Anthem Blue Cross and Blue Shield Virginia prior authorization, page 25

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

Prior authorization codes
Code	Description	Source
81167	BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full duplication/deletion analysis (ie, detection of large gene rearrangements)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 32 Original policy
81170	ABL1 (ABL proto-oncogene 1, non-receptor tyrosine kinase) (eg, acquired imatinib tyrosine kinase inhibitor resistance), gene analysis, variants in the kinase domain	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 32 Original policy
81171	AFF2 (ALF transcription elongation factor 2 [FMR2]) (eg, fragile X intellectual disability 2 [FRAXE]) gene analysis; evaluation to detect abnormal (eg, expanded) alleles	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 32 Original policy
81172	AFF2 (ALF transcription elongation factor 2 [FMR2]) (eg, fragile X intellectual disability 2 [FRAXE]) gene analysis; characterization of alleles (eg, expanded size and methyla	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 32 Original policy
81173	AR (androgen receptor) (eg, spinal and bulbar muscular atrophy, Kennedy disease, X chromosome inactivation) gene analysis; full gene sequence	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 32 Original policy
81174	AR (androgen receptor) (eg, spinal and bulbar muscular atrophy, Kennedy disease, X chromosome inactivation) gene analysis; known familial variant	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 32 Original policy
81175	ASXL1 (additional sex combs like 1, transcriptional regulator) (eg, myelodysplastic syndrome, myeloproliferative neoplasms, chronic myelomonocytic leukemia), gene analysis; fu	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 32 Original policy
81176	ASXL1 (additional sex combs like 1, transcriptional regulator) (eg, myelodysplastic syndrome, myeloproliferative neoplasms, chronic myelomonocytic leukemia), gene analysis; ta	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 32 Original policy
81177	ATN1 (atrophin 1) (eg, dentatorubral-pallidoluysian atrophy) gene analysis, evaluation to detect abnormal (eg, expanded) alleles	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 32 Original policy
81178	ATXN1 (ataxin 1) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 32 Original policy
81179	ATXN2 (ataxin 2) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 32 Original policy
81180	ATXN3 (ataxin 3) (eg, spinocerebellar ataxia, Machado-Joseph disease) gene analysis, evaluation to detect abnormal (eg, expanded) alleles	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 32 Original policy
81181	ATXN7 (ataxin 7) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 32 Original policy
81182	ATXN8OS (ATXN8 opposite strand [non-protein coding]) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 32 Original policy
81183	ATXN10 (ataxin 10) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 32 Original policy
81184	CACNA1A (calcium voltage-gated channel subunit alpha1 A) (eg, spinocerebellar ataxia) gene analysis; evaluation to detect abnormal (eg, expanded) alleles	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 32 Original policy
81185	CACNA1A (calcium voltage-gated channel subunit alpha1 A) (eg, spinocerebellar ataxia) gene analysis; full gene sequence	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 32 Original policy
81186	CACNA1A (calcium voltage-gated channel subunit alpha1 A) (eg, spinocerebellar ataxia) gene analysis; known familial variant	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 32 Original policy
81187	CNBP (CCHC-type zinc finger nucleic acid binding protein) (eg, myotonic dystrophy type 2) gene analysis, evaluation to detect abnormal (eg, expanded) alleles	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 32 Original policy
81188	CSTB (cystatin B) (eg, Unverricht-Lundborg disease) gene analysis; evaluation to detect abnormal (eg, expanded) alleles	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 32 Original policy
81189	CSTB (cystatin B) (eg, Unverricht-Lundborg disease) gene analysis; full gene sequence	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 32 Original policy
81190	CSTB (cystatin B) (eg, Unverricht-Lundborg disease) gene analysis; known familial variant(s)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 32 Original policy
81191	NTRK1 (neurotrophic receptor tyrosine kinase 1) (eg, solid tumors) translocation analysis	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 32 Original policy
81192	NTRK2 (neurotrophic receptor tyrosine kinase 2) (eg, solid tumors) translocation analysis	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 32 Original policy
81193	NTRK3 (neurotrophic receptor tyrosine kinase 3) (eg, solid tumors) translocation analysis	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 32 Original policy
