Anthem Blue Cross and Blue Shield Virginia prior authorization
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 |
|---|---|---|
| 0001U | Red blood cell antigen typing, DNA, human erythrocyte antigen gene analysis of 35 antigens from 11 blood groups, utilizing whole blood, common RBC alleles reported | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 2 Original policy |
| 0002M | Liver disease, ten biochemical assays (ALT, A2-macroglobulin, apolipoprotein A-1, total bilirubin, GGT, haptoglobin, AST, glucose, total cholesterol and triglycerides) utilizi | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 2 Original policy |
| 0003M | Liver disease, ten biochemical assays (ALT, A2-macroglobulin, apolipoprotein A-1, total bilirubin, GGT, haptoglobin, AST, glucose, total cholesterol and triglycerides) utilizi | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 2 Original policy |
| 0005U | Oncology (prostate) gene expression profile by real-time RT-PCR of 3 genes (ERG, PCA3, and SPDEF), urine, algorithm reported as risk score | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 2 Original policy |
| 0006M | Oncology (hepatic), mRNA expression levels of 161 genes, utilizing fresh hepatocellular carcinoma tumor tissue, with alpha-fetoprotein level, algorithm reported as a risk clas | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 2 Original policy |
| 0007M | Oncology (gastrointestinal neuroendocrine tumors), real-time PCR expression analysis of 51 genes, utilizing whole peripheral blood, algorithm reported as a nomogram of tumor d | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 2 Original policy |
| 0011M | Oncology, prostate cancer, mRNA expression assay of 12 genes (10 content and 2 housekeeping), RT-PCR test utilizing blood plasma and urine, algorithms to predict high-grade pr | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 2 Original policy |
| 0012M | Oncology (urothelial), mRNA, gene expression profiling by real-time quantitative PCR of five genes (MDK, HOXA13, CDC2 [CDK1], IGFBP5, and XCR2), utilizing urine, algorithm rep | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 2 Original policy |
| 0013M | Oncology (urothelial), mRNA, gene expression profiling by real-time quantitative PCR of five genes (MDK, HOXA13, CDC2 [CDK1], IGFBP5, and CXCR2), utilizing urine, algorithm re | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 2 Original policy |
| 0016M | Oncology (bladder), mRNA, microarray gene expression profiling of 219 genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as molecular subtype (lumina | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 2 Original policy |
| 0016U | Oncology (hematolymphoid neoplasia), RNA, BCR/ABL1 major and minor breakpoint fusion transcripts, quantitative PCR amplification, blood or bone marrow, report of fusion not de | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 2 Original policy |
| 00170 | Anesthesia, Intraoral Proc, W/Bx; Nos | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 2 Original policy |
| 0017M | Oncology (diffuse large B-cell lymphoma [DLBCL]), mRNA, gene expression profiling by fluorescent probe hybridization of 20 genes, formalin-fixed paraffin-embedded tissue, algo | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 2 Original policy |
| 0017U | Oncology (hematolymphoid neoplasia), JAK2 mutation, DNA, PCR amplification of exons 12- 14 and sequence analysis, blood or bone marrow, report of JAK2 mutation not detected or | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 2 Original policy |
| 0018U | Oncology (thyroid), microRNA profiling by RT-PCR of 10 microRNA sequences, utilizing fine needle aspirate, algorithm reported as a positive or negative result for moderate to | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 2 Original policy |
| 0019U | Oncology, RNA, gene expression by whole transcriptome sequencing, formalin-fixed paraffin embedded tissue or fresh frozen tissue, predictive algorithm reported as potential ta | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 2 Original policy |
| 0020M | Oncology (central nervous system), analysis of 30000 DNA methylation loci by methylation array, utilizing DNA extracted from tumor tissue, diagnostic algorithm reported as pro | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 2 Original policy |
| 0022U | Targeted genomic sequence analysis panel, non-small cell lung neoplasia, DNA and RNA analysis, 23 genes, interrogation for sequence variants and rearrangements, reported as pr | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 2 Original policy |
| 0023U | Oncology (acute myelogenous leukemia), DNA, genotyping of internal tandem duplication, p.D835, p.I836, using mononuclear cells, reported as detection or non-detection of FLT3 | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 2 Original policy |
| 0026U | Oncology (thyroid), DNA and mRNA of 112 genes, next-generation sequencing, fine needle aspirate of thyroid nodule, algorithmic analysis reported as a categorical result ('Posi | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 2 Original policy |
| 0027U | JAK2 (Janus kinase 2) (eg, myeloproliferative disorder) gene analysis, targeted sequence analysis exons 12-15 | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 2 Original policy |
| 0030U | Drug metabolism (warfarin drug response), targeted sequence analysis (ie, CYP2C9, CYP4F2, VKORC1, rs12777823) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 2 Original policy |
| 0032U | COMT (catechol-O-methyltransferase)(drug metabolism) gene analysis, c.472G>A (rs4680) variant | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 2 Original policy |
