Anthem Blue Cross and Blue Shield New Hampshire prior authorization, page 7
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 |
|---|---|---|
| 0270U | Hematology (congenital coagulation disorders), genomic sequence analysis of 20 genes, blood, buccal swab, or amniotic fluid | New Hampshire Precertification List, Pg 37 Original policy |
| 0271T | Revision or removal of carotid sinus baroreflex activation device; pulse generator only (includes intra-operative interrogation, programming, and repositioning, when performed) | New Hampshire Precertification List, Pg 37 Original policy |
| 0271U | Hematology (congenital neutropenia), genomic sequence analysis of 23 genes, blood, buccal swab, or amniotic fluid | New Hampshire Precertification List, Pg 37 Original policy |
| 0272T | Interrogation device evaluation (in person), carotid sinus baroreflex activation system, including telemetric iterative communication with the implantable device to monitor device diagnostics and programmed therapy values, with interpretation and report (eg, battery status, lead impedance, pulse amplitude, pulse width, therapy frequency, pathway mode, burst mode, therapy start/stop times each day) | New Hampshire Precertification List, Pg 37 Original policy |
| 0272U | Hematology (genetic bleeding disorders), genomic sequence analysis of 51 genes, blood, buccal swab, or amniotic fluid, comprehensive | New Hampshire Precertification List, Pg 37 Original policy |
| 0273T | Interrogation device evaluation (in person), carotid sinus baroreflex activation system, including telemetric iterative communication with the implantable device to monitor device diagnostics and programmed therapy values, with interpretation and report (eg, battery status, lead impedance, pulse amplitude, pulse width, therapy frequency, pathway mode, burst mode, therapy start/stop times each day); with programming | New Hampshire Precertification List, Pg 37 Original policy |
| 0273U | Hematology (genetic hyperfibrinolysis, delayed bleeding), analysis of 9 genes (F13A1, F13B, FGA, FGB, FGG, SERPINA1, SERPINE1, SERPINF2 by next-generation sequencing, and PLAU by array comparative genomic hybridization), blood, buccal swab, or amniotic fluid | New Hampshire Precertification List, Pg 38 Original policy |
| 0274T | Percutaneous laminotomy/laminectomy (interlaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy), any method, under indirect image guidance (eg, fluoroscopic, CT), single or multiple levels, unilateral or bilateral; cervical or thoracic | New Hampshire Precertification List, Pg 38 Original policy |
| 0274U | Hematology (genetic platelet disorders), genomic sequence analysis of 43 genes, blood, buccal swab, or amniotic fluid | New Hampshire Precertification List, Pg 38 Original policy |
| 0275T | Percutaneous laminotomy/laminectomy (interlaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy), any method, under indirect image guidance (eg, fluoroscopic, CT), single or multiple levels, unilateral or bilateral; lumbar | New Hampshire Precertification List, Pg 38 Original policy |
| 0276U | Hematology (inherited thrombocytopenia), genomic sequence analysis of 23 genes, blood, buccal swab, or amniotic fluid | New Hampshire Precertification List, Pg 38 Original policy |
| 0277U | Hematology (genetic platelet function disorder), genomic sequence analysis of 31 genes, blood, buccal swab, or amniotic fluid | New Hampshire Precertification List, Pg 38 Original policy |
| 0278T | Transcutaneous electrical modulation pain reprocessing (eg, scrambler therapy), each treatment session (includes placement of electrodes) | New Hampshire Precertification List, Pg 38 Original policy |
| 0278U | Hematology (genetic thrombosis), genomic sequence analysis of 12 genes, blood, buccal swab, or amniotic fluid | New Hampshire Precertification List, Pg 38 Original policy |
| 0285U | Oncology, response to radiation, cell-free DNA, quantitative branched chain DNA amplification, plasma, reported as a radiation toxicity score | New Hampshire Precertification List, Pg 38 Original policy |
| 0286U | CEP72 (centrosomal protein, 72-KDa), NUDT15 (nudix hydrolase 15) and TPMT (thiopurine S-methyltransferase) (eg, drug metabolism) gene analysis, common variants | New Hampshire Precertification List, Pg 38 Original policy |
| 0287U | Oncology (thyroid), DNA and mRNA, next- generation sequencing analysis of 112 genes, fine needle aspirate or formalin- fixed paraffin-embedded (FFPE) tissue, algorithmic prediction of cancer recurrence, reported as a categorical risk result (low, intermediate, high) | New Hampshire Precertification List, Pg 39 Original policy |
