Anthem Blue Cross and Blue Shield New Hampshire prior authorization, page 8
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 |
|---|---|---|
| 0334U | Oncology (solid organ), targeted genomic sequence analysis, formalin-fixed paraffin- embedded (FFPE) tumor tissue, DNA analysis, 84 or more genes, interrogation for sequence variants, gene copy number amplifications, gene rearrangements, microsatellite instability and tumor mutational burden | New Hampshire Precertification List, Pg 43 Original policy |
| 0335T | Insertion of sinus tarsi implant | New Hampshire Precertification List, Pg 43 Original policy |
| 0335U | Rare diseases (constitutional/heritable disorders), whole genome sequence analysis, including small sequence changes, copy number variants, deletions, duplications, mobile element insertions, uniparental disomy (UPD), inversions, aneuploidy, mitochondrial genome sequence analysis with heteroplasmy and large deletions, short tandem repeat (STR) gene expansions, fetal sample, identification and categorization of genetic variants | New Hampshire Precertification List, Pg 43 Original policy |
| 0336U | Rare diseases (constitutional/heritable disorders), whole genome sequence analysis, including small sequence changes, copy number variants, deletions, duplications, mobile element insertions, uniparental disomy (UPD), inversions, aneuploidy, mitochondrial genome sequence analysis with heteroplasmy and large deletions, short tandem repeat (STR) gene expansions, blood or saliva, identification and categorization of genetic variants, each comparator genome (eg, parent) | New Hampshire Precertification List, Pg 43 Original policy |
| 0337U | Oncology (plasma cell disorders and myeloma), circulating plasma cell immunologic selection, identification, morphological characterization, and enumeration of plasma cells based on differential CD138, CD38, CD19, and CD45 protein biomarker expression, peripheral blood | New Hampshire Precertification List, Pg 43 Original policy |
| 0338T | Transcatheter renal sympathetic denervation, percutaneous approach including arterial puncture, selective catheter placement(s) renal artery(ies), fluoroscopy, contrast injection(s), intraprocedural roadmapping and radiological supervision and interpretation, including pressure gradient measurements, flush aortogram and diagnostic renal angiography when performed; unilateral | New Hampshire Precertification List, Pg 44 Original policy |
| 0338U | Oncology (solid tumor), circulating tumor cell selection, identification, morphological characterization, detection and enumeration based on differential EpCAM, cytokeratins 8, 18, and 19, and CD45 protein biomarkers, and quantification of HER2 protein biomarker- expressing cells, peripheral blood | New Hampshire Precertification List, Pg 44 Original policy |
| 0339T | Transcatheter renal sympathetic denervation, percutaneous approach including arterial puncture, selective catheter placement(s) renal artery(ies), fluoroscopy, contrast injection(s), intraprocedural roadmapping and radiological supervision and interpretation, including pressure gradient measurements, flush aortogram and diagnostic renal angiography when performed; bilateral | New Hampshire Precertification List, Pg 44 Original policy |
| 0339U | Oncology (prostate), mRNA expression profiling of HOXC6 and DLX1, reverse transcription polymerase chain reaction (RT-PCR), first-void urine following digital rectal examination, algorithm reported as probability of high-grade cancer | New Hampshire Precertification List, Pg 44 Original policy |
| 0340U | Oncology (pan-cancer), analysis of minimal residual disease (MRD) from plasma, with assays personalized to each patient based on prior next-generation sequencing of the patient's tumor and germline DNA, reported as absence or presence of MRD, with disease-burden correlation, if appropriate | New Hampshire Precertification List, Pg 44 Original policy |
| 0342T | Therapeutic apheresis with selective HDL delipidation and plasma reinfusion | New Hampshire Precertification List, Pg 44 Original policy |
| 0342U | Oncology (pancreatic cancer), multiplex immunoassay of C5, C4, cystatin C, factor B, osteoprotegerin (OPG), gelsolin, IGFBP3, CA125 and multiplex electrochemiluminescent immunoassay (ECLIA) for CA19-9, serum, diagnostic algorithm reported qualitatively as positive, negative, or borderline | New Hampshire Precertification List, Pg 45 Original policy |
| 0343U | Oncology (prostate), exosome-based analysis of 442 small noncoding RNAs (sncRNAs) by quantitative reverse transcription polymerase chain reaction (RT-qPCR), urine, reported as molecular evidence of no-, low-, intermediate- or high-risk of prostate cancer | New Hampshire Precertification List, Pg 45 Original policy |
| 0344U | Hepatology (nonalcoholic fatty liver disease [NAFLD]), semiquantitative evaluation of 28 lipid markers by liquid chromatography with tandem mass spectrometry (LC-MS/MS), serum, reported as at-risk for nonalcoholic steatohepatitis (NASH) or not NASH | New Hampshire Precertification List, Pg 45 Original policy |
