CommercialPrior AuthMedium impact
Special Alert January 2026 - Carelon Radiotracer Management for PET Imaging
Providence Health Plan·Nuclear Medicine, Radiology, Oncology +1 more·Pharmacy
Effective date
Apr 1, 2026
We identified it
Sep 2, 2026
Summary
Effective April 1, 2026, Carelon will require both PET CPT codes and radiotracer CPT codes to be submitted together during the authorization process for Brain PET and Oncologic PET procedures. Approved authorizations will specify which radiotracer categories are allowed based on clinical indication. Cardiac PET is excluded from this requirement.
Action Required
By March 31, 2026: Billing team must update authorization submission processes to require dual code submission (both PET CPT code and radiotracer CPT code) for Brain PET and Oncologic PET procedures with Carelon. Update billing system templates and prior authorization workflows to capture radiotracer codes at intake. Train providers and authorizing staff to submit both codes together when requesting authorization. Coordinate with radiology/nuclear medicine departments to ensure CPT codes are identified before authorization submission. Document approved radiotracer categories in authorization confirmations. After April 1, 2026, claims submitted with only PET codes (missing radiotracer codes) may be denied or require resubmission. Contact Carelon MBM at (800)-252-2021 for specific radiotracer category guidelines.