Anthem Blue Cross Blue Shield of California prior authorization, page 56
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 |
|---|---|---|
| 0672T | Endovaginal cryogen-cooled, monopolar radiofrequency remodeling of the tissues surrounding the female bladder neck and proximal urethra for urinary incontinence | California PPO Prior Authorization List, Pg 144 Original policy |
| 0707T | Injection(s), bone-substitute material (e.g., calcium phosphate) into subchondral bone defect (i.e., bone marrow lesion, bone bruise, stress injury, microtrabecular fracture), including imaging guidance and arthroscopic assistance for joint visualization | California PPO Prior Authorization List, Pg 144 Original policy |
| 0816T | Open insertion or replacement of integrated neurostimulation system for bladder dysfunction including electrode(s) (e.g., array or leadless), and pulse generator or receiver, including analysis, programming, and imaging guidance, when performed, posterior tibial nerve; subcutaneous | California PPO Prior Authorization List, Pg 144 Original policy |
| 0817T | Open insertion or replacement of integrated neurostimulation system for bladder dysfunction including electrode(s) (e.g., array or leadless), and pulse generator or receiver, including analysis, programming, and imaging guidance, when performed, posterior tibial nerve; subfascial | California PPO Prior Authorization List, Pg 144 Original policy |
| 0818T | Revision or removal of integrated neurostimulation system for bladder dysfunction, including analysis, programming, and imaging, when performed, posterior tibial nerve; subcutaneous | California PPO Prior Authorization List, Pg 144 Original policy |
| 0819T | Revision or removal of integrated neurostimulation system for bladder dysfunction, including analysis, programming, and imaging, when performed, posterior tibial nerve; subfascial | California PPO Prior Authorization List, Pg 144 Original policy |
| 0908T | Open implantation of integrated neurostimulation system, vagus nerve, including analysis and programming, when performed | California PPO Prior Authorization List, Pg 144 Original policy |
| 0909T | Replacement of integrated neurostimulation system, vagus nerve, including analysis and programming, when performed | California PPO Prior Authorization List, Pg 144 Original policy |
| 0910T | Removal of integrated neurostimulation system, vagus nerve | California PPO Prior Authorization List, Pg 144 Original policy |
| 0911T | Electronic analysis of implanted integrated neurostimulation system, vagus nerve; without programming by physician or other qualified health care professional | California PPO Prior Authorization List, Pg 144 Original policy |
| 0912T | Electronic analysis of implanted integrated neurostimulation system, vagus nerve; with simple programming by physician or other qualified health care professional | California PPO Prior Authorization List, Pg 145 Original policy |
| 0913T | Percutaneous transcatheter therapeutic drug delivery by intracoronary drug-delivery balloon (e.g., drug-coated, drug- eluting), including mechanical dilation by nondrug-delivery balloon angioplasty, endoluminal imaging using intravascular ultrasound (IVUS) or optical coherence tomography (OCT) when performed, imaging supervision, interpretation, and report, single major coronary artery or branch | California PPO Prior Authorization List, Pg 145 Original policy |
| 0948T | Interrogation device evaluation (remote), up to 90 days, cardiac contractility modulation system with interim analysis, review and report(s) by a physician or other qualified health care professional | California PPO Prior Authorization List, Pg 145 Original policy |
| 0949T | Interrogation device evaluation (remote), up to 90 days, cardiac contractility modulation system, remote data acquisition(s), receipt of transmissions, technician review, technical support, and distribution of results | California PPO Prior Authorization List, Pg 145 Original policy |
| 0966T | Impression and custom preparation of jaw expansion oral prosthesis for obstructive sleep apnea, including initial adjustment; dual arch, with additional mandibular advancement, fixed hinge mechanism | California PPO Prior Authorization List, Pg 145 Original policy |
| 0970T | Ablation, benign breast tumor (e.g., fibroadenoma), percutaneous, laser, including imaging guidance when performed, each tumor | California PPO Prior Authorization List, Pg 145 Original policy |