| 0345T | Transcatheter mitral valve repair percutaneous approach via the coronary sinus | New Hampshire Precertification List, Pg 45 Original policy |
| 0345U | Psychiatry (eg, depression, anxiety, attention deficit hyperactivity disorder [ADHD]), genomic analysis panel, variant analysis of 15 genes, including deletion/duplication analysis of CYP2D6 | New Hampshire Precertification List, Pg 45 Original policy |
| 0347T | Placement of interstitial device(s) in bone for radiostereometric analysis (RSA) | New Hampshire Precertification List, Pg 45 Original policy |
| 0347U | Drug metabolism or processing (multiple conditions), whole blood or buccal specimen, DNA analysis, 16 gene report, with variant analysis and reported phenotypes | New Hampshire Precertification List, Pg 45 Original policy |
| 0348T | Radiologic examination, radiostereometric analysis (RSA); spine, (includes, cervical, thoracic and lumbosacral, when performed) | New Hampshire Precertification List, Pg 45 Original policy |
| 0348U | Drug metabolism or processing (multiple conditions), whole blood or buccal specimen, DNA analysis, 25 gene report, with variant analysis and reported phenotypes | New Hampshire Precertification List, Pg 45 Original policy |
| 0349T | Radiologic examination, radiostereometric analysis (RSA); upper extremity(ies), (includes shoulder, elbow and wrist, when performed) | New Hampshire Precertification List, Pg 45 Original policy |
| 0349U | Drug metabolism or processing (multiple conditions), whole blood or buccal specimen, DNA analysis, 27 gene report, with variant analysis, including reported phenotypes and impacted gene-drug interactions | New Hampshire Precertification List, Pg 46 Original policy |
| 0350T | Radiologic examination, radiostereometric analysis (RSA); lower extremity(ies), (includes hip, proximal femur, knee and ankle, when performed) | New Hampshire Precertification List, Pg 46 Original policy |
| 0350U | Drug metabolism or processing (multiple conditions), whole blood or buccal specimen, DNA analysis, 27 gene report, with variant analysis and reported phenotypes | New Hampshire Precertification List, Pg 46 Original policy |
| 0351T | Optical coherence tomography of breast or axillary lymph node, excised tissue, each specimen; real time intraoperative | New Hampshire Precertification List, Pg 46 Original policy |
| 0352T | Optical coherence tomography of breast or axillary lymph node, excised tissue, each specimen; interpretation and report, real time or referred | New Hampshire Precertification List, Pg 46 Original policy |
| 0353T | Optical coherence tomography of breast, surgical cavity; real time intraoperative | New Hampshire Precertification List, Pg 46 Original policy |
| 0354T | Optical coherence tomography of breast, surgical cavity; interpretation and report, real time or referred | New Hampshire Precertification List, Pg 46 Original policy |
| 0355U | APOL1 (apolipoprotein L1) (eg, chronic kidney disease), risk variants (G1, G2) | New Hampshire Precertification List, Pg 46 Original policy |
| 0356U | Oncology (oropharyngeal or anal), evaluation of 17 DNA biomarkers using droplet digital PCR (ddPCR), cell-free DNA, algorithm reported as a prognostic risk score for cancer recurrence | New Hampshire Precertification List, Pg 46 Original policy |
| 0358U | Neurology (mild cognitive impairment), analysis of B-amyloid 1-42 and 1-40, chemiluminescence enzyme immunoassay, cerebral spinal fluid, reported as positive, likely positive, or negative | New Hampshire Precertification List, Pg 46 Original policy |
| 0359U | Oncology (prostate cancer), analysis of all prostate-specific antigen (PSA) structural isoforms by phase separation and immunoassay, plasma, algorithm reports risk of cancer | New Hampshire Precertification List, Pg 46 Original policy |
| 0360U | Oncology (lung), enzyme-linked immunosorbent assay (ELISA) of 7 autoantibodies (p53, NY-ESO-1, CAGE, GBU4-5, SOX2, MAGE A4, and HuD), plasma, algorithm reported as a categorical result for risk of malignancy | New Hampshire Precertification List, Pg 46 Original policy |
| 0361U | Neurofilament light chain, digital immunoassay, plasma, quantitative | New Hampshire Precertification List, Pg 47 Original policy |
| 0362T | Behavior identification supporting assessment, each 15 minutes of technicians' time face-to-face with a patient, requiring the following components: administration by the physician or other qualified health care professional who is on site; with the assistance of two or more technicians; for a patient who exhibits destructive behavior; completion in an environment that is customized to the patient's behavior. | New Hampshire Precertification List, Pg 47 Original policy |
