Anthem Blue Cross Blue Shield of California prior authorization, page 22
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 |
|---|---|---|
| 67901 | Repair of blepharoptosis; frontalis muscle technique with suture or other material (e.g., banked fascia) | California PPO Prior Authorization List, Pg 44 Original policy |
| 67902 | Repair of blepharoptosis; frontalis muscle technique with autologous fascial sling (includes obtaining fascia) | California PPO Prior Authorization List, Pg 45 Original policy |
| 67903 | Repair of blepharoptosis; (tarso) levator resection or advancement, internal approach | California PPO Prior Authorization List, Pg 45 Original policy |
| 67904 | Repair of blepharoptosis; (tarso) levator resection or advancement, external approach | California PPO Prior Authorization List, Pg 45 Original policy |
| 67906 | Repair of blepharoptosis; superior rectus technique with fascial sling (includes obtaining fascia) | California PPO Prior Authorization List, Pg 45 Original policy |
| 67908 | Repair of blepharoptosis; conjunctivo-tarso-Muller's muscle- levator resection (e.g., Fasanella-Servat type) | California PPO Prior Authorization List, Pg 45 Original policy |
| 69705 | Nasopharyngoscopy, surgical, with dilation of eustachian tube (i.e., balloon dilation); unilateral | California PPO Prior Authorization List, Pg 45 Original policy |
| 69706 | Nasopharyngoscopy, surgical, with dilation of eustachian tube (i.e., balloon dilation); bilateral | California PPO Prior Authorization List, Pg 45 Original policy |
| 69930 | Cochlear device implantation, with or without mastoidectomy | California PPO Prior Authorization List, Pg 45 Original policy |
| 72285 | Discography, cervical or thoracic, radiological supervision and interpretation | California PPO Prior Authorization List, Pg 45 Original policy |
| 76376 | 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality; not requiring image postprocessing on an independent workstation | California PPO Prior Authorization List, Pg 45 Original policy |
| 76377 | 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; requiring image postprocessing on an independent workstation | California PPO Prior Authorization List, Pg 45 Original policy |
| 77423 | High energy neutron radiation treatment delivery; 1 or more isocenter(s) with coplanar or non-coplanar geometry with blocking and/or wedge, and/or compensator(s) | California PPO Prior Authorization List, Pg 45 Original policy |
| 81313 | PCA3/KLK3 (prostate cancer antigen 3 [non-protein coding]/kallikrein-related peptidase 3 [prostate specific antigen]) ratio (e.g., prostate cancer) | California PPO Prior Authorization List, Pg 45 Original policy |
| 81401 | Molecular pathology procedure, Level 2 (e.g., 2-10 SNPs, 1 methylated variant, or 1 somatic variant [typically using nonsequencing target variant analysis], or detection of a dynamic mutation disorder/triplet repeat) | California PPO Prior Authorization List, Pg 45 Original policy |
| 81410 | Aortic dysfunction or dilation (e.g., Marfan syndrome, Loeys Dietz syndrome, Ehler Danlos syndrome type IV, arterial tortuosity syndrome); genomic sequence analysis panel, must include sequencing of at least 9 genes, including FBN1, TGFBR1, TGFBR2, COL3A1, MYH11, ACTA2, SLC2A10, SMAD3, and MYLK | California PPO Prior Authorization List, Pg 45 Original policy |
| 81411 | Aortic dysfunction or dilation (e.g., Marfan syndrome, Loeys Dietz syndrome, Ehler Danlos syndrome type IV, arterial tortuosity syndrome); duplication/ deletion analysis panel, must include analyses for TGFBR1, TGFBR2, MYH11, and COL3A1 | California PPO Prior Authorization List, Pg 45 Original policy |
| 81412 | Ashkenazi Jewish associated disorders (e.g., Bloom syndrome, Canavan disease, cystic fibrosis, familial dysautonomia, Fanconi anemia group C, Gaucher disease, Tay-Sachs disease), genomic sequence analysis panel, must include sequencing of at least 9 genes, including ASPA, BLM, CFTR, FANCC, GBA, HEXA, IKBKAP, MCOLN1, and SMPD1 | California PPO Prior Authorization List, Pg 46 Original policy |
| 81413 | Cardiac ion channelopathies (e.g., Brugada syndrome, long QT syndrome, short QT syndrome, catecholaminergic polymorphic ventricular tachycardia); genomic sequence analysis panel, must include sequencing of at least 10 genes, including ANK2, CASQ2, CAV3, KCN | California PPO Prior Authorization List, Pg 46 Original policy |
| 81415 | Exome (e.g., unexplained constitutional or heritable disorder or syndrome); sequence analysis | California PPO Prior Authorization List, Pg 46 Original policy |
