2025 Commercial Prior Authorization Codes for Administrative Services
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Governs the list of CPT/HCPCS codes and associated administrative prior authorization requirements and management contacts for commercial members (including TDI-identified fully insured members) effective 01/01/2025. Affects providers submitting prior auth requests and internal utilization management teams.
Addition of site of care to the medical necessity criteria for numerous advanced imaging CPT codes, effective 01/01/2025.
Update Category name from "Non-Emergent Air Ambulance" to "Medical Transportation" effective 01/01/2025 and services management changed from BCBSTX to Alacura for certain ambulance codes.
Multiple molecular genetic lab testing codes (0552U - 0571U and many 8xxxx series) were added with Carelon as manager and effective dates (most 10/01/2025 or 04/01/2025).
Coverage, Medical Necessity and Prior Authorization Criteria
Coverage and prior authorization guidance (partial)
Presence of a code on this list does not necessarily indicate coverage; member benefits determine coverage. Prior authorization may be required for listed services.
Prior authorization + site-of-care medical necessity requirement
Prior authorization and medical necessity determinations for listed CPT codes now require consideration of site of care (effective 01/01/2025).
Designated prior authorization vendor for many listed codes is Carelon; follow the payer's submission process.
Prior authorization requirement for listed CPT codes
Provider must obtain prior authorization from the designated reviewer before scheduling or performing the services listed below.
Consult the full code list and vendor mapping for code-level routing information.
Prior authorization code groups
Grouped code sets and their designated prior-authorization managers as shown in the excerpt.
Vendor indicated for many entries: Carelon.
Home infusion prior authorization and billing notes
Home infusion services require prior authorization and have specific billing/per‑diem or hourly rules.
Per-diem codes (e.g., S9325, S9373, S9494) are billed per day as specified; S9810 is per hour and should not be used with per‑diem codes. Do not combine per‑diem codes when guidance prohibits it (see code-specific notes). Vendor mapping: BCBSTX for many home infusion entries.
Medical transportation management change
Category and management changes for certain medical transportation codes effective 01/01/2025.
Prior authorization/process for these codes may now be handled by Alacura (call center information provided in the source).
Molecular genetic testing prior authorization and management
Numerous molecular genetic U-codes and 8xxxx series codes require prior authorization and have vendor/administrative assignments and effective dates.
Several U-codes show 'Add effective' dates (primarily 10/01/2025) and select 8xxxx codes include effective dates; verify code-specific effective/retire dates before submission.
Prior authorization – molecular genetic testing
Gene-specific molecular CPT codes and mappings that require prior authorization; vendor indicated where provided.
See the full code list for detailed gene/test mappings and specimen/methodology information.
Prior authorization required codes
Specific molecular genetic CPT codes require prior authorization and are associated with gene/test descriptions.
Providers must request prior authorization for these CPTs prior to performing or billing services.
Prior authorization and procedure-level mapping
Molecular pathology procedure-level mapping and prior authorization requirement.
Carelon is referenced as the prior-authorization administrator for multiple CPTs in this segment; follow payer-specified submission processes.
Use the procedure-level thresholds provided in the policy when submitting authorizations and coding claims.
Prior authorization requirements for molecular genetic testing
Prior authorization requirements for listed molecular genetic and gene‑expression CPT codes; panel composition requirements when applicable.
Duplication/deletion panels must include named genes when specified (examples: BRCA1/2, MLH1/MSH2, etc.).
Operational notes
- Carelon is the named authorization entity for many codes — route prior authorization requests to Carelon where indicated.
- Some codes are marked for retirement or have add-effective dates (verify effective/retire dates prior to submission).
Prior Authorization Criteria - code list
Representative molecular genetic and gene-expression tests requiring prior authorization; many entries include methodology and reporting format.
Entries commonly include the clinical area (oncology, transplant, cardiology, etc.), assay method (RT-PCR, NGS, microarray) and reporting format (recurrence score, categorical risk, percent donor-derived cfDNA).
Prior authorization list
Enumerated U-codes and PLA-style molecular genetic test codes that require prior authorization.
Clinical indications and specimen types vary by code; consult the code-specific entry for clinical context and effective/add dates.
Prior authorization requirement
Tests listed in this segment require prior authorization through Carelon.
Code retirement notices
Certain PLA/U codes have scheduled retirement actions noted in the policy.
Verify current code applicability and effective/retire dates prior to submission or billing.