| 0362U | Oncology (papillary thyroid cancer), gene- expression profiling via targeted hybrid capture-enrichment RNA sequencing of 82 content genes and 10 housekeeping genes, fine needle aspirate or formalin- fixed paraffin-embedded (FFPE) tissue, algorithm reported as one of three molecular subtypes | New Hampshire Precertification List, Pg 47 Original policy |
| 0363U | Oncology (urothelial), mRNA, gene- expression profiling by real-time quantitative PCR of 5 genes (MDK, HOXA13, CDC2 [CDK1], IGFBP5, and CXCR2), utilizing urine, algorithm incorporates age, sex, smoking history, and macrohematuria frequency, reported as a risk score for having urothelial carcinoma | New Hampshire Precertification List, Pg 47 Original policy |
| 0364U | Oncology (hematolymphoid neoplasm), genomic sequence analysis using multiplex (PCR) and next-generation sequencing with algorithm, quantification of dominant clonal sequence(s), reported as presence or absence of minimal residual disease (MRD) with quantitation of disease burden, when appropriate | New Hampshire Precertification List, Pg 47 Original policy |
| 0368U | Oncology (colorectal cancer), evaluation for mutations of APC, BRAF, CTNNB1, KRAS, NRAS, PIK3CA, SMAD4, and TP53, and methylation markers (MYO1G, KCNQ5, C9ORF50, FLI1, CLIP4, ZNF132 and TWIST1), multiplex quantitative polymerase chain reaction (qPCR), circulating cell-free DNA (cfDNA), plasma, report of risk score for advanced adenoma or colorectal cancer | New Hampshire Precertification List, Pg 47 Original policy |
| 0369U | Infectious agent detection by nucleic acid (DNA and RNA), gastrointestinal pathogens, 31 bacterial, viral, and parasitic organisms and identification of 21 associated antibiotic-resistance genes, multiplex amplified probe technique | New Hampshire Precertification List, Pg 48 Original policy |
| 0370U | Infectious agent detection by nucleic acid (DNA and RNA), surgical wound pathogens, 34 microorganisms and identification of 21 associated antibiotic- resistance genes, multiplex amplified probe technique, wound swab | New Hampshire Precertification List, Pg 48 Original policy |
| 0372U | Infectious disease (genitourinary pathogens), antibiotic-resistance gene detection, multiplex amplified probe technique, urine, reported as an antimicrobial stewardship risk score | New Hampshire Precertification List, Pg 48 Original policy |
| 0373T | Adaptive behavior treatment with protocol modification, each 15 minutes of technicians' time face-to-face with a patient, requiring the following components: administration by the physician or other qualified health care professional who is on site; with the assistance of two or more technicians; for a patient who exhibits destructive behavior; completion in an environment that is customized to the patient's behavior. | New Hampshire Precertification List, Pg 48 Original policy |
| 0373U | Infectious agent detection by nucleic acid (DNA and RNA), respiratory tract infection, 17 bacteria, 8 fungus, 13 virus, and 16 antibiotic-resistance genes, multiplex amplified probe technique, upper or lower respiratory specimen | New Hampshire Precertification List, Pg 48 Original policy |
| 0374U | Infectious agent detection by nucleic acid (DNA or RNA), genitourinary pathogens, identification of 21 bacterial and fungal organisms and identification of 21 associated antibiotic-resistance genes, multiplex amplified probe technique, urine | New Hampshire Precertification List, Pg 48 Original policy |
| 0376U | Oncology (prostate cancer), image analysis of at least 128 histologic features and clinical factors, prognostic algorithm determining the risk of distant metastases, and prostate cancer-specific mortality, includes predictive algorithm to androgen deprivation-therapy response, if appropriate | New Hampshire Precertification List, Pg 48 Original policy |
| 0377U | Cardiovascular disease, quantification of advanced serum or plasma lipoprotein profile, by nuclear magnetic resonance (NMR) spectrometry with report of a lipoprotein profile (including 23 variables) | New Hampshire Precertification List, Pg 49 Original policy |
| 0378T | Visual field assessment, with concurrent real time data analysis and accessible data storage with patient initiated data transmitted to a remote surveillance center for up to 30 days; review and interpretation with report by a physician or other qualified health care professional | New Hampshire Precertification List, Pg 49 Original policy |
| 0378U | RFC1 (replication factor C subunit 1), repeat expansion variant analysis by traditional and repeat-primed PCR, blood, saliva, or buccal swab | New Hampshire Precertification List, Pg 49 Original policy |
| 0379T | Visual field assessment, with concurrent real time data analysis and accessible data storage with patient initiated data transmitted to a remote surveillance center for up to 30 days; technical support and patient instructions, surveillance, analysis, and transmission of daily and emergent data reports as prescribed by a physician or other qualified health care professional | New Hampshire Precertification List, Pg 49 Original policy |