Anthem Blue Cross and Blue Shield New Hampshire prior authorization, page 40
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 |
|---|---|---|
| 81299 | MSH6 (mutS homolog 6 [E. coli]) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; known familial variants | New Hampshire Precertification List, Pg 165 Original policy |
| 81300 | MSH6 (mutS homolog 6 [E. coli]) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; duplication/deletion variants | New Hampshire Precertification List, Pg 165 Original policy |
| 81301 | Microsatellite instability analysis (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) of markers for mismatch repair deficiency (eg, BAT25, BAT26), includes comparison of neoplastic and normal tissue, if performed | New Hampshire Precertification List, Pg 166 Original policy |
| 81302 | MECP2 (methyl CpG binding protein 2) (eg, Rett syndrome) gene analysis; full sequence analysis | New Hampshire Precertification List, Pg 166 Original policy |
| 81303 | MECP2 (methyl CpG binding protein 2) (eg, Rett syndrome) gene analysis; known familial variant | New Hampshire Precertification List, Pg 166 Original policy |
| 81304 | MECP2 (methyl CpG binding protein 2) (eg, Rett syndrome) gene analysis; duplication/deletion variants | New Hampshire Precertification List, Pg 166 Original policy |
| 81305 | MYD88 (myeloid differentiation primary response 88) (eg, Waldenstrom's macroglobulinemia, lymphoplasmacytic leukemia) gene analysis, p.Leu265Pro (L265P) variant | New Hampshire Precertification List, Pg 166 Original policy |
| 81306 | NUDT15 (nudix hydrolase 15) (eg, drug metabolism) gene analysis, common variant(s) (eg, *2, *3, *4, *5, *6) | New Hampshire Precertification List, Pg 166 Original policy |
| 81307 | PALB2 (partner and localizer of BRCA2) (eg, breast and pancreatic cancer) gene analysis; full gene sequence | New Hampshire Precertification List, Pg 166 Original policy |
| 81308 | PALB2 (partner and localizer of BRCA2) (eg, breast and pancreatic cancer) gene analysis; known familial variant | New Hampshire Precertification List, Pg 166 Original policy |
| 81309 | PIK3CA (phosphatidylinositol-4, 5- biphosphate 3-kinase, catalytic subunit alpha) (eg, colorectal and breast cancer) gene analysis, targeted sequence analysis (eg, exons 7, 9, 20) | New Hampshire Precertification List, Pg 166 Original policy |
| 81310 | NPM1 (nucleophosmin) (eg, acute myeloid leukemia) gene analysis, exon 12 variants | New Hampshire Precertification List, Pg 166 Original policy |
| 81311 | NRAS (neuroblastoma RAS viral [v-ras] oncogene homolog) (eg, colorectal carcinoma), gene analysis, variants in exon 2 (eg, codons 12 and 13) and exon 3 (eg, codon 61) | New Hampshire Precertification List, Pg 166 Original policy |
| 81312 | PABPN1 (poly[A] binding protein nuclear 1) (eg, oculopharyngeal muscular dystrophy) gene analysis, evaluation to detect abnormal (eg, expanded) alleles | New Hampshire Precertification List, Pg 166 Original policy |
| 81313 | PCA3/KLK3 (prostate cancer antigen 3 [non-protein coding]/kallikrein-related peptidase 3 [prostate specific antigen]) ratio (eg, prostate cancer) | New Hampshire Precertification List, Pg 166 Original policy |
| 81314 | PDGFRA (platelet-derived growth factor receptor, alpha polypeptide) (eg, gastrointestinal stromal tumor [GIST]), gene analysis, targeted sequence analysis (eg, exons 12, 18) | New Hampshire Precertification List, Pg 167 Original policy |
| 81315 | PML/RARalpha, (t(15;17)), (promyelocytic leukemia/retinoic acid receptor alpha) (eg, promyelocytic leukemia) translocation analysis; common breakpoints (eg, intron 3 and intron 6), qualitative or quantitative | New Hampshire Precertification List, Pg 167 Original policy |
