Precertification / Preapproval Process

Verify member eligibility and benefits via the Anthem provider site or the phone number on the member's ID card before submitting a request. Precertification/prior authorization determinations are based on the member's benefit plan and eligibility at time of review. Except for emergencies, services listed in this document that are rendered without required preapproval are subject to denial of reimbursement.

• Verify eligibility on Anthem website or call member ID card phone number
• Preapproval is benefit-plan dependent and based on eligibility at time of review
• Failure to obtain preapproval (except emergencies) may result in denial

Consequence of No Preapproval

If required preapproval is not obtained prior to rendering designated services (unless the service is an emergency), claims for those services may be denied. Providers will be notified during the precertification check if preapproval is required for the member.

• Non-emergency services without preapproval are at risk of denial
• Providers will be notified when requesting precertification if preapproval is required

Responsible UM Vendor — Carelon

Carelon Medical Benefits Management is the designated utilization management (UM) vendor for the listed categories. Determine whether a Georgia member requires preapproval by using the Medical Policy/Clinical UM Guidelines and Preapproval Requirements link on the provider website or by contacting Carelon via www.providerportal.com (select GA) or toll-free at 866-714-1103, Mon–Fri 8 a.m.–6 p.m. ET.

• Carelon manages Advanced Imaging, Musculoskeletal, Genetic Testing, Radiation Therapy, Cardiovascular services, Rehabilitative and Sleep services, Fertility, Oncology and other listed programs
• Submit preapproval requests at www.providerportal.com (select GA) or call 866-714-1103

Spine Surgery Prior Authorization Linkage

Spine surgery and spinal instrumentation CPT codes listed in this document are assigned to Carelon for prior authorization review and are evaluated using Carelon Spine Surgery medical necessity criteria and referenced MCG spine surgery/GRG guidelines. Obtain prior authorization from Carelon for procedures such as arthrodesis/fusion (e.g., 22600, 22610, 22612, 22614, 22630), laminectomy/discectomy (e.g., 62380, 63001, 63250, 63267, 63005), neurostimulator implantation/revision (e.g., 63655, 63685), and instrumentation codes (e.g., 22843–22846).

• Spine surgery codes linked to Carelon Spine Surgery criteria and MCG GRG/ISC references
• Spinal instrumentation codes assigned to Carelon and linked to pediatric and scoliosis instrumentation guidelines (e.g., 22843–22846)
• Prior authorization required for spine procedures unless emergency

Joint Surgery Prior Authorization Linkage

Shoulder, hip, knee, small joint, and other joint surgery CPT codes in the list are managed by Carelon and evaluated using Carelon Joint Surgery criteria, Site/Level of Care surgical procedures guidance and applicable MCG Joint Surgery guidelines. This includes arthroplasty, arthrotomy, ligament/meniscal repairs, and related procedures.

• Joint surgery codes (shoulder, hip, knee, small joints) require prior authorization through Carelon and reference MCG Joint Surgery guidelines
• Examples include rotator cuff repair and shoulder arthroplasty (23410, 23412, 23470–23474), hip arthroplasty/conversion (27130, 27132), knee arthrotomy/repair (27333, 27403, 27405–27416), and small joint/foot codes (28289, 28291, 28292, 28295, 28306–28312)

Knee Arthroscopy and Joint Surgery Codes

Specific joint and knee procedure codes (including arthroscopy and arthrotomy codes) are subject to Carelon review and prior authorization. Arthroscopy codes are reviewed with attention to site-of-care and level-of-care considerations.

• Knee arthroscopy and related joint surgery codes (e.g., 29873–29876, 27333, 27403) are reviewed by Carelon
• Arthroscopy codes include site-of-care/level-of-care review and may require local precertification

Venous Insufficiency / Varicose Vein Procedures

Venous insufficiency and varicose vein procedures (including endovenous ablation, mechanochemical, radiofrequency, laser, cyanoacrylate adhesive, and related codes such as 36471, 36473, 36475, 36478, 36482) require prior authorization by Carelon and are reviewed under venous treatment guidelines (Treatment of Varicose Veins and Superficial Venous Insufficiency).

