DraftBlue Cross Blue Shield - TexasPolicy N/A
2026 Commercial Prior Authorization Codes for Administrative Services Only
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List of CPT/HCPCS codes and service categories for which prior authorization may be required for Blue Cross Blue Shield of Texas commercial administrative services; intended for providers and administrative staff who submit prior authorization requests.
Policy Summary
PayerBlue Cross Blue Shield - Texas
Policy2026 Commercial Prior Authorization Codes for Administrative Services Only
Policy CodePolicy N/A
Change TypeMinor / informational update
Effective DateN/A
Next Review DateN/A
Key ActionInitiate prior authorization via the searchable PDF (CTRL+F), Blue ApprovrSM, or the prior authorization number on the member's ID card; use vendor contacts (Carelon, Alacura) as indicated per code.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
dozens+codes enumerated
Carelonprimary PA vendor
20+code groups shown
multiplehome infusion codes
Coverage and Authorization Requirements
Coverage and authorization guidance
Prior authorization may be required for the listed services; check member benefits for coverage and follow vendor routing for authorization.
Prior authorization may be required for the CPT/HCPCS codes listed in this document; presence on the list does not guarantee coverage — confirm member benefits before providing service.
Prior authorization requirement (codes listed)
Codes listed are identified as requiring prior authorization and mapped to Carelon and service category.
Provider must obtain prior authorization for the CPT codes shown where the 'Carelon' designation is listed as the managing/authorization entity before performing the service.
Prior authorization requirement — code list
Codes listed require prior authorization via the named vendor (Carelon).
All CPT/HCPCS codes in the molecular and advanced imaging sections that indicate 'Carelon' require submission of a prior authorization request to Carelon as specified in the list.
Prior authorization requirements by code
Codes listed require prior authorization; the assigned authorization vendor is indicated per code.
Examples
- Code 93313 — prior authorization required; auth entity: Carelon.
- Code 95965 — prior authorization required; auth entity: Carelon; effective date noted (Add effective 1/1/2026).
- Code 36516 — prior authorization required; auth entity: BCBSTX.
- Code B4150 — prior authorization required when billed for home infusion/enteral formula; auth entity: BCBSTX.
Prior authorization requirement — code list (home infusion/enteral/parenteral)
This section enumerates codes that require prior authorization when billed for home infusion therapy, enteral or parenteral nutrition, pumps, supplies, and home infusion per diem services.
HCPCS S-codes and B-codes listed for home infusion, enteral formulas, parenteral nutrition premixes, infusion pumps, and related per-diem services require prior authorization as indicated; many entries show BCBSTX as the authorization manager for these home infusion/enteral/parenteral services.
Codes requiring prior authorization and vendor assignments (excerpt)
The listed HCPCS/CPT codes in these chunks are identified as requiring prior authorization and are mapped to internal assignments/vendors where specified.
Molecular genetic CPT codes (example range 81120–81187 and related entries) listed in this section require prior authorization and are routed to Carelon for review as indicated.
Prior authorization list (excerpt)
Listed tests require prior authorization through Carelon; entries map code to gene/test type (e.g., full sequence, known familial variant, common variants, expanded allele evaluation). No clinical eligibility criteria included in this excerpt.
Molecular genetic test codes shown (examples: 81180–81187, 81229, 81230, etc.) require prior authorization and identify Carelon as the reviewer/authorization vendor; each code is mapped to specific gene/test descriptions (full sequence, known familial variant, duplication/deletion analysis, promoter methylation, MSI, etc.).
Authorization requirements for listed CPT codes
Codes listed in this section require prior authorization; many entries indicate Carelon as the reviewer.
Selected molecular CPT codes (e.g., 81254–81261, 81319–81328) are listed as requiring prior authorization; Carelon is identified adjacent to numerous codes as the authorization/review entity.
Coverage stance for listed molecular genetic tests
Prior authorization required for the following molecular genetic and molecular pathology CPT codes and associated analyses through Carelon.
Molecular pathology procedure level codes (81400–81405) and higher-level genomic panel codes listed require prior authorization via Carelon as indicated in the list.
Coverage criteria by panel/code
Coverage requires that condition-specific genomic panels include the listed minimum genes and analyses; panels are mapped to clinical indications (examples):
81410 — Aortic dysfunction/dilation genomic sequence analysis panels must include sequencing of at least 9 genes (including FBN1, TGFBR1, TGFBR2, COL3A1, MYH11, ACTA2, SLC2A10, SMAD3, MYLK); prior authorization routed to Carelon.
