Commercial Prior Authorization Codes for Administrative Services
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Lists CPT and HCPCS codes for which prior authorization may be required for Blue Cross Blue Shield of Texas commercial members, describes vendor routing and how providers should submit requests; coverage depends on member benefits.
No material clinical or coverage changes in this revision.
Coverage Criteria and Prior Authorization Requirements
Coverage notes and management assignments
Presence of codes indicates prior authorization may be required; actual coverage depends on the member benefit contract.
Prior authorization requirement — code list (partial)
Listed CPT/HCPCS codes require prior authorization through Carelon.
Prior authorization list — imaging and nuclear procedures
This section enumerates CPT codes that require prior authorization; Carelon is the named reviewer for many entries across imaging and nuclear medicine.
Prior authorization code criteria
List of procedure codes requiring prior authorization and assigned reviewer/vendor.
Codes requiring prior authorization
This section enumerates codes that require prior authorization and maps them to service descriptors for coverage processing.
Prior authorization requirement
Stated codes require prior authorization; specific service descriptors and vendor mappings are provided for some codes.
Prior authorization requirements for molecular genetic testing (excerpt)
This segment indicates which molecular genetic tests require prior authorization and the routing/vendor for authorization.
Prior authorization list
Listed molecular genetic CPT codes require prior authorization through Carelon. Specific test descriptions (gene, indication, method) are provided alongside each code.
Prior authorization requirement
Prior authorization requirement for listed molecular tests.
Prior authorization criteria and panel content requirements
Prior authorization required for the listed molecular/genomic tests; certain panels must meet minimum gene content and include specified genes for the named clinical indications.
Coverage with prior authorization and panel requirements
Coverage is conditioned on prior authorization and, for many tests, on meeting specified panel composition or gene-count requirements.
Listed codes requiring prior authorization
Procedure codes and brief test descriptions requiring prior authorization.
Prior authorization requirements for listed molecular/genetic tests
Listed molecular/genetic tests require prior authorization; each entry maps a U-code to a test name/clinical indication and notes Carelon as reviewer.
Prior authorization requirements — listed tests
Listed molecular genetic laboratory procedures require prior authorization; entries map U-codes to clinical use-cases and Carelon assignment.
CPT, HCPCS and U-Code Listings
| 70473 | Computed tomographic (CT) cerebral perfusion analysis with contrast material(s), including image postprocessing performed without concurrent CT or CT angiography of the same anatomy. Add effective 4/1/2026 |
| 0042T | Cerebral Perfusion Analysis Using Computed Tomography With Contrast Administration Including Post-Processing Of Parametric Maps With Determination Of Cerebral Blood Flow, Cerebral Blood Volume, And Mean Transit Time. Remove effective 4/1/2026 |
| 81354 | Cytogenomic (genome-wide) analysis for constitutional chromosomal abnormalities; interrogation of structural and copy number variants, optical genome mapping (OGM). Add effective 4/1/2026 |
| 0508U | Hereditary Gynecological Cancer targeted mRNA sequence analysis panel (12 genes). Carelon. Remove effective 4/1/2026 |
| 78811-78816 | PET imaging limited area to whole body and PET/CT with attenuation correction |
| 78830-78832 | Radiopharmaceutical localization tomographic (SPECT) with CT transmission for localization |
| 93303-93351 | Transthoracic and transesophageal echocardiography codes including stress and Doppler complements |
| B4102-B4164, B4168-B4199, B4216-B4224, B5000-B5200 | Enteral and parenteral nutrition formulas, supplies, premix solutions and additives (various unit definitions) |
| B9002, B9004, B9006, B9998, B9999 | Enteral and parenteral infusion pumps and NOC for enteral/parenteral supplies |
| E0779-E0784, E0791, E0782-E0783 | Ambulatory and implantable infusion pumps (miscellaneous mechanical/electric pumps) |
| K0455, Q0081-Q0085 | Infusion pumps for uninterrupted parenteral administration and infusion therapy service codes |
