Anthem Blue Cross Blue Shield of California prior authorization, page 57
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 |
|---|---|---|
| 0172U | Oncology (solid tumor as indicated by the label), somatic mutation analysis of BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) and analysis of homologous recombination deficiency pathways, DNA, formalin-fixed paraffin-embedded tissue, algorithm quantifying tumor genomic instability score | California PPO Prior Authorization List, Pg 147 Original policy |
| 0177U | Oncology (breast cancer), DNA, PIK3CA (phosphatidylinositol- 4,5-bisphosphate 3-kinase catalytic subunit alpha) gene analysis of 11 gene variants utilizing plasma, reported as PIK3CA gene mutation status | California PPO Prior Authorization List, Pg 147 Original policy |
| 0209U | Cytogenomic constitutional (genome-wide) analysis, interrogation of genomic regions for copy number, structural changes and areas of homozygosity for chromosomal abnormalities | California PPO Prior Authorization List, Pg 147 Original policy |
| 0218U | Neurology (muscular dystrophy), DMD gene sequence analysis, including small sequence changes, deletions, duplications, and variants in non-uniquely mappable regions, blood or saliva, identification and characterization of genetic variants | California PPO Prior Authorization List, Pg 147 Original policy |
| 0229U | BCAT1 (Branched chain amino acid transaminase 1) or IKZF1 (IKAROS family zinc finger 1) (e.g., colorectal cancer) promoter methylation analysis | California PPO Prior Authorization List, Pg 147 Original policy |
| 0230U | AR (androgen receptor) (e.g., spinal and bulbar muscular atrophy, Kennedy disease, X chromosome inactivation), full sequence analysis, including small sequence changes in exonic and intronic regions, deletions, duplications, short tandem repeat (STR) expansions, mobile element insertions, and variants in non-uniquely mappable regions | California PPO Prior Authorization List, Pg 147 Original policy |
| 0231U | CACNA1A (calcium voltage-gated channel subunit alpha 1A) (e.g., spinocerebellar ataxia), full gene analysis, including small sequence changes in exonic and intronic regions, deletions, duplications, short tandem repeat (STR) gene expansions, mobile element insertions, and variants in non- uniquely mappable regions | California PPO Prior Authorization List, Pg 147 Original policy |
| 0232U | CSTB (cystatin B) (e.g., progressive myoclonic epilepsy type 1A, Unverricht-Lundborg disease), full gene analysis, including small sequence changes in exonic and intronic regions, deletions, duplications, short tandem repeat (STR) expansions, mobile element insertions, and variants in non- uniquely mappable regions | California PPO Prior Authorization List, Pg 147 Original policy |
| 0233U | FXN (frataxin) (e.g., Friedreich ataxia), gene analysis, including small sequence changes in exonic and intronic regions, deletions, duplications, short tandem repeat (STR) expansions, mobile element insertions, and variants in non- uniquely mappable regions | California PPO Prior Authorization List, Pg 148 Original policy |
| 0234U | MECP2 (methyl CpG binding protein 2) (e.g., Rett syndrome), full gene analysis, including small sequence changes in exonic and intronic regions, deletions, duplications, mobile element insertions, and variants in non-uniquely mappable regions | California PPO Prior Authorization List, Pg 148 Original policy |
| 0235U | PTEN (phosphatase and tensin homolog) (e.g., Cowden syndrome, PTEN hamartoma tumor syndrome), full gene analysis, including small sequence changes in exonic and intronic regions, deletions, duplications, mobile element insertions, and variants in non-uniquely mappable regions | California PPO Prior Authorization List, Pg 148 Original policy |
| 0236U | SMN1 (survival of motor neuron 1, telomeric) and SMN2 (survival of motor neuron 2, centromeric) (e.g., spinal muscular atrophy) full gene analysis, including small sequence changes in exonic and intronic regions, duplications and deletions, and mobile element insertions | California PPO Prior Authorization List, Pg 148 Original policy |