81440 — Nuclear-encoded mitochondrial gene panels must include analysis of at least ~100 genes (examples listed) and require prior authorization via Carelon.
Prior authorization requirement for listed molecular/genetic tests
Listed molecular/genetic CPT and PLA codes require prior authorization and are routed to Carelon for review.
Prior authorization is required for the molecular/genetic CPT and PLA codes listed (examples include 81450–81459 panels and related PLA/U-codes); submit prior authorization requests to Carelon for review as indicated.
Prior authorization requirement for listed molecular/genetic tests
Codes and test descriptions requiring prior authorization
Prior authorization list (no detailed criteria in this excerpt)
This section enumerates molecular/genetic lab tests that require prior authorization and indicates Carelon as reviewer. Specific clinical coverage criteria are not detailed in this excerpt.
U-code and molecular genetic test listings in this segment (e.g., 0170U, 0171U, 0203U, 0205U, 0244U, 0253U, etc.) require prior authorization as noted; Carelon is named repeatedly as the reviewer, and the list includes tests across oncology, neurology, psychiatry, reproductive medicine and other specialties.
Prior authorization listing (segment 234-253)
Codes listed require prior authorization via Carelon. Specific clinical criteria, medical necessity, or coverage determinations are not provided in this excerpt.
All U-codes and specified molecular genetic tests in this segment (e.g., 0286U–0410U examples shown) require prior authorization through Carelon; the entries map each code to its gene/test type or panel description but do not include clinical eligibility rules in this excerpt.
Prior authorization listing (examples)
Listed molecular genetic laboratory procedures require prior authorization through Carelon; examples include oncology NGS panels, pharmacogenomic panels, prenatal cfDNA tests, transplant donor-derived cfDNA quantification, and genome sequencing for rare conditions.
Examples (selected)
CPT / HCPCS / U-code Examples
Examples of listed CPT/HCPCS/U codesmixed
| 70471 | Computed tomographic angiography (CTA), head and neck, with contrast; managed by Carelon; add effective 7/1/2026 |
| 70472 | CT cerebral perfusion analysis with contrast including image postprocessing; managed by Carelon; add effective 7/1/2026 |
| 0628U | Nephrology genomic analysis renal disease panel, NGS 449 genes; managed by Carelon; add effective 7/1/2026 |
| 0630U | Oncology (breast) mRNA gene expression profiling by microarray of 80 genes; managed by Carelon; add effective 7/1/2026 |
| 77436 | Surface radiation therapy; treatment planning and simulation-aided field setting; managed by Carelon; add effective 7/1/2026 |
Imaging codes (sample)mixed
Advanced imaging CPT groups in fragmentCPTCovered
| 73206-73225 | Magnetic resonance/CT imaging of upper extremity variants (with/without contrast, postprocessing) as listed |
| 73700-73725 | Computed tomography / magnetic resonance imaging of lower extremity variants and MRA (with/without contrast) |
| 74150-74183 | CT/MR abdomen and pelvis series (without/with contrast, CTA) and related postprocessing |
| 74261-74263 | CT colonography diagnostic/screening including image postprocessing |
| 74712-74713 | Fetal MRI (single and additional gestations) |
| 75557-75574 | Cardiac MRI/CT procedures including stress, velocity mapping, coronary calcium scoring and CTA |
| 75635 | CTA abdominal aorta and bilateral iliofemoral runoff with postprocessing |
| 76376-76380, 76390 | 3D rendering, image postprocessing, limited CT follow-up, MR spectroscopy |
| 77046-77049, 77078, 77084 | MR elastography and related imaging studies |
| 78012-78020, 78070-78075 | Thyroid/parathyroid/adrenal and related nuclear imaging procedures |
1–10 of 14
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Enteral formula HCPCS codes (examples shown)HCPCSCovered
Parenteral nutrition HCPCS codes (examples shown)HCPCSCovered
| B4164 | Parenteral nutrition solution: dextrose ≤50% (Homemix) |
| B4189 | Parenteral nutrition compounded amino acid/carbohydrates with electrolytes, trace elements, vitamins — premix (10–51g protein) |
| B4193 | Parenteral nutrition premix (52–73g protein) |
| B4197 | Parenteral nutrition premix (74–100g protein) |
