CurrentPremera BluecrossPolicy N/A

Prior Authorization and Code List Guidance (Coverage Criteria)

Describes prior authorization, pre-service, and retrospective review requirements, provides a code list overview, and lists services that typically require prior authorization for Premera Blue Cross members and providers.

Policy Summary

PayerPremera Bluecross

PolicyPrior Authorization and Code List Guidance (Coverage Criteria)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization requests and required documentation online via the Carelon provider portal and verify member coverage via Availity.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Code listCode list present

WA-specificWA plan exception

PA requiredPlanned inpatient stays

SeveralPossible denial / investigative

Coverage Criteria and General Rules

General PA rules: Any planned inpatient stay requires prior authorization except maternity-related services; items listed as 'Prior Authorization Required' must be reviewed and approved before the service is performed; out-of-network services requesting in-network rates require prior authorization.

Use Availity to check code status and submit reviews; member benefits may vary.

inv-02: Per-code coverage and review actions

Coverage and review actions are specified per code as follows

Prior Authorization Required codes: Codes with 'Plan Review Requirement = Prior Authorization Required' require submission of an online review with Carelon and must include requested records such as History and Physical and results of previous diagnostic/procedure reports when specified.

WA plan members may have an exception for certain oncology codes (no PA required for stage 3 or 4 or remittent/recurrent/relapsed/metastatic cancers).

Possible Denial / Investigative codes: Codes listed as 'Possible Denial; Medical Records Optional' are considered investigative, may be denied on review, and have documentation listed as optional; providers may submit documentation if available.

Examples include PLA and some T-codes flagged as Investigative or Possible Denial.

inv-03: Coverage summary

Coverage/authorization stance varies by code; many require prior authorization or are investigational.

Prior Authorization Required: Specific codes identified in the code list are subject to prior authorization and require pre-service approval; submit an online review with Carelon and provide requested records (History & Physical, prior diagnostics) as indicated.

Follow records request instructions in the code entry (Carelon provider portal).

Possible Denial/Investigative: Many biomarker, algorithm-reported, and novel assays are flagged 'Possible Denial; Medical Records Optional' and are treated as investigative — they may be denied and documentation submission is optional.

Providers may be asked for records post-service for these items.

Planned inpatient stays: Any planned inpatient stay always requires prior authorization except maternity-related services.

Verify coverage via Availity and consult the member benefit booklet.

inv-04: Coverage/Review Stances

Coverage/Review stance is specified per code as one of the following:

Prior Authorization Required: Codes marked 'Plan Review Requirement = Prior Authorization Required' must have prior authorization submitted (examples in this section include 0583U, 0585U, 0586U, 0592U, 0597U, 0605U).

Submit via Carelon/provider portal with History & Physical and prior diagnostic/procedure reports where indicated.

Possible Denial/Investigative: Codes marked 'Possible Denial; Medical Records Optional' are reviewed as investigative and may be denied; documentation is optional but may be provided.

Coverage depends on medical necessity review and member contract.

Reviewed for Medical Necessity: Some procedure codes (e.g., islet cell transplant codes 0584T/0585T/0586T) are reviewed for medical necessity and require supporting documentation for approval.

Records request typically includes History & Physical, documentation of medical necessity, and the procedure report.

Services that are not medically necessary are not covered, whether the review is done as a prior authorization or pre-service review. Prior authorization is required when the member's contract mandates it; performing a service without required prior authorization may result in denial of charges or application of a penalty. Pre-service reviews are utilization management reviews; if a pre-service review is not obtained, a retrospective medical necessity review will be conducted and the member or provider may be responsible for the full cost.

Any planned inpatient stay requires prior authorization except for maternity-related planned inpatient stays, which are excluded from the PA requirement. Providers should verify member benefits and plan-specific requirements via Availity before scheduling to confirm whether an inpatient admission requires authorization.

The presence of codes on this list does not necessarily indicate coverage under the member benefits contract. Member contracts differ; always verify coverage using Availity, the member benefit booklet, or by contacting customer service to determine whether a specific service is covered for a particular member.

Codes listed with a particular plan review requirement are administrative flags and do not guarantee coverage. Use Availity and the member benefit booklet to confirm whether a listed code is a covered benefit for the member in question.

Planned inpatient stays always require prior authorization except for maternity-related services. Items denoted as requiring PA must be reviewed and approved before the service is performed; verify plan eligibility and submit authorization requests prior to the scheduled admission.

