Anthem Blue Cross and Blue Shield New Hampshire prior authorization, page 5
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 |
|---|---|---|
| 0132U | Hereditary ovarian cancer-related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer), targeted mRNA sequence analysis panel (17 genes) (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 24 Original policy |
| 0134U | Hereditary pan cancer (eg, hereditary breast and ovarian cancer, hereditary endometrial cancer, hereditary colorectal cancer), targeted mRNA sequence analysis panel (18 genes) (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 24 Original policy |
| 0135U | Hereditary gynecological cancer (eg, hereditary breast and ovarian cancer, hereditary endometrial cancer, hereditary colorectal cancer), targeted mRNA sequence analysis panel (12 genes) (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 24 Original policy |
| 0141U | Infectious disease (bacteria and fungi), gram-positive organism identification and drug resistance element detection, DNA (20 gram-positive bacterial targets, 4 resistance genes, 1 pan gram-negative bacterial target, 1 pan Candida target), blood culture, amplified probe technique, each target reported as detected or not detected | New Hampshire Precertification List, Pg 24 Original policy |
| 0142U | Infectious disease (bacteria and fungi), gram-negative bacterial identification and drug resistance element detection, DNA (21 gram-negative bacterial targets, 6 resistance genes, 1 pan gram-positive bacterial target, 1 pan Candida target), amplified probe technique, each target reported as detected or not detected | New Hampshire Precertification List, Pg 24 Original policy |
| 0152U | Infectious disease (bacteria, fungi, parasites, and DNA viruses), microbial cell-free DNA, plasma, untargeted next- generation sequencing, report for significant positive pathogens | New Hampshire Precertification List, Pg 25 Original policy |
| 0153U | Oncology (breast), mRNA, gene expression profiling by next-generation sequencing of 101 genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a triple negative breast cancer clinical subtype(s) with information on immune cell involvement | New Hampshire Precertification List, Pg 25 Original policy |
| 0154U | Oncology (urothelial cancer), RNA, analysis by real-time RT-PCR of the FGFR3 (fibroblast growth factor receptor 3) gene analysis (ie, p.R248C [c.742C>T], p.S249C [c.746C>G], p.G370C [c.1108G>T], p.Y373C [c.1118A>G], FGFR3-TACC3v1, and FGFR3-TACC3v3) utilizing formalin-fixed paraffin-embedded urothelial cancer tumor tissue, reported as FGFR gene alteration status | New Hampshire Precertification List, Pg 25 Original policy |
| 0155U | Oncology (breast cancer), DNA, PIK3CA (phosphatidylinositol-4,5-bisphosphate 3- kinase, catalytic subunit alpha) (eg, breast cancer) gene analysis (ie, p.C420R, p.E542K, p.E545A, p.E545D [g.1635G>T only], p.E545G, p.E545K, p.Q546E, p.Q546R, p.H1047L, p.H1047R, p.H1047Y), utilizing formalin- fixed paraffin-embedded breast tumor tissue, reported as PIK3CA gene mutation status | New Hampshire Precertification List, Pg 25 Original policy |
| 0156U | Copy number (eg, intellectual disability, dysmorphology), sequence analysis | New Hampshire Precertification List, Pg 25 Original policy |
| 0164T | Removal of total disc arthroplasty, (artificial disc), anterior approach, each additional interspace, lumbar (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 25 Original policy |
| 0164U | Gastroenterology (irritable bowel syndrome [IBS]), immunoassay for anti- CdtB and anti-vinculin antibodies, utilizing plasma, algorithm for elevated or not elevated qualitative results | New Hampshire Precertification List, Pg 25 Original policy |
| 0165T | Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, each additional interspace, lumbar (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 25 Original policy |
| 0166U | Liver disease, 10 biochemical assays (a2- macroglobulin, haptoglobin, apolipoprotein A1, bilirubin, GGT, ALT, AST, triglycerides, cholesterol, fasting glucose) and biometric and demographic data, utilizing serum, algorithm reported as scores for fibrosis, necroinflammatory activity, and steatosis with a summary interpretation | New Hampshire Precertification List, Pg 26 Original policy |
| 0169U | NUDT15 (nudix hydrolase 15) and TPMT (thiopurine S-methyltransferase) (eg, drug metabolism) gene analysis, common variants | New Hampshire Precertification List, Pg 26 Original policy |
| 0170U | Neurology (autism spectrum disorder [ASD]), RNA, next-generation sequencing, saliva, algorithmic analysis, and results reported as predictive probability of ASD diagnosis | New Hampshire Precertification List, Pg 26 Original policy |
