ModifiedBlue Cross Blue Shield - TexasPolicy N/A

2024 Commercial Prior Authorization Codes for Fully Insured & Certain Administrative Services (ASO Groups)

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Lists CPT and HCPCS codes and service categories that may require prior authorization for BCBSTX commercial fully insured and certain ASO groups; describes authorization request methods and indicates many services are managed by Carelon.

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyCommercial Prior Authorization Codes list (2024)

Policy CodePolicy N/A

Change TypeAdded multiple U-codesoperational updates

Effective DateJan 1, 2024

Next Review DateN/A

Key ActionInitiate prior authorization via Availity Authorization & Referrals, Blue_Approvr, or by calling the number on the member's ID; for Carelon-handled services call 1-866-455-8415 or visit careloninsights.com.

SourceLink

POLICY UPDATE CHANGES

Multiple new molecular genetic lab test codes (e.g., 0368U, 0378U, 0379U, 0380U, 0388U, 0389U, 0391U, 0392U, 0396U, 0400U, 0401U, 0405U, 0409U, 0410U, 0411U, 0413U, 0414U, 0417U, 0420U, 0422U, 0423U, 0424U, 0425U, 0426U, 0428U, 0433U, 0434U, 0437U, 0438U, 0439U, 0440U, 0444U, 0448U, 0449U) were added with Carelon mapping and effective dates.

Several tests include specific test descriptions such as minimal residual disease assays, drug metabolism panels including CYP2D6 deletion/duplication, targeted genomic panels (e.g., 523-gene, 361-gene), and specialized oncology and psychiatric panels.

Many codes are explicitly marked 'Carelon = Carelon' indicating internal mapping to Carelon review or management.

2024Effective year

CarelonVendor assigned to majority

100+Approx. CPT/U-code lines in excerpt

Add/Retire notedCodes with add/retire dates

Coverage stance and code-level annotations

Prior authorization stance and process

Prior authorization may be required for codes on this list; routing instructions and how to request authorization are provided.

Codes listed may require prior authorization; presence on this list does not guarantee coverage — verify member benefit contract.

Authorization may be initiated via Availity Authorization & Referrals, Blue_Approvr, or by calling the prior authorization number on the member's ID card; services handled by Carelon require contacting Carelon Medical Benefits Management at 1-866-455-8415 or careloninsights.com.

Operational contact/routing information provided in document.

Many advanced imaging and molecular genetic testing codes in the list are administratively mapped to Carelon for prior review/management (Carelon noted adjacent to code entries).

Code mapping entries

Code-to-specialty and vendor mapping entries (descriptive; do not include explicit coverage criteria in these fragments).

CPT/HCPCS codes are listed with short service descriptions, specialty mappings (e.g., Advanced Imaging/Radiology; Cardiology) and an administrative vendor/reviewer tag (frequently 'Carelon').

These chunks present mapping rows but do not define coverage rules.

Examples include advanced imaging codes (e.g., 78451, 78452) and radiopharmaceutical HCPCS entries (C8908, C8909, etc.) with 'Carelon' shown as reviewer for many lines.

Non-coverage annotations

Some entries include notations about non-covered or limited-use indications.

Select PET/related codes are annotated for non-covered or limited indications (examples: G0235 noted as 'PET imaging whole body; melanoma for non-covered indications'; G0252 annotated for limited initial staging/ surgical planning breast cancer).

No coverage criteria in this fragment

These fragments consist of code-to-description rows; no coverage stance or medical necessity criteria are provided in this window.

Rows list molecular genetics CPT codes (e.g., 81187–81194) with gene/test descriptors and administrative tags (Carelon) but do not include eligibility or coverage criteria in these chunks.

Codes only — no coverage criteria in this segment

Code listings and descriptors are shown; these chunks do not include explicit coverage criteria or medical necessity rules.

Molecular genetic and molecular pathology CPT/PL codes are enumerated with gene-specific descriptors (examples include KRAS, FXN, SMN1, TP53); many lines include 'Carelon' as administrative reviewer but no coverage decision language is present.

Coding-to-indication mappings and panel requirements

Code-level mappings with procedure-level descriptions and example indication/gene mappings; panel composition requirements and approver assignments are noted where present.

Entries list molecular genetics procedure codes (e.g., 81360, 81400–81407, 81410) with procedure-level descriptions (molecular pathology procedure levels) and example genes/variants.

Document maps many of these codes to Carelon as approver.

81400 is described as a molecular pathology procedure level for identification of a single germline variant (e.g., SNP).

Multiple procedure levels (81401–81407, 81410) are defined by analytic complexity (number of exons/amplicons/variants) and example gene uses as listed in the document.

Panel composition and test-specific requirements

Panel composition requirements and minimum gene counts are provided for certain named panels.

81431 hearing loss panels must include sequencing of at least 60 genes and include copy-number analyses for STRC and DFNB1 deletions in GJB2/GJB6.

81432 hereditary breast/ovarian cancer–related disorders panels must include sequencing of at least 10 genes and always include BRCA1, BRCA2, CDH1, MLH1, MSH2, MSH6, PALB2, PTEN, STK11, and TP53.

81441 nuclear-encoded mitochondrial gene panels must include analysis of at least 100 genes; inherited bone marrow failure syndrome panels must include at least 30 genes.

Other examples in the document specify minimum gene counts for named panels (e.g., aortic dysfunction panels >=9 genes; cardiac ion channelopathy panels >=10 genes).

