically‑necessary determinations are stated in these chunks; absence of such statements in the excerpt means providers must consult BCBSNM Medical Policy or Carelon guidance for definitive coverage decisions.
CPT/HCPCS Code Listings
| 81230 | Code from source - listed |
| 81231 | Code from source - listed |
| 81232 | Code from source - listed |
| 81233 | Code from source - listed |
| 81234 | Code from source - listed |
| 81235 | Code from source - listed |
| 81236 | Code from source - listed |
| 81237 | Code from source - listed |
| 81238 | Code from source - listed |
| 81239 | Code from source - listed |
Provider Actions, Prior Authorization & Documentation
How to access prior authorization
This list includes CPT and/or HCPCS codes for which prior authorization or utilization management may be required as of 2025-01-01. Many entries are routed to either Carelon Medical Benefits Management (Carelon) or Blue Cross and Blue Shield of New Mexico (BCBSNM); providers must follow the management/authorization routing indicated for each code.
- For services managed by Carelon: call 1-866-455-8415 or access https://www.careloninsights.com/medical-benefitsmanagement/specialty-care.
- This file is a searchable PDF — use Ctrl+F to find codes or descriptions.
Prior authorization managed by Carelon; site-of-care added to criteria
Many advanced imaging and radiology CPT/HCPCS codes listed are managed by Carelon. Effective 01/01/2025, medical necessity criteria for multiple advanced imaging codes were updated to include site-of-care requirements. Claims for these codes may be subject to prior authorization/management by Carelon and may be denied or returned if site-of-care documentation is missing or if prior authorization through Carelon was not obtained.
- Examples (managed by Carelon with site-of-care added effective 01/01/2025): 70336, 70450, 70460, 70470, 70480, 70481, 73706, 73718–73723, 73725, 74150–74178, 74181.
- Additional advanced imaging/radiology and nuclear medicine PET/SPECT codes (e.g., 78800–78804, 78811–78816, 78830–78832, 0042T, 0633T–0638T, 0648T–0649T, A9602, A9800, C89xx series, G02xx, S8037) are Managed By = Carelon and subject to Carelon utilization management.
Prior authorization/management assignment — Molecular genetic testing (Managed by Carelon)
Numerous molecular and genetic laboratory test codes are designated Managed By = Carelon. These codes are subject to Carelon utilization management; providers should submit prior authorization or utilization management requests to Carelon per the contact information above. Some Category III and proprietary U-codes include retirement or effective-date notes — verify code status before submission.
- Examples: many 00xxU/01xxU/02xxU/03xxU/04xxU and 814xx–813xx series codes are Managed By = Carelon.
- Code retirement risk example: 0078U is marked for retirement effective 07/01/2025 — use beyond that date may be denied.
Provider Actions, Prior Authorization & Documentation
Some service categories and specific codes are designated Managed By = BCBSNM; prior authorization or utilization management for those codes is handled directly by BCBSNM. Providers should follow BCBSNM authorization processes for these services to avoid claim denials.
- Examples of BCBSNM-managed codes: 36516, S2120, ENT (30120, 30400–30450 series), cochlear implant codes (L8614–L8629, L8690–L8693), selected gastroenterology (43647–43648, 43881), and home infusion therapy S‑codes (S5501, S5502, S9208–S9213, S9214, S9325, S9357, S9359, S9372–S9376, S9494, S9497, S9500–S9502).
- title":"BCBSNM-managed service routing","type":"callout","variant":"prior_auth"},{
Contrast Material and Study Sequencing Rules
Background and Scope
This background segment summarizes the document's purpose: it maps a broad set of advanced imaging and molecular testing procedure codes to their utilization manager and provides brief code descriptions. The listings include advanced imaging modalities (CT, MRI, MRA, CTA, PET, SPECT, nuclear medicine), radiopharmaceuticals, quantitative MRI procedures, ENT and cochlear device codes, home infusion per‑diem codes with operational notes, and extensive molecular/genetic testing codes. Many entries include a 'Managed By' field (most often Carelon) and updates such as the addition of site‑of‑care to medical necessity criteria effective 01/01/2025 for numerous advanced imaging CPT codes.
Definitions and Abbreviations
Covered Indications
Various diagnostic and angiographic imaging indications as per CPT descriptions
Select the code that matches the anatomic region and contrast use as described in the CPT code entry.
PET imaging specific use (breast cancer initial diagnosis / surgical planning) for G0252
Managed by Carelon per the code entry.
Policy Revision History
Medical necessity criteria for numerous advanced imaging CPT codes were revised to add 'site of care' requirements effective 01/01/2025; these codes are managed by Carelon for prior authorization determinations.
Select molecular/genetic panel duplication/deletion CPT codes (e.g., 81433, 81436, 81438) are scheduled to retire effective 04/01/2025.
Some Category III HCPCS U-codes are marked as retiring effective 04/01/2025 (examples include 0428U and 0448U as listed in code entries).
Additional Category III codes are scheduled to retire effective 07/01/2025 (examples include 0396U and at least one other U-code with a 07/01/2025 retirement date).
Document last reviewed in July 2025 with multiple code effective/retirement dates noted through 07/01/2025.
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