Obtain prior authorization when required

Services listed in this file are associated with CPT/HCPCS codes for which prior authorization may be required as of January 1, 2025; providers must obtain prior authorization where required prior to rendering services.

Follow Carelon prior-auth process and document site-of-care

Prior authorization and utilization management for the listed CPT codes are managed by Carelon; medical necessity criteria were updated to add site-of-care effective 01/01/2025 — include site-of-care information in requests and follow Carelon processes.

Submit authorization to assigned manager

Listed procedure, supply and molecular/genetic codes are assigned to a manager (Carelon or BCBSOK); submit prior authorization requests to the manager shown for each code and obtain approval before service.

Obtain Carelon authorization for Carelon-managed molecular tests

The HCPCS U‑codes and molecular test entries identified as 'Managed By = Carelon' require prior authorization per Carelon's utilization management process; providers must follow Carelon's authorization procedures when ordering these molecular tests.

Route prior-authorization requests to Carelon

Many CPT codes in the list are marked 'Managed By = Carelon' — prior authorization or utilization management requests for those CPT codes should be routed to Carelon.

Carelon prior authorization for CPT 81307–81405

The molecular genetic CPT codes in the 81307–81405 range are designated 'Managed By = Carelon' and are subject to the payer's utilization management — obtain prior authorization from Carelon for these molecular genetics procedures.

Carelon manages prior authorization for listed surgical/procedural CPTs

Surgical and procedural CPT codes listed under musculoskeletal/spine categories (examples in the document) are managed by Carelon; prior authorization is required through Carelon per the management assignment.

CPT 27412 requires Carelon prior authorization

Certain individual CPTs explicitly require prior authorization through Carelon; for example, CPT 27412 (Autologous Chondrocyte Implantation Knee) requires prior authorization through Carelon.

Reference manager-specific (Carelon) medical necessity criteria

Codes that list a managing organization include an 'Updates' note adding site-of-care to medical necessity; providers should reference the manager-specific (Carelon) medical necessity criteria when preparing authorization requests.

Reference exact procedure code and service category on requests

Claims and authorization submissions must reference the exact procedure code and service category as listed in the document to ensure routing to the correct manager and proper review.

Document specific molecular CPT or U‑code and follow Carelon UM

When submitting authorization or claims for molecular tests or U‑codes, document the specific CPT or U‑code being ordered and follow Carelon's utilization management documentation requirements for that code.

Use correct code effective dates and follow Carelon management

Submit claims and prior-authorization requests using the correct code effective date; many new U‑codes and T‑codes have specific add/effective dates (e.g., U‑codes effective 10/01/2025, 81195 effective 04/01/2025) and are managed by Carelon.

Obtain authorization for advanced imaging effective 01/01/2025

Effective 01/01/2025, prior authorization may be required for advanced imaging (CT, MRI, CTA, MRA) codes listed in this document; specific authorization requirements and site-of-care considerations are determined by Carelon.

Carelon-managed advanced imaging — follow Carelon UM

Advanced imaging CPTs in the list are managed by Carelon; prior authorization and utilization management apply per Carelon processes and the updated site-of-care medical necessity criteria.

Obtain Carelon authorization for listed molecular genetic U‑codes

The listed molecular genetic U‑codes and PLA codes are managed by Carelon; providers must obtain authorization/management through Carelon when ordering these lab-based molecular genetic tests.

Carelon-managed molecular genetic CPTs require authorization

All listed CPT molecular genetic test codes (CPT 81307–81405) and related entries are managed by Carelon; obtain prior authorization and follow Carelon's utilization management procedures for these laboratory services.

Carelon manages 0627T–0630T (effective 10/01/2025) — obtain authorization

Interventional spine codes 0627T–0630T for percutaneous allogeneic disc injection are managed by Carelon with an add-effective date of 10/01/2025; follow Carelon authorization processes when these services are billed on or after that date.

Route surgical/procedural prior-auth to Carelon

Surgical and procedural CPT-coded interventions listed in the document are routed to Carelon for utilization management; submit prior authorization to Carelon as indicated for the specific procedure codes.

Follow Carelon UM for molecular/genetic lab testing

The molecular/genetic lab testing entries and U‑codes in this document are designated 'Managed By = Carelon'; providers must follow Carelon's utilization management and prior-authorization processes for those tests.

Code according to performed contrast sequence

Many CPT codes are provided in 'with' and 'without' contrast variants (or 'without followed by with'); code and bill according to the sequences actually performed and use the contrast-specific CPT variant when appropriate.

Select contrast-specific CPT code that matches performed sequences

Where CPT descriptors include 'without contrast', 'with contrast', or 'without followed by with contrast', select the correct CPT code that matches the contrast sequences performed for the study.

Bill the CPT/HCPCS variant matching the 'without followed by with' sequence

Examples in the list show codes with 'without followed by with contrast' sequences (e.g., 0635T/0638T and C8901→C8902 patterns); bill the CPT/HCPCS code variant that reflects the actual imaging sequence.

Report echocardiographic contrast (CPT 93352) separately and follow Carelon

Use of an echocardiographic contrast agent (CPT 93352) is listed as separately reportable and is managed by Carelon; submit authorization/documentation to the managing entity as required.