Medical/Surgical Procedures Requiring Prior Authorization — Advanced Imaging, Molecular Genetic Testing, Transport and Surgical Procedures
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List of CPT/HCPCS codes and associated prior authorization management for advanced imaging/radiology services for Blue Cross Blue Shield of Texas fully insured and certain ASO groups; indicates services that may require prior authorization and which vendor manages authorization.
Addition of site of care to the medical necessity criteria for multiple imaging CPT codes effective 01/01/2025.
Category name changed from 'Non-Emergent Air Ambulance' to 'Medical Transportation' and services management for air ambulance codes changed from BCBSTX to Alacura (with exception for TRS Fully Insured Account: 212824 through 5/22/25).
Multiple molecular genetic and new U-codes and numerous CPT molecular/genetic codes were added to the prior authorization list with management assigned to Carelon or Alacura.
Coverage Criteria — Prior Authorization Requirements
Prior authorization and upcoming site-of-care criteria
Prior authorization must be obtained and site-of-care requirements will apply starting 01/01/2025.
Per-code management and the effective date for addition of site-of-care are shown in the code list.
Prior authorization routing and requirement
Providers must submit prior authorization requests to the organization identified for each code.
Per-code vendor assignment is indicated in the code listing; follow the designated manager for submission.
Prior Authorization Required
Coverage (or consideration for coverage) for these services is contingent on obtaining prior authorization routed to the designated manager.
Some transport codes list Alacura as manager (with TRS exception through 5/22/25); many molecular/genetic codes list Carelon.
Prior authorization coverage stance
Ordering of the listed molecular genetic and molecular pathology tests requires prior authorization to be considered for coverage.
The code listings provide test descriptors and indicate Carelon as the authorization manager for these codes.
Panel gene-content coverage criteria
Coverage for specified hereditary-condition panels requires that the performed panel include the minimum gene content identified for that indication.
Exact gene lists and minimum counts are provided alongside each CPT code in the code table.
Coverage conditional on panel specification and prior authorization
Coverage is conditional on both panel content matching the listed panel definition and prior authorization being obtained through the designated administrator.
Many entries list minimum gene counts (eg >=5, >=10, >=60) or specific required genes; the performed panel must match the listed descriptor.
Prior Authorization Requirement for Listed Molecular Genetic Tests
The proprietary (PLA) and other molecular genetic test codes listed require prior authorization to be considered for coverage.
Each listed PLA/U-code includes a test descriptor and Carelon is identified as the authorization manager for these entries.
Prior authorization criteria
Prior authorization is required for the U-code (and related) molecular genetic/genomic tests before ordering.
Each U-code in the list maps to a specific test description; Carelon is listed as the administrator for the U-code entries.
Prior authorization for listed molecular genetic tests
Listed molecular genetic laboratory tests (U- and J-codes) are subject to prior authorization through Carelon.
This section enumerates U- and J-codes and their descriptors; clinical medical necessity criteria are not detailed here.
Prior Authorization — Listed Molecular Genetic Tests
The molecular genetic lab tests and other listed codes require prior authorization as indicated.
Per-code descriptors and manager assignments appear in the coding section.
Prior authorization required for listed items
All procedure and test codes enumerated in this section are subject to prior authorization as indicated.
This block is a code-list level requirement; clinical indication details beyond code descriptors are contained in the code entries.
The presence of codes on this list does not necessarily indicate coverage under a member's benefits contract. Member benefits vary by product and group; consult the member benefit booklet or contact customer service to determine whether a specific procedure or test is covered for the member in question. Fully insured groups may have specific prior authorization requirements and exceptions noted in the listing.
This excerpt is a code-level prior authorization listing and does not contain per-procedure clinical coverage criteria. It identifies CPT/HCPCS codes (for example, cardiac MRI and CT heart procedures) and the designated prior authorization administrator for each code; providers must obtain authorization where required and follow the submitting vendor’s process.
The document segment does not provide clinical coverage criteria or explicit exclusions; rather, it enumerates procedure codes (including SPECT/PET myocardial perfusion and related nuclear medicine codes) that require prior authorization and names the managing organization for those codes.
