Anthem Blue Cross and Blue Shield Nevada prior authorization, page 41
CPT code lookup
Each row is one code from the public prior authorization list. The description is the procedure or service name on that source row. This is not a coverage decision.
Prior authorization codes
| Code | Description | Source |
|---|---|---|
| 81205 | Bckdhb (Branched-Chain Keto Acid Dehydrogenase E1, Beta Polypeptide) (Eg, Maple Syrup Urine Disease) Gene Analysis, Common Variants (Eg, R183P, G278S, E422X) | Nevada Prior Authorization List, Pg 89 Original policy |
| 81206 | Bcr/Abl1 (T(9;22)) (Eg, Chronic Myelogenous Leukemia) Translocation Analysis; Major Breakpoint, Qualitative Or Quantitative | Nevada Prior Authorization List, Pg 89 Original policy |
| 81207 | Bcr/Abl1 (T(9;22)) (Eg, Chronic Myelogenous Leukemia) Translocation Analysis; Minor Breakpoint, Qualitative Or Quantitative | Nevada Prior Authorization List, Pg 89 Original policy |
| 81208 | Bcr/Abl1 (T(9;22)) (Eg, Chronic Myelogenous Leukemia) Translocation Analysis; Other Breakpoint, Qualitative Or Quantitative | Nevada Prior Authorization List, Pg 89 Original policy |
| 81209 | Blm (Bloom Syndrome, Recq Helicase-Like) (Eg, Bloom Syndrome) Gene Analysis, 2281Del6Ins7 Variant | Nevada Prior Authorization List, Pg 89 Original policy |
| 81210 | Braf (V-Raf Murine Sarcoma Viral Oncogene Homolog B1) (Eg, Colon Cancer), Gene Analysis, V600E Variant | Nevada Prior Authorization List, Pg 89 Original policy |
| 81212 | BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; 185delAG, 5385insC, 6174delT variants | Nevada Prior Authorization List, Pg 89 Original policy |
| 81215 | BRCA1 (BRCA1, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; known familial variant | Nevada Prior Authorization List, Pg 89 Original policy |
| 81216 | BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis | Nevada Prior Authorization List, Pg 89 Original policy |
| 81217 | BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; known familial variant | Nevada Prior Authorization List, Pg 89 Original policy |
| 81218 | CEBPA (CCAAT/enhancer binding protein [C/EBP], alpha) (eg, acute myeloid leukemia), gene analysis, full gene sequence | Nevada Prior Authorization List, Pg 89 Original policy |
| 81219 | CALR (calreticulin) (eg, myeloproliferative disorders), gene analysis, common variants in exon 9 | Nevada Prior Authorization List, Pg 89 Original policy |
| 81220 | Cftr (Cystic Fibrosis Transmembrane Conductance Regulator) (Eg, Cystic Fibrosis) Gene Analysis; Common Variants (Eg, Acmg/Acog Guidelines) | Nevada Prior Authorization List, Pg 89 Original policy |
| 81221 | Cftr (Cystic Fibrosis Transmembrane Conductance Regulator) (Eg, Cystic Fibrosis) Gene Analysis; Known Familial Variants | Nevada Prior Authorization List, Pg 89 Original policy |
| 81222 | Cftr (Cystic Fibrosis Transmembrane Conductance Regulator) (Eg, Cystic Fibrosis) Gene Analysis; Duplication/Deletion Variants | Nevada Prior Authorization List, Pg 89 Original policy |
| 81223 | Cftr (Cystic Fibrosis Transmembrane Conductance Regulator) (Eg, Cystic Fibrosis) Gene Analysis; Full Gene Sequence | Nevada Prior Authorization List, Pg 89 Original policy |
| 81224 | Cftr (Cystic Fibrosis Transmembrane Conductance Regulator) (Eg, Cystic Fibrosis) Gene Analysis; Intron 8 Poly-T Analysis (Eg, Male Infertility) | Nevada Prior Authorization List, Pg 89 Original policy |