| 0245U | Oncology (thyroid), mutation analysis of 10 genes and 37 RNA fusions and expression of 4 mRNA markers using next- generation sequencing, fine needle aspirate, report includes associated risk of malignancy expressed as a percentage | California PPO Prior Authorization List, Pg 148 Original policy |
| 0254U | Reproductive medicine (preimplantation genetic assessment), analysis of 24 chromosomes using embryonic DNA genomic sequence analysis for aneuploidy, and a mitochondrial DNA score in euploid embryos, results reported as normal (euploidy), monosomy, trisomy, or partial deletion/duplications, mosaicism, and segmental aneuploidy, per embryo tested | California PPO Prior Authorization List, Pg 148 Original policy |
| 0258U | Autoimmune (psoriasis), mRNA, next-generation sequencing, gene expression profiling of 50-100 genes, skin-surface collection using adhesive patch, algorithm reported as likelihood of response to psoriasis biologics | California PPO Prior Authorization List, Pg 148 Original policy |
| 0285U | Oncology, disease progression and response monitoring to radiation, chemotherapy, or other systematic cancer treatments, cell-free DNA, quantitative branched chain DNA amplification, plasma, reported in ng/mL | California PPO Prior Authorization List, Pg 148 Original policy |
| 0286U | CEP72 (centrosomal protein, 72-KDa), NUDT15 (nudix hydrolase 15) and TPMT (thiopurine S-methyltransferase) (e.g., drug metabolism) gene analysis, common variants - CNT (CEP72, NUDT15 and TPMT) Genotyping Panel | California PPO Prior Authorization List, Pg 148 Original policy |
| 0287U | Oncology (thyroid), DNA and mRNA, next-generation sequencing analysis of 112 genes, fine needle aspirate or formalin-fixed paraffin-embedded (FFPE) tissue, algorithmic prediction of cancer recurrence, reported as a categorical risk result (low, intermediate, high) | California PPO Prior Authorization List, Pg 148 Original policy |
| 0288U | Oncology (lung), mRNA, quantitative PCR analysis of 11 genes (BAG1, BRCA1, CDC6, CDK2AP1, ERBB3, FUT3, IL11, LCK, RND3, SH3BGR, WNT3A) and 3 reference genes (ESD, TBP, YAP1), formalin-fixed paraffin-embedded (FFPE) tumor tissue, algorithmic interpretation reported as a recurrence risk score | California PPO Prior Authorization List, Pg 148 Original policy |
| 0289U | Neurology (Alzheimer disease), mRNA, gene expression profiling by RNA sequencing of 24 genes, whole blood, algorithm reported as predictive risk score | California PPO Prior Authorization List, Pg 148 Original policy |
| 0290U | Pain management, mRNA, gene expression profiling by RNA sequencing of 36 genes, whole blood, algorithm reported as predictive risk score | California PPO Prior Authorization List, Pg 148 Original policy |
| 0291U | Psychiatry (mood disorders), mRNA, gene expression profiling by RNA sequencing of 144 genes, whole blood, algorithm reported as predictive risk score | California PPO Prior Authorization List, Pg 148 Original policy |
| 0292U | Psychiatry (stress disorders), mRNA, gene expression profiling by RNA sequencing of 72 genes, whole blood, algorithm reported as predictive risk score | California PPO Prior Authorization List, Pg 148 Original policy |
| 0293U | Psychiatry (suicidal ideation), mRNA, gene expression profiling by RNA sequencing of 54 genes, whole blood, algorithm reported as predictive risk score | California PPO Prior Authorization List, Pg 148 Original policy |
| 0294U | Longevity and mortality risk, mRNA, gene expression profiling by RNA sequencing of 18 genes, whole blood, algorithm reported as predictive risk score | California PPO Prior Authorization List, Pg 149 Original policy |
| 0296U | Oncology (oral and/or oropharyngeal cancer), gene expression profiling by RNA sequencing of at least 20 molecular features (e.g., human and/or microbial mRNA), saliva, algorithm reported as positive or negative for signature associated with malignancy | California PPO Prior Authorization List, Pg 149 Original policy |
