Blue Cross Blue Shield OK — Prior Auth Code List Update | OpenPayer
ModifiedBlue Cross Blue Shield - OklahomaPolicy N/A
BCBSOK ASO Commercial Outpatient Medical Surgical Prior Authorization Code List
A searchable code list of CPT/HCPCS and proprietary U-codes for which prior authorization may be required for BCBS Oklahoma commercial networks; indicates managing organization (Carelon or BCBSOK) and update notes for listed codes.
Policy Summary
PayerBlue Cross Blue Shield - Oklahoma
PolicyASO Commercial Outpatient Medical Surgical Prior Authorization Code List
Policy CodePolicy N/A
Change TypeCode-list updates and management reassignment
Effective DateJan 1, 2024
Next Review DateN/A
Key ActionUse the searchable PDF (Ctrl+F) to find procedure codes and route prior authorization requests to the managing entity (Carelon or BCBSOK) as indicated.
Multiple musculoskeletal and spine surgery procedure codes (CPTs) were added to be managed by Carelon effective 01/01/2024.
81457–81459 entries include an update note: "Add effective 04/01/2024."
538pages
manymanaged by Carelon
multipleadditions effective 01/01/2024
extensiveCPT/HCPCS/U-codes listed
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The file lists codes for which prior authorization may be required; some entries include update notes and a managing entity designation.
ALL of the following
Managed by Carelon
Codes labeled 'Managed By = Carelon' in this list are subject to utilization management/prior authorization via Carelon.
Managed by BCBSOK
Codes labeled 'Managed By = BCBSOK' in this list are subject to utilization management/prior authorization via BCBSOK.
Unless otherwise indicated, prior authorization applicability is effective as of January 1, 2024 (see document header).
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Update notes
Some code entries include 'Updates' fields (for example 'Add effective ' or 'Retire Effective ') indicating administrative changes to managed status or effective dates.
Providers should search the list (searchable PDF) for specific procedure codes or descriptions to determine management assignment and any effective-date notes.
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This excerpt contains code listings and management assignments only; per-code clinical coverage criteria or indication-specific rules are not present in these segments.
Listed CPT codes and management
Advanced Imaging/Radiology CPTs are listed with a 'Managed By = Carelon' designation indicating prior authorization/UM routing to Carelon.
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Example advanced imaging codes
Examples in this segment include CPTs such as 72197, 73200, 73202, 73206, 73218, 73725, 74150, 74160, 74170, 74174, 74175, 74176, 74177, 78072, 78075 (each entry shows 'Managed By = Carelon').
Each listed Advanced Imaging/Radiology code entry includes 'Managed By = Carelon' and an 'Updates' field (often blank or '_' when no update is specified).
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No clinical coverage rules or indication-level criteria are provided in these code listings; management assignment only.
Coverage criteria — not provided
No clinical coverage criteria are provided in this fragment; only code listings and management assignments appear.
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The excerpt lists Advanced Imaging/Radiology CPT codes (e.g., 78608–78610 and others) with 'Managed By = Carelon' but contains no per-code coverage indications, medical necessity criteria, or denial conditions in this section.
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For clinical coverage criteria, refer to the main BCBSOK medical policy resources rather than this managed-code list.
Management routing criteria
Operational routing: the listed codes indicate which organization (Carelon or BCBSOK) manages utilization review/prior authorization for each code group.
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Carelon-managed categories
Cardiology imaging/myocardial perfusion codes (e.g., 78451–78496) and echocardiography codes (e.g., 93303–93352) are managed by Carelon; several echocardiography codes were noted as added to the ASO list effective 1/1/2024.
Molecular genetic lab testing CPTs and U-codes shown in this document are managed by Carelon (see molecular testing lists).
BCBSOK-managed categories
Selected services such as lipid apheresis (e.g., 36516, S2120) and ENT/cochlear device and related codes (e.g., 30120, 30400–30450, 69714–69930, L8614–L8629) are managed by BCBSOK as indicated in the list.
Code listing and management
This section enumerates molecular genetic testing CPT codes and shows 'Managed By = Carelon'; no coverage rules are specified here.
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Codes in the 81176–81286 range (examples listed throughout the excerpt) are enumerated with 'Managed By = Carelon' indicating Carelon performs utilization management for these molecular tests.