| B4199 | Parenteral nutrition premix (>100g protein) |
Home infusion per diem and service codesHCPCSCovered
| S5497 | Home infusion therapy — catheter care/maintenance; includes administrative services; per diem |
| S5501 | Home infusion therapy — catheter care/maintenance complex (more than one lumen); per diem |
| S9340 | Home therapy; Enteral Nutrition; administrative services and supplies; per diem |
| S9343 | Home Therapy; Enteral Nutrition via pump/bolus; administrative services and supplies; per diem |
Selected home infusion S-codes and descriptionsHCPCSCovered
| S9340 | Home infusion therapy, intermittent chemotherapy infusion; administrative services, professional pharmacy services, care coordination, and supplies and equipment (drugs and nursing visits coded separately), per diem |
| S9341 | Home infusion therapy, intermittent chemotherapy infusion; administrative services, professional pharmacy services, care coordination, and supplies and equipment (drugs and nursing visits coded separately), per diem (enteral nutrition via gravity noted) |
| S9364 | Home infusion therapy Total Parenteral Nutrition (TPN); administrative services, pharmacy, care coordination and supplies including standard TPN formula (do not use with S9365-S9368 using daily volume scales) |
Molecular genetic test codes (excerpt)mixedCovered
| 81180-81261 (partial range shown) | Series of molecular genetic lab testing CPT-style codes with specific gene/test mappings (excerpt). |
Selected molecular genetic CPT codes and descriptions from sectionCPT
| 81254 | Molecular genetic lab testing (example entries shown) |
| 81255 | FLT3 gene analysis; TKD variants (example) |
| 81256 | FLT3 gene analysis; TKD variants (alternate mapping shown) |
| 81257 | HBA1/HBA2 gene analysis; common deletions or variants |
| 81258 | HBA1/HBA2 gene analysis; known familial variant |
| 81259 | HBA1/HBA2 gene analysis; full gene sequence |
| 81266 | Comparative analysis using STR markers; patient and comparative specimen |
| 81270 | JAK2 V617F variant analysis |
| 81271 | HTT (Huntingtin) evaluation to detect expanded alleles |
| 81275 | KRAS exon 2 variants (codons 12 and 13) |
1–10 of 21
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Molecular pathology CPT groups (81400-81405)CPTCovered
| 81400 | Molecular Pathology Procedure Level 1 — identification of single germline variant (examples listed) |
| 81401 | Molecular Pathology Procedure Level 2 — 2-10 SNPs, methylated variant, somatic variant examples |
| 81402 | Molecular Pathology Procedure Level 3 — >10 SNPs, immunoglobulin/T-cell receptor rearrangements, UPD/STR analysis |
| 81403 | Molecular Pathology Procedure Level 4 — single exon sequence analysis, mutation scanning, examples of genes |
| 81404 | Molecular Pathology Procedure Level 5 — analysis of 2-5 exons, mutation scanning, characterization of dynamic mutations |
| 81405 | Molecular Pathology Procedure Level 6 — analysis of 6-10 exons, regionally targeted cytogenomic array, full gene sequences |
Listed molecular/genomic CPT codes and descriptionsCPT | mixedCovered
| 81405 | Molecular genetic lab testing / molecular pathology procedure level 6 |
| 81406 | Molecular pathology procedure level 7 |
| 81407 | Molecular pathology procedure level 8 |
| 81408 | Molecular pathology procedure level 9 |
| 81410 | Genomic sequence analysis panels for aortic dysfunction/dilation (≥9 genes listed) |
| 81411 | Duplication/deletion analysis panel for aortic dysfunction (specific genes listed) |
| 81415 | Exome sequencing |
| 81416 | Comparator exome |
| 81417 | Re-evaluation of previously obtained exome |
| 81418 | Drug metabolism / pharmacogenomics (≥6 genes incl CYP2C19, CYP2D6) |
1–10 of 27
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codes flagged for removalmixed
| 0131U | Targeted mRNA sequence analysis panel — note: Remove effective 4/1/2026 |
| 0132U | Targeted mRNA sequence analysis panel — note: Remove effective 4/1/2026 |
examples of listed U-codes and descriptionsmixed
| 0170U | Molecular genetic lab testing — predictive probability of ASD diagnosis / other specified assays |
| 0171U | Targeted genomic sequence analysis panel / PMS2 mRNA sequence analysis etc. |
| 0203U | mRNA gene expression profiling for autoimmune (IBD) 17 genes |
