Anthem Blue Cross and Blue Shield Virginia prior authorization, page 5
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 |
|---|---|---|
| 0333U | Oncology (liver), surveillance for hepatocellular carcinoma (HCC) in high-risk patients, analysis of methylation patterns on circulating cell-free DNA (cfDNA) plus measurement | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 5 Original policy |
| 0334U | Oncology (solid organ), targeted genomic sequence analysis, formalin-fixed paraffin- embedded (FFPE) tumor tissue, DNA analysis, 84 or more genes, interrogation for sequence va | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 5 Original policy |
| 0335T | Insertion of sinus tarsi implant | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 5 Original policy |
| 0335U | Rare diseases (constitutional/heritable disorders), whole genome sequence analysis, including small sequence changes, copy number variants, deletions, duplications, mobile ele | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 5 Original policy |
| 0336U | Rare diseases (constitutional/heritable disorders), whole genome sequence analysis, including small sequence changes, copy number variants, deletions, duplications, mobile ele | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 5 Original policy |
| 0338T | Transcatheter renal sympathetic denervation, percutaneous approach including arterial puncture, selective catheter placement(s) renal artery(ies), fluoroscopy, contrast inject | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 5 Original policy |
| 0339T | Transcatheter renal sympathetic denervation, percutaneous approach including arterial puncture, selective catheter placement(s) renal artery(ies), fluoroscopy, contrast inject | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 5 Original policy |
| 0339U | Oncology (prostate), mRNA expression profiling of HOXC6 and DLX1, reverse transcription polymerase chain reaction (RT-PCR), first-void urine following digital rectal examinati | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 5 Original policy |
| 0340U | Oncology (pan-cancer), analysis of minimal residual disease (MRD) from plasma, with assays personalized to each patient based on prior next-generation sequencing of the patien | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 5 Original policy |
| 0342T | Therapeutic apheresis with selective HDL delipidation and plasma reinfusion | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 5 Original policy |
| 0343U | Oncology (prostate), exosome-based analysis of 442 small noncoding RNAs (sncRNAs) by quantitative reverse transcription polymerase chain reaction (RT-qPCR), urine, reported as | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 5 Original policy |
| 0344U | Hepatology (nonalcoholic fatty liver disease [NAFLD]), semiquantitative evaluation of 28 lipid markers by liquid chromatography with tandem mass spectrometry (LC-MS/MS), serum | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 5 Original policy |
| 0345T | Transcatheter mitral valve repair percutaneous approach via the coronary sinus | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 5 Original policy |
| 0345U | Psychiatry (eg, depression, anxiety, attention deficit hyperactivity disorder [ADHD]), genomic analysis panel, variant analysis of 15 genes, including deletion/duplication ana | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 5 Original policy |
| 0347U | Drug metabolism or processing (multiple conditions), whole blood or buccal specimen, DNA analysis, 16 gene report, with variant analysis and reported phenotypes | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 5 Original policy |
| 0348U | Drug metabolism or processing (multiple conditions), whole blood or buccal specimen, DNA analysis, 25 gene report, with variant analysis and reported phenotypes | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 5 Original policy |
| 0349U | Drug metabolism or processing (multiple conditions), whole blood or buccal specimen, DNA analysis, 27 gene report, with variant analysis, including reported phenotypes and imp | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 5 Original policy |
| 0350U | Drug metabolism or processing (multiple conditions), whole blood or buccal specimen, DNA analysis, 27 gene report, with variant analysis and reported phenotypes | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 5 Original policy |
| 0351T | Optical coherence tomography of breast or axillary lymph node, excised tissue, each specimen; real time intraoperative | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 5 Original policy |
| 0352T | Optical coherence tomography of breast or axillary lymph node, excised tissue, each specimen; interpretation and report, real time or referred | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 5 Original policy |
| 0353T | Optical coherence tomography of breast, surgical cavity; real time intraoperative | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 5 Original policy |
| 0354T | Optical coherence tomography of breast, surgical cavity; interpretation and report, real time or referred | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 5 Original policy |
| 0355U | APOL1 (apolipoprotein L1) (eg, chronic kidney disease), risk variants (G1, G2) | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 6 Original policy |
| 0356U | Oncology (oropharyngeal or anal), evaluation of 17 DNA biomarkers using droplet digital PCR (ddPCR), cell-free DNA, algorithm reported as a prognostic risk score for cancer re | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 6 Original policy |
| 0358U | Neurology (mild cognitive impairment), analysis of B-amyloid 1-42 and 1-40, chemiluminescence enzyme immunoassay, cerebral spinal fluid, reported as positive, likely positive | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 6 Original policy |
| 0359U | Oncology (prostate cancer), analysis of all prostate-specific antigen (PSA) structural isoforms by phase separation and immunoassay, plasma, algorithm reports risk of cancer | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 6 Original policy |
