Premera Blue Cross

Red blood cell antigen typing, DNA, human Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (colorectal), quantitative Possible Denial; Medical Records Investigative Documentation optional

Oncology (ovarian) biochemical assays of Possible Denial; Medical Records Investigative Documentation optional

Scoliosis, DNA analysis of 53 single Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (prostate) gene expression Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (hepatic), mRNA expression Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (gastrointestinal neuroendocrine Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology, prostate cancer, mRNA Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (urothelial), mRNA, gene Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (urothelial), mRNA, gene Prior Authorization Required Genetic Testing Submit online review with Carelon at

Adrenal cortical tumor, biochemical assay Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (bladder), mRNA, microarray Possible Denial; Medical Records Investigative Documentation optional

Oncology (hematolymphoid neoplasia), Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (diffuse large B-cell lymphoma Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (hematolymphoid neoplasia), Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (Thyroid), microRNA profiling by Prior Authorization Required Genetic Testing Submit online review with Carelon at

Cardiovascular disease, plasma, analysis Possible Denial; Medical Records Investigative Documentation optional

Oncology, RNA, gene expression by whole Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (central nervous system), Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (prostate), detection of 8 Possible Denial; Medical Records Investigative Documentation optional

Targeted genomic sequence analysis Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (acute myelogenous leukemia), Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (thyroid), DNA and mRNA of 112 Prior Authorization Required Genetic Testing Submit online review with Carelon at

JAK2 (Janus kinase 2) (eg, Prior Authorization Required Genetic Testing Submit online review with Carelon at

Drug metabolism (warfarin drug response), Prior Authorization Required Genetic Testing Submit online review with Carelon at

COMT (catechol-O- Prior Authorization Required Genetic Testing Submit online review with Carelon at

TPMT (thiopurine S-methyltransferase), Prior Authorization Required Genetic Testing Submit online review with Carelon at

Exome (ie, somatic mutations), paired Prior Authorization Required Genetic Testing Submit online review with Carelon at

Targeted genomic sequence analysis, solid Prior Authorization Required Genetic Testing Submit online review with Carelon at

Vitamin D, 25 hydroxy D2 and D3, by LC- Retrospective Review Medical Necessity Only covered for diagnoses that are

BCR/ABL1 (t(9;22)) (eg, chronic Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (breast ductal carcinoma in situ), Prior Authorization Required Genetic Testing Submit online review with Carelon at

FLT3 (fms-related tyrosine kinase 3) (eg, Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (prostate), mRNA, gene Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (solid organ neoplasia), DNA, Prior Authorization Required Genetic Testing Submit online review with Carelon at

NPM1 (nucleophosmin) (eg, acute myeloid Prior Authorization Required Genetic Testing Submit online review with Carelon at

Targeted genomic sequence analysis Prior Authorization Required Genetic Testing Submit online review with Carelon at

Cardiology (heart transplant), cell-free Prior Authorization Required Genetic Testing Submit online review with Carelon at

Twin zygosity, genomic targeted sequence Prior Authorization Required Genetic Testing Submit online review with Carelon at

Autoimmune (systemic lupus Possible Denial; Medical Records Investigative Documentation optional

Oncology (colorectal), microRNA, RT-PCR Prior Authorization Required Genetic Testing Submit online review with Carelon at

CYP2D6 (cytochrome P450, family 2, Prior Authorization Required Genetic Testing Submit online review with Carelon at

Focused ultrasound ablation of uterine Possible Denial; Medical Records Investigative Documentation optional

CYP2D6 (cytochrome P450, family 2, Prior Authorization Required Genetic Testing Submit online review with Carelon at

Focused ultrasound ablation of uterine Possible Denial; Medical Records Investigative Documentation optional

CYP2D6 (cytochrome P450, family 2, Prior Authorization Required Genetic Testing Submit online review with Carelon at

CYP2D6 (cytochrome P450, family 2, Prior Authorization Required Genetic Testing Submit online review with Carelon at

CYP2D6 (cytochrome P450, family 2, Prior Authorization Required Genetic Testing Submit online review with Carelon at

CYP2D6 (cytochrome P450, family 2, Prior Authorization Required Genetic Testing Submit online review with Carelon at

CYP2D6 (cytochrome P450, family 2, Prior Authorization Required Genetic Testing Submit online review with Carelon at

Comparative DNA analysis using multiple Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (lung), mass spectrometric Possible Denial; Medical Records Investigative Documentation optional

Cardiology (heart transplant), mRNA gene Prior Authorization Required Genetic Testing Submit online review with Carelon at

Transplantation medicine (kidney allograft Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (melanoma), gene expression Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (cutaneous melanoma), mRNA Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (lung), three protein biomarkers, Possible Denial; Medical Records Investigative Documentation optional

Genome (eg, unexplained constitutional or Prior Authorization Required Genetic Testing Submit online review with Carelon at

Revision including replacement of total disc Prior Authorization Required Medical Necessity Including Site Submit recent history and physical, plan

Placement of a subconjunctival retinal Possible Denial; Medical Records Investigative Documentation optional

Extracorporeal shock wave involving Possible Denial; Medical Records Investigative Documentation optional

Hereditary colon cancer disorders (eg, Prior Authorization Required Genetic Testing Submit online review with Carelon at

Extracorporeal shock wave, high energy, Possible Denial; Medical Records Investigative Documentation optional

Hereditary breast cancer-related disorders Prior Authorization Required Genetic Testing Submit online review with Carelon at

Hereditary ovarian cancer (eg, hereditary Prior Authorization Required Genetic Testing Submit online review with Carelon at

Gastroenterology (Barrett's esophagus), Possible Denial; Medical Records Investigative Documentation optional

Oncology (colon cancer), targeted KRAS Prior Authorization Required Genetic Testing Submit online review with Carelon at

Infectious agent detection and Possible Denial; Medical Records Investigative Documentation optional

Oncology (prostate), measurement of Prior Authorization Required Genetic Testing Submit online review with Carelon at

Gastroenterology (Barrett's esophagus), Prior Authorization Required Genetic Testing Submit online review with Carelon at

Transplantation medicine, quantification of Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (B-cell lymphoma classification), Prior Authorization Required Genetic Testing Submit online review with Carelon at

Hereditary breast cancer-related disorders Prior Authorization Required Genetic Testing Submit online review with Carelon at

Hereditary colon cancer disorders (eg, Prior Authorization Required Genetic Testing Submit online review with Carelon at

Hereditary prostate cancer-related Prior Authorization Required Genetic Testing Submit online review with Carelon at

Hereditary pan cancer (eg, hereditary Prior Authorization Required Genetic Testing Submit online review with Carelon at

ATM (ataxia telangiectasia mutated) (eg, Prior Authorization Required Genetic Testing Submit online review with Carelon at

PALB2 (partner and localizer of BRCA2) Prior Authorization Required Genetic Testing Submit online review with Carelon at

BRCA1 (BRCA1, DNA repair associated), Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (breast), MRNA, gene Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (urothelial cancer) RNA, analysis Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (breast cancer) DNA, PIK3CA Prior Authorization Required Genetic Testing Submit online review with Carelon at