Code listing without coverage rules

PLA/U-code style molecular test codes are enumerated with brief service descriptions; these chunks do not define coverage criteria.

Multiple PLA/U-code entries (e.g., 0103U, 0111U, 0129U, 0211U, 0254U, 0266U) are listed with short descriptors (sanger/mlpa, targeted KRAS/NRAS, hereditary panels, cytogenomic constitutional, preimplantation genetic assessment, tissue-specific transcriptome) and many show 'Carelon' as reviewer; no explicit medical necessity criteria are provided in these lines.

U-code descriptors (informational)

U-code entries and related informational descriptors are listed; reviewer designation is included where present.

U-code entries include reproductive medicine (0254U preimplantation genetic assessment), autoimmune/psoriasis expression panels (0258U), rare-disease optical genome mapping (0260U), and MRD/whole-transcriptome/optical mapping U-codes; many entries indicate Carelon as reviewer.

Selected U-code lines describe specimen types and analytic approaches (FFPE, blood/plasma, fresh tissue) and note reviewer mapping but do not contain coverage condition language in these chunks.

Enumerated test code entries

Enumerated test code entries include descriptions and administrative add-effective dates for several U-codes; many are mapped to Carelon.

Selected U-codes (e.g., 0368U, 0378U, 0379U, 0380U, 0388U, 0405U, 0444U) are listed with test descriptions such as MRD assays, repeat expansion analysis, large targeted gene panels, drug metabolism panels including CYP2D6, and methylation-based plasma cancer signal assays.

Several entries carry administrative 'Add effective' annotations (examples: 0405U, 0409U, 0410U annotated 'Add Effective 07/01/2024'; others annotated 01/01/2024 or 04/01/2024) and many are mapped to Carelon for review.

Billing and coding notes (no coverage criteria present)

Billing and coding annotations are provided with list-separately instructions; no coverage criteria are present here.

Several musculoskeletal/spine procedure-related codes (e.g., 20931, 20936, 20974) are annotated as 'List Separately In Addition To Code For Primary Procedure' with administrative mapping to Carelon on many lines.

These chunks provide billing descriptors and indications of list-separately billing but do not include medical necessity/coverage eligibility rules.

Administrative annotations and prior authorization notes

Administrative annotations and prior authorization notes for musculoskeletal and spine CPT codes are listed; one code explicitly requires prior authorization through Carelon.

Numerous musculoskeletal and spine CPT entries are annotated with Carelon mapping and administrative notes including 'Add effective 01/01/2024' for many added codes.

CPT 27412 (Autologous Chondrocyte Implantation, knee) is specifically annotated: 'Prior Authorization required through Carelon.'

Approver assignments

Code assignment rows indicate the approver group for listed CPT ranges and newly added codes.

Large groups of musculoskeletal and spine procedure CPT codes (examples: 29881–29886, 62362, 62380, 63001–63103) are assigned to Carelon as the approver/reviewer; many entries include 'Add effective 01/01/2024' for newly added codes.

Code lists, groups, and coding notes

Covered CPT CodesCPTCovered

81518	Oncology (Breast) mRNA gene expression profiling by real-time RT-PCR of 11 genes (content and 4 housekeeping) utilizing formalin-fixed paraffin-embedded tissue; algorithm reported as percentage risk for metastatic recurrence and likelihood of benefit from extended endocrine therapy.
81519	Oncology (Breast) mRNA gene expression profiling by real-time RT-PCR of 21 genes utilizing formalin-fixed paraffin-embedded tissue; algorithm reported as recurrence score.
81540	Oncology (Breast) mRNA gene expression profiling by hybrid capture of 58 genes (50 content and 8 housekeeping) utilizing formalin-fixed paraffin-embedded tissue; algorithm reported as recurrence risk score.

How providers request authorization and who to contact

Prior Authorization

Prior Authorization — How to Request

Prior authorization requests can be initiated three ways: Availity Authorization & Referrals; Blue_Approvr; or by calling the prior authorization phone number on the member's ID card. For services handled by Carelon Medical Benefits Management call 1-866-455-8415 or visit https://www.careloninsights.com/medical-benefits-management/specialty-care. This section consolidates code-level vendor/approver assignments and administrative notes — many CPT/HCPCS and PLA/U-code molecular and imaging procedures are routed to Carelon for prior review; select ENT/cochlear implant and device codes are routed to BCBSTX. Presence on these lists does not guarantee coverage; check member benefits.

How to request prior authorization: 1) Availity Authorization & Referrals, 2) Blue_Approvr, or 3) call the prior authorization number on the member's ID card.
Carelon-managed services: Call 1-866-455-8415 or visit careloninsights.com for Carelon-handled prior authorization.
Searchable PDF guidance: Use CTRL+F to search codes or descriptions.

Prior Authorization

Vendor assignment for imaging codes

The following imaging and advanced imaging CPT/HCPCS codes are assigned to Carelon for prior review. This group represents vendor assignment for imaging codes and mapping to the review partner Carelon (advanced imaging/radiology, cardiology).

72197, 72198, 73201, 73206, 73200, 73202, 73218 — Carelon assigned
74170, 74174, 74175, 74176, 74177, 74178, 74181, 74182 — Carelon assigned
75574, 76376, 76377, 76380 — Carelon assigned
78445, 78451, 78452 — Carelon assigned
0649T, A9602, A9800, C8900–C8905 series — Carelon assigned

Prior Authorization

Imaging code mappings and review partner

Advanced imaging code mappings and review partner assignments (Carelon) — includes CT, MRI, MRA, CTA, PET, and modality-specific HCPCS codes. These codes may require prior authorization through Carelon as indicated.

