Anthem Blue Cross and Blue Shield Virginia prior authorization, page 28
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 |
|---|---|---|
| 81329 | SMN1 (survival of motor neuron 1, telomeric) (eg, spinal muscular atrophy) gene analysis; dosage/deletion analysis (eg, carrier testing), includes SMN2 (survival of motor neur | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 35 Original policy |
| 81330 | Smpd1(Sphingomyelin Phosphodiesterase 1, Acid Lysosomal) (Eg, Niemann-Pick Disease, Type A) Gene Analysis, Common Variants (Eg, R496L, L302P, Fsp330) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 35 Original policy |
| 81331 | Snrpn/Ube3A (Small Nuclear Ribonucleoprotein Polypeptide N And Ubiquitin Protein Ligase E3A) (Eg, Prader-Willi Syndrome And/Or Angelman Syndrome), Methylation Analysis | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 35 Original policy |
| 81332 | Serpina1 (Serpin Peptidase Inhibitor, Clade A, Alpha-1 Antiproteinase, Antitrypsin, Member 1) (Eg, Alpha-1-Antitrypsin Deficiency), Gene Analysis, Common Variants (Eg, *S And | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 35 Original policy |
| 81333 | TGFBI (transforming growth factor beta-induced) (eg, corneal dystrophy) gene analysis, common variants (eg, R124H, R124C, R124L, R555W, R555Q) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 35 Original policy |
| 81334 | RUNX1 (runt related transcription factor 1) (eg, acute myeloid leukemia, familial platelet disorder with associated myeloid malignancy), gene analysis, targeted sequence analy | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 35 Original policy |
| 81335 | TPMT (thiopurine S-methyltransferase) (eg, drug metabolism), gene analysis, common variants (eg, *2, *3) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 35 Original policy |
| 81336 | SMN1 (survival of motor neuron 1, telomeric) (eg, spinal muscular atrophy) gene analysis; full gene sequence | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 35 Original policy |
| 81337 | SMN1 (survival of motor neuron 1, telomeric) (eg, spinal muscular atrophy) gene analysis; known familial sequence variant(s) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 35 Original policy |
| 81338 | MPL (MPL proto-oncogene, thrombopoietin receptor) (eg, myeloproliferative disorder) gene analysis; common variants (eg, W515A, W515K, W515L, W515R) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 35 Original policy |
| 81339 | MPL (MPL proto-oncogene, thrombopoietin receptor) (eg, myeloproliferative disorder) gene analysis; sequence analysis, exon 10 | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 35 Original policy |
| 81340 | Trb@ (T Cell Antigen Receptor, Beta) (Eg, Leukemia And Lymphoma), Gene Rearrangement Analysis To Detect Abnormal Clonal Population(S); Using Amplification Methodology (Eg, Pol | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 35 Original policy |
| 81341 | Trb@ (T Cell Antigen Receptor, Beta) (Eg, Leukemia And Lymphoma), Gene Rearrangement Analysis To Detect Abnormal Clonal Population(S); Using Direct Probe Methodology (Eg, Sout | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 35 Original policy |
| 81342 | Trg@ (T Cell Antigen Receptor, Gamma) (Eg, Leukemia And Lymphoma), Gene Rearrangement Analysis, Evaluation To Detect Abnormal Clonal Population(S) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 35 Original policy |
| 81343 | PPP2R2B (protein phosphatase 2 regulatory subunit Bbeta) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 35 Original policy |
| 81344 | TBP (TATA box binding protein) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 35 Original policy |
| 81345 | TERT (telomerase reverse transcriptase) (eg, thyroid carcinoma, glioblastoma multiforme) gene analysis, targeted sequence analysis (eg, promoter region) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 35 Original policy |
| 81346 | TYMS (thymidylate synthetase) (eg, 5-fluorouracil/5-FU drug metabolism), gene analysis, common variant(s) (eg, tandem repeat variant) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 35 Original policy |
| 81347 | SF3B1 (splicing factor [3b] subunit B1) (eg, myelodysplastic syndrome/acute myeloid leukemia) gene analysis, common variants (eg, A672T, E622D, L833F, R625C, R625L) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 35 Original policy |
| 81348 | SRSF2 (serine and arginine-rich splicing factor 2) (eg, myelodysplastic syndrome, acute myeloid leukemia) gene analysis, common variants (eg, P95H, P95L) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 35 Original policy |
| 81349 | Cytogenomic (genome-wide) analysis for constitutional chromosomal abnormalities; interrogation of genomic regions for copy number and loss-of-heterozygosity variants, low- pass | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 35 Original policy |
| 81350 | UGT1A1 (UDP glucuronosyltransferase 1 family, polypeptide A1) (eg, drug metabolism, hereditary unconjugated hyperbilirubinemia [Gilbert syndrome]) gene analysis, common varian | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 35 Original policy |
