Searchable file — use code or description to check PA

This file is a searchable PDF; providers can search by procedure code or description to determine whether prior authorization is required.

Prior authorization may be required for listed codes (effective 01/01/2025)

Prior authorization may be required for the listed CPT codes; the document lists numerous advanced imaging/radiology CPTs and states prior authorization may be required as of January 1, 2025.

Carelon manages PA — site-of-care added to medical necessity

Prior authorization/management for the listed advanced imaging CPT codes is handled by Carelon; medical necessity criteria were updated to add site-of-care as a required element effective 01/01/2025.

Carelon-managed codes — follow Carelon authorization processes

These specific procedure codes are managed by Carelon for utilization management; prior authorization or utilization management through Carelon is indicated for the listed codes.

Follow the 'Managed By' designation for authorization routing

Prior authorization and management requirements are governed by the entity listed in each code's 'Managed By' field; entries show codes may be managed by Carelon or BCBSOK and should be routed accordingly.

Route PA requests for listed molecular genetic U-codes to Carelon

Specified U-codes and select CPT/PLA codes (e.g., 0552U–0555U and other 05xxx U-codes) are assigned to Carelon for utilization management and include 'Add effective' dates; providers should route authorization/management requests to Carelon for those entries.

Molecular genetic CPT codes labeled 'Managed By = Carelon' — PA applies

Prior authorization/management oversight is indicated for the listed molecular genetic CPT codes in the 81230–81328 and 81400 series; these entries are labeled 'Managed By = Carelon.'

CPT molecular pathology codes — managed by Carelon

These CPT codes in the molecular genetics/molecular pathology groups are listed with 'Managed By = Carelon'; providers must follow Carelon's utilization management procedures for authorization and review.

Category III/U-codes — Carelon manages utilization and PA

Entries in the Category III (U-code) ranges are marked 'Managed By = Carelon', indicating these molecular genetic lab testing codes are subject to Carelon utilization management and prior authorization processes where applicable.

81558 — management update (Add effective 04/01/2025); PA applies

Code 81558 (transplantation medicine mRNA gene expression profiling) is listed with 'Updates = Add effective 04/01/2025', indicating a management update effective on that date and that prior authorization under Carelon rules will apply when effective.

Category III molecular/genetic tests — PA/UM by Carelon

Category III molecular/genetic lab tests in the listed ranges are identified as managed by Carelon and are therefore subject to utilization management processes often requiring administrative review/prior authorization.

U-codes (198–217) — Managed by Carelon; follow Carelon PA process

Listed U-codes in chunks 198–217 are identified as 'Managed By = Carelon'; providers should follow Carelon prior authorization procedures for these tests.

U-codes and molecular tests — submit authorizations to Carelon

These U-codes and other molecular genetic entries are listed under utilization management and are managed by Carelon; providers should submit authorization requests to Carelon as indicated.

0627T–0630T (percutaneous disc injections) — PA via Carelon when effective 10/01/2025

Percutaneous allogeneic cellular/tissue intervertebral disc injection codes (0627T–0630T) are added and managed by Carelon with an effective date of 10/01/2025; Carelon prior authorization processes will apply when these codes are effective.

Multiple listed codes — Managed By = Carelon (follow Carelon processes)

Codes listed in various imaging and procedural sections are identified as 'Managed By = Carelon', indicating management (including prior authorization) is delegated to Carelon for those service codes.

27412 — Prior authorization required through Carelon

Prior authorization is required through Carelon for CPT 27412 (Autologous Chondrocyte Implantation, Knee); the entry explicitly notes prior authorization required through Carelon.

File is searchable by code or description

This file is a searchable PDF; providers can search by procedure code or description to identify whether a given service requires prior authorization.

Document site-of-care on authorization requests (effective 01/01/2025)

Medical necessity determinations for the listed codes now include site-of-care as a required criterion effective 01/01/2025; providers should document site-of-care when requesting authorization.

Submit authorization/claims using the exact listed procedure code and follow 'Managed By' routing

Providers must submit claims and authorization requests using the exact procedure codes shown in the list; utilization management for these codes is managed by the entity shown in each 'Managed By' field (e.g., Carelon).

Provide supportive clinical documentation that matches the billed code

Documentation should support the specific CPT/HCPCS/PLA code billed; code descriptions in the file indicate required procedure/test details that must be reflected in the clinical record or order.

Use the code-level 'Managed By' designation to determine authorization manager

Each listed code entry includes a 'Managed By' assignment (predominantly 'Managed By = Carelon'); providers should follow the designated manager's utilization management procedures for authorization and appeals.

Ensure panel composition meets code-specific minimum gene list

CPT entries for genomic sequence analysis panels specify minimum required gene content for certain panels (examples: 81410 requires sequencing of at least 9 named genes; 81430 requires at least 60 genes; 81440 requires at least 100 genes) and providers must ensure panel composition meets the code-specific requirements.

'Managed By = Carelon' noted on each code — follow Carelon procedures

Each molecular genetic code entry includes a short description and a 'Managed By = Carelon' designation; providers should follow Carelon's utilization management and authorization procedures for these tests.

Document specimen type and report expectations on the order

Tests list specimen types and expected report formats (e.g., plasma, whole blood, saliva, FFPE tissue, per-embryo reporting for 0553U–0555U); providers should document specimen type on orders and in the clinical record.

Follow Carelon's authorization procedures and respect effective/retire dates

Providers should follow Carelon's utilization management procedures as indicated by the 'Managed By = Carelon' designation for listed codes and ensure coding aligns with effective and retire dates shown in the file.