CT/MR pelvis/abdomen/thorax series (e.g., 72197–72198, 74170–74178, 74181–74182) — Carelon
CT angiography and CTA postprocessing (e.g., 73206, 75574) — Carelon
3D rendering and image postprocessing (76376, 76377) — Carelon
Nuclear/PET tracers and specific HCPCS (A9602, A9800) — Carelon

Note

CPT-to-test mappings (administrative tag)

CPT-to-test mappings and administrative tags: many molecular genetic CPT/PLA codes in this document include an administrative mapping or tag indicating Carelon as the routing/reviewer. These mappings indicate which tests are managed by Carelon (or BCBSTX for specific device/ENT codes).

PLA/U-codes (e.g., 0103U, 0111U, 0113U, 0114U, 0118U, 0254U, 0258U, 0260U, 0262U, 0264U, 0345U, 0347U, 0348U) carry Carelon mapping tags.
Many CPT molecular genetics codes (e.g., 81163–81191 series, 81276–81279, 81360–81364, 81410–81416, 81457–81463, 81504–81520, 81542, 81546) are tagged with Carelon as approver/administrator.

Note

Administrative code listing (no auth instructions)

Administrative code listings: this section contains extensive code lists (molecular genetic testing, PLA/U-codes, imaging, musculoskeletal/spine, ENT/device codes). These listings primarily assign an approver/vendor and sometimes include effective-date notes or billing instructions (e.g., 'list separately in addition to code for primary procedure'). The lists do not themselves define medical necessity criteria in this excerpt.

Large sets of CPT/HCPCS and U-codes are listed with descriptions; many are administrative mappings to Carelon.
Some entries include billing notes such as 'List separately in addition to code for primary procedure.'
Codes listed here should be cross-checked against clinical criteria and member benefits for coverage determination.

Prior Authorization

Code listing and approver assignment

Code listing with approver assignment: numerous molecular genetic CPT codes and test-specific PLA/U-codes explicitly identify Carelon as the approver/management entity; select ENT/cochlear implant codes identify BCBSTX as the reviewer.

Molecular genetic CPT examples: 81163–81165, 81187–81191, 81276–81279, 81360–81364 — Carelon
Comprehensive panels and exome codes: 81410–81416, 81457–81463 — Carelon
Oncology expression profiles and panels: 81504, 81518–81520, 81542, 81546 — Carelon
ENT/cochlear implant and device codes (e.g., 69717, 69930, 92633, L8614–L8618) — BCBSTX

Note

Effective date annotations / administrative notes

Effective-date annotations and administrative notes: several codes include 'Add effective' or 'Add effective 01/01/2024' / '04/01/2024' / '10/01/2024' indicating when the code becomes subject to the listed routing/approver. Providers must note effective dates for newly added codes.

Add effective 01/01/2024: multiple musculoskeletal/spine and arthroscopy entries (e.g., 23700, 27331, 29805–29807, 29881–29886 series, many marked 'Add effective 01/01/2024').
Add effective 04/01/2024: select molecular oncology panels and cell-free tests (e.g., 81457–81459, 81458, 81459, 81463 annotations).
Add effective 10/01/2024: select PLA code entries (e.g., 0204U noted with Add Effective 10/01/2024).

Note

Codes and descriptions (no auth rules in excerpt)

Codes and descriptions (no auth rules in excerpt): many entries provide short procedure/test descriptions without embedding prior authorization rules in this excerpt; they indicate service category and reviewer only.

Examples: 73200 series descriptions for CT upper extremity; 73201 CT with contrast — descriptions present, reviewer Carelon noted for many.
Molecular test descriptions include gene names, assay types (sequence analysis, duplication/deletion analysis, expression profiling) and example indications.

Prior Authorization

Code list and Carelon assignment

Code list with Carelon assignment: numerous PLA/U and CPT codes are explicitly mapped to Carelon for review — this serves as an administrative routing list for utilization management.

PLA/U-codes mapped to Carelon include 0103U, 0113U, 0114U, 0118U, 0254U, 0258U, 0260U, 0262U, 0264U, 0345U, 0347U, 0348U, 0254U, 0258U etc.
CPT molecular genetics codes across multiple ranges (811xx–815xx, 814xx) are repeatedly mapped to Carelon.

Prior Authorization

U-code listing and reviewer designation

U-code listing and reviewer designation: multiple HCPCS U-codes (innovative or proprietary lab tests) are included and many designate Carelon as the reviewer/approver.

U-codes with Carelon: 0103U, 0111U (noted), 0113U, 0114U, 0118U, 0254U, 0258U, 0260U, 0262U, 0264U, 0345U, 0347U, 0348U, 0649T — Carelon assigned where indicated.
Some U-code entries include test descriptions (e.g., MRD assays, cell-free DNA, targeted NGS panels) and are managed by Carelon.

Prior Authorization

Genetic test code listings and Carelon mapping

Genetic test code listings and Carelon mapping: extensive molecular genetic CPT entries are listed with test-level descriptions (genes, panels, analytic methods) and nearly all are routed to Carelon for prior authorization review.

Examples: 81163–81165 (BRCA analyses), 81187–81191 series, 81276–81279 (KRAS and related), 81360–81364 (HBB and related) — Carelon.
Broad panels/exome codes 81410–81416, 81457–81463 and oncology panels 81504–81520 — Carelon.
Markers/panels for transplant, reproductive medicine, rare disease and MRD assays (multiple U-codes and CPTs) — Carelon assigned.

