Anthem Blue Cross and Blue Shield Nevada prior authorization, page 43
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 |
|---|---|---|
| 81314 | PDGFRA (platelet-derived growth factor receptor, alpha polypeptide) (eg, gastrointestinal stromal tumor [GIST]), gene analysis, targeted sequence analysis (eg, exons 12, 18) | Nevada Prior Authorization List, Pg 93 Original policy |
| 81315 | Pml/Raralpha, (T(15;17)), (Promyelocytic Leukemia/Retinoic Acid Receptor Alpha) (Eg, Promyelocytic Leukemia) Translocation Analysis; Common Breakpoints (Eg, Intron 3 And Intro | Nevada Prior Authorization List, Pg 93 Original policy |
| 81316 | Pml/Raralpha, (T(15;17)), (Promyelocytic Leukemia/Retinoic Acid Receptor Alpha) (Eg, Promyelocytic Leukemia) Translocation Analysis; Single Breakpoint (Eg, Intron 3, Intron 6 | Nevada Prior Authorization List, Pg 93 Original policy |
| 81317 | Pms2 (Postmeiotic Segregation Increased 2 [S. Cerevisiae]) (Eg, Hereditary Non- Polyposis Colorectal Cancer, Lynch Syndrome) Gene Analysis; Full Sequence Analysis | Nevada Prior Authorization List, Pg 93 Original policy |
| 81318 | Pms2 (Postmeiotic Segregation Increased 2 [S. Cerevisiae]) (Eg, Hereditary Non- Polyposis Colorectal Cancer, Lynch Syndrome) Gene Analysis; Known Familial Variants | Nevada Prior Authorization List, Pg 93 Original policy |
| 81319 | Pms2 (Postmeiotic Segregation Increased 2 [S. Cerevisiae]) (Eg, Hereditary Non- Polyposis Colorectal Cancer, Lynch Syndrome) Gene Analysis; Duplication/Deletion Variants | Nevada Prior Authorization List, Pg 93 Original policy |
| 81320 | PLCG2 (phospholipase C gamma 2) (eg, chronic lymphocytic leukemia) gene analysis, common variants (eg, R665W, S707F, L845F) | Nevada Prior Authorization List, Pg 93 Original policy |
| 81321 | PTEN (phosphatase and tensin homolog) (eg, Cowden syndrome, PTEN hamartoma tumor syndrome) gene analysis; full sequence analysis | Nevada Prior Authorization List, Pg 93 Original policy |
| 81322 | PTEN (phosphatase and tensin homolog) (eg, Cowden syndrome, PTEN hamartoma tumor syndrome) gene analysis; known familial variant | Nevada Prior Authorization List, Pg 93 Original policy |
| 81323 | PTEN (phosphatase and tensin homolog) (eg, Cowden syndrome, PTEN hamartoma tumor syndrome) gene analysis; duplication/deletion variant | Nevada Prior Authorization List, Pg 94 Original policy |
| 81324 | PMP22 (peripheral myelin protein 22) (eg, Charcot-Marie-Tooth, hereditary neuropathy with liability to pressure palsies) gene analysis; duplication/deletion analysis | Nevada Prior Authorization List, Pg 94 Original policy |
| 81325 | PMP22 (peripheral myelin protein 22) (eg, Charcot-Marie-Tooth, hereditary neuropathy with liability to pressure palsies) gene analysis; full sequence analysis | Nevada Prior Authorization List, Pg 94 Original policy |
| 81326 | PMP22 (peripheral myelin protein 22) (eg, Charcot-Marie-Tooth, hereditary neuropathy with liability to pressure palsies) gene analysis; known familial variant | Nevada Prior Authorization List, Pg 94 Original policy |
| 81327 | SEPT9 (Septin9) (eg, colorectal cancer) promoter methylation analysis | Nevada Prior Authorization List, Pg 94 Original policy |
| 81328 | SLCO1B1 (solute carrier organic anion transporter family, member 1B1) (eg, adverse drug reaction), gene analysis, common variant(s) (eg, *5) | Nevada Prior Authorization List, Pg 94 Original policy |
| 81329 | SMN1 (survival of motor neuron 1, telomeric) (eg, spinal muscular atrophy) gene analysis; dosage/deletion analysis (eg, carrier testing), includes SMN2 (survival of motor neur | Nevada Prior Authorization List, Pg 94 Original policy |
