Anthem Blue Cross and Blue Shield Nevada prior authorization, page 42
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 |
|---|---|---|
| 81259 | HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia, Hb Bart hydrops fetalis syndrome, HbH disease), gene analysis; full gene sequence | Nevada Prior Authorization List, Pg 91 Original policy |
| 81260 | Ikbkap (Inhibitor Of Kappa Light Polypeptide Gene Enhancer In B-Cells, Kinase Complex-Associated Protein) (Eg, Familial Dysautonomia) Gene Analysis, Common Variants (Eg, 2507+ | Nevada Prior Authorization List, Pg 91 Original policy |
| 81261 | Igh@ (Immunoglobulin Heavy Chain Locus) (Eg, Leukemias And Lymphomas, B- Cell), Gene Rearrangement Analysis To Detect Abnormal Clonal Population(S); Amplified Methodology (Eg | Nevada Prior Authorization List, Pg 91 Original policy |
| 81262 | Igh@ (Immunoglobulin Heavy Chain Locus) (Eg, Leukemias And Lymphomas, B- Cell), Gene Rearrangement Analysis To Detect Abnormal Clonal Population(S); Direct Probe Methodology (E | Nevada Prior Authorization List, Pg 91 Original policy |
| 81263 | Igh@ (Immunoglobulin Heavy Chain Locus) (Eg, Leukemia And Lymphoma, B- Cell), Variable Region Somatic Mutation Analysis | Nevada Prior Authorization List, Pg 91 Original policy |
| 81264 | Igk@ (Immunoglobulin Kappa Light Chain Locus) (Eg, Leukemia And Lymphoma, B-Cell), Gene Rearrangement Analysis, Evaluation To Detect Abnormal Clonal Population(S) | Nevada Prior Authorization List, Pg 91 Original policy |
| 81265 | Comparative Analysis Using Short Tandem Repeat (Str) Markers; Patient And Comparative Specimen (Eg, Pre-Transplant Recipient And Donor Germline Testing, Post-Transplant Non-He | Nevada Prior Authorization List, Pg 91 Original policy |
| 81266 | Comparative Analysis Using Short Tandem Repeat (Str) Markers; Each Additional Specimen (Eg, Additional Cord Blood Donor, Additional Fetal Samples From Different Cultures, Or A | Nevada Prior Authorization List, Pg 91 Original policy |
| 81269 | HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia, Hb Bart hydrops fetalis syndrome, HbH disease), gene analysis; duplication/deletion variants | Nevada Prior Authorization List, Pg 91 Original policy |
| 81270 | Jak2 (Janus Kinase 2) (Eg, Myeloproliferative Disorder) Gene Analysis, P.Val617Phe (V617F) Variant | Nevada Prior Authorization List, Pg 91 Original policy |
| 81271 | HTT (huntingtin) (eg, Huntington disease) gene analysis; evaluation to detect abnormal (eg, expanded) alleles | Nevada Prior Authorization List, Pg 91 Original policy |
| 81272 | KIT (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog) (eg, gastrointestinal stromal tumor [GIST], acute myeloid leukemia, melanoma), gene analysis, targeted sequ | Nevada Prior Authorization List, Pg 91 Original policy |
| 81273 | KIT (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog) (eg, mastocytosis), gene analysis, D816 variant(s) | Nevada Prior Authorization List, Pg 91 Original policy |
| 81274 | HTT (huntingtin) (eg, Huntington disease) gene analysis; characterization of alleles (eg, expanded size) | Nevada Prior Authorization List, Pg 92 Original policy |
| 81275 | Kras (V-Ki-Ras2 Kirsten Rat Sarcoma Viral Oncogene) (Eg, Carcinoma) Gene Analysis, Variants In Codons 12 And 13 | Nevada Prior Authorization List, Pg 92 Original policy |
| 81276 | KRAS (Kirsten rat sarcoma viral oncogene homolog) (eg, carcinoma) gene analysis; additional variant(s) (eg, codon 61, codon 146) | Nevada Prior Authorization List, Pg 92 Original policy |
