Anthem Blue Cross and Blue Shield Virginia prior authorization, page 4
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 |
|---|---|---|
| 0264U | Rare diseases (constitutional/heritable disorders), identification of copy number variations, inversions, insertions, translocations, and other structural variants by optical | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 4 Original policy |
| 0265T | Intramuscular autologous bone marrow cell therapy, with preparation of harvested cells, multiple injections, one leg, including ultrasound guidance, if performed; unilateral o | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 4 Original policy |
| 0265U | Rare constitutional and other heritable disorders, whole genome and mitochondrial DNA sequence analysis, blood, frozen and formalin-fixed paraffin-embedded (FFPE) tissue, sali | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 4 Original policy |
| 0266U | Unexplained constitutional or other heritable disorders or syndromes, tissue-specific gene expression by whole-transcriptome and next-generation sequencing, blood, formalin-fi | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 4 Original policy |
| 0267U | Rare constitutional and other heritable disorders, identification of copy number variations, inversions, insertions, translocations, and other structural variants by optical g | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 4 Original policy |
| 0268U | Hematology (atypical hemolytic uremic syndrome [aHUS]), genomic sequence analysis of 15 genes, blood, buccal swab, or amniotic fluid | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 4 Original policy |
| 0269U | Hematology (autosomal dominant congenital thrombocytopenia), genomic sequence analysis of 14 genes, blood, buccal swab, or amniotic fluid | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 4 Original policy |
| 0270U | Hematology (congenital coagulation disorders), genomic sequence analysis of 20 genes, blood, buccal swab, or amniotic fluid | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 4 Original policy |
| 0271U | Hematology (congenital neutropenia), genomic sequence analysis of 23 genes, blood, buccal swab, or amniotic fluid | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 4 Original policy |
| 0272U | Hematology (genetic bleeding disorders), genomic sequence analysis of 51 genes, blood, buccal swab, or amniotic fluid, comprehensive | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 4 Original policy |
| 0273U | Hematology (genetic hyperfibrinolysis, delayed bleeding), genomic sequence analysis of 8 genes (F13A1, F13B, FGA, FGB, FGG, SERPINA1, SERPINE1, SERPINF2, PLAU), blood, buccal | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 4 Original policy |
| 0274T | Percutaneous laminotomy/laminectomy (interlaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or forami | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 4 Original policy |
| 0274U | Hematology (genetic platelet disorders), genomic sequence analysis of 43 genes, blood, buccal swab, or amniotic fluid | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 4 Original policy |
| 0276U | Hematology (inherited thrombocytopenia), genomic sequence analysis of 23 genes, blood, buccal swab, or amniotic fluid | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 4 Original policy |
| 0277U | Hematology (genetic platelet function disorder), genomic sequence analysis of 31 genes, blood, buccal swab, or amniotic fluid | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 4 Original policy |
| 0278T | Transcutaneous Electrical Modulation Pain Reprocessing (Eg, Scrambler Therapy), Each Treatment Session (Includes Placement Of Electrodes) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 4 Original policy |
| 0278U | Hematology (genetic thrombosis), genomic sequence analysis of 12 genes, blood, buccal swab, or amniotic fluid | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 5 Original policy |
| 0285U | Oncology, disease progression and response monitoring to radiation, chemotherapy, or other systematic cancer treatments, cell-free DNA, quantitative branched chain DNA amplifi | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 5 Original policy |
| 0286U | CEP72 (centrosomal protein, 72-KDa), NUDT15 (nudix hydrolase 15) and TPMT (thiopurine S- methyltransferase) (eg, drug metabolism) gene analysis, common variants | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 5 Original policy |
| 0287U | Oncology (thyroid), DNA and mRNA, next-generation sequencing analysis of 112 genes, fine needle aspirate or formalin-fixed paraffin-embedded (FFPE) tissue, algorithmic predict | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 5 Original policy |
| 0288U | Oncology (lung), mRNA, quantitative PCR analysis of 11 genes (BAG1, BRCA1, CDC6, CDK2AP1, ERBB3, FUT3, IL11, LCK, RND3, SH3BGR, WNT3A) and 3 reference genes (ESD, TBP, YAP1) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 5 Original policy |
| 0289U | Neurology (Alzheimer disease), mRNA, gene expression profiling by RNA sequencing of 24 genes, whole blood, algorithm reported as predictive risk score | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 5 Original policy |
| 0290U | Pain management, mRNA, gene expression profiling by RNA sequencing of 36 genes, whole blood, algorithm reported as predictive risk score | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 5 Original policy |
| 0291U | Psychiatry (mood disorders), mRNA, gene expression profiling by RNA sequencing of 144 genes, whole blood, algorithm reported as predictive risk score | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 5 Original policy |
| 0292U | Psychiatry (stress disorders), mRNA, gene expression profiling by RNA sequencing of 72 genes, whole blood, algorithm reported as predictive risk score | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 5 Original policy |