| 0288U | Oncology (lung), mRNA, quantitative PCR analysis of 11 genes (BAG1, BRCA1, CDC6, CDK2AP1, ERBB3, FUT3, IL11, LCK, RND3, SH3BGR, WNT3A) and 3 reference genes (ESD, TBP, YAP1), formalin-fixed paraffin- embedded (FFPE) tumor tissue, algorithmic interpretation reported as a recurrence risk score | New Hampshire Precertification List, Pg 39 Original policy |
| 0289U | Neurology (Alzheimer disease), mRNA, gene expression profiling by RNA sequencing of 24 genes, whole blood, algorithm reported as predictive risk score | New Hampshire Precertification List, Pg 39 Original policy |
| 0290U | Pain management, mRNA, gene expression profiling by RNA sequencing of 36 genes, whole blood, algorithm reported as predictive risk score | New Hampshire Precertification List, Pg 39 Original policy |
| 0291U | Psychiatry (mood disorders), mRNA, gene expression profiling by RNA sequencing of 144 genes, whole blood, algorithm reported as predictive risk score | New Hampshire Precertification List, Pg 39 Original policy |
| 0292U | Psychiatry (stress disorders), mRNA, gene expression profiling by RNA sequencing of 72 genes, whole blood, algorithm reported as predictive risk score | New Hampshire Precertification List, Pg 39 Original policy |
| 0293U | Psychiatry (suicidal ideation), mRNA, gene expression profiling by RNA sequencing of 54 genes, whole blood, algorithm reported as predictive risk score | New Hampshire Precertification List, Pg 39 Original policy |
| 0294U | Longevity and mortality risk, mRNA, gene expression profiling by RNA sequencing of 18 genes, whole blood, algorithm reported as predictive risk score | New Hampshire Precertification List, Pg 39 Original policy |
| 0296U | Oncology (oral and/or oropharyngeal cancer), gene expression profiling by RNA sequencing of at least 20 molecular features (eg, human and/or microbial mRNA), saliva, algorithm reported as positive or negative for signature associated with malignancy | New Hampshire Precertification List, Pg 39 Original policy |
| 0297U | Oncology (pan tumor), whole genome sequencing of paired malignant and normal DNA specimens, fresh or formalin- fixed paraffin-embedded (FFPE) tissue, blood or bone marrow, comparative sequence analyses and variant identification | New Hampshire Precertification List, Pg 40 Original policy |
| 0298U | Oncology (pan tumor), whole transcriptome sequencing of paired malignant and normal RNA specimens, fresh or formalin-fixed paraffin-embedded (FFPE) tissue, blood or bone marrow, comparative sequence analyses and expression level and chimeric transcript identification | New Hampshire Precertification List, Pg 40 Original policy |
| 0299U | Oncology (pan tumor), whole genome optical genome mapping of paired malignant and normal DNA specimens, fresh frozen tissue, blood, or bone marrow, comparative structural variant identification | New Hampshire Precertification List, Pg 40 Original policy |
| 0300U | Oncology (pan tumor), whole genome sequencing and optical genome mapping of paired malignant and normal DNA specimens, fresh tissue, blood, or bone marrow, comparative sequence analyses and variant identification | New Hampshire Precertification List, Pg 40 Original policy |
| 0306U | Oncology (minimal residual disease [MRD]), next-generation targeted sequencing analysis, cell-free DNA, initial (baseline) assessment to determine a patient-specific panel for future comparisons to evaluate for MRD | New Hampshire Precertification List, Pg 40 Original policy |
| 0307U | Oncology (minimal residual disease [MRD]), next-generation targeted sequencing analysis of a patient-specific panel, cell-free DNA, subsequent assessment with comparison to previously analyzed patient specimens to evaluate for MRD | New Hampshire Precertification List, Pg 40 Original policy |
| 0308T | Insertion of ocular telescope prosthesis including removal of crystalline lens or intraocular lens prosthesis | New Hampshire Precertification List, Pg 40 Original policy |
| 0312U | Autoimmune diseases (eg, systemic lupus erythematosus [SLE]), analysis of 8 IgG autoantibodies and 2 cell-bound complement activation products using enzyme-linked immunosorbent immunoassay (ELISA), flow cytometry and indirect immunofluorescence, serum, or plasma and whole blood, individual components reported along with an algorithmic SLE-likelihood assessment | New Hampshire Precertification List, Pg 41 Original policy |