• Endovenous ablation and related venous procedure codes (36471, 36473, 36475, 36478, 36482) assigned to Carelon
• Carelon applies venous insufficiency treatment guidelines and MCG references

Selected Reviewed Procedure Codes (Non‑Exhaustive)

The CPT code lists in this document are examples (non‑exhaustive) of procedures that require precertification/prior authorization and are assigned to Carelon. Providers must check member-specific requirements and submit requests to Carelon for review prior to performing these services.

• Document contains many reviewed procedure codes across specialties (surgical, imaging, genetic, cardiac, oncology, rehab, etc.)
• Providers should not assume coverage — verify and obtain prior authorization for listed services

Spine Imaging Codes

Spine advanced imaging (CT/MR/CTA of spine regions) and spine-related imaging codes (e.g., 72125–72133, 72141, 72127–72133) are assigned to Carelon and reviewed using the Imaging of the Spine and Site of Care for Advanced Imaging criteria. Obtain prior authorization from Carelon when required.

• CT/MR spine codes (72125–72133, 72141, etc.) mapped to Carelon Imaging of the Spine criteria
• Prior authorization may be required for advanced spine imaging per Site of Care guidance

Abdomen / Pelvis / Pelvis Angiography Codes

Computed tomography and magnetic resonance imaging of the abdomen and pelvis (including CT/CTA/CTA abdomen & pelvis codes 74150–74178, 72192–72198 and CTA/angiography codes such as 74174/74175) are assigned to Carelon for review under Imaging of the Abdomen and Pelvis and Site of Care for Advanced Imaging. Preauthorization is required when indicated by member benefit and Carelon guidelines.

• Abdomen/pelvis CT and MR codes (74150–74183, 74174–74178) mapped to Carelon Imaging of the Abdomen/Pelvis criteria
• CTA/angiography codes linked to vascular imaging and Site of Care for Advanced Imaging

Extremities Imaging Codes

Extremity imaging (CT/MR/MRA of upper and lower extremities, joints, and angiography) such as codes 73200–73225, 73700–73725, 73718–73723 and related angiographic codes are reviewed by Carelon under Imaging of the Extremities and Site of Care for Advanced Imaging. Obtain prior authorization when required by Carelon.

• Upper extremity imaging codes (73200–73225) and lower extremity imaging codes (73700–73725) assigned to Carelon
• Extremity MR arthrograms/joint imaging mapped to Oncologic Imaging and Site of Care for Advanced Imaging

Cardiac Imaging (MRI/CT/FFR CT) Authorization

Cardiac MRI and CT imaging codes (e.g., 75557–75563, 75571–75574, 75580) including coronary CTA, cardiac morphology/function studies, and FFR-CT (75580) are assigned to Carelon and reviewed using the Imaging of the Heart guideline. Prior authorization is required when indicated.

• Cardiac MRI/CT codes (75557, 75559, 75561, 75563) mapped to Imaging of the Heart
• Coronary CTA and FFR-CT codes (75571–75574, 75580) require Carelon review

Advanced Imaging and Ultrasound Authorization

Advanced imaging modalities (MRI/MRS, MR spectroscopy, MR elastography), specialized ultrasound (e.g., transrectal ultrasound for brachytherapy planning 76873) and other advanced imaging codes (76390, 76391, 76873, 76965, 77046–77049) are assigned to Carelon and reviewed under appropriate Imaging or Radiation Therapy guidelines.