The presence of codes on this list does not necessarily indicate coverage under the member benefits contract. Member contract terms vary and inpatient authorization expectations generally apply—confirm coverage and PA requirements through Availity or the member benefit booklet.

Any planned inpatient stay requires prior authorization except for maternity-related services. Providers should check member benefits via Availity and submit the required pre-service review when PA is indicated to avoid potential denials or financial liability.

If a code search returns no results, the code does not require review related to a medical policy; however, the presence of codes on this list is not a guarantee of coverage under the member's benefits. Always verify coverage via Availity or the member benefit booklet before proceeding.

Presence of codes on this list does not necessarily indicate coverage under the member benefits contract. Member contracts differ; providers must consult Availity, the member benefit booklet, or customer service to determine whether a specific service is a covered benefit for the member.

Presence of codes on this list does not necessarily indicate coverage under the member benefits contract; member contracts differ and coverage should be confirmed via Availity or the member benefit booklet. Planned inpatient stays generally require prior authorization except maternity-related services.

The presence of codes on this list does not necessarily indicate coverage under the member benefits contract. Member contracts differ in covered benefits; verify coverage through Availity, the member benefit booklet, or customer service before scheduling services or submitting claims.

Codes 0517U, 0518U, and 0519U are listed as Non-covered Service (Benefit Exception) and are considered non-covered unless the member's contract explicitly indicates coverage. Submissions for these codes are likely to be denied if the member's benefits do not include the service.

Specific codes in the list are labeled either 'Non-covered Service' or 'Considered non-covered unless member's contract indicates coverage' (for example, 0517U–0519U, 0520U, 0552T). Such designations indicate the service is a benefit exception and coverage depends on the member's contract.

The presence of codes on this list does not necessarily indicate coverage under the member benefits contract; member contracts differ. Always verify coverage using Availity or the member benefit booklet to confirm whether a listed code is covered for a given member.

The presence of codes on this list does not necessarily indicate coverage under the member benefits contract; member contracts differ. Providers must verify coverage via Availity or by consulting the member benefit booklet before delivering services.

Codes designated as 'Investigative' or 'Possible Denial; Medical Records Optional' are considered not established and may be denied on review. These items are treated as potentially not medically necessary; documentation may be submitted but is often optional per the record request guidance.

Tests labeled 'Investigative' or 'Possible Denial; Medical Records Optional' are treated as not established and may be denied. Submission of medical records for these investigative items is generally optional, though providers may submit documentation if available to support medical necessity.

Code Lists and Code Table Excerpts

Code List — selected examples (neutral)mixed

0186U	Red cell antigen (H blood group) genotyping (H), gene analysis, FUT1 (fucosyltransferase 1) exon(s) as specified; reported with typings.
0193U	Red cell antigen (Kidd blood group) genotyping (JK), gene analysis, SLC14A1 targeted regions; reported with typings.
0347U	Oncology (pancreatic), multiplex molecular marker analysis using next-generation methods, algorithm reported as categorical risk (description per vendor).
0457U	Oncology (urothelial), quantitative methylation or molecular marker panel, algorithm reported as positive or negative for urothelial carcinoma (description per vendor).
0472T	[Procedure] Fractional ablative laser fenestration of burn and traumatic scars for functional improvement; first 100 cm2 (primary) or 1% BSA of infants/children (see billing/site rules).
0472U	Oncology (solid tumor), targeted next-generation sequencing panel (size and gene content per test); interpretation for sequence variants and report of clinically significant findings.
0473T	[Procedure] Fractional ablative laser fenestration — add-on/alternative procedural descriptor (ensure correct CPT/PLA mapping).

Codes Requiring Plan Review — examplesmixed

0186U	Plan Review Requirement = Possible Denial; Medical Records Optional. Reviewed For = Investigative. Records Request = Documentation optional.
0193U	Plan Review Requirement = Possible Denial; Medical Records Optional. Reviewed For = Investigative. Records Request = Documentation optional.
0347U	Plan Review Requirement = Prior Authorization Required. Reviewed For = Genetic Testing. Records Request = Submit online review with Carelon at www.providerportal.com. For Prior Authorization: History and Physical, results of previous diagnostics procedure report.
0457U	Plan Review Requirement = Prior Authorization Required. Reviewed For = Genetic Testing. Records Request = Submit online review with Carelon at www.providerportal.com. For Prior Authorization: History and Physical, results of previous diagnostics procedure report.
0472U	Plan Review Requirement = Prior Authorization Required. Reviewed For = Genetic/Proprietary Testing. Records Request = Submit online review with Carelon at www.providerportal.com. For Prior Authorization: History and Physical, results of previous diagnostics procedure report.
0473U	Plan Review Requirement = Prior Authorization Required. Reviewed For = Genetic Testing. Records Request = Submit online review with Carelon at www.providerportal.com. For Prior Authorization: History and Physical, results of previous diagnostics procedure report.

