Anthem Blue Cross and Blue Shield Virginia prior authorization, page 26
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 |
|---|---|---|
| 81226 | Cyp2D6 (Cytochrome P450, Family 2, Subfamily D, Polypeptide 6) (Eg, Drug Metabolism), Gene Analysis, Common Variants (Eg, *2, *3, *4, *5, *6, *9, *10, *17, *19, *29, *35, *41 | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 33 Original policy |
| 81227 | Cyp2C9 (Cytochrome P450, Family 2, Subfamily C, Polypeptide 9) (Eg, Drug Metabolism), Gene Analysis, Common Variants (Eg, *2, *3, *5, *6) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 33 Original policy |
| 81228 | Cytogenomic (genome-wide) analysis for constitutional chromosomal abnormalities; interrogation of genomic regions for copy number variants, comparative genomic hybridization [ | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 33 Original policy |
| 81229 | Cytogenomic (genome-wide) analysis for constitutional chromosomal abnormalities; interrogation of genomic regions for copy number and single nucleotide polymorphism (SNP) vari | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 33 Original policy |
| 81230 | CYP3A4 (cytochrome P450 family 3 subfamily A member 4) (eg, drug metabolism), gene analysis, common variant(s) (eg, *2, *22) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 33 Original policy |
| 81231 | CYP3A5 (cytochrome P450 family 3 subfamily A member 5) (eg, drug metabolism), gene analysis, common variants (eg, *2, *3, *4, *5, *6, *7) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 33 Original policy |
| 81232 | DPYD (dihydropyrimidine dehydrogenase) (eg, 5-fluorouracil/5-FU and capecitabine drug metabolism), gene analysis, common variant(s) (eg, *2A, *4, *5, *6) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 33 Original policy |
| 81233 | BTK (Bruton's tyrosine kinase) (eg, chronic lymphocytic leukemia) gene analysis, common variants (eg, C481S, C481R, C481F) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 33 Original policy |
| 81234 | DMPK (DM1 protein kinase) (eg, myotonic dystrophy type 1) gene analysis; evaluation to detect abnormal (expanded) alleles | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 33 Original policy |
| 81235 | EGFR (epidermal growth factor receptor) (eg, non-small cell lung cancer) gene analysis, common variants (eg, exon 19 LREA deletion, L858R, T790M, G719A, G719S, L861Q) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 33 Original policy |
| 81236 | EZH2 (enhancer of zeste 2 polycomb repressive complex 2 subunit) (eg, myelodysplastic syndrome, myeloproliferative neoplasms) gene analysis, full gene sequence | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 33 Original policy |
| 81237 | EZH2 (enhancer of zeste 2 polycomb repressive complex 2 subunit) (eg, diffuse large B-cell lymphoma) gene analysis, common variant(s) (eg, codon 646) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 33 Original policy |
| 81238 | F9 (coagulation factor IX) (eg, hemophilia B), full gene sequence | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 33 Original policy |
| 81239 | DMPK (DM1 protein kinase) (eg, myotonic dystrophy type 1) gene analysis; characterization of alleles (eg, expanded size) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 33 Original policy |
| 81240 | F2 (Prothrombin, Coagulation Factor Ii) (Eg, Hereditary Hypercoagulability) Gene Analysis, 20210G>A Variant | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 33 Original policy |
| 81241 | F5 (Coagulation Factor V) (Eg, Hereditary Hypercoagulability) Gene Analysis, Leiden Variant | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 33 Original policy |
| 81242 | Fancc (Fanconi Anemia, Complementation Group C) (Eg, Fanconi Anemia, Type C) Gene Analysis, Common Variant (Eg, Ivs4+4A>T) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 33 Original policy |
| 81243 | FMR1 (fragile X messenger ribonucleoprotein 1) (eg, fragile X syndrome, X-linked intellectual disability [XLID]) gene analysis; evaluation to detect abnormal (eg, expanded) al | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 33 Original policy |
| 81244 | FMR1 (fragile X messenger ribonucleoprotein 1) (eg, fragile X syndrome, X-linked intellectual disability [XLID]) gene analysis; characterization of alleles (eg, expanded size | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 33 Original policy |
| 81245 | Flt3 (Fms-Related Tyrosine Kinase 3) (Eg, Acute Myeloid Leukemia), Gene Analysis, Internal Tandem Duplication (Itd) Variants (Ie, Exons 14, 15) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 33 Original policy |
| 81246 | FLT3 (fms-related tyrosine kinase 3) (eg, acute myeloid leukemia), gene analysis; tyrosine kinase domain (TKD) variants (eg, D835, I836) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 33 Original policy |
| 81247 | G6PD (glucose-6-phosphate dehydrogenase) (eg, hemolytic anemia, jaundice), gene analysis; common variant(s) (eg, A, A-) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 33 Original policy |
| 81248 | G6PD (glucose-6-phosphate dehydrogenase) (eg, hemolytic anemia, jaundice), gene analysis; known familial variant(s) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 33 Original policy |
| 81249 | G6PD (glucose-6-phosphate dehydrogenase) (eg, hemolytic anemia, jaundice), gene analysis; full gene sequence | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 33 Original policy |
| 81250 | G6Pc (Glucose-6-Phosphatase, Catalytic Subunit) (Eg, Glycogen Storage Disease, Type 1A, Von Gierke Disease) Gene Analysis, Common Variants (Eg, R83C, Q347X) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 33 Original policy |
