Anthem Blue Cross and Blue Shield Nevada prior authorization, page 44
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 |
|---|---|---|
| 81400 | MOLECULAR PATHOLOGY PROCEDURE LEVEL 1 | Nevada Prior Authorization List, Pg 95 Original policy |
| 81401 | MOLECULAR PATHOLOGY PROCEDURE LEVEL 2 | Nevada Prior Authorization List, Pg 95 Original policy |
| 81402 | MOLECULAR PATHOLOGY PROCEDURE LEVEL 3 | Nevada Prior Authorization List, Pg 96 Original policy |
| 81403 | MOLECULAR PATHOLOGY PROCEDURE LEVEL 4 | Nevada Prior Authorization List, Pg 96 Original policy |
| 81404 | MOLECULAR PATHOLOGY PROCEDURE LEVEL 5 | Nevada Prior Authorization List, Pg 96 Original policy |
| 81405 | MOLECULAR PATHOLOGY PROCEDURE LEVEL 6 | Nevada Prior Authorization List, Pg 96 Original policy |
| 81406 | MOLECULAR PATHOLOGY PROCEDURE LEVEL 7 | Nevada Prior Authorization List, Pg 96 Original policy |
| 81407 | MOLECULAR PATHOLOGY PROCEDURE LEVEL 8 | Nevada Prior Authorization List, Pg 96 Original policy |
| 81408 | Molecular pathology procedure, Level 9 (eg, analysis of >50 exons in a single gene by DNA sequence analysis) ABCA4 (ATP-binding cassette, sub-family A [ABC1], member 4) (eg, S | Nevada Prior Authorization List, Pg 96 Original policy |
| 81410 | Aortic dysfunction or dilation (eg, Marfan syndrome, Loeys Dietz syndrome, Ehler Danlos syndrome type IV, arterial tortuosity syndrome); genomic sequence analysis panel, must | Nevada Prior Authorization List, Pg 96 Original policy |
| 81411 | Aortic dysfunction or dilation (eg, Marfan syndrome, Loeys Dietz syndrome, Ehler Danlos syndrome type IV, arterial tortuosity syndrome); duplication/deletion analysis panel, m | Nevada Prior Authorization List, Pg 96 Original policy |
| 81412 | Ashkenazi Jewish associated disorders (eg, Bloom syndrome, Canavan disease, cystic fibrosis, familial dysautonomia, Fanconi anemia group C, Gaucher disease, Tay-Sachs disease) | Nevada Prior Authorization List, Pg 96 Original policy |
| 81413 | Cardiac ion channelopathies (eg Brugada syndrome, long QT syndrome, short QT syndrome, catecholaminergic polymorphic ventricular tachycardia); genomic sequence analysis panel | Nevada Prior Authorization List, Pg 96 Original policy |
| 81414 | Cardiac ion channelopathies (eg Brugada syndrome, long QT syndrome, short QT syndrome, catecholaminergic polymorphic ventricular tachycardia); duplication/deletion gene analys | Nevada Prior Authorization List, Pg 96 Original policy |
| 81415 | Exome (eg, unexplained constitutional or heritable disorder or syndrome); sequence analysis | Nevada Prior Authorization List, Pg 96 Original policy |
| 81416 | Exome (eg, unexplained constitutional or heritable disorder or syndrome); sequence analysis, each comparator exome (eg, parents, siblings) (List separately in addition to code | Nevada Prior Authorization List, Pg 96 Original policy |
| 81417 | Exome (eg, unexplained constitutional or heritable disorder or syndrome); re- evaluation of previously obtained exome sequence (eg, updated knowledge or unrelated condition/syn | Nevada Prior Authorization List, Pg 96 Original policy |
| 81418 | Drug metabolism (eg, pharmacogenomics) genomic sequence analysis panel, must include testing of at least 6 genes, including CYP2C19, CYP2D6, and CYP2D6 duplication/deletion an | Nevada Prior Authorization List, Pg 96 Original policy |
| 81419 | Epilepsy genomic sequence analysis panel, must include analyses for ALDH7A1, CACNA1A, CDKL5, CHD2, GABRG2, GRIN2A, KCNQ2, MECP2, PCDH19, POLG, PRRT2, SCN1A, SCN1B, SCN2A, SCN8 | Nevada Prior Authorization List, Pg 96 Original policy |