Investigative / Possible Denial — examplesmixedExperimental

0472T

Listed as Investigative/Possible Denial when used for fractional ablative laser fenestration of scars; documentation optional.

Listed Codes and Descriptions (neutral) — excerptmixed

0186U	Red cell antigen (H blood group) genotyping (H), gene analysis, FUT1 locus — Possible Denial; Medical Records Optional.
0193U	Red cell antigen (Kidd blood group) genotyping (JK), gene analysis, SLC14A1 regions — Possible Denial; Medical Records Optional.
0347U	Oncology (pancreatic), comprehensive multiplex marker panel — Prior Authorization Required; Genetic Testing.
0457U	Oncology (urothelial), molecular methylation or marker assay — Prior Authorization Required; Genetic Testing.
0472T	Fractional ablative laser fenestration of burn and traumatic scars; first 100 cm2 — Investigative/Possible Denial; Documentation optional.
0472U	Tumor profiling or targeted NGS panel variant report — Prior Authorization Required; Genetic Testing.
0473T	Add-on/related procedural code for fractional ablative laser fenestration — Investigative.

Codes with Plan Review Requirements — consolidatedmixed

0347U	Prior Authorization Required; Reviewed For = Genetic Testing; Records Request = Submit online review with Carelon at www.providerportal.com. For Prior Authorization: History and Physical, results of previous diagnostics procedure report.
0457U	Prior Authorization Required; Reviewed For = Genetic Testing; Records Request = Submit online review with Carelon at www.providerportal.com. For Prior Authorization: History and Physical, results of previous diagnostics procedure report.
0472U	Prior Authorization Required; Reviewed For = Genetic Testing/Investigative; Records Request = Submit online review with Carelon at www.providerportal.com. For Prior Authorization: History and Physical, results of previous diagnostics procedure report.
0473U	Prior Authorization Required; Reviewed For = Genetic Testing; Records Request = Submit online review with Carelon at www.providerportal.com. For Prior Authorization: History and Physical, results of previous diagnostics procedure report.

Genetic testing examples (covered/neutral)mixedCovered

0473U	Oncology (solid tumor), NGS of FFPE tissue with matched normal, 648 genes — Prior Authorization Required; Genetic Testing.
0347U	Pancreatic oncology marker panel — Prior Authorization Required; Genetic Testing.

Mixed genetic and procedural codes (mixed)mixed

0472T	Fractional ablative laser fenestration; first 100 cm2 — Investigative/Possible Denial; Documentation optional.
0472U	Related genomic/proprietary test mapping — Prior Authorization Required; Genetic Testing.
0473T	Procedural add-on/related code — Investigative.

Detailed listed codes with plan review requirement — selectedmixed

0186U	Red cell antigen (H) genotyping — Possible Denial; Records Request = Documentation optional.
0193U	Red cell antigen (Kidd) genotyping — Possible Denial; Records Request = Documentation optional.
0347U	Oncology panel — Prior Authorization Required; Records Request = Submit online review with Carelon at www.providerportal.com.
0457U	Urothelial molecular assay — Prior Authorization Required; Records Request = Submit online review with Carelon at www.providerportal.com.
0472U	NGS/tumor profiling panel mapping — Prior Authorization Required; Records Request = Submit online review with Carelon at www.providerportal.com.
0473U	Large NGS panel (648 genes) — Prior Authorization Required; Records Request = Submit online review with Carelon at www.providerportal.com.

What Providers Must Do

Prior Authorization

Prior Authorization Required

Prior Authorization is required for many genetic, molecular, oncology, transplant, and other specialty tests and services listed in the Code List. Before submitting a request, providers must verify the member's plan and benefit details (use Availity) and submit the prior authorization or pre-service review as directed. Failure to obtain required pre-service review may result in retrospective review, claim denial, or financial liability to the provider or member.