| S5035-S5523, S9061, S9208-S9345 | Home infusion therapy per diem codes including catheter care, device maintenance/repair, enteral nutrition per diem and other home therapy per diems |
| S9341 | Home therapy; Enteral Nutrition via gravity; administrative services, professional pharmacy services, care coordination and all necessary supplies and equipment (enteral formula and nursing visits coded separately) per diem |
| S9342 | Home therapy; Enteral Nutrition via pump; administrative services ... per diem |
| S9365 | Home infusion therapy TPN; one liter per day; includes standard TPN formula, supplies and equipment; per diem |
| S9366 | Home infusion therapy TPN; more than one liter but no more than two liters per day; per diem |
| 81121 | Molecular genetic lab testing entry (example code listed) |
| 81162 | Molecular genetic lab testing; BRCA1/BRCA2 full sequence and duplication/deletion |
| 81163 | Molecular genetic lab testing; BRCA1/BRCA2 full sequence |
| 81164 | Molecular genetic lab testing; BRCA1/BRCA2 duplication/deletion analysis |
| 81212 | BRCA1/BRCA2 specific variant entries (examples) |
| 81235 | EGFR gene analysis common variants (NSCLC examples) |
| 81244 | FMR1 fragile X characterization (expanded size and methylation) |
| 81250 | G6PC gene analysis examples (glycogen storage disease variants) |
| 81245-81324 (selected entries in this window) | Molecular genetic laboratory testing codes covering specific gene analyses (full sequence, known familial variant, duplication/deletion, targeted sequence, promoter methylation, rearrangement, STR comparative analysis, microsatellite instability, etc.) as listed. |
| 81319-81339 range | Molecular genetic lab testing codes for single gene analyses, sequence/full/known familial/duplication-deletion variants and other specific gene tests (examples in text). |
| 81340-81364 range | Molecular genetic lab testing codes for gene rearrangement, expanded allele detection, and other sequence analyses. |
| 81400-81402 | Molecular pathology procedure levels 1-3 with examples of genes and variant types per level. |
| 81402 | Molecular pathology procedure / molecular genetic lab testing examples |
| 81403 | Molecular pathology procedure level 4 (single exon by DNA sequence analysis, targeted analyses) |
| 81404 | Molecular pathology procedure level 5 (2-5 exons by sequence analysis; mutation scanning) |
| 81405 | Molecular pathology procedure level 6 (6-10 exons; regionally targeted cytogenomic array) |
| 81406 | Molecular pathology procedure level 7 (11-25 exons) |
| 81407 | Molecular pathology procedure level 8 (26-50 exons; multi-gene platforms) |
| 81408 | Molecular pathology procedure level 9 (>50 exons in single gene) |
| 81410 | Genomic sequence analysis panel for aortic dysfunction/dilation (must include at least 9 specific genes) |
| 81411 | Duplication/deletion analysis panel for aortic dysfunction (specified genes) |
| 81412 | Ashkenazi Jewish associated disorders panel (must include at least 9 genes) |
| 81430 | Genomic sequence analysis panel for hearing loss; must include sequencing of at least 60 genes |
| 81431 | Duplication/deletion analysis panel for hearing loss; must include copy number analyses for STRC and DFNB1 deletions in GJB2 and GJB6 |
| 81432 | Hereditary breast cancer-related genomic panel; sequencing of at least 10 genes always including BRCA1/BRCA2, CDH1, MLH1, MSH2, MSH6, PALB2, PTEN, STK11, TP53 |
| 81434 | Hereditary retinal disorders panel; sequencing of at least 15 genes |
| 81455 | Solid organ or hematolymphoid neoplasm panel with 51 or greater genes |
| 0013M | Algorithm reported as risk score for recurrent urothelial carcinoma |
| 0016M/0016U | Real-time PCR expression analysis of 51 genes; nomogram/tumor disease index (oncology applications) |
| 0017M/0017U | mRNA microarray/gene expression profiling and related assays (oncology profiling) |
| 0022U | Targeted genomic sequence analysis panel for non-small cell lung neoplasia (23 genes) |
| 0036U/0037U/0048U/0050U | Exome/targeted sequencing panels interrogating somatic mutations, copy number, rearrangements, MSI, tumor mutational burden |
| 0045U | mRNA gene expression profiling by RT-PCR of 12 genes for DCIS, reported as recurrence score |
| 0087U/0088U | mRNA gene expression profiling for transplant biopsy tissue (allograft rejection probability scores) |
| 0090U | mRNA gene expression profiling by RT-PCR of 23 genes for cutaneous melanoma (categorical result) |