| 81351 | TP53 (tumor protein 53) (eg, Li-Fraumeni syndrome) gene analysis; full gene sequence | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 35 Original policy |
| 81352 | TP53 (tumor protein 53) (eg, Li-Fraumeni syndrome) gene analysis; targeted sequence analysis (eg, 4 oncology) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 35 Original policy |
| 81353 | TP53 (tumor protein 53) (eg, Li-Fraumeni syndrome) gene analysis; known familial variant | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 35 Original policy |
| 81355 | Vkorc1 (Vitamin K Epoxide Reductase Complex, Subunit 1) (Eg, Warfarin Metabolism), Gene Analysis, Common Variants (Eg, -1639/3673) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 35 Original policy |
| 81357 | U2AF1 (U2 small nuclear RNA auxiliary factor 1) (eg, myelodysplastic syndrome, acute myeloid leukemia) gene analysis, common variants (eg, S34F, S34Y, Q157R, Q157P) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 35 Original policy |
| 81360 | ZRSR2 (zinc finger CCCH-type, RNA binding motif and serine/arginine-rich 2) (eg, myelodysplastic syndrome, acute myeloid leukemia) gene analysis, common variant(s) (eg, E65fs | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 35 Original policy |
| 81361 | HBB (hemoglobin, subunit beta) (eg, sickle cell anemia, beta thalassemia, hemoglobinopathy); common variant(s) (eg, HbS, HbC, HbE) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 35 Original policy |
| 81362 | HBB (hemoglobin, subunit beta) (eg, sickle cell anemia, beta thalassemia, hemoglobinopathy); known familial variant(s) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 35 Original policy |
| 81363 | HBB (hemoglobin, subunit beta) (eg, sickle cell anemia, beta thalassemia, hemoglobinopathy); duplication/deletion variant(s) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 35 Original policy |
| 81364 | HBB (hemoglobin, subunit beta) (eg, sickle cell anemia, beta thalassemia, hemoglobinopathy); full gene sequence | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 35 Original policy |
| 81370 | Hla Class I And Ii Typing, Low Resolution (Eg, Antigen Equivalents); Hla-A, -B, -C, -Drb1/3/4/5, And -Dqb1 | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 35 Original policy |
| 81371 | HLA Class I and II typing, low resolution (eg, antigen equivalents); HLA-A, -B, and -DRB1 (eg, verification typing) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 35 Original policy |
| 81372 | Hla Class I Typing, Low Resolution (Eg, Antigen Equivalents); Complete (Ie, Hla-A, -B, And -C) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 35 Original policy |
| 81373 | Hla Class I Typing, Low Resolution (Eg, Antigen Equivalents); One Locus (Eg, Hla-A, -B, Or -C), Each | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 35 Original policy |
| 81374 | Hla Class I Typing, Low Resolution (Eg, Antigen Equivalents); One Antigen Equivalent (Eg, B*27), Each | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 35 Original policy |
| 81375 | Hla Class Ii Typing, Low Resolution (Eg, Antigen Equivalents); Hla-Drb1/3/4/5 And -Dqb1 | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 35 Original policy |
| 81376 | HLA Class II typing, low resolution (eg, antigen equivalents); one locus (eg, HLA-DRB1, - DRB3/4/5, -DQB1, -DQA1, -DPB1, or -DPA1), each | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 35 Original policy |
| 81378 | Hla Class I And Ii Typing, High Resolution (Ie, Alleles Or Allele Groups), Hla-A, -B, -C, And -Drb1 | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 35 Original policy |
| 81379 | Hla Class I Typing, High Resolution (Ie, Alleles Or Allele Groups); Complete (Ie, Hla-A, -B, And - C) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 35 Original policy |
| 81380 | Hla Class I Typing, High Resolution (Ie, Alleles Or Allele Groups); One Locus (Eg, Hla-A, -B, Or - C), Each | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 35 Original policy |
| 81381 | Hla Class I Typing, High Resolution (Ie, Alleles Or Allele Groups); One Allele Or Allele Group (Eg, B*57:01P), Each | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 35 Original policy |
| 81382 | HLA Class II typing, high resolution (ie, alleles or allele groups); one locus (eg, HLA-DRB1, - DRB3/4/5, -DQB1, -DQA1, -DPB1, or -DPA1), each | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 35 Original policy |
| 81383 | Hla Class Ii Typing, High Resolution (Ie, Alleles Or Allele Groups); One Allele Or Allele Group (Eg, Hla-Dqb1*06:02P), Each | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 36 Original policy |
| 81400 | MOLECULAR PATHOLOGY PROCEDURE LEVEL 1 | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 36 Original policy |
| 81401 | MOLECULAR PATHOLOGY PROCEDURE LEVEL 2 | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 36 Original policy |
| 81402 | MOLECULAR PATHOLOGY PROCEDURE LEVEL 3 | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 36 Original policy |
| 81403 | MOLECULAR PATHOLOGY PROCEDURE LEVEL 4 | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 36 Original policy |
| 81404 | MOLECULAR PATHOLOGY PROCEDURE LEVEL 5 | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 36 Original policy |