Does Ambetter require prior authorization for 81345?

Ambetter lists 81345 on Ambetter from Arizona Complete Health CMS-0057-F prior authorization requirements for exchange plans (list dated December 31, 2025). Verify with the payer before scheduling.

Does AmeriHealth Caritas require prior authorization for 81345?

AmeriHealth Caritas lists 81345 on AmeriHealth Caritas Louisiana Act 233 prior authorization service list for medicaid managed plans. Verify with the payer before scheduling.

Does Anthem BCBS require prior authorization for 81345?

Anthem BCBS lists 81345 on Anthem Local PPO Precertification/Prior Authorization List (California | Anthem Blue Cross | Commercial) for commercial plans (list dated November 1, 2026). Verify with the payer before scheduling.

Does Arizona Complete Health require prior authorization for 81345?

Arizona Complete Health lists 81345 on Arizona Complete Health CMS-0057-F prior authorization requirements for medicaid managed plans (list dated December 31, 2025). Verify with the payer before scheduling.

Does BCBS Illinois require prior authorization for 81345?

BCBS Illinois lists 81345 on 2026 Commercial Outpatient Medical Surgical Prior Authorization Codes for commercial plans, with conditions (list dated January 1, 2026). Verify with the payer before scheduling.

What insurance policy changes affect CPT 81345?

There are 15 tracked policy changes affecting CPT 81345, including updates from Anthem BCBS, Blue Cross Blue Shield of Rhode Island, Excellus BlueCross BlueShield. Each change may modify coverage criteria, reimbursement rates, or prior-authorization requirements.

Which payers have updated policy for CPT 81345?

Payers that have issued tracked updates for CPT 81345 include: Anthem BCBS, Blue Cross Blue Shield of Rhode Island, Excellus BlueCross BlueShield.

How do I get notified when CPT 81345 policy changes?

Create a free account at PolicyChanges.app and save a search filtered to CPT 81345. You will get an email when new policy changes reference this code: daily or weekly, your choice, on every plan.

Why do payers change policies for CPT 81345?

Payers revise policies for individual billing codes to align with updated clinical guidelines, CMS rule changes, fraud and abuse prevention measures, or network cost-management goals. Changes can affect medical necessity criteria, place-of-service restrictions, bundling rules, or whether a code requires prior authorization.

PAYER POLICY CHANGES

81345 Insurance Policy Changes

CPT 81345 is referenced in 15 tracked payer policy changes from Anthem BCBS, Blue Cross Blue Shield of Rhode Island, and 1 other payer. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for CPT 81345 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.

