ModifiedBlue Cross Blue Shield - TexasPolicy N/A

Recommended Clinical Review Procedure Code List (Imaging)

List of CPT/HCPCS procedure codes that are subject to medical necessity review or recommended clinical review for Blue Cross Blue Shield - Texas (TRS). Affects providers submitting claims for the listed advanced imaging and related procedures.

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyRecommended Clinical Review Procedure Code List (Imaging)

Policy CodePolicy N/A

Change TypeSite-of-care additioncode additions and vendor mappings

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization or be prepared for utilization management review (Carelon/BCBSTX/Alacura) when billing listed advanced imaging or molecular genetic codes.

SourceLink

POLICY UPDATE CHANGES

Addition of site of care to the medical necessity criteria for multiple CPT codes effective 01/01/2025.

Carelon is identified as the utilization management vendor for the listed codes.

Multiple molecular genetic and transportation codes were added with effective dates (for example, 0575U added effective 1/1/2026 and several 81xxx codes added effective 1/1/2026 or 04/01/2025).

Category name for A0430 updated from 'Non-Emergent Air Ambulance' to 'Medical Transportation' and services management changed from BCBSTX to Alacura effective 01/01/2025.

~150+procedure codes listed in this partial extract

01/01/2025site-of-care addition effective

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new code additions effective

Carelondesignated UM vendor

04/01/2025explicit retirements noted

Coverage and Medical Necessity Criteria

Subject-to-review criteria (code list inclusion)

Codes are subject to review when billed; inclusion on the Recommended Clinical Review Procedure Code List subjects the claim to medical necessity review (some codes have site-of-care additions effective 01/01/2025 or code additions effective 01/01/2026).

List inclusion: Procedure code is included on the Recommended Clinical Review Procedure Code List

Inclusion on the list triggers medical necessity review and/or recommended clinical review as specified by the payer; many advanced imaging and related CPT/HCPCS codes are listed (see code tables).

Medical necessity update — site-of-care

Site-of-care was added to the medical necessity criteria for multiple advanced imaging CPT codes effective 01/01/2025; prior utilization management review is indicated when these codes are billed.

Site-of-care requirement: Medical necessity criteria for the billed CPT code include site-of-care considerations as specified in the payer list (addition effective 01/01/2025).effective 01/01/2025

Ordering providers must ensure the service is delivered at an appropriate site of care consistent with the payer's medical necessity rules and documentation; codes mapped to a UM vendor (e.g., Carelon) will be routed for review.

Panel gene-content criteria

Coverage applies when genomic sequence analysis panels include the minimum gene content specified for the clinical indication; ordering documentation must demonstrate panel composition.

Panel composition requirement: Panel must include sequencing (and when specified, duplication/deletion analysis) of the named minimum set and number of genes for the indicated clinical condition (examples provided in the list: aortic dysfunction panels >=9 genes including FBN1,TGFBR1,TGFBR2,COL3A1,MYH11,ACTA2,SLC2A10,SMAD3,MYLK; cardiomyopathy panels >=5 cardiomyopathy-related genes; hearing-loss panels >=60 genes).gene list and minimum count as specified per code

Providers must order a test whose gene content meets or exceeds the code-specific minimums and include documentation of the panel gene list with the authorization/claim.

Coverage criteria by code mapping

Coverage is conditioned on a match between the ordered test and the CPT/HCPCS code description (including minimum analytic scope) and on processing through the payer's utilization management where assigned.

Test-to-code match: The ordered test must correspond to the CPT/HCPCS code description in the payer list, including the minimum gene content and analytic modalities (e.g., DNA sequencing, RNA analysis, copy number/duplication–deletion assessment, rearrangement detection, microsatellite instability, tumor mutation burden, or whole mitochondrial genome with heteroplasmy detection where specified).see code-specific descriptions

Many molecular/genetic codes in the list are assigned to a utilization manager (Carelon); prior authorization/UM processing is required per the mapping.

No explicit exclusions are listed in this excerpt of the code list. The document functions as a Recommended Clinical Review Procedure Code List identifying codes that are subject to medical necessity review or utilization management; where exclusions are present they are shown as specific retirements or listed 'not covered' entries rather than broad, general exclusions in this excerpt.

