Anthem Blue Cross Blue Shield of California prior authorization, page 23
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 |
|---|---|---|
| 81463 | Solid organ neoplasm, genomic sequence analysis panel, cell- free nucleic acid (e.g., plasma), interrogation for sequence variants; DNA analysis, copy number variants, and microsatellite instability | California PPO Prior Authorization List, Pg 48 Original policy |
| 81464 | 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, microsatellite instability, tumor mutation burden, and rearrangements | California PPO Prior Authorization List, Pg 48 Original policy |
| 81465 | Whole mitochondrial genome large deletion analysis panel (e.g., Kearns-Sayre syndrome, chronic progressive external ophthalmoplegia), including heteroplasmy detection, if performed. | California PPO Prior Authorization List, Pg 48 Original policy |
| 81470 | X-linked intellectual disability (XLID) (e.g., syndromic and non- syndromic XLID); genomic sequence analysis panel, must include sequencing of at least 60 genes, including ARX, ATRX, CDKL5, FGD1, FMR1, HUWE1,IL1RAPL, KDM5C,L1CAM, MECP2, MED12, MID1, OCRL, RPS6KA3, and SLC16A2 | California PPO Prior Authorization List, Pg 48 Original policy |
| 81471 | X-linked intellectual disability (XLID) (e.g., syndromic and non- syndromic XLID); genomic sequence analysis panel, must include sequencing of at least 60 genes, including ARX, ATRX, CDKL5, FGD1, FMR1, HUWE1,IL1RAPL, KDM5C,L1CAM, MECP2, MED12, MID1, OCRL, RPS6KA3, and SLC16A2 | California PPO Prior Authorization List, Pg 48 Original policy |
| 81479 | Unlisted molecular pathology procedure | California PPO Prior Authorization List, Pg 48 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 | California PPO Prior Authorization List, Pg 48 Original policy |
| 81504 | Oncology (tissue of origin), microarray gene expression profiling of > 2000 genes, utilizing formalin-fixed paraffin- embedded tissue, algorithm reported as tissue similarity scores | California PPO Prior Authorization List, Pg 48 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 reported as a recurrence score | California PPO Prior Authorization List, Pg 48 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 tissue, algorithm reported as recurrence risk, including likelihood of sentinel lymph node metastasis | California PPO Prior Authorization List, Pg 48 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 subtype, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a probability of a predicted main cancer type and subtype | California PPO Prior Authorization List, Pg 49 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, algorithm reported as a disease-specific mortality risk score | California PPO Prior Authorization List, Pg 49 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 score | California PPO Prior Authorization List, Pg 49 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 a likelihood of prostate cancer detection on repeat biopsy | California PPO Prior Authorization List, Pg 49 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 paraffin-embedded tissue, algorithm reported as risk of metastasis | California PPO Prior Authorization List, Pg 49 Original policy |
| 81554 | Pulmonary disease (idiopathic pulmonary fibrosis [IPF]), mRNA, gene expression analysis of 190 genes, utilizing transbronchial biopsies, diagnostic algorithm reported as categorical result (e.g., positive or negative for high probability of usual interstitial pneumonia [UIP]) | California PPO Prior Authorization List, Pg 49 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 blood, algorithm reported as a rejection risk score | California PPO Prior Authorization List, Pg 49 Original policy |
| 86357 | Natural killer (NK) cells, total count | California PPO Prior Authorization List, Pg 49 Original policy |
| 89329 | Sperm evaluation; hamster penetration test | California PPO Prior Authorization List, Pg 49 Original policy |
| 89290 | Biopsy, oocyte polar body or embryo blastomere, microtechnique (for preimplantation genetic diagnosis); less than or equal to 5 embryos | California PPO Prior Authorization List, Pg 49 Original policy |
