Anthem Blue Cross Blue Shield of California prior authorization, page 51
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 |
|---|---|---|
| 81254 | GJB6 (gap junction protein, beta 6, 30kDa, connexin 30) (e.g., nonsyndromic hearing loss) gene analysis, common variants (e.g., 309kb [del(GJB6-D13S1830)] and 232kb [del(GJB6- D13S1854)]) | California PPO Prior Authorization List, Pg 128 Original policy |
| 81255 | HEXA (hexosaminidase A [alpha polypeptide]) (e.g., Tay- Sachs disease) gene analysis, common variants (e.g., 1278insTATC, 1421+1G>C, G269S) | California PPO Prior Authorization List, Pg 128 Original policy |
| 81256 | HFE (hemochromatosis) (e.g., hereditary hemochromatosis) gene analysis, common variants (e.g., C282Y, H63D) | California PPO Prior Authorization List, Pg 129 Original policy |
| 81257 | HBA1/HBA2 (alpha globin 1 and alpha globin 2) (e.g., alpha thalassemia, Hb Bart hydrops fetalis syndrome, HbH disease), gene analysis, for common deletions or variant (e.g., Southeast Asian, Thai, Filipino, Mediterranean, alpha3.7, alpha4.2, alpha20.5, and Constant Spring) | California PPO Prior Authorization List, Pg 129 Original policy |
| 81258 | HBA1/HBA2 (alpha globin 1 and alpha globin 2) (e.g., alpha thalassemia, Hb Bart hydrops fetalis syndrome, HbH disease), gene analysis; known familial variant | California PPO Prior Authorization List, Pg 129 Original policy |
| 81259 | HBA1/HBA2 (alpha globin 1 and alpha globin 2) (e.g., alpha thalassemia, Hb Bart hydrops fetalis syndrome, HbH disease), gene analysis; full gene sequence | California PPO Prior Authorization List, Pg 129 Original policy |
| 81260 | IKBKAP (inhibitor of kappa light polypeptide gene enhancer in B-cells, kinase complex-associated protein) (e.g., familial dysautonomia) gene analysis, common variants (e.g., 2507+6T>C, R696P) | California PPO Prior Authorization List, Pg 129 Original policy |
| 81261 | IGH@ (Immunoglobulin heavy chain locus) (e.g., leukemias and lymphomas, B-cell), gene rearrangement analysis to detect abnormal clonal population(s); amplified methodology (e.g., polymerase chain reaction) | California PPO Prior Authorization List, Pg 129 Original policy |
| 81262 | IGH@ (Immunoglobulin heavy chain locus) (e.g., leukemias and lymphomas, B-cell), gene rearrangement analysis to detect abnormal clonal population(s); direct probe methodology (e.g., Southern blot) | California PPO Prior Authorization List, Pg 129 Original policy |
| 81263 | IGH@ (Immunoglobulin heavy chain locus) (e.g., leukemia and lymphoma, B-cell), variable region somatic mutation analysis | California PPO Prior Authorization List, Pg 129 Original policy |
| 81264 | IGK@ (Immunoglobulin kappa light chain locus) (e.g., leukemia and lymphoma, B-cell), gene rearrangement analysis, evaluation to detect abnormal clonal population(s) | California PPO Prior Authorization List, Pg 129 Original policy |
| 81269 | HBA1/HBA2 (alpha globin 1 and alpha globin 2) (e.g., alpha thalassemia, Hb Bart hydrops fetalis syndrome, HbH disease), gene analysis; duplication/deletion variants | California PPO Prior Authorization List, Pg 129 Original policy |
| 81270 | JAK2 (Janus kinase 2) (e.g., myeloproliferative disorder) gene analysis, p.Val617Phe (V617F) variant | California PPO Prior Authorization List, Pg 129 Original policy |
| 81271 | HTT (huntingtin) (e.g., Huntington disease) gene analysis; evaluation to detect abnormal (e.g., expanded) alleles | California PPO Prior Authorization List, Pg 129 Original policy |
| 81272 | KIT (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog) (e.g., gastrointestinal stromal tumor [GIST], acute myeloid leukemia, melanoma), gene analysis, targeted sequence analysis (e.g., exons 8, 11, 13, 17, 18) | California PPO Prior Authorization List, Pg 129 Original policy |