| 0101U/0103U/0111U/0113U/0114U/0118U | Hereditary cancer panels and related NGS/Sanger/MLPA/arrayCGH with mRNA analytics |
| 0120U | mRNA gene expression profiling of 58 genes for B-cell lymphoma classification / PMBCL vs DLBCL |
| 0154U | FGFR gene alteration reported from FFPE urothelial cancer tumor tissue |
| 0155U | PALB2 mRNA sequence analysis; PIK3CA gene analysis example |
| 0156U | Copy number/sequence analysis examples |
| 0158U | APC mRNA sequence analysis; MLH1 |
| 0159U | APC mRNA sequence analysis; MSH2 |
| 0160U | APC mRNA sequence analysis; MSH6 |
| 0161U | APC mRNA sequence analysis; PMS2 |
| 0162U | Targeted mRNA panel for hereditary colon cancer (MLH1, MSH2, MSH6, PMS2) |
| 0169U | NUDT15 and TPMT gene analysis (drug metabolism) |
| 0170U | Neurology/autism RNA NGS saliva predictive algorithm |
| 0267U | Optical genome mapping / structural variant identification |
| 0268U | Genomic sequence analysis for rare hematology disorders (e.g., AHUS) – multi-gene panels |
| 0297U | Whole genome sequencing of paired malignant and normal DNA specimens |
| 0306U | Oncology MRD initial (baseline) targeted sequencing cell-free DNA |
| 0335U | Whole genome sequence analysis including multiple variant types |
| 0392U | DNA/RNA NGS 437 genes with immunotherapy response score |
| 0400U | DNA/RNA NGS 437 genes; obstetrics expanded carrier screening 145 genes |
| 0389U | IFI27 and MCEMP1 RNA RT-qPCR risk score for KD |
| 0392U | Oncology DNA and RNA NGS 437 genes with immunotherapy response score; drug metabolism panel for psychiatry indications |
| 0400U | Obstetrics expanded carrier screening (145 genes) |
| 0413U | Optical genome mapping for hematolymphoid neoplasm (copy number, structural rearrangements) |
| 0424U | Exosome-based urine analysis for prostate cancer risk |
| 0449U | Carrier screening for severe inherited conditions (minimum gene set) |
| 0474U | NGS of FFPE tumor with matched normal, 648 genes |
| 0493U | Donor-derived cell-free DNA quantification for transplant monitoring |
| 0516U | Pharmacogenomic genotyping of 40 genes with CYP2D6 CNV analysis |
How Providers Initiate Prior Authorization & Actionable Notes
How to initiate prior authorization
Initiate prior authorization using one of three methods: 1) Availity Authorization & Referrals; 2) Blue ApprovrSM; or 3) call the prior authorization number on the member’s ID card. For services managed by Alacura or Carelon, use the vendor contact information (Alacura: 1-866-671-4834; Carelon: 1-866-455-8415 or https://www.careloninsights.com/medical-benefitsmanagement/specialty-care).
Prior authorization required — additional CPT codes (Carelon)
Additional CPT codes in the pelvic/spine and related categories require prior authorization and are routed to Carelon. Providers must obtain authorization prior to service.
Upper extremity imaging prior authorization (Carelon)
Computed tomography of the upper extremity and related imaging procedures require prior authorization and are managed by Carelon. Obtain prior authorization before scheduling.
Prior authorization — imaging and nuclear medicine codes (Carelon)
Various imaging and nuclear medicine CPT/HCPCS procedures listed in the imaging sections require prior authorization; many of these are assigned to Carelon for review. Providers must request authorization prior to rendering these services.
Cardiology echocardiography codes requiring prior authorization (Carelon)
Specific transesophageal and transthoracic echocardiography CPT codes require prior authorization and are routed to Carelon for review. Obtain authorization before performing these procedures.
Doppler and transthoracic/stress echocardiography prior authorization (Carelon)
Doppler, transthoracic and stress echocardiography procedures are listed as requiring prior authorization and are assigned to Carelon. Providers must secure authorization prior to service.
Advanced imaging and radiology prior authorization codes (Carelon)
Advanced imaging and radiology HCPCS/CPT entries (including certain nuclear medicine and radiopharmaceutical codes) require prior authorization; many are assigned to Carelon for review. Providers should contact Carelon for authorization routing.
Mixed reviewer assignments — BCBSTX for select procedures
Some procedures (for example select imaging or therapeutic apheresis codes) are routed to BCBSTX rather than Carelon; these mixed reviewer assignments require providers to submit prior authorization to the mapped reviewer (BCBSTX) when indicated.