Prior Authorization Required for numerous genetic and specialty tests (many U‑ and T‑codes). Submit requests via the Carelon provider portal (www.providerportal.com) unless otherwise noted.
Out‑of‑network services seeking in‑network rates always require prior authorization.
Any planned inpatient stay (except maternity-related services) requires prior authorization; check Availity and the member benefit booklet before scheduling.
If a preservice review for medical necessity is not obtained, the plan will conduct a retrospective medical necessity review; providers may be liable for costs.

Denial Risk

Investigational / Possible Denial Risk

Many individual codes in the Code List are flagged as Investigative or “Possible Denial.” For these items the plan may deny coverage; medical records are often optional but may be requested. Codes explicitly labeled “Non‑covered Service” are considered non‑covered unless the member contract indicates coverage.

Examples of Possible Denial / Investigative flags: 0002U, 0003U, 0019M, 0071T, 0080U, 0206U–0207U, 0220U, 0221T, 0222T, 0239U (investigative entries appear throughout the list).
Non‑covered service examples: 0517U–0520U are listed as Non‑covered Service (Benefit Exception) and are considered non‑covered unless the member contract indicates coverage.
Some novel, investigational, or U‑code tests carry increased risk of denial and may be subject to retrospective review if performed without prior authorization.

Documentation Required

Submission and Documentation Requirements

When Prior Authorization or Pre‑Service Review is required, submit an online review with Carelon via the provider portal and include the requested supporting documentation. For many genetic and oncology tests the Code List specifically requires a History & Physical and results of prior diagnostic procedures. For items reviewed retrospectively (non‑specific codes) submit documentation at claims time as directed.

Submission pathway: Submit online review with Carelon at www.providerportal.com for Prior Authorization requests unless otherwise noted.
Typical required records: History and Physical; results of prior diagnostic procedure reports; operative reports when applicable.
For codes listed as 'Medical Records Optional' (Possible Denial), documentation is optional but may be requested during review or post‑service.
Unlisted anesthesia (01999): include a description of the procedure and supporting documentation (operative report if surgical) with claims submission.
If a plan requests additional records, provide them promptly to avoid delays or denial.

Note

Provider Actions — Verify Coverage and Follow Code List

The Code List indicates per‑code whether review is required and what records (if any) are requested. Always verify code status for the individual member before performing services — presence on the list does not guarantee coverage.

Use Availity to check the code status against the member's plan and then submit the review; consult the member benefit booklet or customer service for coverage specifics.
The Code List shows: code, type, description, Plan Review Requirement (e.g., Prior Authorization Required, Possible Denial, Pre‑Service Review Required, Retrospective Review), Reviewed For (e.g., Genetic Testing, Investigative), and Records Request (what to submit).
All non‑specific codes are reviewed retrospectively.
WA plan members only: certain oncology genetic tests may be exempt from prior authorization for stage 3 or 4 cancer or recurrent/metastatic disease (the Code List includes these WA‑only notes).

Prior Authorization

Examples and Categories (not exhaustive)

Specific callouts from the Code List providers should note: many U‑codes and T‑codes require prior authorization; numerous codes are marked Investigative/Possible Denial; some codes are explicitly Non‑covered. Examples below illustrate these categories but are not exhaustive — always check Availity and the Code List for the current status.

Multiple U‑codes require prior authorization (examples: 0001U, 0004M, 0019U, 0022U, 0029U, 0030U, 0031U, 0034U, 0036U, 0037U, 0038U, 0040U, 0048U, 0049U, 0050U; see Code List for many more).
T‑ and U‑codes: many procedure (T) codes and molecular/genetic (U) codes are listed as Prior Authorization Required or Possible Denial — check each code’s Plan Review Requirement.
Investigational / Possible Denial examples include focused ultrasound and other novel procedures: 0071T, 0080U, 0206U, 0207U, 0263T–0265T, 0274T, 0479T (and many others marked 'Possible Denial; Medical Records Optional').
Non‑covered examples: 0517U–0520U are listed as Non‑covered Service (Benefit Exception).
Pre‑Service Review Required examples: certain tests (e.g., 0358U, 0445U, 0459U) list 'Pre‑Service Review Required' and require History & Physical and documentation of medical necessity.

Definitions and Key Terms

Outpatient Imaging Tests (examples)

Included tests (examples)CT angiography of the heart; CT scans; echocardiograms; MRI/MRA; MR spectroscopy; nuclear cardiology; PET/PET-CT.

ContextThese outpatient imaging tests are listed among services that may require prior review/authorization as noted in the code list and policy guidance.

