Anthem Blue Cross and Blue Shield Nevada prior authorization, page 55
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 |
|---|---|---|
| 0391U | Oncology (solid tumor), DNA and RNA by next-generation sequencing, utilizing formalin-fixed paraffin-embedded (FFPE) tissue, 437 genes, interpretive report for single nucleoti | Nevada Prior Authorization List, Pg 120 Original policy |
| 0392U | Drug metabolism (depression, anxiety, attention deficit hyperactivity disorder [ADHD]), gene-drug interactions, variant analysis of 16 genes, including deletion/duplication an | Nevada Prior Authorization List, Pg 121 Original policy |
| 0394U | Perfluoroalkyl substances (PFAS) (eg, perfluorooctanoic acid, perfluorooctane sulfonic acid), 16 PFAS compounds by liquid chromatography with tandem mass spectrometry (LC-MS/M | Nevada Prior Authorization List, Pg 121 Original policy |
| 0400U | Obstetrics (expanded carrier screening), 145 genes by nextgeneration sequencing, fragment analysis and multiplex ligationdependent probe amplification, DNA, reported as carrie | Nevada Prior Authorization List, Pg 121 Original policy |
| 0401U | Cardiology (coronary heart disease [CAD]), 9 genes (12 variants), targeted variant genotyping, blood, saliva, or buccal swab, algorithm reported as a genetic risk score for a | Nevada Prior Authorization List, Pg 121 Original policy |
| 0402T | Collagen cross-linking of cornea, including removal of the corneal epithelium, when performed, and intraoperative pachymetry, when performed | Nevada Prior Authorization List, Pg 121 Original policy |
| 0403U | Oncology (prostate), mRNA, gene expression profiling of 18 genes, first-catch urine, algorithm reported as percentage of likelihood of detecting clinically significant prostat | Nevada Prior Authorization List, Pg 121 Original policy |
| 0405U | Oncology (pancreatic), 59 methylation haplotype block markers, next- generation sequencing, plasma, reported as cancer signal detected or not detected | Nevada Prior Authorization List, Pg 121 Original policy |
| 0407U | Nephrology (diabetic chronic kidney disease [CKD]), multiplex electrochemiluminescent immunoassay (ECLIA) of soluble tumor necrosis factor receptor 1 (sTNFR1), soluble tumor n | Nevada Prior Authorization List, Pg 121 Original policy |
| 0408T | Insertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic pa | Nevada Prior Authorization List, Pg 121 Original policy |
| 0409T | Insertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic pa | Nevada Prior Authorization List, Pg 121 Original policy |
| 0409U | Oncology (solid tumor), DNA (80 genes) and RNA (36 genes), by next-generation sequencing from plasma, including single nucleotide variants, insertions/deletions, copy number a | Nevada Prior Authorization List, Pg 121 Original policy |
| 0410T | Insertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic pa | Nevada Prior Authorization List, Pg 121 Original policy |
| 0410U | Oncology (pancreatic), DNA, whole genome sequencing with 5- hydroxymethylcytosine enrichment, whole blood or plasma, algorithm reported as cancer detected or not detected | Nevada Prior Authorization List, Pg 121 Original policy |
| 0411T | Insertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic pa | Nevada Prior Authorization List, Pg 121 Original policy |
| 0411U | 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 121 Original policy |
| 0412T | Removal of permanent cardiac contractility modulation system; pulse generator only | Nevada Prior Authorization List, Pg 121 Original policy |
| 0412U | Beta amyloid, AB42/40 ratio, immunoprecipitation with quantitation by liquid chromatography with tandem mass spectrometry (LC-MS/MS) and qualitative ApoE isoform-specific prot | Nevada Prior Authorization List, Pg 121 Original policy |
| 0413T | Removal of permanent cardiac contractility modulation system; transvenous electrode (atrial or ventricular) | Nevada Prior Authorization List, Pg 121 Original policy |
| 0413U | Oncology (hematolymphoid neoplasm), optical genome mapping for copy number alterations, aneuploidy, and balanced/complex structural rearrangements, DNA from blood or bone marr | Nevada Prior Authorization List, Pg 121 Original policy |
| 0414T | Removal and replacement of permanent cardiac contractility modulation system pulse generator only | Nevada Prior Authorization List, Pg 121 Original policy |
| 0414U | Oncology (lung), augmentative algorithmic analysis of digitized whole slide imaging for 8 genes (ALK, BRAF, EGFR, ERBB2, MET, NTRK1-3, RET, ROS1), and KRAS G12C and PD-L1, if | Nevada Prior Authorization List, Pg 121 Original policy |
| 0415T | Repositioning of previously implanted cardiac contractility modulation transvenous electrode, (atrial or ventricular lead) | Nevada Prior Authorization List, Pg 121 Original policy |
| 0416T | Relocation of skin pocket for implanted cardiac contractility modulation pulse generator | Nevada Prior Authorization List, Pg 121 Original policy |
| 0417T | Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values | Nevada Prior Authorization List, Pg 122 Original policy |
| 0417U | Rare diseases (constitutional/heritable disorders), whole mitochondrial genome sequence with heteroplasmy detection and deletion analysis, nuclear-encoded mitochondrial gene a | Nevada Prior Authorization List, Pg 122 Original policy |
