Prior authorization via web-based tool for procedures

Effective October 1, 2025, the following CPT/HCPCS codes will change from requiring prior authorization to being covered for Medicare Advantage plans and commercial products: 

• 55875 and 55876
• 77301, 77338, 77385, 77386, G6015, G6016
• 77520, 77522, 77523, 77525
• 32701, 77373, 77435

Effective November 1, 2025

• Prior authorization will be added for CPT code 25447 utilizing the medical criteria found in the online authorization tool for participating providers for Medicare Advantage Plans and Commercial Products. 
• CPT code 25448 will continue to require prior authorization; however, the medical criteria will change from medical policy, Medical Necessity to the medical criteria found in the online authorization tool for participating providers for Medicare Advantage Plans and Commercial Products. 
• Prior authorization will be removed from CPT codes 63663 and 63664 for Medicare Advantage Plans and Commercial Products.

There will be no other changes in this medical policy. For additional details related to this policy, please click here. 

Ambulance Services - Ground

Effective November 1, 2025, HCPCS codes A0427 and A0428 will be covered when filed with modifier QL for both Medicare Advantage plans and commercial products. There will be no other changes in this medical policy. For additional details related to this policy, please click here.

Minimal Residual Disease Testing

Effective November 1, 2025, ICD-10 codes C83.1A and Z85.72 will be added to the existing covered ICD-10 code list for CPT code 0364U for Medicare Advantage plans and commercial products. There will be no other changes in this medical policy. For additional details related to this policy, please click here. 

Gene Expression Profiling for Cutaneous Melanoma

Effective November 1, 2025, CPT codes 81529 and 0090U will continue to require prior authorization and the medical criteria will be revised for both Medicare Advantage plans and commercial products. There will be no changes for the remaining test(s) in this medical policy. For additional details related to this policy, please click here. 

Molecular Testing in the Management of Pulmonary Nodules 

Effective November 1, 2025:

• CPT code 0080U will continue to require prior authorization; however, the medical criteria will move from this policy to being available in the online authorization tool for participating providers with revisions to the medical necessity criteria for Medicare Advantage plans and commercial products. Coverage guidance will be available in medical policy, Proprietary Laboratory Analyses (PLA) and Multianalyte Assays with Algorithmic Analyses (MAAA). 
• CPT code 81479 will continue to require prior authorization; however, the medical criteria will move from this policy to being available in the online authorization tool for participating providers with revisions to the medical necessity criteria for Medicare Advantage plans and commercial products. Coverage guidance will be available in the medical policy Genetic Testing Services.  
• There will be no other changes in this medical policy. 

For additional details related to this policy, please click here. 

Adult Intensive Services (AIS) and Child and Family Intensive Services (CFIT)                     

Effective July 16, 2025, minor editorial refinements were incorporated into this payment policy to clarify requirements for commercial products. For additional details related to this policy, please click here. 

Evaluation of Biomarkers for Alzheimer’s Disease 

Effective November 1, 2025, the following CPT codes 82233/82234/84393/84394 will be added to this policy and will require prior authorization based on the medical criteria in this policy for both Medicare Advantage plans and commercial products. There will be no other changes in this medical policy. For additional details related to this policy, please click here. 

Digital Health Therapies for Substance Use Disorders

Effective November 1, 2025, CPTs 98978/A9291 will change from being not medically necessary to being a non-covered/contract exclusion for commercial products only. For additional details related to this policy, please click here. 

Intensity Modulated Radiotherapy (IMRT)

Effective October 1, 2025, the following CPT/HCPCS codes will change from requiring prior authorization to being covered for Medicare Advantage plans and commercial products: 

• 77301, 77338, 77385, 77386, G6015, G6016 

There will be no other changes in this medical policy. For additional details related to this policy, please click here. 

Stereotactic Body Radiation Therapy

Effective October 1, 2025, the following CPT/HCPCS codes will change from requiring prior authorization to being covered for Medicare Advantage plans and commercial products: 

• 32701, 77373, 77435 

There will be no other changes in this medical policy. For additional details related to this policy, please click here. 

Genetic Testing Services

Effective November 1, 2025:

• CPT codes 82233, 82234, 84393, 84394: Medical necessity criteria used for review will change from unlisted genetic testing criteria to policy-specific criteria located in the related policy, Evaluation of Biomarkers for Alzheimer’s Disease for Medicare Advantage plans and commercial products.
• CPT 81479 when used to represent Percepta: The location of medical necessity criteria will be updated to reflect criteria is available in the online authorization tool for participating providers for Medicare Advantage plans and commercial products. This is a correction from the Genetic Testing Services article in the August Provider Update.

