Anthem Blue Cross and Blue Shield New Hampshire prior authorization, page 38
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 |
|---|---|---|
| 81186 | CACNA1A (calcium voltage-gated channel subunit alpha1 A) (eg, spinocerebellar ataxia) gene analysis; known familial variant | New Hampshire Precertification List, Pg 157 Original policy |
| 81187 | CNBP (CCHC-type zinc finger nucleic acid binding protein) (eg, myotonic dystrophy type 2) gene analysis, evaluation to detect abnormal (eg, expanded) alleles | New Hampshire Precertification List, Pg 157 Original policy |
| 81188 | CSTB (cystatin B) (eg, Unverricht- Lundborg disease) gene analysis; evaluation to detect abnormal (eg, expanded) alleles | New Hampshire Precertification List, Pg 157 Original policy |
| 81189 | CSTB (cystatin B) (eg, Unverricht- Lundborg disease) gene analysis; full gene sequence | New Hampshire Precertification List, Pg 158 Original policy |
| 81190 | CSTB (cystatin B) (eg, Unverricht- Lundborg disease) gene analysis; known familial variant(s) | New Hampshire Precertification List, Pg 158 Original policy |
| 81191 | NTRK1 (neurotrophic receptor tyrosine kinase 1) (eg, solid tumors) translocation analysis | New Hampshire Precertification List, Pg 158 Original policy |
| 81192 | NTRK2 (neurotrophic receptor tyrosine kinase 2) (eg, solid tumors) translocation analysis | New Hampshire Precertification List, Pg 158 Original policy |
| 81193 | NTRK3 (neurotrophic receptor tyrosine kinase 3) (eg, solid tumors) translocation analysis | New Hampshire Precertification List, Pg 158 Original policy |
| 81194 | NTRK (neurotrophic-tropomyosin receptor tyrosine kinase 1, 2, and 3) (eg, solid tumors) translocation analysis | New Hampshire Precertification List, Pg 158 Original policy |
| 81195 | Cytogenomic analysis, optical genome m | New Hampshire Precertification List, Pg 158 Original policy |
| 81200 | ASPA (aspartoacylase) (eg, Canavan disease) gene analysis, common variants (eg, E285A, Y231X) | New Hampshire Precertification List, Pg 158 Original policy |
| 81201 | APC (adenomatous polyposis coli) (eg, familial adenomatosis polyposis [FAP], attenuated FAP) gene analysis; full gene sequence | New Hampshire Precertification List, Pg 158 Original policy |
| 81202 | APC (adenomatous polyposis coli) (eg, familial adenomatosis polyposis [FAP], attenuated FAP) gene analysis; known familial variants | New Hampshire Precertification List, Pg 158 Original policy |
| 81203 | APC (adenomatous polyposis coli) (eg, familial adenomatosis polyposis [FAP], attenuated FAP) gene analysis; duplication/deletion variants | New Hampshire Precertification List, Pg 158 Original policy |
| 81204 | AR (androgen receptor) (eg, spinal and bulbar muscular atrophy, Kennedy disease, X chromosome inactivation) gene analysis; characterization of alleles (eg, expanded size or methylation status) | New Hampshire Precertification List, Pg 158 Original policy |
| 81205 | BCKDHB (branched-chain keto acid dehydrogenase E1, beta polypeptide) (eg, maple syrup urine disease) gene analysis, common variants (eg, R183P, G278S, E422X) | New Hampshire Precertification List, Pg 158 Original policy |
| 81206 | BCR/ABL1 (t(9;22)) (eg, chronic myelogenous leukemia) translocation analysis; major breakpoint, qualitative or quantitative | New Hampshire Precertification List, Pg 158 Original policy |
| 81207 | BCR/ABL1 (t(9;22)) (eg, chronic myelogenous leukemia) translocation analysis; minor breakpoint, qualitative or quantitative | New Hampshire Precertification List, Pg 158 Original policy |
| 81208 | BCR/ABL1 (t(9;22)) (eg, chronic myelogenous leukemia) translocation analysis; other breakpoint, qualitative or quantitative | New Hampshire Precertification List, Pg 159 Original policy |
| 81209 | BLM (Bloom syndrome, RecQ helicase- like) (eg, Bloom syndrome) gene analysis, 2281del6ins7 variant | New Hampshire Precertification List, Pg 159 Original policy |
| 81210 | BRAF (B-Raf proto-oncogene, serine/threonine kinase) (eg, colon cancer, melanoma), gene analysis, V600 variant(s) | New Hampshire Precertification List, Pg 159 Original policy |
| 81212 | BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; 185delAG, 5385insC, 6174delT variants | New Hampshire Precertification List, Pg 159 Original policy |
| 81215 | BRCA1 (BRCA1, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; known familial variant | New Hampshire Precertification List, Pg 159 Original policy |
| 81216 | BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis | New Hampshire Precertification List, Pg 159 Original policy |
| 81217 | BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; known familial variant | New Hampshire Precertification List, Pg 159 Original policy |
| 81218 | CEBPA (CCAAT/enhancer binding protein [C/EBP], alpha) (eg, acute myeloid leukemia), gene analysis, full gene sequence | New Hampshire Precertification List, Pg 159 Original policy |
| 81219 | CALR (calreticulin) (eg, myeloproliferative disorders), gene analysis, common variants in exon 9 | New Hampshire Precertification List, Pg 159 Original policy |
