Anthem Blue Cross Blue Shield of California prior authorization, page 26
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 |
|---|---|---|
| 0953T | Totally implantable active middle ear hearing implant; revision or replacement, without mastoidectomy and replacement of sound processor | California PPO Prior Authorization List, Pg 56 Original policy |
| 0954T | Totally implantable active middle ear hearing implant; replacement of sound processor only, with attachment to existing transducers | California PPO Prior Authorization List, Pg 56 Original policy |
| 0955T | Totally implantable active middle ear hearing implant; removal, including removal of sound processor and all implant components | California PPO Prior Authorization List, Pg 56 Original policy |
| 0005U | Oncology (prostate) gene expression profile by real-time RT- PCR of 3 genes (ERG, PCA3, and SPDEF), urine, algorithm reported as risk score | California PPO Prior Authorization List, Pg 56 Original policy |
| 0019U | Oncology, RNA, gene expression by whole transcriptome sequencing, formalin-fixed paraffin embedded tissue or fresh frozen tissue, predictive algorithm reported as potential targets for therapeutic agents | California PPO Prior Authorization List, Pg 56 Original policy |
| 0022U | Targeted genomic sequence analysis panel, non-small cell lung neoplasia, DNA and RNA analysis, 23 genes, interrogation for sequence variants and rearrangements, reported as presence or absence of variants and associated therapy(ies) to consider | California PPO Prior Authorization List, Pg 56 Original policy |
| 0030U | Drug metabolism (warfarin drug response), targeted sequence analysis (i.e., CYP2C9, CYP4F2, VKORC1, rs12777823) | California PPO Prior Authorization List, Pg 57 Original policy |
| 0036U | Exome (i.e., somatic mutations), paired formalin-fixed paraffin- embedded tumor tissue and normal specimen, sequence analyses | California PPO Prior Authorization List, Pg 57 Original policy |
| 0037U | Targeted genomic sequence analysis, solid organ neoplasm, DNA analysis of 324 genes, interrogation for sequence variants, gene copy number amplifications, gene rearrangements, microsatellite instability and tumor mutational burden | California PPO Prior Authorization List, Pg 57 Original policy |
| 0047U | Oncology (prostate), mRNA, gene expression profiling by real- time RT-PCR of 17 genes (12 content and 5 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a risk score | California PPO Prior Authorization List, Pg 57 Original policy |
| 0048U | Oncology (solid organ neoplasia), DNA, targeted sequencing of protein-coding exons of 468 cancer-associated genes, including interrogation for somatic mutations and microsatellite instability, matched with normal specimens, utilizing formalin-fixed paraffin-embedded tumor tissue, report of clinically significant mutation(s) | California PPO Prior Authorization List, Pg 57 Original policy |
| 0050U | Targeted genomic sequence analysis panel, acute myelogenous leukemia, DNA analysis, 194 genes, interrogation for sequence variants, copy number variants or rearrangements | California PPO Prior Authorization List, Pg 57 Original policy |
| 0055U | Cardiology (heart transplant), cell-free DNA, PCR assay of 96 DNA target sequences (94 single nucleotide polymorphism targets and two control targets), plasma | California PPO Prior Authorization List, Pg 57 Original policy |
| 0069U | Oncology (colorectal), microRNA, RT-PCR expression profiling of miR-31-3p, formalin-fixed paraffin-embedded tissue, algorithm reported as an expression score | California PPO Prior Authorization List, Pg 57 Original policy |
| 0079U | Comparative DNA analysis using multiple selected single- nucleotide polymorphisms (SNPs), urine and buccal DNA, for specimen identity verification | California PPO Prior Authorization List, Pg 57 Original policy |
| 0087U | Cardiology (heart transplant), mRNA gene expression profiling by microarray of 1283 genes, transplant biopsy tissue, allograft rejection and injury algorithm reported as a probability score | California PPO Prior Authorization List, Pg 57 Original policy |
| 0089U | Oncology (melanoma), gene expression profiling by RTqPCR, PRAME and LINC00518, superficial collection using adhesive patch(es) | California PPO Prior Authorization List, Pg 57 Original policy |
| 0090U | Oncology (cutaneous melanoma), mRNA gene expression profiling by RT-PCR of 23 genes (14 content and 9 housekeeping), utilizing formalin-fixed paraffin-embedded (FFPE) tissue, algorithm reported as a categorical result (i.e., benign, intermediate, malignant) | California PPO Prior Authorization List, Pg 57 Original policy |
| 0094U | Genome (e.g., unexplained constitutional or heritable disorder or syndrome), rapid sequence analysis | California PPO Prior Authorization List, Pg 57 Original policy |