| 81330 | Smpd1(Sphingomyelin Phosphodiesterase 1, Acid Lysosomal) (Eg, Niemann-Pick Disease, Type A) Gene Analysis, Common Variants (Eg, R496L, L302P, Fsp330) | Nevada Prior Authorization List, Pg 94 Original policy |
| 81331 | Snrpn/Ube3A (Small Nuclear Ribonucleoprotein Polypeptide N And Ubiquitin Protein Ligase E3A) (Eg, Prader-Willi Syndrome And/Or Angelman Syndrome), Methylation Analysis | Nevada Prior Authorization List, Pg 94 Original policy |
| 81332 | Serpina1 (Serpin Peptidase Inhibitor, Clade A, Alpha-1 Antiproteinase, Antitrypsin, Member 1) (Eg, Alpha-1-Antitrypsin Deficiency), Gene Analysis, Common Variants (Eg, *S And | Nevada Prior Authorization List, Pg 94 Original policy |
| 81333 | TGFBI (transforming growth factor beta-induced) (eg, corneal dystrophy) gene analysis, common variants (eg, R124H, R124C, R124L, R555W, R555Q) | Nevada Prior Authorization List, Pg 94 Original policy |
| 81334 | RUNX1 (runt related transcription factor 1) (eg, acute myeloid leukemia, familial platelet disorder with associated myeloid malignancy), gene analysis, targeted sequence analy | Nevada Prior Authorization List, Pg 94 Original policy |
| 81335 | TPMT (thiopurine S-methyltransferase) (eg, drug metabolism), gene analysis, common variants (eg, *2, *3) | Nevada Prior Authorization List, Pg 94 Original policy |
| 81336 | SMN1 (survival of motor neuron 1, telomeric) (eg, spinal muscular atrophy) gene analysis; full gene sequence | Nevada Prior Authorization List, Pg 94 Original policy |
| 81337 | SMN1 (survival of motor neuron 1, telomeric) (eg, spinal muscular atrophy) gene analysis; known familial sequence variant(s) | Nevada Prior Authorization List, Pg 94 Original policy |
| 81338 | MPL (MPL proto-oncogene, thrombopoietin receptor) (eg, myeloproliferative disorder) gene analysis; common variants (eg, W515A, W515K, W515L, W515R) | Nevada Prior Authorization List, Pg 94 Original policy |
| 81339 | MPL (MPL proto-oncogene, thrombopoietin receptor) (eg, myeloproliferative disorder) gene analysis; sequence analysis, exon 10 | Nevada Prior Authorization List, Pg 94 Original policy |
| 81340 | Trb@ (T Cell Antigen Receptor, Beta) (Eg, Leukemia And Lymphoma), Gene Rearrangement Analysis To Detect Abnormal Clonal Population(S); Using Amplification Methodology (Eg, Pol | Nevada Prior Authorization List, Pg 94 Original policy |
| 81341 | Trb@ (T Cell Antigen Receptor, Beta) (Eg, Leukemia And Lymphoma), Gene Rearrangement Analysis To Detect Abnormal Clonal Population(S); Using Direct Probe Methodology (Eg, Sout | Nevada Prior Authorization List, Pg 94 Original policy |
| 81342 | Trg@ (T Cell Antigen Receptor, Gamma) (Eg, Leukemia And Lymphoma), Gene Rearrangement Analysis, Evaluation To Detect Abnormal Clonal Population(S) | Nevada Prior Authorization List, Pg 94 Original policy |
| 81343 | PPP2R2B (protein phosphatase 2 regulatory subunit Bbeta) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles | Nevada Prior Authorization List, Pg 94 Original policy |
| 81344 | TBP (TATA box binding protein) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles | Nevada Prior Authorization List, Pg 94 Original policy |
| 81345 | TERT (telomerase reverse transcriptase) (eg, thyroid carcinoma, glioblastoma multiforme) gene analysis, targeted sequence analysis (eg, promoter region) | Nevada Prior Authorization List, Pg 95 Original policy |
