Obtain Evicore prior authorization for selected tests

Prior authorization for selected genetic tests and many procedure codes must be obtained through Evicore via Priority Health Prism; the policy states selected tests require prior authorization administered through Evicore and directs providers to Log into Priority Health Prism → Authorizations → Authorization Criteria Lookup to access Evicore guidelines.

• Applies notably to procedure codes in the 81105–81599 range and many listed CPT/PLA codes.
• Initiate the Evicore request using the procedure code that requires PA via the provider portal.

Submit eC PA for specified hereditary and key gene tests

Many hereditary and clinically significant gene tests are designated 'eC PA' and require electronic prior authorization for Commercial, Medicaid, and Priority Medicare lines; providers must submit PA per the payer's electronic workflow.

• Examples include BRCA1/BRCA2 (81162–81165) and multiple pharmacogenomic genes (81225–81227).
• Follow the eC PA process shown in per-code entries when billing.

Expect panel-level review for 'Review in panels' codes

Some codes are designated 'Review in panels'—these codes are reviewed as part of a panel; they may be covered without PA when reported alone but will be subject to panel review or PA if reported with codes that require authorization.

• Examples: multiple HLA, tumor, and single-gene entries noted as 'Review in panels'.
• If included in a multi-code panel where any code requires PA, the procedure code that requires PA should trigger Evicore access.

Follow annotated PA or panel review processes

Where a code is annotated as 'eC PA' or 'Review in panels' the provider must follow the payer's electronic clinical prior authorization or panel review process before testing or billing.

• Use the procedure code requiring PA to initiate Evicore via the provider portal.
• If codes are reported together, obtain PA for the code that requires authorization to avoid panel combination denial risk.

Obtain electronic prior authorization for eC PA codes

Numerous CPT codes in the molecular/genetics sections are marked 'eC PA'—electronic prior authorization is required for coverage determination and must be obtained prior to testing.

• Examples include 81292, 81295 and many panel/exome/genome codes (81415/81425, 81443, 81448).
• Obtain PA through the payer's eC workflow before performing or billing these tests.

Anticipate panel review for listed CPT codes

Several CPT codes are marked 'Review in panels'; coverage decisions for these codes are made within panel-level review rather than as individually pre-approved tests—providers should expect clinical review and supply requested documentation.

• Examples include microsatellite instability and selected tumor variant codes (81301, 81305, 81309).
• Provide clinical justification and panel-level information when requested during review.

Obtain electronic clinical prior authorization for eC PA codes

Codes annotated 'eC PA' require electronic clinical prior authorization for Commercial, Medicaid, and Priority Medicare plans; obtain the eC PA before testing to avoid coverage delays or denials.

• Examples include many panel codes (81443, 81445, 81448–81451) and exome/genome codes (81415/81425).
• Follow Evicore/Prism instructions to submit required clinical information.

No PA required for 81420 (NIPT), but document counseling and indications

Code 81420 (fetal chromosomal aneuploidy cfDNA panel for chromosomes 13, 18, 21) is designated 'No PA required'; however, documentation must still support medical necessity and pre-test counseling per policy.

• Provide documentation of appropriate education and counseling prior to testing.
• Ensure gestational age and pregnancy type (singleton/twin) meet laboratory-validated criteria.

Obtain eC PA for many listed CPT/PLA codes

Many CPT and PLA U-codes in the lists are annotated 'eC PA' indicating electronic case review/prior authorization is required for Commercial, Medicaid, and Priority Medicare plans; obtain prior authorization through the eC process for those codes.

• Examples include numerous panel and proprietary tests (81552, 81554, 81558, 0003U, many U-codes).
• Do not submit claims for these tests without first securing required eC PA.

Verify per-code 'No PA Required' exceptions before ordering

Certain tests are explicitly listed as 'No PA Required' (OOS or No PA) — examples include some fetal aneuploidy cfDNA entries and screening tests such as Cologuard; verify per-code payer columns before ordering.

• 81507/81528 and select NIPT entries are noted as 'No PA Required' or OOS for eC.
• Confirm the per-code column (Commercial/Medicaid/Priority Medicare) for plan-specific PA requirements.

Obtain eC PA for listed proprietary and panel tests

The per-code listings identify many tests that require electronic prior authorization ('eC PA'); when a test is listed as eC PA providers must obtain authorization through the electronic claims/prior authorization process before testing or billing.