• Advanced imaging and spectroscopy codes (76390, 76391) mapped to brain/abdomen imaging criteria
• Ultrasound codes for therapy planning (76873, 76965) assigned to Carelon and linked to Radiation Therapy criteria

PET Imaging Authorization

PET imaging (brain, myocardial, whole‑body, limited or with CT) CPT codes (e.g., 78429–78432, 78491–78492, 78608–78609, 78811–78816, 78814–78816, 78608) are assigned to Carelon and reviewed using Imaging of the Heart/Brain and Oncologic Imaging criteria. Prior authorization is required for PET studies when indicated by member benefits and Carelon guidelines.

• Myocardial and brain PET codes (78429–78432, 78608–78609) assigned to Carelon
• Whole‑body and region PET/PET‑CT codes (78811–78816) require Carelon review

Genetic Testing Codes and Associated Criteria

Genetic testing codes, including single‑gene tests, molecular pathology Level 1–9 codes (81400–81408), targeted gene analyses (e.g., 81120–81121, 81161, 81162–81167), and large genomic panels (e.g., 81410, 81430, 81455–81459) are assigned to Carelon and require preauthorization/review under Carelon categories such as Hereditary Cancer Testing, Somatic Tumor Testing, Carrier Screening, Pharmacogenetic Testing, and Whole Exome/Genome Sequencing.

• Single‑gene and gene‑analysis CPT examples: 81120, 81121, 81161, 81252–81257, 81335, 81336
• Molecular pathology Level codes 81400–81408 assigned to Carelon
• Genomic panel examples requiring review: 81410, 81430, 81455–81459

Selected Single‑Gene and Gene‑Analysis CPT Codes

Selected single‑gene and gene‑analysis CPT examples are listed and require Carelon review prior to testing; these include, but are not limited to, TPMT (81335), SMN1 (81336–81337), BRCA1/BRCA2 analyses (81162–81167), and various carrier screening gene analyses (81252–81256).

• Examples: TPMT 81335 (pharmacogenetic); SMN1 81336–81337 (SMA testing); BRCA1/2 81162–81167 (hereditary cancer testing)
• Providers must obtain Carelon prior authorization per genetic testing criteria

Molecular Oncology Panels (Examples)

Large molecular oncology/genomic panels (e.g., 81455–81459, 81462–81464) and other somatic tumor testing panels require Carelon prior authorization and are reviewed under Somatic Tumor Testing or Genetic Liquid Biopsy guidelines. These panels often have minimum gene counts and specific criteria for clinical use.

• Molecular oncology panel examples: 81455–81459 (51+ gene panels) assigned to Carelon
• Cell‑free and liquid biopsy panels (81462–81464) reviewed under Genetic Liquid Biopsy guidance

Reproductive Technology and Storage

Assisted reproductive technology and related services (e.g., assisted oocyte fertilization 89281, embryo biopsy 89290–89291, cryopreservation 89337, storage codes 89344/89346, thawing 89354/89356) require prior authorization and are managed by Carelon under Fertility and ART clinical criteria (CG‑MED references).

• Fertility/ART codes (89281, 89290–89291, 89337, 89344, 89346, 89354, 89356) assigned to Carelon
• Carelon applies CG‑MED and program‑specific criteria for ART and storage services

Speech/Language Therapy Services

Speech/language pathology evaluation and treatment codes (e.g., 92507–92508 for treatment, 92521–92524 evaluations, 92526 swallowing therapy, augmentative device evaluation 92605–92608, 92609–92611) are subject to Carelon review and prior authorization under Physical Therapy/Occupational Therapy/Speech Therapy program criteria and Site of Care guidance.

• SLP treatment and evaluation codes (92507–92508, 92521–92526) require Carelon review
• Augmentative and alternative communication device evaluation/training (92605–92609) mapped to Carelon therapy guidelines

Percutaneous Coronary Interventions

Percutaneous coronary interventions (PCI) and related coronary procedure codes (e.g., 92920, 92924, 92928, 92933, 92937, 92943, 92972) require prior authorization and are reviewed by Carelon under the Percutaneous Coronary Intervention program and applicable MCG ISC/GRG guidance.