Anthem BCBS · Effective Apr 4, 2026High impact
[New York] Updates to Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines
Carelon Medical Benefits Management updated clinical appropriateness guidelines effective April 4, 2026 across radiology, oncologic imaging, radiation oncology, genetic testing, and rehabilitative services for Medicare Advantage and Medicaid plans. Changes include removal of certain imaging requirements (pediatric SBO radiographs, sports hernia imaging), alignment with ACR and NCCN guidelines, expanded cancer screening and treatment indications, new hereditary cancer syndrome criteria, and addition of specific billing codes for genetic testing (81218, 81310, 81334, 81338, 81339, 81345).
Anthem BCBS · Effective Apr 4, 2026High impact
[Virginia] Updates to Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines
Carelon Medical Benefits Management has updated clinical appropriateness guidelines for Virginia Medicare Advantage members, effective April 4, 2026. Changes include simplified imaging criteria across radiology, oncology, and genetics testing; expanded coverage for advanced cancer treatments and genetic testing; and clarifications for radiation therapy, theranostics, and rehabilitative services. Billing and clinical teams must review updates in their respective specialty areas and ensure prior authorization requests reflect new guidelines.
Anthem BCBS · Effective Apr 4, 2026High impact
[California] Updates to Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines
Carelon Medical Benefits Management has updated its Clinical Appropriateness Guidelines effective April 4, 2026, with extensive revisions across radiology, oncologic imaging, radiation oncology, genetic testing, and rehabilitation services. Changes include alignment with ACR and NCCN standards, removal of certain imaging requirements, expanded indications for cancer treatments and genetic testing, and addition of new genetic testing sections. Billing teams must review specialty-specific changes to ensure proper prior authorization and claim processing for affected services.
Blue Cross Blue Shield of Rhode Island · Effective Feb 1, 2026High impact
Medical policy updates
Multiple policy updates are rolling out between February-April 2026, including InterQual criteria changes for molecular diagnostics and procedures, fertility coverage modifications, removal of prior authorization for several genetic testing and continuous glucose monitoring codes, and updated diagnosis code lists for various services.
Anthem BCBS · Effective Nov 1, 2026Medium impact
[California] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management
Effective November 1, 2026, CPT code 81345 (TERT gene analysis for thyroid carcinoma and glioblastoma multiforme) now requires precertification/prior authorization through Carelon Medical Benefits Management for all Anthem Blue Cross Medicare Advantage PPO plans in California. Providers must obtain authorization before ordering this genetic test.
Anthem BCBS · Effective Nov 1, 2026Medium impact
[New York] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management
Effective November 1, 2026, CPT code 81345 (TERT gene analysis for thyroid carcinoma and glioblastoma multiforme) now requires precertification/prior authorization through Carelon Medical Benefits Management for Anthem Blue Cross and Blue Shield Medicare Advantage members in New York. Providers must submit authorization requests via Carelon's provider portal, Availity Essentials, or email before performing this genetic test.
Anthem BCBS · Effective Nov 1, 2026Medium impact
[Ohio] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management
Effective November 1, 2026, Anthem Blue Cross and Blue Shield Medicare Advantage in Ohio will require precertification/prior authorization for CPT code 81345 (TERT gene analysis for thyroid carcinoma and glioblastoma multiforme) through Carelon Medical Benefits Management. Providers must submit authorization requests before performing this genetic test or claims will be denied.
Anthem BCBS · Effective Nov 1, 2026Medium impact
[Virginia] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management
Effective November 1, 2026, Anthem Blue Cross and Blue Shield Medicare Advantage plans in Virginia will require prior authorization/precertification through Carelon Medical Benefits Management for CPT 81345 (TERT gene analysis). Ordering and servicing providers must submit authorization requests via Carelon's provider portal, Availity Essentials, or direct contact before performing this genetic test.
Anthem BCBS · Effective Nov 1, 2026Medium impact
[Georgia] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management
Effective November 1, 2026, CPT code 81345 (TERT gene analysis for thyroid carcinoma and glioblastoma multiforme) now requires prior authorization/precertification through Carelon Medical Benefits Management for Anthem Blue Cross and Blue Shield Medicare Advantage plans in Georgia. Providers must submit authorization requests via the Carelon provider portal, Availity Essentials, or email before performing this genetic test.
Anthem BCBS · Effective Aug 1, 2026Medium impact
[New York] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management
Effective August 1, 2026, CPT code 81345 (TERT gene analysis for thyroid carcinoma and glioblastoma multiforme) now requires precertification/prior authorization through Carelon Medical Benefits Management for New York Medicaid beneficiaries. Ordering and servicing providers must submit authorization requests via the Carelon provider portal, Availity Essentials, or email before performing this genetic test.
Anthem BCBS · Effective Apr 4, 2026Medium impact
[Ohio] Updates to Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines
Carelon Medical Benefits Management updated clinical appropriateness guidelines for oncologic imaging, genetic testing, and hereditary cancer syndromes effective April 4, 2026 for Ohio Medicaid and MyCare plans. Multiple guidelines now align with NCCN standards, affecting cancer screening, diagnostic imaging, and genetic testing coverage criteria. Six new genetic testing CPT codes (81218, 81310, 81334, 81338, 81339, 81345) were added, and specific hereditary syndromes and cancer types have expanded or new indications.
Anthem BCBS · Effective Apr 4, 2026Medium impact
[Georgia] Updates to Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines
Carelon Medical Benefits Management updated clinical appropriateness guidelines effective April 4, 2026, affecting radiology imaging protocols, oncologic imaging, radiation oncology, genetic testing, and rehabilitative services for Medicare Advantage plans in Georgia. Changes include alignment with ACR and NCCN criteria, removal of certain indications (e.g., sports hernia imaging), expanded cancer screening/treatment criteria, new genetic testing indications, and clarification of specific imaging requirements. Billing teams must review updates to prior authorization requirements and ensure documentation aligns with new clinical criteria.
Excellus BlueCross BlueShield · Effective Feb 19, 2026Medium impact
Molecular Testing of Tumor Tissue to Identify Targeted Therapies for Cancers 2.02.51
Excellus BlueCross BlueShield policy 2.02.51 considers molecular testing of tumor tissue medically appropriate to direct targeted therapy when the results will guide patient management and the test is for the listed cancers and genes, including metastatic colorectal cancer, non-small-cell lung cancer, stage III high-risk or stage IV melanoma, metastatic pancreatic cancer, recently diagnosed or recurrent ovarian cancer, metastatic prostate cancer, breast cancer, primary brain tumors, ependymomas, and medulloblastoma. For other cancers, testing must be recommended by current NCCN guidelines, include only the number of genes necessary for therapeutic decision making, and be used for biopsy-confirmed advanced stage III or IV or metastatic disease, or for such disease progressing after chemotherapy or immunotherapy when never previously tested. Comprehensive genomic profiling tests such as FoundationOne CDx are considered investigational, as is testing for genes other than those listed, and the version effective February 19, 2026 is an annual review with policy intent unchanged.
Excellus BlueCross BlueShield · Effective Nov 20, 2025Medium impact
Molecular Marker Testing of the Thyroid 2.02.49
Afirma Genomic Sequencing Classifier and ThyroSeq are considered medically necessary when indeterminate cytology (Bethesda category III or IV) is present, there are no strong clinical or radiologic findings suggestive of malignancy, and surgical decision making would be affected by the results. ThyroSeq, ThyraMIR microRNA/ThyGenX, Afirma BRAF and Afirma MTC are also considered medically necessary for Bethesda category III, IV or V cytology when malignancy must be determined and the results guide surgical planning for initial resection. RosettaGX Reveal, single-gene TERT testing, Thyroid GuidePx and Afirma Xpression Atlas are considered investigational. The 11/20/25 annual review made no changes to policy intent, although the policy statements were reformatted for clarity.
Blue Cross Blue Shield of Rhode Island · Identified Jun 20, 2026Medium impact
January 2019
Effective April 1, 2019, the provider taxonomy code must be submitted on all claims. Reported as already effective in the historical source, Medicare Advantage claims for out-of-network payments require the Health Trio referral number in box 23 of the CMS-1500 form. January 2019 CPT and HCPCS code changes are effective January 1, 2019, and the code lists carry coverage designations such as Subject to Medical Review, Not Medically Necessary, Not Separately Reimbursed and Not Covered.

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[New York] Updates to Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines

[Virginia] Updates to Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines

[California] Updates to Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines

Medical policy updates

[California] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management

[New York] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management

[Ohio] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management

[Virginia] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management

[Georgia] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management

[New York] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management

[Ohio] Updates to Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines

[Georgia] Updates to Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines

Molecular Testing of Tumor Tissue to Identify Targeted Therapies for Cancers 2.02.51

Molecular Marker Testing of the Thyroid 2.02.49

January 2019

Prior authorization required

Prior authorization required in some cases