Entries include an 'Updates' field (commonly '_') but do not contain indication-level medical necessity criteria within these code listings.
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Providers should route prior authorization or UM inquiries for these molecular test CPTs to Carelon as the designated manager.
Management assignments for molecular test codes
Management assignments for molecular testing codes: each listed code in these ranges is labeled as managed by Carelon.
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Codes in the ranges 81277–81364 and 81400–81403 (and contiguous molecular pathology codes) are listed with 'Managed By = Carelon' and an 'Updates' indicator; these entries route utilization management to Carelon.
Molecular Pathology Procedure Levels (81400–81403) are included as labeled procedure complexity levels within the molecular testing section.
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No per-code clinical acceptance criteria are present in these listing segments — refer to Carelon policies for coverage determinations.
Panel composition requirements (examples)
Examples of panel composition and minimum gene-count requirements appear for selected molecular panel CPTs.
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81410 (Aortic dysfunction/dilation panel) must include sequencing of at least 9 specified genes (examples provided in the entry).
81412 (Ashkenazi Jewish associated disorders panel) must include sequencing of at least 9 specified genes (examples provided).
81413 (Cardiac ion channelopathies panel) must include sequencing of at least 10 specified genes (examples provided).
81430 (Hearing loss panel) must include sequencing of at least 60 genes.
81440 (Nuclear encoded mitochondrial gene panel) must include analysis of at least 100 genes.
Listing and update notes
Code entries with administrative update notes (effective-date annotations) and manager assignment are listed here; no coverage rules accompany these notes.
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Examples: CPTs 81457–81459 are shown with 'Updates = Add effective 04/01/2024' and 'Managed By = Carelon.'
81460 and related entries include code descriptions and 'Managed By = Carelon' with updates indicated where applicable.
Listing of managed molecular genetic tests
Enumerated U-codes and other molecular/genomic test codes are listed with brief descriptions and 'Managed By = Carelon'.
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Representative U-code examples (e.g., 0055U, 0060U, 0069U, 0070U, 0118U, 0217U–0231U, etc.) are shown with descriptions and 'Managed By = Carelon.'
These listings provide test descriptions (panel size, specimen type, analytic scope) but do not include per-code medical necessity criteria within the excerpt.
Coverage stance absent in this segment
This segment lists molecular testing U-codes with management assignment only; no coverage stance is specified here.
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Entries such as 0217U, 0218U, 0228U, 0229U, 0230U, 0231U and subsequent U-codes are shown with 'Managed By = Carelon' and 'Updates' fields but no coverage determinations within this excerpt.
Providers should consult Carelon for authorization criteria and coverage determinations for these tests.
Coverage note — code listing only
Code list entries are provided with management assignment and occasional effective-date additions; clinical coverage criteria are not included in these chunks.
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Selected entries (e.g., 0326U, 0329U, 0331U, S3840–S3854, etc.) are listed with 'Managed By = Carelon' and some include 'Add effective' annotations (dates vary).
The excerpt explicitly notes absence of per-code coverage rules; utilization management processes apply and providers should follow the designated manager's policies for clinical criteria.
Listed services
Enumerated services across multiple clinical categories are shown as subject to utilization management with a 'Managed By' designation.
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Service categories listed
Molecular Genetic Lab Testing (extensive CPT and U-code listings) — Managed By = Carelon.
Musculoskeletal Joint and Spine Surgery CPTs (numerous entries) — Managed By = Carelon.
Neurology, Outpatient Surgery (Breast), and other service categories include codes managed by BCBSOK in some instances (see list).
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These entries identify which organization manages prior authorization/UM for each code; they do not themselves define clinical eligibility criteria.
Explicit criteria
One explicit prior-authorization action is noted in this excerpt.
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27412 (Autologous chondrocyte implantation knee) is listed with 'Managed By = Carelon' and an explicit note: 'Prior Authorization required through Carelon.'
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Other listed CPTs in this segment include 'Managed By = Carelon' but lack per-code coverage criteria within the excerpt.
Management routing
Operational management routing: the listed CPT codes in this segment are managed by Carelon.
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CPTs in the Musculoskeletal Joint and Spine Surgery sections (examples: 22861–22865, 23105, 23410, 27409–27416, many arthroscopy and spine codes) are designated 'Managed By = Carelon.'