Copy number (EG, intellectual disability, Prior Authorization Required Genetic Testing Submit online review with Carelon at

APC (APC regulator of WNT signaling Prior Authorization Required Genetic Testing Submit online review with Carelon at

MLH1 (MUTL HOMOLOG 1) (EG, Prior Authorization Required Genetic Testing Submit online review with Carelon at

MSH2 (MUTS HOMOLOG 2) (EG, Prior Authorization Required Genetic Testing Submit online review with Carelon at

MSH6 (MUTS HOMOLOG 6) (EG, Prior Authorization Required Genetic Testing Submit online review with Carelon at

PMS2 (PMS1 HOMOLOG 2, mismatch Prior Authorization Required Genetic Testing Submit online review with Carelon at

Hereditary colon cancer (lynch syndrome), Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (colorectal) screening, Possible Denial; Medical Records Investigative Documentation optional

Removal of total disc arthroplasty, anterior Prior Authorization Required Medical Necessity Submit history and physical

Revision of total disc arthroplasty (artificial Prior Authorization Required Investigative Submit history and physical

NUDT15 (nudix hydrolase 15) and TPMT Prior Authorization Required Genetic Testing Submit online review with Carelon at

Neurology (autism spectrum disorder Prior Authorization Required Genetic Testing Submit online review with Carelon at

Targeted genomic sequence analysis Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (solid tumor as indicated by the Prior Authorization Required Genetic Testing Submit online review with Carelon at

Psychiatry (ie, depression, anxiety), Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (solid tumor), mass Possible Denial; Medical Records Investigative Documentation optional

Psychiatry (eg, depression, anxiety), Prior Authorization Required Genetic Testing Submit online review with Carelon at

Cytolethal distending toxin B (CdtB) and Possible Denial; Medical Records Investigative Documentation optional

Oncology (breast cancer), DNA, PIK3CA Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (non-small cell lung cancer), cell- Prior Authorization Required Genetic Testing Submit online review with Carelon at

Red cell antigen (ABO blood group) Possible Denial; Medical Records Investigative Documentation optional

Red cell antigen (Colton blood group) Possible Denial; Medical Records Investigative Documentation optional

Red cell antigen (Cromer blood group) Possible Denial; Medical Records Investigative Documentation optional

Red cell antigen (Diego blood group) Possible Denial; Medical Records Investigative Documentation optional

Red cell antigen (Dombrock blood group) Possible Denial; Medical Records Investigative Documentation optional

Red cell antigen (H blood group) Possible Denial; Medical Records Investigative Documentation optional

Red cell antigen (H blood group) Possible Denial; Medical Records Investigative Documentation optional

Red cell antigen (Duffy blood group) Possible Denial; Medical Records Investigative Documentation optional

Red cell antigen (Gerbich blood group) Possible Denial; Medical Records Investigative Documentation optional

Red cell antigen (MNS blood group) Possible Denial; Medical Records Investigative Documentation optional

Red cell antigen (MNS blood group) Possible Denial; Medical Records Investigative Documentation optional

Red cell antigen (Indian blood group) Possible Denial; Medical Records Investigative Documentation optional

Red cell antigen (Kidd blood group) Possible Denial; Medical Records Investigative Documentation optional

Red cell antigen (JR blood group) Possible Denial; Medical Records Investigative Documentation optional

Red cell antigen (Kell blood group) Possible Denial; Medical Records Investigative Documentation optional

KLF1 (Kruppel-like factor 1), targeted Possible Denial; Medical Records Investigative Documentation optional

Red cell antigen (Lutheran blood group) Possible Denial; Medical Records Investigative Documentation optional

Red cell antigen (Landsteiner-Wiener Possible Denial; Medical Records Investigative Documentation optional

Red cell antigen (RH blood group) Possible Denial; Medical Records Investigative Documentation optional

Unlisted anesthesia procedure(s) Medical necessity review will be Medical Necessity Review required at claims submission

Red cell antigen (Scianna blood group) Possible Denial; Medical Records Investigative Documentation optional

Percutaneous sacral augmentation Prior Authorization Required Investigative Submit history and physical

Red cell antigen (Kx blood group) Possible Denial; Medical Records Investigative Documentation optional

Percutaneous sacral augmentation Prior Authorization Required Investigative Submit history and physical

Red cell antigen (Yt blood group) Possible Denial; Medical Records Investigative Documentation optional

Posterior vertebral joint(s) arthroplasty Pre-Service Review Required Investigative Submit history and physical

Autoimmune (inflammatory bowel disease), Prior Authorization Required Genetic Testing Submit online review with Carelon at

Ophthalmology (age-related macular Prior Authorization Required Genetic Testing Submit online review with Carelon at

Neurology (Alzheimer disease); cell Possible Denial; Medical Records Investigative Documentation optional

Neurology (Alzheimer disease); Possible Denial; Medical Records Investigative Documentation optional

Cytogenomic constitutional (genome-wide) Prior Authorization Required Genetic Testing Submit online review with Carelon at

Syphilis test, non-treponemal antibody, Possible Denial; Medical Records Investigative Documentation optional

Oncology (pan-tumor), DNA and RNA by Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (pan-tumor), DNA and RNA by Prior Authorization Required Genetic Testing Submit online review with Carelon at

Rare diseases (constitutional/heritable Prior Authorization Required Genetic Testing Submit online review with Carelon at

Rare diseases (constitutional/heritable Prior Authorization Required Genetic Testing Submit online review with Carelon at

Rare diseases (constitutional/heritable Prior Authorization Required Genetic Testing Submit online review with Carelon at

Neurology (inherited ataxias), genomic Prior Authorization Required Genetic Testing Submit online review with Carelon at

Neurology (inherited ataxias), genomic Prior Authorization Required Genetic Testing Submit online review with Carelon at

Neurology (muscular dystrophy), DMD Prior Authorization Required Genetic Testing Submit online review with Carelon at

Placement of a posterior intrafacet Possible Denial; Medical Records Investigative Documentation optional

Infectious agent (human immunodeficiency Possible Denial; Medical Records Investigative Documentation optional

Placement of a posterior intrafacet Possible Denial; Medical Records Investigative Documentation optional

Oncology (breast cancer), image analysis Possible Denial; Medical Records Investigative Documentation optional

Placement of a posterior intrafacet Possible Denial; Medical Records Investigative Documentation optional

Red cell antigen (ABO blood group) Possible Denial; Medical Records Investigative Documentation optional

Placement of a posterior intrafacet Possible Denial; Medical Records Investigative Documentation optional

Red cell antigen (RH blood group) Possible Denial; Medical Records Investigative Documentation optional

Oncology (prostate), multianalyte Prior Authorization Required Genetic Testing Submit online review with Carelon at

BCAT1 (Branched chain amino acid Prior Authorization Required Genetic Testing Submit online review with Carelon at

AR (androgen receptor) (eg, spinal and Prior Authorization Required Genetic Testing Submit online review with Carelon at

