Anthem Blue Cross and Blue Shield Nevada prior authorization, page 50
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 |
|---|---|---|
| 0019U | Oncology, RNA, gene expression by whole transcriptome sequencing, formalin- fixed paraffin embedded tissue or fresh frozen tissue, predictive algorithm reported as potential ta | Nevada Prior Authorization List, Pg 109 Original policy |
| 0020M | Oncology (central nervous system), analysis of 30000 DNA methylation loci by methylation array, utilizing DNA extracted from tumor tissue, diagnostic algorithm reported as pro | Nevada Prior Authorization List, Pg 109 Original policy |
| 0022U | Targeted genomic sequence analysis panel, non-small cell lung neoplasia, DNA and RNA analysis, 23 genes, interrogation for sequence variants and rearrangements, reported as pr | Nevada Prior Authorization List, Pg 109 Original policy |
| 0023U | Oncology (acute myelogenous leukemia), DNA, genotyping of internal tandem duplication, p.D835, p.I836, using mononuclear cells, reported as detection or non-detection of FLT3 | Nevada Prior Authorization List, Pg 109 Original policy |
| 0026U | Oncology (thyroid), DNA and mRNA of 112 genes, next-generation sequencing, fine needle aspirate of thyroid nodule, algorithmic analysis reported as a categorical result ('Posi | Nevada Prior Authorization List, Pg 110 Original policy |
| 0027U | JAK2 (Janus kinase 2) (eg, myeloproliferative disorder) gene analysis, targeted sequence analysis exons 12-15 | Nevada Prior Authorization List, Pg 110 Original policy |
| 0028U | CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, copy number variants, common variants with reflex to targeted sequence anal | Nevada Prior Authorization List, Pg 110 Original policy |
| 0029U | Drug metabolism (adverse drug reactions and drug response), targeted sequence analysis (ie, CYP1A2, CYP2C19, CYP2C9, CYP2D6, CYP3A4, CYP3A5, CYP4F2, SLCO1B1, VKORC1 and rs1277 | Nevada Prior Authorization List, Pg 110 Original policy |
| 0030U | Drug metabolism (warfarin drug response), targeted sequence analysis (ie, CYP2C9, CYP4F2, VKORC1, rs12777823) | Nevada Prior Authorization List, Pg 110 Original policy |
| 0031U | CYP1A2 (cytochrome P450 family 1, subfamily A, member 2)(eg, drug metabolism) gene analysis, common variants (ie, *1F, *1K, *6, *7) | Nevada Prior Authorization List, Pg 110 Original policy |
| 0032U | COMT (catechol-O-methyltransferase)(drug metabolism) gene analysis, c.472G>A (rs4680) variant | Nevada Prior Authorization List, Pg 110 Original policy |
| 0034U | TPMT (thiopurine S-methyltransferase), NUDT15 (nudix hydroxylase 15)(eg, thiopurine metabolism), gene analysis, common variants (ie, TPMT *2, *3A, *3B, *3C, *4, *5, *6, *8, *1 | Nevada Prior Authorization List, Pg 110 Original policy |
| 0036U | Exome (ie, somatic mutations), paired formalin-fixed paraffin-embedded tumor tissue and normal specimen, sequence analyses | Nevada Prior Authorization List, Pg 110 Original policy |
| 0037U | Targeted genomic sequence analysis, solid organ neoplasm, DNA analysis of 324 genes, interrogation for sequence variants, gene copy number amplifications, gene rearrangements | Nevada Prior Authorization List, Pg 110 Original policy |
| 0040U | BCR/ABL1 (t(9;22)) (eg, chronic myelogenous leukemia) translocation analysis, major breakpoint, quantitative | Nevada Prior Authorization List, Pg 110 Original policy |
| 0045U | Oncology (breast ductal carcinoma in situ), mRNA, gene expression profiling by real-time RT-PCR of 12 genes (7 content and 5 housekeeping), utilizing formalin- fixed paraffin-e | Nevada Prior Authorization List, Pg 110 Original policy |
| 0046U | FLT3 (fms-related tyrosine kinase 3) (eg, acute myeloid leukemia) internal tandem duplication (ITD) variants, quantitative | Nevada Prior Authorization List, Pg 110 Original policy |
| 0047U | Oncology (prostate), mRNA, gene expression profiling by real-time RT-PCR of 17 genes (12 content and 5 housekeeping), utilizing formalin-fixed paraffin- embedded tissue, algori | Nevada Prior Authorization List, Pg 110 Original policy |
| 0048T | Implantation of a ventricular assist device, extracorporeal, percutaneous transseptal access, single or dual cannulation | Nevada Prior Authorization List, Pg 110 Original policy |
| 0048U | Oncology (solid organ neoplasia), DNA, targeted sequencing of protein-coding exons of 468 cancer-associated genes, including interrogation for somatic mutations and microsatel | Nevada Prior Authorization List, Pg 110 Original policy |
| 0049U | NPM1 (nucleophosmin) (eg, acute myeloid leukemia) gene analysis, quantitative | Nevada Prior Authorization List, Pg 110 Original policy |
| 0050T | Removal of a ventricular assist device, extracorporeal, percutaneous transseptal access, single or dual cannulation | Nevada Prior Authorization List, Pg 110 Original policy |
| 0050U | Targeted genomic sequence analysis panel, acute myelogenous leukemia, DNA analysis, 194 genes, interrogation for sequence variants, copy number variants or rearrangements | Nevada Prior Authorization List, Pg 110 Original policy |
| 0053U | Oncology (prostate cancer), FISH analysis of 4 genes (ASAP1, HDAC9, CHD1 and PTEN), needle biopsy specimen, algorithm reported as probability of higher tumor grade | Nevada Prior Authorization List, Pg 110 Original policy |
