Anthem Blue Cross and Blue Shield Nevada prior authorization, page 54
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 |
|---|---|---|
| 0329U | Oncology (neoplasia), exome and transcriptome sequence analysis for sequence variants, gene copy number amplifications and deletions, gene rearrangements, microsatellite insta | Nevada Prior Authorization List, Pg 118 Original policy |
| 0330T | Tear film imaging, unilateral or bilateral, with interpretation and report | Nevada Prior Authorization List, Pg 118 Original policy |
| 0331T | Myocardial sympathetic innervation imaging, planar qualitative and quantitative assessment | Nevada Prior Authorization List, Pg 118 Original policy |
| 0331U | Oncology (hematolymphoid neoplasia), optical genome mapping for copy number alterations and gene rearrangements utilizing DNA from blood or bone marrow, report of clinically s | Nevada Prior Authorization List, Pg 118 Original policy |
| 0332T | Myocardial sympathetic innervation imaging, planar qualitative and quantitative assessment; with tomographic SPECT | Nevada Prior Authorization List, Pg 118 Original policy |
| 0332U | Oncology (pan-tumor), genetic profiling of 8 DNA-regulatory (epigenetic) markers by quantitative polymerase chain reaction (qPCR), whole blood, reported as a high or low proba | Nevada Prior Authorization List, Pg 118 Original policy |
| 0333U | Oncology (liver), surveillance for hepatocellular carcinoma (HCC) in high-risk patients, analysis of methylation patterns on circulating cell-free DNA (cfDNA) plus measurement | Nevada Prior Authorization List, Pg 118 Original policy |
| 0334U | Oncology (solid organ), targeted genomic sequence analysis, formalin-fixed paraffin-embedded (FFPE) tumor tissue, DNA analysis, 84 or more genes, interrogation for sequence va | Nevada Prior Authorization List, Pg 119 Original policy |
| 0335T | Insertion of sinus tarsi implant | Nevada Prior Authorization List, Pg 119 Original policy |
| 0335U | Rare diseases (constitutional/heritable disorders), whole genome sequence analysis, including small sequence changes, copy number variants, deletions, duplications, mobile ele | Nevada Prior Authorization List, Pg 119 Original policy |
| 0336U | Rare diseases (constitutional/heritable disorders), whole genome sequence analysis, including small sequence changes, copy number variants, deletions, duplications, mobile ele | Nevada Prior Authorization List, Pg 119 Original policy |
| 0337U | Oncology (plasma cell disorders and myeloma), circulating plasma cell immunologic selection, identification, morphological characterization, and enumeration of plasma cells ba | Nevada Prior Authorization List, Pg 119 Original policy |
| 0338T | Transcatheter renal sympathetic denervation, percutaneous approach including arterial puncture, selective catheter placement(s) renal artery(ies), fluoroscopy, contrast inject | Nevada Prior Authorization List, Pg 119 Original policy |
| 0338U | Oncology (solid tumor), circulating tumor cell selection, identification, morphological characterization, detection and enumeration based on differential EpCAM, cytokeratins 8 | Nevada Prior Authorization List, Pg 119 Original policy |
| 0339T | Transcatheter renal sympathetic denervation, percutaneous approach including arterial puncture, selective catheter placement(s) renal artery(ies), fluoroscopy, contrast inject | Nevada Prior Authorization List, Pg 119 Original policy |
| 0339U | Oncology (prostate), mRNA expression profiling of HOXC6 and DLX1, reverse transcription polymerase chain reaction (RT-PCR), first-void urine following digital rectal examinati | Nevada Prior Authorization List, Pg 119 Original policy |
| 0340U | Oncology (pan-cancer), analysis of minimal residual disease (MRD) from plasma, with assays personalized to each patient based on prior next-generation sequencing of the patien | Nevada Prior Authorization List, Pg 119 Original policy |
| 0342T | Therapeutic apheresis with selective HDL delipidation and plasma reinfusion | Nevada Prior Authorization List, Pg 119 Original policy |
| 0342U | Oncology (pancreatic cancer), multiplex immunoassay of C5, C4, cystatin C, factor B, osteoprotegerin (OPG), gelsolin, IGFBP3, CA125 and multiplex electrochemiluminescent immun | Nevada Prior Authorization List, Pg 119 Original policy |
| 0343U | Oncology (prostate), exosome-based analysis of 442 small noncoding RNAs (sncRNAs) by quantitative reverse transcription polymerase chain reaction (RT- qPCR), urine, reported as | Nevada Prior Authorization List, Pg 119 Original policy |
| 0344U | Hepatology (nonalcoholic fatty liver disease [NAFLD]), semiquantitative evaluation of 28 lipid markers by liquid chromatography with tandem mass spectrometry (LC-MS/MS), serum | Nevada Prior Authorization List, Pg 119 Original policy |
| 0345T | Transcatheter mitral valve repair percutaneous approach via the coronary sinus | Nevada Prior Authorization List, Pg 119 Original policy |
| 0345U | Psychiatry (eg, depression, anxiety, attention deficit hyperactivity disorder [ADHD]), genomic analysis panel, variant analysis of 15 genes, including deletion/duplication ana | Nevada Prior Authorization List, Pg 119 Original policy |
| 0347U | Drug metabolism or processing (multiple conditions), whole blood or buccal specimen, DNA analysis, 16 gene report, with variant analysis and reported phenotypes | Nevada Prior Authorization List, Pg 119 Original policy |
| 0348U | Drug metabolism or processing (multiple conditions), whole blood or buccal specimen, DNA analysis, 25 gene report, with variant analysis and reported phenotypes | Nevada Prior Authorization List, Pg 119 Original policy |