| 0313U | Oncology (pancreas), DNA and mRNA next-generation sequencing analysis of 74 genes and analysis of CEA (CEACAM5) gene expression, pancreatic cyst fluid, algorithm reported as a categorical result (i.e., negative, low probability of neoplasia or positive, high probability of neoplasia) | California PPO Prior Authorization List, Pg 149 Original policy |
| 0318U | Pediatrics (congenital epigenetic disorders), whole genome methylation analysis by microarray for 50 or more genes, blood | California PPO Prior Authorization List, Pg 149 Original policy |
| 0319U | Nephrology (renal transplant), RNA expression by select transcriptome sequencing, using pretransplant peripheral blood, algorithm reported as a risk score for early acute rejection | California PPO Prior Authorization List, Pg 149 Original policy |
| 0320U | Nephrology (renal transplant), RNA expression by select transcriptome sequencing, using posttransplant peripheral blood, algorithm reported as a risk score for acute cellular rejection | California PPO Prior Authorization List, Pg 149 Original policy |
| 0355U | APOL1 (apolipoprotein L1) (e.g., chronic kidney disease), risk variants (G1, G2) | California PPO Prior Authorization List, Pg 149 Original policy |
| 0362U | Oncology (papillary thyroid cancer), gene expression profiling via targeted hybrid capture-enrichment RNA sequencing of 82 content genes and 10 housekeeping genes, formalin-fixed paraffin-embedded (FFPE) tissue, algorithm reported as one of three molecular subtypes. The test evaluates a formalin- fixed paraffin-embedded (FFPE) tissue specimen from a patient with papillary thyroid cancer for expression of 82 genes and uses an algorithmic analysis to classify the molecular subtype as it relates to risk of recurrence. | California PPO Prior Authorization List, Pg 149 Original policy |
| 0364U | Oncology (hematolymphoid neoplasm), genomic sequence analysis using multiplex (PCR) and next-generation sequencing with algorithm, quantification of dominant clonal sequence(s), reported as presence or absence of minimal residual disease (MRD) with quantitation of disease burden, when appropriate | California PPO Prior Authorization List, Pg 149 Original policy |
| 0378U | RFC1 (replication factor C subunit 1), repeat expansion variant analysis by traditional and repeat-primed PCR, blood, saliva, or buccal swab | California PPO Prior Authorization List, Pg 149 Original policy |
| 0389U | KawasakiDx, OncoOmicsDx Laboratory from mProbe. The test evaluates a patient blood specimen for RNA expression of two genes listed in the code and reports a risk score for Kawasaki disease (KD), a fever of unknown origin in children. | California PPO Prior Authorization List, Pg 149 Original policy |
| 0433U | Oncology (prostate), 5 DNA regulatory markers by quantitative PCR, whole blood, algorithm, including prostate- specific antigen, reported as likelihood of cancer | California PPO Prior Authorization List, Pg 149 Original policy |
| 0437U | Psychiatry (anxiety disorders), mRNA, gene expression profiling by RNA sequencing of 15 biomarkers, whole blood, algorithm reported as predictive risk score | California PPO Prior Authorization List, Pg 149 Original policy |
| 0439U | Cardiology (coronary heart disease [CHD]), DNA, analysis of 5 single-nucleotide polymorphisms (SNPs) (rs11716050 [LOC105376934], rs6560711 [WDR37], rs3735222 [SCIN/LOC107986769], rs6820447 [intergenic], and rs9638144 [ESYT2]) and 3 DNA methylation markers (cg00300879 [transcription start site {TSS200} of CNKSR1], cg09552548 [intergenic], and cg14789911 [body of SPATC1L]), qPCR and digital PCR, whole blood, algorithm reported as a 4-tiered risk score for a 3-year risk of symptomatic CHD | California PPO Prior Authorization List, Pg 149 Original policy |