Billing Rule

Procedure list and billing note

Procedure list and billing note: certain procedure codes include operational billing notes (for example, 'List separately in addition to code for primary procedure') or indicate when additional procedures should be billed separately. Providers should follow these billing instructions and submit prior authorizations to the assigned reviewer.

Examples: Multiparametric MRI acquisition codes may be billed separately (e.g., additional organ single-organ codes listed separately).
Spine surgery and musculoskeletal procedures note 'List separately in addition to code for primary procedure' for certain structural/allograft codes (e.g., 20931–20933 entries).

Note

Effective-date additions

Effective-date additions: several musculoskeletal and arthroscopy CPT codes and specific molecular or oncology panels were added effective 01/01/2024, 04/01/2024, or 10/01/2024 as noted — verify the effective date for each code when requesting authorization.

Add effective 01/01/2024: many musculoskeletal/spine and arthroscopy codes (e.g., 23700, 27331, 29805–29807, 29881–29886, 29884–29886 series and others) and multiple orthopedics entries.
Add effective 04/01/2024: selected molecular oncology panels and cell-free tests (e.g., 81457–81459, 81458, 81459, 81463).
Add effective 10/01/2024: select PLA entries (e.g., 0204U).

Prior Authorization

CPT to internal approver mappings (excerpt) & Spine procedure approver assignments

CPT to internal approver mappings and spine procedure approver assignments: numerous CPT codes across musculoskeletal, spine, and joint procedure ranges are mapped to Carelon as the internal approver. Providers should route prior authorization requests for these procedures to Carelon unless the code specifically lists BCBSTX.

Spine and spine-related codes assigned to Carelon include: 20931–20933 (structural/allograft entries noted), 62362, 62380, 63001 and other laminectomy/discectomy codes where Carelon is listed.
Musculoskeletal joint and arthroplasty codes mapped to Carelon include: 23470–23474 (shoulder arthroplasty series), 23700 (manipulation under anesthesia) — some entries include 'Add effective 01/01/2024'.
Knee/arthroscopy and meniscal repair codes mapped to Carelon include 27331–27335, 27403, 27407, 27409, 27412–27416, 27425–27428, 27488 etc., many with Carelon as approver and some with effective-date notes.

Terms and administrative tags used in code lists

inv-71: Third-party utilization management vendor handling prior authorization for certain services

Third-party reviewerCarelon is the third-party utilization management vendor referenced as handling prior authorization or review for many listed services

How to request PAPrior authorization requests may be initiated via Availity Authorization & Referrals, Blue_Approvr, or by phone per member ID; Carelon-handled services require contacting Carelon Medical Benefits Management

ApplicabilityList applies to Fully Insured and certain ASO accounts; presence on list does not guarantee coverage — check member benefits

inv-72: Types of group arrangements impacted by this list; some ASO accounts are included

Plan types impactedFully Insured and certain ASO accounts (applicable ASO examples include TRS effective 3/1/2024 and named employer groups)

Coverage noteInclusion on this list does not necessarily indicate coverage; member contracts determine benefit applicability

Effective dateList effective January 1, 2024 (document updated July 2024)

inv-73: Named reviewer/approver organization associated with many CPT entries

Named approverCarelon is the named reviewer/approver organization associated with many CPT and U-code entries in the molecular/genetic sections

ScopeCarelon mapping appears across molecular pathology procedure levels and gene panel listings (e.g., 81400–81416, 81431–81441)

Administrative tagRows frequently show 'Carelon = Carelon' indicating internal approver mapping

inv-74: Service category applied to most listed CPT codes

Service category mappingMost listed CPT codes in the imaging sections are categorized under 'Advanced Imaging/Radiology' (many entries also reference Cardiology)

ExamplesCodes such as 72197, 73200, 78451, and radiopharmaceutical codes (A9602, A9800) are assigned to Advanced Imaging/Radiology

ImplicationCategory guides routing and prior-authorization workflow to the assigned reviewer (often Carelon)

inv-75: Assigned vendor/reviewer responsible for utilization management of the listed imaging services

Assigned reviewer for imaging servicesCarelon is the assigned vendor/reviewer responsible for utilization management of the majority of listed imaging CPT/HCPCS codes

Representative codesExamples include PET/CT (78811–78813), myocardial perfusion (78451–78452), and various CT/MR codes (72197, 73206)

Administrative effectCarelon mapping indicates prior-authorization routing to Carelon’s review processes

inv-76: Specialty mapping indicating the clinical area associated with the CPT/HCPCS code

Specialty mappingEntries commonly map to Advanced Imaging/Radiology and Cardiology specialties for CPT/HCPCS codes

Use in listingsSpecialty field appears in code rows to indicate clinical area (e.g., 78451 tagged Advanced Imaging/Radiology; Cardiology)

Routing impactSpecialty mapping helps determine correct administrative reviewer assignment (Carelon or BCBSTX)

inv-77: Carelon (term reference)

Carelon term reference'Carelon' appears repeatedly as the administrative reviewer/approver tag adjacent to numerous CPT and U-code entries

Alternate reviewerSome entries (notably certain ENT/cochlear codes) map to BCBSTX rather than Carelon

FunctionIndicates routing to Carelon for prior authorization or internal administrative handling

inv-78: BCBSTX (term reference)

