Anthem Blue Cross and Blue Shield New Hampshire prior authorization, page 39
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 |
|---|---|---|
| 81244 | FMR1 (fragile X messenger ribonucleoprotein 1) (eg, fragile X syndrome, X-linked intellectual disability [XLID]) gene analysis; characterization of alleles (eg, expanded size and promoter methylation status) | New Hampshire Precertification List, Pg 161 Original policy |
| 81245 | FLT3 (fms-related tyrosine kinase 3) (eg, acute myeloid leukemia), gene analysis; internal tandem duplication (ITD) variants (ie, exons 14, 15) | New Hampshire Precertification List, Pg 161 Original policy |
| 81246 | FLT3 (fms-related tyrosine kinase 3) (eg, acute myeloid leukemia), gene analysis; tyrosine kinase domain (TKD) variants (eg, D835, I836) | New Hampshire Precertification List, Pg 161 Original policy |
| 81247 | G6PD (glucose-6-phosphate dehydrogenase) (eg, hemolytic anemia, jaundice), gene analysis; common variant(s) (eg, A, A-) | New Hampshire Precertification List, Pg 161 Original policy |
| 81248 | G6PD (glucose-6-phosphate dehydrogenase) (eg, hemolytic anemia, jaundice), gene analysis; known familial variant(s) | New Hampshire Precertification List, Pg 161 Original policy |
| 81249 | G6PD (glucose-6-phosphate dehydrogenase) (eg, hemolytic anemia, jaundice), gene analysis; full gene sequence | New Hampshire Precertification List, Pg 162 Original policy |
| 81250 | G6PC (glucose-6-phosphatase, catalytic subunit) (eg, Glycogen storage disease, type 1a, von Gierke disease) gene analysis, common variants (eg, R83C, Q347X) | New Hampshire Precertification List, Pg 162 Original policy |
| 81251 | GBA (glucosidase, beta, acid) (eg, Gaucher disease) gene analysis, common variants (eg, N370S, 84GG, L444P, IVS2+1G>A) | New Hampshire Precertification List, Pg 162 Original policy |
| 81252 | GJB2 (gap junction protein, beta 2, 26kDa, connexin 26) (eg, nonsyndromic hearing loss) gene analysis; full gene sequence | New Hampshire Precertification List, Pg 162 Original policy |
| 81253 | GJB2 (gap junction protein, beta 2, 26kDa; connexin 26) (eg, nonsyndromic hearing loss) gene analysis; known familial variants | New Hampshire Precertification List, Pg 162 Original policy |
| 81254 | GJB6 (gap junction protein, beta 6, 30kDa, connexin 30) (eg, nonsyndromic hearing loss) gene analysis, common variants (eg, 309kb [del(GJB6- D13S1830)] and 232kb [del(GJB6- D13S1854)]) | New Hampshire Precertification List, Pg 162 Original policy |
| 81255 | HEXA (hexosaminidase A [alpha polypeptide]) (eg, Tay-Sachs disease) gene analysis, common variants (eg, 1278insTATC, 1421+1G>C, G269S) | New Hampshire Precertification List, Pg 162 Original policy |
| 81256 | HFE (hemochromatosis) (eg, hereditary hemochromatosis) gene analysis, common variants (eg, C282Y, H63D) | New Hampshire Precertification List, Pg 162 Original policy |
| 81257 | HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia, Hb Bart hydrops fetalis syndrome, HbH disease), gene analysis; common deletions or variant (eg, Southeast Asian, Thai, Filipino, Mediterranean, alpha3.7, alpha4.2, alpha20.5, Constant Spring) | New Hampshire Precertification List, Pg 162 Original policy |
| 81258 | HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia, Hb Bart hydrops fetalis syndrome, HbH disease), gene analysis; known familial variant | New Hampshire Precertification List, Pg 162 Original policy |
| 81259 | HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia, Hb Bart hydrops fetalis syndrome, HbH disease), gene analysis; full gene sequence | New Hampshire Precertification List, Pg 162 Original policy |