| 0034U | TPMT (thiopurine S-methyltransferase), NUDT15 (nudix hydroxylase 15)(eg, thiopurine metabolism), gene analysis, common variants (ie, TPMT *2, *3A, *3B, *3C, *4, *5, *6, *8, *1 | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 2 Original policy |
| 0036U | Exome (ie, somatic mutations), paired formalin-fixed paraffin-embedded tumor tissue and normal specimen, sequence analyses | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 2 Original policy |
| 0037U | Targeted genomic sequence analysis, solid organ neoplasm, DNA analysis of 324 genes, interrogation for sequence variants, gene copy number amplifications, gene rearrangements | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 2 Original policy |
| 0040U | BCR/ABL1 (t(9;22)) (eg, chronic myelogenous leukemia) translocation analysis, major breakpoint, quantitative | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 2 Original policy |
| 0045U | Oncology (breast ductal carcinoma in situ), mRNA, gene expression profiling by real-time RT- PCR of 12 genes (7 content and 5 housekeeping), utilizing formalin-fixed paraffin-e | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 2 Original policy |
| 0046U | FLT3 (fms-related tyrosine kinase 3) (eg, acute myeloid leukemia) internal tandem duplication (ITD) variants, quantitative | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 2 Original policy |
| 0047U | Oncology (prostate), mRNA, gene expression profiling by real-time RT-PCR of 17 genes (12 content and 5 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algori | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 2 Original policy |
| 0048U | Oncology (solid organ neoplasia), DNA, targeted sequencing of protein-coding exons of 468 cancer-associated genes, including interrogation for somatic mutations and microsatel | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 2 Original policy |
| 0049U | NPM1 (nucleophosmin) (eg, acute myeloid leukemia) gene analysis, quantitative | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 2 Original policy |
| 0050U | Targeted genomic sequence analysis panel, acute myelogenous leukemia, DNA analysis, 194 genes, interrogation for sequence variants, copy number variants or rearrangements | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 2 Original policy |
| 0052U | Lipoprotein, blood, high resolution fractionation and quantitation of lipoproteins, including all five major lipoprotein classes and subclasses of HDL, LDL, and VLDL by vertic | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 2 Original policy |
| 0055U | Cardiology (heart transplant), cell-free DNA, PCR assay of 96 DNA target sequences (94 single nucleotide polymorphism targets and two control targets), plasma | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 2 Original policy |
| 00580 | Anesthesia, Heart Transplant/Heart & Lung Transplant | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 2 Original policy |
| 0069U | Oncology (colorectal), microRNA, RT-PCR expression profiling of miR-31-3p, formalin-fixed paraffin-embedded tissue, algorithm reported as an expression score | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 2 Original policy |
| 0070U | CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, common and select rare variants (ie, *2, *3, *4, *4N, *5, *6, *7, *8, *9, * | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 2 Original policy |
| 0071T | Ultrasound Ablation of Uterine Leioomyomata inc MR Guidance | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 2 Original policy |
| 0071U | CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, full gene sequence (List separately in addition to code for primary procedu | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 2 Original policy |
| 0072T | Ultrasound Ablation of Uterine Leioomyomata inc MR Guidance; Vol>=200 CC | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 2 Original policy |
| 0072U | CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, targeted sequence analysis (ie, CYP2D6-2D7 hybrid gene) (List separately in | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 2 Original policy |
| 0073U | CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, targeted sequence analysis (ie, CYP2D7-2D6 hybrid gene) (List separately in | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 2 Original policy |
| 0074U | CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, targeted sequence analysis (ie, non-duplicated gene when duplication/multip | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 2 Original policy |
| 0075U | CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, targeted sequence analysis (ie, 5 gene duplication/multiplication) (List se | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 2 Original policy |
| 0076U | CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, targeted sequence analysis (ie, 3 gene duplication/ multiplication) (List s | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 2 Original policy |
| 00796 | Anesthesia, Intraperitoneal Proc, Upper Abdomen, W/Laparoscopy; Liver Transplant, Recipient | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 2 Original policy |
| 0079U | Comparative DNA analysis using multiple selected single-nucleotide polymorphisms(SNPs), urine and buccal DNA, for specimen identity verification | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 2 Original policy |
| 0080U | Oncology (lung), mass spectrometric analysis of galectin-3-binding protein and scavenger receptor cysteine-rich type 1 protein M130, with five clinical risk factors (age, smok | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 2 Original policy |
| 00868 | Anesthesia, Extraperitoneal Proc, Lower Abdomen, W/Urinary Tract; Renal Transplant, Recipient | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 2 Original policy |