| 81273 | KIT (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog) (e.g., mastocytosis), gene analysis, D816 variant(s) | California PPO Prior Authorization List, Pg 129 Original policy |
| 81274 | HTT (huntingtin) (e.g., Huntington disease) gene analysis; characterization of alleles (e.g., expanded size) | California PPO Prior Authorization List, Pg 129 Original policy |
| 81275 | KRAS (v-Ki-ras2 Kirsten rat sarcoma viral oncogene) (e.g., carcinoma) gene analysis, variants in codons 12 and 13 | California PPO Prior Authorization List, Pg 129 Original policy |
| 81276 | (KRAS (Kirsten rat sarcoma viral oncogene homolog) (e.g., carcinoma) gene analysis; additional variant(s) (e.g., codon 61, codon 146) | California PPO Prior Authorization List, Pg 129 Original policy |
| 81277 | Cytogenomic neoplasia (genome-wide) microarray analysis, interrogation of genomic regions for copy number and loss-of- heterozygosity variants for chromosomal abnormalities | California PPO Prior Authorization List, Pg 129 Original policy |
| 81278 | IGH@/BCL2 (t(14;18)) (e.g., follicular lymphoma) translocation analysis, major breakpoint region (MBR) and minor cluster region (mcr) breakpoints, qualitative or quantitative | California PPO Prior Authorization List, Pg 130 Original policy |
| 81279 | JAK2 (Janus kinase 2) (e.g., myeloproliferative disorder) targeted sequence analysis (e.g., exons 12 and 13) | California PPO Prior Authorization List, Pg 130 Original policy |
| 81283 | IFNL3 (interferon, lambda 3) (e.g., drug response), gene analysis, rs12979860 variant | California PPO Prior Authorization List, Pg 130 Original policy |
| 81284 | FXN (frataxin) (e.g., Friedreich ataxia) gene analysis; evaluation to detect abnormal (expanded) alleles | California PPO Prior Authorization List, Pg 130 Original policy |
| 81285 | FXN (frataxin) (e.g., Friedreich ataxia) gene analysis; characterization of alleles (e.g., expanded size) | California PPO Prior Authorization List, Pg 130 Original policy |
| 81286 | FXN (frataxin) (e.g., Friedreich ataxia) gene analysis; full gene sequence | California PPO Prior Authorization List, Pg 130 Original policy |
| 81287 | MGMT (O-6-methylguanine-DNA methyltransferase) (e.g., glioblastoma multiforme) promoter methylation analysis | California PPO Prior Authorization List, Pg 130 Original policy |
| 81288 | MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (e.g., hereditary nonpolyposis colorectal cancer, Lynch syndrome) gene analysis; promoter methylation analysis | California PPO Prior Authorization List, Pg 130 Original policy |
| 81289 | FXN (frataxin) (e.g., Friedreich ataxia) gene analysis; known familial variant(s) | California PPO Prior Authorization List, Pg 130 Original policy |
| 81290 | MCOLN1 (mucolipin 1) (e.g., Mucolipidosis, type IV) gene analysis, common variants (e.g., IVS3-2A>G, del6.4kb) | California PPO Prior Authorization List, Pg 130 Original policy |
| 81291 | MTHFR (5,10-methylenetetrahydrofolate reductase) (e.g., hereditary hypercoagulability) gene analysis, common variants (e.g., 677T, 1298C) | California PPO Prior Authorization List, Pg 130 Original policy |
| 81292 | MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (e.g., hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; full sequence analysis | California PPO Prior Authorization List, Pg 130 Original policy |
| 81293 | MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (e.g., hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; known familial variants | California PPO Prior Authorization List, Pg 130 Original policy |
