Evicore prior authorization required

Selected genetic tests require prior authorization administered through Evicore; providers must obtain prior authorization via the Priority Health Prism Evicore workflow before ordering tests that are designated eC PA. See Section VI (Coding) for specific CPT/PLA codes that require Evicore PA.

• Access Evicore: Priority Health Prism → Authorizations → Authorization Criteria Lookup

Check Evicore PA / panel-review status for listed codes

Many molecular and genetic CPT/PLA codes in the coding tables are designated 'eC PA' or 'Review in panels' and therefore require prior authorization or panel-level review through Evicore when applicable; check each code's line-of‑business disposition before ordering.

Meaning of 'eC PA' and 'Review in panels'

'eC PA' next to a code indicates the payer requires electronic prior authorization through Evicore; codes labeled 'Review in panels' are subject to panel-level review and medical necessity assessment rather than standalone coverage.

Electronic prior authorization or panel review required

Many tests in the tables are labeled 'eC PA' or 'Review in panels' for Commercial, Medicaid, and Priority Medicare; providers must obtain electronic prior authorization or complete the panel review process before performing or billing these services.

Obtain PA before billing eC PA or panel‑review codes

Providers must submit prior authorization via Evicore for CPT/PLA codes that are designated 'eC PA' before billing; orders for codes marked 'Review in panels' should follow panel-review initiation per Evicore guidance.

Summary: many codes require prior authorization

Across the coding tables many CPT and PLA/HCPCS codes are annotated as requiring prior authorization ('eC PA') for the indicated plan types; confirm PA requirements for each code in Section VI prior to ordering.

eC PA required before billing

Tests listed with 'eC PA' require electronic prior authorization through Evicore prior to service and billing; do not bill these services without approved PA for the applicable plan.

Verify PA requirement for listed codes

Numerous codes in the tables are annotated 'eC PA' indicating prior authorization is required; verify and obtain Evicore PA for the specific U/CPT code and member plan before performing the test.

Routine eC PA for many listed tests

Tests in the listed CPT ranges are frequently marked 'eC PA'; providers must request and receive Evicore electronic prior authorization for those tests under the applicable plan prior to testing and billing.

eC PA required for many U‑codes

Many U‑codes in the PLA listings show 'COMMERCIAL PLANS = eC PA; MEDICAID = eC PA; PRIORITY MEDICARE = eC PA' — if the ordered U‑code is so annotated, obtain Evicore electronic clinical prior authorization before service.

Electronic case‑by‑case prior authorization required

Some tests require electronic case‑by‑case prior authorization (eC PA) for coverage under Commercial, Medicaid, and Priority Medicare; providers should submit PA requests through Evicore for these entries prior to service.

PA and evidence review required for PLA/HCPCS tests

PLA/HCPCS-coded tests annotated 'eC PA' are covered only after evidence review and prior authorization; submit Evicore PA and supporting documentation per the code entry before performing the test.

Obtain eC PA for listed PLA/U‑codes

Many PLA/HCPCS and U‑code entries are annotated 'eC PA' indicating electronic clinical prior authorization is required before services are rendered or billed for the listed plans.

U‑codes require eC PA across plans

Multiple U‑codes show 'COMMERCIAL PLANS = eC PA. MEDICAID = eC PA. PRIORITY MEDICARE = eC PA.' — providers must obtain Evicore electronic prior authorization for these U‑codes across plan types prior to testing.

G9143 requires prior authorization

Warfarin responsiveness testing (G9143) is designated eC PA and requires prior authorization through Evicore for Commercial, Medicaid, and Priority Medicare before service.

Obtain informed consent and document genetic counseling

Documented informed consent must occur before testing and pre‑ and post‑test genetic counseling must be provided and documented; for specified conditions counseling must be by a board‑certified genetic counselor independent of the testing laboratory.

• Counseling may occur at same visit if documentation meets requirements
• Michigan informed consent law applies (Mich. Comp. Laws 333.17020)

Include medical necessity and counseling documentation with PA/claims

When submitting authorization or claims, include documentation supporting medical necessity (diagnosis, clinical rationale) and document genetic counseling; CPT/HCPCS counseling codes 96041 and S0265 are available when criteria are met.