• PCI codes (92920, 92924, 92928, 92933, 92937, 92943, 92972) assigned to Carelon
• Carelon applies MCG Percutaneous Coronary Intervention criteria

Cardiac Imaging and Device Services

Cardiac imaging, device services and monitoring codes (e.g., pacemaker/ICD implantation/replacement 33206–33227, device interrogation/programming 93150–93153, transthoracic/transesophageal echocardiography 93303–93317/93350–93351) are managed by Carelon and reviewed under Imaging of the Heart, Permanent Implantable Pacemakers and related Cardiac Device criteria.

• Permanent pacemaker/device implantation and revision codes (33206–33227) require Carelon review
• Device interrogation/programming and echocardiography codes (93150–93153, 93303–93317, 93350–93351) assigned to Carelon

Echocardiography Prior Authorization

Echocardiography codes (transthoracic and transesophageal; rest and stress studies — e.g., 93306–93308, 93312–93317, 93350–93351) are assigned to Carelon and reviewed using Imaging of the Heart criteria. Prior authorization is required when indicated by the member's benefits and Carelon guidelines.

• TTE/TEE and stress echo codes (93306–93308, 93312–93317, 93350–93351) mapped to Imaging of the Heart
• Obtain Carelon prior authorization when required by benefit plan

Coronary Angiography Prior Authorization

Diagnostic coronary angiography and left/right heart catheterization codes (e.g., 93454–93461, 93458–93460) require prior authorization and are reviewed by Carelon using Diagnostic Coronary Angiography and MCG guidance. Ensure preapproval is obtained when required.

• Coronary angiography catheterization codes (93454–93461, 93458–93460) assigned to Carelon
• Carelon applies MCG Diagnostic Coronary Angiography criteria

Electrophysiology / Ablation Prior Authorization

Electrophysiology study and ablation codes (e.g., 93600–93624, 93650, 93653–93657) are managed by Carelon and reviewed using Electrophysiological Studies and Ablation MCG guidelines. Prior authorization is required for EP studies and ablations when indicated.

• EP study and ablation codes (93600–93624, 93650, 93653–93657) assigned to Carelon
• Carelon references MCG Electrophysiological Studies and Ablation guidelines

Vascular Imaging Prior Authorization

Vascular imaging (duplex, CTA, physiologic studies) and noninvasive arterial studies (codes 93880–93882, 93922–93931, 93923–93926) are assigned to Carelon and reviewed under Vascular Imaging criteria. Prior authorization is required when indicated by benefit design and Carelon policies.

• Duplex vascular scan and physiologic study codes (93880–93882, 93922–93931) mapped to Vascular Imaging
• Providers should obtain Carelon preauthorization for vascular imaging when required

Respiratory / Sleep Study Prior Authorization

Respiratory and sleep study codes (polysomnography, unattended sleep testing, MSLT) such as 95782–95783, 95800–95811, and related service codes are reviewed by Carelon under Sleep Disorder Management. Obtain prior authorization for sleep testing and therapy when required.

• Sleep study and polysomnography codes (95782–95783, 95800–95811) assigned to Carelon
• Carelon applies Sleep Disorder Management criteria for prior authorization

Neuro / Function Imaging Prior Authorization

Neuro/function imaging and specialized functional testing (e.g., autonomic testing 95921–95923, MEG 95965–95967, motion analysis 96001) are reviewed by Carelon under Imaging of the Brain and related functional imaging criteria. Prior authorization is required when indicated.

• Autonomic testing codes (95921–95923) mapped to specific MED policies
• MEG codes (95965–95967) and motion analysis (96001) assigned to Carelon

PT / OT / SLP Services Prior Authorization

Physical, occupational and speech therapy services (PT/OT/SLP) including evaluation and established plan codes (97110 therapeutic exercise; 97112 neuromuscular reeducation; 97113 aquatic therapy; 97116 gait training; 97124 massage; 97129/97130 cognitive therapy; 97140 manual therapy; evaluation/re-evaluation codes 97161–97164, 97165–97168; activity/device codes 97530–97763) require review and prior authorization by Carelon under Rehabilitative Services and Site of Care for Therapies policies.