BCBSTX term referenceBCBSTX is listed as the reviewer/approver for select ENT and cochlear implant related codes (e.g., 69930, L8614-L8617)

ContextBCBSTX mapping appears in the cochlear/ENT rows indicating a different reviewer assignment than Carelon for some device codes

Example codes69930 (cochlear device implantation), L8614 (cochlear device components) show BCBSTX mapping

inv-79: Carelon (quoted occurrences)

Quoted 'Carelon' occurrencesThe document explicitly records 'Carelon = Carelon' or 'Carelon' adjacent to many genetic/molecular test entries indicating the reviewer tag

ExamplesMultiple molecular test CPT and U-code rows show 'Carelon = Carelon' in the listing (e.g., 81314, 81407, various U-codes)

InterpretationServes as consistent administrative mapping across code groups for prior-authorization processing

inv-80: Comparative STR analysis — definition and examples

Comparative STR analysis definitionComparative Analysis Using Short Tandem Repeat (STR) markers is described for patient and comparative specimens (examples: pre-transplant recipient and donor germline testing)

Use caseApplied to zygosity testing, donor/recipient comparative analyses and additional specimen testing (listed as 'list separately' when applicable)

Reviewer mappingEntries for STR analysis are mapped to Carelon in the document

inv-81: molecular pathology procedure level — definition reference

Molecular pathology procedure level definitionProcedure levels 1–9 map to increasing complexity (e.g., 81400 = level for single germline variant detection; levels up through 81410 represent analysis of increasing exons/genes/complexity)

Level mapping examples81400 (single variant), 81407 (level 8: 26–50 exons or multiple genes), 81410 (level 9: >50 exons in a single gene)

Administrative mappingThese levels are used in molecular genetic CPT groupings where Carelon is frequently listed as approver

inv-82: Procedure level (levels 1–9) mapped to complexity/number of variants/exons/genes analyzed

Procedure level to complexity mappingProcedure levels 1–9 correspond to complexity metrics such as number of variants detected, exons analyzed, or genes interrogated (document lists level descriptions tied to CPT codes 81400–81410)

ExamplesLevel 3: 2–10 variants or rearrangements; Level 5: 6–10 exons or triplet repeat characterization; Level 8: analysis of multiple genes on one platform

Use in listingsUsed to classify molecular pathology CPT entries and guide administrative review assignment

inv-83: Panel composition requirement

Panel composition requirementGenomic sequence analysis panels for named indications must include sequencing of a minimum number of specified genes (examples: Ashkenazi Jewish disorders >=9 genes; cardiac ion channelopathy panel >=10 genes)

Document examples81412 (Ashkenazi disorders >=9 genes), 81413 (cardiac ion channelopathies >=10 genes), 81411 duplication/deletion analyses require specific gene coverage

Reviewer noteThese panel composition rules are listed alongside Carelon as approver for many entries

inv-84: Genomic Sequence Analysis Panel (term)

Genomic Sequence Analysis Panel termRefers to targeted sequencing panels requiring a minimum gene set for named clinical indications (e.g., hereditary disorders, mitochondrial panels)

Examples81431 hearing loss panels (>=60 genes); 81441 mitochondrial gene panels (>=100 genes)

ImplicationTerm used to denote multi-gene sequencing panels subject to minimum-size requirements in the listing

inv-85: Duplication/Deletion Analysis Panel (term)

Duplication/Deletion Analysis Panel termPanel type requiring copy-number/duplication-deletion analysis for specified genes (document lists required gene coverage for some indications)

Example81411 duplication/deletion panel for aortic dysfunction must include analyses for TGFBR1, TGFBR2, MYH11, COL3A1

Use caseUsed where CNV analysis is clinically indicated alongside sequencing

inv-86: Cell-Free Nucleic Acid testing (term)

Cell-Free Nucleic Acid testing termDescribes plasma/cfDNA interrogation for tumor-derived variants and other cell-free assays (examples: solid organ neoplasm panels and cfDNA panels)

Examples in document81457–81459 and various U-codes reference cell-free/plasma assays for tumor variant detection and MSI/TMB interrogation

Reviewer mappingMany cfDNA/cell-free entries are assigned to Carelon for review

inv-87: FFPE (term reference)

FFPE term referenceFormalin-Fixed Paraffin-Embedded (FFPE) tissue is cited as a common specimen input for many gene expression and sequencing assays in the listing

ExamplesMultiple tumor and expression assays (e.g., 0048U, 81542, 0244U) specify FFPE as the specimen type

ImplicationSpecimen type influences assay applicability and is documented for test definitions

inv-88: Risk score / probability score (definition)

Risk/probability score termAlgorithmic outputs from gene expression or sequencing assays reported as risk or probability scores (e.g., metastasis, recurrence, rejection) are documented in test descriptions

Examples81542 prostate metastasis risk score; 81595 heart transplant rejection risk score; 0245U thyroid risk of malignancy percentage

ReportingThese scores are reported as part of assay interpretive outputs in the listed code descriptors

inv-89: cytogenomic constitutional (term)

Cytogenomic constitutional termDescribes genome-wide cytogenomic analysis for constitutional/chromosomal abnormalities and cancer pan-tumor NGS reporting (e.g., 0211U)

Examples0211U cytogenomic constitutional analysis with SNVs, CNAs, TMB, MSI reporting for oncology pan-tumor applications

ScopeUsed across rare disease and oncology testing entries in the document

inv-90: preimplantation genetic assessment (term)