| 0205U | Analysis of 3 gene variants for neovascular AMD risk |
| 0211U | Cytogenomic constitutional genome-wide analysis / oncology pan-tumor NGS DNA/RNA |
| 0212U | Whole genome and mitochondrial DNA sequence analysis for rare/heritable disorders |
| 0228U | Multianalyte molecular profile for prostate cancer (urine) |
| 0244U | DNA comprehensive genomic profiling 257 genes (solid organ) |
| 0253U | Endometrial receptivity analysis RNA gene expression profile 238 genes |
| 0254U | Preimplantation genetic assessment — 24 chromosome analysis per embryo |
1–10 of 13
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Representative U-code group from segmentmixedCovered
| 0286U | Molecular genetic lab testing — variant described in list |
| 0326U | Targeted genomic sequence analysis panel, cell-free circulating DNA, 83+ genes |
| 0340U | Analysis of minimal residual disease from plasma, patient-personalized assays |
| 0392U | DNA and RNA NGS on FFPE tissue, 437 genes, includes immunotherapy response score |
| 0400U | DNA/RNA NGS 437 genes; also used for expanded carrier screening (145 genes) |
| 0410U | Whole genome sequencing with 5-hydroxymethylcytosine enrichment reported as cancer detected/not detected |
inv-42: Effective date note
Effective as listedThis code list reflects prior authorization requirements as of January 1, 2025
Future additions notedSpecific codes include 'Add effective 4/1/2026' or 'Add effective 7/1/2026' as indicated in the list
List scope and limitationsPresence of a code on this list does not guarantee coverage; consult member benefit contract for coverage determination
inv-43: Protein quantity groupings for premix codes
Protein premix group: 10–51gB4189 premix strength defined as 10–51 grams of protein
Protein premix group: 52–73gB4193 premix strength defined as 52–73 grams of protein
Protein premix group: 74–100gB4197 premix strength defined as 74–100 grams of protein
Protein premix group: >100gB4199 premix strength defined as over 100 grams of protein
inv-44: Minimum gene counts for specific panels (examples)
Cardiac/aortic panelsCode 81410 requires sequencing of at least 9 genes for aortic dysfunction/dilation panels
Cardiac ion channelopathiesCode 81413 requires sequencing of at least 10 genes for cardiac ion channelopathy panels
Hearing loss panelsCode 81431/81432 require sequencing of at least 60 genes and CNV analysis for STRC and DFNB1 where indicated
Mitochondrial gene panelsCode 81440 nuclear-encoded mitochondrial gene panels must include analysis of at least 100 genes
inv-45: Gene panel size examples — ranges from single-gene to whole genome
Single-gene to small panelsDocument includes single-gene assays and small targeted panels (examples across CPT/PLA entries)
Mid-size panels (5–50 genes)Codes such as 81450 represent genomic sequence analysis panels of 5–50 genes (hematolymphoid neoplasm panels)
Large panels to whole genomeU- and specific PLA codes (e.g., 0250U, 0403U) include large panels up to 505 genes and whole-genome sequencing entries
How to Request Prior Authorization
Prior Authorization
How to initiate prior authorization
This file is a searchable PDF. Press CTRL+F to find a procedure code or service. Prior authorization requests for services handled by BCBSTX can be submitted three ways: use the searchable PDF (CTRL+F), Blue ApprovrSM, or call the prior authorization number on the member's ID card. For services handled by Alacura call 1-866-671-4834. For services handled by Carelon Medical Benefits Management call 1-866-455-8415 or access https://www.careloninsights.com/medical-benefitsmanagement/specialty-care.
- How to initiate prior authorization: searchable PDF (CTRL+F), Blue ApprovrSM, or call the prior authorization number on the member's ID card.
- Vendor contacts: Alacura — 1-866-671-4834; Carelon — 1-866-455-8415 or https://www.careloninsights.com/medical-benefitsmanagement/specialty-care.
Prior Authorization
Prior authorization assignment (Carelon)
Many advanced imaging, PET, echocardiography/cardiac imaging, MEG/CT/MRI and related codes listed in the Medical/Surgical Procedures Requiring Prior Authorization table are assigned to Carelon for prior authorization review. When Carelon is listed beside a CPT/HCPCS code, prior authorization must be requested through Carelon.