| 0440U | Cardiology (coronary heart disease [CHD]), DNA, analysis of 10 single-nucleotide polymorphisms (SNPs) (rs710987 [LINC010019], rs1333048 [CDKN2B-AS1], rs12129789 [KCND3], rs942317 [KTN1-AS1], rs1441433 [PPP3CA], rs2869675 [PREX1], rs4639796 [ZBTB41], rs4376434 [LINC00972], rs12714414 [TMEM18], and rs7585056 [TMEM18]) and 6 DNA methylation markers (cg03725309 [SARS1], cg12586707 [CXCL1, cg04988978 [MPO], cg17901584 [DHCR24-DT], cg21161138 [AHRR], and cg12655112 [EHD4]), qPCR and digital PCR, whole blood, algorithm reported as detected or not detected for CHD | California PPO Prior Authorization List, Pg 150 Original policy |
| 0444U | Oncology (solid organ neoplasia), targeted genomic sequence analysis panel of 361 genes, interrogation for gene fusions, translocations, or other rearrangements, using DNA from formalin-fixed paraffin-embedded (FFPE) tumor tissue, report of clinically significant variant(s) | California PPO Prior Authorization List, Pg 150 Original policy |
| 0449U | Carrier screening for severe inherited conditions (e.g., cystic fibrosis, spinal muscular atrophy, beta hemoglobinopathies [including sickle cell disease], alpha thalassemia), regardless of race or self-identified ancestry, genomic sequence analysis panel, must include analysis of 5 genes (CFTR, SMN1, HBB, HBA1, HBA2) | California PPO Prior Authorization List, Pg 150 Original policy |
| 0452U | Oncology (bladder), methylated PENK DNA detection by linear target enrichment-quantitative methylation-specific real- time PCR (LTE-qMSP), urine, reported as likelihood of bladder cancer | California PPO Prior Authorization List, Pg 150 Original policy |
| 0453U | Oncology (colorectal cancer), cell free DNA (cfDNA), methylation-based quantitative PCR assay (SEPTIN9, IKZF1, BCAT1, Septin9-2, VAV3, BCAN), plasma, reported as presence or absence of circulating tumor DNA (ctDNA) | California PPO Prior Authorization List, Pg 150 Original policy |
| 0454U | Rare diseases (constitutional/heritable disorders), identification of copy number variations, inversions, insertions, translocations, and other structural variants by optical genome mapping | California PPO Prior Authorization List, Pg 150 Original policy |
| 0460U | Oncology, whole blood or buccal, DNA single-nucleotide polymorphism (SNP) genotyping by real-time PCR of 24 genes, with variant analysis and reported phenotypes | California PPO Prior Authorization List, Pg 150 Original policy |
| 0461U | Oncology, pharmacogenomic analysis of single-nucleotide polymorphism (SNP) genotyping by real-time PCR of 24 genes, whole blood or buccal swab, with variant analysis, including impacted gene-drug interactions and reported phenotypes | California PPO Prior Authorization List, Pg 150 Original policy |
| 0465U | Oncology (urothelial carcinoma), DNA, quantitative methylation-specific PCR of 2 genes (ONECUT2, VIM), algorithmic analysis reported as positive or negative | California PPO Prior Authorization List, Pg 150 Original policy |
| 0466U | Cardiology (coronary artery disease [CAD]), DNA, genome- wide association studies (564856 single-nucleotide polymorphisms [SNPs], targeted variant genotyping), patient lifestyle and clinical data, buccal swab, algorithm reported as polygenic risk to acquired heart disease | California PPO Prior Authorization List, Pg 150 Original policy |
| 0467U | Oncology (bladder), DNA, next-generation sequencing (NGS) of 60 genes and whole genome aneuploidy, urine, algorithms reported as minimal residual disease (MRD) status positive or negative and quantitative disease burden | California PPO Prior Authorization List, Pg 150 Original policy |
| 0469U | Rare diseases (constitutional/heritable disorders), whole genome sequence analysis for chromosomal abnormalities, copy number variants, duplications/deletions, inversions, unbalanced translocations, regions of homozygosity (ROH), inheritance pattern that indicate uniparental disomy (UPD), and aneuploidy, fetal sample (amniotic fluid, chorionic villus sample, or products of conception), identification and categorization of genetic variants, diagnostic report of fetal results based on phenotype with maternal sample and paternal sample, if performed, as comparators and/or maternal cell contamination | California PPO Prior Authorization List, Pg 150 Original policy |