Anthem Blue Cross and Blue Shield Virginia prior authorization, page 30
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 |
|---|---|---|
| 81504 | Oncology (tissue of origin), microarray gene expression profiling of > 2000 genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as tissue similarity s | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 37 Original policy |
| 81506 | Endocrinology, Biochemical Assays Of Seven Analytes Utilizing Serum Or Plasma, Algorithm Reporting A Risk Score | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 37 Original policy |
| 81508 | Fetal Congenital Abnormalities, Assays Of Two Proteins, Maternal Serum, Algorithm Reported As A Risk Score | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 37 Original policy |
| 81509 | Fetal Congenital Abnormalities, Assays Of Three Proteins, Maternal Serum, Algorithm Reported As A Risk Score | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 37 Original policy |
| 81510 | Fetal Congenital Abnormalities, Assays Of Three Analytes, Maternal Serum, Algorithm Reported As A Risk Score | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 37 Original policy |
| 81511 | Fetal Congenital Abnormalities, Assays Of Four Analytes, Maternal Serum, Algorithm Reported As A Risk Score | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 37 Original policy |
| 81512 | Fetal Congenital Abnormalities, Assays Of Five Analytes, Maternal Serum, Algorithm Reported As A Risk Score | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 37 Original policy |
| 81517 | Liver disease, analysis of 3 biomarkers (hyaluronic acid [HA], procollagen III amino terminal peptide [PIIINP], tissue inhibitor of metalloproteinase 1 [TIMP-1]), using immuno | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 37 Original policy |
| 81518 | Oncology (breast), mRNA, gene expression profiling by real-time RT-PCR of 11 genes (7 content and 4 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 37 Original policy |
| 81519 | Oncology (breast), mRNA, gene expression profiling by real-time RT-PCR of 21 genes, utilizing formalin-fixed paraffin embedded tissue, algorithm reported as recurrence score | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 37 Original policy |
| 81520 | Oncology (breast), mRNA gene expression profiling by hybrid capture of 58 genes (50 content and 8 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm r | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 37 Original policy |
| 81521 | Oncology (breast), mRNA, microarray gene expression profiling of 70 content genes and 465 housekeeping genes, utilizing fresh frozen or formalin-fixed paraffin-embedded tissue | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 37 Original policy |
| 81522 | Oncology (breast), mRNA, gene expression profiling by RT-PCR of 12 genes (8 content and 4 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 37 Original policy |
| 81523 | Oncology (breast), mRNA, next-generation sequencing gene expression profiling of 70 content genes and 31 housekeeping genes, utilizing formalin-fixed paraffin-embedded tissue | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 37 Original policy |
| 81525 | Oncology (colon), mRNA, gene, expression profiling by real-time RT-PCR of 12 genes (7 content and 5 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 37 Original policy |
| 81529 | Oncology (cutaneous melanoma), mRNA, gene expression profiling by real-time RT-PCR of 31 genes (28 content and 3 housekeeping), utilizing formalin-fixed paraffin-embedded tiss | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 37 Original policy |
| 81535 | Oncology (gynecologic), live tumor cell culture and chemotherapeutic response by DAPI stain and morphology, predictive algorithm reported as a drug response score; first singl | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 37 Original policy |
| 81538 | Oncology (lung), mass spectrometric 8-protein signature, including amyloid A, utilizing serum, prognostic and predictive algorithm reported as good versus poor overall surviva | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 37 Original policy |
| 81539 | Oncology (high-grade prostate cancer), biochemical assay of four proteins (Total PSA, Free PSA, Intact PSA, and human kallikrein-2 hK2), utilizing plasma or serum, prognostic | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 37 Original policy |
| 81540 | Oncology (tumor of unknown origin), mRNA, gene expression profiling by real-time RT-PCR of 92 genes (87 content and 5 housekeeping) to classify tumor into main cancer type and | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 37 Original policy |
| 81541 | Oncology (prostate), mRNA gene expression profiling by real-time RT-PCR of 46 genes (31 content and 15 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algori | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 37 Original policy |