- Prior authorization assignment: Carelon is the reviewer for numerous advanced imaging and molecular/genetic codes.
- When Carelon is the assigned vendor for a code, submit prior authorization via Carelon (phone or website).
Prior Authorization
Prior authorization required — selected codes
Selected advanced imaging and related procedure codes require prior authorization. Review the Medical/Surgical Procedures Requiring Prior Authorization list to confirm vendor assignment and authorization requirement before scheduling or billing.
- Examples of selected advanced imaging codes requiring prior authorization (vendor shown where assigned): 73206, 73218, 73219, 73220, 73221, 73222 — Carelon listed.
- Many additional CPT codes in the Advanced Imaging/Radiology, Cardiology group are subject to prior authorization; confirm per the searchable list.
Prior Authorization
PET imaging prior authorization
PET imaging CPT codes require prior authorization and are assigned to Carelon for review. Submit prior authorization requests to Carelon for PET studies.
Prior Authorization
Echocardiography and related advanced imaging prior authorization
Echocardiography and other cardiac imaging CPT codes require prior authorization through Carelon. This includes transthoracic, transesophageal, Doppler, stress echocardiography, and related contrast or monitoring codes.
- Echocardiography/cardiac imaging codes assigned to Carelon include (examples): 93303–93308, 93312–93317, 93320, 93321, 93325, 93350–93352, 93351 — prior authorization via Carelon.
- Use Carelon for authorization of echocardiography procedures, including studies performed at rest, stress, with contrast, or transesophageal approaches.
Prior Authorization
Advanced imaging / MEG / CT / MRI prior authorization
Advanced imaging (CT/MRI), magnetoencephalography (MEG), and related advanced procedures listed require prior authorization and are routed to Carelon when indicated. Some temporary codes have notes for future effective or removal dates — confirm the code-specific entry in the searchable list.
Prior Authorization
Cardiology / ENT procedures prior authorization assignments
Certain cardiology and ENT surgical procedure codes are assigned to BCBSTX (not Carelon) for prior authorization processing. Confirm vendor assignment per code in the searchable list before initiating authorization.
Prior Authorization
Home infusion / enteral nutrition prior authorization codes
Home infusion and enteral nutrition HCPCS codes require prior authorization and many are routed to BCBSTX for processing. Submit prior authorization using the plan's standard channels when BCBSTX is listed, or follow vendor routing if another vendor is assigned.
- Home infusion/enteral codes requiring prior authorization include (examples): B4103, B4104, B4149, B4150, B4152–B4154 — BCBSTX listed as reviewer for these HCPCS codes.
- Home infusion per diem codes S9339–S9341 are listed and require prior authorization; drugs and nursing visits are coded separately.
- Transport and medical transportation codes (A0430, S9960) route to Alacura when noted.
Prior Authorization
Molecular genetic and specialty panel prior authorization routing
Molecular genetic and laboratory testing CPT, PLA and U-codes listed require prior authorization. Carelon is the reviewer for many of these tests — submit prior authorization requests to Carelon when they are the assigned vendor.
- Selected molecular genetic CPT examples assigned to Carelon: 81120–81121, 81162–81163, 81175–81182, 81229–81233, 81254–81256, 81319–81324, 81350–81357, 81405–81408, 81450–81456, 81462–81464, 81522–81525, 81529, 81558, 81595.
- Specialty panels and newer PLA/U-codes (0001U, 0004M, 0005U, 0006M, 0007M, 0011M, 0030U–0045U, 0131U–0132U, 0170U–0171U, 0203U, 0205U, 0286U–0297U, 0401U–0405U, 0422U–0424U, 0469U, 0471U, 0473U–0474U, 0403U, 0422U, 0473U etc.) are shown with Carelon assignment; some include notes to add or remove effective dates (see list).
- Future effective/removal notes: codes such as 95965/95966 (add effective 1/1/2026), 0042T and certain U-codes (remove effective 4/1/2026), and 81354 / 81524 (add effective 4/1/2026) are flagged — verify timing on the code-specific entry.