| 81220 | CFTR (cystic fibrosis transmembrane conductance regulator) (eg, cystic fibrosis) gene analysis; common variants (eg, ACMG/ACOG guidelines) | New Hampshire Precertification List, Pg 159 Original policy |
| 81221 | CFTR (cystic fibrosis transmembrane conductance regulator) (eg, cystic fibrosis) gene analysis; known familial variants | New Hampshire Precertification List, Pg 159 Original policy |
| 81222 | CFTR (cystic fibrosis transmembrane conductance regulator) (eg, cystic fibrosis) gene analysis; duplication/deletion variants | New Hampshire Precertification List, Pg 159 Original policy |
| 81223 | CFTR (cystic fibrosis transmembrane conductance regulator) (eg, cystic fibrosis) gene analysis; full gene sequence | New Hampshire Precertification List, Pg 159 Original policy |
| 81224 | CFTR (cystic fibrosis transmembrane conductance regulator) (eg, cystic fibrosis) gene analysis; intron 8 poly-T analysis (eg, male infertility) | New Hampshire Precertification List, Pg 159 Original policy |
| 81225 | Cyp2C19 (Cytochrome P450, Family 2, Subfamily C, Polypeptide 19) (Eg, Drug Metabolism), Gene Analysis, Common Variants (Eg, *2, *3, *4, *8, *17) | New Hampshire Precertification List, Pg 160 Original policy |
| 81226 | CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism), gene analysis, common variants (eg, *2, *3, *4, *5, *6, *9, *10, *17, *19, *29, *35, *41, *1XN, *2XN, *4XN) | New Hampshire Precertification List, Pg 160 Original policy |
| 81227 | Cyp2C9 (Cytochrome P450, Family 2, Subfamily C, Polypeptide 9) (Eg, Drug Metabolism), Gene Analysis, Common Variants (Eg, *2, *3, *5, *6) | New Hampshire Precertification List, Pg 160 Original policy |
| 81228 | Cytogenomic (genome-wide) analysis for constitutional chromosomal abnormalities; interrogation of genomic regions for copy number variants, comparative genomic hybridization [CGH] microarray analysis | New Hampshire Precertification List, Pg 160 Original policy |
| 81229 | Cytogenomic (genome-wide) analysis for constitutional chromosomal abnormalities; interrogation of genomic regions for copy number and single nucleotide polymorphism (SNP) variants, comparative genomic hybridization (CGH) microarray analysis | New Hampshire Precertification List, Pg 160 Original policy |
| 81230 | CYP3A4 (cytochrome P450 family 3 subfamily A member 4) (eg, drug metabolism), gene analysis, common variant(s) (eg, *2, *22) | New Hampshire Precertification List, Pg 160 Original policy |
| 81231 | CYP3A5 (cytochrome P450 family 3 subfamily A member 5) (eg, drug metabolism), gene analysis, common variants (eg, *2, *3, *4, *5, *6, *7) | New Hampshire Precertification List, Pg 160 Original policy |
| 81232 | DPYD (dihydropyrimidine dehydrogenase) (eg, 5-fluorouracil/5-FU and capecitabine drug metabolism), gene analysis, common variant(s) (eg, *2A, *4, *5, *6) | New Hampshire Precertification List, Pg 160 Original policy |
| 81233 | BTK (Bruton's tyrosine kinase) (eg, chronic lymphocytic leukemia) gene analysis, common variants (eg, C481S, C481R, C481F) | New Hampshire Precertification List, Pg 160 Original policy |
| 81234 | DMPK (DM1 protein kinase) (eg, myotonic dystrophy type 1) gene analysis; evaluation to detect abnormal (expanded) alleles | New Hampshire Precertification List, Pg 160 Original policy |
| 81235 | EGFR (epidermal growth factor receptor) (eg, non-small cell lung cancer) gene analysis, common variants (eg, exon 19 LREA deletion, L858R, T790M, G719A, G719S, L861Q) | New Hampshire Precertification List, Pg 160 Original policy |
| 81236 | EZH2 (enhancer of zeste 2 polycomb repressive complex 2 subunit) (eg, myelodysplastic syndrome, myeloproliferative neoplasms) gene analysis, full gene sequence | New Hampshire Precertification List, Pg 161 Original policy |
| 81237 | EZH2 (enhancer of zeste 2 polycomb repressive complex 2 subunit) (eg, diffuse large B-cell lymphoma) gene analysis, common variant(s) (eg, codon 646) | New Hampshire Precertification List, Pg 161 Original policy |
| 81239 | DMPK (DM1 protein kinase) (eg, myotonic dystrophy type 1) gene analysis; characterization of alleles (eg, expanded size) | New Hampshire Precertification List, Pg 161 Original policy |
| 81240 | F2 (prothrombin, coagulation factor II) (eg, hereditary hypercoagulability) gene analysis, 20210G>A variant | New Hampshire Precertification List, Pg 161 Original policy |
| 81241 | F5 (coagulation factor V) (eg, hereditary hypercoagulability) gene analysis, Leiden variant | New Hampshire Precertification List, Pg 161 Original policy |
| 81242 | FANCC (Fanconi anemia, complementation group C) (eg, Fanconi anemia, type C) gene analysis, common variant (eg, IVS4+4A>T) | New Hampshire Precertification List, Pg 161 Original policy |
| 81243 | FMR1 (fragile X messenger ribonucleoprotein 1) (eg, fragile X syndrome, X-linked intellectual disability [XLID]) gene analysis; evaluation to detect abnormal (eg, expanded) alleles | New Hampshire Precertification List, Pg 161 Original policy |