Anthem Blue Cross and Blue Shield New Hampshire prior authorization, page 42
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 |
|---|---|---|
| 81445 | Solid organ neoplasm, genomic sequence analysis panel, 5-50 genes, interrogation for sequence variants and copy number variants or rearrangements, if performed; DNA analysis or combined DNA and RNA analysis | New Hampshire Precertification List, Pg 176 Original policy |
| 81448 | Hereditary peripheral neuropathies (eg, Charcot-Marie-Tooth, spastic paraplegia), genomic sequence analysis panel, must include sequencing of at least 5 peripheral neuropathy-related genes (eg, BSCL2, GJB1, MFN2, MPZ, REEP1, SPAST, SPG11, SPTLC1) | New Hampshire Precertification List, Pg 177 Original policy |
| 81449 | Solid organ neoplasm, genomic sequence analysis panel, 5-50 genes, interrogation for sequence variants and copy number variants or rearrangements, if performed; RNA analysis | New Hampshire Precertification List, Pg 177 Original policy |
| 81450 | Hematolymphoid neoplasm or disorder, genomic sequence analysis panel, 5-50 genes, interrogation for sequence variants, and copy number variants or rearrangements, or isoform expression or mRNA expression levels, if performed; DNA analysis or combined DNA and RNA analysis | New Hampshire Precertification List, Pg 177 Original policy |
| 81451 | Hematolymphoid neoplasm or disorder, genomic sequence analysis panel, 5-50 genes, interrogation for sequence variants, and copy number variants or rearrangements, or isoform expression or mRNA expression levels, if performed; RNA analysis | New Hampshire Precertification List, Pg 177 Original policy |
| 81455 | Solid organ or hematolymphoid neoplasm or disorder, 51 or greater genes, genomic sequence analysis panel, interrogation for sequence variants and copy number variants or rearrangements, or isoform expression or mRNA expression levels, if performed; DNA analysis or combined DNA and RNA analysis | New Hampshire Precertification List, Pg 177 Original policy |
| 81456 | Solid organ or hematolymphoid neoplasm or disorder, 51 or greater genes, genomic sequence analysis panel, interrogation for sequence variants and copy number variants or rearrangements, or isoform expression or mRNA expression levels, if performed; RNA analysis | New Hampshire Precertification List, Pg 177 Original policy |
| 81457 | Solid organ neoplasm, genomic sequence analysis panel, interrogation for sequence variants; DNA analysis, microsatellite instability | New Hampshire Precertification List, Pg 177 Original policy |
| 81458 | Solid organ neoplasm, genomic sequence analysis panel, interrogation for sequence variants; DNA analysis, copy number variants and microsatellite instability | New Hampshire Precertification List, Pg 177 Original policy |
| 81459 | Solid organ neoplasm, genomic sequence analysis panel, interrogation for sequence variants; DNA analysis or combined DNA and RNA analysis, copy number variants, microsatellite instability, tumor mutation burden, and rearrangements | New Hampshire Precertification List, Pg 178 Original policy |
| 81460 | Whole mitochondrial genome (eg, Leigh syndrome, mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes [MELAS], myoclonic epilepsy with ragged-red fibers [MERFF], neuropathy, ataxia, and retinitis pigmentosa [NARP], Leber hereditary optic neuropathy [LHON]), genomic sequence, must include sequence analysis of entire mitochondrial genome with heteroplasmy detection | New Hampshire Precertification List, Pg 178 Original policy |
| 81462 | Solid organ neoplasm, genomic sequence analysis panel, cell-free nucleic acid (eg, plasma), interrogation for sequence variants; DNA analysis or combined DNA and RNA analysis, copy number variants and rearrangements | New Hampshire Precertification List, Pg 178 Original policy |
| 81463 | Solid organ neoplasm, genomic sequence analysis panel, cell-free nucleic acid (eg, plasma), interrogation for sequence variants; DNA analysis, copy number variants, and microsatellite instability | New Hampshire Precertification List, Pg 178 Original policy |
| 81464 | Solid organ neoplasm, genomic sequence analysis panel, cell-free nucleic acid (eg, plasma), interrogation for sequence variants; DNA analysis or combined DNA and RNA analysis, copy number variants, microsatellite instability, tumor mutation burden, and rearrangements | New Hampshire Precertification List, Pg 178 Original policy |
| 81465 | Whole mitochondrial genome large deletion analysis panel (eg, Kearns-Sayre syndrome, chronic progressive external ophthalmoplegia), including heteroplasmy detection, if performed | New Hampshire Precertification List, Pg 178 Original policy |