Provider actionVerify coverage via Availity and follow plan submission procedures for prior authorization when required.

Surgical/Procedural Categories

Scope of categoriesNumerous inpatient and outpatient surgical, medical, therapeutic, diagnostic and reconstructive procedures are enumerated (eg, ablation therapy, cochlear implantation, major joint arthroplasty, transcatheter valve procedures).

ExamplesIncludes device implantations (pacemaker, ventricular assist devices), complex spine surgeries, bariatric procedures, transplant-related procedures, and select reconstructive surgeries.

VerificationPlanned inpatient stays generally require prior authorization (except maternity); use Availity to confirm member-specific requirements.

algorithm-reported test (definition)

DefinitionA laboratory assay (eg, gene expression profiling, methylation array, proteomic panel) where results are processed through an algorithm to produce a risk score, probability, or categorical interpretation for clinical decision support.

Review stanceSuch algorithm-reported tests are frequently designated as Reviewed For = Investigative or Reviewed For = Genetic Testing and have plan review flags (eg, Prior Authorization Required or Possible Denial).

DocumentationRecords request for algorithm-reported tests varies by code; follow the 'Records Request' entry for each code (often submit online review with Carelon).

mRNA gene expression profiling

Test typemRNA gene expression profiling (examples include tests reported as risk scores or categorical results using mRNA expression from tissue or blood).

Plan reviewMany mRNA gene expression profiling assays are Plan Review Requirement = Prior Authorization Required (submit online review via Carelon).

Records requestWhen PA is required, include History & Physical and prior diagnostic procedure reports as specified in the code entry.

Donor-derived cell-free DNA

DefinitionDonor-derived cell-free DNA is reported as the percentage of donor cfDNA in total cfDNA for transplant rejection assessment (eg, code 0118U, 0493U, 0540U, 0576U).

Plan review requirementDonor-derived cfDNA assays are frequently Plan Review Requirement = Prior Authorization Required; submit online review with Carelon and include History & Physical and prior diagnostic procedure reports when requested.

Use caseUsed in transplant medicine to assess allograft rejection risk; entries specify specimen type (plasma) and NGS-based quantification methods.

Plan Review Requirement / Records Request (definitions)

Plan Review Requirement — PAIndicates the code requires Prior Authorization (providers must submit an online review with Carelon and include requested documentation such as History & Physical and prior diagnostic reports).

Possible DenialIndicates the code may be denied upon review (labeled 'Possible Denial; Medical Records Optional'); documentation submission is optional but can be provided.

Records RequestSpecifies what documentation to submit with a PA or review request (commonly History & Physical and prior diagnostic procedure reports); follow the code-specific 'Records Request' entry.

Records Request / Prior authorization submission

Submission pathwaySubmit prior authorization and pre-service reviews online with Carelon at www.providerportal.com as directed in code-specific entries.

Required documentsFor many genetic and specialty tests, include History & Physical and results of previous diagnostic procedure reports; specific codes may request additional records (eg, procedure report, plan of care).

Optional documentationCodes labeled 'Possible Denial; Medical Records Optional' list documentation as optional; submit if requested or to support medical necessity.

WA PLAN MEMBERS ONLY exception

WA plan member exceptionWashington plan members only: for certain oncology codes (where noted) no prior authorization is required for requests related to stage 3 or 4 cancer or remittent, recurrent, relapsed, or metastatic cancers; post-service review may be performed.

ScopeThe WA exception is explicitly noted on multiple genetic/oncology code entries (see individual code entries that include 'WA PLAN MEMBERS ONLY').

Provider actionIf WA plan member, confirm exception applicability via Availity and submit records per plan instructions if post-service review is indicated.

Prior Authorization Required (definition)

DefinitionPrior Authorization Required — the plan review must be performed and approved before the service is performed.

Provider requirementsProviders must submit an online review with Carelon and include specified documentation (eg, History & Physical, prior diagnostic reports) when the code indicates Prior Authorization Required.

Verification stepUse Availity to check code status against the member's plan before submitting a PA; presence on the list does not guarantee coverage.

Background and Scope

This section catalogs clinical procedures, imaging, surgical, transplant, and specialized diagnostic/genetic tests that are subject to planned review or prior authorization to ensure appropriate utilization and coverage. It includes items such as complex organ transplants, algorithm-reported laboratory assays, and many genetic and specialty tests that require pre-service review or PA.