Anthem Blue Cross and Blue Shield New Hampshire prior authorization, page 9
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 |
|---|---|---|
| 0379U | Targeted genomic sequence analysis panel, solid organ neoplasm, DNA (523 genes) and RNA (55 genes) by next- generation sequencing, interrogation for sequence variants, gene copy number amplifications, gene rearrangements, microsatellite instability, and tumor mutational burden | New Hampshire Precertification List, Pg 49 Original policy |
| 0380U | Drug metabolism (adverse drug reactions and drug response), targeted sequence analysis, 20 gene variants and CYP2D6 deletion or duplication analysis with reported genotype and phenotype | New Hampshire Precertification List, Pg 49 Original policy |
| 0388U | Oncology (non-small cell lung cancer), next-generation sequencing with identification of single nucleotide variants, copy number variants, insertions and deletions, and structural variants in 37 cancer-related genes, plasma, with report for alteration detection | New Hampshire Precertification List, Pg 49 Original policy |
| 0389U | Pediatric febrile illness (Kawasaki disease [KD]), interferon alpha-inducible protein 27 (IFI27) and mast cell- expressed membrane protein 1 (MCEMP1), RNA, using quantitative reverse transcription polymerase chain reaction (RT-qPCR), blood, reported as a risk score for KD | New Hampshire Precertification List, Pg 50 Original policy |
| 0390U | Obstetrics (preeclampsia), kinase insert domain receptor (KDR), Endoglin (ENG), and retinol-binding protein 4 (RBP4), by immunoassay, serum, algorithm reported as a risk score | New Hampshire Precertification List, Pg 50 Original policy |
| 0391U | Oncology (solid tumor), DNA and RNA by next-generation sequencing, utilizing formalin-fixed paraffin-embedded (FFPE) tissue, 437 genes, interpretive report for single nucleotide variants, splice-site variants, insertions/deletions, copy number alterations, gene fusions, tumor mutational burden, and microsatellite instability, with algorithm quantifying immunotherapy response score | New Hampshire Precertification List, Pg 50 Original policy |
| 0392U | Drug metabolism (depression, anxiety, attention deficit hyperactivity disorder [ADHD]), gene-drug interactions, variant analysis of 16 genes, including deletion/duplication analysis of CYP2D6, reported as impact of gene-drug interaction for each drug | New Hampshire Precertification List, Pg 50 Original policy |
| 0394U | Perfluoroalkyl substances (PFAS) (eg, perfluorooctanoic acid, perfluorooctane sulfonic acid), 16 PFAS compounds by liquid chromatography with tandem mass spectrometry (LC-MS/M | New Hampshire Precertification List, Pg 50 Original policy |
| 0400U | Obstetrics (expanded carrier screening), 145 genes by next-generation sequencing, fragment analysis and multiplex ligation-dependent probe amplification, DNA, reported as carrier positive or negative | New Hampshire Precertification List, Pg 50 Original policy |
| 0401U | Cardiology (coronary heart disease [CHD]), 9 genes (12 variants), targeted variant genotyping, blood, saliva, or buccal swab, algorithm reported as a genetic risk score for a coronary event | New Hampshire Precertification List, Pg 50 Original policy |
| 0402T | Collagen cross-linking of cornea, including removal of the corneal epithelium, when performed, and intraoperative pachymetry, when performed | New Hampshire Precertification List, Pg 50 Original policy |
| 0403U | Oncology (prostate), mRNA, gene expression profiling of 18 genes, first- catch urine, algorithm reported as percentage of likelihood of detecting clinically significant prostate cancer | New Hampshire Precertification List, Pg 51 Original policy |
| 0405U | Oncology (pancreatic), 59 methylation haplotype block markers, next-generation sequencing, plasma, reported as cancer signal detected or not detected | New Hampshire Precertification List, Pg 51 Original policy |
| 0407U | Nephrology (diabetic chronic kidney disease [CKD]), multiplex electrochemiluminescent immunoassay (ECLIA) of soluble tumor necrosis factor receptor 1 (sTNFR1), soluble tumor necrosis receptor 2 (sTNFR2), and kidney injury molecule 1 (KIM-1) combined with clinical data, plasma, algorithm reported as risk for progressive decline in kidney function | New Hampshire Precertification List, Pg 51 Original policy |