| 0293U | Psychiatry (suicidal ideation), mRNA, gene expression profiling by RNA sequencing of 54 genes, whole blood, algorithm reported as predictive risk score | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 5 Original policy |
| 0294U | Longevity and mortality risk, mRNA, gene expression profiling by RNA sequencing of 18 genes, whole blood, algorithm reported as predictive risk score | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 5 Original policy |
| 0296U | Oncology (oral and/or oropharyngeal cancer), gene expression profiling by RNA sequencing at least 20 molecular features (eg, human and/or microbial mRNA), saliva, algorithm re | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 5 Original policy |
| 0297U | Oncology (pan tumor), whole genome sequencing of paired malignant and normal DNA specimens, fresh or formalin-fixed paraffin-embedded (FFPE) tissue, blood or bone marrow, comp | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 5 Original policy |
| 0298U | Oncology (pan tumor), whole transcriptome sequencing of paired malignant and normal RNA specimens, fresh or formalin-fixed paraffin-embedded (FFPE) tissue, blood or bone marro | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 5 Original policy |
| 0299U | Oncology (pan tumor), whole genome optical genome mapping of paired malignant and normal DNA specimens, fresh frozen tissue, blood, or bone marrow, comparative structural vari | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 5 Original policy |
| 0300U | Oncology (pan tumor), whole genome sequencing and optical genome mapping of paired malignant and normal DNA specimens, fresh tissue, blood, or bone marrow, comparative sequenc | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 5 Original policy |
| 0306U | Oncology (minimal residual disease [MRD]), next-generation targeted sequencing analysis, cell-free DNA, initial (baseline) assessment to determine a patient specific panel for | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 5 Original policy |
| 0307U | Oncology (minimal residual disease [MRD]), next-generation targeted sequencing analysis of a patient-specific panel, cell-free DNA, subsequent assessment with comparison to pr | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 5 Original policy |
| 0312U | Autoimmune diseases (eg, systemic lupus erythematosus [SLE]), analysis of 8 IgG autoantibodies and 2 cell-bound complement activation products using enzyme-linked immunosorben | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 5 Original policy |
| 0313U | Oncology (pancreas), DNA and mRNA next-generation sequencing analysis of 74 genes and analysis of CEA (CEACAM5) gene expression, pancreatic cyst fluid, algorithm reported as a | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 5 Original policy |
| 0314U | Oncology (cutaneous melanoma), mRNA gene expression profiling by RT-PCR of 35 genes (32 content and 3 housekeeping), utilizing formalin-fixed paraffin-embedded (FFPE) tissue | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 5 Original policy |
| 0315U | Oncology (cutaneous squamous cell carcinoma), mRNA gene expression profiling by RT-PCR of 40 genes (34 content and 6 housekeeping), utilizing formalin-fixed paraffin-embedded | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 5 Original policy |
| 0318U | Pediatrics (congenital epigenetic disorders), whole genome methylation analysis by microarray for 50 or more genes, blood | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 5 Original policy |
| 0319U | Nephrology (renal transplant), RNA expression by select transcriptome sequencing, using pretransplant peripheral blood, algorithm reported as a risk score for early acute reje | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 5 Original policy |
| 0320U | Nephrology (renal transplant), RNA expression by select transcriptome sequencing, using posttransplant peripheral blood, algorithm reported as a risk score for acute cellular | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 5 Original policy |
| 0323U | Infectious agent detection by nucleic acid (DNA and RNA), central nervous system pathogen, metagenomic next-generation sequencing, cerebrospinal fluid (CSF), identification of | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 5 Original policy |
| 0326U | Targeted genomic sequence analysis panel, solid organ neoplasm, cell-free circulating DNA analysis of 83 or more genes, interrogation for sequence variants, gene copy number a | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 5 Original policy |
| 0329T | Monitoring of intraocular pressure for 24 hours or longer, unilateral or bilateral, with interpretation and report | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 5 Original policy |
| 0329U | Oncology (neoplasia), exome and transcriptome sequence analysis for sequence variants, gene copy number amplifications and deletions, gene rearrangements, microsatellite insta | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 5 Original policy |
| 0330T | Tear film imaging, unilateral or bilateral, with interpretation and report | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 5 Original policy |
| 0331T | Myocardial sympathetic innervation imaging, planar qualitative and quantitative assessment | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 5 Original policy |
| 0331U | Oncology (hematolymphoid neoplasia), optical genome mapping for copy number alterations and gene rearrangements utilizing DNA from blood or bone marrow, report of clinically s | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 5 Original policy |
| 0332T | Myocardial sympathetic innervation imaging, planar qualitative and quantitative assessment; with tomographic SPECT | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 5 Original policy |
| 0332U | Oncology (pan-tumor), genetic profiling of 8 DNA-regulatory (epigenetic) markers by quantitative polymerase chain reaction (qPCR), whole blood, reported as a high or low proba | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 5 Original policy |