Anthem Blue Cross Blue Shield of California prior authorization, page 50
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 |
|---|---|---|
| 81200 | ASPA (aspartoacylase) (e.g., Canavan disease) gene analysis, common variants (e.g., E285A, Y231X) | California PPO Prior Authorization List, Pg 125 Original policy |
| 81201 | APC (adenomatous polyposis coli) (e.g., familial adenomatosis polyposis [FAP], attenuated FAP) gene analysis; full gene sequence | California PPO Prior Authorization List, Pg 126 Original policy |
| 81202 | APC (adenomatous polyposis coli) (e.g., familial adenomatosis polyposis [FAP], attenuated FAP) gene analysis; known familial variants | California PPO Prior Authorization List, Pg 126 Original policy |
| 81203 | APC (adenomatous polyposis coli) (e.g., familial adenomatosis polyposis [FAP], attenuated FAP) gene analysis; duplication/deletion variants | California PPO Prior Authorization List, Pg 126 Original policy |
| 81204 | AR (androgen receptor) (e.g., spinal and bulbar muscular atrophy, Kennedy disease, X chromosome inactivation) gene analysis; characterization of alleles (e.g., expanded size or methylation status) | California PPO Prior Authorization List, Pg 126 Original policy |
| 81205 | BCKDHB (branched-chain keto acid dehydrogenase E1, beta polypeptide) (e.g., maple syrup urine disease) gene analysis, common variants (e.g., R183P, G278S, E422X) | California PPO Prior Authorization List, Pg 126 Original policy |
| 81206 | BCR/ABL1 (t(9;22)) (e.g., chronic myelogenous leukemia) translocation analysis; major breakpoint, qualitative or quantitative | California PPO Prior Authorization List, Pg 126 Original policy |
| 81207 | BCR/ABL1 (t(9;22)) (e.g., chronic myelogenous leukemia) translocation analysis; minor breakpoint, qualitative or quantitative | California PPO Prior Authorization List, Pg 126 Original policy |
| 81208 | BCR/ABL1 (t(9;22)) (e.g., chronic myelogenous leukemia) translocation analysis; other breakpoint, qualitative or quantitative | California PPO Prior Authorization List, Pg 126 Original policy |
| 81209 | BLM (Bloom syndrome, RecQ helicase-like) (e.g., Bloom syndrome) gene analysis, 2281del6ins7 variant | California PPO Prior Authorization List, Pg 126 Original policy |
| 81210 | BRAF (v-raf murine sarcoma viral oncogene homolog B1) (e.g., colon cancer), gene analysis, V600E variant | California PPO Prior Authorization List, Pg 126 Original policy |
| 81212 | BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated (e.g., hereditary breast and ovarian cancer) gene analysis; 185delAG, 5385insC, 6174delT variants | California PPO Prior Authorization List, Pg 126 Original policy |
| 81215 | BRCA1 (BRCA1, DNA repair associated) (e.g., hereditary breast and ovarian cancer) gene analysis; known familial variant | California PPO Prior Authorization List, Pg 126 Original policy |
| 81216 | BRCA2 (BRCA2, DNA repair associated) (e.g., hereditary breast and ovarian cancer) gene analysis; full sequence analysis | California PPO Prior Authorization List, Pg 126 Original policy |
| 81217 | BRCA2 (BRCA2, DNA repair associated) (e.g., hereditary breast and ovarian cancer) gene analysis; known familial variant | California PPO Prior Authorization List, Pg 126 Original policy |
| 81218 | CEBPA (CCAAT/enhancer binding protein [C/EBP], alpha) (e.g., acute myeloid leukemia), full gene sequence | California PPO Prior Authorization List, Pg 126 Original policy |
| 81219 | CALR (calreticulin) (e.g., myeloproliferative disorders), gene analysis, common variants in exon 9 | California PPO Prior Authorization List, Pg 126 Original policy |