Definitions and Notes
inv-72: 'TDI' indicated on member ID card for Fully Insured Members
TDI identifier"TDI" will be indicated on the member's ID card for Fully Insured Members
ApplicabilityApplies to fully insured members as noted in the document header
Reference locationSee document title/header for the TDI note and effective/update information
inv-73: Scope note — prior authorization code list
List purposeThis list includes CPT and/or HCPCS codes for which prior authorization may be required
Not exhaustiveLists are not exhaustive; absence from the list does not imply lack of prior authorization requirement
No coverage guaranteePresence on the list does not necessarily indicate coverage under a member's contract; consult benefit booklet
inv-74: Carelon — assigned prior authorization vendor for many advanced imaging codes shown
Carelon roleCarelon is assigned as the prior authorization vendor for many advanced imaging CPT codes shown (examples throughout imaging sections)
Examples of assignmentMultiple imaging codes (e.g., 73206, 75573, 76376) are annotated with 'Carelon' in the list
Routing implicationProviders must submit prior authorization requests to Carelon for codes mapped to that vendor
inv-75: 3D rendering / image postprocessing — billable when indicated
Billable when indicated3D rendering with interpretation and image postprocessing (e.g., CPT 76376/76377) is listed and billable when indicated
Vendor mappingThese 3D rendering/postprocessing codes are mapped to Carelon for prior authorization
Service categoryAppears under Advanced Imaging/Radiology service category alongside imaging CPT codes
inv-76: Carelon — designated prior authorization vendor referenced for processing authorizations
Carelon designated reviewerCarelon is identified repeatedly as the designated prior authorization vendor for many listed procedures and tests
Multiple sectionsCarelon mapping appears across imaging, molecular genetic testing, and other sections
Provider actionSubmit prior authorization requests to Carelon where the code is annotated with 'Carelon'
inv-75: Service categories shown alongside CPT codes
Service categories shownService categories (e.g., Advanced Imaging/Radiology, Cardiology) are listed alongside CPT codes to indicate clinical area
ExamplesImaging and cardiology categories repeatedly annotated in imaging CPT groups
Use for routingService category helps identify appropriate clinical area and vendor mapping
inv-78: Carelon (single-token reference)
CarelonCarelon
UsageSingle-token reference used throughout the document to indicate the assigned prior authorization vendor
ImplicationCodes annotated with 'Carelon' must be routed to that vendor for prior authorization processing
inv-79: BCBSTX — Blue Cross Blue Shield of Texas assigned as authorization manager for certain codes
BCBSTX assignmentBCBSTX (Blue Cross Blue Shield of Texas) is identified as the authorization manager for certain codes (e.g., B4103, S2120, 36516)
Provider routingSome home infusion and procedural codes are mapped to BCBSTX rather than external vendors
Document noteMapping appears inline next to specific HCPCS/CPT entries in the list
inv-80: Enteral formula — definition and variants
DefinitionEnteral formula: nutrition administered through an enteral feeding tube; unit definitions provided (e.g., 500 mL = 1 unit; 100 kcal = 1 unit for some products)
VariantsIncludes nutritionally complete, incomplete/modular, blenderized natural foods, calorically dense (≥1.5 kcal/mL), pediatric/adult variants
Coding examplesExamples shown include B4103, B4149, B4150, B4152 with unit conversion notes
inv-81: Parenteral nutrition — definition
DefinitionParenteral nutrition: intravenous nutrition solutions including amino acids, dextrose, lipids, electrolytes, trace elements and vitamins; provided as homemix or premix
Premix protein groupingsPremix codes specify protein amounts (10–51g, 52–73g, 74–100g, >100g) as shown for B4189, B4193, B4197, B4199
ExamplesHCPCS examples include B4164, B4189, B4193, B4197, B4199
inv-82: Home infusion per diem — definition and components
Per diem bundleHome infusion per diem codes represent a bundled daily rate including administrative services, professional pharmacy services, care coordination, and necessary supplies/equipment; drugs and nursing visits are coded separately
ExamplesS9340, S9341, S9364, S9368 and related S-codes are listed as per diem home infusion services
Billing noteDo not bill per diem codes with separate per-hour codes; follow coding notes in the list
inv-83: Home Infusion Therapy / Home Injectable Therapy — descriptor mapping to multiple S-codes
Descriptor mappingHome Infusion Therapy / Home Injectable Therapy services are represented by multiple S-codes describing administrative services, professional pharmacy services, care coordination, and supplies/equipment; drugs and nursing visits coded separately