| 81225 | Cyp2C19 (Cytochrome P450, Family 2, Subfamily C, Polypeptide 19) (Eg, Drug Metabolism), Gene Analysis, Common Variants (Eg, *2, *3, *4, *8, *17) | Nevada Prior Authorization List, Pg 89 Original policy |
| 81226 | Cyp2D6 (Cytochrome P450, Family 2, Subfamily D, Polypeptide 6) (Eg, Drug Metabolism), Gene Analysis, Common Variants (Eg, *2, *3, *4, *5, *6, *9, *10, *17, *19, *29, *35, *41 | Nevada Prior Authorization List, Pg 90 Original policy |
| 81227 | Cyp2C9 (Cytochrome P450, Family 2, Subfamily C, Polypeptide 9) (Eg, Drug Metabolism), Gene Analysis, Common Variants (Eg, *2, *3, *5, *6) | Nevada Prior Authorization List, Pg 90 Original policy |
| 81228 | Cytogenomic (genome-wide) analysis for constitutional chromosomal abnormalities; interrogation of genomic regions for copy number variants, comparative genomic hybridization [ | Nevada Prior Authorization List, Pg 90 Original policy |
| 81229 | Cytogenomic (genome-wide) analysis for constitutional chromosomal abnormalities; interrogation of genomic regions for copy number and single nucleotide polymorphism (SNP) vari | Nevada Prior Authorization List, Pg 90 Original policy |
| 81230 | CYP3A4 (cytochrome P450 family 3 subfamily A member 4) (eg, drug metabolism), gene analysis, common variant(s) (eg, *2, *22) | Nevada Prior Authorization List, Pg 90 Original policy |
| 81231 | CYP3A5 (cytochrome P450 family 3 subfamily A member 5) (eg, drug metabolism), gene analysis, common variants (eg, *2, *3, *4, *5, *6, *7) | Nevada Prior Authorization List, Pg 90 Original policy |
| 81232 | DPYD (dihydropyrimidine dehydrogenase) (eg, 5-fluorouracil/5-FU and capecitabine drug metabolism), gene analysis, common variant(s) (eg, *2A, *4, *5, *6) | Nevada Prior Authorization List, Pg 90 Original policy |
| 81233 | BTK (Bruton's tyrosine kinase) (eg, chronic lymphocytic leukemia) gene analysis, common variants (eg, C481S, C481R, C481F) | Nevada Prior Authorization List, Pg 90 Original policy |
| 81234 | DMPK (DM1 protein kinase) (eg, myotonic dystrophy type 1) gene analysis; evaluation to detect abnormal (expanded) alleles | Nevada Prior Authorization List, Pg 90 Original policy |
| 81235 | EGFR (epidermal growth factor receptor) (eg, non-small cell lung cancer) gene analysis, common variants (eg, exon 19 LREA deletion, L858R, T790M, G719A, G719S, L861Q) | Nevada Prior Authorization List, Pg 90 Original policy |
| 81236 | EZH2 (enhancer of zeste 2 polycomb repressive complex 2 subunit) (eg, myelodysplastic syndrome, myeloproliferative neoplasms) gene analysis, full gene sequence | Nevada Prior Authorization List, Pg 90 Original policy |
| 81237 | EZH2 (enhancer of zeste 2 polycomb repressive complex 2 subunit) (eg, diffuse large B-cell lymphoma) gene analysis, common variant(s) (eg, codon 646) | Nevada Prior Authorization List, Pg 90 Original policy |
| 81239 | DMPK (DM1 protein kinase) (eg, myotonic dystrophy type 1) gene analysis; characterization of alleles (eg, expanded size) | Nevada Prior Authorization List, Pg 90 Original policy |
| 81240 | F2 (Prothrombin, Coagulation Factor Ii) (Eg, Hereditary Hypercoagulability) Gene Analysis, 20210G>A Variant | Nevada Prior Authorization List, Pg 90 Original policy |
| 81241 | F5 (Coagulation Factor V) (Eg, Hereditary Hypercoagulability) Gene Analysis, Leiden Variant | Nevada Prior Authorization List, Pg 90 Original policy |
