Anthem Blue Cross and Blue Shield New Hampshire prior authorization, page 4
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 |
|---|---|---|
| 0049U | NPM1 (nucleophosmin) (eg, acute myeloid leukemia) gene analysis, quantitative | New Hampshire Precertification List, Pg 18 Original policy |
| 0050U | Targeted genomic sequence analysis panel, acute myelogenous leukemia, DNA analysis, 194 genes, interrogation for sequence variants, copy number variants or rearrangements | New Hampshire Precertification List, Pg 18 Original policy |
| 00530 | Anesthesia for permanent transvenous pacemaker insertion | New Hampshire Precertification List, Pg 18 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 | New Hampshire Precertification List, Pg 18 Original policy |
| 00580 | Anesthesia for heart transplant or heart/lung transplant | New Hampshire Precertification List, Pg 18 Original policy |
| 0062U | Autoimmune (systemic lupus erythematosus), IgG and IgM analysis of 80 biomarkers, utilizing serum, algorithm reported with a risk score | New Hampshire Precertification List, Pg 18 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 | New Hampshire Precertification List, Pg 19 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, *10, *11, *12, *13, *14A, *14B, *15, *17, *29, *35, *36, *41, *57, *61, *63, *68, *83, *xN) | New Hampshire Precertification List, Pg 19 Original policy |
| 0071T | Focused ultrasound ablation of uterine leiomyomata, including MR guidance; total leiomyomata volume less than 200 cc of tissue | New Hampshire Precertification List, Pg 19 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 procedure) | New Hampshire Precertification List, Pg 19 Original policy |
| 0072T | Focused ultrasound ablation of uterine leiomyomata, including MR guidance; total leiomyomata volume greater or equal to 200 cc of tissue | New Hampshire Precertification List, Pg 19 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 addition to code for primary procedure) | New Hampshire Precertification List, Pg 19 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 addition to code for primary procedure) | New Hampshire Precertification List, Pg 19 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/multiplication is trans) (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 19 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 separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 19 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 separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 20 Original policy |
| 00796 | Anesthesia for intraperitoneal procedures in upper abdomen including laparoscopy; liver transplant (recipient) | New Hampshire Precertification List, Pg 20 Original policy |
| 0079U | Comparative DNA analysis using multiple selected single-nucleotide polymorphisms (SNPs), urine and buccal DNA, for specimen identity verification | New Hampshire Precertification List, Pg 20 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, smoking status, nodule diameter, nodule-spiculation status and nodule location), utilizing plasma, algorithm reported as a categorical probability of malignancy | New Hampshire Precertification List, Pg 20 Original policy |
| 00868 | Anesthesia for extraperitoneal procedures in lower abdomen, including urinary tract; renal transplant (recipient) | New Hampshire Precertification List, Pg 20 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 probability score | New Hampshire Precertification List, Pg 20 Original policy |
| 0088U | Transplantation medicine (kidney allograft rejection), microarray gene expression profiling of 1494 genes, utilizing transplant biopsy tissue, algorithm reported as a probability score for rejection | New Hampshire Precertification List, Pg 20 Original policy |
| 0089U | Oncology (melanoma), gene expression profiling by RTqPCR, PRAME and LINC00518, superficial collection using adhesive patch(es) | New Hampshire Precertification List, Pg 20 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, algorithm reported as a categorical result (ie, benign, intermediate, malignant) | New Hampshire Precertification List, Pg 20 Original policy |
| 0092U | Oncology (lung), three protein biomarkers, immunoassay using magnetic nanosensor technology, plasma, algorithm reported as risk score for likelihood of malignancy | New Hampshire Precertification List, Pg 21 Original policy |
| 0094U | Genome (eg, unexplained constitutional or heritable disorder or syndrome), rapid sequence analysis | New Hampshire Precertification List, Pg 21 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) | New Hampshire Precertification List, Pg 21 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 primary procedure) | New Hampshire Precertification List, Pg 21 Original policy |
| 0100T | Placement of a subconjunctival retinal prosthesis receiver and pulse generator, and implantation of intra-ocular retinal electrode array, with vitrectomy | New Hampshire Precertification List, Pg 21 Original policy |
| 0101T | Extracorporeal shock wave involving musculoskeletal system, not otherwise specified | New Hampshire Precertification List, Pg 21 Original policy |
| 0101U | Hereditary colon cancer disorders (eg, Lynch syndrome, PTEN hamartoma syndrome, Cowden syndrome, familial adenomatosis polyposis), genomic sequence analysis panel utilizing a combination of NGS, Sanger, MLPA, and array CGH, with mRNA analytics to resolve variants of unknown significance when indicated (15 genes [sequencing and deletion/duplication], EPCAM and GREM1 [deletion/duplication only]) | New Hampshire Precertification List, Pg 21 Original policy |