• Examples span proprietary U-codes and multi-gene panels where eC PA is the listed coverage action.
• Follow Evicore via Priority Health Prism for submission and required documentation.

0003U is OOS for commercial plans (no PA) — verify payer column for coverage

Code 0003U (Overa/OVA1 Next Generation) is listed as OOS for commercial plans and requires no PA for in-network providers; Medicaid is listed as Not Covered for this test.

• Confirm plan-specific status before ordering; OOS indicates out-of-scope for Evicore management and No PA required for in-network providers.
• If member has Medicaid, the code is Not Covered per the listing.

Check per-code coverage/PA notes (No PA required vs Not Covered)

Per-code payer columns show some codes explicitly labeled 'No PA required' or 'Not Covered' depending on the plan; providers must verify the code-specific payer column (Commercial/Medicaid/Priority Medicare) prior to ordering and billing.

• Examples: 0027U may be No PA required for certain plans; 0040U/0046U/0049U are listed Not Covered in specified columns.
• Use the code-specific annotation to determine whether to request PA or expect denial.

Obtain eC PA via electronic claims/prior authorization for eC PA codes

Codes listed as 'eC PA' require prior authorization through the payer's electronic prior authorization process; obtain the eC PA before performing or billing the test to meet coverage requirements.

• This applies to many U-code proprietary tests and newer PLA entries designated eC PA.
• Submit required clinical rationale and supporting documentation in the eC PA request.

eC PA required before billing for 'eC PA' tests

Tests identified as 'eC PA' in code entries must have electronic prior authorization per the plan designation; providers should not proceed without completing the eC PA workflow for those codes.

• This is reiterated across many code groups—eC PA is the expected authorization pathway for panels, cfDNA, and specialty tests.
• Follow Evicore/Prism instructions to submit complete clinical information.

Obtain PA for many proprietary molecular/genetic tests

Numerous proprietary molecular/genetic tests (U-codes and PLA codes) are designated 'eC PA' across Commercial, Medicaid, and Priority Medicare — obtain prior authorization per the payer policy for these tests before testing.

• Examples include optical genome mapping (0260U), whole genome sequencing (0265U), and many tumor/ctDNA panels.
• Failure to obtain required PA may lead to denial or medical necessity review.

Obtain eC PA for U-code proprietary tests before billing

Many U-codes in the U-code listings are labeled 'eC PA' indicating electronic claim prior authorization is required for coverage; obtain prior authorization through Evicore/Priority Health Prism when billing these U-codes.

• Examples: 0326U (Guardant360), 0334U, 0340U (Signatera) and numerous cfDNA/oncology U-codes.
• Submit specimen type, prior tumor/germline sequencing when requested, and clinical rationale with the PA.

Obtain evidence-based clinical prior authorization for many tests

Many listed tests across sections are labeled 'eC PA' for Commercial, Medicaid, and Priority Medicare; providers must obtain evidence-based clinical prior authorization per the payer policy before testing.

• This includes transplant, oncology, reproductive, and specialty genomic assays (eg, 0422U, 0473U, 0485U).
• Follow Evicore guidance and include required clinical details for the review.

Secure eC PA for PLA/U-code tests per plan annotations

Tests marked 'eC PA' in the PLA/test code listings require electronic clinical prior authorization before they will be covered for the specified plan(s); secure the eC PA via the payer's system.

• Examples include many PLA codes in the 0490–0578U range and beyond.
• Include diagnosis, prior testing, specimen type, and test description in the PA submission as indicated.

Obtain eC PA for listed U-codes via Evicore

Multiple U-codes in the later U-code lists are designated 'eC PA' for commercial, Medicaid, and Priority Medicare; providers must obtain electronic prior authorization for these U-codes prior to testing or billing.

• Examples include 0572U, 0575U, 0582U, 0585U, 0592U.
• Follow Evicore/Priority Health Prism to submit PA and required documentation.

Follow Priority Health/ Evicore PA and benefit-rider rules

Certain genetic tests require prior authorization via Priority Health systems or are covered only with specific benefit riders; providers should follow Evicore guidelines via Priority Health Prism and submit requests demonstrating medical necessity.

• Examples: G9143 (warfarin pharmacogenetic testing) requires eC PA; preimplantation genetic biopsy codes 89290/89291 are covered only with a Fertility Rider.
• When tests are covered only with a rider, verify member benefits before ordering.

