Anthem Blue Cross Blue Shield of California prior authorization, page 52
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 |
|---|---|---|
| 81311 | NRAS (neuroblastoma RAS viral [v-ras] oncogene homolog) (e.g., colorectal carcinoma), gene analysis, variants in exon 2 (e.g., codons 12 and 13) and exon 3 (e.g., codon 61) | California PPO Prior Authorization List, Pg 131 Original policy |
| 81312 | PABPN1 (poly[A] binding protein nuclear 1) (e.g., oculopharyngeal muscular dystrophy) gene analysis, evaluation to detect abnormal (e.g., expanded) alleles | California PPO Prior Authorization List, Pg 131 Original policy |
| 81314 | PDGFRA (platelet-derived growth factor receptor, alpha polypeptide) (e.g., gastrointestinal stromal tumor [GIST]), gene analysis, targeted sequence analysis (e.g., exons 12, 18) | California PPO Prior Authorization List, Pg 131 Original policy |
| 81315 | PML/RARalpha, (t(15;17)), (promyelocytic leukemia/retinoic acid receptor alpha) (e.g., promyelocytic leukemia) translocation analysis; common breakpoints (e.g., intron 3 and intron 6), qualitative or quantitative | California PPO Prior Authorization List, Pg 131 Original policy |
| 81316 | PML/RARalpha, (t(15;17)), (promyelocytic leukemia/retinoic acid receptor alpha) (e.g., promyelocytic leukemia) translocation analysis; single breakpoint (e.g., intron 3, intron 6 or exon 6), qualitative or quantitative | California PPO Prior Authorization List, Pg 131 Original policy |
| 81317 | PMS2 (postmeiotic segregation increased 2 [S. cerevisiae]) (e.g., hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; full sequence analysis | California PPO Prior Authorization List, Pg 131 Original policy |
| 81318 | PMS2 (postmeiotic segregation increased 2 [S. cerevisiae]) (e.g., hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; known familial variants | California PPO Prior Authorization List, Pg 132 Original policy |
| 81319 | PMS2 (postmeiotic segregation increased 2 [S. cerevisiae]) (e.g., hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; duplication/deletion variants | California PPO Prior Authorization List, Pg 132 Original policy |
| 81320 | PLCG2 (phospholipase C gamma 2) (e.g., chronic lymphocytic leukemia) gene analysis, common variants (e.g., R665W, S707F, L845F) | California PPO Prior Authorization List, Pg 132 Original policy |
| 81321 | PTEN (phosphatase and tensin homolog) (e.g., Cowden syndrome, PTEN hamartoma tumor syndrome) gene analysis; full sequence analysis | California PPO Prior Authorization List, Pg 132 Original policy |
| 81322 | PTEN (phosphatase and tensin homolog) (e.g., Cowden syndrome, PTEN hamartoma tumor syndrome) gene analysis; known familial variant | California PPO Prior Authorization List, Pg 132 Original policy |
| 81323 | PTEN (phosphatase and tensin homolog) (e.g., Cowden syndrome, PTEN hamartoma tumor syndrome) gene analysis; duplication/deletion variant | California PPO Prior Authorization List, Pg 132 Original policy |
| 81324 | PMP22 (peripheral myelin protein 22) (e.g., Charcot-Marie- Tooth, hereditary neuropathy with liability to pressure palsies) gene analysis; duplication/deletion analysis | California PPO Prior Authorization List, Pg 132 Original policy |
| 81325 | PMP22 (peripheral myelin protein 22) (e.g., Charcot-Marie- Tooth, hereditary neuropathy with liability to pressure palsies) gene analysis; full sequence analysis | California PPO Prior Authorization List, Pg 132 Original policy |
| 81326 | PMP22 (peripheral myelin protein 22) (e.g., Charcot-Marie- Tooth, hereditary neuropathy with liability to pressure palsies) gene analysis; familial variant | California PPO Prior Authorization List, Pg 132 Original policy |
| 81327 | SEPT9 (Septin9) (e.g., colorectal cancer) promoter methylation analysis; lab test to detect, in free circulating DNA in the blood, methylation of gene promoter regions that affect expression of suppressor gene Septin9 (SEPT9), which serves as a marker for conditions such as colorectal cancer. | California PPO Prior Authorization List, Pg 132 Original policy |
