Anthem Blue Cross and Blue Shield Nevada prior authorization, page 45
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 |
|---|---|---|
| 81479 | Unlisted molecular pathology procedure | Nevada Prior Authorization List, Pg 98 Original policy |
| 81490 | Autoimmune (rheumatoid arthritis), analysis of 12 biomarkers using immunoassays, utilizing serum, prognostic algorithm reported as a disease activity score | Nevada Prior Authorization List, Pg 98 Original policy |
| 81493 | Coronary artery disease, mRNA, gene expression profiling by real-time RT-PCR of 23 genes, utilizing whole peripheral blood, algorithm reported as a risk score | Nevada Prior Authorization List, Pg 98 Original policy |
| 81504 | Oncology (tissue of origin), microarray gene expression profiling of > 2000 genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as tissue similarity s | Nevada Prior Authorization List, Pg 98 Original policy |
| 81506 | Endocrinology, Biochemical Assays Of Seven Analytes Utilizing Serum Or Plasma, Algorithm Reporting A Risk Score | Nevada Prior Authorization List, Pg 98 Original policy |
| 81517 | Liver disease, analysis of 3 biomarkers (hyaluronic acid [HA], procollagen III amino terminal peptide [PIIINP], tissue inhibitor of metalloproteinase 1 [TIMP- 1]), using immuno | Nevada Prior Authorization List, Pg 98 Original policy |
| 81518 | Oncology (breast), mRNA, gene expression profiling by real-time RT-PCR of 11 genes (7 content and 4 housekeeping), utilizing formalin-fixed paraffin- embedded tissue, algorithm | Nevada Prior Authorization List, Pg 98 Original policy |
| 81519 | Oncology (breast), mRNA, gene expression profiling by real-time RT-PCR of 21 genes, utilizing formalin-fixed paraffin embedded tissue, algorithm reported as recurrence score | Nevada Prior Authorization List, Pg 98 Original policy |
| 81520 | Oncology (breast), mRNA gene expression profiling by hybrid capture of 58 genes (50 content and 8 housekeeping), utilizing formalin-fixed paraffin- embedded tissue, algorithm r | Nevada Prior Authorization List, Pg 98 Original policy |
| 81521 | Oncology (breast), mRNA, microarray gene expression profiling of 70 content genes and 465 housekeeping genes, utilizing fresh frozen or formalin-fixed paraffin-embedded tissue | Nevada Prior Authorization List, Pg 98 Original policy |
| 81522 | Oncology (breast), mRNA, gene expression profiling by RT-PCR of 12 genes (8 content and 4 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported | Nevada Prior Authorization List, Pg 98 Original policy |
| 81523 | Oncology (breast), mRNA, next-generation sequencing gene expression profiling of 70 content genes and 31 housekeeping genes, utilizing formalin-fixed paraffin-embedded tissue | Nevada Prior Authorization List, Pg 99 Original policy |
| 81525 | Oncology (colon), mRNA, gene, expression profiling by real-time RT-PCR of 12 genes (7 content and 5 housekeeping), utilizing formalin-fixed paraffin- embedded tissue, algorithm | Nevada Prior Authorization List, Pg 99 Original policy |
| 81529 | Oncology (cutaneous melanoma), mRNA, gene expression profiling by real-time RT-PCR of 31 genes (28 content and 3 housekeeping), utilizing formalin-fixed paraffin-embedded tiss | Nevada Prior Authorization List, Pg 99 Original policy |
| 81535 | Oncology (gynecologic), live tumor cell culture and chemotherapeutic response by DAPI stain and morphology, predictive algorithm reported as a drug response score; first singl | Nevada Prior Authorization List, Pg 99 Original policy |
| 81538 | Oncology (lung), mass spectrometric 8-protein signature, including amyloid A, utilizing serum, prognostic and predictive algorithm reported as good versus poor overall surviva | Nevada Prior Authorization List, Pg 99 Original policy |
| 81539 | Oncology (high-grade prostate cancer), biochemical assay of four proteins (Total PSA, Free PSA, Intact PSA, and human kallikrein-2 hK2), utilizing plasma or serum, prognostic | Nevada Prior Authorization List, Pg 99 Original policy |
| 81540 | Oncology (tumor of unknown origin), mRNA, gene expression profiling by real- time RT-PCR of 92 genes (87 content and 5 housekeeping) to classify tumor into main cancer type and | Nevada Prior Authorization List, Pg 99 Original policy |
| 81541 | Oncology (prostate), mRNA gene expression profiling by real-time RT-PCR of 46 genes (31 content and 15 housekeeping), utilizing formalin-fixed paraffin- embedded tissue, algori | Nevada Prior Authorization List, Pg 99 Original policy |
| 81542 | Oncology (prostate), mRNA, microarray gene expression profiling of 22 content genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as metastasis risk s | Nevada Prior Authorization List, Pg 99 Original policy |
