Anthem Blue Cross and Blue Shield Virginia prior authorization, page 27
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 |
|---|---|---|
| 81276 | KRAS (Kirsten rat sarcoma viral oncogene homolog) (eg, carcinoma) gene analysis; additional variant(s) (eg, codon 61, codon 146) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 34 Original policy |
| 81277 | Cytogenomic neoplasia (genome-wide) microarray analysis, interrogation of genomic regions for copy number and loss-of-heterozygosity variants for chromosomal abnormalities | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 34 Original policy |
| 81278 | IGH@/BCL2 (t(14;18)) (eg, follicular lymphoma) translocation analysis, major breakpoint region (MBR) and minor cluster region (mcr) breakpoints, qualitative or quantitative | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 34 Original policy |
| 81279 | JAK2 (Janus kinase 2) (eg, myeloproliferative disorder) targeted sequence analysis (eg, exons 12 and 13) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 34 Original policy |
| 81283 | IFNL3 (interferon, lambda 3) (eg, drug response), gene analysis, rs12979860 variant | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 34 Original policy |
| 81284 | FXN (frataxin) (eg, Friedreich ataxia) gene analysis; evaluation to detect abnormal (expanded) alleles | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 34 Original policy |
| 81285 | FXN (frataxin) (eg, Friedreich ataxia) gene analysis; characterization of alleles (eg, expanded size) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 34 Original policy |
| 81286 | FXN (frataxin) (eg, Friedreich ataxia) gene analysis; full gene sequence | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 34 Original policy |
| 81287 | MGMT (O-6-methylguanine-DNA methyltransferase) (eg, glioblastoma multiforme) promoter methylation analysis | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 34 Original policy |
| 81288 | MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; promoter methylation analysis | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 34 Original policy |
| 81289 | FXN (frataxin) (eg, Friedreich ataxia) gene analysis; known familial variant(s) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 34 Original policy |
| 81290 | Mcoln1 (Mucolipin 1) (Eg, Mucolipidosis, Type Iv) Gene Analysis, Common Variants (Eg, Ivs3- 2A>G, Del6.4Kb) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 34 Original policy |
| 81291 | Mthfr (5,10-Methylenetetrahydrofolate Reductase) (Eg, Hereditary Hypercoagulability) Gene Analysis, Common Variants (Eg, 677T, 1298C) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 34 Original policy |
| 81292 | Mlh1 (Mutl Homolog 1, Colon Cancer, Nonpolyposis Type 2) (Eg, Hereditary Non-Polyposis Colorectal Cancer, Lynch Syndrome) Gene Analysis; Full Sequence Analysis | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 34 Original policy |
| 81293 | Mlh1 (Mutl Homolog 1, Colon Cancer, Nonpolyposis Type 2) (Eg, Hereditary Non-Polyposis Colorectal Cancer, Lynch Syndrome) Gene Analysis; Known Familial Variants | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 34 Original policy |
| 81294 | Mlh1 (Mutl Homolog 1, Colon Cancer, Nonpolyposis Type 2) (Eg, Hereditary Non-Polyposis Colorectal Cancer, Lynch Syndrome) Gene Analysis; Duplication/Deletion Variants | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 34 Original policy |
| 81295 | Msh2 (Muts Homolog 2, Colon Cancer, Nonpolyposis Type 1) (Eg, Hereditary Non-Polyposis Colorectal Cancer, Lynch Syndrome) Gene Analysis; Full Sequence Analysis | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 34 Original policy |
| 81296 | Msh2 (Muts Homolog 2, Colon Cancer, Nonpolyposis Type 1) (Eg, Hereditary Non-Polyposis Colorectal Cancer, Lynch Syndrome) Gene Analysis; Known Familial Variants | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 34 Original policy |
| 81297 | Msh2 (Muts Homolog 2, Colon Cancer, Nonpolyposis Type 1) (Eg, Hereditary Non-Polyposis Colorectal Cancer, Lynch Syndrome) Gene Analysis; Duplication/Deletion Variants | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 34 Original policy |
| 81298 | Msh6 (Muts Homolog 6 [E. Coli]) (Eg, Hereditary Non-Polyposis Colorectal Cancer, Lynch Syndrome) Gene Analysis; Full Sequence Analysis | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 34 Original policy |
| 81299 | Msh6 (Muts Homolog 6 [E. Coli]) (Eg, Hereditary Non-Polyposis Colorectal Cancer, Lynch Syndrome) Gene Analysis; Known Familial Variants | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 34 Original policy |
| 81300 | Msh6 (Muts Homolog 6 [E. Coli]) (Eg, Hereditary Non-Polyposis Colorectal Cancer, Lynch Syndrome) Gene Analysis; Duplication/Deletion Variants | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 34 Original policy |
| 81301 | Microsatellite Instability Analysis (Eg, Hereditary Non-Polyposis Colorectal Cancer, Lynch Syndrome) Of Markers For Mismatch Repair Deficiency (Eg, Bat25, Bat26), Includes Com | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 34 Original policy |
| 81302 | Mecp2 (Methyl Cpg Binding Protein 2) (Eg, Rett Syndrome) Gene Analysis; Full Sequence Analysis | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 34 Original policy |
| 81303 | Mecp2 (Methyl Cpg Binding Protein 2) (Eg, Rett Syndrome) Gene Analysis; Known Familial Variant | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 34 Original policy |
| 81304 | Mecp2 (Methyl Cpg Binding Protein 2) (Eg, Rett Syndrome) Gene Analysis; Duplication/Deletion Variants | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 34 Original policy |
