June 27, 2025
We’re updating 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.
For some services and members, prior authorization may be required through Blue Cross and Blue Shield of Texas. Utilization management and related services for some commercial members will be reviewed by Carelon Medical Benefits Management.
Here is a summary of changes, effective Oct. 1, 2025:
- Addition of sleep codes to be reviewed by Carelon
- Addition of genetic testing codes to be reviewed by Carelon
- Addition of a musculoskeletal code to be reviewed by Carelon
- Addition of medical oncology drug codes to be reviewed by Carelon
- Replacement of medical oncology codes reviewed by Carelon
- Removal of a drug therapy code previously reviewed by BCBSTX
- Addition of various drug codes to be reviewed by BCBSTX
For more information, refer to utilization management and to the revised prior authorization lists for fully insured and administrative services only plans.
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 AMA. All rights reserved. CPT is a registered trademark of the AMA.
Carelon Medical Benefits Management (Carelon) is an independent company that has contracted with BCBSTX 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 third party vendors and the products and services they offer.