Preimplantation genetic assessment term0254U defines preimplantation genetic assessment as analysis of 24 chromosomes using embryonic DNA with mitochondrial DNA scoring per embryo

Reporting formatResults reported as normal (euploidy), monosomy, trisomy, partial deletion/duplication, mosaicism or segmental aneuploidy per embryo

Reviewer mapping0254U entry lists Carelon as reviewer in the document

inv-91: MRD (term)

MRD termMinimal Residual Disease (MRD) testing is documented for plasma-based oncology assays, sometimes personalized to the patient’s prior tumor/germline sequencing

Examples0341U/0343U describe MRD assays personalized to prior NGS of tumor and germline DNA; 0388U describes MRD quantitation for hematolymphoid neoplasms

ReportingMRD reported as presence/absence with quantitation of disease burden when appropriate

inv-92: Molecular Genetic Lab Testing (term)

Molecular Genetic Lab Testing termUsed as the service category for many U-code and CPT molecular/genetic test entries in the document

ScopeIncludes genomic sequence panels, expression profiling, cfDNA assays, duplication/deletion analyses and other molecular diagnostics

Reviewer mappingMany items under this category are assigned to Carelon for review

inv-93: MRD (term duplicate)

MRD (duplicate)Minimal residual disease testing entries describe plasma-based assays and personalization to prior NGS; multiple U-code rows reference MRD workflows

Representative codes0341U, 0343U and 0388U indicate MRD analyses with patient-specific or assay-specific quantitation

Administrative mappingThese MRD entries are mapped to Carelon in the listing

inv-94: cfDNA (term)

cfDNA termCell-free circulating DNA (cfDNA) plasma testing is referenced for tumor marker detection and monitoring (e.g., liquid biopsy panels)

Examples0388U NSCLC plasma 37-gene panel; 0055U donor-derived dd-cfDNA for transplant monitoring

UseAppears in oncology and transplant test descriptors with Carelon mapping

inv-95: list-separately (term)

List separately definition'List Separately In Addition To Code For Primary Procedure' is used for grafts, implants, and instrumentation that must be billed in addition to the primary procedure code

Examples20931–20939 allograft/autograft entries and instrumentation codes such as 22853/22854 are noted to be listed separately when performed

Billing implicationIndicates separate chargeable items that may require prior authorization and reviewer mapping

inv-96: Carelon (term reference repeated)

Carelon repeated tagCarelon appears repeatedly adjacent to many musculoskeletal and spine CPT code rows, indicating internal approver/reviewer assignment

ExamplesSpine instrumentation codes (22846–22854) and shoulder arthroplasty/arthrodesis entries show Carelon mapping

Operational noteRepeated Carelon tag denotes consistent administrative routing for these procedure groups

inv-97: Carelon indicates routing to Carelon for prior authorization/administrative handling of the listed CPT code

Carelon routing meaning'Carelon' indicates routing of the CPT/U-code row to Carelon for prior authorization/administrative handling

Document evidenceNumerous rows in imaging, molecular, and musculoskeletal sections explicitly list 'Carelon = Carelon' or 'Carelon' in the reviewer column

Action implicationProviders should route prior-authorization requests for Carelon-mapped services to Carelon per the document guidance

inv-98: Add effective 01/01/2024 — administrative annotation

Add effective 01/01/2024 meaning'Add effective 01/01/2024' marks codes administratively added to the prior-authorization/code list effective January 1, 2024

ExamplesMultiple musculoskeletal and arthroscopy CPTs (e.g., 29881–29886, 29805–29807) display this annotation

Other effective datesThe document also includes other add effective dates (04/01/2024, 07/01/2024) for select molecular/U-code entries

inv-99: Internal approver/review organization assigned to listed CPT codes

Internal approver assignmentCarelon is the internal approver/review organization assigned to a large set of listed CPT codes (imaging, molecular, musculoskeletal) in this document

ExamplesCodes across sections (e.g., 78811, 81407, 29881, 62362) show Carelon mapping in the reviewer column

Provider implicationPrior authorization routing for these codes should follow the Carelon process where indicated

inv-100: Procedure descriptors

Procedure descriptor examplesDocument includes descriptive procedure phrases such as 'Injection/Infusion Of Neurolytic Substance' and 'Implantation Or Replacement Of Device For Intrathecal Or Epidural Drug Infusion' adjacent to CPT rows

Use in listingDescriptors accompany CPT codes to clarify clinical procedure and billing context for reviewer mapping

Billing noteMany descriptors are paired with 'List Separately' or Carelon mapping to guide administrative processing

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyCommercial Prior Authorization Codes list (2024)

Policy CodePolicy N/A

Change TypeAdded multiple U-codesoperational updates

Effective DateJan 1, 2024

Next Review DateN/A

SourceLink

On This Page

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

2024 Commercial Prior Authorization Codes for Fully Insured & Certain Administrative Services (ASO Groups)

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Coverage stance and code-level annotations

Prior authorization stance and process

Prior authorization may be required for codes on this list; routing instructions and how to request authorization are provided.

Codes listed may require prior authorization; presence on this list does not guarantee coverage — verify member benefit contract.

Operational contact/routing information provided in document.

Many advanced imaging and molecular genetic testing codes in the list are administratively mapped to Carelon for prior review/management (Carelon noted adjacent to code entries).

Code mapping entries

Code-to-specialty and vendor mapping entries (descriptive; do not include explicit coverage criteria in these fragments).