Per diem examplesS9340, S9341, S9364 and other S-codes shown with per diem descriptions
Use caseThese S-codes identify bundled home infusion services to be routed per mapping (BCBSTX in many entries)
inv-84: Medical Transportation (Fixed Wing) — codes A0430, S9960 referenced
Codes referencedFixed-wing medical transportation codes referenced include A0430 and S9960
Mapping/vendorA0430 and S9960 entries show vendor mapping (e.g., Alacura/BCBSTX as annotated)
DefinitionRepresents nonemergency fixed-wing ambulance transport (per-chunk description)
inv-85: Molecular Genetic Lab Testing — CPT codes 81120-81187 mapping to vendor 'Carelon'
CPT range mappingMolecular Genetic Lab Testing entries cover CPT-style codes in the 81120–81187 range and map many entries to Carelon for prior authorization
ExamplesExamples include 81162 (BRCA1/2 full sequence and duplication/deletion) and numerous other gene-specific analyses
Routing noteMolecular genetic CPT codes in this range are annotated with vendor mapping for authorization processing
inv-86: Carelon — designated prior authorization vendor for listed molecular genetic tests
Carelon assignedCarelon is repeatedly identified as the designated prior authorization reviewer for the listed molecular genetic tests and U-codes
Sections referencedCarelon mapping appears in CPT 811xx–814xx ranges and across U-code entries (e.g., 0037U, 0048U, 0403U)
Provider actionSubmit prior authorization requests for listed molecular/genetic tests to Carelon where annotated
inv-87: Category label used repeatedly to identify genetic analysis services
Category labelThe label 'Molecular Genetic Lab Testing' is used repeatedly to identify genetic analysis services mapped to individual codes
Scope examplesApplied to gene-specific tests (BRCA, FLT3, HBA1/HBA2), procedure-level panels and U-code assays
Document presenceThis category header appears in multiple sections of the code list
inv-88: Comparative STR analysis — definition
Comparative STR analysisComparative analysis using short tandem repeat (STR) markers for patient and comparative specimens (e.g., pre-transplant recipient and donor) is described (CPT 81266, 81269, etc.)
Use casesIncludes zygosity testing, maternal cell contamination checks, and transplant donor/recipient comparisons
Coding examplesCPT 81266 and 81269 entries reference comparative STR analysis with Carelon mapping
inv-89: MSI analysis — microsatellite instability analysis definition
MSI analysis definitionMSI (microsatellite instability) analysis assesses markers for mismatch repair deficiency and may include comparison of neoplastic and normal tissue if performed (e.g., CPT 81301)
Clinical contextUsed in tumor profiling and Lynch syndrome–related assessments as annotated in molecular sections
Vendor mappingMSI analyses listed are mapped to Carelon for prior authorization where indicated
inv-90: Molecular Pathology Procedure Levels — Levels 1-6 explanation
Procedure level scaleMolecular Pathology Procedure Levels (81400–81405) describe increasing complexity from Level 1 (single variant detection) up to Level 6 (analysis of 6–10 exons or regional arrays)
ExamplesLevel descriptions include examples such as single SNP detection (Level 1) through multi-exon or regional arrays (Level 6)
ImplicationLevels guide coding and prior authorization expectations for molecular pathology services
inv-91: Carelon reference (supporting)
Carelon as reviewerCarelon is referenced across molecular sections as the prior authorization/review entity for many molecular/genetic test codes
Multiple code typesCarelon mapping applies to CPT, PLA, and U-code entries throughout the molecular testing sections
Submission expectationProviders should route authorization requests for annotated tests to Carelon unless another vendor is specified
inv-92: Genomic Sequence Analysis Panel must include sequencing of specified minimum number of genes for indicated hereditary condition
Genomic Sequence Analysis Panel requirementGenomic sequence analysis panels for specified hereditary conditions must include sequencing of the minimum number of genes indicated (examples provided per code, e.g., 81410, 81412)
Examples includedCodes such as 81410 (aortic dysfunction) and 81412 (Ashkenazi Jewish–associated disorders) specify minimum gene counts in the list
Carelon mappingThese panel requirements are annotated alongside vendor mapping to Carelon in the list
inv-93: Duplication/Deletion Analysis Panel — includes copy number analysis examples
Duplication/deletion (CNV) panelsDuplication/deletion analysis panels include copy number analysis examples for specific genes (e.g., 81411 for TGFBR1/TGFBR2/MYH11/COL3A1; 81431 includes CNV analyses for STRC and DFNB1)