• Include clinical rationale and relevant diagnosis codes with PA/claim
• Use 96041 or S0265 when counseling is provided

Include test description, vendor alias, and indication with PA/claims

PA/panel-review actions are indicated per code in the table (eC PA, Review in panels, Not Covered); providers should include documentation (test description, vendor/test alias, clinical indication, and relevant diagnosis codes) to support PA or billing.

• Include the vendor/test alias as shown in the code table when available
• Document the clinical indication and matching diagnosis codes

Attach explanatory notes for unlisted codes (81479, 81599, 84999)

For unlisted molecular pathology (81479) and other unlisted codes (81599, 84999) include explanatory notes identifying the specific test and details sufficient for review when submitting the claim or PA request.

• Attach explanatory notes identifying the specific assay and vendor/lab
• Provide clinical rationale and documentation of medical necessity

Include test description and laboratory alias with requests

Each code entry includes a brief description and example vendor/test alias; include the test description and alias/laboratory when requesting prior authorization or submitting claims to support medical necessity.

Document diagnosis codes for diagnosis‑restricted tests

Some tests are covered only for specific diagnoses (for example, 0471U is covered for colorectal cancer diagnoses C18.0–C18.5); document the listed diagnosis code(s) on the PA request and claim.

• For 0471U include diagnosis C18.0–C18.5 as applicable

Provide explanatory notes for other unlisted codes (88299, 89240, 88399)

For unlisted cytogenetic/pathology procedure codes (88299, 89240, 88399, etc.) include explanatory notes identifying the specific test and relevant details with the claim or PA submission.

Denial risk for missing Evicore PA or panel review

Failure to obtain required Evicore prior authorization or to complete required panel review for codes marked 'eC PA' or 'Review in panels' may result in claim denial.

Initiate Evicore PA using the panel code that requires PA

If any procedure code in a multi‑test panel requires prior authorization, that procedure code should initiate the Evicore PA workflow; failure to submit the required PA for the triggering code may lead to denial of the panel.

Not‑covered tests will be denied if billed

Tests labeled 'Not Covered' for the member's line of business (Commercial, Medicaid, Priority Medicare) will be denied if billed for that plan; confirm plan‑level coverage status before ordering.

• Examples: multiple U‑codes and CPT entries are explicitly marked Not Covered in the tables

Panel‑level review may be required for 'Review in panels' codes

Some single‑gene tests and other entries are annotated 'Review in panels' — these require panel‑level review prior to coverage decisions; if included in a multi‑test panel, panel rules apply and PA must be initiated as noted.

No prior authorization required for 81420 (NIPT common aneuploidies)

Code 81420 (fetal chromosomal aneuploidy cfDNA NIPT) is designated 'No PA required' for Commercial, Medicaid, and Priority Medicare; do not initiate Evicore PA for 81420.

Billing Not Covered tests risks denial and patient liability

Tests explicitly labeled 'Not Covered' in the tables will trigger claim denials when billed for the specified plan(s); review the Not Covered entries before ordering and consider alternative testing or patient financial responsibility discussions.

Not Covered entries and benefit‑rider exceptions may trigger denials

Tests marked 'Not Covered' or otherwise unsupported for the member's plan (e.g., codes listed as Not Covered for Medicaid or Priority Medicare) are denial triggers; verify plan status and benefit riders (e.g., Fertility Rider) before ordering.

• 89290/89291 covered only with Fertility Rider for commercial plans; Not Covered for Medicaid and Priority Medicare

Failure to obtain eC PA may cause denial

Many tests labeled 'eC PA' require electronic clinical prior authorization; failure to obtain Evicore authorization prior to service may result in denial for Commercial, Medicaid, and Priority Medicare plan members.

Not Covered codes for benefit types will be denied absent rider

Codes marked 'Not Covered' for specific benefit types (for example, 89290/89291 Not Covered for Medicaid and Priority Medicare) will be denied when billed unless coverage conditions (such as a Fertility Rider) apply.