Skip to main content
COVID-19

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

CPT® is a registered trademark of the American Medical Association.