| 81470 | X-linked intellectual disability (XLID) (eg, syndromic and non-syndromic XLID); genomic sequence analysis panel, must include sequencing of at least 60 genes, including ARX, ATRX, CDKL5, FGD1, FMR1, HUWE1, IL1RAPL, KDM5C, L1CAM, MECP2, MED12, MID1, OCRL, RPS6KA3, and SLC16A2 | New Hampshire Precertification List, Pg 178 Original policy |
| 81471 | X-linked intellectual disability (XLID) (eg, syndromic and non-syndromic XLID); duplication/deletion gene analysis, must include analysis of at least 60 genes, including ARX, ATRX, CDKL5, FGD1, FMR1, HUWE1, IL1RAPL, KDM5C, L1CAM, MECP2, MED12, MID1, OCRL, RPS6KA3, and SLC16A2 | New Hampshire Precertification List, Pg 179 Original policy |
| 81479 | Unlisted molecular pathology procedure | New Hampshire Precertification List, Pg 179 Original policy |
| 81490 | Autoimmune (rheumatoid arthritis), analysis of 12 biomarkers using immunoassays, utilizing serum, prognostic algorithm reported as a disease activity score | New Hampshire Precertification List, Pg 179 Original policy |
| 81493 | Coronary artery disease, mRNA, gene expression profiling by real-time RT-PCR of 23 genes, utilizing whole peripheral blood, algorithm reported as a risk score | New Hampshire Precertification List, Pg 179 Original policy |
| 81504 | Oncology (tissue of origin), microarray gene expression profiling of > 2000 genes, utilizing formalin-fixed paraffin- embedded tissue, algorithm reported as tissue similarity scores | New Hampshire Precertification List, Pg 179 Original policy |
| 81506 | Endocrinology (type 2 diabetes), biochemical assays of seven analytes (glucose, HbA1c, insulin, hs-CRP, adiponectin, ferritin, interleukin 2- receptor alpha), utilizing serum or plasma, algorithm reporting a risk score | New Hampshire Precertification List, Pg 179 Original policy |
| 81517 | Liver disease, analysis of 3 biomarkers (hyaluronic acid [HA], procollagen III amino terminal peptide [PIIINP], tissue inhibitor of metalloproteinase 1 [TIMP-1]), using immunoassays, utilizing serum, prognostic algorithm reported as a risk score and risk of liver fibrosis and liver- related clinical events within 5 years | New Hampshire Precertification List, Pg 179 Original policy |
| 81518 | Oncology (breast), mRNA, gene expression profiling by real-time RT-PCR of 11 genes (7 content and 4 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithms reported as percentage risk for metastatic recurrence and likelihood of benefit from extended endocrine therapy | New Hampshire Precertification List, Pg 179 Original policy |
| 81519 | Oncology (breast), mRNA, gene expression profiling by real-time RT-PCR of 21 genes, utilizing formalin-fixed paraffin embedded tissue, algorithm reported as recurrence score | New Hampshire Precertification List, Pg 179 Original policy |
| 81520 | Oncology (breast), mRNA gene expression profiling by hybrid capture of 58 genes (50 content and 8 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a recurrence risk score | New Hampshire Precertification List, Pg 180 Original policy |
| 81521 | Oncology (breast), mRNA, microarray gene expression profiling of 70 content genes and 465 housekeeping genes, utilizing fresh frozen or formalin-fixed paraffin-embedded tissue, algorithm reported as index related to risk of distant metastasis | New Hampshire Precertification List, Pg 180 Original policy |
| 81522 | Oncology (breast), mRNA, gene expression profiling by RT-PCR of 12 genes (8 content and 4 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as recurrence risk score | New Hampshire Precertification List, Pg 180 Original policy |
| 81523 | Oncology (breast), mRNA, next- generation sequencing gene expression profiling of 70 content genes and 31 housekeeping genes, utilizing formalin- fixed paraffin-embedded tissue, algorithm reported as index related to risk to distant metastasis | New Hampshire Precertification List, Pg 180 Original policy |
| 81525 | Oncology (colon), mRNA, gene expression profiling by real-time RT-PCR of 12 genes (7 content and 5 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a recurrence score | New Hampshire Precertification List, Pg 180 Original policy |
| 81529 | Oncology (cutaneous melanoma), mRNA, gene expression profiling by real-time RT- PCR of 31 genes (28 content and 3 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as recurrence risk, including likelihood of sentinel lymph node metastasis | New Hampshire Precertification List, Pg 180 Original policy |