PA may be required for advanced imaging codes (01/01/2025)

Prior authorization may be required for the listed advanced imaging/radiology procedure codes effective 01/01/2025; failure to obtain prior authorization when required may trigger claim denial or coverage delay.

Denial risk if site-of-care not documented

Claims or authorizations for the listed advanced imaging CPT codes may be denied or require review if medical necessity criteria (which now include site-of-care) are not met; document site-of-care to reduce denial risk.

• Site-of-care must be included in medical necessity documentation (effective 01/01/2025).

Carelon-managed codes — risk of denial without Carelon authorization

Claims for the listed procedure codes may be subject to utilization management by Carelon and could be denied if not authorized or managed per Carelon processes.

Managed-by designation affects authorization and denial risk

Claims for codes listed as 'Managed By = Carelon' or 'Managed By = BCBSOK' may be subject to that manager's utilization management rules; failure to comply with the assigned manager's requirements may trigger denial.

Route authorizations correctly — misrouting to BCBSOK vs Carelon may cause denial

Tests or codes delegated to Carelon but routed incorrectly (not submitted to Carelon) could result in denial if prior authorization/management was required but not obtained.

Molecular genetic tests — potential denial without Carelon authorization

Claims for the listed molecular genetic CPT codes and U-codes may be managed by Carelon; lack of authorization or failure to follow Carelon processes could trigger claim denial.

Retired codes — risk of different handling after retire dates

Codes marked 'Retire Effective' (examples: codes with retirement dates such as 92633 retire effective 01/01/2025 or select U-codes retired 04/01/2025 or 07/01/2025) may be handled differently after retirement dates and could affect coverage/authorization.

• 92633 — Retire Effective 01/01/2025
• 0456U — Retire Effective 04/01/2025
• 0078U — Retire Effective 07/01/2025

Carelon utilization management may deny services not meeting review criteria

Services billed with the listed codes are managed by Carelon; claims or requests for listed molecular genetic tests may be subject to Carelon utilization management review and potentially denied if not meeting that reviewer’s policies.

UM oversight and code effective/retire dates affect adjudication

Claims for the listed molecular genetic tests may be subject to utilization management oversight by Carelon; codes marked as 'Retire' or with future effective dates may affect claim adjudication if billed outside effective periods.

MRI/CT/CTA/MRA — PA may be required via Carelon (effective 01/01/2025)

Prior authorization may be required for listed MRI/CT/CTA/MRA CPT codes effective 01/01/2025 and these are managed by Carelon; obtain authorization from Carelon when indicated.

Advanced imaging — Carelon evaluates medical necessity including site-of-care

Advanced imaging CPTs shown in the list are managed by Carelon and medical necessity evaluation for these codes includes site-of-care as a review element.

Multiple imaging modalities — Carelon-managed PA

Multiple listed modalities (CT, MRI, MRA, PET, nuclear medicine, echocardiography) are indicated as prior authorization/managed by Carelon; follow Carelon processes for authorization.

PET/echo/PLA testing — follow assigned manager for PA

For PET, echocardiography, and PLA molecular testing entries, prior authorization/management is assigned to the entity shown for each code; submit requests to that manager (often Carelon).

Molecular genetic lab tests — submit PA to 'Managed By' entity (Carelon)

For molecular genetic laboratory testing codes (81400 series and others) the file directs providers to submit authorization/management requests to the entity listed in 'Managed By' (predominantly Carelon).

81400-series molecular pathology codes — managed by Carelon (PA implied)

Molecular genetic CPT codes in the 81400 series are labeled 'Managed By = Carelon' indicating administrative/authorization review is implied for many entries in that series.

Molecular genetic lab testing — Carelon management and PA processes implied

Management by Carelon is indicated for many molecular genetic lab testing codes, implying administrative/prior authorization processes apply; providers should follow Carelon rules.

U-codes — Carelon manages utilization and PA

Listed U-codes for molecular genetic testing are managed by Carelon; utilization management applies and providers should follow Carelon prior authorization procedures.

Molecular genetic tests (various) — PA via Carelon

Various molecular genetic tests and U-codes across the document are managed by Carelon; providers should submit authorization requests to Carelon per the 'Managed By' field.

0627T–0630T — PA required via Carelon when effective 10/01/2025

Percutaneous allogeneic intervertebral disc injection codes 0627T–0630T will require prior authorization when they become effective on 10/01/2025 and are managed by Carelon.

Carelon manages listed codes — follow Carelon for PA thresholds

Codes listed are managed by Carelon (delegated); the excerpt does not provide numeric PA thresholds — follow Carelon's authorization rules for specifics.

Contrast status indicated per CPT (with/without/followed by contrast)

Code descriptions indicate contrast status (with/without/followed by contrast) for many CPTs; prior authorization applicability is listed per CPT code and reflects the code's contrast variant.

Use the exact CPT variant that reflects contrast technique

Codes include both contrast and non-contrast variants and sequences (non-contrast followed by contrast); providers must use the exact CPT that matches the contrast technique performed when requesting authorization.

Bill the specific contrast variant code (C-/T- variants) shown in the file

Multiple T- and C-codes specify 'with' or 'without' contrast variants and post-processing; these are listed separately and managed by Carelon — billers and providers must select the correct code for authorization and claims.

93352 — use this code when echocardiographic contrast agent is administered (managed by Carelon)

Use of echocardiographic contrast agent during stress echocardiography is represented by code 93352 (listed as 'Use Of Echocardiographic Contrast Agent During Stress Echocardiography') and is managed by Carelon; submit authorization/claims using that code when contrast agent is used.