Prior authorization requirements and administrative notes
Administrative notes and vendor assignments for molecular genetic tests; check code‑level effective/retire dates.
Authorization-required codes (partial list)
Partial list of authorization-required codes with examples and vendor routing.
Specific clinical criteria are code-dependent; consult the detailed entry for the code for clinical and effective-date guidance.
Prior authorization list (excerpt)
Musculoskeletal and spine procedure codes require prior authorization and are assigned to the designated reviewer.
When additional interspaces or segments are performed, list each additional interspace/segment separately as instructed in the policy.
Procedure and Billing Codes (CPT / HCPCS / U / PLA) Requiring Prior Authorization
| 73206 | Computed Tomographic Angiography Upper Extremity With Contrast Material (includes noncontrast images if performed) and related MRI/CT upper extremity codes referenced |
| 73218 | Magnetic Resonance Imaging Upper Extremity Other Than Joint; Without Contrast |
| 73219 | Magnetic Resonance Imaging Upper Extremity Other Than Joint; With Contrast |
| 73220 | Magnetic Resonance Imaging Upper Extremity Other Than Joint; Without Contrast Followed By Contrast |
| 73701 | Computed Tomography Lower Extremity; With Contrast |
| 74160 | Computed Tomography Abdomen (various variants) / related abdomen CT/MR codes |
| 75571 | Computed Tomography Heart Without Contrast (coronary calcium) |
| 76376 | Rendering with interpretation and reporting with image postprocessing (CT/MR/US) |
| 77046 | Magnetic Resonance Imaging Breast Without Contrast; Unilateral |
| 78430 | Myocardial Imaging PET Perfusion Study (single study) with CT transmission |
| 78266 | Multiple Days (radiopharmaceutical imaging) |
| 78278 | Acute Gastrointestinal Blood Loss Imaging |
| 78290 | Intestine Imaging (Eg Meckel's localization) |
| 78291 | Peritoneal-Venous Shunt Patency Test |
| 78300 | Bone and/or Joint Imaging; Limited Area |
| 78305 | Bone and/or Joint Imaging; Multiple Areas |
| 78306 | Bone and/or Joint Imaging; Whole Body |
| 78315 | Bone and/or Joint Imaging; 3 Phase Study |
| 78429 | Myocardial PET metabolic evaluation with CT transmission scan |
| 78430 | Myocardial PET perfusion single study with CT |
| 93350-93352 | Transthoracic echocardiography with stress and contrast (various) |
| 0042T | Cerebral perfusion analysis using CT with contrast |
| 0633T-0638T | Computed tomography breast codes (unilateral/bilateral; with/without contrast) |
| S9211 | Home Infusion Therapy; electronic analysis of implanted neurostimulator pulse generator system / home management entries |
| S9213 | Home Infusion Therapy; home management of postpartum/gestational hypertension/ preeclampsia entries |
| S9325 | Home infusion therapy management; administrative services per diem |
| S9373 | Home infusion therapy; hydration therapy per diem |
| S9494 | Home infusion therapy; antibiotic/antiviral/antifungal per diem |
| S9810 | Home therapy; professional pharmacy services per hour (not per diem) |
| 0552U | Reproductive medicine preimplantation genetic assessment — analysis for known genetic disorders from trophectoderm biopsy |
| 0553U | Preimplantation genetic assessment; 24 chromosome analysis |
| 0560U | Oncology MRD genomic sequence analysis baseline assessment |
| 0571U | Oncology (solid tumor); DNA and RNA panel by NGS, plasma |
| 81120 | IDH1 common variants |
| 81162 | BRCA1/BRCA2 full sequence and duplication/deletion analysis |
| 81170 | ABL1 kinase domain variant analysis |
| 81203-81292 | Molecular genetic laboratory testing codes mapping to specific gene analyses (gene-specific tests and variants listed across entries) |
| 81285-81400+ | Wide range of molecular genetic and molecular pathology CPT codes listed (examples include 81285-81364, 81400 and many others) as requiring prior authorization. |
| 81400 | Molecular genetic lab testing / molecular pathology procedure level (single variant identification examples listed) |
| 81401 | Molecular pathology procedure level 2 (2–10 SNPs, methylation or somatic variant detection examples) |
| 81402 | Molecular pathology procedure level 3 (>10 SNPs, immunoglobulin/T-cell receptor rearrangements, LOH/UPD) |