| 0102T | Extracorporeal shock wave performed by a physician, requiring anesthesia other than local, and involving the lateral humeral epicondyle | New Hampshire Precertification List, Pg 21 Original policy |
| 0102U | Hereditary breast cancer-related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer), genomic sequence analysis panel utilizing a combination of NGS, Sanger, MLPA, and array CGH, with mRNA analytics to resolve variants of unknown significance when indicated (17 genes [sequencing and deletion/duplication]) | New Hampshire Precertification List, Pg 21 Original policy |
| 0103U | Hereditary ovarian cancer (eg, hereditary ovarian cancer, hereditary endometrial cancer), genomic sequence analysis panel utilizing a combination of NGS, Sanger, MLPA, and array CGH, with mRNA analytics to resolve variants of unknown significance when indicated (24 genes [sequencing and deletion/duplication], EPCAM [deletion/duplication only]) | New Hampshire Precertification List, Pg 22 Original policy |
| 0105U | Nephrology (chronic kidney disease), multiplex electrochemiluminescent immunoassay (ECLIA) of tumor necrosis factor receptor 1A, receptor superfamily 2 (TNFR1, TNFR2), and kidney injury molecule-1 (KIM-1) combined with longitudinal clinical data, including APOL1 genotype if available, and plasma (isolated fresh or frozen), algorithm reported as probability score for rapid kidney function decline (RKFD) | New Hampshire Precertification List, Pg 22 Original policy |
| 0106T | Quantitative sensory testing (QST), testing and interpretation per extremity; using touch pressure stimuli to assess large diameter sensation | New Hampshire Precertification List, Pg 22 Original policy |
| 0107T | Quantitative sensory testing (QST), testing and interpretation per extremity; using vibration stimuli to assess large diameter fiber sensation | New Hampshire Precertification List, Pg 22 Original policy |
| 0108T | Quantitative sensory testing (QST), testing and interpretation per extremity; using cooling stimuli to assess small nerve fiber sensation and hyperalgesia | New Hampshire Precertification List, Pg 22 Original policy |
| 0108U | Gastroenterology (Barrett's esophagus), whole slide-digital imaging, including morphometric analysis, computer- assisted quantitative immunolableing of 9 protein biomarkers (p1 | New Hampshire Precertification List, Pg 22 Original policy |
| 0109T | Quantitative sensory testing (QST), testing and interpretation per extremity; using heat-pain stimuli to assess small nerve fiber sensation and hyperalgesia | New Hampshire Precertification List, Pg 22 Original policy |
| 0110T | Quantitative sensory testing (QST), testing and interpretation per extremity; using other stimuli to assess sensation | New Hampshire Precertification List, Pg 22 Original policy |
| 0111U | Oncology (colon cancer), targeted KRAS (codons 12, 13, and 61) and NRAS (codons 12, 13, and 61) gene analysis utilizing formalin-fixed paraffin-embedded tissue | New Hampshire Precertification List, Pg 22 Original policy |
| 0112U | Infectious agent detection and identification, targeted sequence analysis (16S and 18S rRNA genes) with drug- resistance gene | New Hampshire Precertification List, Pg 23 Original policy |
| 0113U | Oncology (prostate), measurement of PCA3 and TMPRSS2-ERG in urine and PSA in serum following prostatic massage, by RNA amplification and fluorescence-based detection, algorithm reported as risk score | New Hampshire Precertification List, Pg 23 Original policy |
| 0117U | Pain management, analysis of 11 endogenous analytes (methylmalonic acid, xanthurenic acid, homocysteine, pyroglutamic acid, vanilmandelate, 5- hydroxyindoleacetic acid, hydroxymethylglutarate, ethylmalonate, 3- hydroxypropyl mercapturic acid (3- HPMA), quinolinic acid, kynurenic acid), LC-MS/MS, urine, algorithm reported as a pain-index score with likelihood of atypical biochemical function associated with pain | New Hampshire Precertification List, Pg 23 Original policy |
| 0118U | Transplantation medicine, quantification of donor-derived cell-free DNA using whole genome next-generation sequencing, plasma, reported as percentage of donor-derived cell-free DNA in the total cell-free DNA | New Hampshire Precertification List, Pg 23 Original policy |
| 0120U | Oncology (B-cell lymphoma classification), mRNA, gene expression profiling by fluorescent probe hybridization of 58 genes (45 content and 13 housekeeping genes), formalin-fixed paraffin-embedded tissue, algorithm reported as likelihood for primary mediastinal B-cell lymphoma (PMBCL) and diffuse large B-cell lymphoma (DLBCL) with cell of origin subtyping in the latter | New Hampshire Precertification List, Pg 23 Original policy |
| 0129U | Hereditary breast cancer-related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer), genomic sequence analysis and deletion/duplication analysis panel (ATM, BRCA1, BRCA2, CDH1, CHEK2, PALB2, PTEN, and TP53) | New Hampshire Precertification List, Pg 23 Original policy |
| 0130U | Hereditary colon cancer disorders (eg, Lynch syndrome, PTEN hamartoma syndrome, Cowden syndrome, familial adenomatosis polyposis), targeted mRNA sequence analysis panel (APC, CDH1, CHEK2, MLH1, MSH2, MSH6, MUTYH, PMS2, PTEN, and TP53) (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 24 Original policy |
| 0131U | Hereditary breast cancer-related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer), targeted mRNA sequence analysis panel (13 genes) (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 24 Original policy |