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Services and CPT codes

  

Commercial codes

Medicare codes

Commercial codes

Enter CPT and HCPCS codes in the search to determine if they require prior authorization. Codes that require prior authorization will have a link to direct you to related requirements and instructions. 

The PDF versions of the code lists have been removed. Please use the search tool to determine if the service requires prior authorization.

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Using the commercial CPT code search tool

Last revised in January 2025. This list is updated at least quarterly. Any changes will be published on the Blue Cross NC website by the 10th of January, April, July, and October. Unlisted and Miscellaneous health service codes should be utilized only when a specific code has not been established by the American Medical Association.

The PDF versions of the code lists have been removed. Please use the search tool to determine if the service requires prior authorization. You can also view the entire code lists as web pages:

  • Avalon, Cover My Meds, and Blue Cross NC UM Prior Authorization Code List
  • Carelon Medical Benefit Management Prior Authorization Code List
  • All Prior Authorization Code List (Avalon, Cover My Meds, Blue Cross NC, and Carelon code lists combined)

AVALON = Avalon Lab

Blue Cross NC = Blue Cross Utilization Management (UM)

CMM = Cover My Meds

MHK

Oncology = Oncology

Sleep = Sleep Study

DIM = Diagnostic Imaging

Cardiology = Cardiology

MSK = Musculoskeletal

Rehab = Rehabilitation (PT/OT/ST)

Surg = Surgical

[i] = Investigational

* Prior authorization is required for all drugs listed regardless of the HCPCS code submitted on the claim. The requirement is based on the drug itself – not the code chosen to submit on the claim. 

New to market drugs are defined as drugs that have only been available on the US market for 90 days or less from the FDA approval date. Individual drug names will be added to the prior authorization list as soon as possible but even if the drug is not listed by name and it is new to market prior authorization is required.

** If this procedure is performed at the time as an approved procedure, it will require a separate post service clinical review. To initiate post service review, please contact Carelon or log on to the Provider Portal within 10 days The results of the approved procedure will be required to complete the post service review.

If the member’s group is not enrolled in the Carelon program indicated, prior authorization is not required for that procedure/drug in the specified place of service.

  • Notice Date: The listed date is when the notice of the existing code was added.
  • Effective Date: The listed date is when the code will require prior authorization for correct claims processing. If there is no date in this field, the requirement is in effect.
  • Ineffective Date: The listed date is when the code became invalid.
  • What is a CPT® code? The Current Procedural Terminology (CPT®) codes offer doctors and health care professionals a uniform language for coding medical services and procedures to streamline reporting, increase accuracy and efficiency. CPT codes are also used for administrative management purposes such as claims processing and developing guidelines for medical care review.

Blue Medicare Prior Plan Approval code lists

Requirements for utilization of in-network and out-of-network facilities and professionals must be verified in conjunction with obtaining prior plan approval. Blue Medicare℠ may authorize a service received out-of-network at the in-network benefit level if the service is not available in-network or if there is a transition of care issue. Services not covered by Original Medicare are not covered by Blue Medicare.

Diagnostic Imaging Management Programs

Medical Oncology Program

Request Prior Plan Approval

Related topics

Medical policies and guidelines

Prior authorization