Procedure Codes Reviewed by Carelon
Carelon℠ Medical Benefits Management will conduct prospective Prior Authorization/Medical Necessity Determination (PA/MND) reviews of the following elective outpatient CT, CTA, MRA, MRI nuclear cardiology, PET scans, echocardiography exams, sleep management, major joint and pain management services to be provided to Horizon members enrolled in certain National Account self-insured groups.
This information was last revised on August 21, 2023, and may be subject to change.
| Service Categories | Procedure Codes Reviewed by Carelon |
| CT | 70450, 70460, 70470, 70480, 70481, 70482, 70486, 70487, 70488, 70490, 70491, 70492, 71250, 71260, 71270, 72125, 72126, 72127, 72128, 72129, 72130, 72131, 72132, 72133, 72192, 72193, 72194, 73200, 73201, 73202, 73700, 73701, 73702, 74150, 74160, 74170, 74176, 74177, 74178, 74261, 74262, 74263, 75571, 75572, 75573, 77078, G0297 |
| CTA | 70496, 70498, 71275, 72191, 73206, 73706, 74174, 74174, 74175, 75574, 75635, 75635 |
| MRI | 70336, 70540 70542, 70543, 70551, 70552, 70553, 70554, 70555, 71550, 71551, 71552, 72141, 72142, 72146, 72147, 72148, 72149, 72156, 72157, 72158, 72195, 72196, 72197, 73218, 73219, 73220, 73221, 73222, 73223, 73718, 73719, 73720, 73721, 73722, 73723, 74181, 74182, 74183, 74712, 75557, 75559, 75561, 75563, 76390, 77058, 77059, 77084 |
| MRA | 70544, 70545, 70546, 70547, 70548, 70549, 71555, 72159, 72198, 73225, 73725, 74185 |
| Pain Management (Advansix, Alcon, BASF, Catalent, DSM, Honeywell, Merck, Organon, Sanofi & Signify) |
27096, 62320, 62321, 62322, 62323, 63650, 63655, 63663, 63664, 63685, 63688, 64479, 64480, 64483, 64484, 64490, 64491, 64492, 64493, 64494, 64495, 64510, 64520, 64633, 64634, 64635, 64636, G0260, 0213T, 0214T, 0215T, 0216T, 0217T, 0218T |
| Medical Oncology (Advansix, Catalent, & Pfizer) |
View the Oncology Program Code List. |
| Nuclear Cardiology | 78451, 78452, 78453, 78454, 78466, 78468, 78469, 78472, 78473, 78481, 78483, 78494 |
| Major Joint (Advansix, Catalent, DSM, Honeywell, Merck & Sanofi) |
23105, 23107, 23120, 23130, 23410, 23412, 23415, 23420, 23430 ,23440, 23450, 23455, 23460, 23462, 23465, 23466, 27331, 27332, 27333, 27334, 27335, 27403, 27405, 27407, 27409, 27412, 27415, 27416, 27427, 27428, 27429, 29805, 29806, 29807, 29819, 29820, 29821, 29822, 29823, 29824, 29825, 29826, 29827, 29828, 29860, 29861, 29862, 29863, 29866, 29867, 29868, 29870, 29873, 29874, 29875, 29876, 29877, 29879, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889, 29914, 29915, 29916, 23700, J7330, S2112, G0289 |
| PET scans | 78459, 78491, 78492, 78608, 78609, 78811, 78812, 78813, 78814, 78815, 78816 |
| Echocardiography | 93303, 93304, 93306, 93307, 93308, 93312, 93313, 93314, 93315, 93316, 93317, 93350, 93351 |
| Sleep Management and Radiology | 95782, 95783, 95783, 95800, 95801, 95805, 95806, 95807, 95808, 95810, 95811, 95811, A4604, A7027, A7028, A7029, A7030, A7031, A7032, A7033, A7034, A7035, A7036, A7037, A7038, A7039, A7044, A7045, A7046, E0470, E0471, E0485, E0486, E0561, E0562, E0601, E1399, G0398, G0399, G0400 |
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