2024 Commercial Prior Authorization Codes for ASO (partial list)
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List of CPT and HCPCS codes and service categories for which prior authorization may be required for Blue Cross Blue Shield of Texas commercial plans; identifies managed-by entity (Carelon) and provides initiation methods for authorization requests. Affects providers seeking prior authorization for listed services.
No material clinical or coverage changes in this revision.
Prior Authorization Coverage Criteria
inv-01: Prior authorization requirement summary
Prior authorization may be required for the CPT/HCPCS codes and service categories listed below; many entries designate Carelon as the managing reviewer and some codes include effective-date annotations.
inv-02: Prior authorization list (partial)
Procedures listed below require prior authorization through the indicated reviewer/vendor.
Examples (partial)
- 72159 — Magnetic Resonance Angiography Spinal Canal and Contents; Managed by Carelon (authorization required).
inv-03: Prior authorization and routing rules (code list)
Listed CPT and temporary T-codes require prior authorization; many are routed to Carelon. Specific echocardiography and Doppler codes are flagged for ASO list inclusion effective 01/01/2024.
Echocardiography / Doppler ASO flags
- 93303–93308, 93312–93317 — transthoracic and transesophageal echocardiography entries routed to Carelon and noted 'Add to ASO List effective 1/1/2024'.
inv-04: Prior authorization code list (partial)
This excerpt enumerates selected procedure and HCPCS/T-code examples that require prior authorization and often designates the reviewer/manager.
inv-05: Prior authorization requirement (partial)
Prior authorization is required for the molecular genetic CPT codes in this segment; Carelon is indicated as the reviewer for most entries.
Selected gene-specific examples
- 81174–81180 series (gene analyses for neurologic/expansion disorders) — Carelon routing indicated (authorization required).
- 81274–81287 series (Huntingtin, KRAS, JAK2 etc.) — Carelon routing indicated (authorization required).
- 81360–81364 (hemoglobin gene analyses) — managed by Carelon (authorization required).
inv-06: Prior authorization list - molecular genetic testing (excerpt)
Listed molecular genetic CPT codes and molecular pathology procedure levels require prior authorization.
inv-07: Prior authorization requirement for molecular genetic and genomic testing
The listed CPT codes for molecular genetic and molecular pathology testing require prior authorization and are routed to Carelon; certain codes include panel composition or analytic requirements.
inv-08: Prior authorization coverage criteria and panel composition notes
Prior authorization is required for the molecular genetic/genomic procedure codes listed; per-code panel composition, minimum gene counts, and analytic notes are provided where specified.
Panel composition examples
- 81431 — Hearing loss panels must include sequencing of ≥60 genes and include copy-number analysis for STRC and DFNB1 (prior authorization required).
- 81432 — Hereditary breast cancer panel must include ≥10 genes including BRCA1, BRCA2, and other listed genes (prior authorization required).
- 81441 — Nuclear-encoded mitochondrial genomic panel must include ≥100 genes; inherited bone marrow failure syndromes panel must include ≥30 genes (prior authorization required).
inv-09: Prior authorization listing and mapping
Procedure and laboratory codes in this section require prior authorization; many map to Carelon for authorization handling and include clinical context notes.
inv-10: Prior authorization required tests (U-codes)
Prior authorization is required for the following U-code molecular genetic tests and panels; many entries designate Carelon as reviewer.
Selected U-code examples
- 0131U / 0132U / 0134U — targeted mRNA sequence panels for hereditary cancer indications; listed as 'List Separately In Addition To Code For Primary Procedure' and routed to Carelon.
inv-11: Authorization criteria — enumerated tests
Listed molecular/genetic U-codes and high-complexity tests require prior authorization and, where indicated, are managed by Carelon.
Representative high-complexity test examples
- 0274U–0278U — hematology/genetic platelet and thrombocytopenia panels (Carelon routing; prior authorization required).
inv-12: Prior authorization requirement (listing)
Codes and test descriptions requiring prior authorization through Carelon are listed; some codes include effective dates for addition.
Effective-date flag examples
inv-13: Prior authorization requirement for listed procedures
Musculoskeletal, joint and spine procedure codes listed here require prior authorization through the designated reviewer (Carelon); many codes include effective-date annotations.
Selected musculoskeletal/spine examples
- 22208–22220 series — spinal osteotomy and related procedures listed with Carelon routing (authorization required).