| 0971T | Ablation, malignant breast tumor(s), percutaneous, laser, including imaging guidance when performed, unilateral | California PPO Prior Authorization List, Pg 145 Original policy |
| 0978T | Submucosal cryolysis therapy; soft palate, base of tongue, and lingual tonsil | California PPO Prior Authorization List, Pg 145 Original policy |
| 0979T | Submucosal cryolysis therapy; soft palate only | California PPO Prior Authorization List, Pg 145 Original policy |
| 0980T | Submucosal cryolysis therapy; base of tongue and lingual tonsil only | California PPO Prior Authorization List, Pg 145 Original policy |
| 0001U | Red blood cell antigen typing, DNA, human erythrocyte antigen gene analysis of 35 antigens from 11 blood groups, utilizing whole blood, common RBC alleles reported | California PPO Prior Authorization List, Pg 145 Original policy |
| 0016U | Oncology (hematolymphoid neoplasia), RNA, BCR/ABL1 major and minor breakpoint fusion transcripts, quantitative PCR amplification, blood or bone marrow, report of fusion not detected or detected with quantitation | California PPO Prior Authorization List, Pg 145 Original policy |
| 0017U | Oncology (hematolymphoid neoplasia), JAK2 mutation, DNA, PCR amplification of exons 12-14 and sequence analysis, blood or bone marrow, report of JAK2 mutation not detected or detected | California PPO Prior Authorization List, Pg 145 Original policy |
| 0018U | Oncology (thyroid), microRNA profiling by RT-PCR of 10 microRNA sequences, utilizing fine needle aspirate, algorithm reported as a positive or negative result for moderate to high risk of malignancy | California PPO Prior Authorization List, Pg 145 Original policy |
| 0023U | Oncology (acute myelogenous leukemia), DNA, genotyping of internal tandem duplication, p.D835, p.I836, using mononuclear cells, reported as detection or non-detection of FLT3 mutation and indication for or against the use of midostaurin | California PPO Prior Authorization List, Pg 145 Original policy |
| 0026U | Oncology (thyroid), DNA and mRNA of 112 genes, next- generation sequencing, fine needle aspirate of thyroid nodule, algorithmic analysis reported as a categorical result ("Positive, high probability of malignancy" or "Negative, low probability of malignancy) | California PPO Prior Authorization List, Pg 145 Original policy |
| 0027U | JAK2 (Janus kinase 2) (e.g., myeloproliferative disorder) gene analysis, targeted sequence analysis exons 12-15 | California PPO Prior Authorization List, Pg 145 Original policy |
| 0032U | COMT (catechol-O-methyltransferase)(drug metabolism) gene analysis, c.472G>A (rs4680) variant | California PPO Prior Authorization List, Pg 145 Original policy |
| 0034U | TPMT (thiopurine S-methyltransferase), NUDT15 (nudix hydroxylase 15)(e.g., thiopurine metabolism), gene analysis, common variants (i.e., TPMT *2, *3A, *3B, *3C, *4, *5, *6, *8, *12; NUDT15 *3, *4, *5) | California PPO Prior Authorization List, Pg 146 Original policy |
| 0040U | BCR/ABL1 (t(9;22)) (e.g., chronic myelogenous leukemia) translocation analysis, major breakpoint, quantitative | California PPO Prior Authorization List, Pg 146 Original policy |
| 0045U | Oncology (breast ductal carcinoma in situ), mRNA, gene expression profiling by realtime RT-PCR of 12 genes (7 content and 5 housekeeping), utilizing formalin-fixed paraffin- embedded tissue, algorithm reported as recurrence score | California PPO Prior Authorization List, Pg 146 Original policy |
| 0046U | FLT3 (fms-related tyrosine kinase 3) (e.g., acute myeloid leukemia) internal tandem duplication (ITD) variants, quantitative | California PPO Prior Authorization List, Pg 146 Original policy |
| 0049U | NPM1 (nucleophosmin) (e.g., acute myeloid leukemia) gene analysis, quantitative | California PPO Prior Authorization List, Pg 146 Original policy |
| 0070U | CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (e.g., drug metabolism) gene analysis, common and select rare variants (i.e., *2, *3, *4, *4N, *5, *6, *7, *8, *9, *10, *11, *12, *13, *14A, *14B, *15, *17, *29, *35, *36, *41, *57, *61, *63, *68, *83, *xN) | California PPO Prior Authorization List, Pg 146 Original policy |
| 0071U | CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (e.g., drug metabolism) gene analysis, full gene sequence (List separately in addition to code for primary procedure) | California PPO Prior Authorization List, Pg 146 Original policy |
