Prior authorization and vendor routing for advanced imaging and molecular genetic testing
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Lists CPT/HCPCS codes and service categories for which prior authorization may be required for Blue Cross Blue Shield of Texas members; affects providers requesting authorization for advanced imaging and related services. Applies to services managed by Carelon and other named vendors as indicated.
Effective 01/01/2025, addition of site of care to the medical necessity criteria for multiple advanced imaging CPT codes.
Update Category name from 'Non-Emergent Air Ambulance' to 'Medical Transportation' and changed services management from BCBSTX to Alacura for selected codes (with an exception for TRS Fully Insured Account: 212824 through 5/22/25).
Multiple U-codes (0575U, 0576U, 0578U, 0582U, 0583U, 0585U, 0586U, 0592U, 0597U) and other molecular/genetic test codes are assigned to Alacura/Carelon for management with effective add dates (e.g., Add effective 1/1/2026).
Coverage Criteria and Routing
Prior authorization list (administrative)
Prior authorization required for listed codes and updates:
Providers must contact Carelon Medical Benefits Management for prior authorization/management as indicated in the code listings.
Site-of-care additions (administrative)
Site-of-care addition and Carelon routing
Providers must contact Carelon for prior authorization/medical necessity review.
Carelon management requirement
Management routing
Providers must contact Carelon via phone (1-866-455-8415) or the Carelon website for management/authorization.
Management requirement (informational)
Services handled by Carelon
This excerpt lists code descriptors and vendor assignment; individual clinical medical necessity criteria are not included here.
Panel composition + Carelon management
Covered when testing meets panel composition and Carelon management requirements
Providers must contact Carelon and supply documentation of panel composition (gene list, methods) when requesting authorization.
Carelon-managed molecular genetic testing
Codes listed in this section are identified as services handled by Carelon and have specific panel/gene content descriptions when provided.
Individual medical necessity criteria for each specific test are not provided in this extract — use code descriptions (panel size, gene content) and contact Carelon for review.
The excerpt identifies code G0219 with the descriptor "PET Imaging Whole Body; Melanoma For Non-Covered Indications", indicating this specific PET whole‑body application is noted as a non‑covered example in the document fragment.
The document shows reassignment of service management for selected medical transportation and related codes to third‑party vendors: effective 01/01/2025 the category name for non‑emergent air ambulance is updated to "Medical Transportation" and services A0430/A0435 transition from BCBSTX to Alacura (with an exception for TRS Fully Insured Account: 212824 until 5/22/25 and Alacura management effective 5/23/25). Several U‑code molecular testing entries are likewise assigned to Alacura/Carelon with additional effective dates noted (e.g., add effective 1/1/2026 for some U‑codes). Providers must follow the vendor routing specified for prior authorization and benefit management.
Within the provided excerpt there are no explicit coverage exclusions or full medical necessity denial rules described; the section primarily lists molecular genetic CPT codes, brief test descriptors, and indicates that these services are handled by Carelon Medical Benefits Management for authorization and review.
Multiple entries include retirement notices. Examples in the fragment show codes flagged with "Retire Effective" dates (for example, several 814xx entries include Retire Effective 04/01/2025 and other PLA/U codes such as J0428U and codes in the 0380U/0396U range are marked with retire effective dates). These retire notices indicate the listed code will be removed or superseded effective on the stated date.
This document fragment does not state explicit coverage exclusions for the molecular genetic testing sections; instead it enumerates codes, minimum panel/gene composition requirements for some CPT panels, and notes that management/authorization is routed to Carelon for review.
The listing for PLA/U codes includes a specific retirement notice for 0078U (Pain Management opioid‑use disorder genotyping panel), shown as "Retire Effective 07/01/2025" in the fragment.
The excerpt contains multiple "Retire Effective" notices for select PLA/U codes across the molecular/genomic lists (examples include 0380U Retire Effective 04/01/2025, 0396U Retire Effective 07/01/2025, and J0428U Retire Effective 04/01/2025, among others), indicating several codes are scheduled for retirement on the dates stated.