| 81542 | Oncology (prostate), mRNA, microarray gene expression profiling of 22 content genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as metastasis risk s | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 37 Original policy |
| 81546 | Oncology (thyroid), mRNA, gene expression analysis of 10,196 genes, utilizing fine needle aspirate, algorithm reported as a categorical result (eg, benign or suspicious) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 37 Original policy |
| 81551 | Oncology (prostate), promoter methylation profiling by real-time PCR of 3 genes (GSTP1, APC, RASSF1), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 37 Original policy |
| 81552 | Oncology (uveal melanoma), mRNA, gene expression profiling by real-time RT-PCR of 15 genes (12 content and 3 housekeeping), utilizing fine needle aspirate or formalin-fixed pa | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 37 Original policy |
| 81554 | Pulmonary disease (idiopathic pulmonary fibrosis [IPF]), mRNA, gene expression analysis of 190 genes, utilizing transbronchial biopsies, diagnostic algorithm reported as categ | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 37 Original policy |
| 81558 | Transplantation medicine (allograft rejection, kidney), mRNA, gene expression profiling | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 37 Original policy |
| 81560 | Transplantation medicine (allograft rejection, pediatric liver and small bowel), measurement of donor and third-party-induced CD154+T-cytotoxic memory cells, utilizing whole p | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 37 Original policy |
| 81595 | Cardiology (heart transplant), mRNA, gene expression profiling by real-time quantitative PCR of 20 genes (11 content and 9 housekeeping), utilizing subfraction of peripheral b | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 37 Original policy |
| 81596 | Infectious disease, chronic hepatitis C virus (HCV) infection, six biochemical assays (ALT, A2- macroglobulin, apolipoprotein A-1, total bilirubin, GGT, and haptoglobin) utiliz | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 37 Original policy |
| 82009 | Ketone body(s) (eg, acetone, acetoacetic acid, beta-hydroxybutyrate); qualitative | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 37 Original policy |
| 82010 | Ketone body(s) (eg, acetone, acetoacetic acid, beta-hydroxybutyrate); quantitative | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 37 Original policy |
| 82013 | Acetylcholinesterase | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 37 Original policy |
| 82016 | Acylcarnitines; Qualitative, Each Specimen | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 37 Original policy |
| 82017 | Acylcarnitines; Quantitative, Each Specimen | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 37 Original policy |
| 82024 | Assay Of Adrenocorticotropic Hormone (Acth) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 37 Original policy |
| 82030 | Adenosine, 5-Monophosphate, Cyclic (Cyclic Amp) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 37 Original policy |
| 82040 | Albumin; serum, plasma or whole blood | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 37 Original policy |
| 82042 | Albumin; other source, quantitative, each specimen | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 37 Original policy |
| 82043 | Albumin; urine (eg, microalbumin), quantitative | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 37 Original policy |
| 82044 | Albumin; urine (eg, microalbumin), semiquantitative (eg, reagent strip assay) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 37 Original policy |
| 82045 | Albumin; Ischemia Modified | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 37 Original policy |
| 82075 | Alcohol (ethanol); breath | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 37 Original policy |
| 82085 | Aldolase | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 37 Original policy |
| 82088 | Aldosterone | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 37 Original policy |
| 82103 | Alpha-1-Antitrypsin; Total | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 37 Original policy |
| 82104 | Alpha-1-Antitrypsin; Phenotype | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 37 Original policy |
| 82105 | Alpha-fetoprotein (AFP); serum | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 37 Original policy |
| 82106 | Alpha-fetoprotein (AFP); amniotic fluid | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 37 Original policy |
| 82107 | Alpha-fetoprotein (AFP); AFP-L3 fraction isoform and total AFP (including ratio) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 37 Original policy |