| 81220 | CFTR (cystic fibrosis transmembrane conductance regulator) (e.g., cystic fibrosis) gene analysis; common variants (e.g., ACMG/ACOG guidelines) | California PPO Prior Authorization List, Pg 126 Original policy |
| 81221 | CFTR (cystic fibrosis transmembrane conductance regulator) (e.g., cystic fibrosis) gene analysis; known familial variants | California PPO Prior Authorization List, Pg 126 Original policy |
| 81222 | CFTR (cystic fibrosis transmembrane conductance regulator) (e.g., cystic fibrosis) gene analysis; duplication/deletion variants | California PPO Prior Authorization List, Pg 127 Original policy |
| 81223 | CFTR (cystic fibrosis transmembrane conductance regulator) (e.g., cystic fibrosis) gene analysis; full gene sequence | California PPO Prior Authorization List, Pg 127 Original policy |
| 81224 | CFTR (cystic fibrosis transmembrane conductance regulator) (e.g., cystic fibrosis) gene analysis; intron 8 poly-T analysis (e.g., male infertility) | California PPO Prior Authorization List, Pg 127 Original policy |
| 81225 | CYP2C19 (cytochrome P450, family 2, subfamily C, polypeptide 19) (e.g., drug metabolism), gene analysis, common variants (e.g., *2, *3, *4, *8, *17) | California PPO Prior Authorization List, Pg 127 Original policy |
| 81226 | CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (e.g., drug metabolism), gene analysis, common variants (e.g., *2, *3, *4, *5, *6, *9, *10, *17, *19, *29, *35, *41, *1XN, *2XN, *4XN) | California PPO Prior Authorization List, Pg 127 Original policy |
| 81227 | CYP2C9 (cytochrome P450, family 2, subfamily C, polypeptide 9) (e.g., drug metabolism), gene analysis, common variants (e.g., *2, *3, *5, *6) | California PPO Prior Authorization List, Pg 127 Original policy |
| 81228 | Cytogenomic (genome-wide) analysis for constitutional chromosomal abnormalities; interrogation of genomic regions for copy number variants, comparative genomic hybridization (CGH) microarray analysis | California PPO Prior Authorization List, Pg 127 Original policy |
| 81229 | Cytogenomic (genome-wide) analysis for constitutional chromosomal abnormalities; interrogation of genomic regions for copy number and single nucleotide polymorphism (SNP) variants, comparative genomic hybridization (CGH) microarray analysis | California PPO Prior Authorization List, Pg 127 Original policy |
| 81230 | CYP3A4 (cytochrome P450 family 3 subfamily A member 4) (e.g., drug metabolism), gene analysis, common variant(s) (e.g., *2, *22) | California PPO Prior Authorization List, Pg 127 Original policy |
| 81231 | CYP3A5 (cytochrome P450 family 3 subfamily A member 5) (e.g., drug metabolism), gene analysis, common variants (e.g., *2, *3, *4, *5, *6, *7) | California PPO Prior Authorization List, Pg 127 Original policy |
| 81232 | DPYD (dihydropyrimidine dehydrogenase) (e.g., 5- fluorouracil/5-FU and capecitabine drug metabolism), gene analysis, common variant(s) (e.g., *2A, *4, *5, *6) | California PPO Prior Authorization List, Pg 127 Original policy |
| 81233 | BTK (Bruton's tyrosine kinase) (e.g., chronic lymphocytic leukemia) gene analysis, common variants (e.g., C481S, C481R, C481F) | California PPO Prior Authorization List, Pg 127 Original policy |
| 81234 | DMPK (DM1 protein kinase) (e.g., myotonic dystrophy type 1) gene analysis; evaluation to detect abnormal (expanded) alleles | California PPO Prior Authorization List, Pg 127 Original policy |
| 81235 | EGFR (epidermal growth factor receptor) (e.g., non-small cell lung cancer) gene analysis, common variants (e.g., exon 19 LREA deletion, L858R, T790M, G719A, G719S, L861Q) | California PPO Prior Authorization List, Pg 127 Original policy |
