Prior Authorization and Medical Necessity Updates for Advanced Imaging, Molecular Genetic, and Related Services
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Lists CPT/HCPCS/temporary codes for advanced imaging, molecular genetic, and selected procedure categories that may require prior authorization, describes managed-by assignments (Carelon, Alacura), and notes addition of site-of-care to medical necessity criteria effective 01/01/2025.
Addition of site of care to the medical necessity criteria for numerous advanced imaging CPT codes effective 01/01/2025.
Update Category name from "Non-Emergent Air Ambulance" to "Medical Transportation" effective 01/01/2025 and changed services management from BCBSTX to Alacura for affected codes.
Multiple molecular genetic and U‑codes (e.g., 0575U, 0576U, 0578U, 0582U, 0583U, 0585U, 0586U, 0592U, 0597U) are assigned to "Medical Transportation" category and services management changed to Carelon/Alacura with effective add-dates (01/01/2025 and 01/01/2026 or 04/01/2025 for specific codes).
Multiple new molecular genetic laboratory test codes (04xxxU–05xxxU and specific S/G/G codes) were added with Carelon listed as the prior authorization administrator and various effective dates (many 07/01/2025, 10/01/2025, or 04/01/2025).
Several oncology and obstetrics noninvasive prenatal test codes (e.g., 0485U, 0486U, 0487U, 0489U, 0493U–0499U) added and marked Carelon.
High-complexity tumor sequencing and transplant donor-derived cfDNA quantification codes (e.g., 0473U, 0538U, 0543U–0544U, 0508U–0509U) added requiring prior authorization.
Coverage and Medical Necessity Criteria
Prior authorization and medical necessity updates
Listed procedures may require prior authorization and have updated medical necessity criteria
Presence on list does not guarantee coverage; member benefits determine final coverage
See individual code entries for managed-by vendor
Applies to codes indicated in the list
General prior authorization and medical necessity requirement (excerpt)
Covered when prior authorization is obtained and medical necessity criteria (including site-of-care) are met
Prior authorization required
Covered when prior authorization is obtained for the listed CPT codes from the designated reviewer
Applies to the CPT codes enumerated in this section; submit to Carelon.
Prior authorization requirement
Listed procedures require prior authorization
Many entries indicate the authorization processor (Carelon or BCBSTX).
Prior authorization requirement
Covered when prior authorization is obtained for listed procedures/codes and routed to the assigned services manager where indicated.
No additional clinical criteria provided in this excerpt; provider must follow payer/vendor submission instructions.
Prior authorization required
Prior authorization required
Carelon is listed as the authorization vendor in multiple entries
Panel-specific coverage criteria
Coverage applies when panel-specific gene content and indication requirements are met
Each CPT code in the list includes its own required gene list or minimum gene count.
Coverage contingent on prior authorization
Covered when prior authorization is obtained for the listed tests
Includes a variety of molecular/genetic CPT and proprietary codes
Prior Authorization
Listed molecular genetic lab testing services require prior authorization
Each code entry includes 'Carelon' indicating the prior authorization vendor.
Authorization requirement
Covered when prior authorized through Carelon per payer policy
No additional clinical necessity criteria provided in these chunks.
Prior authorization requirement for listed molecular/genetic tests
Covered when prior authorization is obtained for the listed codes and indications as specified
Effective dates provided for many codes; include code-specific effective date when requesting PA.
Authorization requirement
Covered when prior authorization is obtained
Prior auth routing specified to Carelon in document excerpts
The presence of codes on this prior authorization list does not by itself guarantee coverage under a member's benefits contract. Member benefits vary; providers should consult the member's benefit booklet or contact customer service to confirm whether a specific service is covered before scheduling or performing the procedure. Codes on this list indicate that prior authorization may be required beginning 01/01/2025 unless otherwise noted, but final coverage depends on the individual member contract.
This excerpt does not enumerate explicit clinical denial conditions, but it makes clear that failure to obtain required prior authorization or to supply requested information (including the newly required site-of-care detail effective 01/01/2025) may result in denial of coverage for services listed under the advanced imaging/radiology codes. Providers should submit prior authorization requests to the designated administrator (Carelon when indicated) and ensure that all requested documentation is included.
No explicit exclusion conditions for the listed codes are provided in this excerpt. The document enumerates codes that require prior authorization or routing to a specific services manager but does not list service-level exclusions within these chunks; absence of an exclusion here does not imply coverage — verify member benefits and any code-specific guidance in the full policy.
This excerpt does not state any specific additional clinical coverage conditions beyond the requirement for prior authorization. Where molecular genetic CPT codes are listed, the document identifies authorization routing (e.g., Carelon) and, for some codes, effective or retirement dates; no further explicit exclusions are described in these segments.