| 0418T | Interrogation device evaluation (in person) with analysis, review and report, includes connection, recording and disconnection per patient encounter, implantable cardiac contr | Nevada Prior Authorization List, Pg 122 Original policy |
| 0419U | Neuropsychiatry (eg, depression, anxiety), genomic sequence analysis panel, variant analysis of 13 genes, saliva or buccal swab, report of each gene phenotype | Nevada Prior Authorization List, Pg 122 Original policy |
| 0420U | Oncology (urothelial), mRNA expression profiling by real-time quantitative PCR of MDK, HOXA13, CDC2, IGFBP5, and CXCR2 in combination with droplet digital PCR (ddPCR) analysis | Nevada Prior Authorization List, Pg 122 Original policy |
| 0422U | Oncology (pan-solid tumor), analysis of DNA biomarker response to anti-cancer therapy using cell-free circulating DNA, biomarker comparison to a previous baseline pre-treatmen | Nevada Prior Authorization List, Pg 122 Original policy |
| 0423U | Psychiatry (eg, depression, anxiety), genomic analysis panel, including variant analysis of 26 genes, buccal swab, report including metabolizer status and risk of drug toxicit | Nevada Prior Authorization List, Pg 122 Original policy |
| 0424U | Oncology (prostate), exosome-based analysis of 53 small noncoding RNAs (sncRNAs) by quantitative reverse transcription polymerase chain reaction (RT- qPCR), urine, reported as | Nevada Prior Authorization List, Pg 122 Original policy |
| 0425U | Genome (eg, unexplained constitutional or heritable disorder or syndrome), rapid sequence analysis, each comparator genome (eg, parents, siblings) | Nevada Prior Authorization List, Pg 122 Original policy |
| 0426U | Genome (eg, unexplained constitutional or heritable disorder or syndrome), ultra-rapid sequence analysis | Nevada Prior Authorization List, Pg 122 Original policy |
| 0430U | Gastroenterology, malabsorption evaluation of alpha-1-antitrypsin, calprotectin, pancreatic elastase and reducing substances, feces, quantitative | Nevada Prior Authorization List, Pg 122 Original policy |
| 0433U | Oncology (prostate), 5 DNA regulatory markers by quantitative PCR, whole blood, algorithm, including prostate-specific antigen, reported as likelihood of cancer | Nevada Prior Authorization List, Pg 122 Original policy |
| 0434U | Drug metabolism (adverse drug reactions and drug response), genomic analysis panel, variant analysis of 25 genes with reported phenotypes | Nevada Prior Authorization List, Pg 122 Original policy |
| 0435U | Oncology, chemotherapeutic drug cytotoxicity assay of cancer stem cells (CSCs), from cultured CSCs and primary tumor cells, categorical drug response reported based on cytotox | Nevada Prior Authorization List, Pg 122 Original policy |
| 0437U | Psychiatry (anxiety disorders), mRNA, gene expression profiling by RNA sequencing of 15 biomarkers, whole blood, algorithm reported as predictive risk score | Nevada Prior Authorization List, Pg 122 Original policy |
| 0438U | Drug metabolism (adverse drug reactions and drug response), buccal specimen, gene-drug interactions, variant analysis of 33 genes, including deletion/duplication analysis of C | Nevada Prior Authorization List, Pg 122 Original policy |
| 0439U | Cardiology (coronary heart disease [CHD]), DNA, analysis of 5 single-nucleotide polymorphisms (SNPs) (rs11716050 [LOC105376934], rs6560711 [WDR37], rs3735222 [SCIN/LOC10798676 | Nevada Prior Authorization List, Pg 122 Original policy |
| 0440T | Ablation, percutaneous, cryoablation, includes imaging guidance; upper extremity distal/peripheral nerve | Nevada Prior Authorization List, Pg 122 Original policy |
| 0440U | Cardiology (coronary heart disease [CHD]), DNA, analysis of 10 single-nucleotide polymorphisms (SNPs) (rs710987 [LINC010019], rs1333048 [CDKN2B-AS1], rs12129789 [KCND3], rs942 | Nevada Prior Authorization List, Pg 122 Original policy |
| 0441T | Ablation, percutaneous, cryoablation, includes imaging guidance; lower extremity distal/peripheral nerve | Nevada Prior Authorization List, Pg 122 Original policy |
| 0442T | Ablation, percutaneous, cryoablation, includes imaging guidance; nerve plexus or other truncal nerve (eg, brachial plexus, pudendal nerve) | Nevada Prior Authorization List, Pg 122 Original policy |
| 0444U | Oncology (solid organ neoplasia), targeted genomic sequence analysis panel of 361 genes, interrogation for gene fusions, translocations, or other rearrangements, using DNA fro | Nevada Prior Authorization List, Pg 122 Original policy |
| 0445U | B-amyloid (Abeta42) and phospho tau (181P) (pTau181), electrochemiluminescent immunoassay (ECLIA), cerebral spinal fluid, ratio reported as positive or negative for amyloid pa | Nevada Prior Authorization List, Pg 123 Original policy |
| 0449T | Insertion of aqueous drainage device, without extraocular reservoir, internal approach, into the subconjunctival space; initial device | Nevada Prior Authorization List, Pg 123 Original policy |
| 0449U | Carrier screening for severe inherited conditions (eg, cystic fibrosis, spinal muscular atrophy, beta hemoglobinopathies [including sickle cell disease], alpha thalassemia), r | Nevada Prior Authorization List, Pg 123 Original policy |
| 0450T | Insertion of aqueous drainage device, without extraocular reservoir, internal approach, into the subconjunctival space; each additional device (List separately in addition to | Nevada Prior Authorization List, Pg 123 Original policy |