Document genetic counseling and informed consent

Document that pre- and post-test genetic counseling occurred and retain informed consent records; Michigan law (Public Health Code Act 368 of 1978: 333.17020) requires informed consent for genetic testing.

• Genetic counseling must be by a board‑certified genetic counselor independent of the testing laboratory for specified conditions.
• Document counseling and informed consent in the medical record prior to testing.

Initiate PA using the procedure code that requires authorization

Initiate Evicore prior authorization using the procedure code that requires PA; the policy specifies the procedure requiring PA should initiate access to Evicore via the provider portal.

• If multiple codes are reported, use the procedure code that requires PA to start the Evicore request.
• Access Evicore via Priority Health Prism → Authorizations → Authorization Criteria Lookup.

Follow eC PA and panel review workflows

When a code is annotated 'eC PA' or 'Review in panels' providers must follow the payer's eC PA or panel review process and supply requested clinical evidence during the electronic review.

• Follow Evicore guidance for clinical documentation and criteria submission via Priority Health Prism.
• Panel-reviewed codes may require additional clinical justification beyond single-code claims.

Include concise test description (genes/type of analysis) on PA/claim

Provide a brief test description with claims or prior authorization requests (including gene names and type of analysis) as many CPT entries include a test description and the policy expects this supporting information.

• Include gene names, panel size, and type of analysis (DNA/RNA/mitochondrial/cfDNA) in the PA or claim documentation.
• For unlisted codes, include explanatory notes identifying the specific test.

Document NIPT clinical rationale despite No PA for 81420

Even when 81420 is designated 'No PA required', providers should still document counseling and the clinical indication to support medical necessity per the policy's prenatal testing section.

• Document pre-test education and counseling, pregnancy type, and laboratory-validated gestational age.
• Provide supporting documentation with the claim when requested.

Attach explanatory notes when billing unlisted codes

When billing unlisted codes (e.g., 81479, 81599, 84999) include explanatory notes identifying the specific test and the methodology; the policy requires explanatory notes to accompany claims for unlisted procedures.

• Attach explanatory notes that identify the test name, method, genes/panels interrogated, and clinical rationale.
• Failure to include explanatory notes may impede adjudication or result in denial.

Provide explanatory notes with unlisted-code claims

Unlisted codes such as 81599 and 84999 must be accompanied by explanatory documentation identifying the specific test when submitting claims.

• Provide test name, lab alias, methodology, and clinical justification with the claim.
• Use explanatory notes to clarify the billed service for adjudication.

Obtain PA for tests annotated 'eC PA'

Providers must obtain prior authorization where tests are listed as 'eC PA'—the policy repeatedly instructs that tests marked eC PA require electronic prior authorization per the plan designations.

• This operational requirement applies across CPT, PLA, and U-code entries annotated 'eC PA'.
• Submit requisite clinical documentation and test details via Evicore/Priority Health Prism.

Use eC PA process for tests labeled 'eC PA'

Tests designated 'eC PA' require electronic prior authorization; providers should use the electronic PA process to secure authorization prior to testing and claims submission.

• This is an operational reminder repeated throughout the per-code listings.
• Include diagnosis, prior testing, specimen type, and brief test description in the eC PA request.

Obtain eC PA before claims submission for eC PA tests

When a test is labeled 'eC PA' the provider must obtain prior authorization through the electronic clinical prior authorization process before submitting a claim; failure to do so may result in denial.

• Examples: multiple U-codes and PLA codes list eC PA—obtain PA via Evicore prior to performing the test.
• Provide complete clinical justification and attach supporting reports as requested.

Submit specimen source and report documentation with PA/claims

Include specimen source and the laboratory report showing clinically significant findings when submitting documentation; many code descriptions specify specimen requirements (eg, plasma for cfDNA, tumor and normal blood/saliva for paired tumor-normal testing).

• Examples: Signatera (0340U) requires prior tumor/germline NGS context; cfDNA assays request plasma specimen documentation.
• Attach lab reports and specimen source documentation with PA requests and claims.

Include required ICD‑10 when test coverage is diagnosis‑limited

Provide the correct ICD‑10 diagnosis codes when coverage is diagnosis‑specific; certain tests (eg, 0471U CRCdx RAS kit) are covered only for listed ICD‑10 codes and claims should include the indicated diagnosis.