There are no explicit clinical coverage criteria or exclusions given in these chunks; instead, the molecular genetic CPT codes are listed with the authorization manager (Carelon) and — for many entries — panel composition or gene-count expectations. Coverage consideration requires that prior authorization be obtained per the listing and that any code-specific panel requirements (when noted) be met.
Certain molecular genetic codes in this excerpt are annotated with retirement actions. For example, entries for codes such as 81433 and 81436 (and others noted in the same segment) include a retirement effective date of 04/01/2025. Providers should confirm code validity and effective/retirement dates when preparing prior authorization requests and submitting claims.
This section of the document does not list explicit exclusions; it primarily identifies molecular/genetic test codes that require prior authorization through the named administrator (typically Carelon) and, where applicable, provides effective dates or panel composition requirements. Absence of exclusions in these chunks means providers must rely on the code-specific descriptors and the member contract to determine coverage and necessity.
Codes and Coding Details
| 81283 | MLH1 gene analysis, full sequence |
| 81284 | MLH1 gene analysis, known familial variant |
| 81285 | MSH2 gene analysis, full sequence |
| 81286 | MSH2 gene analysis, known familial variant |
| 81287 | MSH6 gene analysis, full sequence |
| 81288 | MSH6 gene analysis, known familial variant |
| 81289 | PMS2 gene analysis, full sequence |
| 81290 | PMS2 gene analysis, known familial variant |
| 81291 | EPCAM deletion analysis (Lynch-related) |
| 81292 | BRCA1 gene analysis, full sequence |
| OOO1U | Red blood cell antigen typing DNA (35 antigens) |
| OO04M | Scoliosis SNP panel (53 SNPs) saliva prognostic algorithm |
| OOO6M | Hepatic mRNA expression 161 genes, algorithmic risk classifier |
| OOO7M | Gastrointestinal neuroendocrine tumor 51-gene PCR expression nomogram |
| 0011M | Prostate mRNA assay of 12 genes (plasma/urine) |
| 0012M | Urothelial 5-gene mRNA panel (urine) |
| 0071U | CYP2D6 full gene sequence |
| 0072U | CYP2D6 targeted sequence (hybrid gene) |
| 0073U | CYP2D6 targeted sequence (2D7-2D6 hybrid) |
| 0074U | CYP2D6 targeted analysis for non-duplicated gene |
| 0211U | Pan-tumor DNA/RNA NGS (FFPE) interpretive report |
| 0212U | Whole genome and mitochondrial DNA sequence analysis (rare diseases) |
| 0228U | Photometric multianalyte prostate molecular profile (urine) |
| 0236U | SMN1/SMN2 full gene analysis (spinal muscular atrophy) |
| 0339U | Prostate HOXC6/DLX1 mRNA assay (urine) |
| 0340U | Personalized MRD ctDNA minimal residual disease assay |
| 0489U | Noninvasive prenatal fetal antigen and single-gene tests (cfDNA) |
| 0508U | Donor-derived cfDNA (40 SNPs) plasma and urine |
| 0539U | CTDNA 152-gene panel, whole-blood NGS |
| 0569U | Tumor methylation ctDNA (>20,000 DMRs) |
| 81407 | Molecular pathology procedure level 8 (analysis of 26-50 exons) |
| 81410 | Aortic dysfunction panel — sequencing of >=9 genes (incl FBN1,TGFBR1,TGFBR2,COL3A1,MYH11,ACTA2) |
| 81411 | Duplication/deletion analysis for aortic dysfunction panel |
| 81412 | Ashkenazi Jewish disorders panel (>=9 genes) |
| 81413 | Cardiac ion channelopathy panel (>=10 genes) |
| 81414 | Cardiac ion channelopathy duplication/deletion analysis (>=2 genes) |
| 81415 | Exome sequencing (clinical) |
| 81416 | Comparator exome sequencing (e.g., parents) |
| 81417 | Re-evaluation of previously obtained exome sequence |
| 81418 | Pharmacogenomics/drug metabolism panel (>=6 genes incl CYP2C19,CYP2D6) |
What Providers Must Do
What Providers Must Do
This list includes CPT, HCPCS, and proprietary codes for which prior authorization may be required effective January 1, 2025 (unless an alternate effective/retirement date is shown). Presence of a code on this prior authorization list does not guarantee coverage under the member's benefits contract — verify the member's benefit booklet or contact Customer Service. Failure to obtain required prior authorization may result in claim denial.
- Prior authorization may be required for listed codes — the codes shown throughout the document are included on the payer's prior authorization list and may require prior authorization.