- 23455–23474 series — shoulder capsulorrhaphy and arthroplasty codes listed with Carelon routing (authorization required).
- 23700 — manipulation under anesthesia, shoulder joint — annotated 'Add effective 01/01/2024' and listed as requiring prior authorization via Carelon.
inv-14: Prior authorization list (musculoskeletal/joint and spine)
Procedures in the musculoskeletal/joint and spine categories require prior authorization through Carelon; some entries indicate they were added effective 01/01/2024.
Arthroscopy / hip examples
- 29860–29916 series — hip and knee arthroscopy codes listed with Carelon routing; several annotated 'Add effective 01/01/2024'.
- 29887–29892 — osteochondritis and related arthroscopy procedures listed with Carelon routing and effective-date notes (authorization required).
inv-15: Prior authorization criteria for listed CPTs
Listed spine and related CPTs require prior authorization with Carelon as the designated reviewer.
Selected spine procedure examples
- 62280–62327 series — spine injection and neurolytic injection CPTs require prior authorization via Carelon.
- 63001–63057 series — laminectomy/laminotomy and decompression CPTs listed with Carelon routing (authorization required).
- 63101–63103, 63250–63285 — vertebral corpectomy and vertebral resection entries routed to Carelon (prior authorization required).
Representative Codes and Coding Notes
| 0204U | Oncology (Thyroid) mRNA gene expression analysis of 593 genes; FNA; reported detected/not detected |
| 0452U | Oncology (bladder) methylated PENK DNA detection by LTE-qMSP, urine |
| 72159 | Magnetic Resonance Angiography Spinal Canal And Contents With Or Without Contrast Material(s) |
| 72191 | Computed Tomographic Angiography Pelvis With Contrast Material(s) Including Noncontrast Images If Performed And Image Postprocessing |
| 73200 | Computed Tomography Upper Extremity; Without Contrast Material |
| 93351 | Echocardiography code listed under prior authorization |
| 93352 | Use of echocardiographic contrast agent during stress echocardiography; listed as prior auth |
| 0042T | Cerebral perfusion analysis using CT with contrast; prior auth |
| 0633T | Computed tomography breast, unilateral without contrast; prior auth |
| 0648T | Quantitative MRI for tissue composition; prior auth |
| 81174 | Spinal And Bulbar Muscular Atrophy (Kennedy Disease) gene analysis; known familial variant |
| 81212 | BRCA1/BRCA2 gene analysis; specific variants |
| 81223 | CFTR gene analysis; full gene sequence |
| 81271 | HTT (Huntingtin) gene analysis; evaluation to detect expanded alleles |
| 81244 | FMR1 (Fragile X) gene analysis; characterization of alleles including methylation |
| 81270 | JAK2 gene analysis; V617F variant |
| 81274 | Htt (Huntingtin) gene analysis; characterization of alleles (expanded size) |
| 81275 | Molecular genetic lab testing (example entry) |
| 81361 | Hbb (Hemoglobin Subunit Beta) gene analysis; common variants (eg Hbs Hbc Hbe) |
| 81400 | Molecular pathology procedure level (identification of single germline variant by techniques such as restriction enzyme digestion or melt curve analysis) with multiple gene examples |
| 81401 | Molecular Pathology Procedure Level 2 (2-10 targets; examples and genes listed) |
| 81403 | Molecular Pathology Procedure Level 4 (single exon or >10 amplicons; examples and genes listed) |
| 81404 | Molecular Pathology Procedure Level 5 (analysis of 2-5 exons; examples and genes listed) |
| 81405 | Molecular Pathology Procedure Level 6 (6-10 exons or regionally targeted cytogenomic analysis) |
| 81406 | Molecular Pathology Procedure Level 7 (11-25 exons; examples and genes listed) |
| 81407 | Molecular Pathology Procedure Level 8 (26-50 exons or multi-gene platforms) |
| 81410 | Molecular Pathology Procedure Level 9 (>50 exons in single gene) |
| 81418 | Exome; re-evaluation or drug metabolism panel with at least 6 genes including CYP2C19 and CYP2D6 with duplication/deletion analysis |
| 81419 | Exome; re-evaluation or epilepsy genomic panel including a long list of epilepsy genes (e.g., SCN1A, SCN8A, etc.) |