Prior authorization — home infusion and nutrition codes
Home infusion, enteral and parenteral nutrition supplies, pumps, catheter care and related HCPCS/CPT and S-/B- codes require prior authorization. Prior authorization must be obtained before initiating home infusion or home nutrition services.
Prior authorization required — home infusion/home therapy S‑codes
Per‑diem and hourly home infusion/home therapy S‑codes require prior authorization; descriptors include enteral nutrition (gravity/pump/bolus), TPN tiers, hydration tiers, and various infusion therapies. Obtain authorization per the mapped reviewer before billing.
Prior authorization required — select medical transport codes (Alacura)
Certain nonemergent medical transport codes (including fixed-wing air transport and ambulance service codes) require prior authorization and are mapped to vendor Alacura; contact Alacura for authorization routing.
Prior authorization required — listed molecular genetic CPT codes (Carelon)
Selected molecular genetic CPT codes (examples: 81120, 81121, 81162–81171) require prior authorization and are routed to Carelon for review. Providers must obtain prior authorization for these molecular genetic laboratory tests before testing.
Prior authorization routing for molecular genetic tests (Carelon)
Numerous molecular genetic laboratory procedure CPT codes are routed to Carelon for prior authorization; providers must submit authorization requests to Carelon per the listed mapping before performing testing.
Prior authorization required — molecular genetic CPT codes (81245–81324)
A broad range of CPT molecular genetic test codes (81245–81324 range and related entries) require prior authorization through Carelon; obtain authorization before ordering/testing.
- 81245
- 81246
- 81247
- 81248
- 81249
- 81250
- 81251
- 81252
- 81253
- 81254
- 81255
- 81256
- 81257
- 81258
- 81259
- 81260
- 81261
- 81262
- 81263
- 81264
- 81265
- 81266
- 81269
- 81271
- 81272
- 81273
- 81274
- 81275
- 81276
- 81277
- 81278
- 81279
- 81283
- 81284
- 81286
- 81287
- 81288
- 81289
- 81290
- 81291
- 81292
- 81293
- 81294
- 81295
- 81296
- 81297
- 81298
- 81299
- 81300
- 81301
- 81302
- 81303
- 81304
- 81305
- 81306
- 81308
- 81309
- 81310
- 81311
- 81312
- 81313
- 81314
- 81315
- 81317
- 81318
- 81319
- 81320
- 81321
- 81322
- 81323
- 81324
Prior authorization required — additional molecular CPT codes (Carelon)
Additional molecular genetic and molecular pathology CPT codes are listed as requiring prior authorization through Carelon; providers must obtain authorization prior to testing.
Prior authorization required — molecular genetic CPT codes with panel requirements (Carelon)
A range of molecular genetic/genomic CPT codes (81402–81434 and related) require prior authorization and include panel‑specific requirements; Carelon is identified as the reviewer for many entries. Obtain prior authorization and ensure panels meet any minimum gene or content requirements noted.
Prior authorization — panel gene‑count and content requirements
Certain genomic sequence analysis panels have minimum gene‑count or named‑gene requirements (examples): hearing loss panels must include sequencing of at least 60 genes; hereditary breast‑cancer panels must include at least 10 genes including BRCA1/BRCA2; aortic panels must include at least 9 specified genes. Prior authorization and panel content verification are required.
- 81410 (aortic panel) — must include at least 9 specified genes
- 81430 (hearing loss) — must include sequencing of at least 60 genes
- 81431 (hearing loss duplication/deletion) — must include STRC and DFNB1 copy number analyses
- 81432 (hereditary breast cancer) — must include sequencing of at least 10 genes including BRCA1/BRCA2
- 81434 (hereditary retinal disorders) — must include sequencing of at least 15 genes
Prior authorization required — molecular/genetic U‑codes (Carelon)
Many molecular genetic and genomic U‑codes require prior authorization and are mapped to Carelon as the reviewer; providers must obtain prior authorization for these U‑coded laboratory services before performance.
Prior authorization mapping and vendor — molecular/genetic U‑codes (Carelon)
The policy maps numerous molecular genetic/genomic procedure U‑codes to Carelon for prior authorization and medical review; submit prior authorization requests to Carelon per the code-specific mapping before ordering testing.
Definitions and Notes
Policy Revision History
Listings reflect prior authorization requirements as of January 1, 2025; presence on the list does not guarantee coverage — verify member benefits.
Document updated January 2026 noting file title '2026 Commercial Prior Authorization Codes for Administrative Services Only' and an effective date of 1/1/2026 for updated content.
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