Anthem Blue Cross and Blue Shield New Hampshire prior authorization, page 6
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 |
|---|---|---|
| 0217T | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; second level (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 30 Original policy |
| 0217U | Neurology (inherited ataxias), genomic DNA sequence analysis of 51 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 |
| 0218T | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 30 Original policy |
| 0218U | Neurology (muscular dystrophy), DMD gene sequence analysis, including small sequence changes, deletions, duplications, and variants in non-uniquely mappable regions, blood or saliva, identification and characterization of genetic variants | New Hampshire Precertification List, Pg 31 Original policy |
| 0219T | Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; cervical | New Hampshire Precertification List, Pg 31 Original policy |
| 0220T | Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; thoracic | New Hampshire Precertification List, Pg 31 Original policy |
| 0221T | Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; lumbar | New Hampshire Precertification List, Pg 31 Original policy |
| 0222T | Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; each additional vertebral segment (List separately in addition to code for primary procedure) | New Hampshire Precertification List, Pg 31 Original policy |
| 0228U | Oncology (prostate), multianalyte molecular profile by photometric detection of macromolecules adsorbed on nanosponge array slides with machine learning, utilizing first morning voided urine, algorithm reported as likelihood of prostate cancer | New Hampshire Precertification List, Pg 31 Original policy |
| 0229U | BCAT1 (Branched chain amino acid transaminase 1) and IKZF1 (IKAROS family zinc finger 1) (eg, colorectal cancer) promoter methylation analysis | New Hampshire Precertification List, Pg 31 Original policy |
| 0230U | AR (androgen receptor) (eg, spinal and bulbar muscular atrophy, Kennedy disease, X chromosome inactivation), full sequence analysis, including small sequence changes in exonic and intronic regions, deletions, duplications, short tandem repeat (STR) expansions, mobile element insertions, and variants in non- uniquely mappable regions | New Hampshire Precertification List, Pg 31 Original policy |
| 0231U | CACNA1A (calcium voltage-gated channel subunit alpha 1A) (eg, spinocerebellar ataxia), full gene analysis, including small sequence changes in exonic and intronic regions, deletions, duplications, short tandem repeat (STR) gene expansions, mobile element insertions, and variants in non- uniquely mappable regions | New Hampshire Precertification List, Pg 32 Original policy |
| 0232T | Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed | New Hampshire Precertification List, Pg 32 Original policy |
| 0232U | CSTB (cystatin B) (eg, progressive myoclonic epilepsy type 1A, Unverricht- Lundborg disease), full gene analysis, including small sequence changes in exonic and intronic regions, deletions, duplications, short tandem repeat (STR) expansions, mobile element insertions, and variants in non-uniquely mappable regions | New Hampshire Precertification List, Pg 32 Original policy |
| 0233U | FXN (frataxin) (eg, Friedreich ataxia), gene analysis, including small sequence changes in exonic and intronic regions, deletions, duplications, short tandem repeat (STR) expansions, mobile element insertions, and variants in non-uniquely mappable regions | New Hampshire Precertification List, Pg 32 Original policy |
| 0234U | MECP2 (methyl CpG binding protein 2) (eg, Rett syndrome), full gene analysis, including small sequence changes in exonic and intronic regions, deletions, duplications, mobile element insertions, and variants in non-uniquely mappable regions | New Hampshire Precertification List, Pg 32 Original policy |
| 0235U | PTEN (phosphatase and tensin homolog) (eg, Cowden syndrome, PTEN hamartoma tumor syndrome), full gene analysis, including small sequence changes in exonic and intronic regions, deletions, duplications, mobile element insertions, and variants in non-uniquely mappable regions | New Hampshire Precertification List, Pg 32 Original policy |
| 0236U | SMN1 (survival of motor neuron 1, telomeric) and SMN2 (survival of motor neuron 2, centromeric) (eg, spinal muscular atrophy) full gene analysis, including small sequence changes in exonic and intronic regions, duplications, deletions, and mobile element insertions | New Hampshire Precertification List, Pg 32 Original policy |
