Anthem Blue Cross Blue Shield of California prior authorization, page 53
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 |
|---|---|---|
| 81380 | HLA Class I typing, high resolution (i.e., alleles or allele groups); HLA Class I typing, high resolution (i.e., alleles or allele groups) | California PPO Prior Authorization List, Pg 134 Original policy |
| 81381 | HLA Class I typing, high resolution (i.e., alleles or allele groups); one allele or allele group (e.g., B*57:01P), each | California PPO Prior Authorization List, Pg 134 Original policy |
| 81400 | Molecular pathology procedure, Level 1(e.g., identification of single germline variant [e.g., SNP] by techniques such as restriction enzyme digestion or melt curve analysis) | California PPO Prior Authorization List, Pg 134 Original policy |
| 81402 | Molecular pathology procedure, Level 3 (e.g., >10 SNPs, 2-10 methylated variants, or 2-10 somatic variants [typically using non-sequencing target variant analysis], immunoglobulin and T-cell receptor gene rearrangements, duplication/deletion variants of 1 exon, loss of heterozygosity [LOH], uniparental disomy [UPD]) | California PPO Prior Authorization List, Pg 134 Original policy |
| 81403 | Molecular pathology procedure, Level 4 (e.g., analysis of single exon by DNA sequence analysis, analysis of >10 amplicons using multiplex PCR in 2 or more independent reactions, mutation scanning or duplication/deletion variants of 2-5 exons) | California PPO Prior Authorization List, Pg 134 Original policy |
| 81404 | Molecular pathology procedure, Level 5 (e.g., analysis of 2-5 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of 6-10 exons, or characterization of a dynamic mutation disorder/triplet repeat by Southern blot analysis) | California PPO Prior Authorization List, Pg 135 Original policy |
| 81405 | Molecular pathology procedure, Level 6 (e.g., analysis of 6-10 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of 11-25 exons, regionally targeted cytogenomic array analysis) | California PPO Prior Authorization List, Pg 135 Original policy |
| 81406 | Molecular pathology procedure, Level 7 (e.g., analysis of 11- 25 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of 26-50 exons, cytogenomic array analysis for neoplasia) | California PPO Prior Authorization List, Pg 135 Original policy |
| 81407 | Molecular pathology procedure, Level 8 (e.g., analysis of 26- 50 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of >50 exons, sequence analysis of multiple genes on one platform) | California PPO Prior Authorization List, Pg 135 Original policy |
| 81408 | Molecular pathology procedure, Level 9 (e.g., analysis of >50 exons in a single gene by DNA sequence analysis) | California PPO Prior Authorization List, Pg 135 Original policy |
| 81414 | Cardiac ion channelopathies (e.g., Brugada syndrome, long QT syndrome, short QT syndrome, catecholaminergic polymorphic ventricular tachycardia); duplication/ deletion gene analysis panel, must include analysis of at least 2 genes, including KCNH2 and KCNQ1 | California PPO Prior Authorization List, Pg 135 Original policy |
| 81518 | Oncology (breast), mRNA, gene expression profiling by real- time RT-PCR of 11 genes (7 content and 4 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithms reported as percentage risk for metastatic recurrence and likelihood of benefit from extended endocrine therapy | California PPO Prior Authorization List, Pg 135 Original policy |
| 81519 | Oncology (breast), mRNA, gene expression profiling by real- time RT-PCR of 21 genes utilizing formalin-fixed paraffin embedded tissue, algorithm reported as recurrence score | California PPO Prior Authorization List, Pg 135 Original policy |
| 81520 | Oncology (breast), mRNA gene expression profiling by hybrid capture of 58 genes (50 content and 8 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a recurrence risk score | California PPO Prior Authorization List, Pg 135 Original policy |
| 81521 | Oncology (breast), mRNA, microarray gene expression profiling of 70 content genes and 465 housekeeping genes, utilizing fresh frozen or formalin-fixed paraffin-embedded tissue, algorithm reported as index related to risk of distant metastasis | California PPO Prior Authorization List, Pg 135 Original policy |
| 81522 | Oncology (breast), mRNA, gene expression profiling by RT- PCR of 12 genes (8 content and 4 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as recurrence risk score | California PPO Prior Authorization List, Pg 135 Original policy |
| 81523 | Oncology (breast), mRNA, next-generation sequencing gene expression profiling of 70 content genes and 31 housekeeping genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as index related to risk to distant metastasis | California PPO Prior Authorization List, Pg 135 Original policy |
| 81524 | Oncology (central nervous system tumor), DNA methylation analysis of at least 10,000 methylation sites, utilizing DNA extracted from formalin-fixed tumor tissue, algorithm(s) reported as probability of matching a reference tumor family and class, and MGMT (O-6-methylguanine-DNA methyltransferase) promoter methylation status, if performed | California PPO Prior Authorization List, Pg 136 Original policy |
| 81546 | Oncology (thyroid), mRNA, gene expression analysis of 10,196 genes, utilizing fine needle aspirate, algorithm reported as a categorical result (e.g., benign or suspicious) | California PPO Prior Authorization List, Pg 136 Original policy |
| 81558 | Transplantation medicine (allograft rejection, kidney), mRNA, gene expression profiling by quantitative polymerase chain reaction (qPCR) of 139 genes, utilizing whole blood, algorithm reported as a binary categorization as transplant excellence, which indicates immune quiescence, or not transplant excellence, indicating subclinical rejection | California PPO Prior Authorization List, Pg 136 Original policy |
| 89280 | Assisted oocyte fertilization, microtechnique; less than or equal to 10 oocytes | California PPO Prior Authorization List, Pg 136 Original policy |
