01/06/2025
We’re updating lists of codes requiring prior authorization, for some commercial members, to reflect new, replaced or removed codes. These changes are based on updates from Utilization Management prior authorization assessment, Current Procedural Terminology (CPT®) code changes released by the American Medical Association or Healthcare Common Procedure Coding System changes from the Centers for Medicaid & Medicare Services.
Changes effective April 1, 2025, include:
- April 1, 2025 – Addition of Cardiology codes to be reviewed by Carelon
- April 1, 2025 – Addition of Genetic Testing codes to be reviewed by Carelon
- April 1, 2025 – Removal of Genetic Testing codes previously reviewed by Carelon
- April 1, 2025 – Addition of a Musculoskeletal code to be reviewed by Carelon
- April 1, 2025 – Addition of Medical Oncology drug codes to be reviewed by Carelon
- April 1, 2025 – Removal of a Medical Oncology code previously reviewed by Carelon
- April 1, 2025 – Removal of a ISoC Specialty Pharmacy code previously reviewed by BCBSTX
- ·April 1, 2025 – Addition of a ISoC Specialty Pharmacy code to be reviewed by BCBSTX
- April 1, 2025 – Removal of a Specialty Pharmacy code previously reviewed by BCBSTX
- April 1, 2025 – Addition of Specialty Pharmacy codes to be reviewed by BCBSTX
More Information: Refer to Prior Authorization Lists on the Utilization Management section of our provider website, Revised lists can be found on the Prior Authorization Lists for Fully Insured and Administrative Services Only Plans.
Check Eligibility and Benefits: To identify if a service requires prior authorization for our members, check eligibility and benefits through Availity® Essentials or your preferred vendor.
Avoid post-service medical necessity reviews and delays in claim processing by obtaining prior authorization before rendering services. If prior authorization is required, services performed without prior authorization or that do not meet medical necessity criteria may be denied for payment and the rendering provider may not seek reimbursement from the member.
CPT copyright 2024 American Medical Association. All rights reserved. CPT is a registered trademark of the AMA.
Carelon Medical Benefits Management is an independent company that has contracted with Blue Cross and Blue Shield of Texas to provide utilization management services for members with coverage through BCBSTX.
Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSTX.
BCBSTX makes no endorsement, representations or warranties regarding any products or services provided by third party vendors.