| 81431 | Hearing loss panel—sequencing of at least 60 genes and copy number analysis for STRC and DFNB1 deletions |
| 81432 | Hearing loss panel (60+ genes) and hereditary breast cancer panel (≥10 genes including BRCA1/2, TP53, etc.) |
| 81441 | Nuclear-encoded mitochondrial genomic panel (≥100 genes) and inherited bone marrow failure syndromes panel (≥30 genes) |
| 81455 | Solid organ or hematolymphoid neoplasm panel with 51+ genes; interrogation for sequence and copy number variants |
| 81518 | Oncology (breast) mRNA gene expression profiling by RT-PCR of 11 genes |
| 81554 | Utilizing transbronchial biopsies diagnostic algorithm reported as categorical result (e.g., UIP) |
| 81595 | mRNA gene expression profiling by RT-qPCR (cardiology heart transplant) reported as rejection risk score |
| OO01U | Red blood cell antigen typing DNA — human erythrocyte antigen gene analysis |
| 0048U | DNA targeted sequencing of protein-coding exons of 468 cancer-associated genes |
| 0071U | CYP2D6 full gene sequence analysis |
| 0118U | Donor-derived cell-free DNA quantification by whole genome NGS |
| 0131U | Targeted mRNA sequence analysis panel (13 genes) - hereditary endometrial cancer |
| 0132U | Targeted mRNA sequence analysis panel (17 genes) - hereditary ovarian cancer–related disorders |
| 0211U | Cytogenomic constitutional (genome-wide) analysis / oncology pan-tumor DNA and RNA by NGS |
| 0244U | Oncology (solid organ) DNA comprehensive genomic profiling (257 genes) |
| 0253U | Endometrial receptivity analysis - RNA gene expression profile (238 genes) |
| 0274U | Hematology (genetic platelet disorders) genomic sequence analysis (62 genes) |
| 0297U | Oncology (Pan Tumor) Whole Genome Sequencing of paired malignant and normal DNA |
| 0298U | Oncology (Pan Tumor) Whole Transcriptome Sequencing of paired malignant and normal RNA |
| 0335U | Targeted genomic sequence analysis / whole genome sequence analysis for rare diseases |
| 0341U | Analysis of minimal residual disease (MRD) from plasma personalized to each patient |
| 0368U | Genomic sequence analysis with MRD quantification; colorectal cancer circulating cfDNA risk score |
| 0368U | Molecular Genetic Lab Testing — Oncology (Hematolymphoid Neoplasm) Genomic Sequence Analysis ... minimal residual disease (MRD); also referenced as Carelon |
| 0378U | Molecular Genetic Lab Testing — Rfc1 repeat expansion variant analysis by PCR |
| 0379U | Molecular Genetic Lab Testing — Targeted genomic sequence analysis panel (solid organ neoplasm, 523 DNA genes / 55 RNA genes) |
| 22208 | Osteotomy Of Spine Posterior Or Posterolateral Approach 1 vertebral segment; each additional segment listed separately |
| 22510 | Percutaneous vertebroplasty vertebral body injection; cervicothoracic |
| 22856 | Total disc arthroplasty anterior approach, single interspace cervical |
| 23700 | Manipulation under anesthesia, shoulder joint (note: 'Add effective 01/01/2024') |
| 23450-23466 | Shoulder capsulorrhaphy and related shoulder procedures (various CPT codes listed in this range) |
| 27130-27138 | Total hip arthroplasty and revisions |
| 27403-27447 | Knee arthrotomy/arthroplasty/ligament procedures |
| 29805-29916 | Arthroscopy procedures for shoulder, hip, knee (many codes listed) |
| 62280-62320 | Spine injection/neurolytic and injection procedures |
| 29887 | Drilling For Intact Osteochondritis Dissecans Lesion With Internal Fixation |
| 29916 | Arthroscopy Hip With Labral Repair |
| 62280 | Injection/Infusion Of Neurolytic Substance; Subarachnoid |
| 62320 | Interlaminar epidural/subarachnoid injection without imaging guidance |
| 63001 | Laminectomy with exploration/decompression; cervical (<=2 segments) |
How Providers Request Authorizations and Operational Notes
How to request prior authorization
For requests handled by Blue Cross Blue Shield of Texas, initiate authorization via: Availity Authorization & Referrals; Blue Approvr; or by calling the prior authorization number on the member's ID card. For services handled by Carelon Medical Benefits Management call 1-866-455-8415.