| 81316 | PML/RARalpha, (t(15;17)), (promyelocytic leukemia/retinoic acid receptor alpha) (eg, promyelocytic leukemia) translocation analysis; single breakpoint (eg, intron 3, intron 6 or exon 6), qualitative or quantitative | New Hampshire Precertification List, Pg 167 Original policy |
| 81317 | PMS2 (postmeiotic segregation increased 2 [S. cerevisiae]) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; full sequence analysis | New Hampshire Precertification List, Pg 167 Original policy |
| 81318 | PMS2 (postmeiotic segregation increased 2 [S. cerevisiae]) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; known familial variants | New Hampshire Precertification List, Pg 167 Original policy |
| 81319 | PMS2 (postmeiotic segregation increased 2 [S. cerevisiae]) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; duplication/deletion variants | New Hampshire Precertification List, Pg 167 Original policy |
| 81320 | PLCG2 (phospholipase C gamma 2) (eg, chronic lymphocytic leukemia) gene analysis, common variants (eg, R665W, S707F, L845F) | New Hampshire Precertification List, Pg 167 Original policy |
| 81321 | PTEN (phosphatase and tensin homolog) (eg, Cowden syndrome, PTEN hamartoma tumor syndrome) gene analysis; full sequence analysis | New Hampshire Precertification List, Pg 167 Original policy |
| 81322 | PTEN (phosphatase and tensin homolog) (eg, Cowden syndrome, PTEN hamartoma tumor syndrome) gene analysis; known familial variant | New Hampshire Precertification List, Pg 167 Original policy |
| 81323 | PTEN (phosphatase and tensin homolog) (eg, Cowden syndrome, PTEN hamartoma tumor syndrome) gene analysis; duplication/deletion variant | New Hampshire Precertification List, Pg 167 Original policy |
| 81324 | PMP22 (peripheral myelin protein 22) (eg, Charcot-Marie-Tooth, hereditary neuropathy with liability to pressure palsies) gene analysis; duplication/deletion analysis | New Hampshire Precertification List, Pg 167 Original policy |
| 81325 | PMP22 (peripheral myelin protein 22) (eg, Charcot-Marie-Tooth, hereditary neuropathy with liability to pressure palsies) gene analysis; full sequence analysis | New Hampshire Precertification List, Pg 168 Original policy |
| 81326 | PMP22 (peripheral myelin protein 22) (eg, Charcot-Marie-Tooth, hereditary neuropathy with liability to pressure palsies) gene analysis; known familial variant | New Hampshire Precertification List, Pg 168 Original policy |
| 81327 | SEPT9 (Septin9) (eg, colorectal cancer) promoter methylation analysis | New Hampshire Precertification List, Pg 168 Original policy |
| 81328 | SLCO1B1 (solute carrier organic anion transporter family, member 1B1) (eg, adverse drug reaction), gene analysis, common variant(s) (eg, *5) | New Hampshire Precertification List, Pg 168 Original policy |
| 81329 | SMN1 (survival of motor neuron 1, telomeric) (eg, spinal muscular atrophy) gene analysis; dosage/deletion analysis (eg, carrier testing), includes SMN2 (survival of motor neuron 2, centromeric) analysis, if performed | New Hampshire Precertification List, Pg 168 Original policy |
| 81330 | SMPD1(sphingomyelin phosphodiesterase 1, acid lysosomal) (eg, Niemann-Pick disease, Type A) gene analysis, common variants (eg, R496L, L302P, fsP330) | New Hampshire Precertification List, Pg 168 Original policy |
| 81331 | SNRPN/UBE3A (small nuclear ribonucleoprotein polypeptide N and ubiquitin protein ligase E3A) (eg, Prader- Willi syndrome and/or Angelman syndrome), methylation analysis | New Hampshire Precertification List, Pg 168 Original policy |