CACNA1A (calcium voltage-gated channel Prior Authorization Required Genetic Testing Submit online review with Carelon at

Injection(s), platelet rich plasma, any Possible Denial; Medical Records Investigative Documentation optional

CSTB (cystatin B) (eg, progressive Prior Authorization Required Genetic Testing Submit online review with Carelon at

FXN (frataxin) (eg, Friedreich ataxia), gene Prior Authorization Required Genetic Testing Submit online review with Carelon at

MECP2 (methyl CpG binding protein 2) Prior Authorization Required Genetic Testing Submit online review with Carelon at

PTEN (phosphatase and tensin homolog) Prior Authorization Required Genetic Testing Submit online review with Carelon at

SMN1 (survival of motor neuron 1, Prior Authorization Required Genetic Testing Submit online review with Carelon at

Cardiac ion channelopathies (eg, Brugada Prior Authorization Required Genetic Testing Submit online review with Carelon at

Transluminal peripheral atherectomy, open Prior Authorization Required Medical Necessity Submit history and physical

Oncology (Lynch syndrome), genomic DNA Prior Authorization Required Genetic Testing Submit online review with Carelon at

Targeted genomic sequence analysis Prior Authorization Required Genetic Testing Submit online review with Carelon at

Targeted genomic seq analysis panel, solid Prior Authorization Required Genetic Testing Submit online review with Carelon at

Obstetrics (preeclampsia), biochemical Possible Denial; Medical Records Investigative Documentation optional

Oncology DNA, comprehensive genomic Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (thyroid) mutation analysis of 10 Prior Authorization Required Genetic Testing Submit online review with Carelon at

Obstetrics (preterm birth), insulin-like Possible Denial; Medical Records Investigative Documentation optional

Oncology (solid organ neoplasm), targeted Prior Authorization Required Genetic Testing Submit online review with Carelon at

Fetal aneuploidy short tandem-repeat Prior Authorization Required Genetic Testing Submit online review with Carelon at

Reproductive medicine (endometrial Prior Authorization Required Genetic Testing Submit online review with Carelon at

Reproductive medicine (preimplantation Prior Authorization Required Genetic Testing Submit online review with Carelon at

Autoimmune (psoriasis), mRNA, next- Prior Authorization Required Genetic Testing Submit online review with Carelon at

Rare diseases (constitutional/heritable Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (solid tumor), gene expression Prior Authorization Required Genetic Testing Submit online review with Carelon at

Intramuscular autologous bone marrow cell Possible Denial; Medical Records Investigative Documentation optional

Intramuscular autologous bone marrow cell Possible Denial; Medical Records Investigative Documentation optional

Rare diseases (constitutional/heritable Prior Authorization Required Genetic Testing Submit online review with Carelon at

Intramuscular autologous bone marrow cell Possible Denial; Medical Records Investigative Documentation optional

Rare constitutional and other heritable Prior Authorization Required Genetic Testing Submit online review with Carelon at

Unexplained constitutional or other Prior Authorization Required Genetic Testing Submit online review with Carelon at

Rare constitutional and other heritable Prior Authorization Required Genetic Testing Submit online review with Carelon at

Hematology (atypical hemolytic uremic Prior Authorization Required Genetic Testing Submit online review with Carelon at

Hematology (autosomal dominant Prior Authorization Required Genetic Testing Submit online review with Carelon at

Hematology (congenital coagulation Prior Authorization Required Genetic Testing Submit online review with Carelon at

Hematology (congenital neutropenia), Prior Authorization Required Genetic Testing Submit online review with Carelon at

Hematology (genetic bleeding disorders), Prior Authorization Required Genetic Testing Submit online review with Carelon at

Hematology (genetic hyperfibrinolysis, Prior Authorization Required Genetic Testing Submit online review with Carelon at

Percutaneous laminotomy/laminectomy Possible Denial; Medical Records Investigative Documentation optional

Hematology (genetic platelet disorders), Prior Authorization Required Genetic Testing Submit online review with Carelon at

Hematology (inherited thrombocytopenia), Prior Authorization Required Genetic Testing Submit online review with Carelon at

Hematology (genetic platelet function Prior Authorization Required Genetic Testing Submit online review with Carelon at

Transcutaneous electrical modulation pain Possible Denial; Medical Records Investigative Documentation optional

Hematology (genetic thrombosis), genomic Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology, disease progression and Prior Authorization Required Genetic Testing Submit online review with Carelon at

CEP72 (centrosomal protein, 72-KDa), Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (thyroid), DNA and mRNA, next- Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (lung), mRNA, quantitative PCR Prior Authorization Required Genetic Testing Submit online review with Carelon at

Neurology (Alzheimer disease), mRNA, Prior Authorization Required Genetic Testing Submit online review with Carelon at

Pain management, mRNA, gene Prior Authorization Required Genetic Testing Submit online review with Carelon at

Psychiatry (mood disorders), mRNA, gene Prior Authorization Required Genetic Testing Submit online review with Carelon at

Psychiatry (stress disorders), mRNA, gene Prior Authorization Required Genetic Testing Submit online review with Carelon at

Psychiatry (suicidal ideation), mRNA, gene Prior Authorization Required Genetic Testing Submit online review with Carelon at

Longevity and mortality risk, mRNA, gene Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (breast ductal carcinoma in situ), Possible Denial; Medical Records Investigative Documentation optional

Oncology (oral and/or oropharyngeal Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (pan tumor), whole genome Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (pan tumor), whole transcriptome Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (pan tumor), whole genome Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (pan tumor), whole genome Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (minimal residual disease Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (minimal residual disease Prior Authorization Required Genetic Testing Submit online review with Carelon at

Autoimmune diseases (eg, systemic lupus Possible Denial; Medical Records Investigative Documentation optional

Oncology (pancreas), DNA and mRNA Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (cutaneous melanoma), mRNA Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (cutaneous squamous cell Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (lung cancer), four-probe FISH Prior Authorization Required Genetic Testing Submit online review with Carelon at

Pediatrics (congenital epigenetic Prior Authorization Required Genetic Testing Submit online review with Carelon at

Nephrology (renal transplant), RNA Prior Authorization Required Genetic Testing Submit online review with Carelon at

Nephrology (renal transplant), RNA Prior Authorization Required Genetic Testing Submit online review with Carelon at

Targeted genomic sequence analysis Prior Authorization Required Genetic Testing Submit online review with Carelon at

Fetal aneuploidy (trisomy 13, 18, and 21), Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (neoplasia), exome and Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (hematolymphoid neoplasia), Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (pan-tumor), genetic profiling of Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (liver), surveillance for Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (solid organ), targeted genomic Prior Authorization Required Genetic Testing Submit online review with Carelon at

Insertion of sinus tarsi implant. Possible Denial; Medical Records Investigative Documentation optional

Rare diseases (constitutional/heritable Prior Authorization Required Genetic Testing Submit online review with Carelon at

Rare diseases (constitutional/heritable Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (plasma cell disorders and Possible Denial; Medical Records Investigative Documentation optional

Oncology (solid tumor), circulating tumor Possible Denial; Medical Records Investigative Documentation optional