| 81425 | Genome (eg, unexplained constitutional or heritable disorder or syndrome); sequence analysis | Nevada Prior Authorization List, Pg 97 Original policy |
| 81426 | Genome (eg, unexplained constitutional or heritable disorder or syndrome); sequence analysis, each comparator genome (eg, parents, siblings) (List separately in addition to co | Nevada Prior Authorization List, Pg 97 Original policy |
| 81427 | Genome (eg, unexplained constitutional or heritable disorder or syndrome); re- evaluation of previously obtained genome sequence (eg, updated knowledge or unrelated condition/s | Nevada Prior Authorization List, Pg 97 Original policy |
| 81430 | Hearing loss (eg, nonsyndromic hearing loss, Usher syndrome, Pendred syndrome); genomic sequence analysis panel, must include sequencing of at least 60 genes, including CDH23 | Nevada Prior Authorization List, Pg 97 Original policy |
| 81431 | Hearing loss (eg, nonsyndromic hearing loss, Usher syndrome, Pendred syndrome); duplication/deletion analysis panel, must include copy number analyses for STRC and DFNB1 delet | Nevada Prior Authorization List, Pg 97 Original policy |
| 81432 | Hereditary breast cancer-related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer, hereditary pancreatic cancer, hereditary pr | Nevada Prior Authorization List, Pg 97 Original policy |
| 81434 | Hereditary retinal disorders (eg, retinitis pigmentosa, Leber congenital amaurosis, cone-rod dystrophy), genomic sequence analysis panel, must include sequencing of at least 1 | Nevada Prior Authorization List, Pg 97 Original policy |
| 81435 | Hereditary colon cancer-related disorders (eg, Lynch syndrome, PTEN hamartoma syndrome, Cowden syndrome, familial adenomatosis polyposis), genomic sequence analysis panel, 5 o | Nevada Prior Authorization List, Pg 97 Original policy |
| 81437 | Hereditary neuroendocrine tumor-related disorders (eg, medullary thyroid carcinoma, parathyroid carcinoma, malignant pheochromocytoma or paraganglioma), genomic sequence analy | Nevada Prior Authorization List, Pg 97 Original policy |
| 81439 | Hereditary cardiomyopathy (eg, hypertrophic cardiomyopathy, dilated cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy), genomic sequence analysis panel, must inc | Nevada Prior Authorization List, Pg 97 Original policy |
| 81440 | Nuclear encoded mitochondrial genes (eg, neurologic or myopathic phenotypes), genomic sequence panel, must include analysis of at least 100 genes, including BCS1L, C10orf2, CO | Nevada Prior Authorization List, Pg 97 Original policy |
| 81441 | Inherited bone marrow failure syndromes (IBMFS) (eg, Fanconi anemia, dyskeratosis congenita, Diamond-Blackfan anemia, Shwachman-Diamond syndrome, GATA2 deficiency syndrome, co | Nevada Prior Authorization List, Pg 97 Original policy |
| 81442 | Noonan spectrum disorders (eg, Noonan syndrome, cardio-facio-cutaneous syndrome, Costello syndrome, LEOPARD syndrome, Noonan-like syndrome), genomic sequence analysis panel, m | Nevada Prior Authorization List, Pg 97 Original policy |
| 81443 | Genetic testing for severe inherited conditions (eg, cystic fibrosis, Ashkenazi Jewish-associated disorders [eg, Bloom syndrome, Canavan disease, Fanconi anemia type C, mucoli | Nevada Prior Authorization List, Pg 97 Original policy |
| 81445 | Solid organ neoplasm, genomic sequence analysis panel, 5-50 genes, interrogation for sequence variants and copy number variants or rearrangements, if performed; DNA analysis o | Nevada Prior Authorization List, Pg 97 Original policy |
| 81448 | Hereditary peripheral neuropathies (eg, Charcot-Marie-Tooth, spastic paraplegia), genomic sequence analysis panel, must include sequencing of at least 5 peripheral neuropathy | Nevada Prior Authorization List, Pg 97 Original policy |
