Anthem Blue Cross Blue Shield of California prior authorization, page 49
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 |
|---|---|---|
| 78481 | First pass tech; single study, wall motion study plus ejection fraction | California PPO Prior Authorization List, Pg 123 Original policy |
| 78483 | First pass tech; multiple studies, wall motion study plus ejection fraction | California PPO Prior Authorization List, Pg 123 Original policy |
| 78491 | PET myocardial, perfusion, single study | California PPO Prior Authorization List, Pg 123 Original policy |
| 78492 | PET myocardial, perfusion, multiple studies | California PPO Prior Authorization List, Pg 123 Original policy |
| 78494 | Gated equilibrium, SPECT, at rest, wall motion study plus ejection fraction | California PPO Prior Authorization List, Pg 123 Original policy |
| 78608 | PET brain, metabolic evaluation | California PPO Prior Authorization List, Pg 123 Original policy |
| 78609 | PET brain, perfusion evaluation | California PPO Prior Authorization List, Pg 123 Original policy |
| 78811 | PET imaging, limited | California PPO Prior Authorization List, Pg 123 Original policy |
| 78812 | PET imaging, skull to mid-thigh | California PPO Prior Authorization List, Pg 123 Original policy |
| 78813 | PET imaging, whole body | California PPO Prior Authorization List, Pg 123 Original policy |
| 78814 | PET imaging with concurrent CT, limited | California PPO Prior Authorization List, Pg 123 Original policy |
| 78815 | PET imaging with concurrent CT, skull to mid-thigh | California PPO Prior Authorization List, Pg 123 Original policy |
| 78816 | PET imaging with concurrent CT, whole body | California PPO Prior Authorization List, Pg 123 Original policy |
| 79101 | Radiopharmaceutical therapy, by intravenous administration [injection of Iobenguane I 131 (Azedra)] | California PPO Prior Authorization List, Pg 123 Original policy |
| 79403 | Radiopharmaceutical therapy, radiolabeled monoclonal antibody by intravenous infusion [when specified as injection of yttrium Y-90 ibritumomab tiuxetan (Zevalin)] | California PPO Prior Authorization List, Pg 123 Original policy |
| 81120 | IDH1 (isocitrate dehydrogenase 1 [NADP+], soluble) (e.g., glioma), common variants (e.g., R132H, R132C) | California PPO Prior Authorization List, Pg 124 Original policy |
| 81121 | IDH2 (isocitrate dehydrogenase 2 [NADP+], mitochondrial) (e.g., glioma), common variants (e.g., R140W, R172M) | California PPO Prior Authorization List, Pg 124 Original policy |
| 81161 | DMD (dystrophin) (e.g., Duchenne/Becker muscular dystrophy) deletion analysis, and duplication analysis, if performed | California PPO Prior Authorization List, Pg 124 Original policy |
| 81162 | (BRCA1, BRCA2 (breast cancer 1 and 2) (e.g., hereditary breast and ovarian cancer) gene analysis; full sequence analysis and full duplication/deletion analysis) | California PPO Prior Authorization List, Pg 124 Original policy |
| 81163 | BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (e.g., hereditary breast and ovarian cancer) gene analysis; full sequence analysis | California PPO Prior Authorization List, Pg 124 Original policy |
| 81164 | BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (e.g., hereditary breast and ovarian cancer) gene analysis; full duplication/deletion analysis (i.e., detection of large gene rearrangements) | California PPO Prior Authorization List, Pg 124 Original policy |
| 81165 | BRCA1 (BRCA1, DNA repair associated) (e.g., hereditary breast and ovarian cancer) gene analysis; full sequence analysis | California PPO Prior Authorization List, Pg 124 Original policy |
| 81166 | BRCA1 (BRCA1, DNA repair associated) (e.g., hereditary breast and ovarian cancer) gene analysis; full duplication/deletion analysis (i.e., detection of large gene rearrangements) | California PPO Prior Authorization List, Pg 124 Original policy |
| 81167 | BRCA2 (BRCA2, DNA repair associated) (e.g., hereditary breast and ovarian cancer) gene analysis; full duplication/deletion analysis (i.e., detection of large gene rearrangements) | California PPO Prior Authorization List, Pg 124 Original policy |
| 81170 | (ABL1 (ABL proto-oncogene 1, non-receptor tyrosine kinase) (e.g., acquired imatinib tyrosine kinase inhibitor resistance), gene analysis, variants in the kinase domain) | California PPO Prior Authorization List, Pg 124 Original policy |
| 81171 | AFF2 (AF4/FMR2 family, member 2 [FMR2]) (e.g., fragile X mental retardation 2 [FRAXE]) gene analysis; evaluation to detect abnormal (e.g., expanded) alleles | California PPO Prior Authorization List, Pg 124 Original policy |
| 81172 | AFF2 (AF4/FMR2 family, member 2 [FMR2]) (e.g., fragile X mental retardation 2 [FRAXE]) gene analysis; characterization of alleles (e.g., expanded size and methylation status) | California PPO Prior Authorization List, Pg 124 Original policy |