Many entries include 'Updates = Add effective 01/01/2024' indicating administrative additions to Carelon's managed list effective that date.
Utilization management assignment
Utilization management assignment and update notes: multiple CPTs were added to Carelon's managed list effective 01/01/2024; other CPTs list Carelon management without update notes.
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Examples of additions: arthroscopy knee and hip CPTs (e.g., 29873–29888, 29892) show 'Updates = Add effective 01/01/2024' and 'Managed By = Carelon.'
Other spine and musculoskeletal CPTs in the segment are listed as 'Managed By = Carelon' with 'Updates' either blank or indicating earlier management; use the 'Updates' field to identify recent additions.
Coverage stance
This document segment contains code listings and manager assignments only; clinical coverage criteria are not present.
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Codes are listed with their service category and the managing entity (Carelon or BCBSOK).
For clinical coverage determinations and medical necessity criteria, providers should consult the manager’s authorization policies (Carelon or BCBSOK) referenced by the 'Managed By' field.
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Examples of BCBSOK-managed entries in this window include neurologic implant and sacral nerve stimulation codes (e.g., 61868, 64561, 64581) and certain outpatient surgery (breast) entries; these are routed to BCBSOK for management.
Code Tables and Code Metadata
Musculoskeletal Joint and Spine Surgery (selected CPT codes)CPT
63001
Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina without facetectomy foraminotomy or discectomy; 1 or 2 vertebral segments; cervical.
63003
Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina without facetectomy foraminotomy or discectomy; 1 or 2 vertebral segments; thoracic.
63005
Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina without facetectomy foraminotomy or discectomy; 1 or 2 vertebral segments; lumbar except for spondylolisthesis.
63012
Laminectomy with removal of abnormal facets and/or pars inter-articularis with decompression of cauda equina and nerve roots for spondylolisthesis lumbar (Gill type procedure).
63015
Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina without facetectomy foraminotomy or discectomy; more than 2 vertebral segments; cervical.
63016
Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina without facetectomy foraminotomy or discectomy; more than 2 vertebral segments.
63017
Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina without facetectomy foraminotomy or discectomy; more than 2 vertebral segments; lumbar.
63020
Laminotomy (hemilaminectomy) with decompression of nerve root(s) including partial facetectomy foraminotomy and/or excision of herniated intervertebral disc; 1 interspace; cervical.
63030
Laminotomy (hemilaminectomy) with decompression of nerve root(s) including partial facetectomy foraminotomy and/or excision of herniated intervertebral disc; 1 interspace; lumbar.
63035
Laminotomy (hemilaminectomy) with decompression of nerve root(s) including partial facetectomy foraminotomy and/or excision of herniated intervertebral disc; each additional interspace cervical or lumbar (list separately in addition to code for primary procedure).
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What Providers Must Do / Prior Authorization Routing
Prior Authorization
Search and prior authorization notice — This file is a searchable PDF. Press "CTRL" and "F" keys at the same time to bring up the search box. Enter a procedure code or description of the service.
This file is a searchable PDF. Press "CTRL" and "F" keys at the same time to bring up the search box. Enter a procedure code or description of the service.
Advanced Imaging sample codes: Examples of advanced imaging CPT codes listed below are managed by Carelon for utilization management and prior authorization routing. Providers should route prior authorization requests for these services to Carelon.
Carelon-managed molecular genetic testing codes: The following molecular genetic laboratory testing CPT/HCPCS/U-codes are managed by Carelon for utilization management and prior authorization routing. Providers must submit prior authorization/UM inquiries to Carelon for these codes.
Solid organ neoplasm panels with effective-date updates: Codes 81457, 81458, and 81459 are added with an effective date of 04/01/2024 and are managed by Carelon; prior authorization routing applies starting on that effective date.
Utilization management assignments & code list: Codes across advanced imaging, cardiology imaging, echocardiography, molecular genetic testing, musculoskeletal/joint/spine surgery, and others are assigned to either Carelon or BCBSOK for utilization management. Providers must follow the managed-by assignment when routing prior authorization/UM requests.
Management and effective-date updates: Several codes across categories include update notes such as "Add effective 01/01/2024", "Add effective 04/01/2024", "Add to ASO List effective 1/1/2024", "Prior Authorization required through Carelon", and other annotations. Providers should rely on the managed-by entity and effective dates when submitting requests.