The provided excerpt contains extensive code listings and routing instructions to Carelon for prior authorization, but it does not include detailed medical necessity rule text or full clinical decision logic for individual tests — the fragment is administrative and descriptive rather than a complete set of medical necessity criteria.
Several code lists are presented without an explicit coverage decision in the fragment; codes are mapped to test descriptors and to Carelon for management, but the excerpt itself does not contain the granular coverage determinations or clinical justification for each listed code.
The fragment does not include any statements explicitly labeled "Not Medically Necessary"; instead the document lists codes and indicates that Carelon manages prior authorization and reviews for those services.
Reiterating the same point for clarity: the excerpted sections contain code listings and vendor routing instructions but do not present explicit not‑medically‑necessary determinations within the provided text.
Code Listings and Descriptions
| 73722 | Magnetic Resonance (eg proton) Imaging Any Joint Of Lower Extremity; With Contrast Material(s) |
| 73723 | Magnetic Resonance (eg proton) Imaging Any Joint Of Lower Extremity; Without Contrast Material(s) Followed By Contrast Material(s) And Further Sequences |
| 73725 | Magnetic Resonance Angiography Lower Extremity With Or Without Contrast Material(s) |
| 74150 | Computed Tomography Abdomen; Without Contrast Material |
| 74160 | Computed Tomography Abdomen; With Contrast Material(s) |
| 74170 | Computed Tomography Abdomen; Without Contrast Material Followed By Contrast Material(s) And Further Sections |
| 74174 | Computed Tomographic Angiography Abdomen And Pelvis With Contrast Material(s) Including Noncontrast Images If Performed And Image Postprocessing |
| 74175 | Computed Tomographic Angiography Abdomen With Contrast Material(s) Including Noncontrast Images If Performed And Image Postprocessing |
| 74176 | Computed Tomography Abdomen And Pelvis; Without Contrast Material |
| 74177 | Computed Tomography Abdomen And Pelvis; With Contrast Material(s) |
| 81205 | See molecular genetic code list (BRCA and others) |
| 81208 | See molecular genetic code list |
| 81209 | See molecular genetic code list |
| 81210 | See molecular genetic code list |
| 81212 | See molecular genetic code list |
| 81215 | See molecular genetic code list |
| 81216 | See molecular genetic code list |
| 81217 | See molecular genetic code list |
| 81218 | See molecular genetic code list |
| 81221 | See molecular genetic code list |
| 0016M | See source |
| 0016U | See source |
| 0017M | See source |
| 0017U | See source |
| 0018U | Oncology RNA whole-transcriptome sequencing — see policy |
| 0019U | Oncology RNA whole-transcriptome sequencing — see policy |
| 0022U | Targeted genomic sequence analysis panel — see policy |
| 0023U | Oncology AML genotyping — see policy |
| 0026U | See source |
| 0027U | See source |
Provider Responsibilities and Authorization Steps
Coverage and Denial Risk / How to Initiate Authorization
Prior authorization is required for many services listed in this document. Presence of a code on this list does not guarantee coverage under the member's benefit contract; failure to obtain required prior authorization may result in claim denial. Providers must verify member benefits and obtain authorization per the routing rules below before scheduling or performing services.
- The presence of a code on this list does not indicate coverage — consult member benefits.
- Failure to obtain required prior authorization may risk claim denial.
Carelon Prior Authorization Routing and Contact
Services that are managed by Carelon Medical Benefits Management require prior authorization via Carelon. Providers must contact Carelon by phone at 1-866-455-8415 or via the Carelon website (https://careloninsights.com/medical-benefits_management/specialty-care) to initiate or obtain prior authorization for routed services.