| 81546 | Oncology (thyroid), mRNA, gene expression analysis of 10,196 genes, utilizing fine needle aspirate, algorithm reported as a categorical result (eg, benign or suspicious) | Nevada Prior Authorization List, Pg 99 Original policy |
| 81551 | Oncology (prostate), promoter methylation profiling by real-time PCR of 3 genes (GSTP1, APC, RASSF1), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as | Nevada Prior Authorization List, Pg 99 Original policy |
| 81552 | Oncology (uveal melanoma), mRNA, gene expression profiling by real-time RT- PCR of 15 genes (12 content and 3 housekeeping), utilizing fine needle aspirate or formalin-fixed pa | Nevada Prior Authorization List, Pg 99 Original policy |
| 81554 | Pulmonary disease (idiopathic pulmonary fibrosis [IPF]), mRNA, gene expression analysis of 190 genes, utilizing transbronchial biopsies, diagnostic algorithm reported as categ | Nevada Prior Authorization List, Pg 99 Original policy |
| 81558 | Transplantation medicine (allograft rejection, kidney), mRNA, gene expression profiling | Nevada Prior Authorization List, Pg 99 Original policy |
| 81560 | Transplantation medicine (allograft rejection, pediatric liver and small bowel), measurement of donor and third-party-induced CD154+T-cytotoxic memory cells, utilizing whole p | Nevada Prior Authorization List, Pg 99 Original policy |
| 81595 | Cardiology (heart transplant), mRNA, gene expression profiling by real-time quantitative PCR of 20 genes (11 content and 9 housekeeping), utilizing subfraction of peripheral b | Nevada Prior Authorization List, Pg 99 Original policy |
| 81596 | Infectious disease, chronic hepatitis C virus (HCV) infection, six biochemical assays (ALT, A2-macroglobulin, apolipoprotein A-1, total bilirubin, GGT, and haptoglobin) utiliz | Nevada Prior Authorization List, Pg 99 Original policy |
| 82233 | Beta-amyloid; 1-40 | Nevada Prior Authorization List, Pg 99 Original policy |
| 82234 | Beta-amyloid; 1-42 | Nevada Prior Authorization List, Pg 99 Original policy |
| 82542 | Column Chromatography/Mass Spectrometry; Quantitative, Single Stationary & Mobile Phase | Nevada Prior Authorization List, Pg 99 Original policy |
| 82787 | Gammaglobulin (immunoglobulin); immunoglobulin subclasses (eg, IgG1, 2, 3, or 4), each | Nevada Prior Authorization List, Pg 99 Original policy |
| 83516 | Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; qualitative or semiquantitativ | Nevada Prior Authorization List, Pg 99 Original policy |
| 83520 | Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; quantitative, not otherwise sp | Nevada Prior Authorization List, Pg 99 Original policy |
| 83884 | Neurofilament light chain | Nevada Prior Authorization List, Pg 99 Original policy |
| 83921 | Organic Acid, Single, Quantitative | Nevada Prior Authorization List, Pg 99 Original policy |
| 84393 | Tau, phosphorylated | Nevada Prior Authorization List, Pg 99 Original policy |
| 84394 | Tau, total | Nevada Prior Authorization List, Pg 99 Original policy |
| 86001 | Allergen Specific Igg Quantitative/Semiquantitative, Ea Allergen | Nevada Prior Authorization List, Pg 99 Original policy |
| 86152 | Cell enumeration using immunologic selection and identification in fluid specimen (eg, circulating tumor cells in blood) | Nevada Prior Authorization List, Pg 100 Original policy |
| 86153 | Cell enumeration using immunologic selection and identification in fluid specimen (eg, circulating tumor cells in blood); physician interpretation and report, when required | Nevada Prior Authorization List, Pg 100 Original policy |
| 86343 | Leukocyte Histamine Release Test (Lhr) | Nevada Prior Authorization List, Pg 100 Original policy |
| 86352 | Cellular function assay involving stimulation (eg, mitogen or antigen) and detection of biomarker (eg, ATP) | Nevada Prior Authorization List, Pg 100 Original policy |
| 86357 | Natural killer (NK) cells, total count | Nevada Prior Authorization List, Pg 100 Original policy |
| 88356 | Morphometric Analysis; Nerve | Nevada Prior Authorization List, Pg 100 Original policy |
| 89280 | Assisted Oocyte Fertilization, Microtechnique; Less Than or Equal To 10 Oocytes | Nevada Prior Authorization List, Pg 100 Original policy |
| 89281 | Assisted Oocyte Fertilization, Microtechnique; Greater Than 10 Oocytes | Nevada Prior Authorization List, Pg 100 Original policy |
| 89290 | Biopsy, Oocyte Polar Body or Embryo Blastomere, Microtechnique; Less Than or Equal To 5 Embryos | Nevada Prior Authorization List, Pg 100 Original policy |
| 89291 | Biopsy, Oocyte Polar Body or Embryo Blastomere, Microtechnique; Greater Than 5 Embryos | Nevada Prior Authorization List, Pg 100 Original policy |
| 89329 | Sperm Evaluation; Hamster Penetration Test | Nevada Prior Authorization List, Pg 100 Original policy |