Anthem Blue Cross and Blue Shield Virginia prior authorization, page 29
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 |
|---|---|---|
| 81405 | MOLECULAR PATHOLOGY PROCEDURE LEVEL 6 | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 36 Original policy |
| 81406 | MOLECULAR PATHOLOGY PROCEDURE LEVEL 7 | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 36 Original policy |
| 81407 | MOLECULAR PATHOLOGY PROCEDURE LEVEL 8 | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 36 Original policy |
| 81408 | Molecular pathology procedure, Level 9 (eg, analysis of >50 exons in a single gene by DNA sequence analysis) ABCA4 (ATP-binding cassette, sub-family A [ABC1], member 4) (eg, S | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 36 Original policy |
| 81410 | Aortic dysfunction or dilation (eg, Marfan syndrome, Loeys Dietz syndrome, Ehler Danlos syndrome type IV, arterial tortuosity syndrome); genomic sequence analysis panel, must | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 36 Original policy |
| 81411 | Aortic dysfunction or dilation (eg, Marfan syndrome, Loeys Dietz syndrome, Ehler Danlos syndrome type IV, arterial tortuosity syndrome); duplication/deletion analysis panel, m | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 36 Original policy |
| 81412 | Ashkenazi Jewish associated disorders (eg, Bloom syndrome, Canavan disease, cystic fibrosis, familial dysautonomia, Fanconi anemia group C, Gaucher disease, Tay-Sachs disease) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 36 Original policy |
| 81413 | Cardiac ion channelopathies (eg Brugada syndrome, long QT syndrome, short QT syndrome, catecholaminergic polymorphic ventricular tachycardia); genomic sequence analysis panel | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 36 Original policy |
| 81414 | Cardiac ion channelopathies (eg Brugada syndrome, long QT syndrome, short QT syndrome, catecholaminergic polymorphic ventricular tachycardia); duplication/deletion gene analys | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 36 Original policy |
| 81415 | Exome (eg, unexplained constitutional or heritable disorder or syndrome); sequence analysis | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 36 Original policy |
| 81416 | Exome (eg, unexplained constitutional or heritable disorder or syndrome); sequence analysis, each comparator exome (eg, parents, siblings) (List separately in addition to code | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 36 Original policy |
| 81417 | Exome (eg, unexplained constitutional or heritable disorder or syndrome); re-evaluation of previously obtained exome sequence (eg, updated knowledge or unrelated condition/syn | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 36 Original policy |
| 81418 | Drug metabolism (eg, pharmacogenomics) genomic sequence analysis panel, must include testing of at least 6 genes, including CYP2C19, CYP2D6, and CYP2D6 duplication/deletion an | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 36 Original policy |
| 81419 | Epilepsy genomic sequence analysis panel, must include analyses for ALDH7A1, CACNA1A, CDKL5, CHD2, GABRG2, GRIN2A, KCNQ2, MECP2, PCDH19, POLG, PRRT2, SCN1A, SCN1B, SCN2A, SCN8 | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 36 Original policy |
| 81425 | Genome (eg, unexplained constitutional or heritable disorder or syndrome); sequence analysis | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 36 Original policy |
| 81426 | Genome (eg, unexplained constitutional or heritable disorder or syndrome); sequence analysis, each comparator genome (eg, parents, siblings) (List separately in addition to co | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 36 Original policy |
| 81427 | Genome (eg, unexplained constitutional or heritable disorder or syndrome); re-evaluation of previously obtained genome sequence (eg, updated knowledge or unrelated condition/s | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 36 Original policy |
| 81430 | Hearing loss (eg, nonsyndromic hearing loss, Usher syndrome, Pendred syndrome); genomic sequence analysis panel, must include sequencing of at least 60 genes, including CDH23 | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 36 Original policy |
| 81431 | Hearing loss (eg, nonsyndromic hearing loss, Usher syndrome, Pendred syndrome); duplication/deletion analysis panel, must include copy number analyses for STRC and DFNB1 delet | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 36 Original policy |
| 81432 | Hereditary breast cancer-related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer, hereditary pancreatic cancer, hereditary pr | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 36 Original policy |
| 81434 | Hereditary retinal disorders (eg, retinitis pigmentosa, Leber congenital amaurosis, cone-rod dystrophy), genomic sequence analysis panel, must include sequencing of at least 1 | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 36 Original policy |
| 81435 | Hereditary colon cancer-related disorders (eg, Lynch syndrome, PTEN hamartoma syndrome, Cowden syndrome, familial adenomatosis polyposis), genomic sequence analysis panel, 5 o | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 36 Original policy |
| 81437 | Hereditary neuroendocrine tumor-related disorders (eg, medullary thyroid carcinoma, parathyroid carcinoma, malignant pheochromocytoma or paraganglioma), genomic sequence analy | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 36 Original policy |
| 81439 | Hereditary cardiomyopathy (eg, hypertrophic cardiomyopathy, dilated cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy), genomic sequence analysis panel, must inc | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 36 Original policy |
| 81440 | Nuclear encoded mitochondrial genes (eg, neurologic or myopathic phenotypes), genomic sequence panel, must include analysis of at least 100 genes, including BCS1L, C10orf2, CO | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 36 Original policy |