Oncology (prostate), mRNA expression Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (pan-cancer), analysis of minimal Prior Authorization Required Genetic Testing Submit online review with Carelon at

Fetal aneuploidy DNA sequencing Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (pancreatic cancer), multiplex Possible Denial; Medical Records Investigative Documentation optional

Oncology (prostate), exosome-based Prior Authorization Required Genetic Testing Submit online review with Carelon at

Hepatology (nonalcoholic fatty liver Possible Denial; Medical Records Investigative Documentation optional

Transcatheter mitral valve repair Prior Authorization Required Medical Necessity Submit documentation of medical

Psychiatry (eg, depression, anxiety, Prior Authorization Required Genetic Testing Submit online review with Carelon at

Drug metabolism or processing (multiple Prior Authorization Required Genetic Testing Submit online review with Carelon at

Drug metabolism or processing (multiple Prior Authorization Required Genetic Testing Submit online review with Carelon at

Drug metabolism or processing (multiple Prior Authorization Required Genetic Testing Submit online review with Carelon at

Drug metabolism or processing (multiple Prior Authorization Required Genetic Testing Submit online review with Carelon at

APOL1 (apolipoprotein L1) (eg, chronic Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (oropharyngeal or anal), Prior Authorization Required Genetic Testing Submit online review with Carelon at

Bioelectrical impedance analysis whole Possible Denial; Medical Records Investigative Documentation optional

Neurology (mild cognitive impairment), Pre-Service Review Required Investigative Submit history and physical

Oncology (lung), enzyme-linked Possible Denial; Medical Records Investigative Documentation optional

Oncology (papillary thyroid cancer), gene- Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (urothelial), mRNA, Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (hematolymphoid neoplasm), Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (bladder), 10 protein biomarkers Possible Denial; Medical Records Investigative Documentation optional

Oncology (bladder), analysis of 10 protein Possible Denial; Medical Records Investigative Documentation optional

Oncology (bladder), analysis of 10 protein Possible Denial; Medical Records Investigative Documentation optional

Oncology (colorectal cancer), evaluation Prior Authorization Required Genetic Testing Submit online review with Carelon at

Infectious agent detection by nucleic acid Possible Denial; Medical Records Investigative Documentation optional

Infectious disease, antibiotic-resistance Possible Denial; Medical Records Investigative Documentation optional

Infectious agent detection by nucleic acid Possible Denial; Medical Records Investigative Documentation optional

Infectious agent detection by nucleic acid Possible Denial; Medical Records Investigative Documentation optional

Oncology (ovarian), biochemical assays of Possible Denial; Medical Records Investigative Documentation optional

Oncology (prostate cancer), image analysis Possible Denial; Medical Records Investigative Documentation optional

Cardiovascular disease, quantification of Possible Denial; Medical Records Investigative Documentation optional

RFC1 (replication factor C subunit 1), Prior Authorization Required Genetic Testing Submit online review with Carelon at

Targeted genomic sequence analysis Prior Authorization Required Genetic Testing Submit online review with Carelon at

Nephrology carboxymethyllsine, Possible Denial; Medical Records Investigative Documentation optional

Nephrology apolipoprotein A4, CD5 Possible Denial; Medical Records Investigative Documentation optional

Oncology (non-small cell lung cancer), next Prior Authorization Required Genetic Testing Submit online review with Carelon at

Pediatric febrile illness (Kawasaki disease Prior Authorization Required Genetic Testing Submit online review with Carelon at

Obstetrics (preeclampsia), kinase insert Possible Denial; Medical Records Investigative Documentation optional

Oncology (solid tumor), DNA and RNA by Prior Authorization Required Genetic Testing Submit online review with Carelon at

Drug metabolism (depression, anxiety, Prior Authorization Required Genetic Testing Submit online review with Carelon at

Neurology (eg, Parkinson disease, Possible Denial; Medical Records Investigative Documentation optional

Oncology (lung), multi-omics (microbial Possible Denial; Medical Records Investigative Documentation optional

Gastroenterology (Barrett Possible Denial; Medical Records Investigative Documentation optional

Obstetrics (expanded carrier screening), Prior Authorization Required Genetic Testing Submit online review with Carelon at

Cardiology (coronary heart disease [CAD]), Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (prostate), MRNA, gene Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (breast), semiquantitative Possible Denial; Medical Records Investigative Documentation optional

Oncology (pancreatic), 59 methylation Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (lung), flow cytometry, sputum, 5 Possible Denial; Medical Records Investigative Documentation optional

Insertion or replacement of permanent Possible Denial; Medical Records Investigative Documentation optional

Oncology (solid tumor), DNA (80 genes) Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (pancreatic), DNA, whole Prior Authorization Required Genetic Testing Submit online review with Carelon at

Psychiatry (depression, anxiety, attention Prior Authorization Required Genetic Testing Submit online review with Carelon at

Beta amyloid, A?42/40 ratio, Possible Denial; Medical Records Investigative Documentation optional

Oncology optical genome mapping for copy Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (lung), augmentative algorithmic Prior Authorization Required Genetic Testing Submit online review with Carelon at

Cardiovascular disease IL-16, FAS, Possible Denial; Medical Records Investigative Documentation optional

Rare diseases whole mitochondrial Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (breast), augmentative Possible Denial; Medical Records Investigative Documentation optional

Neuropsychiatry (eg depression, anxiety,) Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (urothelial), MRNA expression Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (colorectal) screening, Possible Denial; Medical Records Investigative Documentation optional

Oncology (pan-solid tumor) analysis of Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (prostate), exosome-based Prior Authorization Required Genetic Testing Submit online review with Carelon at

Genome (eg, unexplained constitutional or Prior Authorization Required Genetic Testing Submit online review with Carelon at

Genome (eg, unexplained constitutional or Prior Authorization Required Genetic Testing Submit online review with Carelon at

Gastroenterology, malabsorption Possible Denial; Medical Records Investigative Documentation optional

Oncology (prostate), 5 DNA regulatory Prior Authorization Required Genetic Testing Submit online review with Carelon at

Drug metabolism (adverse drug reactions Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology, chemotherapeutic drug Possible Denial; Medical Records Investigative Documentation optional

Oncology (lung), plasma analysis of 388 Possible Denial; Medical Records Investigative Documentation optional

Psychiatry (anxiety disorders), MRNA, Prior Authorization Required Genetic Testing Submit online review with Carelon at

Drug metabolism (adverse drug reactions Prior Authorization Required Genetic Testing Submit online review with Carelon at

Cardiology (coronary heart disease [CHD]), Prior Authorization Required Genetic Testing Submit online review with Carelon at

Cardiology (coronary heart disease) DNA Prior Authorization Required Genetic Testing Submit online review with Carelon at

Ablation, percutaneous, cryoablation, Possible Denial; Medical Records Investigative Documentation optional

Infectious disease (bacterial, fungal, or Possible Denial; Medical Records Investigative Documentation optional

Infectious disease (respiratory infection), Possible Denial; Medical Records Investigative Documentation optional