| 89281 | Assisted oocyte fertilization, microtechnique; greater than 10 oocytes | California PPO Prior Authorization List, Pg 136 Original policy |
| 89337 | Cryopreservation, mature oocyte(s) | California PPO Prior Authorization List, Pg 136 Original policy |
| 89344 | Storage, (per year); reproductive tissue, testicular/ovarian [when specified as ovarian tissue] | California PPO Prior Authorization List, Pg 136 Original policy |
| 89346 | Storage (per year); oocyte(s) | California PPO Prior Authorization List, Pg 136 Original policy |
| 89354 | Thawing of cryopreserved; reproductive tissue, testicular/ovarian [when specified as ovarian tissue] | California PPO Prior Authorization List, Pg 136 Original policy |
| 89356 | Thawing of cryopreserved; oocytes, each aliquot | California PPO Prior Authorization List, Pg 136 Original policy |
| 90281 | Immune globulin, Immune globulin (Ig), Intramuscular | California PPO Prior Authorization List, Pg 136 Original policy |
| 92920 | Percutaneous transluminal coronary angioplasty; single major coronary artery and/or branch(es) | California PPO Prior Authorization List, Pg 136 Original policy |
| 92924 | Percutaneous transluminal coronary atherectomy, with coronary angioplasty when performed; single major coronary artery and/or branch(es) | California PPO Prior Authorization List, Pg 136 Original policy |
| 92928 | Percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty when performed; single major coronary artery or branch | California PPO Prior Authorization List, Pg 136 Original policy |
| 92930 | Percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty when performed, single major coronary artery and/or its branch(es); 2 or more distinct coronary lesions with 2 or more coronary stents deployed in 2 or more coronary segments, or a bifurcation lesion requiring angioplasty and/or stenting in both the main artery and the side branch | California PPO Prior Authorization List, Pg 136 Original policy |
| 92933 | Percutaneous transluminal coronary atherectomy, with intracoronary stent, with coronary angioplasty when performed; single major coronary artery or branch | California PPO Prior Authorization List, Pg 136 Original policy |
| 92937 | Percutaneous transluminal revascularization of or through coronary artery bypass graft (internal mammary, free arterial, venous), any combination of intracoronary stent, atherectomy and angioplasty, including distal protection when performed; single vessel | California PPO Prior Authorization List, Pg 136 Original policy |
| 92943 | Percutaneous transluminal revascularization of chronic total occlusion, coronary artery, coronary artery branch, or coronary artery bypass graft, any combination of intracoronary stent, atherectomy and angioplasty; single vessel | California PPO Prior Authorization List, Pg 137 Original policy |
| 92945 | Percutaneous transluminal revascularization of chronic total occlusion, single coronary artery, coronary artery branch, or coronary artery bypass graft, and/or subtended major coronary artery branches of the bypass graft, any combination of intracoronary stent, atherectomy and angioplasty; combined antegrade and retrograde approaches | California PPO Prior Authorization List, Pg 137 Original policy |
| 93150 | Therapy activation of implanted phrenic nerve stimulator system, including all interrogation and programming | California PPO Prior Authorization List, Pg 137 Original policy |
| 93151 | Interrogation and programming (minimum one parameter) of implanted phrenic nerve stimulator system | California PPO Prior Authorization List, Pg 137 Original policy |
| 93152 | Interrogation and programming of implanted phrenic nerve stimulator system during polysomnography | California PPO Prior Authorization List, Pg 137 Original policy |
| 93153 | Interrogation without programming of implanted phrenic nerve stimulator system | California PPO Prior Authorization List, Pg 137 Original policy |
| 93228 | Wearable mobile cardiovascular telemetry with electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of accessible ECG data storage (retrievable with query) with ECG triggered and patient selected events | California PPO Prior Authorization List, Pg 137 Original policy |
| 93229 | Wearable mobile cardiovascular telemetry with electrocardiographic recording, concurrent computerized real time data analysis and greater than 24 hours of accessible ECG data storage (retrievable with query) with ECG triggered and patient selected events | California PPO Prior Authorization List, Pg 137 Original policy |
| 93303 | Transthoracic echocardiography or congenital cardiac anomalies; complete | California PPO Prior Authorization List, Pg 137 Original policy |
| 93304 | Transthoracic echocardiography or congenital cardiac anomalies; follow-up or limited study | California PPO Prior Authorization List, Pg 137 Original policy |
| 93306 | Echocardiography, transthoracic, real-time with image documentation (2D), includes M-mode recording, when performed, complete, with spectral Doppler echocardiography, and with color flow Doppler echocardiography | California PPO Prior Authorization List, Pg 137 Original policy |
| 93307 | Transthoracic echocardiography; complete, without spectral Doppler echocardiography, or color flow Doppler echocardiography | California PPO Prior Authorization List, Pg 137 Original policy |
| 93308 | Transthoracic echocardiography; complete, without spectral Doppler echocardiography, or color flow Doppler echocardiography follow-up or limited study | California PPO Prior Authorization List, Pg 137 Original policy |
| 93312 | Echocardiography, transesophageal, real-time with image documentation (2-D) (with or without M-mode recording) | California PPO Prior Authorization List, Pg 137 Original policy |
| 93313 | Echocardiography, transesophageal, probe placement only | California PPO Prior Authorization List, Pg 137 Original policy |
| 93314 | Echocardiography, transesophageal, image acquisition, interpretation and report only | California PPO Prior Authorization List, Pg 137 Original policy |