| 0313U | Oncology (pancreas), DNA and mRNA next-generation sequencing analysis of 74 genes and analysis of CEA (CEACAM5) gene expression, pancreatic cyst fluid, algorithm reported as a categorical result (ie, negative, low probability of neoplasia or positive, high probability of neoplasia) | New Hampshire Precertification List, Pg 41 Original policy |
| 0314U | Oncology (cutaneous melanoma), mRNA gene expression profiling by RT-PCR of 35 genes (32 content and 3 housekeeping), utilizing formalin-fixed paraffin-embedded (FFPE) tissue, algorithm reported as a categorical result (ie, benign, intermediate, malignant) | New Hampshire Precertification List, Pg 41 Original policy |
| 0315U | Oncology (cutaneous squamous cell carcinoma), mRNA gene expression profiling by RT-PCR of 40 genes (34 content and 6 housekeeping), utilizing formalin-fixed paraffin-embedded (FFPE) tissue, algorithm reported as a categorical risk result (ie, Class 1, Class 2A, Class 2B) | New Hampshire Precertification List, Pg 41 Original policy |
| 0318U | Pediatrics (congenital epigenetic disorders), whole genome methylation analysis by microarray for 50 or more genes, blood | New Hampshire Precertification List, Pg 41 Original policy |
| 0319U | Nephrology (renal transplant), RNA expression by select transcriptome sequencing, using pretransplant peripheral blood, algorithm reported as a risk score for early acute rejection | New Hampshire Precertification List, Pg 41 Original policy |
| 0320U | Nephrology (renal transplant), RNA expression by select transcriptome sequencing, using posttransplant peripheral blood, algorithm reported as a risk score for acute cellular rejection | New Hampshire Precertification List, Pg 41 Original policy |
| 0321U | Infectious agent detection by nucleic acid (DNA or RNA), genitourinary pathogens, identification of 20 bacterial and fungal organisms and identification of 16 associated antibiotic-resistance genes, multiplex amplified probe technique | New Hampshire Precertification List, Pg 41 Original policy |
| 0323U | Infectious agent detection by nucleic acid (DNA and RNA), central nervous system pathogen, metagenomic next-generation sequencing, cerebrospinal fluid (CSF), identification of pathogenic bacteria, viruses, parasites, or fungi | New Hampshire Precertification List, Pg 42 Original policy |
| 0326U | Targeted genomic sequence analysis panel, solid organ neoplasm, cell-free circulating DNA analysis of 83 or more genes, interrogation for sequence variants, gene copy number amplifications, gene rearrangements, microsatellite instability and tumor mutational burden | New Hampshire Precertification List, Pg 42 Original policy |
| 0329T | Monitoring of intraocular pressure for 24 hours or longer, unilateral or bilateral, with interpretation and report | New Hampshire Precertification List, Pg 42 Original policy |
| 0329U | Oncology (neoplasia), exome and transcriptome sequence analysis for sequence variants, gene copy number amplifications and deletions, gene rearrangements, microsatellite instability and tumor mutational burden utilizing DNA and RNA from tumor with DNA from normal blood or saliva for subtraction, report of clinically significant mutation(s) with therapy associations | New Hampshire Precertification List, Pg 42 Original policy |
| 0330T | Tear film imaging, unilateral or bilateral, with interpretation and report | New Hampshire Precertification List, Pg 42 Original policy |
| 0331T | Myocardial sympathetic innervation imaging, planar qualitative and quantitative assessment | New Hampshire Precertification List, Pg 42 Original policy |
| 0331U | Oncology (hematolymphoid neoplasia), optical genome mapping for copy number alterations and gene rearrangements utilizing DNA from blood or bone marrow, report of clinically significant alterations | New Hampshire Precertification List, Pg 42 Original policy |
| 0332T | Myocardial sympathetic innervation imaging, planar qualitative and quantitative assessment; with tomographic SPECT | New Hampshire Precertification List, Pg 42 Original policy |
| 0332U | Oncology (pan-tumor), genetic profiling of 8 DNA-regulatory (epigenetic) markers by quantitative polymerase chain reaction (qPCR), whole blood, reported as a high or low probability of responding to immune checkpoint-inhibitor therapy | New Hampshire Precertification List, Pg 42 Original policy |
| 0333U | Oncology (liver), surveillance for hepatocellular carcinoma (HCC) in high- risk patients, analysis of methylation patterns on circulating cell-free DNA (cfDNA) plus measurement of serum of AFP/AFP-L3 and oncoprotein des- gamma-carboxy-prothrombin (DCP), algorithm reported as normal or abnormal result | New Hampshire Precertification List, Pg 43 Original policy |