Neurofilament light chain (NfL), ultra- Possible Denial; Medical Records Investigative Documentation optional

Oncology (solid organ neoplasia), targeted Prior Authorization Required Genetic Testing Submit online review with Carelon at

B-amyloid (Abeta42) and phospho tau Pre-Service Review Required Medical Necessity Submit history and physical

Autoimmune diseases (systemic lupus Possible Denial; Medical Records Investigative Documentation optional

Autoimmune diseases (systemic lupus Possible Denial; Medical Records Investigative Documentation optional

Carrier screening for severe inherited Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (bladder), methylated PENK Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (colorectal cancer), cell-free Prior Authorization Required Genetic Testing Submit online review with Carelon at

Rare diseases (constitutional/heritable Prior Authorization Required Genetic Testing Submit online review with Carelon at

Perfluoroalkyl substances (PFAS) (eg, Possible Denial; Medical Records Investigative Documentation optional

Oncology (breast cancer), S100A8 and Possible Denial; Medical Records Investigative Documentation optional

B-amyloid (Abeta42) and total tau (tTau), Pre-Service Review Required Medical Necessity Submit history and physical

Oncology, whole blood or buccal, DNA Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology, pharmacogenomic analysis of Prior Authorization Required Genetic Testing Submit online review with Carelon at

Melatonin levels test, sleep study, 7 or 9 Possible Denial; Medical Records Investigative Documentation optional

Oncology (cervix), mRNA gene expression Possible Denial; Medical Records Investigative Documentation optional

Oncology (urothelial carcinoma), DNA, Prior Authorization Required Genetic Testing Submit online review with Carelon at

Cardiology (coronary artery disease Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (bladder), DNA, next-generation Prior Authorization Required Genetic Testing Submit online review with Carelon at

Hepatology (nonalcoholic steatohepatitis Possible Denial; Medical Records Investigative Documentation optional

Retinal polarization scan, ocular screening Possible Denial; Medical Records Investigative Documentation optional

Rare diseases (constitutional/heritable Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (oropharyngeal), detection of Possible Denial; Medical Records Investigative Documentation optional

Oncology (colorectal cancer), qualitative Prior Authorization Required Genetic Testing Submit online review with Carelon at

Device evaluation, interrogation, and initial Possible Denial; Medical Records Investigative Documentation optional

Carbonic anhydrase VI (CA VI), parotid Possible Denial; Medical Records Investigative Documentation optional

Device evaluation and interrogation of Possible Denial; Medical Records Investigative Documentation optional

Oncology (solid tumor), next-generation Prior Authorization Required Genetic Testing Submit online review with Carelon at

Hereditary pan-cancer (eg, hereditary Prior Authorization Required Genetic Testing Submit online review with Carelon at

Hereditary prostate cancer-related Prior Authorization Required Genetic Testing Submit online review with Carelon at

Drug metabolism, psychiatry (eg, major Prior Authorization Required Genetic Testing Submit online review with Carelon at

Drug metabolism, psychiatry (eg, major Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (non-small cell lung cancer), Prior Authorization Required Genetic Testing Submit online review with Carelon at

Fractional ablative laser fenestration of Possible Denial; Medical Records Investigative Documentation optional

Tau, phosphorylated, pTau217 Possible Denial; Medical Records Investigative Documentation optional

Fractional ablative laser fenestration of Possible Denial; Medical Records Investigative Documentation optional

IDH1 (isocitrate dehydrogenase 1 Prior Authorization Required Genetic Testing Submit online review with Carelon at

Obstetrics (preeclampsia), biochemical Possible Denial; Medical Records Investigative Documentation optional

Transcatheter mitral valve Prior Authorization Required Medical Necessity Submit history and physical

Transcatheter mitral valve Prior Authorization Required Medical Necessity Submit history and physical

Optical coherence tomography (OCT) of Possible Denial; Medical Records Investigative Documentation optional

Oncology (solid tumor), cell-free DNA and Prior Authorization Required Genetic Testing Submit online review with Carelon at

Optical coherence tomography (OCT) of Possible Denial; Medical Records Investigative Documentation optional

Oncology (pan-solid tumor), next- Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (solid tumor), cell-free circulating Prior Authorization Required Genetic Testing Submit online review with Carelon at

Obstetrics (fetal antigen noninvasive Prior Authorization Required Genetic Testing Submit online review with Carelon at

Autologous adipose-derived regenerative Possible Denial; Medical Records Investigative Documentation optional

Obstetrics (single-gene noninvasive Prior Authorization Required Genetic Testing Submit online review with Carelon at

Autologous adipose-derived regenerative Possible Denial; Medical Records Investigative Documentation optional

Oncology (cutaneous or uveal melanoma), Possible Denial; Medical Records Investigative Documentation optional

Oncology (solid tumor), circulating tumor Possible Denial; Medical Records Investigative Documentation optional

Oncology (solid tumor), circulating tumor Possible Denial; Medical Records Investigative Documentation optional

Transplantation medicine, quantification of Prior Authorization Required Genetic Testing Submit online review with Carelon at

Red blood cell antigen (fetal RhD gene Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (prostate), analysis of circulating Possible Denial; Medical Records Investigative Documentation optional

Oncology (colorectal), cell-free DNA, 8 Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (prostate), mRNA gene- Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (colorectal), next-generation Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (colorectal and lung), DNA from Prior Authorization Required Genetic Testing Submit online review with Carelon at

Autoinflammatory disease (VEXAS Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (colorectal), blood, quantitative Possible Denial; Medical Records Investigative Documentation optional

Neurology (Alzheimer disease), beta Possible Denial; Medical Records Investigative Documentation optional

Endovenous femoral-popliteal arterial Prior Authorization Required Medical Necessity Submit history and physical

Gastroenterology (Barrett's esophagus), Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (ovarian), DNA, whole-genome Prior Authorization Required Genetic Testing Submit online review with Carelon at

Removal of sinus tarsi implant Possible Denial; Medical Records Investigative Documentation optional

Oncology (pancreatic cancer), Possible Denial; Medical Records Investigative Documentation optional

Removal and reinsertion of sinus tarsi Possible Denial; Medical Records Investigative Documentation optional

Oncology (solid tumor), tumor cell culture Possible Denial; Medical Records Investigative Documentation optional

Oncology (prostate), augmentative Possible Denial; Medical Records Investigative Documentation optional

Oncology (prostate), augmentative Possible Denial; Medical Records Investigative Documentation optional

Drug metabolism, whole blood, Prior Authorization Required Genetic Testing Submit online review with Carelon at

Therapeutic drug monitoring, 80 or more Non-covered Service Benefit Exception Considered non-covered unless

Therapeutic drug monitoring, 90 or more Non-covered Service Benefit Exception Considered non-covered unless

Therapeutic drug monitoring, medications Non-covered Service Benefit Exception Considered non-covered unless

Therapeutic drug monitoring, 200 or more Non-covered Service Benefit Exception Considered non-covered unless

Rheumatoid factor IgA and IgM, cyclic Possible Denial; Medical Records Investigative Documentation optional