• 0471U is covered only for colorectal cancer ICD‑10 codes C18.0–C18.9, C19, C20, C21.0–C21.8.
• Verify and include the covered diagnosis code on the PA request and claim.

Failure to obtain required eC PA may lead to denial

Many tests labeled 'eC PA' require prior authorization; failure to obtain required PA through Evicore or the eC process may lead to denial or medical necessity review.

• Obtain eC PA for codes annotated 'eC PA' before testing or billing.
• If testing is urgent, notify Priority Health/Evicore per Evicore guidelines to avoid delays.

Include specified diagnosis codes for diagnosis‑restricted tests

When coverage for a test is limited to specific diagnoses (example: 86294 BTA Stat for specified bladder diagnoses), include the appropriate diagnosis code to support coverage.

• 86294 is covered only for diagnoses C67.0–C67.9, D09.0, D49.4, and Z85.51.
• Claims without the required diagnosis may be denied or returned for clarification.

Attach explanatory notes for unlisted codes with claims

Unlisted procedure codes (e.g., 81599, 84999, 88299, 89240, 88399) require explanatory notes identifying the specific test or procedure when billed; attach detailed explanatory documentation to the claim.

• Explain the test methodology, genes/panels interrogated, clinical indication and lab performing the test.
• Failure to include explanatory notes may delay processing or trigger denial.

Denial risk if Evicore PA not obtained where required

Failure to obtain prior authorization via Evicore for selected tests may result in claim denial or requirement for retrospective review; obtain PA before testing when codes are annotated as requiring Evicore authorization.

• Evicore-managed tests include many codes in the 81105–81599 range and numerous U-codes; access Evicore via Priority Health Prism.
• Denials are likely if required prior authorization is not obtained.

Not Covered procedures: no PA required but voluntary authorization possible

Procedures that are explicitly 'Not Covered' do not require prior authorization, but providers may submit voluntary authorization requests for a non‑coverage determination if desired; verify per-code coverage status before ordering.

• Not Covered entries (per payer column) will be denied if billed under that plan.
• Voluntary authorization can be requested for non‑coverage determination in selected cases.

Panel combination denial risk — obtain PA for the code that requires it

When multiple procedure codes within the 81105–81599 range are reported as part of a panel, all included procedure codes are subject to medical necessity review if any code requires prior authorization; obtain PA for the code that requires it to reduce panel combination denial risk.

• If a multi-code panel contains any eC PA code, the entire panel may be reviewed.
• Use the procedure code requiring PA to initiate the Evicore request to document the clinical rationale for the panel.

Not Covered codes will be denied if billed under the listed plan

Tests explicitly annotated 'Not Covered' in the per‑code listings will be denied if submitted for coverage under the listed plan(s); verify the Not Covered annotations in code columns prior to ordering.

• Examples: selected single-gene and PLA codes annotated Not Covered for certain plans (eg, 81324 PMP22 Not Covered for Medicaid and Priority Medicare).
• Do not expect reimbursement for codes marked Not Covered for the member's plan.

Per-code 'Not Covered' annotations indicate high denial risk

Some CPT and PLA codes are explicitly listed as 'Not Covered' for certain lines of business (Commercial, Medicaid, Priority Medicare); billing those codes for affected plans is likely to trigger denial—check the code-specific payer column.

• Examples include 81324 (PMP22 duplication/deletion) and several U-codes shown as Not Covered in the per-code listings.
• If a test is needed despite Not Covered status, consider submitting a voluntary non-coverage determination request as noted.

Lack of required eC PA may trigger denial

Tests labeled 'eC PA' in the policy require electronic clinical prior authorization; failure to obtain such authorization before testing or billing may result in denial.

• This operational requirement applies across CPT, PLA, and U-code entries designated eC PA.
• Obtain PA through Evicore/Priority Health Prism and include required clinical documentation.

Obtain eC case review to avoid denials for eC PA codes

Many tests require electronic case review (eC PA); failure to obtain electronic case review/prior authorization where indicated (most CPT entries list 'eC PA') may trigger claim denial.

• Obtain eC PA for codes annotated 'eC PA' to avoid denials.
• If uncertain, verify the code's per-plan annotation before testing.