The PET whole-body entry GO219 is identified in the list as PET imaging whole body; melanoma and is documented as a non-covered indication for those melanoma-related uses. Providers should not expect coverage for GO219 when billed for the non-covered melanoma indications described in the source listing and should reference the document's 'Not Covered' entries for PET melanoma uses.

The auditory rehabilitation entry for postlingual hearing loss is annotated in the code list with Retire Effective 01/01/2025. This indicates that the specific listing for postlingual auditory rehabilitation (and its associated code assignment to BCBSTX review in the excerpt) is scheduled for retirement effective that date and will be removed from the active review listing after retirement.

Several home-infusion and related per-diem S-codes in this excerpt include billing instructions that are mutually exclusive: specific entries state do not use this code with any home infusion per diem code or otherwise annotate a code as do not use with other specified home infusion per-diem codes. These notes are intended to prevent conflicting per-diem billing combinations and to guide correct code selection when submitting home infusion claims.

Certain molecular CPT codes are annotated as retired in the listing. For example, 81433 and 81436 are shown with retirement annotations (81433: "Retire Effective 04/01/2025"; 81436: "Retire Effective 04/01/2025"). These retired codes will not be active for coverage after the indicated retirement date and may be denied if billed post-retirement.

No explicit exclusions are listed in this excerpt beyond the specific retire/’not covered’ annotations and code-level notes already shown elsewhere in the document. The listing primarily identifies codes subject to medical necessity review rather than enumerating broad categorical exclusions in this extract.

Multiple U-codes in the molecular/genetic sections are annotated with retirement notes. Several entries in this region show Retire Effective 07/01/2025, indicating those specific U-code listings are scheduled for retirement effective that date and may be removed from active management lists thereafter.

The code list includes multiple entries annotated with specific retirement effective dates. Examples in the molecular/PLA group show codes such as 0388U, 0389U, 0391U, 0392U, 0400U, 0401U, 0403U, 0405U, 0409U, 0410U, 0411U, 0413U, 0414U, 0428U annotated as Retire Effective on the listed dates. These annotations signal that the codes will be removed from active coverage/management after the stated retirement date.

A subset of PLA (proprietary laboratory analysis) codes in this extract are marked with retirement annotations. Examples include PLA codes such as 0428U, 0448U, and 0456U which are shown as Retire Effective 04/01/2025. Providers should not rely on retired PLA codes after the specified retirement date and should confirm active code mappings when seeking authorization or submitting claims.

This excerpt does not define specific conditions that are labeled as Not Medically Necessary. The update shown in the document focuses on additions to medical necessity criteria (for example, site-of-care additions) and code-level annotations rather than listing explicit 'not medically necessary' conditions in this extract.

The excerpt does not list any items under a general 'Not Medically Necessary' category for the codes shown. Coverage determinations in this section are driven by code-specific composition or analytic requirements (for molecular panels) and by vendor-managed medical necessity review rather than explicit 'not medically necessary' statements in this fragment.

Procedure Codes and Code Lists

Provider Responsibilities and Prior Authorization Guidance

Prior Authorization

Prior Authorization and Vendor Review

Services and procedure codes listed in this section are subject to medical necessity and utilization management review. Providers must confirm prior authorization requirements and route requests to the assigned vendor (Carelon, BCBSTX, or Alacura) as indicated for the code. Failure to obtain required prior review or to meet medical policy criteria may result in denial.

Searchable list: providers may search the source PDF by procedure code or description to determine review status (use CTRL+F).
Utilization management vendor: many molecular genetic and advanced imaging codes are assigned to Carelon; durable medical equipment and home infusion per-diem codes often route to BCBSTX; medical transportation and ambulance codes route to Alacura.
Expect vendor documentation requests: when routed to a vendor (e.g., Carelon, BCBSTX, Alacura), be prepared to supply clinical documentation to support medical necessity and site-of-care justifications.

Denial Risk

Retired and Retiring Codes — Action Required

Prior Authorization and Utilization Management Routing

Note

Contrast Use and Code Variants

Note

Background and Scope

This document is a procedural code list used to identify CPT and HCPCS procedure codes that the payer places on the Recommended Clinical Review Procedure Code List and subjects to medical necessity or utilization management review. Inclusion on the list signals that claims for the listed procedures may require prior review and that providers should supply documentation to demonstrate medical necessity where applicable.