Carbonic anhydrase VI, parotid Possible Denial; Medical Records Investigative Documentation optional

Oncology (solid tumor), DNA, qualitative, Prior Authorization Required Genetic Testing No review for non-cancer diagnoses

Endovenous catheter directed chemical Prior Authorization Required Medical Necessity Submit history and physical

Obstetrics (preeclampsia), sFlt-1/PlGF Possible Denial; Medical Records Investigative Documentation optional

Oncology, spheroid cell culture, 11-drug Possible Denial; Medical Records Investigative Documentation optional

Nephrology (renal transplant), Possible Denial; Medical Records Investigative Documentation optional

Lower respiratory tract infectious agent Possible Denial; Medical Records Investigative Documentation optional

Hematology (venous thromboembolism Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (pan-solid tumor), ctDNA, Prior Authorization Required Genetic Testing No review for non-cancer diagnoses

Infectious disease (acid-fast bacteria and Possible Denial; Medical Records Investigative Documentation optional

Rare diseases (constitutional Prior Authorization Required Genetic Testing Submit online review with Carelon at

Drug metabolism (adverse drug reactions Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (prostate), microRNA, single- Prior Authorization Required Genetic Testing Submit online review with Carelon at

Perfluoroalkyl substances (PFAS) (eg, Possible Denial; Medical Records Medical Necessity Documentation optional

Red blood cell antigen (fetal RhD), PCR Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (colorectal cancer), analysis of Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (solid tumor), next-generation Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (solid tumor), cell-free circulating Prior Authorization Required Genetic Testing Submit online review with Carelon at

Transplantation medicine, quantification of Prior Authorization Required Genetic Testing Submit online review with Carelon at

Cardiovascular disease (HDL reverse Possible Denial; Medical Records Medical Necessity Documentation optional

Oncology (solid tumor), next-generation Prior Authorization Required Genetic Testing Submit online review with Carelon at

Transcatheter mitral valve annulus Prior Authorization Required Medical Necessity Submit History and Physical

Low-density lipoprotein receptor-related Possible Denial; Medical Records Medical Necessity Documentation optional

Neurofilament light chain (NfL), Possible Denial; Medical Records Medical Necessity Documentation optional

Glial fibrillary acidic protein (GFAP), Possible Denial; Medical Records Medical Necessity Documentation optional

Oncology (urothelial), DNA, quantitative Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (prostate), enzyme-linked Possible Denial; Medical Records Medical Necessity Documentation optional

Low-level laser therapy, dynamic photonic Non-covered Service Benefit Exception Considered non-covered unless

Reproductive medicine (preimplantation Prior Authorization Required Genetic Testing Submit online review with Carelon at

Reproductive medicine (preimplantation Prior Authorization Required Genetic Testing Submit online review with Carelon at

Reproductive medicine (preimplantation Prior Authorization Required Genetic Testing Submit online review with Carelon at

Reproductive medicine (preimplantation Prior Authorization Required Genetic Testing Submit online review with Carelon at

Infectious disease (bacterial or viral Possible Denial; Medical Records Investigative Documentation optional

Oncology (colorectal), quantitative enzyme- Possible Denial; Medical Records Investigative Documentation optional

Oncology (breast), quantitative enzyme- Possible Denial; Medical Records Investigative Documentation optional

Oncology (minimal residual disease Prior Authorization Required Genetic Testing Submit online review with Carelon at

Anatomic guide 3D-printed and designed Possible Denial; Medical Records Investigative Documentation optional

Oncology (minimal residual disease Prior Authorization Required Genetic Testing Submit online review with Carelon at

Anatomic guide 3D-printed and designed Possible Denial; Medical Records Investigative Documentation optional

Oncology (solid tumor), targeted genomic Prior Authorization Required Genetic Testing Submit online review with Carelon at

Infectious disease (bacterial and/or viral Possible Denial; Medical Records Investigative Documentation optional

Infectious disease (bacterial and/or viral Possible Denial; Medical Records Investigative Documentation optional

Autologous cellular implant derived from Possible Denial; Medical Records Investigative Documentation optional

Oncology (hepatocellular carcinoma), next- Prior Authorization Required Genetic Testing Submit online review with Carelon at

Autologous cellular implant derived from Possible Denial; Medical Records Investigative Documentation optional

Oncology (lung), qPCR-based analysis of Prior Authorization Required Genetic Testing Submit online review with Carelon at

Rare diseases (constitutional/heritable Prior Authorization Required Genetic Testing Submit online review with Carelon at

Neurology (dementia), beta amyloid (AB40, Possible Denial; Medical Records Investigative Documentation optional

Transcatheter tricuspid valve repair, Prior Authorization Required Medical Necessity Submit history and physical

Oncology (solid tumor), next-generation Prior Authorization Required Genetic Testing Submit online review with Carelon at

Transcatheter tricuspid valve repair, Prior Authorization Required Medical Necessity Submit history and physical

Neurology (traumatic brain injury), analysis Possible Denial; Medical Records Investigative Documentation optional

Insertion or replacement of implantable Prior Authorization Required Medical Necessity Submit history and physical

Oncology (solid tumor), DNA (80 genes) Prior Authorization Required Medical Necessity Submit online review with Carelon at

Insertion of substernal implantable Prior Authorization Required Medical Necessity Submit history and physical

Oncology (prostate), high-throughput Possible Denial; Medical Records Investigative Documentation optional

Oncology (pancreas), 3 biomarkers Possible Denial; Medical Records Investigative Documentation optional

Mycobacterium tuberculosis, culture filtrate Possible Denial; Medical Records Investigative Documentation optional

Transplantation medicine (liver allograft Prior Authorization Required Genetic Testing Submit online review with Carelon at

Transplantation medicine (liver allograft Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (cutaneous melanoma), RNA, Prior Authorization Required Genetic Testing Submit online review with Carelon at

Nephrology (diabetic chronic kidney Possible Denial; Medical Records Investigative Documentation optional

Borrelia burgdorferi, antibody detection of Possible Denial; Medical Records Investigative Documentation optional

Ablation, malignant breast tumor(s), Possible Denial; Medical Records Investigative Documentation optional

Transplantation medicine, antibody to non- Possible Denial; Medical Records Investigative Documentation optional

Transurethral ablation of malignant Possible Denial; Medical Records Investigative Documentation optional

Rare diseases (constitutional Prior Authorization Required Genetic Testing Submit online review with Carelon at

Rare diseases (constitutional Prior Authorization Required Genetic Testing Submit online review with Carelon at

Islet cell transplant, includes portal vein Prior Authorization Required Medical Necessity Submit history and physical

Neurology (prion disease), cerebrospinal Possible Denial; Medical Records Investigative Documentation optional

Islet cell transplant, includes portal vein Prior Authorization Required Medical Necessity Submit history and physical

Targeted genomic sequence analysis Prior Authorization Required Genetic Testing Submit online review with Carelon at

Islet cell transplant, includes portal vein Prior Authorization Required Medical Necessity Submit history and physical

Oncology, mRNA, gene expression Prior Authorization Required Genetic Testing Submit online review with Carelon at