| 0072U | CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (e.g., drug metabolism) gene analysis, targeted sequence analysis (i.e., CYP2D6-2D7 hybrid gene) (List separately in addition to code for primary procedure) | California PPO Prior Authorization List, Pg 146 Original policy |
| 0073U | CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (e.g., drug metabolism) gene analysis, targeted sequence analysis (i.e., CYP2D7-2D6 hybrid gene) (List separately in addition to code for primary procedure) | California PPO Prior Authorization List, Pg 146 Original policy |
| 0074U | CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (e.g., drug metabolism) gene analysis, targeted sequence analysis (i.e., non-duplicated gene when duplication/multiplication is trans) (List separately in addition to code for primary procedure) | California PPO Prior Authorization List, Pg 146 Original policy |
| 0075U | CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (e.g., drug metabolism) gene analysis, targeted sequence analysis (i.e., 5’ gene duplication/multiplication) (List separately in addition to code for primary procedure) | California PPO Prior Authorization List, Pg 146 Original policy |
| 0076U | CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (e.g., drug metabolism) gene analysis, targeted sequence analysis (i.e., 3’ gene duplication/ multiplication) (List separately in addition to code for primary procedure) | California PPO Prior Authorization List, Pg 146 Original policy |
| 0111U | Oncology (colon cancer), targeted KRAS (codons 12, 13, and 61) and NRAS (codons 12, 13, and 61) gene analysis utilizing formalin-fixed paraffin-embedded tissue | California PPO Prior Authorization List, Pg 146 Original policy |
| 0120U | Oncology (B-cell lymphoma classification), mRNA, gene expression profiling by fluorescent probe hybridization of 58 genes (45 content and 13 housekeeping genes), formalin- fixed paraffin-embedded tissue, algorithm reported as likelihood for primary mediastinal B-cell lymphoma (PMBCL) and diffuse large B-cell lymphoma (DLBCL) with cell of origin subtyping in the latter | California PPO Prior Authorization List, Pg 146 Original policy |
| 0138U | BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (e.g., hereditary breast and ovarian cancer) mRNA sequence analysis | California PPO Prior Authorization List, Pg 146 Original policy |
| 0153U | Oncology (breast), mRNA, gene expression profiling by next- generation sequencing of 101 genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a triple negative breast cancer clinical subtype(s) with information on immune cell involvement | California PPO Prior Authorization List, Pg 146 Original policy |
| 0154U | Oncology (urothelial cancer), RNA, analysis by real-time RT- PCR of the FGFR3 (fibroblast growth factor receptor 3) gene analysis (i.e., p.R248C [c.742C>T], p.S249C [c.746C>G], p.G370C [c.1108G>T], p.Y373C [c.1118A>G], FGFR3- TACC3v1, and FGFR3-TACC3 v3), utilizing formalin-fixed paraffin-embedded urothelial cancer tumor tissue, reported as FGFR gene alteration status | California PPO Prior Authorization List, Pg 147 Original policy |
| 0155U | Oncology (breast cancer), DNA, PIK3CA (phosphatidylinositol- 4,5- bisphosphate 3-kinase, catalytic subunit alpha) (e.g., breast cancer) gene analysis (i.e., p.C420R, p.E542K, p.E545A, p.E545D [g.1635G>T only], p.E545G, p.E545K, p.Q546E, p.Q546R, p.H1047L, p.H1047R, p.H1047Y), utilizing formalin-fixed paraffin-embedded breast tumor tissue, reported as PIK3CA gene mutation status | California PPO Prior Authorization List, Pg 147 Original policy |
| 0156U | Copy number (e.g., intellectual disability, dysmorphology), sequence analysis | California PPO Prior Authorization List, Pg 147 Original policy |
| 0169U | NUDT15 (nudix hydrolase 15) and TPMT (thiopurine S- methyltransferase) (e.g., drug metabolism) gene analysis, common variants | California PPO Prior Authorization List, Pg 147 Original policy |
| 0170U | Neurology (autism spectrum disorder [ASD]), RNA, next- generation sequencing, saliva, algorithmic analysis, and results reported as predictive probability of ASD diagnosis | California PPO Prior Authorization List, Pg 147 Original policy |
| 0171U | Targeted genomic sequence analysis panel, acute myeloid leukemia, myelodysplastic syndrome, and myeloproliferative neoplasms, DNA analysis, 23 genes, interrogation for sequence variants, rearrangements and minimal residual disease, reported as presence/absence | California PPO Prior Authorization List, Pg 147 Original policy |