ExamplesCPT entries explicitly require duplication/deletion analyses where clinically indicated
Submission noteThese CNV/dup-del panel analyses are mapped to Carelon for prior authorization in the list
inv-95: Whole mitochondrial genome — definition
Whole mitochondrial genomeCPT 81462–81465 describe sequencing of the entire mitochondrial genome for mitochondrial disorders (whole mitochondrial genome analysis)
Clinical examplesUsed for conditions such as MELAS, MERRF, NARP and other mitochondrial encephalomyopathies as noted
Vendor mappingThese mitochondrial genome tests are annotated with Carelon for prior authorization processing
inv-96: Carelon (reference)
Carelon repeated mappingCarelon is listed repeatedly as the prior authorization/review entity for molecular genetic test codes in multiple sections (CPT, PLA, U-codes)
ScopeApplies to a broad set of molecular genetic and genomic assays across oncology, hereditary disorders, transplant and pharmacogenomics
Provider expectationSubmit authorization requests to Carelon for codes annotated with Carelon in the list
inv-97: Molecular Genetic Lab Testing — includes oncology, hereditary disorder panels, transplant assays, pharmacogenomics
Included test typesMolecular genetic lab testing entries include oncology panels, hereditary disorder panels, transplant assays, pharmacogenomics and other genomic analyses
ExamplesEntries reference MRD assays, predictive risk scores, comprehensive genomic profiling, and pharmacogenomic panels (e.g., CYP genes)
Vendor mappingMany of these tests are routed to Carelon for prior authorization review as annotated
inv-98: Carelon is the listed prior authorization/review entity for tests in this section
Carelon as PA/reviewer for tests in this sectionCarelon is the listed prior authorization/review entity for the molecular genetic tests enumerated in the molecular sections
Wide clinical coverageApplies across oncology, neurology, cardiology, reproductive medicine, transplant and rare disease testing
Submission routingProviders should follow vendor routing and submit to Carelon where codes are annotated accordingly
inv-99: Predictive/risk/algorithmic report — tests may report continuous or categorical scores
Predictive/risk reportsSome tests produce predictive or risk algorithmic reports that may be reported as continuous or categorical scores (examples appear in U-code entries like 0203U, 0289U, 0291U)
Reporting formatsAlgorithms reported as continuous risk scores or categorical classifications (e.g., low/intermediate/high) depending on assay
Clinical examplesIncludes ASD predictive probability (0170U), Alzheimer predictive risk (0289U), psychiatry gene expression profiles (0291U)
inv-100: Molecular genetic lab testing (label)
Molecular Genetic Lab Testing labelThe document uses 'Molecular Genetic Lab Testing' as a section label to group genetic tests and panel codes throughout the list
Applies to diverse codesLabel covers CPT, PLA and U-code entries with gene analyses, panels, and algorithmic reports
Vendor mappingEntries under this label commonly show Carelon as the prior authorization reviewer
inv-101: Minimal Residual Disease (MRD) — definition
MRD definitionMinimal Residual Disease (MRD) testing detects low levels of disease post-treatment using patient-specific panels or targeted sequencing and is listed (e.g., 0306U/0307U for baseline and subsequent assessments)
Use case0306U indicates initial baseline assessment to determine patient-specific panel; 0307U denotes subsequent MRD assessment comparing to prior specimen
Vendor mappingMRD assays in the list are routed to Carelon as annotated
inv-103: cfDNA definition — circulating donor- or tumor-derived cell-free DNA quantified by NGS
cfDNA definitioncfDNA refers to circulating donor- or tumor-derived cell-free DNA quantified by NGS and reported as percent or as detected/not detected (e.g., 0494U donor-derived cfDNA)
Examples0494U quantifies donor-derived cfDNA for transplant monitoring and reports percentage; prenatal assays report detected/not detected for fetal RHD
Specimen typeTypically performed on plasma and reported as percentage or qualitative detected/not detected per code descriptions
Policy Summary
PayerBlue Cross Blue Shield - Texas
Policy2026 Commercial Prior Authorization Codes for Administrative Services Only
Policy CodePolicy N/A
Change TypeMinor / informational update
Effective DateN/A
Next Review DateN/A
Key ActionInitiate prior authorization via the searchable PDF (CTRL+F), Blue ApprovrSM, or the prior authorization number on the member's ID card; use vendor contacts (Carelon, Alacura) as indicated per code.
SourceLink
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