Recommended Clinical Review Procedure Code List (Imaging)
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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.
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.
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).
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.
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.
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.
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 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.
Retired and Retiring Codes — Action Required
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.
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.
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.
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.
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.
Prior Authorization and Utilization Management Routing
Contrast Use and Code Variants
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
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
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.
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).
Select CPT/PLA codes (examples: 81433, 81436 and several PLA codes annotated in the list) were scheduled as retired effective 04/01/2025.
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.
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