• Therapeutic exercise 97110 and related modalities (97010–97036, 97032–97035) mapped to Carelon therapy criteria
• Therapy evaluations (97161–97164 PT; 97165–97168 OT) and cognitive/manual/group therapy codes require Carelon review
• Activity/device and work conditioning codes (97530, 97533, 97535, 97542, 97545–97546, 97750–97763) assigned to Carelon

Therapeutic Exercise (97110)

Therapeutic exercise code 97110 (therapeutic exercises to develop strength, endurance, ROM and flexibility; each 15 minutes) is assigned to Carelon and requires prior authorization per the Physical Therapy program criteria and Site of Care guidance.

• 97110 requires Carelon review under Physical Therapy criteria
• Document therapy frequency, duration, and functional goals when submitting prior authorization requests

Various Therapy Modalities

Various therapy modalities (neuromuscular reeducation 97112, aquatic therapy 97113, gait training 97116, massage 97124, cognitive therapy 97129/97130, manual therapy 97140, group therapy 97150) and assistive device/orthotic/prosthetic management codes (97750–97763) are managed by Carelon and require prior authorization when indicated.

• Neuromuscular reeducation (97112), aquatic therapy (97113), gait training (97116) require Carelon review
• Orthotic/prosthetic management and assistive device training (97750–97763) assigned to Carelon

Therapy Cognitive / Manual / Group / Evaluation Codes

Cognitive, manual, group and evaluation codes for therapy (97129–97130 cognitive interventions; 97140 manual therapy; 97150 group therapy; evaluation/re-evaluation series 97161–97168) require Carelon prior authorization and must include documentation of functional deficits, treatment goals, and expected duration.

• Include measurable functional goals and justification when requesting authorization for cognitive/manual/group therapies
• Therapy evaluation codes (97161–97164 PT; 97165–97168 OT) mapped to Carelon review

Therapy Activity and Device‑Related Codes

Therapy activity and device‑related codes (e.g., therapeutic activities 97530, wheelchair management 97542, work hardening 97545–97546, assistive technology assessment 97755) require prior authorization under Carelon's Physical/Occupational Therapy and device management criteria. Provide assessment details and measurable objectives when requesting authorization.

• Therapeutic activities and device assessments (97530, 97542, 97755) assigned to Carelon
• Work hardening and conditioning codes (97545–97546) require Carelon review and documentation of work‑related goals

Genetic and Somatic Testing PLA Codes

Molecular pathology PLA/unique laboratory (0001U– and other PLA/unique codes) and numerous genetic/somatic testing PLA codes listed in this document are assigned to Carelon for prior authorization and are reviewed under the applicable Carelon genetic and somatic testing criteria (Somatic Tumor Testing, Hereditary Cancer Testing, Pharmacogenetic Testing, Whole Exome/Genome Sequencing, Genetic Liquid Biopsy, etc.).

• PLA/unique molecular oncology and liquid biopsy codes (0001U, 0006M, 0011M, 0012M, 0016M–0017M, 0019U–0020M, etc.) assigned to Carelon
• Carelon review required for novel/PLA molecular tests with linkage to Somatic Tumor Testing or Genetic Liquid Biopsy guidance

Genetic and Somatic Testing Codes (Excerpt)

An excerpt of genetic and somatic testing codes (examples) are included for provider awareness; these codes are reviewed by Carelon and mapped to specific Carelon criteria such as Carrier Screening, Hereditary Cancer Testing, Somatic Tumor Testing, Pharmacogenetic Testing, and Whole Exome/Genome Sequencing. Obtain preauthorization per Carelon processes.