| 0408T | Insertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic parameters; pulse generator with transvenous electrodes | New Hampshire Precertification List, Pg 51 Original policy |
| 0409T | Insertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic parameters; pulse generator only | New Hampshire Precertification List, Pg 51 Original policy |
| 0409U | Oncology (solid tumor), DNA (80 genes) and RNA (36 genes), by next-generation sequencing from plasma, including single nucleotide variants, insertions/deletions, copy number alterations, microsatellite instability, and fusions, report showing identified mutations with clinical actionability | New Hampshire Precertification List, Pg 51 Original policy |
| 0410T | Insertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic parameters; atrial electrode only | New Hampshire Precertification List, Pg 51 Original policy |
| 0410U | Oncology (pancreatic), DNA, whole genome sequencing with 5- hydroxymethylcytosine enrichment, whole blood or plasma, algorithm reported as cancer detected or not detected | New Hampshire Precertification List, Pg 51 Original policy |
| 0411T | Insertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic parameters; ventricular electrode only | New Hampshire Precertification List, Pg 52 Original policy |
| 0411U | 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 52 Original policy |
| 0412T | Removal of permanent cardiac contractility modulation system; pulse generator only | New Hampshire Precertification List, Pg 52 Original policy |
| 0412U | Beta amyloid, AB42/40 ratio, immunoprecipitation with quantitation by liquid chromatography with tandem mass spectrometry (LC-MS/MS) and qualitative ApoE isoform-specific proteotyping, plasma combined with age, algorithm reported as presence or absence of brain amyloid pathology | New Hampshire Precertification List, Pg 52 Original policy |
| 0413T | Removal of permanent cardiac contractility modulation system; transvenous electrode (atrial or ventricular) | New Hampshire Precertification List, Pg 52 Original policy |
| 0413U | Oncology (hematolymphoid neoplasm), optical genome mapping for copy number alterations, aneuploidy, and balanced/complex structural rearrangements, DNA from blood or bone marrow, report of clinically significant alterations | New Hampshire Precertification List, Pg 52 Original policy |
| 0414T | Removal and replacement of permanent cardiac contractility modulation system pulse generator only | New Hampshire Precertification List, Pg 52 Original policy |
| 0414U | Oncology (lung), augmentative algorithmic analysis of digitized whole slide imaging for 8 genes (ALK, BRAF, EGFR, ERBB2, MET, NTRK1-3, RET, ROS1), and KRAS G12C and PD-L1, if performed, formalin-fixed paraffin- embedded (FFPE) tissue, reported as positive or negative for each biomarker | New Hampshire Precertification List, Pg 52 Original policy |
| 0415T | Repositioning of previously implanted cardiac contractility modulation transvenous electrode, (atrial or ventricular lead) | New Hampshire Precertification List, Pg 52 Original policy |
| 0416T | Relocation of skin pocket for implanted cardiac contractility modulation pulse generator | New Hampshire Precertification List, Pg 52 Original policy |
| 0417T | Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, including review and report, implantable cardiac contractility modulation system | New Hampshire Precertification List, Pg 53 Original policy |
| 0417U | Rare diseases (constitutional/heritable disorders), whole mitochondrial genome sequence with heteroplasmy detection and deletion analysis, nuclear-encoded mitochondrial gene analysis of 335 nuclear genes, including sequence changes, deletions, insertions, and copy number variants analysis, blood or saliva, identification and categorization of mitochondrial disorder-associated genetic variants | New Hampshire Precertification List, Pg 53 Original policy |
| 0418T | Interrogation device evaluation (in person) with analysis, review and report, includes connection, recording and disconnection per patient encounter, implantable cardiac contractility modulation system | New Hampshire Precertification List, Pg 53 Original policy |