Therapeutic drug monitoring, 60-150 drugs Possible Denial; Medical Records Investigative Documentation optional

Infectious disease (bacterial or viral), 32 Possible Denial; Medical Records Investigative Documentation optional

Perfluoroalkyl substances (PFAS) (eg, Possible Denial; Medical Records Investigative Documentation optional

Infectious disease (bacterial and fungal), Possible Denial; Medical Records Investigative Documentation optional

Oncology (prostate cancer), biochemical Possible Denial; Medical Records Investigative Documentation optional

Oncology (hematolymphoid neoplasms), Prior Authorization Required Genetic Testing Submit online review with Carelon at

Infectious disease (genitourinary Possible Denial; Medical Records Investigative Documentation optional

Osteotomy, humerus, with insertion of an Possible Denial; Medical Records Investigative Documentation optional

Infectious disease (sepsis), Possible Denial; Medical Records Investigative Documentation optional

Infectious disease (tropical fever Possible Denial; Medical Records Investigative Documentation optional

Temporary female intraurethral valve-pump Possible Denial; Medical Records Investigative Documentation optional

Neurology (Alzheimer disease), plasma, 3 Possible Denial; Medical Records Investigative Documentation optional

Temporary female intraurethral valve-pump Possible Denial; Medical Records Investigative Documentation optional

Oncology (breast), RNA expression Prior Authorization Required Genetic Testing Submit online review with Carelon at

Real-time fluorescence wound imaging Possible Denial; Medical Records Investigative Documentation optional

Gastroenterology (irritable bowel Possible Denial; Medical Records Investigative Documentation optional

Real-time fluorescence wound imaging Possible Denial; Medical Records Investigative Documentation optional

Oncology (pancreatic cancer), multiplex Possible Denial; Medical Records Investigative Documentation optional

Ablation, irreversible electroporation; 1 or Possible Denial; Medical Records Investigative Documentation optional

Infectious disease (wound infection) Possible Denial; Medical Records Investigative Documentation optional

Ablation, irreversible electroporation; 1 or Possible Denial; Medical Records Investigative Documentation optional

Endocrinology (diabetes), insulin (INS) Possible Denial; Medical Records Investigative Documentation optional

Glomerular filtration rate (GFR) Possible Denial; Medical Records Investigative Documentation optional

Endocrinology (diabetes), insulin (INS) Possible Denial; Medical Records Investigative Documentation optional

Glomerular filtration rate (GFR) monitoring, Possible Denial; Medical Records Investigative Documentation optional

Optical coherence tomography (OCT) of Possible Denial; Medical Records Investigative Documentation optional

Optical coherence tomography (OCT) of Possible Denial; Medical Records Investigative Documentation optional

Allergy and immunology (hereditary alpha Prior Authorization Required Genetic Testing Submit history and physical

Optical coherence tomography (OCT) of Possible Denial; Medical Records Investigative Documentation optional

Hematology (red cell membrane disorders), Possible Denial; Medical Records Investigative Documentation optional

Remote monitoring of an external Possible Denial; Medical Records Investigative Documentation optional

Reproductive medicine (endometrial Possible Denial; Medical Records Investigative Documentation optional

Remote monitoring of an external Possible Denial; Medical Records Investigative Documentation optional

Reproductive medicine (endometrial Possible Denial; Medical Records Investigative Documentation optional

Magnetic resonance spectroscopy, Possible Denial; Medical Records Investigative Documentation optional

Oncology (prostate), immunoassay for total Possible Denial; Medical Records Investigative Documentation optional

Magnetic resonance spectroscopy, Possible Denial; Medical Records Investigative Documentation optional

Magnetic resonance spectroscopy, Possible Denial; Medical Records Investigative Documentation optional

Oncology (liver), analysis of over 1,000 Prior Authorization Required Genetic Testing Submit history and physical

Magnetic resonance spectroscopy, Possible Denial; Medical Records Investigative Documentation optional

See Appendix O or the most

Percutaneous transcatheter implantation of Possible Denial; Medical Records Investigative Documentation optional

Oncology (urothelial carcinoma), DNA Prior Authorization Required Genetic Testing Submit history and physical

Inborn error of metabolism (primary Possible Denial; Medical Records Investigative Documentation optional

Automated analysis of binocular eye Possible Denial; Medical Records Investigative Documentation optional

Neurology (dementia), DNA methylation Possible Denial; Medical Records Investigative Documentation optional

Cardiovascular (atherosclerotic Possible Denial; Medical Records Investigative Documentation optional

Psychiatry (bipolar disorder), DNA Possible Denial; Medical Records Investigative Documentation optional

Oncology (hepatocellular carcinoma), DNA Possible Denial; Medical Records Investigative Documentation optional

Endovascular venous arterialization, tibial Possible Denial; Medical Records Investigative Documentation optional

Oncology (hepatocellular carcinoma), DNA Possible Denial; Medical Records Investigative Documentation optional

Trabeculostomy ab interno by laser Possible Denial; Medical Records Investigative Documentation optional

Infectious disease (Lyme borreliosis), DNA Possible Denial; Medical Records Investigative Documentation optional

Trabeculostomy ab interno by laser; with Possible Denial; Medical Records Investigative Documentation optional

Psychiatry (major depressive disorder), Possible Denial; Medical Records Investigative Documentation optional

Autoimmune (multiple sclerosis), DNA Possible Denial; Medical Records Investigative Documentation optional

Hepatology (nonalcoholic steatohepatitis Possible Denial; Medical Records Investigative Documentation optional

Endocrinology (osteoporosis), DNA Possible Denial; Medical Records Investigative Documentation optional

Neurology (Parkinson disease), DNA Possible Denial; Medical Records Investigative Documentation optional

Psychiatry (schizophrenia), DNA Possible Denial; Medical Records Investigative Documentation optional

Nephrology (kidney disease related genetic Prior Authorization Required Genetic Testing Submit history and physical

Infectious disease (tuberculosis), DNA, Possible Denial; Medical Records Investigative Documentation optional

Oncology (breast), MRNA, gene Prior Authorization Required Genetic Testing Submit history and physical

Transcutaneous visible light hyperspectral Possible Denial; Medical Records Investigative Documentation optional

Oncology (solid tumor), DNA, sequence Prior Authorization Required Genetic Testing Submit online review with Carelon at

Percutaneous transcatheter ultrasound Possible Denial; Medical Records Investigative Documentation optional

Red blood cell antigen (fetal RhD gene Prior Authorization Required Genetic Testing Submit online review with Carelon at

Computed tomography, breast, including Prior Authorization Required Advanced Imaging Submit online review with Carelon at

Obstetrics (single-gene noninvasive Prior Authorization Required Genetic Testing Submit online review with Carelon at

Computed tomography, breast, including Prior Authorization Required Advanced Imaging Submit online review with Carelon at

Oncology (breast cancer), cell-free DNA Prior Authorization Required Genetic Testing Submit online review with Carelon at

Computed tomography, breast, including Prior Authorization Required Advanced Imaging Submit online review with Carelon at

