Anthem Blue Cross Blue Shield of California prior authorization, page 27
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 |
|---|---|---|
| 0262U | Oncology (solid tumor), gene expression profiling by real-time RT-PCR of 7 gene pathways (ER, AR, PI3K, MAPK, HH, TGFB, Notch), formalin-fixed paraffin-embedded (FFPE), algorithm reported as gene pathway activity score | California PPO Prior Authorization List, Pg 59 Original policy |
| 0264U | 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 |
| 0265U | Rare constitutional and other heritable disorders, whole genome and mitochondrial DNA sequence analysis, blood, frozen and formalin-fixed paraffin embedded (FFPE) tissue, saliva, buccal swabs or cell lines, identification of single nucleotide and copy number variants | California PPO Prior Authorization List, Pg 59 Original policy |
| 0266U | Unexplained constitutional or other heritable disorders or syndromes, tissue specific gene expression by whole transcriptome and next-generation sequencing, blood, formalin-fixed paraffin embedded (FFPE) tissue or fresh frozen tissue, reported as presence or absence of splicing or expression changes | California PPO Prior Authorization List, Pg 60 Original policy |
| 0267U | Rare constitutional and other heritable disorders, identification of copy number variations, inversions, insertions, translocations, and other structural variants by optical genome mapping and whole genome sequencing | California PPO Prior Authorization List, Pg 60 Original policy |
| 0268U | Hematology (atypical hemolytic uremic syndrome [aHUS]), genomic sequence analysis of 15 genes, blood, buccal swab, or amniotic fluid | California PPO Prior Authorization List, Pg 60 Original policy |
| 0269U | Hematology (autosomal dominant congenital thrombocytopenia), genomic sequence analysis of 14 genes, blood, buccal swab, or amniotic fluid | California PPO Prior Authorization List, Pg 60 Original policy |
| 0270U | Hematology (congenital coagulation disorders), genomic sequence analysis of 20 genes, blood, buccal swab, or amniotic fluid | California PPO Prior Authorization List, Pg 60 Original policy |
| 0271U | Hematology (congenital neutropenia), genomic sequence analysis of 23 genes, blood, buccal swab, or amniotic fluid | California PPO Prior Authorization List, Pg 60 Original policy |
| 0272U | Hematology (genetic bleeding disorders), genomic sequence analysis of 51 genes, blood, buccal swab, or amniotic fluid, comprehensive | California PPO Prior Authorization List, Pg 60 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 swab, or amniotic fluid | California PPO Prior Authorization List, Pg 60 Original policy |
| 0274U | Hematology (genetic platelet disorders), genomic sequence analysis of 43 genes, blood, buccal swab, or amniotic fluid | California PPO Prior Authorization List, Pg 60 Original policy |
| 0276U | Hematology (inherited thrombocytopenia), genomic sequence analysis of 42 genes, blood, buccal swab, or amniotic fluid | California PPO Prior Authorization List, Pg 60 Original policy |
| 0277U | Hematology (genetic platelet function disorder), genomic sequence analysis of 31 genes, blood, buccal swab, or amniotic fluid | California PPO Prior Authorization List, Pg 60 Original policy |
| 0278U | Hematology (genetic thrombosis), genomic sequence analysis of 12 genes, blood, buccal swab, or amniotic fluid | California PPO Prior Authorization List, Pg 60 Original policy |
| 0297U | Oncology (pan tumor), whole genome sequencing of paired malignant and normal DNA specimens, fresh or formalinfixed paraffin-embedded (FFPE) tissue, blood or bone marrow, comparative sequence analyses and variant identification | California PPO Prior Authorization List, Pg 60 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 marrow, comparative sequence analyses and expression level and chimeric transcript identification | California PPO Prior Authorization List, Pg 60 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 variant identification | California PPO Prior Authorization List, Pg 60 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 sequence analyses and variant identification | California PPO Prior Authorization List, Pg 60 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 future comparisons to evaluate for MRD | California PPO Prior Authorization List, Pg 60 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 previously analyzed patient specimens to evaluate for MRD | California PPO Prior Authorization List, Pg 60 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, algorithm reported as a categorical result (i.e., benign, intermediate, malignant) | California PPO Prior Authorization List, Pg 61 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 (FFPE) tissue, algorithm reported as a categorical risk result (i.e., Class 1, Class 2A, Class 2B) | California PPO Prior Authorization List, Pg 61 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 pathogenic bacteria, viruses, parasites, or fungi | California PPO Prior Authorization List, Pg 61 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 amplifications, gene rearrangements, microsatellite instability and tumor mutational burden | California PPO Prior Authorization List, Pg 61 Original policy |
| 0329U | Oncology (neoplasia), exome and transcriptome sequence analysis for sequence variants, gene copy number amplifications and deletions, gene rearrangements, microsatellite instability and tumor mutational burden utilizing DNA and RNA from tumor with and DNA from normal blood or saliva for subtraction, report of clinically significant mutation(s) with therapy associations | California PPO Prior Authorization List, Pg 61 Original policy |