| 89291 | Biopsy, oocyte polar body or embryo blastomere, microtechnique (for preimplantation genetic diagnosis); greater than 5 embryos | California PPO Prior Authorization List, Pg 49 Original policy |
| 89330 | Sperm evaluation; cervical mucus penetration test, with or without spinnbarkeit test | California PPO Prior Authorization List, Pg 49 Original policy |
| 91112 | Gastrointestinal transit and pressure measurement, stomach through colon, wireless capsule, with interpretation and report | California PPO Prior Authorization List, Pg 49 Original policy |
| 93145 | Interrogation device evaluation (in person), carotid sinus baroreflex activation therapy (BAT) modulation system including telemetric iterative communication with the implantable device to monitor device diagnostics and programmed therapy values, with interpretation and report (e.g., battery status, lead impedance, pulse amplitude, pulse width, therapy frequency, pathway mode, burst mode, therapy start/stop times each day); without programming | California PPO Prior Authorization List, Pg 49 Original policy |
| 93146 | Interrogation device evaluation (in person), carotid sinus baroreflex activation therapy (BAT) modulation system including telemetric iterative communication with the implantable device to monitor device diagnostics and programmed therapy values, with interpretation and report (e.g., battery status, lead impedance, pulse amplitude, pulse width, therapy frequency, pathway mode, burst mode, therapy start/stop times each day); with programming, including optimization of tolerated therapeutic level setting | California PPO Prior Authorization List, Pg 49 Original policy |
| 93264 | Remote monitoring of a wireless pulmonary artery pressure sensor for up to 30 days, including at least weekly downloads of pulmonary artery pressure recordings, interpretation(s), trend analysis, and report(s) by a physician or other qualified health care professional | California PPO Prior Authorization List, Pg 49 Original policy |
| 93580 | Percutaneous transcatheter closure of congenital interatrial communication (i.e., Fontan fenestration, atrial septal defect) with implant | California PPO Prior Authorization List, Pg 49 Original policy |
| 93640 | Electrophysiologic evaluation of single or dual chamber pacing cardioverter-defibrillator leads including defibrillation threshold evaluation (induction of arrhythmia evaluation of sensing and pacing for arrhythmia termination) at time of initial implantation or replacement | California PPO Prior Authorization List, Pg 50 Original policy |
| 93641 | Electrophysiologic evaluation of single or dual chamber pacing cardioverter-defibrillator leads including defibrillation threshold evaluation (induction of arrhythmia evaluation of sensing and pacing for arrhythmia termination) at time of initial implantation or replacement; with testing of single or dual chamber pacing cardioverter-defibrillator pulse generator | California PPO Prior Authorization List, Pg 50 Original policy |
| 93701 | Bioimpedance-derived physiologic cardiovascular analysis | California PPO Prior Authorization List, Pg 50 Original policy |
| 95905 | Motor and/or sensory nerve conduction, using preconfigured electrode array(s), amplitude and latency/velocity study, each limb, includes F-wave study when performed, with interpretation and report | California PPO Prior Authorization List, Pg 50 Original policy |
| 95976 | Electronic analysis of implanted neurostimulator pulse generator/transmitter (e.g., contact group[s], interleaving, amplitude, pulse width, frequency [Hz], on/off cycling, burst, magnet mode, dose lockout, patient selectable parameters, responsive neurostimulation, detection algorithms, closed loop parameters, and passive parameters) by physician or other qualified health care professional; with simple cranial nerve neurostimulator pulse generator/transmitter programming by physician or other qualified health care professional | California PPO Prior Authorization List, Pg 50 Original policy |