| 0237U | Cardiac ion channelopathies (eg, Brugada syndrome, long QT syndrome, short QT syndrome, catecholaminergic polymorphic ventricular tachycardia), genomic sequence analysis panel including ANK2, CASQ2, CAV3, KCNE1, KCNE2, KCNH2, KCNJ2, KCNQ1, RYR2, and SCN5A, including small sequence changes in exonic and intronic regions, deletions, duplications, mobile element insertions, and variants in non-uniquely mappable regions | New Hampshire Precertification List, Pg 33 Original policy |
| 0238U | Oncology (Lynch syndrome), genomic DNA sequence analysis of MLH1, MSH2, MSH6, PMS2, and EPCAM, including small sequence changes in exonic and intronic regions, deletions, duplications, mobile element insertions, and variants in non-uniquely mappable regions | New Hampshire Precertification List, Pg 33 Original policy |
| 0239U | Targeted genomic sequence analysis panel, solid organ neoplasm, cell-free DNA, analysis of 311 or more genes, interrogation for sequence variants, including substitutions, insertions, deletions, select rearrangements, and copy number variations | New Hampshire Precertification List, Pg 33 Original policy |
| 0242U | Targeted genomic sequence analysis panel, solid organ neoplasm, cell-free circulating DNA analysis of 55-74 genes, interrogation for sequence variants, gene copy number amplifications, and gene rearrangements | New Hampshire Precertification List, Pg 33 Original policy |
| 0243U | Obstetrics (preeclampsia), biochemical assay of placental-growth factor, time- resolved fluorescence immunoassay, maternal serum, predictive algorithm reported as a risk score for preeclampsia | New Hampshire Precertification List, Pg 33 Original policy |
| 0244U | Oncology (solid organ), DNA, comprehensive genomic profiling, 257 genes, interrogation for single-nucleotide variants, insertions/deletions, copy number alterations, gene rearrangements, tumor-mutational burden and microsatellite instability, utilizing formalin-fixed paraffin-embedded tumor tissue | New Hampshire Precertification List, Pg 33 Original policy |
| 0245U | Oncology (thyroid), mutation analysis of 10 genes and 37 RNA fusions and expression of 4 mRNA markers using next-generation sequencing, fine needle aspirate, report includes associated risk of malignancy expressed as a percentage | New Hampshire Precertification List, Pg 34 Original policy |
| 0247U | Obstetrics (preterm birth), insulin-like growth factor-binding protein 4 (IBP4), sex hormone-binding globulin (SHBG), quantitative measurement by LC-MS/MS, utilizing maternal serum, combined with clinical data, reported as predictive-risk stratification for spontaneous preterm birth | New Hampshire Precertification List, Pg 34 Original policy |
| 0248U | Oncology, spheroid cell culture in 3D microenvironment, 12-drug panel, brain- or brain metastasis-response prediction for each drug | New Hampshire Precertification List, Pg 34 Original policy |
| 0249U | Oncology (breast), semiquantitative analysis of 32 phosphoproteins and protein analytes, includes laser capture microdissection, with algorithmic analysis and interpretative report | New Hampshire Precertification List, Pg 34 Original policy |
| 0250U | Oncology (solid organ neoplasm), targeted genomic sequence DNA analysis of 505 genes, interrogation for somatic alterations (SNVs [single nucleotide variant], small insertions and deletions, one amplification, and four translocations), microsatellite instability and tumor-mutation burden | New Hampshire Precertification List, Pg 34 Original policy |
| 0253T | Insertion of anterior segment aqueous drainage device, without extraocular reservoir; internal approach, into the suprachoroidal space | New Hampshire Precertification List, Pg 34 Original policy |
| 0253U | Reproductive medicine (endometrial receptivity analysis), RNA gene expression profile, 238 genes by next- generation sequencing, endometrial tissue, predictive algorithm reported as endometrial window of implantation (eg, pre-receptive, receptive, post- receptive) | New Hampshire Precertification List, Pg 34 Original policy |
| 0254U | Reproductive medicine (preimplantation genetic assessment), analysis of 24 chromosomes using embryonic DNA genomic sequence analysis for aneuploidy, and a mitochondrial DNA score in euploid embryos, results reported as normal (euploidy), monosomy, trisomy, or partial deletion/duplication, mosaicism, and segmental aneuploidy, per embryo tested | New Hampshire Precertification List, Pg 34 Original policy |
| 0255U | Andrology (infertility), sperm-capacitation assessment of ganglioside GM1 distribution patterns, fluorescence microscopy, fresh or frozen specimen, reported as percentage of capacitated sperm and probability of generating a pregnancy score | New Hampshire Precertification List, Pg 35 Original policy |