• Examples include 0048U (large cancer panel), 0055U (heart transplant cfDNA), 81162–81167 (BRCA analyses), 81455–81459 (large somatic panels)
• Providers should submit requested clinical information consistent with the applicable Carelon criteria

Additional Genetic / Testing Codes

Additional genetic and testing codes (multiple U‑codes, PLA codes and conventional CPTs across hereditary, pharmacogenetic, and somatic testing) are assigned to Carelon and require prior authorization. Review Carelon criteria for test‑specific documentation requirements before ordering.

• Additional examples: 0016U, 0017U, 0022U, 0026U, 0036U, 0037U, 0046U
• Carelon may require clinical indication, prior treatments, pathology reports, and prior test results when authorizing advanced genetic testing

Predictive, WES/WGS, and Surgical Codes

Predictive tests, whole exome sequencing (WES)/whole genome sequencing (WGS), and certain surgical T‑codes or novel procedure codes are assigned to Carelon and reviewed under Predictive/Prognostic testing, WES/WGS criteria, or relevant surgical MCG guidance. Examples include WES/WGS panels (81425–81427, 81460, 81465), predictive polygenic tests, and specialized surgical T‑codes (e.g., 0095T, 0164T, 0169U).

• WES/WGS and related codes (81425–81427, 81460, 81465) assigned to Carelon
• Predictive polygenic tests and specialized surgical T‑codes require test‑specific Carelon review

Hereditary and Somatic Testing Codes

Hereditary cancer and somatic tumor testing codes (including many panel, sequence and copy number tests, e.g., 81162–81167, 81432, 81455–81459, 81462–81464, 0101U–0103U, 0129U) are assigned to Carelon and reviewed under Hereditary Cancer Testing and Somatic Tumor Testing criteria. Preauthorization and required clinical documentation are determined per Carelon guidelines.

• Hereditary cancer panels (e.g., 81162–81167, 81432, 0101U–0103U) and somatic tumor panels (81455–81459, 81462–81464) require Carelon review
• Providers should supply family history, tumor pathology, and prior testing when requested

Mixed Genetic and Procedure Codes

Mixed lists of genetic and procedure codes in this document indicate Carelon responsibility for both diagnostic/procedural prior authorization and genetic test review. For combined procedures (e.g., image‑guided interventions with molecular testing), follow Carelon submission processes and include all pertinent clinical and imaging/pathology documentation.

• When procedures and genetic tests are ordered together, submit both clinical and diagnostic documentation to Carelon
• Mixed code sets include interventional, imaging, surgical and genetic testing codes mapped to corresponding Carelon criteria

Polygenic, Pharmacogenetic, Cytogenomic, and Interventional Codes

Polygenic, pharmacogenetic, cytogenomic, and interventional molecular codes (e.g., 81418, 81419, 81335, 81381, 0036U, 0037U, 0070U–0076U, 0029U–0031U) are assigned to Carelon and require review under Pharmacogenetic Testing, Predictive and Prognostic Polygenic Testing, Chromosomal Microarray and Somatic testing criteria.

• Pharmacogenetic and polygenic panels (81418, 81419) assigned to Carelon
• CYP2D6 and related pharmacogenetic U‑codes (0070U–0076U, 0031U) require specific review/documentation

WES/WGS, Interventional, and Remaining Genetic Codes

Final entries including WES/WGS, interventional genetics, and remaining genetic codes (e.g., 0212U, 0213U, 0214U, 0215U, 0216U, 0217U, 0218U and other U‑codes listed) are reviewed by Carelon under the Whole Exome/Genome Sequencing, Genetic Testing for Inherited Conditions, and related Carelon clinical criteria. Obtain preauthorization per Carelon submission instructions.

• WES/WGS and rare disease genome codes (0212U, 0213U, 0214U) assigned to Carelon
• Interventional and paravertebral facet ultrasound guidance T‑codes (0213T–0218T) mapped to Interventional Pain Management and Carelon review