| 81403 | Molecular pathology procedure level 4 (single exon sequencing, >10 amplicons, mutation scanning) |
| 81404 | Molecular pathology procedure level 5 (analysis of 2–5 exons by DNA sequence analysis) |
| 81405 | Molecular pathology procedure level 6 (analysis of 6–10 exons; regionally targeted cytogenomic analysis) |
| 81406 | Molecular pathology procedure level 7 (analysis of 11–25 exons by DNA sequence analysis) |
| 81407 | Molecular pathology procedure level 8 (analysis of 26–50 exons or >50 exons / large panels) |
| 81410 | Molecular pathology procedure (exons in single gene by DNA sequence analysis / full gene sequencing) |
| 81410 | Molecular genetic lab testing / full gene and sequence analyses (examples listed) |
| 81415 | Exome sequence analysis |
| 81430 | Hearing loss panel (≥60 genes) |
| 81432 | Hereditary breast cancer-related disorders panel (≥10 genes including BRCA1/2) |
| 81518 | Oncology (breast) mRNA gene expression profiling, 11 genes |
| 81540 | Oncology tumor of unknown origin mRNA profiling, 92 genes |
| 81522 | Gene expression profiling by RT-PCR of 12 genes reported as recurrence risk score |
| 81523 | mRNA NGS gene expression profiling of 70 content genes reported as index related to risk to distant metastasis |
| 81525 | mRNA gene expression profiling by real-time RT-PCR of 12 genes (colon) reported as a recurrence score |
| 81529 | mRNA gene expression profiling by real-time RT-PCR of 31 genes (cutaneous melanoma) reported as recurrence risk including likelihood of sentinel lymph node metastasis |
| J0266U | Molecular genetic lab testing — unexplained constitutional or other heritable disorders; tissue-specific gene expression by whole-transcriptome and NGS |
| 0267U | Molecular genetic lab testing — identification of structural variants by optical genome mapping and whole genome sequencing |
| 0306U | Oncology MRD NGS targeted sequencing analysis cell-free DNA initial assessment |
| 0326U | Targeted genomic sequence analysis panel (83+ genes) for solid organ neoplasm |
| 0380U | Listed as 'Retire Effective 04/01/2025' |
| 0396U | Listed as 'Retire Effective 07/01/2025' |
| 0392U | Gene-drug interactions variant analysis of 16 genes including CYP2D6 deletion/duplication |
| 0396U | Repeat expansion variant analysis; various genomic testing descriptions (Retire Effective 07/01/2025 indicated) |
| 0401U | Expanded carrier screening / cardiology genetic risk score (9 genes) and other assays |
| 0411U | Genomic analysis panel (15 genes) for psychiatry including CYP2D6 |
| 0449U | Carrier screening panel must include CFTR, SMN1, HBB, HBA1, HBA2 |
| J0428U | Circulating tumor DNA targeted hybrid-capture panel (56+ genes) - Carelon; marked retire 04/01/2025 |
| 0489U | Noninvasive prenatal fetal antigen and single-gene NIPT; 'Add effective 07/01/2025' noted |
| 0497U | Gene-expression profiling by RT-PCR for prostate cancer (6 genes) reported as risk score |
| 0498U | Cell-free DNA fetal antigen noninvasive prenatal test; detection of fetal antigens (Rh, C, D, E, Duffy, Kell) |
| 0500U | UBA1 gene mutation targeted variant analysis (VEXAS) |
| 0538U | NGS targeted sequencing of 600 genes for solid tumors |
| 22515 | Percutaneous vertebral augmentation (e.g., kyphoplasty) |
| 22532 | Arthrodesis lateral extracavitary technique; thoracic |
| 22533 | Arthrodesis lateral extracavitary technique; lumbar |
| 22600 | Arthrodesis posterior or posterolateral technique; single interspace; cervical below C2 |
| 22856 | Total disc arthroplasty, cervical, single interspace |
| 27130 | Total hip arthroplasty |
How Providers Request Authorization and Operational Notes
Prior Authorization Required for Listed Imaging and Cardiology CPT Codes (Carelon)
Prior authorization is required for the imaging and cardiology CPT codes listed in this section. These requests are managed by Carelon (Carelon Clinical Review). Submit prior authorization requests through the payer’s designated portals (Blue ApprovrSM), by phone using the number on the member ID card, or via the vendor-specific instructions. Effective 2025-01-01, site-of-care additions and vendor assignments (Carelon) apply to listed advanced imaging and cardiology codes.