Definitions and Key Terms

Recommended Clinical Review Procedure Code List — definition

DefinitionRecommended Clinical Review Procedure Code List: procedure codes that, based on medical policy, are subject to medical necessity review or recommended clinical review

PurposeIdentifies CPT/HCPCS codes routed for utilization management review or prior authorization per payer policies

Access noteProviders may search the PDF by code or description to determine if a code is on this list

MEG (95965, 95966) — MEG recording and analysis codes

Codes95965, 95966 — Magnetoencephalography (MEG) recording and analysis codes

Effective dateBoth codes added effective 01/01/2026 per the document

Not Covered / Exclusions

GO219 is explicitly called out in the source as PET imaging whole body; melanoma and is associated with non-covered melanoma indications in the listing. Providers should treat GO219 as a non-covered PET whole-body melanoma indication per the document's 'Not Covered' annotation and verify alternative coding or clinical justification where appropriate.

Policy Update Changes

2026-01-01code_additionLatest

Multiple molecular genetic CPT and proprietary codes (including MEG codes and others noted in the molecular genetics section) were added or assigned effective 01/01/2026.

2025-01-01medical_necessity_update

Site-of-care requirements were added to the medical necessity criteria for multiple advanced imaging CPT codes, requiring consideration of location of service for claims (effective 01/01/2025).

2025-04-01

Policy Summary

PayerBlue Cross Blue Shield - Texas

PolicyRecommended Clinical Review Procedure Code List (Imaging)

Policy CodePolicy N/A

Change TypeSite-of-care additioncode additions and vendor mappings

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization or be prepared for utilization management review (Carelon/BCBSTX/Alacura) when billing listed advanced imaging or molecular genetic codes.

SourceLink

On This Page

Some entries in the molecular and proprietary (U-code/PLA) test listings are marked with retirement or provisional retirement dates. Providers should verify current code status before ordering or billing; use updated coding when a code is retired to avoid claim denials.

Retired/provisionally retired codes: examples include CPT codes 81433 and 81436 (Retire Effective 04/01/2025) and select U-codes annotated with 'Retire Effective' dates (e.g., 0428U, 0456U, OO79U/0087U/0088U/0089U series).
Some codes are marked 'Retire Effective' — verify effective/retirement dates and replace with current codes or updated coding guidance prior to billing.

Documentation Required

Molecular/Genetic Test Documentation and Panel Requirements

The molecular genetic testing section includes extensive panel and gene-level specifications. When requesting or billing genomic sequence analysis panels, documentation must demonstrate the panel composition meets the stated minimum gene content and that duplication/deletion analysis is included when required.

Panel composition requirement: many CPT panels (for example 81411, 81434–81441, 81440 series) require that the panel include sequencing of specified genes and, where noted, duplication/deletion analysis for named genes.
Each listed U-code entry includes a short descriptive test name and is frequently assigned to Carelon for utilization management — include the descriptive test identifiers, specimen type, and panel/gene details on authorization requests and claims.
This section enumerates CPT molecular genetic procedure codes and numerous U-code/PLA entries; providers should reference the listed test descriptors when submitting prior authorization requests.

Prior Authorization

Home Infusion and Home Therapy Prior Authorization

Home infusion, enteral/parenteral nutrition, and other home therapy per-diem codes are routed to BCBSTX and typically require prior authorization. Documentation should support home setting medical necessity, and certain per-diem codes may not be used together.

Prior authorization expectation: home infusion/home therapy per-diem HCPCS/S-codes (examples: S5501, S5517–S5521 series, S9502–S9562, B4xxx/B9xxx/E07xx series) are subject to BCBSTX utilization management review.
Per-diem service components: per-diem codes include administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment — do not separately bill included components.
Conflicting per-diem code billing: do not bill per-diem codes that are documented as 'do not use with' other per-diem codes; conflicting billing may result in denial.

Prior Authorization

High-Cost Durable Medical Equipment Review

Durable medical equipment items identified as high-cost (Durable Medical Equipment >$5,000) are routed to BCBSTX for review and typically require utilization management authorization. Provide brand/model information and clinical justification when requested.