| 95977 | Electronic analysis of implanted neurostimulator pulse generator/transmitter (e.g., contact group[s], interleaving, amplitude, pulse width, frequency [Hz], on/off cycling, burst, magnet mode, dose lockout, patient selectable parameters, responsive neurostimulation, detection algorithms, closed loop parameters, and passive parameters) by physician or other qualified health care professional; with complex cranial nerve neurostimulator pulse generator/transmitter programming by physician or other qualified health care professional | California PPO Prior Authorization List, Pg 50 Original policy |
| 96904 | Whole body integumentary photography, for monitoring of high risk patients with dysplastic nevus syndrome or a history of dysplastic nevi, or patients with a personal or familial history of melanoma | California PPO Prior Authorization List, Pg 50 Original policy |
| 96931 | Reflectance confocal microscopy (RCM) for cellular and sub- cellular imaging of skin; image acquisition and interpretation and report, first lesion | California PPO Prior Authorization List, Pg 50 Original policy |
| 96932 | Reflectance confocal microscopy (RCM) for cellular and sub- cellular imaging of skin; image acquisition only, first lesion | California PPO Prior Authorization List, Pg 50 Original policy |
| 96933 | Reflectance confocal microscopy (RCM) for cellular and sub- cellular imaging of skin; interpretation and report only, first lesion | California PPO Prior Authorization List, Pg 50 Original policy |
| 96934 | Reflectance confocal microscopy (RCM) for cellular and sub- cellular imaging of skin; image acquisition and interpretation and report, each additional lesion | California PPO Prior Authorization List, Pg 50 Original policy |
| 96935 | Reflectance confocal microscopy (RCM) for cellular and sub- cellular imaging of skin; image acquisition only, each additional lesion | California PPO Prior Authorization List, Pg 50 Original policy |
| 96936 | Reflectance confocal microscopy (RCM) for cellular and sub- cellular imaging of skin; interpretation and report only, each additional lesion | California PPO Prior Authorization List, Pg 50 Original policy |
| 99183 | Physician attendance and supervision of hyperbaric oxygen therapy, per session | California PPO Prior Authorization List, Pg 50 Original policy |
| 0011M | Oncology, prostate cancer, mRNA expression assay of 12 genes (10 content and 2 housekeeping), RT-PCR test utilizing blood plasma and/or urine, algorithms to predict high-grade prostate cancer risk | California PPO Prior Authorization List, Pg 50 Original policy |
| 0012M | Oncology (urothelial), mRNA, gene expression profiling by real-time quantitative PCR of five genes (MDK, HOXA13, CDC2 [CDK1], IGFBP5, and CXCR2), utilizing urine, algorithm reported as a risk score for having urothelial carcinoma | California PPO Prior Authorization List, Pg 50 Original policy |
| 0013M | Oncology (urothelial), mRNA, gene expression profiling by real-time quantitative PCR of five genes (MDK, HOXA13, CDC2 [CDK1], IGFBP5, and CXCR2), utilizing urine, algorithm reported as a risk score for having recurrent urothelial carcinoma | California PPO Prior Authorization List, Pg 50 Original policy |
| 0016M | Oncology (bladder), mRNA, microarray gene expression profiling of 209 genes, utilizing formalin-fixed paraffin- embedded tissue, algorithm reported as molecular subtype (luminal, luminal infiltrated, basal, basal claudin-low, neuroendocrine-like) | California PPO Prior Authorization List, Pg 51 Original policy |
| 0071T | Focused ultrasound ablation of uterine leiomyomata, including MR guidance; total leiomyomata volume less than 200 cc of tissue | California PPO Prior Authorization List, Pg 51 Original policy |
| 0072T | Focused ultrasound ablation of uterine leiomyomata, including MR guidance; total leiomyomata volume greater or equal to 200 cc of tissue | California PPO Prior Authorization List, Pg 51 Original policy |
| 0101T | Extracorporeal shock wave involving musculoskeletal system, not otherwise specified | California PPO Prior Authorization List, Pg 51 Original policy |
| 0102T | Extracorporeal shock wave, performed by a physician, requiring anesthesia other than local, and involving the lateral humeral epicondyle | California PPO Prior Authorization List, Pg 51 Original policy |
| 0106T | Quantitative sensory testing (QST), testing and interpretation per extremity; using touch pressure stimuli to assess large diameter sensation | California PPO Prior Authorization List, Pg 51 Original policy |