| 81328 | SLCO1B1 (solute carrier organic anion transporter family, member 1B1) (e.g., adverse drug reaction), gene analysis, common variant(s) (e.g., *5) | California PPO Prior Authorization List, Pg 132 Original policy |
| 81329 | SMN1 (survival of motor neuron 1, telomeric) (e.g., spinal muscular atrophy) gene analysis; dosage/deletion analysis (e.g., carrier testing), includes SMN2 (survival of motor neuron 2, centromeric) analysis, if performed | California PPO Prior Authorization List, Pg 132 Original policy |
| 81330 | SMPD1(sphingomyelin phosphodiesterase 1, acid lysosomal) (e.g., Niemann-Pick disease, Type A) gene analysis, common variants (e.g., R496L, L302P, fsP330) | California PPO Prior Authorization List, Pg 132 Original policy |
| 81331 | SNRPN/UBE3A (small nuclear ribonucleoprotein polypeptide N and ubiquitin protein ligase E3A) (e.g., Prader-Willi syndrome and/or Angelman syndrome), methylation analysis | California PPO Prior Authorization List, Pg 132 Original policy |
| 81332 | SERPINA1 (serpin peptidase inhibitor, clade A, alpha-1 antiproteinase, antitrypsin, member 1) (e.g., alpha-1- antitrypsin deficiency), gene analysis, common variants (e.g., *S and *Z) | California PPO Prior Authorization List, Pg 132 Original policy |
| 81333 | TGFBI (transforming growth factor beta-induced) (e.g., corneal dystrophy) gene analysis, common variants (e.g., R124H, R124C, R124L, R555W, R555Q) | California PPO Prior Authorization List, Pg 132 Original policy |
| 81334 | RUNX1 (runt related transcription factor 1) (e.g., acute myeloid leukemia, familial platelet disorder with associated myeloid malignancy), gene analysis, targeted sequence analysis (e.g., exons 3-8) | California PPO Prior Authorization List, Pg 132 Original policy |
| 81335 | TPMT (thiopurine S-methyltransferase) (e.g., drug metabolism), gene analysis, common variants (e.g., *2, *3) | California PPO Prior Authorization List, Pg 132 Original policy |
| 81336 | SMN1 (survival of motor neuron 1, telomeric) (e.g., spinal muscular atrophy) gene analysis; full gene sequence | California PPO Prior Authorization List, Pg 133 Original policy |
| 81337 | SMN1 (survival of motor neuron 1, telomeric) (e.g., spinal muscular atrophy) gene analysis; known familial sequence variant(s) | California PPO Prior Authorization List, Pg 133 Original policy |
| 81338 | MPL (MPL proto-oncogene, thrombopoietin receptor) (e.g., myeloproliferative disorder) gene analysis; common variants (e.g., W515A, W515K, W515L, W515R) | California PPO Prior Authorization List, Pg 133 Original policy |
| 81339 | MPL (MPL proto-oncogene, thrombopoietin receptor) (e.g., myeloproliferative disorder) gene analysis; sequence analysis, exon 10 | California PPO Prior Authorization List, Pg 133 Original policy |
| 81345 | TERT (telomerase reverse transcriptase) (e.g., thyroid carcinoma, glioblastoma multiforme) gene analysis, targeted sequence analysis (e.g., promoter region) | California PPO Prior Authorization List, Pg 133 Original policy |
| 81340 | TRB@ (T cell antigen receptor, beta) (e.g., leukemia and lymphoma), gene rearrangement analysis to detect abnormal clonal population(s); using amplification methodology (e.g., polymerase chain reaction) | California PPO Prior Authorization List, Pg 133 Original policy |
| 81341 | TRB@ (T cell antigen receptor, beta) (e.g., leukemia and lymphoma), gene rearrangement analysis to detect abnormal clonal population(s); using direct probe methodology (e.g., Southern blot) | California PPO Prior Authorization List, Pg 133 Original policy |
| 81342 | TRG@ (T cell antigen receptor, gamma) (e.g., leukemia and lymphoma), gene rearrangement analysis, evaluation to detect abnormal clonal population(s) | California PPO Prior Authorization List, Pg 133 Original policy |