| 0171U | Targeted genomic sequence analysis panel, acute myeloid leukemia, myelodysplastic syndrome, and myeloproliferative neoplasms, DNA analysis, 23 genes, interrogation for sequence variants, rearrangements and minimal residual disease, reported as presence/absence | New Hampshire Precertification List, Pg 26 Original policy |
| 0172U | Oncology (solid tumor as indicated by the label), somatic mutation analysis of BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) and analysis of homologous recombination deficiency pathways, DNA, formalin-fixed paraffin-embedded tissue, algorithm quantifying tumor genomic instability score | New Hampshire Precertification List, Pg 26 Original policy |
| 0173U | Psychiatry (ie, depression, anxiety), genomic analysis panel, includes variant analysis of 14 genes | New Hampshire Precertification List, Pg 26 Original policy |
| 0174U | Oncology (solid tumor), mass spectrometric 30 protein targets, formalin- fixed paraffin-embedded tissue, prognostic and predictive algorithm reported as likely, unlikely, or uncertain benefit of 39 chemotherapy and targeted therapeutic oncology agents | New Hampshire Precertification List, Pg 26 Original policy |
| 0175U | Psychiatry (eg, depression, anxiety), genomic analysis panel, variant analysis of 15 genes | New Hampshire Precertification List, Pg 26 Original policy |
| 0176U | Cytolethal distending toxin B (CdtB) and vinculin IgG antibodies by immunoassay (ie, ELISA) | New Hampshire Precertification List, Pg 26 Original policy |
| 0177U | Oncology (breast cancer), DNA, PIK3CA (phosphatidylinositol-4,5-bisphosphate 3- kinase catalytic subunit alpha) gene analysis of 11 gene variants utilizing plasma, reported as PIK3CA gene mutation status | New Hampshire Precertification List, Pg 27 Original policy |
| 0179U | Oncology (non-small cell lung cancer), cell-free DNA, targeted sequence analysis of 23 genes (single nucleotide variations, insertions and deletions, fusions without prior knowledge of partner/breakpoint, copy number variations), with report of significant mutation(s) | New Hampshire Precertification List, Pg 27 Original policy |
| 01937 | Anesthesia for percutaneous image- guided injection, drainage or aspiration procedures on the spine or spinal cord; cervical or thoracic | New Hampshire Precertification List, Pg 27 Original policy |
| 01938 | Anesthesia for percutaneous image- guided injection, drainage or aspiration procedures on the spine or spinal cord; lumbar or sacral | New Hampshire Precertification List, Pg 27 Original policy |
| 01939 | Anesthesia for percutaneous image- guided destruction procedures by neurolytic agent on the spine or spinal cord; cervical or thoracic | New Hampshire Precertification List, Pg 27 Original policy |
| 01940 | Anesthesia for percutaneous image- guided destruction procedures by neurolytic agent on the spine or spinal cord; lumbar or sacral | New Hampshire Precertification List, Pg 27 Original policy |
| 01941 | Anesthesia for percutaneous image- guided neuromodulation or intravertebral procedures (eg, kyphoplasty, vertebroplasty) on the spine or spinal cord; cervical or thoracic | New Hampshire Precertification List, Pg 27 Original policy |
| 01942 | Anesthesia for percutaneous image- guided neuromodulation or intravertebral procedures (eg, kyphoplasty, vertebroplasty) on the spine or spinal cord; lumbar or sacral | New Hampshire Precertification List, Pg 27 Original policy |
| 01991 | Anesthesia for diagnostic or therapeutic nerve blocks and injections (when block or injection is performed by a different physician or other qualified health care professional); other than the prone position | New Hampshire Precertification List, Pg 27 Original policy |
| 01992 | Anesthesia for diagnostic or therapeutic nerve blocks and injections (when block or injection is performed by a different physician or other qualified health care professional); prone position | New Hampshire Precertification List, Pg 27 Original policy |
| 0200T | Percutaneous sacral augmentation (sacroplasty), unilateral injection(s), including the use of a balloon or mechanical device, when used, 1 or more needles, includes imaging guidance and bone biopsy, when performed | New Hampshire Precertification List, Pg 28 Original policy |
| 0201T | Percutaneous sacral augmentation (sacroplasty), bilateral injections, including the use of a balloon or mechanical device, when used, 2 or more needles, includes imaging guidance and bone biopsy, when performed | New Hampshire Precertification List, Pg 28 Original policy |