CPT/HCPCS codes are listed with short service descriptions, specialty mappings (e.g., Advanced Imaging/Radiology; Cardiology) and an administrative vendor/reviewer tag (frequently 'Carelon').

These chunks present mapping rows but do not define coverage rules.

Examples include advanced imaging codes (e.g., 78451, 78452) and radiopharmaceutical HCPCS entries (C8908, C8909, etc.) with 'Carelon' shown as reviewer for many lines.

Non-coverage annotations

Some entries include notations about non-covered or limited-use indications.

No coverage criteria in this fragment

These fragments consist of code-to-description rows; no coverage stance or medical necessity criteria are provided in this window.

Rows list molecular genetics CPT codes (e.g., 81187–81194) with gene/test descriptors and administrative tags (Carelon) but do not include eligibility or coverage criteria in these chunks.

Codes only — no coverage criteria in this segment

Code listings and descriptors are shown; these chunks do not include explicit coverage criteria or medical necessity rules.

Coding-to-indication mappings and panel requirements

Code-level mappings with procedure-level descriptions and example indication/gene mappings; panel composition requirements and approver assignments are noted where present.

Entries list molecular genetics procedure codes (e.g., 81360, 81400–81407, 81410) with procedure-level descriptions (molecular pathology procedure levels) and example genes/variants.

Document maps many of these codes to Carelon as approver.

81400 is described as a molecular pathology procedure level for identification of a single germline variant (e.g., SNP).

Multiple procedure levels (81401–81407, 81410) are defined by analytic complexity (number of exons/amplicons/variants) and example gene uses as listed in the document.

Panel composition and test-specific requirements

Panel composition requirements and minimum gene counts are provided for certain named panels.

81431 hearing loss panels must include sequencing of at least 60 genes and include copy-number analyses for STRC and DFNB1 deletions in GJB2/GJB6.

81432 hereditary breast/ovarian cancer–related disorders panels must include sequencing of at least 10 genes and always include BRCA1, BRCA2, CDH1, MLH1, MSH2, MSH6, PALB2, PTEN, STK11, and TP53.

81441 nuclear-encoded mitochondrial gene panels must include analysis of at least 100 genes; inherited bone marrow failure syndrome panels must include at least 30 genes.

Other examples in the document specify minimum gene counts for named panels (e.g., aortic dysfunction panels >=9 genes; cardiac ion channelopathy panels >=10 genes).

Code listing without coverage rules

PLA/U-code style molecular test codes are enumerated with brief service descriptions; these chunks do not define coverage criteria.

U-code descriptors (informational)

U-code entries and related informational descriptors are listed; reviewer designation is included where present.

Selected U-code lines describe specimen types and analytic approaches (FFPE, blood/plasma, fresh tissue) and note reviewer mapping but do not contain coverage condition language in these chunks.

Enumerated test code entries

Enumerated test code entries include descriptions and administrative add-effective dates for several U-codes; many are mapped to Carelon.

Billing and coding notes (no coverage criteria present)

Billing and coding annotations are provided with list-separately instructions; no coverage criteria are present here.

These chunks provide billing descriptors and indications of list-separately billing but do not include medical necessity/coverage eligibility rules.

Administrative annotations and prior authorization notes

Administrative annotations and prior authorization notes for musculoskeletal and spine CPT codes are listed; one code explicitly requires prior authorization through Carelon.

Numerous musculoskeletal and spine CPT entries are annotated with Carelon mapping and administrative notes including 'Add effective 01/01/2024' for many added codes.

CPT 27412 (Autologous Chondrocyte Implantation, knee) is specifically annotated: 'Prior Authorization required through Carelon.'

Approver assignments

Code assignment rows indicate the approver group for listed CPT ranges and newly added codes.

Code lists, groups, and coding notes

Covered CPT CodesCPTCovered

81518	Oncology (Breast) mRNA gene expression profiling by real-time RT-PCR of 11 genes (content and 4 housekeeping) utilizing formalin-fixed paraffin-embedded tissue; algorithm reported as percentage risk for metastatic recurrence and likelihood of benefit from extended endocrine therapy.
81519	Oncology (Breast) mRNA gene expression profiling by real-time RT-PCR of 21 genes utilizing formalin-fixed paraffin-embedded tissue; algorithm reported as recurrence score.
81540	Oncology (Breast) mRNA gene expression profiling by hybrid capture of 58 genes (50 content and 8 housekeeping) utilizing formalin-fixed paraffin-embedded tissue; algorithm reported as recurrence risk score.

How providers request authorization and who to contact

Prior Authorization

Prior Authorization — How to Request

How to request prior authorization: 1) Availity Authorization & Referrals, 2) Blue_Approvr, or 3) call the prior authorization number on the member's ID card.
Carelon-managed services: Call 1-866-455-8415 or visit careloninsights.com for Carelon-handled prior authorization.
Searchable PDF guidance: Use CTRL+F to search codes or descriptions.

