This document is an administrative prior authorization list of CPT and HCPCS procedure codes for which prior authorization or utilization management may be required for Blue Cross and Blue Shield of Oklahoma networks; it is not a clinical guideline. Examples of affected networks are listed in the source. Providers should consult the payer website for full medical policy details.

The excerpt does not enumerate explicit clinical exclusions. Instead, many entries are presented as a managed-code roster (each line showing a code and a "Managed By" assignment). Where present, operational updates (for example the addition of site-of-care to medical necessity criteria effective 01/01/2025) change how requests are evaluated rather than providing standalone exclusion clauses.

The listing shows individual codes annotated with status updates. For example, procedure code 92633 is documented in the file as "Retire Effective 01/01/2025," indicating it will be removed from the active managed list on that date and should not be relied on for future authorization workflows after retirement.

Many entries in the code lists include a Managed By = Carelon field. Across imaging and molecular/genetic sections, codes marked "Managed By = Carelon" indicate that Carelon is the utilization manager and the provider must follow Carelon's prior authorization and medical necessity processes for those services.

Several test codes include scheduled retirements noted in the listing. Examples in the molecular/genetic section include 0078U — Retire Effective 07/01/2025 and multiple PLA/U entries marked "Retire Effective 04/01/2025"; other codes show planned add/retirement effective dates in 2025. Providers should not order or bill retired codes after their retire date and should confirm current code status with Carelon or the payer.

Within the excerpt there are no explicit standalone exclusion conditions (e.g., lists of specific non-covered clinical scenarios). Instead, the file functions as a managed-code index: services are subject to utilization management and coverage is contingent on meeting the payer/Carelon medical necessity criteria (including updated site-of-care requirements where noted).

The entry for code 0078U (a pain-management pharmacogenomic genotyping panel) is annotated "Retire Effective 07/01/2025," which indicates that this proprietary panel will be removed from the active managed-code list on that date and may no longer be available for prior authorization or claims processing thereafter.

Several PLA/U and U-code entries in the molecular/genetic sections are annotated with retirement or effective-date notes (for example, codes shown as "Retire Effective 04/01/2025" or entries with "Add effective" dates in 2025). The file therefore includes a mix of active managed tests and codes with scheduled retire/add effective dates; review the specific code lines for exact retire/add dates.

Entries in this document are primarily presented as code listings with administrative fields (code, service category, code description, and a "Managed By" assignment). The excerpt does not contain detailed stepwise coverage logic for each entry; instead it functions as an index indicating which codes are subject to utilization management and which vendor (e.g., Carelon) manages the process.

Where a code is designated "Managed By = Carelon" the listing implies utilization management oversight by Carelon. This managed-by flag appears across advanced imaging, cardiac imaging, molecular genetic, and other service categories and signals that prior authorization and medical necessity review are processed through Carelon for those codes.

The administrative sections include device and HCPCS/HCPCS-L (L-, S-, G-, etc.) codes in addition to CPT procedure codes. Examples include hearing device HCPCS codes (e.g., L8619) and spine/musculoskeletal CPT codes (e.g., 22844–22849) that are listed for utilization management assignment.

The excerpt does not include explicit "not medically necessary" statements tied to specific clinical conditions. Rather, it documents that coverage and authorization are contingent on meeting the payer's medical necessity criteria as managed by Carelon; failure to meet those criteria (including updated site-of-care requirements) can result in denial.

No direct, standalone statements labeled "not medically necessary" are provided in the excerpt. The file instead lists codes under utilization management and notes operational updates (such as code retirements), so determinations about medical necessity must be made against the Carelon-managed criteria referenced in each code entry.

The document identifies G0219 (PET imaging whole body; melanoma) in the not-covered context within the excerpt, noting this code is associated with whole-body PET imaging for melanoma under non-covered indications. Providers should confirm clinical appropriateness and payer coverage rules before ordering.

Background: this file is an administrative utilization management roster that identifies advanced imaging and related CPT/HCPCS codes that may require prior authorization for BCBSOK networks. It is intended to direct providers to the appropriate utilization manager (for many codes, Carelon) and to note operational updates (code additions, retirements, and the effective inclusion of site-of-care in medical necessity criteria). Clinical medical policy details remain available on the BCBSOK Medical Policy Website.