Definitions and Field Notes
inv-71: Prior authorization code list
Prior authorization code list contentsThe document lists CPT, HCPCS and U-codes for services that may require prior authorization as of 01/01/2024 unless otherwise noted.
Managed By annotationEach code line includes 'Managed By =' to indicate which entity manages utilization/prior authorization for that code.
Searchable PDF guidanceThe file is a searchable PDF; use search to locate specific codes and their management/effective-date notes.
inv-72: Managed By — Carelon
Managed By = CarelonEntries across molecular genetic and molecular pathology codes consistently list 'Managed By = Carelon', indicating Carelon is the utilization manager.
Scope of managementCarelon is designated to manage a broad range of molecular genetic lab testing CPT and U-codes (examples shown in the excerpt).
Policy Summary
PayerBlue Cross Blue Shield - Oklahoma
PolicyASO Commercial Outpatient Medical Surgical Prior Authorization Code List
Policy CodePolicy N/A
Change TypeCode-list updates and management reassignment
Effective DateJan 1, 2024
Next Review DateN/A
Key ActionUse the searchable PDF (Ctrl+F) to find procedure codes and route prior authorization requests to the managing entity (Carelon or BCBSOK) as indicated.
The 'Managed By' field on each code entry directs providers to the appropriate utilization management organization for authorization inquiries.
ALL of the following
The list provides routing but does not include authorization submission instructions; providers should contact the designated manager (Carelon or BCBSOK) per the manager’s processes.
Carelon management assignment for listed procedures: Numerous procedure codes (e.g., advanced imaging codes such as 70336, 70450–70480, 72197–72198, 73200–73219, neuroimaging PET codes 78608–78660, cardiology imaging 78451–78453, echocardiography series 93303–93352, molecular and sequencing panels 81120–81286, 81402–81403, 81451–81459, U-codes 0055U–0333U, S-codes and others) are explicitly assigned "Managed By = Carelon" and require routing to Carelon for prior authorization/UM.
Note on BCBSOK-managed codes: Certain ENT, cochlear, lipid apheresis, and selected device/service codes (for example 36516, S2120, 30120, 30400–30435, 31296–31299, 69714, 69930, 92633, L8614–L8628 and others) are managed by BCBSOK; route prior authorization/UM requests to BCBSOK as indicated.
Note
Advanced Imaging sample codes
Sample listing of advanced imaging CPT codes. These examples are managed by Carelon for utilization management and prior authorization routing. Providers must route prior authorization requests for these CPT codes to Carelon.
70336 - Magnetic Resonance (Eg Proton) Imaging Temporomandibular Joint(S)
70450 - CT Head or Brain; Without Contrast
70460 - CT Head or Brain; With Contrast
70470 - CT Head or Brain; Without then With Contrast and Further Sections
70480 - CT Orbit/Sella/Posterior Fossa/Inner Ear; Without Contrast
72197 - MRI Pelvis; Without then With Contrast and Further Sequences
72198 - MRA Pelvis With or Without Contrast
73200–73202, 73206, 73218–73219 - CT/MRI Upper Extremity series
78608–78610, 78630–78660 - PET and cerebrospinal fluid flow imaging series
78700–78701 - Kidney imaging morphology
Prior Authorization
Carelon-managed molecular genetic testing codes
Utilization management for molecular genetic testing codes is managed by Carelon. The following is a consolidated representation of molecular genetic and related panel codes flagged as "Managed By = Carelon". Providers must submit prior authorization/UM inquiries to Carelon for these codes.
Common single-gene and targeted tests: 81120, 81121, 81162–81171, 81172–81190+ (and many sequential 811xx codes listed)
Extended targeted and sequence analyses: 81277–81286 (cytogenomic/neoplasia and targeted analyses)
Molecular pathology levels and large panels: 81402–81403 (molecular pathology procedures Level 3–4)
Hematolymphoid and solid neoplasm panels: 81451, 81455–81456 (hematolymphoid and combined DNA/RNA panels)
Solid organ neoplasm panels (effective 04/01/2024): 81457, 81458, 81459 — added effective 04/01/2024 and managed by Carelon
Additional U-codes and S-codes: 0055U, 0060U, 0069U, 0070U, 0217U–0333U, 0326U–0329U, S3840–S3870, S3861–S3870 series — all Managed By = Carelon
Note
Solid organ neoplasm panels with effective-date updates
Solid organ neoplasm genomic sequence analysis panels are added with effective-date updates and are managed by Carelon. Providers should note the effective dates and route prior authorization accordingly.