| 0055U | Cardiology (heart transplant), cell-free DNA, PCR assay of 96 DNA target sequences (94 single nucleotide polymorphism targets and two control targets), plasma | Nevada Prior Authorization List, Pg 110 Original policy |
| 0062U | Autoimmune (systemic lupus erythematosus), IgG and IgM analysis of 80 biomarkers, utilizing serum, algorithm reported with a risk score | Nevada Prior Authorization List, Pg 110 Original policy |
| 0069U | Oncology (colorectal), microRNA, RT-PCR expression profiling of miR-31-3p, formalin-fixed paraffin-embedded tissue, algorithm reported as an expression score | Nevada Prior Authorization List, Pg 110 Original policy |
| 0070U | CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, common and select rare variants (ie, *2, *3, *4, *4N, *5, *6, *7, *8, *9, * | Nevada Prior Authorization List, Pg 110 Original policy |
| 0071T | Ultrasound Ablation of Uterine Leioomyomata inc MR Guidance | Nevada Prior Authorization List, Pg 110 Original policy |
| 0071U | CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, full gene sequence (List separately in addition to code for primary procedu | Nevada Prior Authorization List, Pg 111 Original policy |
| 0072T | Ultrasound Ablation of Uterine Leioomyomata inc MR Guidance; Vol>=200 CC | Nevada Prior Authorization List, Pg 111 Original policy |
| 0072U | CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, targeted sequence analysis (ie, CYP2D6-2D7 hybrid gene) (List separately in | Nevada Prior Authorization List, Pg 111 Original policy |
| 0073U | CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, targeted sequence analysis (ie, CYP2D7-2D6 hybrid gene) (List separately in | Nevada Prior Authorization List, Pg 111 Original policy |
| 0074U | CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, targeted sequence analysis (ie, non-duplicated gene when duplication/multip | Nevada Prior Authorization List, Pg 111 Original policy |
| 0075U | CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, targeted sequence analysis (ie, 5 gene duplication/multiplication) (List se | Nevada Prior Authorization List, Pg 111 Original policy |
| 0076U | CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, targeted sequence analysis (ie, 3 gene duplication/ multiplication) (List s | Nevada Prior Authorization List, Pg 111 Original policy |
| 0078U | Pain management (opioid-use disorder) genotyping panel, 16 common variants (ie, ABCB1, COMT, DAT1, DBH, DOR, DRD1, DRD2, DRD4, GABA, GAL, HTR2A, HTTLPR, MTHFR, MUOR, OPRK1, OP | Nevada Prior Authorization List, Pg 111 Original policy |
| 0079U | Comparative DNA analysis using multiple selected single-nucleotide polymorphisms(SNPs), urine and buccal DNA, for specimen identity verification | Nevada Prior Authorization List, Pg 111 Original policy |
| 0080U | Oncology (lung), mass spectrometric analysis of galectin-3-binding protein and scavenger receptor cysteine-rich type 1 protein M130, with five clinical risk factors (age, smok | Nevada Prior Authorization List, Pg 111 Original policy |
| 0085T | Breath test for heart transplant rejection | Nevada Prior Authorization List, Pg 111 Original policy |
| 0087U | Cardiology (heart transplant), mRNA gene expression profiling by microarray of 1283 genes, transplant biopsy tissue, allograft rejection and injury algorithm reported as a pro | Nevada Prior Authorization List, Pg 111 Original policy |
| 0088U | Transplantation medicine (kidney allograft rejection), microarray gene expression profiling of 1494 genes, utilizing transplant biopsy tissue, algorithm reported as a probabil | Nevada Prior Authorization List, Pg 111 Original policy |
| 0089U | Oncology (melanoma), gene expression profiling by RTqPCR, PRAME and LINC00518, superficial collection using adhesive patch(es) | Nevada Prior Authorization List, Pg 111 Original policy |
| 0090U | Oncology (cutaneous melanoma), mRNA gene expression profiling by RT-PCR of 23 genes (14 content and 9 housekeeping), utilizing formalin-fixed paraffin- embedded (FFPE) tissue | Nevada Prior Authorization List, Pg 111 Original policy |
| 0092U | Oncology (lung), three protein biomarkers, immunoassay using magnetic nanosensor technology, plasma, algorithm reported as risk score for likelihood of malignancy | Nevada Prior Authorization List, Pg 111 Original policy |
| 0094U | Genome (eg, unexplained constitutional or heritable disorder or syndrome), rapid sequence analysis | Nevada Prior Authorization List, Pg 111 Original policy |
| 0095T | Removal of total disc arthroplasty (artificial disc), anterior approach, each additional interspace, cervical (List separately in addition to code for primary procedure) | Nevada Prior Authorization List, Pg 111 Original policy |
| 0098T | Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, each additional interspace, cervical (List separately in addition to code for p | Nevada Prior Authorization List, Pg 111 Original policy |
| 0100T | Placement of a subconjunctival retinal prosthesis receiver and pulse generator, and implantation of intra-ocular retinal electrode array, with vitrectomy | Nevada Prior Authorization List, Pg 111 Original policy |
| 0101T | Extracorporeal shock wave involving musculoskeletal system, not otherwise specified | Nevada Prior Authorization List, Pg 111 Original policy |