| 81535 | Oncology (gynecologic), live tumor cell culture and chemotherapeutic response by DAPI stain and morphology, predictive algorithm reported as a drug response score; first single drug or drug combination | New Hampshire Precertification List, Pg 180 Original policy |
| 81538 | Oncology (lung), mass spectrometric 8- protein signature, including amyloid A, utilizing serum, prognostic and predictive algorithm reported as good versus poor overall survival | New Hampshire Precertification List, Pg 180 Original policy |
| 81540 | Oncology (tumor of unknown origin), mRNA, gene expression profiling by real- time RT-PCR of 92 genes (87 content and 5 housekeeping) to classify tumor into main cancer type and subtype, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a probability of a predicted main cancer type and subtype | New Hampshire Precertification List, Pg 181 Original policy |
| 81541 | Oncology (prostate), mRNA gene expression profiling by real-time RT-PCR of 46 genes (31 content and 15 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a disease-specific mortality risk score | New Hampshire Precertification List, Pg 181 Original policy |
| 81542 | Oncology (prostate), mRNA, microarray gene expression profiling of 22 content genes, utilizing formalin-fixed paraffin- embedded tissue, algorithm reported as metastasis risk score | New Hampshire Precertification List, Pg 181 Original policy |
| 81546 | Oncology (thyroid), mRNA, gene expression analysis of 10,196 genes, utilizing fine needle aspirate, algorithm reported as a categorical result (eg, benign or suspicious) | New Hampshire Precertification List, Pg 181 Original policy |
| 81551 | Oncology (prostate), promoter methylation profiling by real-time PCR of 3 genes (GSTP1, APC, RASSF1), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a likelihood of prostate cancer detection on repeat biopsy | New Hampshire Precertification List, Pg 181 Original policy |
| 81552 | Oncology (uveal melanoma), mRNA, gene expression profiling by real-time RT- PCR of 15 genes (12 content and 3 housekeeping), utilizing fine needle aspirate or formalin-fixed paraffin- embedded tissue, algorithm reported as risk of metastasis | New Hampshire Precertification List, Pg 181 Original policy |
| 81554 | Pulmonary disease (idiopathic pulmonary fibrosis [IPF]), mRNA, gene expression analysis of 190 genes, utilizing transbronchial biopsies, diagnostic algorithm reported as categorical result (eg, positive or negative for high probability of usual interstitial pneumonia [UIP]) | New Hampshire Precertification List, Pg 181 Original policy |
| 81558 | Transplantation medicine (allograft rejectio | New Hampshire Precertification List, Pg 181 Original policy |
| 81560 | Transplantation medicine (allograft rejection, pediatric liver and small bowel), measurement of donor and third-party- induced CD154+T-cytotoxic memory cells, utilizing whole peripheral blood, algorithm reported as a rejection risk score | New Hampshire Precertification List, Pg 182 Original policy |
| 81595 | Cardiology (heart transplant), mRNA, gene expression profiling by real-time quantitative PCR of 20 genes (11 content and 9 housekeeping), utilizing subfraction of peripheral blood, algorithm reported as a rejection risk score | New Hampshire Precertification List, Pg 182 Original policy |
| 81596 | Infectious disease, chronic hepatitis C virus (HCV) infection, six biochemical assays (ALT, A2-macroglobulin, apolipoprotein A-1, total bilirubin, GGT, and haptoglobin) utilizing serum, prognostic algorithm reported as scores for fibrosis and necroinflammatory activity in liver | New Hampshire Precertification List, Pg 182 Original policy |
| 81599 | Unlisted multianalyte assay with algorithmic analysis | New Hampshire Precertification List, Pg 182 Original policy |
| 82233 | Beta-amyloid; 1-40 (Abeta 40) | New Hampshire Precertification List, Pg 182 Original policy |
| 82234 | Beta-amyloid; 1-42 (Abeta 42) | New Hampshire Precertification List, Pg 182 Original policy |
| 82542 | Column Chromatography/Mass Spectrometry; Quantitative, Single Stationary & Mobile Phase | New Hampshire Precertification List, Pg 182 Original policy |
| 82787 | Gammaglobulin (immunoglobulin); immunoglobulin subclasses (eg, IgG1, 2, 3, or 4), each | New Hampshire Precertification List, Pg 182 Original policy |
| 83516 | Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; qualitative or semiquantitative, multiple step method | New Hampshire Precertification List, Pg 182 Original policy |