| 0331U | Oncology (hematolymphoid neoplasia), optical for copy number alterations and gene rearrangements utilizing DNA from blood or bone marrow, report of clinically significant alternations | California PPO Prior Authorization List, Pg 61 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 probability of responding to immune checkpointinhibitor therapy | California PPO Prior Authorization List, Pg 61 Original policy |
| 0333U | Oncology (liver), surveillance for hepatocellular carcinoma (HCC) in high-risk patients, analysis of methylation patterns on circulating cell-free DNA (cfDNA) plus measurement of serum of AFP/AFP-L3 and oncoprotein des-gamma-carboxy- prothrombin (DCP), algorithm reported as normal or abnormal result | California PPO Prior Authorization List, Pg 61 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 variants, gene copy number amplifications, gene rearrangements, microsatellite instability and tumor mutational burden | California PPO Prior Authorization List, Pg 61 Original policy |
| 0335U | Rare diseases (constitutional/heritable disorders), whole genome sequence analysis, including small sequence changes, copy number variants, deletions, duplications, mobile element insertions, uniparental disomy (UPD), inversions, aneuploidy, mitochondrial genome sequence analysis with heteroplasmy and large deletions, short tandem repeat (STR) gene expansions, fetal sample, identification and categorization of genetic variants | California PPO Prior Authorization List, Pg 61 Original policy |
| 0336U | Rare diseases (constitutional/heritable disorders), whole genome sequence analysis, including small sequence changes, copy number variants, deletions, duplications, mobile element insertions, uniparental disomy (UPD), inversions, aneuploidy, mitochondrial genome sequence analysis with heteroplasmy and large deletions, short tandem repeat (STR) gene expansions, blood or saliva, identification and categorization of genetic variants, each comparator genome (e.g., parent) | California PPO Prior Authorization List, Pg 61 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 examination, algorithm reported as probability of high-grade cancer | California PPO Prior Authorization List, Pg 61 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 patient’s tumor and germline DNA, reported as absence or presence of MRD, with disease-burden correlation, if appropriate | California PPO Prior Authorization List, Pg 61 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 molecular evidence of no-, low-, intermediate- or high-risk of prostate cancer | California PPO Prior Authorization List, Pg 61 Original policy |
| 0345U | Psychiatry (e.g., depression, anxiety, attention deficit hyperactivity disorder [ADHD]), genomic analysis panel, variant analysis of 15 genes, including deletion/duplication analysis of CYP2D6 | California PPO Prior Authorization List, Pg 62 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 | California PPO Prior Authorization List, Pg 62 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 | California PPO Prior Authorization List, Pg 62 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 impacted gene-drug interactions | California PPO Prior Authorization List, Pg 62 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 | California PPO Prior Authorization List, Pg 62 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 recurrence | California PPO Prior Authorization List, Pg 62 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 incorporates age, sex, smoking history, and macrohematuria frequency, reported as a risk score for having urothelial carcinoma | California PPO Prior Authorization List, Pg 62 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, ZNF132 and TWIST1), multiplex quantitative polymerase chain reaction (qPCR), circulating cell-free DNA (cfDNA), plasma, report of risk score for advanced adenoma or colorectal cancer | California PPO Prior Authorization List, Pg 62 Original policy |
| 0379U | Targeted genomic sequence analysis panel, solid organ neoplasm, DNA (523 genes) and RNA (55 genes) by nextgeneration sequencing, interrogation for sequence variants, gene copy number amplifications, gene rearrangements, microsatellite instability, and tumor mutational burden | California PPO Prior Authorization List, Pg 62 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 structural variants in 37 cancer-related genes, plasma, with report for alteration detection | California PPO Prior Authorization List, Pg 62 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 nucleotide variants, splice-site variants, insertions/deletions, copy number alterations, gene fusions, tumor mutational burden, and microsatellite instability, with algorithm quantifying immunotherapy response score | California PPO Prior Authorization List, Pg 62 Original policy |
| 0392U | Drug metabolism (depression, anxiety, attention deficit hyperactivity disorder [ADHD]), gene-drug interactions, variant analysis of 16 genes, including deletion/duplication analysis of CYP2D6, reported as impact of gene-drug interaction for each drug | California PPO Prior Authorization List, Pg 62 Original policy |
| 0400U | Obstetrics (expanded carrier screening), 145 genes by next- generation sequencing, fragment analysis and multiplex ligation-dependent probe amplification, DNA, reported as carrier positive or negative | California PPO Prior Authorization List, Pg 62 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 coronary event | California PPO Prior Authorization List, Pg 62 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 prostate cancer | California PPO Prior Authorization List, Pg 62 Original policy |