DME >$5,000 examples include E0641, E0652, E0747–E0749, many E1xxx entries and device generator codes (e.g., C1052, C1062, C1822).
Documentation note: when a code is categorized under Durable Medical Equipment >$5,000, include model/brand, measurements, and justification in the authorization/claim documentation to expedite review.

Documentation Required

Outpatient Therapy Documentation Expectations

Outpatient therapy services listed (physical, occupational, speech) are subject to utilization management review by BCBSTX; ensure therapy documentation supports medical necessity and skill requirements.

Therapy documentation: codes such as 92507–92508, 92521–92522, S9152, S9443, S9472, T1027 and related CPT/HCPCS require sufficient documentation of functional deficits, skilled service rationale, frequency, and progress.
Provider action: attach therapy evaluations, re-evaluations, and plans of care when requesting prior authorization to demonstrate medical necessity.

UM mappingDocument lists these as service category Advanced Imaging/Radiology, Cardiology and notes Carelon as manager in entries

Utilization management vendor identified as responsible for reviews — Carelon

Assigned UM vendorCarelon — named utilization management vendor assigned to many listed molecular genetic and advanced imaging codes

ImplicationCodes mapped to Carelon require prior authorization/UM processing per the payer's program

Provider actionFollow Carelon's documentation and prior authorization processes where Carelon is listed as the reviewer

Carelon — utilization management vendor assigned to many codes

Carelon assignment examplesCarelon is recorded as the managing UM vendor for numerous advanced imaging and molecular test codes (examples shown across PET, MRI, CT, and molecular code sections)

Effect on claimsWhen Carelon is assigned, prior authorization or clinical review requests should be directed to Carelon as specified by payer procedures

Provider expectationAnticipate vendor-specific documentation requests for clinical justification when Carelon is the assignee

BCBSTX — internal review assignment for certain DME and specialty codes

BCBSTX internal reviewBCBSTX is recorded as the internal review assignment for certain Durable Medical Equipment and specialty codes (e.g., many E- and K-series DME codes)

Category examplesEntries labeled 'Durable Medical Equipment >$5,000' are routed to BCBSTX for utilization management review

ImplicationProviders should follow BCBSTX prior authorization processes for DME items assigned to this reviewer

Durable Medical Equipment >$5,000 — UM review category

Category nameDurable Medical Equipment >$5,000 — a utilization management review category used by BCBSTX to route higher-cost DME items for review

ExamplesMultiple E-, K-, and power wheelchair codes are listed under this category in the document

Provider actionExpect DME prior authorization and documentation requirements when an item is categorized as >$5,000

Per-diem home infusion therapy — bundled per-diem services

Per-diem definitionPer-diem home infusion therapy: bundled daily charge including administrative services, professional pharmacy services, care coordination, and necessary supplies and equipment (drugs and nursing visits coded separately)

IncludesAdministrative services, professional pharmacy services, care coordination, supplies and equipment needed to deliver home infusion per diem

Billing noteSelect appropriate per-diem S-code consistent with the service components; do not bill conflicting per-diem codes together

TPN per-diem — Total parenteral nutrition per-diem

TPN per-diem descriptionTotal parenteral nutrition (TPN) per-diem covers administrative services, professional pharmacy services, care coordination and standard TPN formula supplies; specialty additives and nursing visits are coded separately

Code examplesS9364–S9368 series for TPN per-diem levels and volumes mapped to BCBSTX in the document

Provider actionDocument formula volume and components; bill according to per-diem level and volume guidelines

Combined cfDNA and mRNA gene expression profiling (transplant rejection risk) — example

Combined cfDNA + mRNA profiling exampleCPT 81120/81121 described as quantitative donor-derived cell-free DNA (cfDNA) by whole genome NGS combined with mRNA gene expression profiling reported as a rejection risk score (liver allograft example)

Use caseTransplant rejection risk assessment combining cfDNA and mRNA algorithmic reporting

UM assignmentThese tests are assigned to Carelon for utilization management in the document