This section includes operational notes about category and vendor management changes. Effective 01/01/2025 the category name was updated from “Non‑Emergent Air Ambulance” to Medical Transportation, and services management moved from BCBSTX to Alacura, with a TRS fully insured account exception managed by BCBSTX through 05/22/2025 and transitioning to Alacura effective 05/23/2025.
The chunks in this portion are primarily code listings for molecular genetic and molecular pathology CPT codes requiring prior authorization; they do not contain explicit medical necessity criteria within the excerpt. Providers should obtain prior authorization as indicated and submit required documentation to the designated manager.
Several molecular pathology/molecular genetic codes in the list are flagged with retirement lifecycle notes. For example, some entries show 'Retire Effective 04/01/2025' for specified codes; these retirement flags should be tracked because they may change how authorizations or billing are handled after the effective retirement date.
Retirement examples include codes such as 81433, 81436, and 81438 which are noted as 'Retire Effective 04/01/2025' in the listing. Treat such entries as lifecycle notes that may affect future authorization routing or code validity and consult payer guidance at or before the retirement effective date.
This excerpt is a prior‑authorization code list and does not set out explicit exclusions; it lists services that require authorization and names the administering organization for those entries.
Some proprietary U‑codes and other test codes are marked with 'Retire Effective' dates (for example, 0380U, J0428U, 0448U, 0456U, 0396U). Codes with 'Retire Effective' flags may be removed or replaced on the payer’s authorization lists after the stated date and therefore can change authorization handling or billing workflows.
The available excerpt does not include explicit exclusions for the listed molecular genetic and molecular pathology CPT codes; it provides per‑code entries and identifies the required prior authorization process.
These chunks list codes requiring prior authorization and do not state explicit exclusions. Clinical coverage decisions remain subject to individual member contract terms and medical necessity determinations.
This code list segment does not specify conditions that are explicitly ‘not medically necessary.’ It functions as an authorization requirement list; medical necessity determinations (including potential NMN findings) must be made using the payer’s medical policy and member benefit terms.
Fallback/unknown chunk indices in the planner correspond to code‑list material in the source. The excerpt remains a prior authorization list without embedded clinical exclusion rules — consult the full medical policy for indication‑specific coverage rules.
No 'not medically necessary' statements are specified in these chunks; the document portion is a list of codes that require prior authorization. Providers should rely on detailed medical policies for determinations of medical necessity.
The molecular genetic code listings in this excerpt do not include explicit 'not medically necessary' language; instead, they enumerate tests that require prior authorization through the designated administrator.
Coding — Codes Subject to Prior Authorization
| 0042T | Cerebral perfusion analysis using CT with contrast, including post-processing |
| 0633T | CT breast including 3D rendering when performed; unilateral without contrast |
| 0634T | CT breast including 3D rendering when performed; unilateral with contrast |
| 0635T | CT breast including 3D rendering when performed; unilateral without contrast followed by contrast |
| 0636T | CT breast including 3D rendering when performed; bilateral without contrast |
| 0637T | CT breast including 3D rendering when performed; bilateral with contrast |
| 0628T | Percutaneous injection of allogeneic cellular/tissue product, intervertebral disc, lumbar; first level |
| 0629T | Percutaneous injection of allogeneic cellular/tissue product, intervertebral disc, lumbar; with CT guidance, first level |
| 20930 | Allograft morselized or placement of osteopromotive material for spine surgery |
| 20931 | Allograft structural spine surgery |
| 75565 | CT coronary calcium scoring |
| 75571 | CT heart, coronary CTA, with contrast |
| 75572 | CT heart, coronary CTA, without contrast |