81457 - Solid Organ Neoplasm Genomic Sequence Analysis Panel; DNA Analysis; Microsatellite Instability — Managed By = Carelon; Updates = Add effective 04/01/2024
81458 - Solid Organ Neoplasm Genomic Sequence Analysis Panel; DNA Analysis Copy Number Variants and Microsatellite Instability — Managed By = Carelon; Updates = Add effective 04/01/2024
81459 - Solid Organ Neoplasm Genomic Sequence Analysis Panel; DNA or Combined DNA and RNA Analysis, Copy Number Variants, Microsatellite Instability, Tumor Mutation Burden, and Rearrangements — Managed By = Carelon; Updates = Add effective 04/01/2024
Prior Authorization
Utilization management assignments
Utilization management assignments: codes across multiple service categories are assigned to Carelon or BCBSOK. Providers must use the managing entity shown for prior authorization routing and respect any noted update/effective dates.
Managed by Carelon (selected examples across categories): Advanced imaging (70336, 70450–70480, 72197–72198, 73200–73219, 78608–78660, 78700–78701), Cardiology imaging (78451–78453), Echocardiography series (93303–93352 and related Doppler codes), Musculoskeletal/joint/spine surgery codes (20930–20931, 23473–23474, 27120–27132, 27412–27416, 27425, 27447, 27486–27488, 29805–29881, 63267–63282, etc.), Molecular genetic and panel codes (81120–81286, 81402–81403, 81451–81459), U-codes and S-codes listed (0055U–0333U, S3840–S3870 series) — all Managed By = Carelon.
Managed by BCBSOK (selected examples): Lipid apheresis and related codes (36516, S2120), ENT and cochlear device codes (30120, 30400–30435, 31296–31299, 69714, 69930, 92633, L8614–L8628), gastroenterology device/stimulator codes (95980, E0765) — Managed By = BCBSOK.
Documentation Required
Management and effective-date updates
Management and effective-date updates consolidated for provider action. Several codes include notes requiring attention to effective dates, ASO list inclusion, or explicit prior authorization requirements.
Add effective 01/01/2024: Multiple musculoskeletal/arthroscopy/spine and other procedure codes (e.g., 23700, 27409, 29805–29828, 29860–29881, 29863, 29866–29881 series) have been added effective 01/01/2024 and are Managed By = Carelon; route prior authorization accordingly on/after that date.
Add to ASO List effective 1/1/2024: Echocardiography and related codes 93303–93352 series — Managed By = Carelon; note ASO list inclusion effective 1/1/2024.
Prior Authorization required through Carelon: Specific codes such as 27412 (Autologous Chondrocyte Implantation Knee) explicitly state "Prior Authorization required through Carelon." Follow Carelon's prior authorization process.
Add effective 04/01/2024: Solid organ neoplasm panel codes 81457–81459 — Managed By = Carelon beginning 04/01/2024.
Prior Authorization
Carelon-managed prior authorization
Carelon management assignment for listed procedures — providers must route prior authorization and utilization management requests for these procedures to Carelon per the managed-by designation.
Cardiology & Echocardiography: 78451–78453, 93303–93352 (and associated 93312–93320 series) — Managed By = Carelon (many added to ASO list effective 1/1/2024)
Molecular Genetic & Pathology Panels: 81120–81190 series, 81277–81286, 81402–81403, 81451–81459, U-codes 0055U–0333U, S3840–S3870 series — Managed By = Carelon (note effective-date additions such as 81457–81459 effective 04/01/2024)
Musculoskeletal Joint/Spine Surgery & Arthroscopy: 20930–20931, 23473–23474, 27120–27132, 27409, 27412–27416, 27425, 27447, 27486–27488, 28446, 29805–29881, 29863–29881, 63267–63282, 63275–63280, etc. — Managed By = Carelon (many with Add effective 01/01/2024)
Where BCBSOK is the manager (e.g., lipid apheresis, ENT/cochlear/device codes), route requests to BCBSOK per the managed-by designation.
Provider actionRoute prior authorization or utilization management inquiries for listed Carelon-managed codes to Carelon per the document instructions.