- Managed by Carelon (vendor) for advanced imaging and cardiology CPTs
- Request methods: Blue ApprovrSM portal, phone (member ID card), or vendor portal as directed
- Effective date: 2025-01-01 (site-of-care criteria additions)
Prior Authorization for Echocardiography and Doppler Procedures
Transthoracic, transesophageal, and Doppler echocardiography codes require prior authorization and are managed by Carelon. This includes complete, limited, congenital, stress, and Doppler add-on studies. Ensure authorization is obtained before scheduling.
Echocardiography and Advanced Imaging Prior Authorization
Echocardiography and advanced imaging studies (CT, MRI, PET and related procedures) listed in this section require prior authorization through Carelon. Site-of-care criteria updates effective 2025-01-01 may affect medical necessity determinations. Obtain authorization prior to service to avoid denials.
- Advanced imaging categories: CT, MRI, PET, related add-on and modality-specific CPTs
- Carelon is the managing vendor for listed advanced imaging CPTs
- Site-of-care criteria added effective 2025-01-01
ENT / Cochlear / Rhinoplasty Prior Authorization
ENT procedures including rhinoplasty codes, cochlear implant procedures, osseointegrated implant codes, and related ENT surgical/endoscopic procedures require prior authorization. Many of these services are managed directly by BCBSTX for ENT-specific items; check the listed assignments and obtain prior authorization before scheduling.
Gastroenterology / Home Infusion / Neurostimulator Prior Authorization
Gastroenterology services, home infusion therapy per-diem codes, and implanted neurostimulator/neuromodulation device services require prior authorization. Home infusion management and certain neurostimulator services are managed by BCBSTX; specific codes may have vendor assignments as listed.
- Gastroenterology and neurostimulator examples: E0765 (gastric neurostimulator intraoperative programming)
- Home infusion per-diem codes: S5501, S5502, S9208, S9209, S9211, S9213, S9214, S9325 (BCBSTX-managed)
- Obtain prior authorization before initiating home infusion or implanted neurostimulator procedures
Prior Authorization Required for Listed Molecular Pathology and Genetic Tests
A broad list of molecular pathology and molecular genetic CPTs and proprietary test codes require prior authorization and are routed to Carelon for review. This includes single-gene tests, multi-gene panels, genomic sequencing assays, transplant monitoring assays, oncology panels, and many newer U- and number-series codes. Verify vendor routing and obtain authorization prior to ordering or specimen submission.
- Molecular pathology/molecular genetic examples include many CPTs in the 812xx–814xx and 815xx ranges and U-codes (e.g., 0114U, 0129U, 0552U–0555U, 0560U–0561U)
- Transplant and cardiology molecular tests (e.g., 81558, 81595) are included and managed by Carelon
- New and retiring codes and effective-date changes are noted in the listing—check the code list for specifics and effective dates
Molecular/Genetic Tests Requiring Prior Authorization (Examples)
Representative molecular/genetic tests requiring prior authorization include hereditary disease gene analyses, oncology next-generation sequencing panels, donor-derived cell-free DNA transplant monitoring assays, and preimplantation genetic testing panels. Carelon manages prior authorization for these tests—confirm code-level requirements and effective dates in the list.
Transplant / Cardiology Molecular Tests Prior Authorization
Test types used in transplantation or cardiology monitoring (for example, gene expression and cell-free DNA assays used to assess rejection risk) require prior authorization and are managed by Carelon. Some transplant and cardiology assays have specific added effective dates — confirm prior to ordering.
Prior Authorization Requirement and Vendor / Routing Notes
Operational notes: many prior authorization requests for imaging, cardiology, and molecular/genetic tests are routed to Carelon. Some services remain managed by BCBSTX or were reassigned to Alacura (e.g., medical transportation). Always confirm the current managing vendor and use the appropriate prior authorization portal or phone number. Failing to obtain authorization from the correct vendor may result in claim denials.
- Carelon is the primary vendor for advanced imaging, cardiology, and molecular/genetic prior authorizations in this list
- Alacura manages certain medical transportation codes (e.g., A0430, A0435, S9960)
- BCBSTX manages some ENT, cochlear, and home infusion codes—see listing for assignments
- Confirm vendor and effective dates before submitting prior authorization requests
Definitions and Vendor / Term References
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