- Prior authorization required — designated reviewer: Carelon — Many advanced imaging, molecular/genetic, musculoskeletal/spine, and other procedure codes listed identify Carelon as the prior authorization reviewer/authorization manager. Providers must submit requests to Carelon for those codes.
- Codes requiring prior authorization (partial) — This section contains partial listings (examples) of CPT/HCPCS/U-codes and proprietary codes that require prior authorization; the full searchable list should be used to confirm all affected codes.
- Prior authorization requirement for listed test codes — Molecular genetic laboratory tests and many genomic panels listed (CPT 812xx, 813xx, 814xx; U-/004xx/00xxx series) require prior authorization; each entry includes a code and a short descriptor (specialty/indication, specimen type, and testing method) to support the request.
- Prior authorization required for listed CPT codes — Many procedure and advanced imaging CPT codes (including but not limited to CT, MRI, PET, angiography, and specialized nuclear medicine procedures) require prior authorization.
- Claims for the listed procedure codes may be denied without prior authorization — Services included in this document (Medical Surgical Procedures Requiring Prior Authorization) may be denied if prior authorization is not obtained when required.
- Claims for the listed molecular genetic lab testing CPT codes may be denied without prior authorization — The molecular/genetic CPT, PLA, U- and J-codes listed are subject to prior authorization review by Carelon and may be denied if authorization is not obtained.
- Tests listed in this section are identified as "Medical Surgical Procedures Requiring Prior Authorization" and therefore will be subject to utilization management review.
- Submit prior authorization requests to designated reviewer — For codes managed by Carelon, providers must submit prior authorization requests to Carelon; for codes managed by BCBSTX or Alacura the document indicates the routing vendor. Site-of-care information and supporting documentation (test description, specimen type, clinical indication, panel composition when applicable) are often required.
- Prior authorization routing vendor is specified for many codes (Carelon or BCBSTX or Alacura) — Providers must reference the list to determine the correct services management vendor for submission.
- Submission routing and vendor — Prior authorization requests for advanced imaging and molecular/genetic tests are generally routed to Carelon as the vendor; some services (e.g., certain infusion or transportation codes) may be routed to Alacura or handled by BCBSTX as indicated in the list.
- Authorization manager and required submission — Each code entry includes the designated authorization manager (e.g., Carelon, BCBSTX, Alacura); providers must submit to the named administrator and include the code, short test/procedure descriptor, and any required clinical documentation.
- Provider must submit prior authorization to the listed administrator — For each molecular/genetic or procedural test identified, the provider must submit the PA request to the named reviewer (Carelon in most molecular cases) including the code and supporting documentation.
- Each listed procedure is identified by its code and short descriptor — Use the code and descriptor provided in the list when preparing prior authorization requests to ensure accurate routing and review.
- Test code and description required — When submitting PA for molecular/genetic tests, include the test code (CPT/PLA/U/J), brief test description (genes/panel and methodology), specimen type, and indication as shown in the list.
- Authorization routing — Verify the services management vendor in the code listing (Carelon, BCBSTX, Alacura) before submission; routing affects where and how the PA is submitted.
- Some specific codes include retirement or alternate effective dates — Several U-/0078U/0380U/etc. entries include retire or add effective dates (e.g., 0078U retire effective 07/01/2025; 0380U retire effective 04/01/2025; others add effective 07/01/2025 or 01/01/2026). Check the 'Updates' column for date-specific handling.
Prior Authorization Scope
Contrast and Study Variant Rules
Background and Scope
This background material explains that the file provides administrative and utilization management context for imaging and related services, including the prior authorization process and managed-by assignments. It notes the policy update effective 01/01/2025site of care to medical necessity evaluation for many advanced imaging CPT codes and repeatedly identifies Carelon (and where applicable Alacura/BCBSTX) as the authorization manager for listed codes. The document excerpt does not include detailed clinical indications within these chunks; its primary purpose here is to list codes and the operational PA routing and requirements.
Definitions and Acronyms
Policy Update Changes
Effective 01/01/2025, site-of-care was added to medical necessity criteria for numerous advanced imaging CPT codes and prior authorization routing/managed-by assignments were updated (Carelon/Alacura) including renaming the category 'Non-Emergent Air Ambulance' to 'Medical Transportation'.
Several molecular genetic CPT codes (e.g., 81195 and others noted in the list) were assigned specific effective or retirement dates effective 04/01/2025 as indicated in code entries.
Multiple new molecular genetic and proprietary U/J codes (including oncology, obstetrics, transplant, and broad genomic panels) were added with Carelon identified as the prior authorization administrator and effective add-dates of 07/01/2025 for many entries.
Selected molecular genetic U‑codes and certain medical transportation codes were reassigned to category 'Medical Transportation' with services management changed to Alacura/Carelon and additional effective add-dates (some added for 01/01/2026).
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