| 81449 | Solid organ neoplasm, genomic sequence analysis panel, 5-50 genes, interrogation for sequence variants and copy number variants or rearrangements, if performed; RNA analysis | Nevada Prior Authorization List, Pg 97 Original policy |
| 81450 | Hematolymphoid neoplasm or disorder, genomic sequence analysis panel, 5-50 genes, interrogation for sequence variants, and copy number variants or rearrangements, or isoform e | Nevada Prior Authorization List, Pg 97 Original policy |
| 81451 | Hematolymphoid neoplasm or disorder, genomic sequence analysis panel, 5-50 genes, interrogation for sequence variants, and copy number variants or rearrangements, or isoform e | Nevada Prior Authorization List, Pg 97 Original policy |
| 81455 | Solid organ or hematolymphoid neoplasm or disorder, 51 or greater genes, genomic sequence analysis panel, interrogation for sequence variants and copy number variants or rearr | Nevada Prior Authorization List, Pg 97 Original policy |
| 81456 | Solid organ or hematolymphoid neoplasm or disorder, 51 or greater genes, genomic sequence analysis panel, interrogation for sequence variants and copy number variants or rearr | Nevada Prior Authorization List, Pg 97 Original policy |
| 81457 | Solid organ neoplasm, genomic sequence analysis panel, interrogation for sequence variants; DNA analysis, microsatellite instability | Nevada Prior Authorization List, Pg 97 Original policy |
| 81458 | Solid organ neoplasm, genomic sequence analysis panel, interrogation for sequence variants; DNA analysis, copy number variants and microsatellite instability | Nevada Prior Authorization List, Pg 98 Original policy |
| 81459 | Solid organ neoplasm, genomic sequence analysis panel, interrogation for sequence variants; DNA analysis or combined DNA and RNA analysis, copy number variants, microsatellite | Nevada Prior Authorization List, Pg 98 Original policy |
| 81460 | Whole mitochondrial genome (eg, Leigh syndrome, mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes [MELAS], myoclonic epilepsy with ragged-red fibers [ | Nevada Prior Authorization List, Pg 98 Original policy |
| 81462 | Solid organ neoplasm, genomic sequence analysis panel, cell-free nucleic acid (eg, plasma), interrogation for sequence variants; DNA analysis or combined DNA and RNA analysis | Nevada Prior Authorization List, Pg 98 Original policy |
| 81463 | Solid organ neoplasm, genomic sequence analysis panel, cell-free nucleic acid (eg, plasma), interrogation for sequence variants; DNA analysis, copy number variants, and micros | Nevada Prior Authorization List, Pg 98 Original policy |
| 81464 | Solid organ neoplasm, genomic sequence analysis panel, cell-free nucleic acid (eg, plasma), interrogation for sequence variants; DNA analysis or combined DNA and RNA analysis | Nevada Prior Authorization List, Pg 98 Original policy |
| 81465 | Whole mitochondrial genome large deletion analysis panel (eg, Kearns-Sayre syndrome, chronic progressive external ophthalmoplegia), including heteroplasmy detection, if perfor | Nevada Prior Authorization List, Pg 98 Original policy |
| 81470 | X-linked intellectual disability (XLID) (eg, syndromic and non-syndromic XLID); genomic sequence analysis panel, must include sequencing of at least 60 genes, including ARX, A | Nevada Prior Authorization List, Pg 98 Original policy |
| 81471 | X-linked intellectual disability (XLID) (eg, syndromic and non-syndromic XLID); duplication/deletion gene analysis, must include analysis of at least 60 genes, including ARX | Nevada Prior Authorization List, Pg 98 Original policy |