| 81441 | Inherited bone marrow failure syndromes (IBMFS) (eg, Fanconi anemia, dyskeratosis congenita, Diamond-Blackfan anemia, Shwachman-Diamond syndrome, GATA2 deficiency syndrome, co | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 36 Original policy |
| 81442 | Noonan spectrum disorders (eg, Noonan syndrome, cardio-facio-cutaneous syndrome, Costello syndrome, LEOPARD syndrome, Noonan-like syndrome), genomic sequence analysis panel, m | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 36 Original policy |
| 81443 | Genetic testing for severe inherited conditions (eg, cystic fibrosis, Ashkenazi Jewish- associated disorders [eg, Bloom syndrome, Canavan disease, Fanconi anemia type C, mucoli | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 36 Original policy |
| 81445 | Solid organ neoplasm, genomic sequence analysis panel, 5-50 genes, interrogation for sequence variants and copy number variants or rearrangements, if performed; DNA analysis o | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 36 Original policy |
| 81448 | Hereditary peripheral neuropathies (eg, Charcot-Marie-Tooth, spastic paraplegia), genomic sequence analysis panel, must include sequencing of at least 5 peripheral neuropathy | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 36 Original policy |
| 81449 | Solid organ neoplasm, genomic sequence analysis panel, 5-50 genes, interrogation for sequence variants and copy number variants or rearrangements, if performed; RNA analysis | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 36 Original policy |
| 81450 | Hematolymphoid neoplasm or disorder, genomic sequence analysis panel, 5-50 genes, interrogation for sequence variants, and copy number variants or rearrangements, or isoform e | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 36 Original policy |
| 81451 | Hematolymphoid neoplasm or disorder, genomic sequence analysis panel, 5-50 genes, interrogation for sequence variants, and copy number variants or rearrangements, or isoform e | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 36 Original policy |
| 81455 | Solid organ or hematolymphoid neoplasm or disorder, 51 or greater genes, genomic sequence analysis panel, interrogation for sequence variants and copy number variants or rearr | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 36 Original policy |
| 81456 | Solid organ or hematolymphoid neoplasm or disorder, 51 or greater genes, genomic sequence analysis panel, interrogation for sequence variants and copy number variants or rearr | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 36 Original policy |
| 81457 | Solid organ neoplasm, genomic sequence analysis panel, interrogation for sequence variants; DNA analysis, microsatellite instability | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 36 Original policy |
| 81458 | Solid organ neoplasm, genomic sequence analysis panel, interrogation for sequence variants; DNA analysis, copy number variants and microsatellite instability | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 36 Original policy |
| 81459 | Solid organ neoplasm, genomic sequence analysis panel, interrogation for sequence variants; DNA analysis or combined DNA and RNA analysis, copy number variants, microsatellite | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 36 Original policy |
| 81460 | Whole mitochondrial genome (eg, Leigh syndrome, mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes [MELAS], myoclonic epilepsy with ragged-red fibers [ | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 36 Original policy |
| 81462 | Solid organ neoplasm, genomic sequence analysis panel, cell-free nucleic acid (eg, plasma), interrogation for sequence variants; DNA analysis or combined DNA and RNA analysis | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 36 Original policy |
| 81463 | Solid organ neoplasm, genomic sequence analysis panel, cell-free nucleic acid (eg, plasma), interrogation for sequence variants; DNA analysis, copy number variants, and micros | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 36 Original policy |
| 81464 | Solid organ neoplasm, genomic sequence analysis panel, cell-free nucleic acid (eg, plasma), interrogation for sequence variants; DNA analysis or combined DNA and RNA analysis | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 36 Original policy |
| 81465 | Whole mitochondrial genome large deletion analysis panel (eg, Kearns-Sayre syndrome, chronic progressive external ophthalmoplegia), including heteroplasmy detection, if perfor | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 36 Original policy |
| 81470 | X-linked intellectual disability (XLID) (eg, syndromic and non-syndromic XLID); genomic sequence analysis panel, must include sequencing of at least 60 genes, including ARX, A | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 36 Original policy |
| 81471 | X-linked intellectual disability (XLID) (eg, syndromic and non-syndromic XLID); duplication/deletion gene analysis, must include analysis of at least 60 genes, including ARX | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 36 Original policy |
| 81479 | Unlisted molecular pathology procedure | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 36 Original policy |
| 81490 | Autoimmune (rheumatoid arthritis), analysis of 12 biomarkers using immunoassays, utilizing serum, prognostic algorithm reported as a disease activity score | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 36 Original policy |
| 81493 | Coronary artery disease, mRNA, gene expression profiling by real-time RT-PCR of 23 genes, utilizing whole peripheral blood, algorithm reported as a risk score | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 36 Original policy |
| 81500 | Oncology (Ovarian), Biochemical Assays Of Two Proteins, Serum, W Menopausal Status, Algorithm Reported As A Risk Score | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 36 Original policy |
| 81503 | Oncology (Ovarian), Biochemical Assays Of Five Proteins, Utilizing Serum, Algorithm Reported As A Risk Score | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 36 Original policy |