| 81236 | EZH2 (enhancer of zeste 2 polycomb repressive complex 2 subunit) (e.g., myelodysplastic syndrome, myeloproliferative neoplasms) gene analysis, full gene sequence | California PPO Prior Authorization List, Pg 127 Original policy |
| 81237 | EZH2 (enhancer of zeste 2 polycomb repressive complex 2 subunit) (e.g., diffuse large B-cell lymphoma) gene analysis, common variant(s) (e.g., codon 646) | California PPO Prior Authorization List, Pg 127 Original policy |
| 81239 | DMPK (DM1 protein kinase) (e.g., myotonic dystrophy type 1) gene analysis; characterization of alleles (e.g., expanded size) | California PPO Prior Authorization List, Pg 127 Original policy |
| 81240 | F2 (prothrombin, coagulation factor II) (e.g., hereditary hypercoagulability) gene analysis, 20210G>A variant | California PPO Prior Authorization List, Pg 127 Original policy |
| 81241 | F5 (coagulation factor V) (e.g., hereditary hypercoagulability) gene analysis, Leiden variant | California PPO Prior Authorization List, Pg 128 Original policy |
| 81242 | FANCC (Fanconi anemia, complementation group C) (e.g., Fanconi anemia, type C) gene analysis, common variant (e.g., IVS4+4A>T) | California PPO Prior Authorization List, Pg 128 Original policy |
| 81243 | FMR1 (Fragile X Mental Retardation 1) (e.g., Fragile X Mental Retardation) gene analysis; evaluation to detect abnormal (e.g., expanded) alleles | California PPO Prior Authorization List, Pg 128 Original policy |
| 81244 | FMR1 (fragile X mental retardation 1) (e.g., fragile X mental retardation) gene analysis; characterization of alleles (e.g., expanded size and promoter methylation status) | California PPO Prior Authorization List, Pg 128 Original policy |
| 81245 | FLT3 (fms-Related tyrosine kinase 3) (e.g., Acute Myeloid Leukemia), Gene Analysis, Internal Tandem Duplication (Itd) Variants (i.e., Exons 14, 15) | California PPO Prior Authorization List, Pg 128 Original policy |
| 81246 | FLT3 (fms-related tyrosine kinase 3) (e.g., acute myeloid leukemia), gene analysis; tyrosine kinase domain (TKD) variants (e.g., D835, I836) | California PPO Prior Authorization List, Pg 128 Original policy |
| 81247 | G6PD (glucose-6-phosphate dehydrogenase) (e.g., hemolytic anemia, jaundice), gene analysis; common variant(s) (e.g., A, A-) | California PPO Prior Authorization List, Pg 128 Original policy |
| 81248 | G6PD (glucose-6-phosphate dehydrogenase) (e.g., hemolytic anemia, jaundice), gene analysis; known familial variant(s) | California PPO Prior Authorization List, Pg 128 Original policy |
| 81249 | G6PD (glucose-6-phosphate dehydrogenase) (e.g., hemolytic anemia, jaundice), gene analysis; full gene sequence | California PPO Prior Authorization List, Pg 128 Original policy |
| 81250 | G6PC (glucose-6-phosphatase, catalytic subunit) (e.g., Glycogen storage disease, type 1a, von Gierke disease) gene analysis, common variants (e.g., R83C, Q347X) | California PPO Prior Authorization List, Pg 128 Original policy |
| 81251 | GBA (glucosidase, beta, acid) (e.g., Gaucher disease) gene analysis, common variants (e.g., N370S, 84GG, L444P, IVS2+1G>A) | California PPO Prior Authorization List, Pg 128 Original policy |
| 81252 | GJB2 (gap junction protein, beta 2, 26kDa, connexin 26) (e.g., nonsyndromic hearing loss) gene analysis; full gene sequence | California PPO Prior Authorization List, Pg 128 Original policy |
| 81253 | GJB2 (gap junction protein, beta 2, 26kDa, connexin 26) (e.g., nonsyndromic hearing loss) gene analysis; known familial variants | California PPO Prior Authorization List, Pg 128 Original policy |