| 81260 | IKBKAP (inhibitor of kappa light polypeptide gene enhancer in B-cells, kinase complex-associated protein) (eg, familial dysautonomia) gene analysis, common variants (eg, 2507+6T>C, R696P) | New Hampshire Precertification List, Pg 163 Original policy |
| 81261 | IGH@ (Immunoglobulin heavy chain locus) (eg, leukemias and lymphomas, B- cell), gene rearrangement analysis to detect abnormal clonal population(s); amplified methodology (eg, polymerase chain reaction) | New Hampshire Precertification List, Pg 163 Original policy |
| 81262 | IGH@ (Immunoglobulin heavy chain locus) (eg, leukemias and lymphomas, B- cell), gene rearrangement analysis to detect abnormal clonal population(s); direct probe methodology (eg, Southern blot) | New Hampshire Precertification List, Pg 163 Original policy |
| 81263 | IGH@ (Immunoglobulin heavy chain locus) (eg, leukemia and lymphoma, B- cell), variable region somatic mutation analysis | New Hampshire Precertification List, Pg 163 Original policy |
| 81264 | IGK@ (Immunoglobulin kappa light chain locus) (eg, leukemia and lymphoma, B- cell), gene rearrangement analysis, evaluation to detect abnormal clonal population(s) | New Hampshire Precertification List, Pg 163 Original policy |
| 81265 | Comparative analysis using Short Tandem Repeat (STR) markers; patient and comparative specimen (eg, pre- transplant recipient and donor germline testing, post-transplant non- hematopoietic recipient germline [eg, buccal swab or other germline tissue sample] and donor testing, twin zygosity testing, or maternal cell contamination of fetal cells) | New Hampshire Precertification List, Pg 163 Original policy |
| 81266 | Comparative analysis using Short Tandem Repeat (STR) markers; each additional specimen (eg, additional cord blood donor, additional fetal samples from different cultures, or additional zygosity in multiple birth pregnancies) (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 163 Original policy |
| 81269 | HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia, Hb Bart hydrops fetalis syndrome, HbH disease), gene analysis; duplication/deletion variants | New Hampshire Precertification List, Pg 163 Original policy |
| 81270 | JAK2 (Janus kinase 2) (eg, myeloproliferative disorder) gene analysis, p.Val617Phe (V617F) variant | New Hampshire Precertification List, Pg 163 Original policy |
| 81271 | HTT (huntingtin) (eg, Huntington disease) gene analysis; evaluation to detect abnormal (eg, expanded) alleles | New Hampshire Precertification List, Pg 163 Original policy |
| 81272 | KIT (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog) (eg, gastrointestinal stromal tumor [GIST], acute myeloid leukemia, melanoma), gene analysis, targeted sequence analysis (eg, exons 8, 11, 13, 17, 18) | New Hampshire Precertification List, Pg 164 Original policy |
| 81273 | KIT (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog) (eg, mastocytosis), gene analysis, D816 variant(s) | New Hampshire Precertification List, Pg 164 Original policy |
| 81274 | HTT (huntingtin) (eg, Huntington disease) gene analysis; characterization of alleles (eg, expanded size) | New Hampshire Precertification List, Pg 164 Original policy |
| 81275 | KRAS (Kirsten rat sarcoma viral oncogene homolog) (eg, carcinoma) gene analysis; variants in exon 2 (eg, codons 12 and 13) | New Hampshire Precertification List, Pg 164 Original policy |
| 81276 | KRAS (Kirsten rat sarcoma viral oncogene homolog) (eg, carcinoma) gene analysis; additional variant(s) (eg, codon 61, codon 146) | New Hampshire Precertification List, Pg 164 Original policy |
| 81277 | Cytogenomic neoplasia (genome-wide) microarray analysis, interrogation of genomic regions for copy number and loss-of-heterozygosity variants for chromosomal abnormalities | New Hampshire Precertification List, Pg 164 Original policy |