| 81294 | MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (e.g., hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; duplication/deletion variants | California PPO Prior Authorization List, Pg 130 Original policy |
| 81295 | MSH2 (mutS homolog 2, colon cancer, nonpolyposis type 1) (e.g., hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; full sequence analysis | California PPO Prior Authorization List, Pg 130 Original policy |
| 81296 | MSH2 (mutS homolog 2, colon cancer, nonpolyposis type 1) (e.g., hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; known familial variants | California PPO Prior Authorization List, Pg 130 Original policy |
| 81297 | MSH2 (mutS homolog 2, colon cancer, nonpolyposis type 1) (e.g., hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; duplication/deletion variants | California PPO Prior Authorization List, Pg 130 Original policy |
| 81298 | MSH6 (mutS homolog 6 [E. coli]) (e.g., hereditary non- polyposis colorectal cancer, Lynch syndrome) gene analysis; full sequence analysis | California PPO Prior Authorization List, Pg 130 Original policy |
| 81299 | MSH6 (mutS homolog 6 [E. coli]) (e.g., hereditary non- polyposis colorectal cancer, Lynch syndrome) gene analysis; known familial variants | California PPO Prior Authorization List, Pg 131 Original policy |
| 81300 | MSH6 (mutS homolog 6 [E. coli]) (e.g., hereditary non- polyposis colorectal cancer, Lynch syndrome) gene analysis; duplication/deletion variants | California PPO Prior Authorization List, Pg 131 Original policy |
| 81301 | Microsatellite instability analysis (e.g., hereditary non- polyposis colorectal cancer, Lynch syndrome) of markers for mismatch repair deficiency (e.g., BAT25, BAT26), includes comparison of neoplastic and normal tissue, if performed | California PPO Prior Authorization List, Pg 131 Original policy |
| 81302 | MECP2 (methyl CpG binding protein 2) (e.g., Rett syndrome) gene analysis; full sequence analysis | California PPO Prior Authorization List, Pg 131 Original policy |
| 81303 | MECP2 (methyl CpG binding protein 2) (e.g., Rett syndrome) gene analysis; known familial variant | California PPO Prior Authorization List, Pg 131 Original policy |
| 81304 | MECP2 (methyl CpG binding protein 2) (e.g., Rett syndrome) gene analysis; duplication/deletion variants | California PPO Prior Authorization List, Pg 131 Original policy |
| 81305 | MYD88 (myeloid differentiation primary response 88) (e.g., Waldenstrom’s macroglobulinemia, lymphoplasmacytic leukemia) gene analysis, p.Leu265Pro (L265P) variant | California PPO Prior Authorization List, Pg 131 Original policy |
| 81306 | MYD88 (myeloid differentiation primary response 88) (e.g., Waldenstrom’s macroglobulinemia, lymphoplasmacytic leukemia) gene analysis, p.Leu265Pro (L265P) variant | California PPO Prior Authorization List, Pg 131 Original policy |
| 81307 | PALB2 (partner and localizer of BRCA2) (e.g., breast and pancreatic cancer) gene analysis; full gene sequence | California PPO Prior Authorization List, Pg 131 Original policy |
| 81308 | PALB2 (partner and localizer of BRCA2) (e.g., breast and pancreatic cancer) gene analysis; known familial variant | California PPO Prior Authorization List, Pg 131 Original policy |
| 81309 | PIK3CA (phosphatidylinositol-4, 5-biphosphate 3-kinase, catalytic subunit alpha) (e.g., colorectal and breast cancer) gene analysis, targeted sequence analysis (e.g., exons 7, 9, 20) | California PPO Prior Authorization List, Pg 131 Original policy |
| 81310 | NPM1 (nucleophosmin) (e.g., acute myeloid leukemia) gene analysis, exon 12 variants | California PPO Prior Authorization List, Pg 131 Original policy |