| 0419U | Neuropsychiatry (eg, depression, anxiety), genomic sequence analysis panel, variant analysis of 13 genes, saliva or buccal swab, report of each gene phenotype | New Hampshire Precertification List, Pg 53 Original policy |
| 0420U | Oncology (urothelial), mRNA expression profiling by real-time quantitative PCR of MDK, HOXA13, CDC2, IGFBP5, and CXCR2 in combination with droplet digital PCR (ddPCR) analysis of 6 single- nucleotide polymorphisms (SNPs) genes TERT and FGFR3, urine, algorithm reported as a risk score for urothelial carcinoma | New Hampshire Precertification List, Pg 53 Original policy |
| 0422U | Oncology (pan-solid tumor), analysis of DNA biomarker response to anti-cancer therapy using cell-free circulating DNA, biomarker comparison to a previous baseline pre-treatment cell-free circulating DNA analysis using next- generation sequencing, algorithm reported as a quantitative change from baseline, including specific alterations, if appropriate | New Hampshire Precertification List, Pg 53 Original policy |
| 0423U | Psychiatry (eg, depression, anxiety), genomic analysis panel, including variant analysis of 26 genes, buccal swab, report including metabolizer status and risk of drug toxicity by condition | New Hampshire Precertification List, Pg 54 Original policy |
| 0424U | Oncology (prostate), exosome-based analysis of 53 small noncoding RNAs (sncRNAs) by quantitative reverse transcription polymerase chain reaction (RT-qPCR), urine, reported as no molecular evidence, low-, moderate- or elevated-risk of prostate cancer | New Hampshire Precertification List, Pg 54 Original policy |
| 0425U | Genome (eg, unexplained constitutional or heritable disorder or syndrome), rapid sequence analysis, each comparator genome (eg, parents, siblings) | New Hampshire Precertification List, Pg 54 Original policy |
| 0426U | Genome (eg, unexplained constitutional or heritable disorder or syndrome), ultra- rapid sequence analysis | New Hampshire Precertification List, Pg 54 Original policy |
| 0428U | Oncology (breast), targeted hybrid- capture genomic sequence analysis panel, circulating tumor DNA (ctDNA) analysis of 56 or more genes, interrogation for sequence variants, gene copy number amplifications, gene rearrangements, microsatellite instability, and tumor mutation burden | New Hampshire Precertification List, Pg 54 Original policy |
| 0430U | Gastroenterology, malabsorption evaluation of alpha-1-antitrypsin, calprotectin, pancreatic elastase and reducing substances, feces, quantitative | New Hampshire Precertification List, Pg 54 Original policy |
| 0433U | Oncology (prostate), 5 DNA regulatory markers by quantitative PCR, whole blood, algorithm, including prostate- specific antigen, reported as likelihood of cancer | New Hampshire Precertification List, Pg 54 Original policy |
| 0434U | Drug metabolism (adverse drug reactions and drug response), genomic analysis panel, variant analysis of 25 genes with reported phenotypes | New Hampshire Precertification List, Pg 54 Original policy |
| 0435U | Oncology, chemotherapeutic drug cytotoxicity assay of cancer stem cells (CSCs), from cultured CSCs and primary tumor cells, categorical drug response reported based on cytotoxicity percentage observed, minimum of 14 drugs or drug combinations | New Hampshire Precertification List, Pg 54 Original policy |
| 0437U | Psychiatry (anxiety disorders), mRNA, gene expression profiling by RNA sequencing of 15 biomarkers, whole blood, algorithm reported as predictive risk score | New Hampshire Precertification List, Pg 55 Original policy |
| 0438U | Drug metabolism (adverse drug reactions and drug response), buccal specimen, gene-drug interactions, variant analysis of 33 genes, including deletion/duplication analysis of CYP2D6, including reported phenotypes and impacted gene-drug interactions | New Hampshire Precertification List, Pg 55 Original policy |
| 0439U | Cardiology (coronary heart disease [CHD] | New Hampshire Precertification List, Pg 55 Original policy |
| 0440T | Ablation, percutaneous, cryoablation, inclu | New Hampshire Precertification List, Pg 55 Original policy |
| 0440U | Cardiology (coronary heart disease [CHD] | New Hampshire Precertification List, Pg 55 Original policy |
| 0441T | Ablation, percutaneous, cryoablation, inclu | New Hampshire Precertification List, Pg 55 Original policy |