| 81416 | Exome (e.g., unexplained constitutional or heritable disorder or syndrome); sequence analysis, each comparator exome (e.g., parents, siblings) (List separately in addition to code for primary procedure) | California PPO Prior Authorization List, Pg 46 Original policy |
| 81417 | Exome (e.g., unexplained constitutinoal or heritable disorder or syndrome); re-evaluation of previously obtained exome sequence (e.g., updated knowldege or unrelated condition/syndrome) | California PPO Prior Authorization List, Pg 46 Original policy |
| 81418 | Drug metabolism (e.g., pharmacogenomics) genomic sequence analysis panel, must include testing of at least 6 genes, including CYP2C19, CYP2D6, and CYP2D6 duplication/deletion analysis | California PPO Prior Authorization List, Pg 46 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, SCN8A, SLC2A1, SLC9A6, STXBP1, SYNGAP1, TCF4, TPP1, TSC1, TSC2, and ZEB2 | California PPO Prior Authorization List, Pg 46 Original policy |
| 81425 | Genome (e.g., unexplained constitutional or heritable disorder or syndrome); sequence analysis | California PPO Prior Authorization List, Pg 46 Original policy |
| 81426 | Genome (e.g., unexplained constitutional or heritable disorder or syndrome); sequence analysis, each comparator genome (e.g., parents, siblings) (List separately in addition to code for primary procedure) | California PPO Prior Authorization List, Pg 46 Original policy |
| 81427 | Genome (e.g., unexplained constitutional or heritable disorder or syndrome); re-evaluation of previously obtained genome sequence (e.g., updated knowledge or unrelated condition/syndrome) | California PPO Prior Authorization List, Pg 46 Original policy |
| 81430 | Hearing loss (e.g., nonsyndromic hearing loss, Usher syndrome, Pendred sydnrome); genomic sequence analysis panel, must include sequencing of at least 60 genes, including CDH23, CLRN1, GJB2, GPR98, MTRNR1, MYO7A, MYO15A, PCDH15, OTOF, SLC26A4, TMC1, TMPRSS3 | California PPO Prior Authorization List, Pg 46 Original policy |
| 81431 | Hearing loss (e.g., nonsyndromic hearing loss, Usher syndrome, Pendred sydnrome); duplication/deletion analysis panel, must include copy number analysis for STRC and DFNB1 deletions in GJB2 and GJB6 genes | California PPO Prior Authorization List, Pg 46 Original policy |
| 81432 | Hereditary breast cancer-related disorders (e.g., hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer, hereditary pancreatic cancer, hereditary prostate cancer), genomic sequence analysis panel, 5 or more genes, interrogation for sequence variants and copy number variants | California PPO Prior Authorization List, Pg 46 Original policy |
| 81434 | Hereditary retinal disorders (e.g., retinitis pigmentosa, Leber congenital amaurosis, cone-rod dystrophy), genomic sequence analysis panel, must include sequencing of at least 15 genes, including ABCA4, CNGA1, CRB1, EYS, PDE6A, PDE6B, PRPF31, PRPH2, RDH12, RHO, RP1, RP2, RPE65, RPGR, and USH2A | California PPO Prior Authorization List, Pg 46 Original policy |
| 81435 | Hereditary colon cancer-related disorders (e.g., Lynch syndrome, PTEN hamartoma syndrome, Cowden syndrome, familial adenomatosis polyposis), genomic sequence analysis panel, 5 or more genes, interrogation for sequence variants and copy number variants | California PPO Prior Authorization List, Pg 46 Original policy |
| 81437 | Hereditary neuroendocrine tumor-related disorders (e.g., medullary thyroid carcinoma, parathyroid carcinoma, malignant pheochromocytoma or paraganglioma), genomic sequence analysis panel, 5 or more genes, interrogation for sequence variants and copy number variants | California PPO Prior Authorization List, Pg 46 Original policy |
| 81439 | Inherited cardiomyopathy (e.g., hypertrophic cardiomyopathy, dilated cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy) genomic sequence analysis panel, must include sequencing of at least 5 genes, including DSG2, MYBPC3, MYH7, PKP2 and TTN | California PPO Prior Authorization List, Pg 47 Original policy |
| 81440 | Nuclear encoded mitochondrial genes (e.g., neurologic or myopathic phenotypes), genomic sequence panel, must include analysis of at least 100 genes, including BCS1L, C10orf2, COQ2, COX10, DGUOK, MPV17, OPA1, PDSS2, POLG, POLG2, RRM2B, SCO1, SCO2, SLC25A4, SUCLA2, SUCLG1, TAZ, TK2, and TYMP | California PPO Prior Authorization List, Pg 47 Original policy |