| 0101U | Hereditary colon cancer disorders (e.g., Lynch syndrome, PTEN hamartoma syndrome, Cowden syndrome, familial adenomatosis polyposis), genomic sequence analysis panel utilizing a combination of NGS, Sanger, MLPA, and array CGH, with MRNA analytics to resolve variants of unknown significance when indicated (15 genes [sequencing and deletion/duplication], EPCAM and GREM1 [deletion/duplication only]) | California PPO Prior Authorization List, Pg 57 Original policy |
| 0102U | Hereditary breast cancer-related disorders (e.g., hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer), genomic sequence analysis panel utilizing a combination of NGS, Sanger, MLPA, and array CGH, with MRNA analytics to resolve variants of unknown significance when indicated (17 genes [sequencing and deletion/duplication]) | California PPO Prior Authorization List, Pg 57 Original policy |
| 0103U | Hereditary ovarian cancer (e.g., hereditary ovarian cancer, hereditary endometrial cancer), genomic sequence analysis panel utilizing a combination of NGS, Sanger, MLPA, and array CGH, with MRNA analytics to resolve variants of unknown significance when indicated (24 genes [sequencing and deletion/duplication], EPCAM [deletion/duplication only]) | California PPO Prior Authorization List, Pg 57 Original policy |
| 0112U | Infectious agent detection and identification, targeted sequence analysis (16S and 18S rRNA genes) with drug- resistance gene | California PPO Prior Authorization List, Pg 57 Original policy |
| 0113U | Oncology (prostate), measurement of PCA3 and TMPRSS2- ERG in urine and PSA in serum following prostatic massage, by RNA amplification and fluorescence-based detection, algorithm reported as risk score | California PPO Prior Authorization List, Pg 58 Original policy |
| 0118U | Transplantation medicine, quantification of donor-derived cell- free DNA using whole genome next-generation sequencing, plasma, reported as percentage of donor-derived cell-free DNA in the total cell-free DNA [when specified for heart transplant rejection] | California PPO Prior Authorization List, Pg 58 Original policy |
| 0130U | Hereditary colon cancer disorders (e.g., Lynch syndrome, PTEN hamartoma syndrome, Cowden syndrome, familial adenomatosis polyposis), targeted mRNA sequence analysis panel (APC, CDH1, CHEK2, MLH1, MSH2, MSH6, MUTYH, PMS2, PTEN, and TP53) | California PPO Prior Authorization List, Pg 58 Original policy |
| 0134U | Hereditary pan cancer (e.g., hereditary breast and ovarian cancer, hereditary endometrial cancer, hereditary colorectal cancer), targeted mRNA sequence analysis panel (18 genes) (List separately in addition to code for primary procedure) | California PPO Prior Authorization List, Pg 58 Original policy |
| 0136U | ATM (ataxia telangiectasia mutated) (e.g., ataxia telangiectasia) mRNA sequence analysis | California PPO Prior Authorization List, Pg 58 Original policy |
| 0137U | PALB2 (partner and localizer of BRCA2) (e.g., breast and pancreatic cancer) mRNA sequence analysis | California PPO Prior Authorization List, Pg 58 Original policy |
| 0152U | Infectious disease (bacteria, fungi, parasites, and DNA viruses), DNA, plasma, untargeted next-generation sequencing, report for significant positive pathogens | California PPO Prior Authorization List, Pg 58 Original policy |
| 0173U | Psychiatry (i.e., depression, anxiety), genomic analysis panel, includes variant analysis of 14 genes | California PPO Prior Authorization List, Pg 58 Original policy |
| 0175U | Psychiatry (e.g., depression, anxiety), genomic analysis panel, variant analysis of 15 genes | California PPO Prior Authorization List, Pg 58 Original policy |
| 0179U | Oncology (non-small cell lung cancer), cell-free DNA, targeted sequence analysis of 23 genes (single nucleotide variations, insertions and deletions, fusions without prior knowledge of partner/breakpoint, copy number variations), with report of significant mutation(s) | California PPO Prior Authorization List, Pg 58 Original policy |
| 0203U | Autoimmune (inflammatory bowel disease), mRNA, gene expression profiling by quantitative RT-PCR, 17 genes (15 target and 2 reference genes), whole blood, reported as a continuous risk score and classification of inflammatory bowel disease aggressiveness | California PPO Prior Authorization List, Pg 58 Original policy |
| 0205U | Ophthalmology (age-related macular degeneration), analysis of 3 gene variants (2 CFH gene, 1 ARMS2 gene), using PCR and MALDI-TOF, buccal swab, reported as positive or negative for neovascular age-related macular-degeneration risk associated with zinc supplements | California PPO Prior Authorization List, Pg 58 Original policy |
| 0211U | Oncology (pan-tumor), DNA and RNA by next-generation sequencing, utilizing formalin-fixed paraffin-embedded tissue, interpretative report for single nucleotide variants, copy number alterations, tumor mutational burden, and microsatellite instability, with therapy association | California PPO Prior Authorization List, Pg 58 Original policy |