| 75573 | Cardiac MR with contrast |
| 75574 | Cardiac MR without contrast |
| 75635 | Angiography, peripheral, diagnostic |
| 76376 | 3D rendering with interpretation and report |
| 76377 | Computer-aided detection/3D post-processing |
| 76380 | CT/MR elastography |
| 76390 | Qualitative/quantitative image analysis |
| 72125 | CT cervical spine without contrast |
| 72126 | CT cervical spine with contrast |
| 72127 | CT cervical spine without followed by with contrast |
| 72128 | CT thoracic spine without contrast |
| 72129 | CT thoracic spine with contrast |
| 72130 | CT thoracic spine without followed by with contrast |
| 72131 | CT lumbar spine without contrast |
| 72132 | CT lumbar spine with contrast |
| 72133 | CT lumbar spine without followed by with contrast |
| 72141 | MRI spinal canal and contents cervical without contrast |
| 72191 | CT pelvis angiography with contrast |
| 72192 | CT pelvis without contrast |
| 72193 | CT pelvis with contrast |
| 72194 | CT pelvis without followed by with contrast |
| 72195 | MRI pelvis without contrast |
| 72196 | MRI pelvis with contrast |
| 72197 | MRI pelvis without followed by with contrast |
| 72198 | MRA pelvis with or without contrast |
| 72141 | MRI spinal canal and contents cervical; without contrast |
| 72142 | MRI spinal canal and contents cervical; with contrast |
| 73200 | CT upper extremity without contrast |
| 73202 | CT upper extremity with contrast |
| 73206 | CT angiography upper extremity with contrast |
| 73218 | CT/MR upper extremity other than joint without contrast |
| 73219 | CT/MR upper extremity other than joint with contrast |
| 73220 | CT/MR upper extremity without then with contrast sequences |
| 73221 | CT/MR any joint of upper extremity without contrast |
| 73222 | CT/MR joint of upper extremity with contrast |
| 73223 | CT/MR any joint of upper extremity without then with contrast |
| 73225 | MR angiography upper extremity with or without contrast |
| 71271 | CT chest low dose for lung cancer screening without contrast |
| 71275 | CT angiography chest (noncoronary) with contrast |
| 71550 | MRI chest without contrast |
| 71551 | MRI chest with contrast |
| 71552 | MRI chest without followed by with contrast |
| 75565 | CT coronary calcium scoring |
| 75571 | CT heart/coronary CTA with contrast |
| 75572 | CT heart/coronary CTA without contrast |
| 75573 | Cardiac MRI with contrast |
| 75574 | Cardiac MRI without contrast |
| 78070 | Pulmonary ventilation imaging (planar) |
| 78071 | Pulmonary perfusion imaging (planar) |
| 78072 | Pulmonary ventilation and perfusion imaging |
| 78075 | Thyroid imaging and uptake |
| 78102 | Radioactive bile duct imaging |
| 78103 | Gastric emptying study |
| 78104 | Gastric emptying quantitative |
| 78185 | Lymphoscintigraphy, including imaging |
| 78195 | Bone imaging, whole body |
| 78201 | Liver/spleen imaging |
| 78215 | Renal cortical imaging |
| 78216 | Renal cortical imaging with quantitative analysis |
| 78226 | Testicular imaging with vascular flow |
| 78227 | Pulmonary imaging with ventilation/ perfusion |
| 78230 | Renal imaging morphology |
| 78231 | Renal imaging morphology with flow |
| 78232 | Renal imaging multiple studies |
| 78258 | Parathyroid imaging |
| 78261 | Thyroid uptake and imaging |
| 78262 | Thyroid uptake only |
| 78429 | Myocardial perfusion imaging, planar; single study |
| 78430 | Myocardial perfusion imaging, planar; multiple studies |
| 78431 | Myocardial perfusion imaging, tomographic (SPECT) single study |
| 78432 | Myocardial perfusion imaging, tomographic (SPECT) multiple studies |
| 78433 | Myocardial PET perfusion study |
| 78445 | Cardiac blood pool imaging, gated equilibrium |
| 93325 | Doppler echocardiography, complete |
| 93351 | Stress echocardiography with performance of continuous ECG monitoring |
| 93350 | Stress echocardiography (exercise/pharmacologic) |
| 81170 | ABL1 gene analysis; kinase domain variants |
| 81171 | AFF2 gene analysis; expanded alleles detection |
| 81172 | AFF2 allele characterization |
| 81173 | AR full gene sequence analysis |
| 81174 | AR known familial variant analysis |
| 81175 | ASXL1 full gene sequence analysis |
| 81176 | ASXL1 targeted sequence analysis |
| 81177 | ATN1 expanded allele detection |
| 81178 | ATXN1 expanded allele detection |
| 81179 | ATXN2 expanded allele detection |
| 81200 | ASPA common variant analysis |