| 81173 | AR (androgen receptor) (e.g., spinal and bulbar muscular atrophy, Kennedy disease, X chromosome inactivation) gene analysis; full gene sequence | California PPO Prior Authorization List, Pg 124 Original policy |
| 81174 | AR (androgen receptor) (e.g., spinal and bulbar muscular atrophy, Kennedy disease, X chromosome inactivation) gene analysis; known familial variant | California PPO Prior Authorization List, Pg 124 Original policy |
| 81175 | ASXL1 (additional sex combs like 1, transcriptional regulator) (e.g., myelodysplastic syndrome, myeloproliferative neoplasms, chronic myelomonocytic leukemia), gene analysis; full gene sequence | California PPO Prior Authorization List, Pg 124 Original policy |
| 81176 | ASXL1 (additional sex combs like 1, transcriptional regulator) (e.g., myelodysplastic syndrome, myeloproliferative neoplasms, chronic myelomonocytic leukemia), gene analysis; targeted sequence analysis (e.g., exon 12) | California PPO Prior Authorization List, Pg 124 Original policy |
| 81177 | ATN1 (atrophin1) (e.g., dentatorubral-pallidoluysian atrophy) gene analysis, evaluation to detect abnormal (e.g., expanded) alleles | California PPO Prior Authorization List, Pg 124 Original policy |
| 81178 | ATXN1 (ataxin 1) (e.g., spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (e.g., expanded) alleles | California PPO Prior Authorization List, Pg 124 Original policy |
| 81179 | ATXN2 (ataxin 2) (e.g., spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (e.g., expanded) alleles | California PPO Prior Authorization List, Pg 125 Original policy |
| 81180 | ATXN3 (ataxin 3) (e.g., spinocerebellar ataxia, Machado- Joseph disease) gene analysis, evaluation to detect abnormal (e.g., expanded) alleles | California PPO Prior Authorization List, Pg 125 Original policy |
| 81181 | ATXN7 (ataxin 7) (e.g., spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (e.g., expanded) alleles | California PPO Prior Authorization List, Pg 125 Original policy |
| 81182 | ATXN8OS (ataxin 8 opposite strand [non-protein coding]) (e.g., spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (e.g., expanded) alleles | California PPO Prior Authorization List, Pg 125 Original policy |
| 81183 | ATXN10 (ataxin 10) (e.g., spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (e.g., expanded) alleles | California PPO Prior Authorization List, Pg 125 Original policy |
| 81184 | CACNA1A (calcium voltage-gated channel subunit alpha1 A) (e.g., spinocerebellar ataxia) gene analysis; evaluation to detect abnormal (e.g., expanded) alleles | California PPO Prior Authorization List, Pg 125 Original policy |
| 81185 | CACNA1A (calcium voltage-gated channel subunit alpha1 A) (e.g., spinocerebellar ataxia) gene analysis; full gene sequence | California PPO Prior Authorization List, Pg 125 Original policy |
| 81186 | CACNA1A (calcium voltage-gated channel subunit alpha1 A) (e.g., spinocerebellar ataxia) gene analysis; known familial variant | California PPO Prior Authorization List, Pg 125 Original policy |
| 81187 | CNBP (CCHC-type zinc finger nucleic acid binding protein) (e.g., mytonic dystrophy type 2) gene analysis, evaluation to detect abnormal (e.g., expanded alleles) | California PPO Prior Authorization List, Pg 125 Original policy |
| 81188 | CSTB (cystatin B) (e.g., Unverricht-Lundborg disease) gene analysis; evaluation to detect abnormal (e.g., expanded) alleles | California PPO Prior Authorization List, Pg 125 Original policy |
| 81189 | CSTB (cystatin B) (e.g., Unverricht-Lundborg disease) gene analysis; full gene sequence | California PPO Prior Authorization List, Pg 125 Original policy |
| 81190 | CSTB (cystatin B) (e.g., Unverricht-Lundborg disease) gene analysis; known familial variant(s) | California PPO Prior Authorization List, Pg 125 Original policy |
| 81191 | NTRK1 (neurotrophic receptor tyrosine kinase 1) (e.g., solid tumors) translocation analysis | California PPO Prior Authorization List, Pg 125 Original policy |
| 81192 | NTRK2 (neurotrophic receptor tyrosine kinase 2) (e.g., solid tumors) translocation analysis | California PPO Prior Authorization List, Pg 125 Original policy |
| 81193 | NTRK3 (neurotrophic receptor tyrosine kinase 3) (e.g., solid tumors) translocation analysis | California PPO Prior Authorization List, Pg 125 Original policy |
| 81194 | NTRK (neurotrophic-tropomyosin receptor tyrosine kinase 1, 2, and 3) (e.g., solid tumors) translocation analysis | California PPO Prior Authorization List, Pg 125 Original policy |
| 81195 | Cytogenomic (genome-wide) analysis, hematologic malignancy, structural variants and copy number variants, optical genome mapping (OGM) | California PPO Prior Authorization List, Pg 125 Original policy |