| 81441 | Inherited bone marrow failure syndromes (IBMFS) (e.g., Fanconi anemia, dyskeratosis congenita, Diamond-Blackfan anemia, Shwachman-Diamond syndrome, GATA2 deficiency syndrome, congenital amegakaryocytic thrombocytopenia) sequence analysis panel, must include sequencing of at least 30 genes, including BRCA2, BRIP1, DKC1, FANCA, FANCB, FANCC, FANCD2, FANCE, FANCF, FANCG, FANCI, FANCL, GATA1, GATA2, MPL, NHP2, NOP10, PALB2, RAD51C, RPL11, RPL35A, RPL5, RPS10, RPS19, RPS24, RPS26, RPS7, SBDS, TERT, and TINF2 | California PPO Prior Authorization List, Pg 47 Original policy |
| 81442 | Noonan spectrum disorders (e.g., Noonan syndrome, cardio- facio-cutaneous syndrome, Costello syndrome, LEOPARD syndrome, Noonan-like syndrome), genomic sequence analysis panel, must include sequencing of at least 12 genes, including BRAF, CBL, HRAS, KRAS, MAP2K1, MAP2K2, NRAS, PTPN11, RAF1, RIT1, SHOC2, and SOS1 | California PPO Prior Authorization List, Pg 47 Original policy |
| 81443 | Genetic testing for severe inherited conditions (e.g., cystic fibrosis, Ashkenazi Jewish-associated disorders [e.g., Bloom syndrome, Canavan disease, Fanconi anemia type C, mucolipidosis type VI, Gaucher disease, Tay-Sachs disease], beta hemoglobinopathies, phenylketonuria, galactosemia), genomic sequence analysis panel, must include sequencing of at least 15 genes (e.g., ACADM, ARSA, ASPA, ATP7B, BCKDHA, BCKDHB, BLM, CFTR, DHCR7, FANCC, G6PC, GAA, GALT, GBA, GBE1, HBB, HEXA, IKBKAP, MCOLN1, PAH) | California PPO Prior Authorization List, Pg 47 Original policy |
| 81445 | Solid organ neoplasm, 5-50 genes, interrogation for sequence variants and copy number variants or rearrangements, if performed; DNA analysis or combined DNA and RNA analysis | California PPO Prior Authorization List, Pg 47 Original policy |
| 81448 | Hereditary peripheral neuropathies (e.g., Charcot-Marie- Tooth, spastic paraplegia), genomic sequence analysis panel, must include sequencing of at least 5 peripheral neuropathy- related genes (e.g., BSCL2, GJB1, MFN2, MPZ, REEP1, SPAST, SPG11, SPTLC1) | California PPO Prior Authorization List, Pg 47 Original policy |
| 81449 | Targeted genomic sequence analysis panel, solid organ neoplasm, 5-50 genes (e.g., ALK, BRAF, CDKN2A, EGFR, ERBB2, KIT, KRAS, MET, NRAS, PDGFRA, PDGFRB, PGR, PIK3CA, PTEN, RET), interrogation for sequence variants and copy number variants or rearrangements, if performed; RNA analysis | California PPO Prior Authorization List, Pg 47 Original policy |
| 81450 | Hematolymphoid neoplasm or disorder, 5-50 genes, interrogation for sequence variants and copy number variants or rearrangements, or isoform expression or mRNA expression levels, if performed; DNA analysis or combined DNA and RNA analysis | California PPO Prior Authorization List, Pg 47 Original policy |
| 81451 | Hematolymphoid neoplasm or disorder, 5-50 genes, interrogation for sequence variants, and copy number variants or rearrangements, or isoform expression or mRNA expression levels, if performed; RNA analysis | California PPO Prior Authorization List, Pg 47 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 rearrangements, or isoform expression or mRNA expression levels, if performed; DNA analysis or combined DNA and RNA analysis | California PPO Prior Authorization List, Pg 47 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 rearrangements, or isoform expression or mRNA expression levels, if performed; RNA analysis | California PPO Prior Authorization List, Pg 47 Original policy |
| 81457 | Solid organ neoplasm, genomic sequence analysis panel, interrogation for sequence variants; DNA analysis, microsatellite instability | California PPO Prior Authorization List, Pg 47 Original policy |
| 81458 | Solid organ neoplasm, genomic sequence analysis panel, interrogation for sequence variants; DNA analysis, copy number variants and microsatellite instability | California PPO Prior Authorization List, Pg 47 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 instability, tumor mutation burden, and rearrangements | California PPO Prior Authorization List, Pg 48 Original policy |
| 81460 | Whole mitochondrial genome (e.g., Leigh syndrome, mitochondrial encephalomyopathy, lactic acidosis, and stroke- like episodes [MELAS], myoclonic epilepsy with ragged-red fibers [MERFF], neuropathy, ataxia, and retinitis pigmentosa [NARP], Leber hereditary optic neuropathy [LHON]), genomic sequence, must include sequence analysis of entire mitochondrial genome with heteroplasmy detection | California PPO Prior Authorization List, Pg 48 Original policy |
| 81462 | Solid organ neoplasm, genomic sequence analysis panel, cell- free nucleic acid (e.g., plasma), interrogation for sequence variants; DNA analysis or combined DNA and RNA analysis, copy number variants and rearrangements | California PPO Prior Authorization List, Pg 48 Original policy |