| 0212U | Rare diseases (constitutional/heritable disorders), whole genome and mitochondrial DNA sequence analysis, including small sequence changes, deletions, duplications, short tandem repeat gene expansions, and variants in non-uniquely mappable regions, blood or saliva, identification and categorization of genetic variants, proband | California PPO Prior Authorization List, Pg 58 Original policy |
| 0213U | Rare diseases (constitutional/heritable disorders), whole genome and mitochondrial DNA sequence analysis, including small sequence changes, deletions, duplications, short tandem repeat gene expansions, and variants in non-uniquely mappable regions, blood or saliva, identification and categorization of genetic variants, each comparator genome (e.g., parent, sibling) | California PPO Prior Authorization List, Pg 58 Original policy |
| 0214U | Rare diseases (constitutional/heritable disorders), whole exome and mitochondrial DNA sequence analysis, including small sequence changes, deletions, duplications, short tandem repeat gene expansions, and variants in non-uniquely mappable regions, blood or saliva, identification and categorization of genetic variants, proband | California PPO Prior Authorization List, Pg 58 Original policy |
| 0215U | Rare diseases (constitutional/heritable disorders), whole exome and mitochondrial DNA sequence analysis, including small sequence changes, deletions, duplications, short tandem repeat gene expansions, and variants in non-uniquely mappable regions, blood or saliva, identification and categorization of genetic variants, each comparator exome (e.g., parent, sibling) | California PPO Prior Authorization List, Pg 59 Original policy |
| 0216U | Neurology (inherited ataxias), genomic DNA sequence analysis of 12 common genes including small sequence changes, deletions, duplications, short tandem repeat gene expansions, and variants in non-uniquely mappable regions, blood or saliva, identification and categorization of genetic variants | California PPO Prior Authorization List, Pg 59 Original policy |
| 0217U | Neurology (inherited ataxias), genomic DNA sequence analysis of 51 genes including small sequence changes, deletions, duplications, short tandem repeat gene expansions, and variants in non-uniquely mappable regions, blood or saliva, identification and categorization of genetic variants | California PPO Prior Authorization List, Pg 59 Original policy |
| 0237U | Cardiac ion channelopathies (e.g., Brugada syndrome, long QT syndrome, short QT syndrome, catecholaminergic polymorphic ventricular tachycardia), genomic sequence analysis panel including ANK2, CASQ2, CAV3, KCNE1, KCNE2, KCNH2, KCNJ2, KCNQ1, RYR2, and SCN5A, including small sequence changes in exonic and intronic regions, deletions, duplications, mobile element insertions, and variants in non-uniquely mappable regions | California PPO Prior Authorization List, Pg 59 Original policy |
| 0238U | Oncology (Lynch syndrome), genomic DNA sequence analysis of MLH1, MSH2, MSH6, PMS2, and EPCAM, including small sequence changes in exonic and intronic regions, deletions, duplications, mobile element insertions, and variants in non-uniquely mappable regions | California PPO Prior Authorization List, Pg 59 Original policy |
| 0239U | Targeted genomic sequence analysis panel, solid organ neoplasm, cell-free DNA, analysis of 311 or more genes, interrogation for sequence variants, including substitutions, insertions, deletions, select rearrangements, and copy number variations | California PPO Prior Authorization List, Pg 59 Original policy |
| 0242U | Targeted genomic sequence analysis panel, solid organ neoplasm, cell-free circulating DNA analysis of 55-74 genes, interrogation for sequence variants, gene copy number amplifications, and gene rearrangements | California PPO Prior Authorization List, Pg 59 Original policy |
| 0244U | Oncology (solid organ), DNA, comprehensive genomic profiling, 257 genes, interrogation for single-nucleotide variants, insertions/deletions, copy number alterations, gene rearrangements, tumor-mutational burden and microsatellite instability, utilizing formalin-fixed paraffin-embedded tumor tissue | California PPO Prior Authorization List, Pg 59 Original policy |
| 0250U | Oncology (solid organ neoplasm), targeted genomic sequence DNA analysis of 505 genes, interrogation for somatic alterations (SNVs [single nucleotide variant], small insertions and deletions, one amplification, and four translocations), microsatellite instability and tumor-mutation burden | California PPO Prior Authorization List, Pg 59 Original policy |
| 0255U | Andrology (infertility), sperm-capacitation assessment of ganglioside GM1 distribution patterns, fluorescence microscopy, fresh or frozen specimen, reported as percentage of capacitated sperm and probability of generating a pregnancy score | California PPO Prior Authorization List, Pg 59 Original policy |
| 0260U | Rare diseases (constitutional/heritable disorders), identification of copy number variations, inversions, insertions, translocations, and other structural variants by optical genome mapping | California PPO Prior Authorization List, Pg 59 Original policy |