| 81277 | Cytogenomic neoplasia (genome-wide) microarray analysis, interrogation of genomic regions for copy number and loss-of-heterozygosity variants for chromosomal abnormalities | Nevada Prior Authorization List, Pg 92 Original policy |
| 81278 | IGH@/BCL2 (t(14;18)) (eg, follicular lymphoma) translocation analysis, major breakpoint region (MBR) and minor cluster region (mcr) breakpoints, qualitative or quantitative | Nevada Prior Authorization List, Pg 92 Original policy |
| 81279 | JAK2 (Janus kinase 2) (eg, myeloproliferative disorder) targeted sequence analysis (eg, exons 12 and 13) | Nevada Prior Authorization List, Pg 92 Original policy |
| 81283 | IFNL3 (interferon, lambda 3) (eg, drug response), gene analysis, rs12979860 variant | Nevada Prior Authorization List, Pg 92 Original policy |
| 81284 | FXN (frataxin) (eg, Friedreich ataxia) gene analysis; evaluation to detect abnormal (expanded) alleles | Nevada Prior Authorization List, Pg 92 Original policy |
| 81285 | FXN (frataxin) (eg, Friedreich ataxia) gene analysis; characterization of alleles (eg, expanded size) | Nevada Prior Authorization List, Pg 92 Original policy |
| 81286 | FXN (frataxin) (eg, Friedreich ataxia) gene analysis; full gene sequence | Nevada Prior Authorization List, Pg 92 Original policy |
| 81287 | MGMT (O-6-methylguanine-DNA methyltransferase) (eg, glioblastoma multiforme) promoter methylation analysis | Nevada Prior Authorization List, Pg 92 Original policy |
| 81288 | MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (eg, hereditary non- polyposis colorectal cancer, Lynch syndrome) gene analysis; promoter methylation analysis | Nevada Prior Authorization List, Pg 92 Original policy |
| 81289 | FXN (frataxin) (eg, Friedreich ataxia) gene analysis; known familial variant(s) | Nevada Prior Authorization List, Pg 92 Original policy |
| 81290 | Mcoln1 (Mucolipin 1) (Eg, Mucolipidosis, Type Iv) Gene Analysis, Common Variants (Eg, Ivs3-2A>G, Del6.4Kb) | Nevada Prior Authorization List, Pg 92 Original policy |
| 81291 | Mthfr (5,10-Methylenetetrahydrofolate Reductase) (Eg, Hereditary Hypercoagulability) Gene Analysis, Common Variants (Eg, 677T, 1298C) | Nevada Prior Authorization List, Pg 92 Original policy |
| 81292 | Mlh1 (Mutl Homolog 1, Colon Cancer, Nonpolyposis Type 2) (Eg, Hereditary Non-Polyposis Colorectal Cancer, Lynch Syndrome) Gene Analysis; Full Sequence Analysis | Nevada Prior Authorization List, Pg 92 Original policy |
| 81293 | Mlh1 (Mutl Homolog 1, Colon Cancer, Nonpolyposis Type 2) (Eg, Hereditary Non-Polyposis Colorectal Cancer, Lynch Syndrome) Gene Analysis; Known Familial Variants | Nevada Prior Authorization List, Pg 92 Original policy |
| 81294 | Mlh1 (Mutl Homolog 1, Colon Cancer, Nonpolyposis Type 2) (Eg, Hereditary Non-Polyposis Colorectal Cancer, Lynch Syndrome) Gene Analysis; Duplication/Deletion Variants | Nevada Prior Authorization List, Pg 92 Original policy |
| 81295 | Msh2 (Muts Homolog 2, Colon Cancer, Nonpolyposis Type 1) (Eg, Hereditary Non-Polyposis Colorectal Cancer, Lynch Syndrome) Gene Analysis; Full Sequence Analysis | Nevada Prior Authorization List, Pg 92 Original policy |
| 81296 | Msh2 (Muts Homolog 2, Colon Cancer, Nonpolyposis Type 1) (Eg, Hereditary Non-Polyposis Colorectal Cancer, Lynch Syndrome) Gene Analysis; Known Familial Variants | Nevada Prior Authorization List, Pg 92 Original policy |