| 81343 | PPP2R2B (protein phosphatase 2 regulatory subunit Bbeta) (e.g., spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (e.g., expanded) alleles | California PPO Prior Authorization List, Pg 133 Original policy |
| 81344 | TBP (TATA box binding protein) (e.g., spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (e.g., expanded) alleles | California PPO Prior Authorization List, Pg 133 Original policy |
| 81346 | TYMS (thymidylate synthetase) (e.g., 5-fluorouracil/ 5-FU drug metabolism), gene analysis, common variant(s) (e.g., tandem repeat variant) | California PPO Prior Authorization List, Pg 133 Original policy |
| 81347 | SF3B1 (splicing factor [3b] subunit B1) (e.g., myelodysplastic syndrome/acute myeloid leukemia) gene analysis, common variants (e.g., A672T, E622D, L833F, R625C, R625L) | California PPO Prior Authorization List, Pg 133 Original policy |
| 81348 | SRSF2 (serine and arginine-rich splicing factor 2) (e.g., myelodysplastic syndrome, acute myeloid leukemia) gene analysis, common variants (e.g., P95H, P95L) | California PPO Prior Authorization List, Pg 133 Original policy |
| 81349 | Cytogenomic (genome-wide) analysis for constitutional chromosomal abnormalities; interrogation of genomic regions for copy number and loss-of-heterozygosity variants, low-pass sequencing analysis | California PPO Prior Authorization List, Pg 133 Original policy |
| 81350 | UGT1A1 (UDP glucuronosyltransferase 1 family, polypeptide A1) (e.g., irinotecan metabolism), gene analysis, common variants (e.g., *28, *36, *37) | California PPO Prior Authorization List, Pg 133 Original policy |
| 81351 | TP53 (tumor protein 53) (e.g., Li-Fraumeni syndrome) gene analysis; full gene sequence | California PPO Prior Authorization List, Pg 133 Original policy |
| 81352 | TP53 (tumor protein 53) (e.g., Li-Fraumeni syndrome) gene analysis; targeted sequence analysis (e.g., 4 oncology) | California PPO Prior Authorization List, Pg 133 Original policy |
| 81353 | TP53 (tumor protein 53) (e.g., Li-Fraumeni syndrome) gene analysis; known familial variant | California PPO Prior Authorization List, Pg 134 Original policy |
| 81354 | Cytogenomic (genome-wide) analysis for constitutional chromosomal abnormalities; interrogation of structural and copy number variants, optical genome mapping (OGM) | California PPO Prior Authorization List, Pg 134 Original policy |
| 81355 | VKORC1 (vitamin K epoxide reductase complex, subunit 1) (e.g., warfarin metabolism), gene analysis, common variants (e.g., -1639/3673) | California PPO Prior Authorization List, Pg 134 Original policy |
| 81357 | U2AF1 (U2 small nuclear RNA auxiliary factor 1) (e.g., myelodysplastic syndrome, acute myeloid leukemia) gene analysis, common variants (e.g., S34F, S34Y, Q157R, Q157P) | California PPO Prior Authorization List, Pg 134 Original policy |
| 81360 | ZRSR2 (zinc finger CCCH-type, RNA binding motif and serine/arginine-rich 2) (e.g., myelodysplastic syndrome, acute myeloid leukemia) gene analysis, common variant(s) (e.g., E65fs, E122fs, R448fs) | California PPO Prior Authorization List, Pg 134 Original policy |
| 81361 | HBB (hemoglobin, subunit beta) (e.g., sickle cell anemia, beta thalassemia, hemoglobinopathy); common variant(s) (e.g., HbS, HbC, HbE) | California PPO Prior Authorization List, Pg 134 Original policy |
| 81362 | HBB (hemoglobin, subunit beta) (e.g., sickle cell anemia, beta thalassemia, hemoglobinopathy); known familial variant(s) | California PPO Prior Authorization List, Pg 134 Original policy |
| 81363 | HBB (hemoglobin, subunit beta) (e.g., sickle cell anemia, beta thalassemia, hemoglobinopathy); duplication/deletion variant(s) | California PPO Prior Authorization List, Pg 134 Original policy |
| 81364 | HBB (hemoglobin, subunit beta) (e.g., sickle cell anemia, beta thalassemia, hemoglobinopathy); full gene sequence | California PPO Prior Authorization List, Pg 134 Original policy |