| 81242 | Fancc (Fanconi Anemia, Complementation Group C) (Eg, Fanconi Anemia, Type C) Gene Analysis, Common Variant (Eg, Ivs4+4A>T) | Nevada Prior Authorization List, Pg 90 Original policy |
| 81243 | FMR1 (fragile X messenger ribonucleoprotein 1) (eg, fragile X syndrome, X- linked intellectual disability [XLID]) gene analysis; evaluation to detect abnormal (eg, expanded) al | Nevada Prior Authorization List, Pg 90 Original policy |
| 81244 | FMR1 (fragile X messenger ribonucleoprotein 1) (eg, fragile X syndrome, X- linked intellectual disability [XLID]) gene analysis; characterization of alleles (eg, expanded size | Nevada Prior Authorization List, Pg 90 Original policy |
| 81245 | Flt3 (Fms-Related Tyrosine Kinase 3) (Eg, Acute Myeloid Leukemia), Gene Analysis, Internal Tandem Duplication (Itd) Variants (Ie, Exons 14, 15) | Nevada Prior Authorization List, Pg 90 Original policy |
| 81246 | FLT3 (fms-related tyrosine kinase 3) (eg, acute myeloid leukemia), gene analysis; tyrosine kinase domain (TKD) variants (eg, D835, I836) | Nevada Prior Authorization List, Pg 90 Original policy |
| 81247 | G6PD (glucose-6-phosphate dehydrogenase) (eg, hemolytic anemia, jaundice), gene analysis; common variant(s) (eg, A, A-) | Nevada Prior Authorization List, Pg 90 Original policy |
| 81248 | G6PD (glucose-6-phosphate dehydrogenase) (eg, hemolytic anemia, jaundice), gene analysis; known familial variant(s) | Nevada Prior Authorization List, Pg 90 Original policy |
| 81249 | G6PD (glucose-6-phosphate dehydrogenase) (eg, hemolytic anemia, jaundice), gene analysis; full gene sequence | Nevada Prior Authorization List, Pg 91 Original policy |
| 81250 | G6Pc (Glucose-6-Phosphatase, Catalytic Subunit) (Eg, Glycogen Storage Disease, Type 1A, Von Gierke Disease) Gene Analysis, Common Variants (Eg, R83C, Q347X) | Nevada Prior Authorization List, Pg 91 Original policy |
| 81251 | Gba (Glucosidase, Beta, Acid) (Eg, Gaucher Disease) Gene Analysis, Common Variants (Eg, N370S, 84Gg, L444P, Ivs2+1G>A) | Nevada Prior Authorization List, Pg 91 Original policy |
| 81252 | GJB2 (gap junction protein, beta 2, 26kDa, connexin 26) (eg, nonsyndromic hearing loss) gene analysis; full gene sequence | Nevada Prior Authorization List, Pg 91 Original policy |
| 81253 | GJB2 (gap junction protein, beta 2, 26kDa; connexin 26) (eg, nonsyndromic hearing loss) gene analysis; known familial variants | Nevada Prior Authorization List, Pg 91 Original policy |
| 81254 | GJB6 (gap junction protein, beta 6, 30kDa, connexin 30) (eg, nonsyndromic hearing loss) gene analysis, common variants (eg, 309kb [del(GJB6-D13S1830)] and 232kb [del(GJB6-D13S | Nevada Prior Authorization List, Pg 91 Original policy |
| 81255 | Hexa (Hexosaminidase A [Alpha Polypeptide]) (Eg, Tay-Sachs Disease) Gene Analysis, Common Variants (Eg, 1278Instatc, 1421+1G>C, G269S) | Nevada Prior Authorization List, Pg 91 Original policy |
| 81256 | Hfe (Hemochromatosis) (Eg, Hereditary Hemochromatosis) Gene Analysis, Common Variants (Eg, C282Y, H63D) | Nevada Prior Authorization List, Pg 91 Original policy |
| 81257 | HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia, Hb Bart hydrops fetalis syndrome, HbH disease), gene analysis; common deletions or variant (eg, Southeast | Nevada Prior Authorization List, Pg 91 Original policy |
| 81258 | HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia, Hb Bart hydrops fetalis syndrome, HbH disease), gene analysis; known familial variant | Nevada Prior Authorization List, Pg 91 Original policy |