Prior Authorization

Vendor assignment for imaging codes

72197, 72198, 73201, 73206, 73200, 73202, 73218 — Carelon assigned
74170, 74174, 74175, 74176, 74177, 74178, 74181, 74182 — Carelon assigned
75574, 76376, 76377, 76380 — Carelon assigned
78445, 78451, 78452 — Carelon assigned
0649T, A9602, A9800, C8900–C8905 series — Carelon assigned

Prior Authorization

Imaging code mappings and review partner

CT/MR pelvis/abdomen/thorax series (e.g., 72197–72198, 74170–74178, 74181–74182) — Carelon
CT angiography and CTA postprocessing (e.g., 73206, 75574) — Carelon
3D rendering and image postprocessing (76376, 76377) — Carelon
Nuclear/PET tracers and specific HCPCS (A9602, A9800) — Carelon

Note

CPT-to-test mappings (administrative tag)

PLA/U-codes (e.g., 0103U, 0111U, 0113U, 0114U, 0118U, 0254U, 0258U, 0260U, 0262U, 0264U, 0345U, 0347U, 0348U) carry Carelon mapping tags.
Many CPT molecular genetics codes (e.g., 81163–81191 series, 81276–81279, 81360–81364, 81410–81416, 81457–81463, 81504–81520, 81542, 81546) are tagged with Carelon as approver/administrator.

Note

Administrative code listing (no auth instructions)

Large sets of CPT/HCPCS and U-codes are listed with descriptions; many are administrative mappings to Carelon.
Some entries include billing notes such as 'List separately in addition to code for primary procedure.'
Codes listed here should be cross-checked against clinical criteria and member benefits for coverage determination.

Prior Authorization

Code listing and approver assignment

Molecular genetic CPT examples: 81163–81165, 81187–81191, 81276–81279, 81360–81364 — Carelon
Comprehensive panels and exome codes: 81410–81416, 81457–81463 — Carelon
Oncology expression profiles and panels: 81504, 81518–81520, 81542, 81546 — Carelon
ENT/cochlear implant and device codes (e.g., 69717, 69930, 92633, L8614–L8618) — BCBSTX

Note

Effective date annotations / administrative notes

Add effective 01/01/2024: multiple musculoskeletal/spine and arthroscopy entries (e.g., 23700, 27331, 29805–29807, 29881–29886 series, many marked 'Add effective 01/01/2024').
Add effective 04/01/2024: select molecular oncology panels and cell-free tests (e.g., 81457–81459, 81458, 81459, 81463 annotations).
Add effective 10/01/2024: select PLA code entries (e.g., 0204U noted with Add Effective 10/01/2024).

Note

Codes and descriptions (no auth rules in excerpt)

Examples: 73200 series descriptions for CT upper extremity; 73201 CT with contrast — descriptions present, reviewer Carelon noted for many.
Molecular test descriptions include gene names, assay types (sequence analysis, duplication/deletion analysis, expression profiling) and example indications.

Prior Authorization

Code list and Carelon assignment

Code list with Carelon assignment: numerous PLA/U and CPT codes are explicitly mapped to Carelon for review — this serves as an administrative routing list for utilization management.

PLA/U-codes mapped to Carelon include 0103U, 0113U, 0114U, 0118U, 0254U, 0258U, 0260U, 0262U, 0264U, 0345U, 0347U, 0348U, 0254U, 0258U etc.
CPT molecular genetics codes across multiple ranges (811xx–815xx, 814xx) are repeatedly mapped to Carelon.

Prior Authorization

U-code listing and reviewer designation

U-code listing and reviewer designation: multiple HCPCS U-codes (innovative or proprietary lab tests) are included and many designate Carelon as the reviewer/approver.

U-codes with Carelon: 0103U, 0111U (noted), 0113U, 0114U, 0118U, 0254U, 0258U, 0260U, 0262U, 0264U, 0345U, 0347U, 0348U, 0649T — Carelon assigned where indicated.
Some U-code entries include test descriptions (e.g., MRD assays, cell-free DNA, targeted NGS panels) and are managed by Carelon.

Prior Authorization

Genetic test code listings and Carelon mapping

Examples: 81163–81165 (BRCA analyses), 81187–81191 series, 81276–81279 (KRAS and related), 81360–81364 (HBB and related) — Carelon.
Broad panels/exome codes 81410–81416, 81457–81463 and oncology panels 81504–81520 — Carelon.
Markers/panels for transplant, reproductive medicine, rare disease and MRD assays (multiple U-codes and CPTs) — Carelon assigned.

Billing Rule

Procedure list and billing note

Examples: Multiparametric MRI acquisition codes may be billed separately (e.g., additional organ single-organ codes listed separately).
Spine surgery and musculoskeletal procedures note 'List separately in addition to code for primary procedure' for certain structural/allograft codes (e.g., 20931–20933 entries).

Note

Effective-date additions

Add effective 01/01/2024: many musculoskeletal/spine and arthroscopy codes (e.g., 23700, 27331, 29805–29807, 29881–29886, 29884–29886 series and others) and multiple orthopedics entries.
Add effective 04/01/2024: selected molecular oncology panels and cell-free tests (e.g., 81457–81459, 81458, 81459, 81463).
Add effective 10/01/2024: select PLA entries (e.g., 0204U).

Prior Authorization

CPT to internal approver mappings (excerpt) & Spine procedure approver assignments

Spine and spine-related codes assigned to Carelon include: 20931–20933 (structural/allograft entries noted), 62362, 62380, 63001 and other laminectomy/discectomy codes where Carelon is listed.
Musculoskeletal joint and arthroplasty codes mapped to Carelon include: 23470–23474 (shoulder arthroplasty series), 23700 (manipulation under anesthesia) — some entries include 'Add effective 01/01/2024'.
Knee/arthroscopy and meniscal repair codes mapped to Carelon include 27331–27335, 27403, 27407, 27409, 27412–27416, 27425–27428, 27488 etc., many with Carelon as approver and some with effective-date notes.