Policy Updates Prior AuthorizationMedicaidAugust 20, 2024

Carelon Medical Benefits Management, Inc. genetic testing code updates

Effective for dates of service on and after October 1, 2024, the following CPT® codes will require prior authorization through Carelon Medical Benefits Management, Inc.

CPT code

Description

81457

Solid organ neoplasm, genomic sequence analysis panel, interrogation for sequence variants; DNA analysis, and microsatellite instability

81458

Solid organ neoplasm, genomic sequence analysis panel, interrogation for sequence variants; DNA analysis, copy number variants, and microsatellite instability

81459

Solid organ neoplasm, genomic sequence analysis panel, interrogation for sequence variants; DNA analysis or combined DNA and RNA analysis, copy number variants, microsatellite instability, tumor mutation burden, and rearrangements

81462

Solid organ neoplasm, genomic sequence analysis panel, cell-free nucleic acid (plasma), interrogation for sequence variants; DNA analysis or combined DNA and RNA analysis, copy number variants, and rearrangements

81463

Solid organ neoplasm, genomic sequence analysis panel, cell-free nucleic acid (plasma), interrogation for sequence variants; DNA analysis, copy number variants, and microsatellite instability

81464

Solid organ neoplasm, genomic sequence analysis panel, cell-free nucleic acid (plasma), interrogation for sequence variants; DNA analysis or combined DNA and RNA analysis, copy number variants, microsatellite instability, tumor mutation burden, and rearrangements

As a reminder, ordering and servicing providers may submit prior authorization requests to Carelon Medical Benefits Management in one of the following ways:

  • Access the Carelon Medical Benefits Management ProviderPortalSM at providerportal.com:
    • Online access is available 24/7 to process orders in real-time and is the fastest and most convenient way to request authorization.
  • Access Carelon Medical Benefits Management via Availity.com.

If you have questions related to guidelines, please contact Carelon Medical Benefits Management via email at MedicalBenefitsManagement.guidelines@Carelon.com. Additionally, you may access and download a copy of the current and upcoming guidelines here.

Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan.

Medicaid coverage provided by Wellpoint Insurance Company to members in the Medicaid Rural Service Area and the STAR Kids program and Wellpoint Texas, Inc. to all other Wellpoint members in Texas.

TXWP-CD-063366-24

PUBLICATIONS: September 2024 Provider Newsletter