81194	NTRK (neurotrophic-tropomyosin receptor tyrosine kinase 1, 2, and 3) (eg, solid tumors) translocation analysis	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 32 Original policy
81195	Cytogenomic analysis, optical genome mapping	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 33 Original policy
81200	Aspa (Aspartoacylase) (Eg, Canavan Disease) Gene Analysis, Common Variants (Eg, E285A, Y231X)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 33 Original policy
81201	APC (adenomatous polyposis coli) (eg, familial adenomatosis polyposis [FAP], attenuated FAP) gene analysis; full gene sequence	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 33 Original policy
81202	APC (adenomatous polyposis coli) (eg, familial adenomatosis polyposis [FAP], attenuated FAP) gene analysis; known familial variants	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 33 Original policy
81203	APC (adenomatous polyposis coli) (eg, familial adenomatosis polyposis [FAP], attenuated FAP) gene analysis; duplication/deletion variants	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 33 Original policy
81204	AR (androgen receptor) (eg, spinal and bulbar muscular atrophy, Kennedy disease, X chromosome inactivation) gene analysis; characterization of alleles (eg, expanded size or me	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 33 Original policy
81205	Bckdhb (Branched-Chain Keto Acid Dehydrogenase E1, Beta Polypeptide) (Eg, Maple Syrup Urine Disease) Gene Analysis, Common Variants (Eg, R183P, G278S, E422X)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 33 Original policy
81206	Bcr/Abl1 (T(9;22)) (Eg, Chronic Myelogenous Leukemia) Translocation Analysis; Major Breakpoint, Qualitative Or Quantitative	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 33 Original policy
81207	Bcr/Abl1 (T(9;22)) (Eg, Chronic Myelogenous Leukemia) Translocation Analysis; Minor Breakpoint, Qualitative Or Quantitative	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 33 Original policy
81208	Bcr/Abl1 (T(9;22)) (Eg, Chronic Myelogenous Leukemia) Translocation Analysis; Other Breakpoint, Qualitative Or Quantitative	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 33 Original policy
81209	Blm (Bloom Syndrome, Recq Helicase-Like) (Eg, Bloom Syndrome) Gene Analysis, 2281Del6Ins7 Variant	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 33 Original policy
81210	Braf (V-Raf Murine Sarcoma Viral Oncogene Homolog B1) (Eg, Colon Cancer), Gene Analysis, V600E Variant	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 33 Original policy
81212	BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; 185delAG, 5385insC, 6174delT variants	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 33 Original policy
81215	BRCA1 (BRCA1, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; known familial variant	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 33 Original policy
81216	BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 33 Original policy
81217	BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; known familial variant	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 33 Original policy
81218	CEBPA (CCAAT/enhancer binding protein [C/EBP], alpha) (eg, acute myeloid leukemia), gene analysis, full gene sequence	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 33 Original policy
81219	CALR (calreticulin) (eg, myeloproliferative disorders), gene analysis, common variants in exon 9	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 33 Original policy
81220	Cftr (Cystic Fibrosis Transmembrane Conductance Regulator) (Eg, Cystic Fibrosis) Gene Analysis; Common Variants (Eg, Acmg/Acog Guidelines)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 33 Original policy
81221	Cftr (Cystic Fibrosis Transmembrane Conductance Regulator) (Eg, Cystic Fibrosis) Gene Analysis; Known Familial Variants	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 33 Original policy
81222	Cftr (Cystic Fibrosis Transmembrane Conductance Regulator) (Eg, Cystic Fibrosis) Gene Analysis; Duplication/Deletion Variants	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 33 Original policy
81223	Cftr (Cystic Fibrosis Transmembrane Conductance Regulator) (Eg, Cystic Fibrosis) Gene Analysis; Full Gene Sequence	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 33 Original policy
81224	Cftr (Cystic Fibrosis Transmembrane Conductance Regulator) (Eg, Cystic Fibrosis) Gene Analysis; Intron 8 Poly-T Analysis (Eg, Male Infertility)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 33 Original policy
81225	Cyp2C19 (Cytochrome P450, Family 2, Subfamily C, Polypeptide 19) (Eg, Drug Metabolism), Gene Analysis, Common Variants (Eg, 2, 3, 4, 8, *17)	Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 33 Original policy

Sources

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