| 81305 | MYD88 (myeloid differentiation primary response 88) (eg, Waldenstrom's macroglobulinemia, lymphoplasmacytic leukemia) gene analysis, p.Leu265Pro (L265P) variant | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 34 Original policy |
| 81306 | NUDT15 (nudix hydrolase 15) (eg, drug metabolism) gene analysis, common variant(s) (eg, *2, *3, *4, *5, *6) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 34 Original policy |
| 81307 | PALB2 (partner and localizer of BRCA2) (eg, breast and pancreatic cancer) gene analysis; full gene sequence | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 34 Original policy |
| 81308 | PALB2 (partner and localizer of BRCA2) (eg, breast and pancreatic cancer) gene analysis; known familial variant | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 34 Original policy |
| 81309 | PIK3CA (phosphatidylinositol-4, 5-biphosphate 3-kinase, catalytic subunit alpha) (eg, colorectal and breast cancer) gene analysis, targeted sequence analysis (eg, exons 7, 9 | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 34 Original policy |
| 81310 | Npm1 (Nucleophosmin) (Eg, Acute Myeloid Leukemia) Gene Analysis, Exon 12 Variants | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 34 Original policy |
| 81311 | NRAS (neuroblastoma RAS viral [v-ras] oncogene homolog) (eg, colorectal carcinoma), gene analysis, variants in exon 2 (eg, codons 12 and 13) and exon 3 (eg, codon 61) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 34 Original policy |
| 81312 | PABPN1 (poly[A] binding protein nuclear 1) (eg, oculopharyngeal muscular dystrophy) gene analysis, evaluation to detect abnormal (eg, expanded) alleles | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 34 Original policy |
| 81313 | PCA3/KLK3 (prostate cancer antigen 3 [non-protein coding]/kallikrein-related peptidase 3 [prostate specific antigen]) ratio (eg, prostate cancer) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 34 Original policy |
| 81314 | PDGFRA (platelet-derived growth factor receptor, alpha polypeptide) (eg, gastrointestinal stromal tumor [GIST]), gene analysis, targeted sequence analysis (eg, exons 12, 18) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 34 Original policy |
| 81315 | Pml/Raralpha, (T(15;17)), (Promyelocytic Leukemia/Retinoic Acid Receptor Alpha) (Eg, Promyelocytic Leukemia) Translocation Analysis; Common Breakpoints (Eg, Intron 3 And Intro | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 34 Original policy |
| 81316 | Pml/Raralpha, (T(15;17)), (Promyelocytic Leukemia/Retinoic Acid Receptor Alpha) (Eg, Promyelocytic Leukemia) Translocation Analysis; Single Breakpoint (Eg, Intron 3, Intron 6 | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 34 Original policy |
| 81317 | Pms2 (Postmeiotic Segregation Increased 2 [S. Cerevisiae]) (Eg, Hereditary Non-Polyposis Colorectal Cancer, Lynch Syndrome) Gene Analysis; Full Sequence Analysis | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 35 Original policy |
| 81318 | Pms2 (Postmeiotic Segregation Increased 2 [S. Cerevisiae]) (Eg, Hereditary Non-Polyposis Colorectal Cancer, Lynch Syndrome) Gene Analysis; Known Familial Variants | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 35 Original policy |
| 81319 | Pms2 (Postmeiotic Segregation Increased 2 [S. Cerevisiae]) (Eg, Hereditary Non-Polyposis Colorectal Cancer, Lynch Syndrome) Gene Analysis; Duplication/Deletion Variants | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 35 Original policy |
| 81320 | PLCG2 (phospholipase C gamma 2) (eg, chronic lymphocytic leukemia) gene analysis, common variants (eg, R665W, S707F, L845F) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 35 Original policy |
| 81321 | PTEN (phosphatase and tensin homolog) (eg, Cowden syndrome, PTEN hamartoma tumor syndrome) gene analysis; full sequence analysis | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 35 Original policy |
| 81322 | PTEN (phosphatase and tensin homolog) (eg, Cowden syndrome, PTEN hamartoma tumor syndrome) gene analysis; known familial variant | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 35 Original policy |
| 81323 | PTEN (phosphatase and tensin homolog) (eg, Cowden syndrome, PTEN hamartoma tumor syndrome) gene analysis; duplication/deletion variant | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 35 Original policy |
| 81324 | PMP22 (peripheral myelin protein 22) (eg, Charcot-Marie-Tooth, hereditary neuropathy with liability to pressure palsies) gene analysis; duplication/deletion analysis | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 35 Original policy |
| 81325 | PMP22 (peripheral myelin protein 22) (eg, Charcot-Marie-Tooth, hereditary neuropathy with liability to pressure palsies) gene analysis; full sequence analysis | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 35 Original policy |
| 81326 | PMP22 (peripheral myelin protein 22) (eg, Charcot-Marie-Tooth, hereditary neuropathy with liability to pressure palsies) gene analysis; known familial variant | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 35 Original policy |
| 81327 | SEPT9 (Septin9) (eg, colorectal cancer) promoter methylation analysis | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 35 Original policy |
| 81328 | SLCO1B1 (solute carrier organic anion transporter family, member 1B1) (eg, adverse drug reaction), gene analysis, common variant(s) (eg, *5) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 35 Original policy |