Blue Cross Blue Shield NM advanced imaging Prior Auth | OpenPayer
ModifiedBlue Cross Blue Shield - New MexicoPolicy N/A
Advanced Imaging/Radiology prior authorization code list (site-of-care updates)
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.
Policy Summary
PayerBlue Cross Blue Shield - New Mexico
PolicyAdvanced Imaging/Radiology prior authorization code list (site-of-care updates)
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).
01/01/2025date change applies
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CPT codes with site-of-care update
Careloncodes overseen by utilization manager
20+codes noted with updates adding site of care
Retire 04/01/2025codes with retire date
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.
site_of_care_added: Medical necessity criteria for the listed advanced imaging CPT codes were updated to include site-of-care considerations effective 01/01/2025.
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.
Panel composition requirement: Genomic sequence analysis panels must include the minimum set of named genes for the indicated condition as specified by the CPT panel code (examples: 81410 requires at least 9 genes including FBN1, TGFBR1, TGFBR2, COL3A1, MYH11, ACTA2, SLC2A10, SMAD3, MYLK; 81413 requires at least 10 cardiac ion channel genes; 81430 requires at least 60 genes for hearing loss panels; 81432 requires at least 10 genes including BRCA1 and BRCA2).minimum gene list per CPT code
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
Molecular Genetic CPT and HCPCS Codes (listed)mixed
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
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.
Prior Authorization Summary
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Contrast Material and Study Sequencing Rules
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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
site-of-care update
Site-of-care updateSite of care was added to the medical necessity criteria effective 01/01/2025
ImplicationProviders should supply site-of-care information when submitting authorization requests to Carelon for affected codes
Cerebral Perfusion Analysis Using Computed Tomography With Contrast
0042TCerebral perfusion analysis using CT with contrast (includes post-processing parametric maps for CBF, CBV, MTT)
Managed ByCarelon (per code entry)
Quantitative Magnetic Resonance For Analysis Of Tissue Composition
Covered Indications
Various diagnostic and angiographic imaging indications as per CPT descriptions
Various diagnostic and angiographic imaging indications as per CPT descriptions: Includes diagnostic CT/MR studies and angiographic variants described by CPT (examples: low-dose CT for lung cancer screening 71271; CT/MR angiography and CTA codes for thorax/abdomen/pelvis; CT chest/brain/neck/orbit variants).
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
PET for initial breast cancer staging: G0252: PET imaging for initial diagnosis of breast cancer and/or surgical planning (including evaluation of axillary nodal disease) as specified by the CPT/HCPCS description.
Managed by Carelon per the code entry.
Policy Revision History
2025-01-01criteria_updateLatest
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.
2025-04-01code_retirement
Select molecular/genetic panel duplication/deletion CPT codes (e.g., 81433, 81436, 81438) are scheduled to retire effective 04/01/2025.
2025-04-01
Policy Summary
PayerBlue Cross Blue Shield - New Mexico
PolicyAdvanced Imaging/Radiology prior authorization code list (site-of-care updates)
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
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.
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"},{
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0648TQuantitative MR for analysis of tissue composition — without diagnostic MRI
0649TQuantitative MR for analysis of tissue composition — add-on with diagnostic MRI
Managed By — Carelon
Managed By = CarelonIndicates the listed CPT/HCPCS code is subject to utilization management by Carelon (third‑party UM vendor)
Action for providersRoute prior authorization/UM requests to Carelon for codes marked 'Managed By = Carelon'
81403 (Level 4)Analysis of a single exon by DNA sequence analysis, targeted exon analyses, mutation scanning, or >10 amplicons using multiplex PCR in multiple reactions
ExamplesFull gene sequence analyses and targeted exon sequencing described in code text
Provider noteThese tests are assigned 'Managed By = Carelon' in the listing and require routing to the named manager for utilization management
Management entity
Management entity (shorthand)Managed By = Carelon (management/authorization vendor responsible for listed molecular genetic tests)
Provider instructionFollow Carelon prior authorization processes for codes managed by Carelon
code_retirement
Some Category III HCPCS U-codes are marked as retiring effective 04/01/2025 (examples include 0428U and 0448U as listed in code entries).
2025-07-01code_retirement
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).
2025-07last_review
Document last reviewed in July 2025 with multiple code effective/retirement dates noted through 07/01/2025.