Not Covered tests are denial triggers when billed

Tests explicitly labeled 'Not Covered' in the PLA/CPT/U-code entries (many listed examples) will be denied if submitted for coverage under the listed plan(s); providers should avoid billing those tests under those plans.

• Examples include many PLA U-codes and select CPT codes annotated as Not Covered across plan columns.
• Confirm member coverage and consider alternative testing or documentation if clinically necessary.

Billing 'Not Covered' tests to the listed plan will likely be denied

Tests listed as 'Not Covered' in the per-code entries will be denied if billed under the specified plan(s); providers should verify Not Covered status for the member's plan before ordering.

• The policy lists many specific Not Covered codes (e.g., 0078U, 0086U, 0115U, 0152U).
• Consider requesting individual case review if the test is investigational yet potentially beneficial.

Routinely check Not Covered PLA code ranges to avoid denials

Multiple contiguous PLA/CPT codes and ranges are explicitly marked 'Not Covered' in the policy (examples shown) and will be denied if billed under the listed plans; providers must check each code's plan column before ordering.

• The 0181U–0200U range contains many red blood cell antigen genotyping tests marked Not Covered.
• Avoid billing Not Covered PLA codes to the affected plans.

Program‑specific 'Not Covered' status will trigger denials

Tests listed as Not Covered for a given program (eg, Medicaid, Commercial, Priority Medicare) are subject to denial for that program when billed; verify program-specific status prior to performing the test.

• Examples include PLA codes and U-codes with plan-level Not Covered annotations.
• If clinically necessary, consider individual case review and prior plan approval when applicable.

Explicit Not Covered tests are high-risk for denial

Specific tests are explicitly marked Not Covered in the listings (examples include entries across chunks); providers should not expect reimbursement for those tests and billing them will likely result in denial.

• Examples include 0279U–0281U (VWD assays) with mixed coverage and 0295U (DCISionRT) marked Not Covered.
• Check the code-level annotation and plan column before ordering.

Certain tests (e.g., 0328U) are Not Covered across plans — avoid billing

Tests explicitly designated 'Not Covered' in the document (e.g., 0328U) are listed as Not Covered for Commercial, Medicaid, and Priority Medicare and will be denied if billed under those plans.

• 0328U (definitive drug assay ≥120 drugs) is listed Not Covered across plans.
• Do not bill these codes to the listed plans; consider alternative testing or individual case review.

Verify OOS vs eC PA distinctions to determine PA need

Some tests are designated OOS for eC (No PA required) while others are eC PA; verify whether a code is OOS versus eC PA as this affects whether prior authorization is required and whether denials may occur without PA.

• Example: 0402U (Abbott Alinity m STI Assay) is OOS for eC — No PA required.
• Other tests listed as eC PA will be denied if PA is not obtained.

Billing Not Covered tests to listed plans will result in denials

Tests flagged as 'Not Covered' (multiple U-codes and CPT entries are examples) will be denied when billed under the listed plans; providers should verify coverage status and consider individual case review if clinically necessary.

• Examples include 0425U/0426U/0429U/0463U/0490U–0492U marked Not Covered.
• If a test is clinically critical, submit an individual case review request per policy (requires prior plan approval).

Not Covered annotation indicates likely claim denial for that plan

Tests listed as 'Not Covered' for a given plan (Commercial, Medicaid, Priority Medicare) are subject to denial if billed to that plan; verify plan column and do not bill Not Covered tests to those plans.

• Examples include multiple PLA/U-codes annotated Not Covered for specific plans.
• Consider voluntary authorization or individual case review when appropriate.

OOS-for-eC 'Not Covered' codes are denial risks

Codes explicitly listed as 'OOS for eC - Not Covered' in the excerpt (examples provided) may be denied if submitted for payment under the affected plans; verify the OOS/Not Covered listing before ordering.

• Examples: 83006, 83951, 86152, 86153, 86300, 86305, 86352 appear as OOS for eC - Not Covered.
• Do not submit these codes for payment under plans where they are listed Not Covered.

Investigational/experimental tests require prior plan approval for exceptions

Coverage determinations for experimental, investigational, or unproven tests may be denied unless an exception is granted via individual case review; such exceptions require prior plan approval and adjudication by a Priority Health medical director or clinical pharmacist.

• Individual case review can allow coverage for investigational yet promising care, but requires prior plan approval.
• Submit requests with full clinical justification and supporting evidence for consideration.