| 81297 | Msh2 (Muts Homolog 2, Colon Cancer, Nonpolyposis Type 1) (Eg, Hereditary Non-Polyposis Colorectal Cancer, Lynch Syndrome) Gene Analysis; Duplication/Deletion Variants | Nevada Prior Authorization List, Pg 92 Original policy |
| 81298 | Msh6 (Muts Homolog 6 [E. Coli]) (Eg, Hereditary Non-Polyposis Colorectal Cancer, Lynch Syndrome) Gene Analysis; Full Sequence Analysis | Nevada Prior Authorization List, Pg 92 Original policy |
| 81299 | Msh6 (Muts Homolog 6 [E. Coli]) (Eg, Hereditary Non-Polyposis Colorectal Cancer, Lynch Syndrome) Gene Analysis; Known Familial Variants | Nevada Prior Authorization List, Pg 92 Original policy |
| 81300 | Msh6 (Muts Homolog 6 [E. Coli]) (Eg, Hereditary Non-Polyposis Colorectal Cancer, Lynch Syndrome) Gene Analysis; Duplication/Deletion Variants | Nevada Prior Authorization List, Pg 93 Original policy |
| 81301 | Microsatellite Instability Analysis (Eg, Hereditary Non-Polyposis Colorectal Cancer, Lynch Syndrome) Of Markers For Mismatch Repair Deficiency (Eg, Bat25, Bat26), Includes Com | Nevada Prior Authorization List, Pg 93 Original policy |
| 81302 | Mecp2 (Methyl Cpg Binding Protein 2) (Eg, Rett Syndrome) Gene Analysis; Full Sequence Analysis | Nevada Prior Authorization List, Pg 93 Original policy |
| 81303 | Mecp2 (Methyl Cpg Binding Protein 2) (Eg, Rett Syndrome) Gene Analysis; Known Familial Variant | Nevada Prior Authorization List, Pg 93 Original policy |
| 81304 | Mecp2 (Methyl Cpg Binding Protein 2) (Eg, Rett Syndrome) Gene Analysis; Duplication/Deletion Variants | Nevada Prior Authorization List, Pg 93 Original policy |
| 81305 | MYD88 (myeloid differentiation primary response 88) (eg, Waldenstrom's macroglobulinemia, lymphoplasmacytic leukemia) gene analysis, p.Leu265Pro (L265P) variant | Nevada Prior Authorization List, Pg 93 Original policy |
| 81306 | NUDT15 (nudix hydrolase 15) (eg, drug metabolism) gene analysis, common variant(s) (eg, *2, *3, *4, *5, *6) | Nevada Prior Authorization List, Pg 93 Original policy |
| 81307 | PALB2 (partner and localizer of BRCA2) (eg, breast and pancreatic cancer) gene analysis; full gene sequence | Nevada Prior Authorization List, Pg 93 Original policy |
| 81308 | PALB2 (partner and localizer of BRCA2) (eg, breast and pancreatic cancer) gene analysis; known familial variant | Nevada Prior Authorization List, Pg 93 Original policy |
| 81309 | PIK3CA (phosphatidylinositol-4, 5-biphosphate 3-kinase, catalytic subunit alpha) (eg, colorectal and breast cancer) gene analysis, targeted sequence analysis (eg, exons 7, 9 | Nevada Prior Authorization List, Pg 93 Original policy |
| 81310 | Npm1 (Nucleophosmin) (Eg, Acute Myeloid Leukemia) Gene Analysis, Exon 12 Variants | Nevada Prior Authorization List, Pg 93 Original policy |
| 81311 | NRAS (neuroblastoma RAS viral [v-ras] oncogene homolog) (eg, colorectal carcinoma), gene analysis, variants in exon 2 (eg, codons 12 and 13) and exon 3 (eg, codon 61) | Nevada Prior Authorization List, Pg 93 Original policy |
| 81312 | PABPN1 (poly[A] binding protein nuclear 1) (eg, oculopharyngeal muscular dystrophy) gene analysis, evaluation to detect abnormal (eg, expanded) alleles | Nevada Prior Authorization List, Pg 93 Original policy |
| 81313 | PCA3/KLK3 (prostate cancer antigen 3 [non-protein coding]/kallikrein-related peptidase 3 [prostate specific antigen]) ratio (eg, prostate cancer) | Nevada Prior Authorization List, Pg 93 Original policy |