| 81346 | TYMS (thymidylate synthetase) (eg, 5-fluorouracil/5-FU drug metabolism), gene analysis, common variant(s) (eg, tandem repeat variant) | Nevada Prior Authorization List, Pg 95 Original policy |
| 81347 | SF3B1 (splicing factor [3b] subunit B1) (eg, myelodysplastic syndrome/acute myeloid leukemia) gene analysis, common variants (eg, A672T, E622D, L833F, R625C, R625L) | Nevada Prior Authorization List, Pg 95 Original policy |
| 81348 | SRSF2 (serine and arginine-rich splicing factor 2) (eg, myelodysplastic syndrome, acute myeloid leukemia) gene analysis, common variants (eg, P95H, P95L) | Nevada Prior Authorization List, Pg 95 Original policy |
| 81349 | Cytogenomic (genome-wide) analysis for constitutional chromosomal abnormalities; interrogation of genomic regions for copy number and loss-of- heterozygosity variants, low-pass | Nevada Prior Authorization List, Pg 95 Original policy |
| 81350 | UGT1A1 (UDP glucuronosyltransferase 1 family, polypeptide A1) (eg, drug metabolism, hereditary unconjugated hyperbilirubinemia [Gilbert syndrome]) gene analysis, common varian | Nevada Prior Authorization List, Pg 95 Original policy |
| 81351 | TP53 (tumor protein 53) (eg, Li-Fraumeni syndrome) gene analysis; full gene sequence | Nevada Prior Authorization List, Pg 95 Original policy |
| 81352 | TP53 (tumor protein 53) (eg, Li-Fraumeni syndrome) gene analysis; targeted sequence analysis (eg, 4 oncology) | Nevada Prior Authorization List, Pg 95 Original policy |
| 81353 | TP53 (tumor protein 53) (eg, Li-Fraumeni syndrome) gene analysis; known familial variant | Nevada Prior Authorization List, Pg 95 Original policy |
| 81355 | Vkorc1 (Vitamin K Epoxide Reductase Complex, Subunit 1) (Eg, Warfarin Metabolism), Gene Analysis, Common Variants (Eg, -1639/3673) | Nevada Prior Authorization List, Pg 95 Original policy |
| 81357 | U2AF1 (U2 small nuclear RNA auxiliary factor 1) (eg, myelodysplastic syndrome, acute myeloid leukemia) gene analysis, common variants (eg, S34F, S34Y, Q157R, Q157P) | Nevada Prior Authorization List, Pg 95 Original policy |
| 81360 | ZRSR2 (zinc finger CCCH-type, RNA binding motif and serine/arginine-rich 2) (eg, myelodysplastic syndrome, acute myeloid leukemia) gene analysis, common variant(s) (eg, E65fs | Nevada Prior Authorization List, Pg 95 Original policy |
| 81361 | HBB (hemoglobin, subunit beta) (eg, sickle cell anemia, beta thalassemia, hemoglobinopathy); common variant(s) (eg, HbS, HbC, HbE) | Nevada Prior Authorization List, Pg 95 Original policy |
| 81362 | HBB (hemoglobin, subunit beta) (eg, sickle cell anemia, beta thalassemia, hemoglobinopathy); known familial variant(s) | Nevada Prior Authorization List, Pg 95 Original policy |
| 81363 | HBB (hemoglobin, subunit beta) (eg, sickle cell anemia, beta thalassemia, hemoglobinopathy); duplication/deletion variant(s) | Nevada Prior Authorization List, Pg 95 Original policy |
| 81364 | HBB (hemoglobin, subunit beta) (eg, sickle cell anemia, beta thalassemia, hemoglobinopathy); full gene sequence | Nevada Prior Authorization List, Pg 95 Original policy |
| 81379 | Hla Class I Typing, High Resolution (Ie, Alleles Or Allele Groups); Complete (Ie, Hla-A, -B, And -C) | Nevada Prior Authorization List, Pg 95 Original policy |
| 81380 | Hla Class I Typing, High Resolution (Ie, Alleles Or Allele Groups); One Locus (Eg, Hla-A, -B, Or -C), Each | Nevada Prior Authorization List, Pg 95 Original policy |
| 81381 | Hla Class I Typing, High Resolution (Ie, Alleles Or Allele Groups); One Allele Or Allele Group (Eg, B*57:01P), Each | Nevada Prior Authorization List, Pg 95 Original policy |