- Availity Authorization & Referrals
- Blue Approvr
- Call the prior authorization number on the member's ID card
- For Carelon-managed services call 1-866-455-8415
Prior authorization required for listed imaging codes
Numerous advanced imaging and related CPT/HCPCS codes in the list require prior authorization; many of these entries identify Carelon as the reviewer/vendor responsible for authorization.
- Examples include CT/MR angiography, PET/SPECT and other advanced imaging CPTs routed to Carelon
- Presence on the list indicates prior authorization is required; consult the listed reviewer
General prior authorization requirement for listed imaging/cardiology codes
A broad set of advanced imaging, cardiology CPTs and temporary T-codes (PET, SPECT, CT, MRI quantitative/T-codes) require prior authorization; many of these entries designate Carelon as the review vendor.
- Includes PET/SPECT myocardial perfusion (e.g., 78430–78433, 78451), various nuclear medicine/CT/T-codes and advanced MRI codes
- Carelon is identified as the reviewer/vendor for many listed advanced imaging and cardiology codes
Prior authorization required — selected advanced imaging and cardiology codes
The document enumerates specific advanced imaging and cardiology procedure and HCPCS/T-codes (examples include 93351, 93352, 0042T, 0633T, 0648T) that require prior authorization, with Carelon noted as the reviewer for many entries.
Prior authorization required — ENT/cochlear device codes
ENT procedures and cochlear implant/device supply codes (including L8614–L8629, L8690–L8693 and multiple CPTs) require prior authorization and are routed to Blue Cross Blue Shield of Texas (BCBSTX) for authorization.
- Examples include implant and supply HCPCS codes L8615–L8619, L8621–L8624, L8627–L8629
- BCBSTX is listed as the authorization routing for these ENT/cochlear device items
Prior authorization required — gastroenterology and molecular genetic testing codes
Gastroenterology procedures and numerous molecular genetic testing CPTs are listed as requiring prior authorization; many molecular genetic entries identify Carelon as the reviewer/vendor.
Prior authorization required for listed molecular genetic tests
A long list of molecular genetic CPT procedure codes (e.g., 81174–81287 and many others) require prior authorization; Carelon is identified as the managing review organization for most codes in this segment.
- Includes gene-specific tests (BRCA, CFTR, HTT, FMR1, JAK2, etc.)
- Carelon is shown as the reviewer for the majority of these molecular genetic entries
Prior authorization requirement and vendor (specific CPTs 81360–81364)
Molecular genetic lab testing CPT codes in the 81360–81364 range require prior authorization and are managed by Carelon.
- 81360–81364 listed with Carelon as the authorization manager
Molecular pathology and genomic sequencing prior authorization
Molecular pathology and genomic sequencing CPT codes in the 81400–81427 range require prior authorization; many entries specify procedure levels, example indications and list Carelon as the review entity.
- Includes molecular pathology procedure levels (81401–81410) and exome/genome sequencing codes (81415–81427)
- Carelon is identified as the reviewer for many of these codes
Prior authorization required for listed molecular genetic tests (panel notes)
A broad set of molecular genetic/genomic testing codes (numerous CPT/HCPCS/U codes listed) require prior authorization; many entries indicate Carelon as the authorization manager.
- Examples include exome/genome re-evaluation codes and panel-specific entries that note Carelon as reviewer
- Panel composition and minimum gene counts are specified for several codes
Prior authorization required for listed molecular/genetic tests
Numerous molecular genetic and related procedure codes—including many CPT and U-codes—are listed as requiring prior authorization and are associated with Carelon as the authorization manager.
Prior authorization requirement (vendor) for U-codes
Prior authorization is required for numerous U-code molecular genetic lab tests; Carelon is identified as the designated authorization vendor for these U-code entries.
- Selected U-codes (e.g., 0131U–0135U series) list Carelon as the reviewer
- Panel tests often include 'List Separately In Addition To Code For Primary Procedure' instructions
Newly effective codes requiring prior authorization (effective 01/01/2024)
Several oncology MRD and large genomic panel codes (e.g., 0368U, 0378U, 0379U, 0380U) are flagged with 'Add effective 01/01/2024', indicating they were newly added to the prior authorization list effective that date.