| 81251 | Gba (Glucosidase, Beta, Acid) (Eg, Gaucher Disease) Gene Analysis, Common Variants (Eg, N370S, 84Gg, L444P, Ivs2+1G>A) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 33 Original policy |
| 81252 | GJB2 (gap junction protein, beta 2, 26kDa, connexin 26) (eg, nonsyndromic hearing loss) gene analysis; full gene sequence | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 33 Original policy |
| 81253 | GJB2 (gap junction protein, beta 2, 26kDa; connexin 26) (eg, nonsyndromic hearing loss) gene analysis; known familial variants | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 33 Original policy |
| 81254 | GJB6 (gap junction protein, beta 6, 30kDa, connexin 30) (eg, nonsyndromic hearing loss) gene analysis, common variants (eg, 309kb [del(GJB6-D13S1830)] and 232kb [del(GJB6-D13S | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 33 Original policy |
| 81255 | Hexa (Hexosaminidase A [Alpha Polypeptide]) (Eg, Tay-Sachs Disease) Gene Analysis, Common Variants (Eg, 1278Instatc, 1421+1G>C, G269S) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 33 Original policy |
| 81256 | Hfe (Hemochromatosis) (Eg, Hereditary Hemochromatosis) Gene Analysis, Common Variants (Eg, C282Y, H63D) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 33 Original policy |
| 81257 | HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia, Hb Bart hydrops fetalis syndrome, HbH disease), gene analysis; common deletions or variant (eg, Southeast | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 33 Original policy |
| 81258 | HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia, Hb Bart hydrops fetalis syndrome, HbH disease), gene analysis; known familial variant | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 34 Original policy |
| 81259 | HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia, Hb Bart hydrops fetalis syndrome, HbH disease), gene analysis; full gene sequence | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 34 Original policy |
| 81260 | Ikbkap (Inhibitor Of Kappa Light Polypeptide Gene Enhancer In B-Cells, Kinase Complex- Associated Protein) (Eg, Familial Dysautonomia) Gene Analysis, Common Variants (Eg, 2507+ | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 34 Original policy |
| 81261 | Igh@ (Immunoglobulin Heavy Chain Locus) (Eg, Leukemias And Lymphomas, B-Cell), Gene Rearrangement Analysis To Detect Abnormal Clonal Population(S); Amplified Methodology (Eg | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 34 Original policy |
| 81262 | Igh@ (Immunoglobulin Heavy Chain Locus) (Eg, Leukemias And Lymphomas, B-Cell), Gene Rearrangement Analysis To Detect Abnormal Clonal Population(S); Direct Probe Methodology (E | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 34 Original policy |
| 81263 | Igh@ (Immunoglobulin Heavy Chain Locus) (Eg, Leukemia And Lymphoma, B-Cell), Variable Region Somatic Mutation Analysis | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 34 Original policy |
| 81264 | Igk@ (Immunoglobulin Kappa Light Chain Locus) (Eg, Leukemia And Lymphoma, B-Cell), Gene Rearrangement Analysis, Evaluation To Detect Abnormal Clonal Population(S) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 34 Original policy |
| 81265 | Comparative Analysis Using Short Tandem Repeat (Str) Markers; Patient And Comparative Specimen (Eg, Pre-Transplant Recipient And Donor Germline Testing, Post-Transplant Non-He | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 34 Original policy |
| 81266 | Comparative Analysis Using Short Tandem Repeat (Str) Markers; Each Additional Specimen (Eg, Additional Cord Blood Donor, Additional Fetal Samples From Different Cultures, Or A | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 34 Original policy |
| 81267 | Chimerism (Engraftment) Analysis, Post Transplantation Specimen (Eg, Hematopoietic Stem Cell), Includes Comparison To Previously Performed Baseline Analyses; Without Cell Sele | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 34 Original policy |
| 81268 | Chimerism (Engraftment) Analysis, Post Transplantation Specimen (Eg, Hematopoietic Stem Cell), Includes Comparison To Previously Performed Baseline Analyses; With Cell Selecti | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 34 Original policy |
| 81269 | HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia, Hb Bart hydrops fetalis syndrome, HbH disease), gene analysis; duplication/deletion variants | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 34 Original policy |
| 81270 | Jak2 (Janus Kinase 2) (Eg, Myeloproliferative Disorder) Gene Analysis, P.Val617Phe (V617F) Variant | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 34 Original policy |
| 81271 | HTT (huntingtin) (eg, Huntington disease) gene analysis; evaluation to detect abnormal (eg, expanded) alleles | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 34 Original policy |
| 81272 | KIT (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog) (eg, gastrointestinal stromal tumor [GIST], acute myeloid leukemia, melanoma), gene analysis, targeted sequ | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 34 Original policy |
| 81273 | KIT (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog) (eg, mastocytosis), gene analysis, D816 variant(s) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 34 Original policy |
| 81274 | HTT (huntingtin) (eg, Huntington disease) gene analysis; characterization of alleles (eg, expanded size) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 34 Original policy |
| 81275 | Kras (V-Ki-Ras2 Kirsten Rat Sarcoma Viral Oncogene) (Eg, Carcinoma) Gene Analysis, Variants In Codons 12 And 13 | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 34 Original policy |