| 0202T | Posterior vertebral joint(s) arthroplasty (eg, facet joint[s] replacement), including facetectomy, laminectomy, foraminotomy, and vertebral column fixation, injection of bone cement, when performed, including fluoroscopy, single level, lumbar spine | New Hampshire Precertification List, Pg 28 Original policy |
| 0203U | Autoimmune (inflammatory bowel disease), mRNA, gene expression profiling by quantitative RT-PCR, 17 genes (15 target and 2 reference genes), whole blood, reported as a continuous risk score and classification of inflammatory bowel disease aggressiveness | New Hampshire Precertification List, Pg 28 Original policy |
| 0205U | Ophthalmology (age-related macular degeneration), analysis of 3 gene variants (2 CFH gene, 1 ARMS2 gene), using PCR and MALDI-TOF, buccal swab, reported as positive or negative for neovascular age-related macular- degeneration risk associated with zinc supplements | New Hampshire Precertification List, Pg 28 Original policy |
| 0206U | Neurology (Alzheimer disease); cell aggregation using morphometric imaging and protein kinase C-epsilon (PKCe) concentration in response to amylospheroid treatment by ELISA, cultured skin fibroblasts, each reported as positive or negative for Alzheimer disease | New Hampshire Precertification List, Pg 28 Original policy |
| 0207T | Evacuation of meibomian glands, automated, using heat and intermittent pressure, unilateral | New Hampshire Precertification List, Pg 28 Original policy |
| 0209U | Cytogenomic constitutional (genome- wide) analysis, interrogation of genomic regions for copy number, structural changes and areas of homozygosity for chromosomal abnormalities | New Hampshire Precertification List, Pg 28 Original policy |
| 0211U | Oncology (pan-tumor), DNA and RNA by next-generation sequencing, utilizing formalin-fixed paraffin-embedded tissue, interpretative report for single nucleotide variants, copy number alterations, tumor mutational burden, and microsatellite instability, with therapy association | New Hampshire Precertification List, Pg 29 Original policy |
| 0212U | Rare diseases (constitutional/heritable disorders), whole genome and mitochondrial DNA sequence analysis, including small sequence changes, deletions, duplications, short tandem repeat gene expansions, and variants in non-uniquely mappable regions, blood or saliva, identification and categorization of genetic variants, proband | New Hampshire Precertification List, Pg 29 Original policy |
| 0213T | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; single level | New Hampshire Precertification List, Pg 29 Original policy |
| 0213U | Rare diseases (constitutional/heritable disorders), whole genome and mitochondrial DNA sequence analysis, including small sequence changes, deletions, duplications, short tandem repeat gene expansions, and variants in non-uniquely mappable regions, blood or saliva, identification and categorization of genetic variants, each comparator genome (eg, parent, sibling) | New Hampshire Precertification List, Pg 29 Original policy |
| 0214T | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; second level (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 29 Original policy |
| 0214U | Rare diseases (constitutional/heritable disorders), whole exome and mitochondrial DNA sequence analysis, including small sequence changes, deletions, duplications, short tandem repeat gene expansions, and variants in non-uniquely mappable regions, blood or saliva, identification and categorization of genetic variants, proband | New Hampshire Precertification List, Pg 29 Original policy |
| 0215T | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; third and any additional level(s) (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 30 Original policy |
| 0215U | Rare diseases (constitutional/heritable disorders), whole exome and mitochondrial DNA sequence analysis, including small sequence changes, deletions, duplications, short tandem repeat gene expansions, and variants in non-uniquely mappable regions, blood or saliva, identification and categorization of genetic variants, each comparator exome (eg, parent, sibling) | New Hampshire Precertification List, Pg 30 Original policy |
| 0216T | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; single level | New Hampshire Precertification List, Pg 30 Original policy |
| 0216U | Neurology (inherited ataxias), genomic DNA sequence analysis of 12 common genes including small sequence changes, deletions, duplications, short tandem repeat gene expansions, and variants in non-uniquely mappable regions, blood or saliva, identification and categorization of genetic variants | New Hampshire Precertification List, Pg 30 Original policy |