Prior authorization vendor assignment — Carelon
Carelon is listed repeatedly as the authorization entity for many of the molecular genetic and other listed procedures (examples include codes in the 0368U–0380U and 0405U ranges).
- Carelon is denoted as the reviewer/authorization manager for multiple molecular genetic codes
Upcoming additions with effective dates
Certain molecular genetic codes include future 'Add effective' annotations (for example 0405U Add Effective 07/01/2024; 0428U Add effective 04/01/2024), indicating those codes will require prior authorization beginning on the noted effective dates.
Prior authorization required — musculoskeletal/spine surgery categories
Musculoskeletal and spine surgery procedure categories (including numerous CPTs for arthroscopy, arthroplasty, spine procedures and injections) require prior authorization; Carelon is listed as the reviewer/administrator for these entries.
- Includes spine CPTs (e.g., 22208–22510, 22800–22865) and musculoskeletal procedures routed to Carelon
- Some codes include 'Add effective 01/01/2024' annotations
Prior authorization required — listed musculoskeletal procedures
Specific procedures listed in the musculoskeletal/spine sections require prior authorization and are routed to Carelon for authorization review.
- Provider must obtain prior authorization through Carelon for the listed musculoskeletal CPTs
Effective date notes — codes added 01/01/2024
Many CPT codes in the list are annotated 'Add effective 01/01/2024', indicating those CPTs were added to the prior authorization requirement list effective January 1, 2024.
- Examples: 23700 and multiple arthroscopy/arthroplasty/orthopedic codes include the 'Add effective 01/01/2024' note
Arthroscopy and related procedures prior authorization
Hip and other arthroscopy procedure codes (e.g., 29887–29916 series) require prior authorization via Carelon; several entries are annotated 'Add effective 01/01/2024'.
Spine injection procedures prior authorization
Spine injection procedures and neurolytic substance injections (CPTs such as 62280–62292, 62320–62327) require prior authorization and are routed to Carelon.
- 62280–62292 (neurolytic/injection procedures) and 62320–62327 (epidural/diagnostic/therapeutic injections) require prior authorization through Carelon
Implantation and decompression procedures prior authorization
Implantation, revision or replacement procedures for intrathecal/epidural catheters and pumps (e.g., 62350–62362) and decompression/laminectomy codes require prior authorization through Carelon.
- 62350–62362 (implantation/revision of intrathecal/epidural catheters and pumps) routed to Carelon
- Decompression/laminectomy related CPTs require prior authorization
Spinal surgery prior authorization
An extensive set of spinal surgery CPTs (laminectomy, laminotomy, corpectomy, discectomy, vertebral resection and related codes) require prior authorization; Carelon is listed as the authorization reviewer for these procedures.
Terms and Vendor Definitions
Document Status and Revision Notes
Document lists prior authorization requirements effective 01/01/2024 (codes added/flagged with 'Add effective 01/01/2024', and lists apply as of this date).
Several codes (including multiple molecular/genetic and infusion-site/drug codes) were added with 'Add effective 04/01/2024' annotations indicating they require prior authorization from this date.
Additional codes (notably specialty pharmacy and certain molecular/genetic codes) annotated 'Add Effective 07/01/2024' were scheduled to require prior authorization as of this date.
Multiple U-codes and other molecular/genetic codes show 'Add Effective 10/01/2024' or retire effective 10/01/2024 indicating further updates to prior authorization routing and requirements effective this date.
Header notes the list is 'Effective 1/1/2024 (Updated July 2024)', indicating a document update in July 2024 that revised the effective list content.
Change log entry indicating updates effective 10/01/2024 were posted on 06/25/2024 (Additions/removals of genetic testing and oncology code reviews).
Change log entry for 03/25/2024 describing additions effective 07/01/2024 including specialty pharmacy and genetic testing codes to be reviewed by Carelon.
Change log entry noting additions effective 04/01/2024 (gene therapy codes) posted 12/22/2023.
Change log entry noting additions effective 01/01/2024: specialty pharmacy medications and additions to genetic testing, medical oncology, and musculoskeletal categories (posted 09/18/2023).
Replacement/addition of certain oncology and specialty pharmacy code assignments noted in updates (e.g., J3055 replacing C9163 on 07/01/2024).
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