| 0360U | Oncology (lung), enzyme-linked immunosorbent assay (ELISA) of 7 autoantibodies (p53, NY- ESO-1, CAGE, GBU4-5, SOX2, MAGE A4, and HuD), plasma, algorithm reported as a categoric | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 6 Original policy |
| 0362T | Behavior identification supporting assessment, each 15 minutes of technicians' time face-to- face with a patient, requiring the following components: administration by the phys | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 6 Original policy |
| 0362U | Oncology (papillary thyroid cancer), gene-expression profiling via targeted hybrid captureenrichment RNA sequencing of 82 content genes and 10 housekeeping genes, formalin-fi | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 6 Original policy |
| 0363U | Oncology (urothelial), mRNA, gene-expression profiling by real-time quantitative PCR of 5 genes (MDK, HOXA13, CDC2 [CDK1], IGFBP5, and CXCR2), utilizing urine, algorithm incor | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 6 Original policy |
| 0364U | Oncology (hematolymphoid neoplasm), genomic sequence analysis using multiplex (PCR) and next-generation sequencing with algorithm, quantification of dominant clonal sequence(s | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 6 Original policy |
| 0368U | Oncology (colorectal cancer), evaluation for mutations of APC, BRAF, CTNNB1, KRAS, NRAS, PIK3CA, SMAD4, and TP53, and methylation markers (MYO1G, KCNQ5, C9ORF50, FLI1, CLIP4 | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 6 Original policy |
| 0373T | Adaptive behavior treatment with protocol modification, each 15 minutes of technicians' time face-to-face with a patient, requiring the following components: administration by | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 6 Original policy |
| 0376U | Oncology (prostate cancer), image analysis of at least 128 histologic features and clinical factors, prognostic algorithm determining the risk of distant metastases, and prost | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 6 Original policy |
| 0378T | Visual field assessment, with concurrent real time data analysis and accessible data storage with patient initiated data transmitted to a remote surveillance center for up to | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 6 Original policy |
| 0378U | RFC1 (replication factor C subunit 1), repeat expansion variant analysis by traditional and repeat-primed PCR, blood, saliva, or buccal swab | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 6 Original policy |
| 0379T | Visual field assessment, with concurrent real time data analysis and accessible data storage with patient initiated data transmitted to a remote surveillance center for up to | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 6 Original policy |
| 0379U | Targeted genomic sequence analysis panel, solid organ neoplasm, DNA (523 genes) and RNA (55 genes) by next-generation sequencing, interrogation for sequence variants, gene cop | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 6 Original policy |
| 0388U | Oncology (non-small cell lung cancer), next-generation sequencing with identification of single nucleotide variants, copy number variants, insertions and deletions, and struct | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 6 Original policy |
| 0389U | Pediatric febrile illness (Kawasaki disease [KD]), interferon alpha-inducible protein 27 (IFI27) and mast cell-expressed membrane protein 1 (MCEMP1), RNA, using reverse transc | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 6 Original policy |
| 0391U | Oncology (solid tumor), DNA and RNA by next-generation sequencing, utilizing formalin-fixed paraffin-embedded (FFPE) tissue, 437 genes, interpretive report for single nucleoti | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 6 Original policy |
| 0392U | Drug metabolism (depression, anxiety, attention deficit hyperactivity disorder [ADHD]), gene- drug interactions, variant analysis of 16 genes, including deletion/duplication an | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 6 Original policy |
| 0400U | Obstetrics (expanded carrier screening), 145 genes by nextgeneration sequencing, fragment analysis and multiplex ligationdependent probe amplification, DNA, reported as carrie | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 6 Original policy |
| 0401U | Cardiology (coronary heart disease [CAD]), 9 genes (12 variants), targeted variant genotyping, blood, saliva, or buccal swab, algorithm reported as a genetic risk score for a | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 6 Original policy |
| 0402T | Collagen cross-linking of cornea, including removal of the corneal epithelium, when performed, and intraoperative pachymetry, when performed | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 6 Original policy |
| 0403U | Oncology (prostate), mRNA, gene expression profiling of 18 genes, first-catch urine, algorithm reported as percentage of likelihood of detecting clinically significant prostat | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 6 Original policy |
| 0405U | Oncology (pancreatic), 59 methylation haplotype block markers, next-generation sequencing, plasma, reported as cancer signal detected or not detected | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 6 Original policy |
| 0407U | Nephrology (diabetic chronic kidney disease [CKD]), multiplex electrochemiluminescent immunoassay (ECLIA) of soluble tumor necrosis factor receptor 1 (sTNFR1), soluble tumor n | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 6 Original policy |
| 0408T | Insertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic pa | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 6 Original policy |
| 0409T | Insertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic pa | Virginia HMO/EPO standard precertification/prior authorization requirements, Pg 6 Original policy |