| 0349U | Drug metabolism or processing (multiple conditions), whole blood or buccal specimen, DNA analysis, 27 gene report, with variant analysis, including reported phenotypes and imp | Nevada Prior Authorization List, Pg 119 Original policy |
| 0350U | Drug metabolism or processing (multiple conditions), whole blood or buccal specimen, DNA analysis, 27 gene report, with variant analysis and reported phenotypes | Nevada Prior Authorization List, Pg 119 Original policy |
| 0351T | Optical coherence tomography of breast or axillary lymph node, excised tissue, each specimen; real time intraoperative | Nevada Prior Authorization List, Pg 119 Original policy |
| 0352T | Optical coherence tomography of breast or axillary lymph node, excised tissue, each specimen; interpretation and report, real time or referred | Nevada Prior Authorization List, Pg 119 Original policy |
| 0353T | Optical coherence tomography of breast, surgical cavity; real time intraoperative | Nevada Prior Authorization List, Pg 120 Original policy |
| 0354T | Optical coherence tomography of breast, surgical cavity; interpretation and report, real time or referred | Nevada Prior Authorization List, Pg 120 Original policy |
| 0355U | APOL1 (apolipoprotein L1) (eg, chronic kidney disease), risk variants (G1, G2) | Nevada Prior Authorization List, Pg 120 Original policy |
| 0356U | Oncology (oropharyngeal or anal), evaluation of 17 DNA biomarkers using droplet digital PCR (ddPCR), cell-free DNA, algorithm reported as a prognostic risk score for cancer re | Nevada Prior Authorization List, Pg 120 Original policy |
| 0358U | Neurology (mild cognitive impairment), analysis of B-amyloid 1-42 and 1-40, chemiluminescence enzyme immunoassay, cerebral spinal fluid, reported as positive, likely positive | Nevada Prior Authorization List, Pg 120 Original policy |
| 0359U | Oncology (prostate cancer), analysis of all prostate-specific antigen (PSA) structural isoforms by phase separation and immunoassay, plasma, algorithm reports risk of cancer | Nevada Prior Authorization List, Pg 120 Original policy |
| 0360U | Oncology (lung), enzyme-linked immunosorbent assay (ELISA) of 7 autoantibodies (p53, NY-ESO-1, CAGE, GBU4-5, SOX2, MAGE A4, and HuD), plasma, algorithm reported as a categoric | Nevada Prior Authorization List, Pg 120 Original policy |
| 0362U | Oncology (papillary thyroid cancer), gene-expression profiling via targeted hybrid captureenrichment RNA sequencing of 82 content genes and 10 housekeeping genes, formalin-fi | Nevada Prior Authorization List, Pg 120 Original policy |
| 0363U | Oncology (urothelial), mRNA, gene-expression profiling by real-time quantitative PCR of 5 genes (MDK, HOXA13, CDC2 [CDK1], IGFBP5, and CXCR2), utilizing urine, algorithm incor | Nevada Prior Authorization List, Pg 120 Original policy |
| 0364U | Oncology (hematolymphoid neoplasm), genomic sequence analysis using multiplex (PCR) and next-generation sequencing with algorithm, quantification of dominant clonal sequence(s | Nevada Prior Authorization List, Pg 120 Original policy |
| 0368U | Oncology (colorectal cancer), evaluation for mutations of APC, BRAF, CTNNB1, KRAS, NRAS, PIK3CA, SMAD4, and TP53, and methylation markers (MYO1G, KCNQ5, C9ORF50, FLI1, CLIP4 | Nevada Prior Authorization List, Pg 120 Original policy |
| 0375T | Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompres | Nevada Prior Authorization List, Pg 120 Original policy |
| 0376U | Oncology (prostate cancer), image analysis of at least 128 histologic features and clinical factors, prognostic algorithm determining the risk of distant metastases, and prost | Nevada Prior Authorization List, Pg 120 Original policy |
| 0377U | Cardiovascular disease, quantification of advanced serum or plasma lipoprotein profile, by nuclear magnetic resonance (NMR) spectrometry with report of a lipoprotein profile ( | Nevada Prior Authorization List, Pg 120 Original policy |
| 0378T | Visual field assessment, with concurrent real time data analysis and accessible data storage with patient initiated data transmitted to a remote surveillance center for up to | Nevada Prior Authorization List, Pg 120 Original policy |
| 0378U | RFC1 (replication factor C subunit 1), repeat expansion variant analysis by traditional and repeat-primed PCR, blood, saliva, or buccal swab | Nevada Prior Authorization List, Pg 120 Original policy |
| 0379T | Visual field assessment, with concurrent real time data analysis and accessible data storage with patient initiated data transmitted to a remote surveillance center for up to | Nevada Prior Authorization List, Pg 120 Original policy |
| 0379U | Targeted genomic sequence analysis panel, solid organ neoplasm, DNA (523 genes) and RNA (55 genes) by next-generation sequencing, interrogation for sequence variants, gene cop | Nevada Prior Authorization List, Pg 120 Original policy |
| 0388U | Oncology (non-small cell lung cancer), next-generation sequencing with identification of single nucleotide variants, copy number variants, insertions and deletions, and struct | Nevada Prior Authorization List, Pg 120 Original policy |
| 0389U | Pediatric febrile illness (Kawasaki disease [KD]), interferon alpha-inducible protein 27 (IFI27) and mast cell-expressed membrane protein 1 (MCEMP1), RNA, using reverse transc | Nevada Prior Authorization List, Pg 120 Original policy |
| 0390U | Obstetrics (preeclampsia), kinase insert domain receptor (KDR), Endoglin (ENG), and retinol-binding protein 4 (RBP4), by immunoassay, serum, algorithm reported as a risk score | Nevada Prior Authorization List, Pg 120 Original policy |