For additional details related to this policy, please click here.   

Proprietary Laboratory Analyses (PLA) and Multianalyte Assays with Algorithmic Analyses (MAAA)                                                                                                                                    

Effective November 1, 2025: 

• CPT code 0080U: The location of medical necessity criteria will be updated to reflect criteria is available in the online authorization tool for participating providers for Medicare Advantage plans and commercial products. 

For additional details related to this policy, please click here.

Laser Treatment for Proliferative Vascular Lesions

Effective October 1, 2025, CPT codes 17106,17107, 17108 will continue to require prior authorization; however, the medical criteria will change from medical policy, Laser Treatment for Proliferative Vascular Lesions to the medical criteria found in the online authorization tool for participating providers for Medicare Advantage Plans only. There will be no other changes in this medical policy. For additional details related to this policy, please click here.

Microprocessor-Controlled Prostheses for the Lower Limb

Effective November, 1, 2025 the following code L5615 for Medicare Advantage Members will transition to LCD Criteria found in the online authorization tool.  There was no change to Commercial. For additional details related to this policy, please click here. 

Prior Authorization of Spinal Procedures               

Effective 11/1/2025, this policy will be updated to include Fully-Funded Commercial Products. All other Commercial Products, including Self-Funded, will be addressed in the Prior Authorization via Web Based Tool for Procedures policy.  

As a result of this updated expansion, several CPT codes will have prior authorization added for Commercial Products. 

The CPT codes identified below in the following policies will be addressed in this Prior Authorization of Spinal Procedures policy and the Prior Authorization via Web Based Tool for Procedures policy, and the following policies will be archived:  

• Artificial Intervertebral Disc Insertion Lumbar Spine 
• CPT Codes 22857, 22860, 22862, 0165T 
• Axial Lumbosacral Interbody Fusion 
• CPT Code 22586 
• Electrical Bone Growth Stimulation of the Appendicular Skeleton 
• CPT Code 20975 
• HCPCS Code E0749 changing to Covered for Commercial Products 
• Interspinous Interlaminar Stabilization Distraction Devices Spacers 
• CPT Codes 22867, 22868, 22869, 22870 
• HCPCS Code C1821 changing to Covered for Commercial Products 

The select CPT codes identified below in the following policies will be addressed in the Prior Authorization of Spinal Procedures and Prior Authorization via Web Based Tool for Procedures policies. However, these policies continue to address other services and will not be archived.  

• Diagnosis and Treatment of SI Joint Pain 
• CPT Codes 27278 and 27279 
• Image Guided Minimally Invasive Spinal Decompression for Spinal Stenosis 
• CPT Codes 0274T and 0275T 
• New Technology and Miscellaneous Services 
• CPT Codes 0095T, 0098T, 0164T, 0165T 

In addition:  

• Prior authorization will be removed from HCPCS code C9757 for Medicare Advantage Plans and Commercial Products, and 
• Prior authorization will be added to CPT Codes 22585, 22840 and 27280 for Medicare Advantage Plans. 

For additional details related to this policy, please click here.

Fully-Funded Commercial Products – Policies effected by change 

Effective October 1, 2025, the policies listed below are being updated to identify that prior authorization requests may not be needed for Fully-Funded Commercial Products when the requesting physician is a BCBSRI Contracted Primary Care Provider. Prior authorization continues to be needed for all other Commercial Products, including Self-Funded and Medicare Advantage Plans. Prior authorization is also still needed from Primary Care Providers for drugs. The following specialties, that are credentialed as a primary care provider, are included in this exemption: 

• Internal Medicine 
• Pediatric Medicine 
• Family Practice 
• Obstetrics and Gynecology 
• Doctor of Osteopathic Medicine 
• NP (Nurse Practitioner) / PCP (Primary Care Physician or Provider) 
• PA (Physician Assistant) 

Please see the following policies for detail: 

• Acute Inpatient Rehabilitation Level of Care 
• Genetic Testing Services 
• Long Term Acute Care Hospital (LTACH) 
• New Technology and Miscellaneous Services 
• Prior Authorization for Cardiology and Radiology 
• Prior Authorization for Durable Medical Equipment (DME) 
• Prior Authorization for Procedures 
• Proprietary Laboratory Analyses (PLA) and Multianalyte Assays with Algorithmic Analyses (MAAA) 
• Skilled Nursing Facilities (SNF) Admission and Concurrent Review