| 81201 | APC full gene sequence |
| 81202 | APC known familial variant analysis |
| 81203 | APC duplication/deletion analysis |
| 81400 | Molecular pathology procedure level — single germline variant detection |
| 81401 | Molecular pathology procedure level 2 (2-10 snps/methylation/targeted) |
| 81402 | Molecular pathology procedure level 3 (>10 snps or complex analyses) |
| 81403 | Molecular pathology procedure level 4 (single exon by DNA sequence analysis etc.) |
| 81404 | Molecular pathology procedure level 5 (analysis of 2-5 exons) |
| 81405 | Molecular pathology procedure level 6 (analysis of 6-10 exons) |
| OOO1U | Red blood cell antigen typing DNA — PLA |
| OOO6M | Oncology hepatic mRNA expression PLA |
| 0011M | Prostate cancer mRNA expression assay — PLA |
| 0055U | Cardiology cell-free DNA assay (96 targets) |
| 0543U | Transplant dd-cfDNA NGS quantification |
| 0552U | Preimplantation genetic assessment — reproductive medicine |
| 0560U | Oncology MRD personalized panel — Add effective 10/1/2025 |
| 0561U | Oncology MRD subsequent assessment — Add effective 10/1/2025 |
Provider Actions — Submitting Prior Authorization and Documentation
Prior Authorization Required
Prior authorization is required for the molecular genetic/proprietary PLA tests listed in this document. Providers must obtain prior authorization before ordering these tests; failure to obtain prior authorization may result in claim denial or adverse payment action.
- PLA molecular genetic tests (U-codes and other proprietary PLA codes) listed throughout the Medical Surgical Procedures Requiring Prior Authorization section require prior authorization and are managed by Carelon as indicated.
- Presence of a code on the prior authorization list does not guarantee coverage under the member's benefits contract; coverage is determined by the member's specific benefit booklet or contract.
- Some codes in the molecular genetic section are marked as retired or retiring (examples: CPT 81433, 81436, 81438 marked Retire effective 04/01/2025; select U-codes and others list add/retire effective dates). Providers should note code lifecycle changes when submitting requests.
- Denial risk: Claims submitted without required prior authorization for listed molecular genetic tests, PLA codes, or other listed CPT/HCPCS codes may be denied.
- The policy file is a searchable PDF. Providers should use search to locate specific codes and descriptors when preparing authorization requests.
- Authorization submission destination: Prior authorization requests for codes managed by a vendor (for example, Carelon or Alacura) must be submitted to the named vendor per that vendor's submission processes and channels.
- Submit prior authorization to the listed vendor: when an entry identifies Carelon (or Alacura/BCBSTX for certain codes), route requests to that organization. For example, molecular genetic entries indicate Carelon as the authorization administrator.
- Authorization channel: Submit authorizations via the vendor's accepted channels (vendor portal, fax, or phone) as specified by the vendor; follow the vendor's documentation and submission instructions.
- Route prior authorization to the designated manager: site-of-care or service-management changes (e.g., transition of A0430/A0435 to Alacura effective 1/1/25, TRS account exceptions) require routing to the manager shown for the specific member/account.
- Documentation requirements: Include relevant clinical documentation, test type, specimen source (e.g., FFPE tumor tissue, plasma, whole blood), panel composition (when applicable), and indication to support medical necessity.
- Test-specific documentation: For genomic sequence analysis panels, document the genes included (minimum gene lists where specified), sequencing method, and specimen. For U-code entries and PLA tests, include report type and algorithm descriptions when available.
- Where to submit prior authorization: Use the authorization administrator shown next to each code (e.g., Carelon for most molecular genetic CPT/PLA/U-codes; Alacura for select medical transportation codes; BCBSTX for specified services).
- Code lifecycle note: Monitor effective and retire dates shown in the list (e.g., codes added with future effective dates or codes retired effective 04/01/2025) because these affect authorization routing and coverage determination.