- Carelon phone: 1-866-455-8415
- Carelon website: https://careloninsights.com/medical-benefits_management/specialty-care
- Claims for services routed to Carelon (advanced imaging, cardiology, nuclear medicine, PET/SPECT, molecular genetic testing, etc.) are subject to Carelon review prior to payment.
BCBSTX and Vendor Routing / Site-of-Care Updates
Certain codes and service categories continue to be handled by Blue Cross Blue Shield of Texas (BCBSTX) or other vendors. For services assigned to BCBSTX (for example selected ENT/cochlear device replacement components and specific therapeutic apheresis codes), follow BCBSTX authorization processes shown on the member ID card or the BCBSTX provider resources. For medical transportation and related services, management has transitioned to Alacura (see vendor/exceptions notes) — verify routing before requesting authorization.
- BCBSTX-managed examples: L8615–L8619 device/component codes and select procedure codes (see list).
- Alacura now manages many Medical Transportation codes (A0430, A0435, etc.) — exceptions apply (TRS Fully Insured account 212824 through 5/22/25).
- Verify vendor routing (Carelon, BCBSTX, Alacura) for each code prior to submission.
Document Vendor / Exception Identifiers and Service-Management Changes
Service management assignments and exceptions (vendor identifiers, account-level exceptions, service-management changes) are documented in the code list. Providers must check the management assignment for each code and note any account-level exceptions (for example TRS Fully Insured Account: 212824) that affect where to route prior authorization requests.
- Document vendor/exception identifiers (e.g., Carelon, BCBSTX, Alacura) before requesting authorization.
- Service management changes (example: medical transportation moved from BCBSTX to Alacura) may change prior authorization routing — verify the current manager and effective dates.
- Account-level exceptions (TRS Fully Insured Account: 212824) are noted on the list — follow those exception instructions.
Panel Composition and Documentation Requirements
Molecular and genomic test panels that require prior authorization via Carelon must include documentation of panel composition when specified. Where the policy requires a minimum gene list (for example certain genomic sequence panels), include the panel gene list and methodology with the authorization request.
- When panel composition is specified, include the minimum gene list in the authorization documentation (examples: 81410, 81441, 81442 panels).
- Provide assay methodology and specimen type when requested.
- Carelon may require additional clinical documentation to determine medical necessity for complex genomic tests.
Service Changes, Effective Dates, and Code Retirement
Prior authorization requirements and routing can change over time. Providers should confirm the effective dates and retirement notes in the code list (for example: code 0078U is noted as retiring effective 07/01/2025) and verify current routing before submitting authorization requests.
- Code retirement note: 0078U — retire effective 07/01/2025.
- Check the 'Updates' or effective date column for each code to confirm current management and prior authorization requirements.
- If service management changes (e.g., transition to Alacura or Carelon), follow the new routing instructions beginning on the stated effective date.
Contrast and Imaging Technique Notes
Prior authorization applies regardless of contrast specification
Prior authorization applies regardless of contrast usage for the listed imaging CPT codes; the policy lists each code with its contrast specification (without, with, or without then with contrast).
Include contrast usage details when submitting authorizations
Many CPT descriptions explicitly indicate 'With or Without Contrast' or sequences 'Without then With Contrast'; providers should include contrast details in authorization requests as shown in code descriptors.
Definitions and Vendor Identifiers
Background and Context
This fragment of the background highlights that the document primarily contains code descriptors and administrative handling assignments. It includes codes for home infusion per‑diem services (S‑series), medical transportation (A0430/A0435) with vendor reassignment to Alacura, and numerous molecular genetic PLA/U/CPT codes with descriptors and management routing to Carelon for prior authorization.
Not Covered Examples
As an example of not‑covered content in the fragment, G0219 is described as "PET Imaging Whole Body; Melanoma For Non‑Covered Indications." The excerpt also shows that many PET, nuclear medicine, and molecular testing codes are routed to Carelon for management; providers should confirm coverage under the member's benefits and obtain any required prior authorization through the vendor pathways noted.
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