Computed tomography, breast, including Prior Authorization Required Advanced Imaging Submit online review with Carelon at

Computed tomography, breast, including Prior Authorization Required Advanced Imaging Submit online review with Carelon at

Computed tomography, breast, including Prior Authorization Required Advanced Imaging Submit online review with Carelon at

Wireless skin sensor thermal anisotropy Possible Denial; Medical Records Investigative Documentation optional

Oncology (minimal residual disease Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (minimal residual disease Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (genitourinary cancer), cell-free Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (leukemia), minimal residual Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (leukemia), minimal residual Prior Authorization Required Genetic Testing Submit online review with Carelon at

Transcatheter tricuspid valve implantation Prior Authorization Required Medical Necessity Submit history and physical

Oncology (molecular residual disease), Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (molecular residual disease), Prior Authorization Required Genetic Testing Submit online review with Carelon at

Quantitative magnetic resonance for Prior Authorization Required Advanced Imaging Submit online review with Carelon at

Oncology (solid tumor), targeted genomic Prior Authorization Required Genetic Testing Submit online review with Carelon at

Quantitative magnetic resonance for Prior Authorization Required Advanced Imaging Submit online review with Carelon at

Neurology (Alzheimer disease), DNA, Prior Authorization Required Genetic Testing Submit online review with Carelon at

Drug metabolism (adverse drug reactions Prior Authorization Required Genetic Testing Submit online review with Carelon at

Oncology (hereditary cancer), genomic Prior Authorization Required Genetic Testing Submit online review with Carelon at

Drug metabolism (adverse drug reactions), Prior Authorization Required Genetic Testing Submit online review with Carelon at

Nephrology (inherited kidney disorders), Prior Authorization Required Genetic Testing Submit online review with Carelon at

Transperineal focal laser ablation of Possible Denial; Medical Records Investigative Documentation optional

Rare diseases (constitutional/heritable Prior Authorization Required Genetic Testing Submit online review with Carelon at

Rare diseases (constitutional/heritable Prior Authorization Required Genetic Testing Submit online review with Carelon at

Rare diseases (constitutional/heritable Prior Authorization Required Genetic Testing Submit online review with Carelon at

Scalp cooling, mechanical; initial Non-covered Service Benefit Exception Considered non-covered unless

Donor hysterectomy (including cold Possible Denial; Medical Records Investigative Documentation optional

Donor hysterectomy (including cold Possible Denial; Medical Records Investigative Documentation optional

Donor hysterectomy (including cold Possible Denial; Medical Records Investigative Documentation optional

Donor hysterectomy (including cold Possible Denial; Medical Records Investigative Documentation optional

Backbench standard preparation of Possible Denial; Medical Records Investigative Documentation optional

Backbench reconstruction of cadaver or Possible Denial; Medical Records Investigative Documentation optional

Backbench reconstruction of cadaver or Possible Denial; Medical Records Investigative Documentation optional

Endovaginal cryogen-cooled, monopolar Possible Denial; Medical Records Investigative Documentation optional

Ablation, benign thyroid nodule(s), Possible Denial; Medical Records Investigative Documentation optional

Laparoscopic insertion of new or Possible Denial; Medical Records Investigative Documentation optional

Laparoscopic insertion of new or Possible Denial; Medical Records Investigative Documentation optional

Laparoscopic insertion of new or Possible Denial; Medical Records Investigative Documentation optional

Laparoscopic repositioning of Possible Denial; Medical Records Investigative Documentation optional

Laparoscopic repositioning of Possible Denial; Medical Records Investigative Documentation optional

Laparoscopic removal of diaphragmatic Possible Denial; Medical Records Investigative Documentation optional

Insertion or replacement of pulse generator Possible Denial; Medical Records Investigative Documentation optional

Relocation of pulse generator only, Possible Denial; Medical Records Investigative Documentation optional

Removal of pulse generator only, Possible Denial; Medical Records Investigative Documentation optional

Programming device evaluation (in-person) Possible Denial; Medical Records Investigative Documentation optional

Peri-procedural device evaluation (in- Possible Denial; Medical Records Investigative Documentation optional

Interrogation device evaluation (in-person) Possible Denial; Medical Records Investigative Documentation optional

Histotripsy (ie, non-thermal ablation via Possible Denial; Medical Records Investigative Documentation optional

Treatment of amblyopia using an online Possible Denial; Medical Records Investigative Documentation optional

Treatment of amblyopia using an online Possible Denial; Medical Records Investigative Documentation optional

Quantitative ultrasound tissue Possible Denial; Medical Records Investigative Documentation optional

Quantitative ultrasound tissue Possible Denial; Medical Records Investigative Documentation optional

Automated analysis of an existing Possible Denial; Medical Records Investigative Documentation optional

Therapeutic ultrafiltration Possible Denial; Medical Records Investigative Documentation optional

Comprehensive full body computer-based Possible Denial; Medical Records Investigative Documentation optional

3-dimensional volumetric imaging and Possible Denial; Medical Records Investigative Documentation optional

Body surface-activation mapping of Possible Denial; Medical Records Investigative Documentation optional

Body surface-activation mapping of Possible Denial; Medical Records Investigative Documentation optional

Quantitative magnetic resonance for Possible Denial; Medical Records Investigative Documentation optional

Quantitative magnetic resonance for Possible Denial; Medical Records Investigative Documentation optional

Molecular fluorescent imaging of Possible Denial; Medical Records Investigative Documentation optional

Molecular fluorescent imaging of Possible Denial; Medical Records Investigative Documentation optional

Remote treatment of amblyopia using an Pre-Service Review Required Medical Necessity Submit history and physical

Remote treatment of amblyopia using an Possible Denial; Medical Records Investigative Documentation optional

Remote treatment of amblyopia using an Possible Denial; Medical Records Investigative Documentation optional

Injection(s), bone-substitute material (eg, Possible Denial; Medical Records Investigative Documentation optional

Intradermal cancer immunotherapy; Possible Denial; Medical Records Investigative Documentation optional

Intradermal cancer immunotherapy; each Possible Denial; Medical Records Investigative Documentation optional

Noninvasive arterial plaque analysis using Possible Denial; Medical Records Investigative Documentation optional

Noninvasive arterial plaque analysis using Possible Denial; Medical Records Investigative Documentation optional

Noninvasive arterial plaque analysis using Possible Denial; Medical Records Investigative Documentation optional

Noninvasive arterial plaque analysis using Possible Denial; Medical Records Investigative Documentation optional

Quantitative computed tomography (CT) Possible Denial; Medical Records Investigative Documentation optional

Quantitative computed tomography (CT) Possible Denial; Medical Records Investigative Documentation optional

Quantitative magnetic resonance Possible Denial; Medical Records Investigative Documentation optional

Quantitative magnetic resonance Possible Denial; Medical Records Investigative Documentation optional

Augmentative AI-based facial phenotype Possible Denial; Medical Records Investigative Documentation optional

Immunotherapy administration with Possible Denial; Medical Records Investigative Documentation optional