Documentation Requirements
Providers must include test type, specimen, panel gene composition (when required), and any algorithm/report descriptors in the authorization request. When a panel requires sequencing of a specified minimum gene list, document that the panel meets the minimum gene set described in the policy.
- Document test type and specimen (e.g., FFPE tumor tissue, plasma cell-free DNA, whole blood, buccal swab).
- For genomic panels that specify a minimum gene list (examples in 81410, 81430, 81432, etc.), include confirmation the panel includes the named genes.
- Include clinical indication and relevant prior test results that support medical necessity for the requested test.
Denial Risk for Missing Prior Authorization
Claims for listed CPT/HCPCS/PLA/U-codes may be denied if prior authorization is not obtained when required. Providers should verify authorization status before performing or billing for services.
- Denial risk applies across advanced imaging, molecular genetic tests, home infusion, medical transportation, musculoskeletal/spine surgery codes, and other categories listed in this document.
- Retired codes (e.g., 81433, 81436, 81438 retire effective 04/01/2025) may affect authorization processing or submission — verify current code status at time of request.
Authorization Submission Destination
Authorization submissions must be directed to the administrator identified next to each code entry. Carelon is the primary prior authorization administrator for the majority of advanced imaging and molecular genetic tests in this list; Alacura manages specified medical transportation codes; BCBSTX manages select services and Fully Insured account exceptions.
- Carelon: submit authorization requests per Carelon processes for the CPT/HCPCS/PLA/U-codes that list Carelon as Managed By/Authorization Administrator.
- Alacura: submit prior authorization requests for A0430/A0435 and other medical transportation codes now managed by Alacura (note TRS Fully Insured account exceptions and effective dates).
- BCBSTX: some services remain managed by Blue Cross Blue Shield of Texas (BCBSTX) — follow the instruction in the code row when BCBSTX is listed as manager.
- If a code entry lists a vendor and an effective date or account exception, route the request according to the effective/account-specific instructions.
Code Lifecycle Note
The policy includes code lifecycle information such as add and retire dates. Providers should confirm code validity and effective/retire dates before submitting authorizations to avoid processing issues.
- Examples: certain CPT codes are marked 'Retire Effective 04/01/2025' (e.g., 81433, 81436, 81438); other codes show future add effective dates (e.g., select U-codes with Add effective 07/01/2025 or 10/01/2025).
- If a code is retired, consult the vendor and payor guidance for replacement codes or alternative submission instructions.
Prior Authorization — Modalities and Scope
Contrast and Sequence Coding Notes
Background — Document Scope and Content
This policy excerpt enumerates CPT and HCPCS procedure codes across nuclear medicine (SPECT, PET), radiopharmaceutical studies, CT breast, quantitative MRI tissue composition and a broad range of molecular and genetic laboratory tests that require prior authorization. Many imaging and molecular test codes identify Carelon as the designated prior authorization manager and include effective dates or operational notes (for example, site‑of‑care additions effective 01/01/2025).
Definitions and Abbreviations
Covered Indications — When Authorization Applies
Advanced imaging procedures — prior authorization and site-of-care effective 01/01/2025
Advanced imaging CPT codes listed in this policy require prior authorization; site-of-care additions become effective 01/01/2025.
Follow the designated authorization routing and include site-of-care information once the 1/1/2025 medical necessity updates are in effect.
Request for any listed advanced imaging procedure
Requesting any advanced imaging procedure shown in the list requires prior authorization.
This applies across modalities included in the code list.
Procedures (echocardiography, PET, SPECT, nuclear medicine) requiring prior authorization
Certain echocardiography, PET, SPECT and other nuclear medicine procedures listed require prior authorization.
echocardiography_pet_spect
- echocardiography: Transthoracic and transesophageal echocardiography codes listed (eg 93303-93306, 93350-93352) require prior authorization per the listing.
PET and advanced MRI studies
PET imaging and select advanced MRI studies listed require prior authorization.
Spine and related musculoskeletal procedures requiring authorization
Spine and related interventional/surgical procedures require prior authorization when billed under the listed CPT codes.
Some newer procedure codes (eg 0627T–0630T) have add-effective dates; follow the policy and code-level effective dates.
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