Home infusion therapy per diem — definition and components

Home infusion per-diem componentsHome infusion per diem includes administrative services, professional pharmacy services, care coordination, and necessary supplies and equipment (drugs and nursing visits coded separately)

Examples of covered itemsSupply kits, pumps, catheter care, medication preparation services referenced under home infusion categories (S-codes and B/C series)

DocumentationProvide documentation supporting per-diem selection and clinical need for home infusion services

Molecular Genetic Lab Testing — category definition

Molecular Genetic Lab Testing definitionProcedure category for genetic testing assays including full sequence analysis, targeted sequence analysis, known familial variant testing, duplication/deletion analysis, and related molecular pathology procedures

IncludesCPT and PLA codes for gene panels, exome/genome tests, and molecular pathology procedure levels

UM assignmentMany entries in this category are mapped to Carelon for utilization management review

Molecular Pathology Procedure Level — levels correspond to complexity

Procedure levelsMolecular pathology procedure levels (e.g., Level 3–9) correspond to increasing analytic complexity (number of exons/genes or types of analyses performed)

ExamplesLevel 3: targeted/non-sequencing variant analysis; Level 4: single exon by DNA sequence or >10 amplicons by multiplex PCR; higher levels cover multi-exon or multi-gene analyses

Use in codingSelect appropriate molecular pathology level code matching the laboratory analytic scope

Whole Mitochondrial Genome — sequencing requirement

Whole mitochondrial genome requirementWhole mitochondrial genome sequencing must include sequence analysis of the entire mitochondrial genome with heteroplasmy detection (document example: 81460/81465)

Clinical examplesUsed for mitochondrial disorders such as MELAS, MERRF and other mitochondrial encephalomyopathies where heteroplasmy detection is required

UM mappingThese tests are assigned to Carelon for utilization management in the document

Genomic Sequence Analysis Panel (5–50 genes) — typical panel description

Genomic Sequence Analysis Panel (5–50 genes)Typical panels interrogate 5–50 genes for solid organ or hematolymphoid neoplasms and include analysis for sequence variants and, when specified, copy number variants or rearrangements; DNA or combined DNA/RNA analysis may be required

Example codesCPT 81445, 81450, 81455 (5–50 gene panels) referenced in the document

DocumentationProvider must document that the ordered panel meets the minimum gene/content and analytic scope as listed for the CPT code

Carelon — named UM vendor assigned to many molecular genetic tests

Carelon assignmentCarelon — named utilization management vendor assigned to many listed molecular genetic tests and advanced imaging codes

ActionProviders should route prior authorization and clinical review requests per payer instructions to Carelon when it is the listed reviewer

Documentation expectationAnticipate requests for panel composition, gene lists, specimen type, and reportable results when Carelon is assigned

FFPE — Formalin-fixed paraffin-embedded tissue specimen definition

FFPE definitionFormalin-fixed paraffin-embedded (FFPE) tissue — commonly the specimen type for tumor molecular testing and referenced across numerous molecular test entries

UsageMany oncology mRNA/DNA assays and PLA tests specify FFPE as the required specimen type for analysis

Reporting implicationReports from FFPE-processed specimens often include variant calls, TMB, MSI and relevant interpretive comments required for UM review

PLA / Proprietary Laboratory Analyses codes (e.g., 0420U–0456U)

PLA / Category III descriptorPLA (Proprietary Laboratory Analyses) codes identify manufacturer-specific molecular/transcriptomic assays (examples: 0420U–0456U series) with detailed assay descriptions

Examples0420U (urine exosome sncRNA), 0428U (ctDNA panel of 56+ genes), 0433U (5 DNA regulatory markers) — some PLA codes show retire dates in the document

UM assignmentPLA codes are often assigned to Carelon for utilization management review per the document

Select CPT/PLA codes (examples: 81433, 81436 and several PLA codes annotated in the list) were scheduled as retired effective 04/01/2025.

2025-05-30vendor_assignment

Medical transportation/air and ground ambulance codes management was reassigned to Alacura Medical Transportation Management with review responsibilities effective 05/30/2025.

The document's change summary records that this file has a material change with an effective date of 01/01/2026 and is marked MODIFIED. The excerpt also shows related effective-date updates (for example, site-of-care additions effective 01/01/2025) indicating staged operational changes across the code list.