| 0258U | Autoimmune (psoriasis), mRNA, next- generation sequencing, gene expression profiling of 50-100 genes, skin-surface collection using adhesive patch, algorithm reported as likelihood of response to psoriasis biologics | New Hampshire Precertification List, Pg 35 Original policy |
| 0260U | Rare diseases (constitutional/heritable disorders), identification of copy number variations, inversions, insertions, translocations, and other structural variants by optical genome mapping | New Hampshire Precertification List, Pg 35 Original policy |
| 0262U | Oncology (solid tumor), gene expression profiling by real-time RT-PCR of 7 gene pathways (ER, AR, PI3K, MAPK, HH, TGFB, Notch), formalin-fixed paraffin- embedded (FFPE), algorithm reported as gene pathway activity score | New Hampshire Precertification List, Pg 35 Original policy |
| 0263T | Intramuscular autologous bone marrow cell therapy, with preparation of harvested cells, multiple injections, one leg, including ultrasound guidance, if performed; complete procedure including unilateral or bilateral bone marrow harvest | New Hampshire Precertification List, Pg 35 Original policy |
| 0264T | Intramuscular autologous bone marrow cell therapy, with preparation of harvested cells, multiple injections, one leg, including ultrasound guidance, if performed; complete procedure excluding bone marrow harvest | New Hampshire Precertification List, Pg 35 Original policy |
| 0264U | Rare diseases (constitutional/heritable disorders), identification of copy number variations, inversions, insertions, translocations, and other structural variants by optical genome mapping | New Hampshire Precertification List, Pg 35 Original policy |
| 0265T | Intramuscular autologous bone marrow cell therapy, with preparation of harvested cells, multiple injections, one leg, including ultrasound guidance, if performed; unilateral or bilateral bone marrow harvest only for intramuscular autologous bone marrow cell therapy | New Hampshire Precertification List, Pg 35 Original policy |
| 0265U | Rare constitutional and other heritable disorders, whole genome and mitochondrial DNA sequence analysis, blood, frozen and formalin-fixed paraffin- embedded (FFPE) tissue, saliva, buccal swabs or cell lines, identification of single nucleotide and copy number variants | New Hampshire Precertification List, Pg 36 Original policy |
| 0266T | Implantation or replacement of carotid sinus baroreflex activation device; total system (includes generator placement, unilateral or bilateral lead placement, intra-operative interrogation, programming, and repositioning, when performed) | New Hampshire Precertification List, Pg 36 Original policy |
| 0266U | Unexplained constitutional or other heritable disorders or syndromes, tissue- specific gene expression by whole- transcriptome and next-generation sequencing, blood, formalin-fixed paraffin- embedded (FFPE) tissue or fresh frozen tissue, reported as presence or absence of splicing or expression changes | New Hampshire Precertification List, Pg 36 Original policy |
| 0267T | Implantation or replacement of carotid sinus baroreflex activation device; lead only, unilateral (includes intra-operative interrogation, programming, and repositioning, when performed) | New Hampshire Precertification List, Pg 36 Original policy |
| 0267U | Rare constitutional and other heritable disorders, identification of copy number variations, inversions, insertions, translocations, and other structural variants by optical genome mapping and whole genome sequencing | New Hampshire Precertification List, Pg 36 Original policy |
| 0268T | Implantation or replacement of carotid sinus baroreflex activation device; pulse generator only (includes intra-operative interrogation, programming, and repositioning, when performed) | New Hampshire Precertification List, Pg 36 Original policy |
| 0268U | Hematology (atypical hemolytic uremic syndrome [aHUS]), genomic sequence analysis of 15 genes, blood, buccal swab, or amniotic fluid | New Hampshire Precertification List, Pg 36 Original policy |
| 0269T | Revision or removal of carotid sinus baroreflex activation device; total system (includes generator placement, unilateral or bilateral lead placement, intra- operative interrogation, programming, and repositioning, when performed) | New Hampshire Precertification List, Pg 36 Original policy |
| 0269U | Hematology (autosomal dominant congenital thrombocytopenia), genomic sequence analysis of 22 genes, blood, buccal swab, or amniotic fluid | New Hampshire Precertification List, Pg 37 Original policy |
| 0270T | Revision or removal of carotid sinus baroreflex activation device; lead only, unilateral (includes intra-operative interrogation, programming, and repositioning, when performed) | New Hampshire Precertification List, Pg 37 Original policy |