| 81278 | IGH@/BCL2 (t(14;18)) (eg, follicular lymphoma) translocation analysis, major breakpoint region (MBR) and minor cluster region (mcr) breakpoints, qualitative or quantitative | New Hampshire Precertification List, Pg 164 Original policy |
| 81279 | JAK2 (Janus kinase 2) (eg, myeloproliferative disorder) targeted sequence analysis (eg, exons 12 and 13) | New Hampshire Precertification List, Pg 164 Original policy |
| 81283 | IFNL3 (interferon, lambda 3) (eg, drug response), gene analysis, rs12979860 variant | New Hampshire Precertification List, Pg 164 Original policy |
| 81284 | FXN (frataxin) (eg, Friedreich ataxia) gene analysis; evaluation to detect abnormal (expanded) alleles | New Hampshire Precertification List, Pg 164 Original policy |
| 81285 | FXN (frataxin) (eg, Friedreich ataxia) gene analysis; characterization of alleles (eg, expanded size) | New Hampshire Precertification List, Pg 164 Original policy |
| 81286 | FXN (frataxin) (eg, Friedreich ataxia) gene analysis; full gene sequence | New Hampshire Precertification List, Pg 164 Original policy |
| 81287 | MGMT (O-6-methylguanine-DNA methyltransferase) (eg, glioblastoma multiforme) promoter methylation analysis | New Hampshire Precertification List, Pg 164 Original policy |
| 81288 | MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (eg, hereditary non- polyposis colorectal cancer, Lynch syndrome) gene analysis; promoter methylation analysis | New Hampshire Precertification List, Pg 164 Original policy |
| 81289 | FXN (frataxin) (eg, Friedreich ataxia) gene analysis; known familial variant(s) | New Hampshire Precertification List, Pg 165 Original policy |
| 81290 | MCOLN1 (mucolipin 1) (eg, Mucolipidosis, type IV) gene analysis, common variants (eg, IVS3-2A>G, del6.4kb) | New Hampshire Precertification List, Pg 165 Original policy |
| 81291 | MTHFR (5,10-methylenetetrahydrofolate reductase) (eg, hereditary hypercoagulability) gene analysis, common variants (eg, 677T, 1298C) | New Hampshire Precertification List, Pg 165 Original policy |
| 81292 | MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (eg, hereditary non- polyposis colorectal cancer, Lynch syndrome) gene analysis; full sequence analysis | New Hampshire Precertification List, Pg 165 Original policy |
| 81293 | MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (eg, hereditary non- polyposis colorectal cancer, Lynch syndrome) gene analysis; known familial variants | New Hampshire Precertification List, Pg 165 Original policy |
| 81294 | MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (eg, hereditary non- polyposis colorectal cancer, Lynch syndrome) gene analysis; duplication/deletion variants | New Hampshire Precertification List, Pg 165 Original policy |
| 81295 | MSH2 (mutS homolog 2, colon cancer, nonpolyposis type 1) (eg, hereditary non- polyposis colorectal cancer, Lynch syndrome) gene analysis; full sequence analysis | New Hampshire Precertification List, Pg 165 Original policy |
| 81296 | MSH2 (mutS homolog 2, colon cancer, nonpolyposis type 1) (eg, hereditary non- polyposis colorectal cancer, Lynch syndrome) gene analysis; known familial variants | New Hampshire Precertification List, Pg 165 Original policy |
| 81297 | MSH2 (mutS homolog 2, colon cancer, nonpolyposis type 1) (eg, hereditary non- polyposis colorectal cancer, Lynch syndrome) gene analysis; duplication/deletion variants | New Hampshire Precertification List, Pg 165 Original policy |
| 81298 | MSH6 (mutS homolog 6 [E. coli]) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; full sequence analysis | New Hampshire Precertification List, Pg 165 Original policy |