| 81332 | SERPINA1 (serpin peptidase inhibitor, clade A, alpha-1 antiproteinase, antitrypsin, member 1) (eg, alpha-1- antitrypsin deficiency), gene analysis, common variants (eg, *S and *Z) | New Hampshire Precertification List, Pg 168 Original policy |
| 81333 | TGFBI (transforming growth factor beta- induced) (eg, corneal dystrophy) gene analysis, common variants (eg, R124H, R124C, R124L, R555W, R555Q) | New Hampshire Precertification List, Pg 168 Original policy |
| 81334 | RUNX1 (runt related transcription factor 1) (eg, acute myeloid leukemia, familial platelet disorder with associated myeloid malignancy), gene analysis, targeted sequence analysis (eg, exons 3-8) | New Hampshire Precertification List, Pg 168 Original policy |
| 81335 | TPMT (thiopurine S-methyltransferase) (eg, drug metabolism), gene analysis, common variants (eg, *2, *3) | New Hampshire Precertification List, Pg 168 Original policy |
| 81336 | SMN1 (survival of motor neuron 1, telomeric) (eg, spinal muscular atrophy) gene analysis; full gene sequence | New Hampshire Precertification List, Pg 169 Original policy |
| 81337 | SMN1 (survival of motor neuron 1, telomeric) (eg, spinal muscular atrophy) gene analysis; known familial sequence variant(s) | New Hampshire Precertification List, Pg 169 Original policy |
| 81338 | MPL (MPL proto-oncogene, thrombopoietin receptor) (eg, myeloproliferative disorder) gene analysis; common variants (eg, W515A, W515K, W515L, W515R) | New Hampshire Precertification List, Pg 169 Original policy |
| 81339 | MPL (MPL proto-oncogene, thrombopoietin receptor) (eg, myeloproliferative disorder) gene analysis; sequence analysis, exon 10 | New Hampshire Precertification List, Pg 169 Original policy |
| 81340 | TRB@ (T cell antigen receptor, beta) (eg, leukemia and lymphoma), gene rearrangement analysis to detect abnormal clonal population(s); using amplification methodology (eg, polymerase chain reaction) | New Hampshire Precertification List, Pg 169 Original policy |
| 81341 | TRB@ (T cell antigen receptor, beta) (eg, leukemia and lymphoma), gene rearrangement analysis to detect abnormal clonal population(s); using direct probe methodology (eg, Southern blot) | New Hampshire Precertification List, Pg 169 Original policy |
| 81342 | TRG@ (T cell antigen receptor, gamma) (eg, leukemia and lymphoma), gene rearrangement analysis, evaluation to detect abnormal clonal population(s) | New Hampshire Precertification List, Pg 169 Original policy |
| 81343 | PPP2R2B (protein phosphatase 2 regulatory subunit Bbeta) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles | New Hampshire Precertification List, Pg 169 Original policy |
| 81344 | TBP (TATA box binding protein) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles | New Hampshire Precertification List, Pg 169 Original policy |
| 81345 | TERT (telomerase reverse transcriptase) (eg, thyroid carcinoma, glioblastoma multiforme) gene analysis, targeted sequence analysis (eg, promoter region) | New Hampshire Precertification List, Pg 169 Original policy |
| 81346 | TYMS (thymidylate synthetase) (eg, 5- fluorouracil/5-FU drug metabolism), gene analysis, common variant(s) (eg, tandem repeat variant) | New Hampshire Precertification List, Pg 169 Original policy |
| 81347 | SF3B1 (splicing factor [3b] subunit B1) (eg, myelodysplastic syndrome/acute myeloid leukemia) gene analysis, common variants (eg, A672T, E622D, L833F, R625C, R625L) | New Hampshire Precertification List, Pg 170 Original policy |
| 81348 | SRSF2 (serine and arginine-rich splicing factor 2) (eg, myelodysplastic syndrome, acute myeloid leukemia) gene analysis, common variants (eg, P95H, P95L) | New Hampshire Precertification List, Pg 170 Original policy |