Anthem Blue Cross Blue Shield of California prior authorization, page 58
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 |
|---|---|---|
| 0471U | Oncology (colorectal cancer), qualitative real-time PCR of 35 variants of KRAS and NRAS genes (exons 2, 3, 4), formalin- fixed paraffin-embedded (FFPE), predictive, identification of detected mutations | California PPO Prior Authorization List, Pg 150 Original policy |
| 0473U | Oncology (solid tumor), next-generation sequencing (NGS) of DNA from formalin-fixed paraffin-embedded (FFPE) tissue with comparative sequence analysis from a matched normal specimen (blood or saliva), 648 genes, interrogation for sequence variants, insertion and deletion alterations, copy number variants, rearrangements, microsatellite instability, and tumor-mutation burden | California PPO Prior Authorization List, Pg 151 Original policy |
| 0474U | Hereditary pan-cancer (e.g., hereditary sarcomas, hereditary endocrine tumors, hereditary neuroendocrine tumors, hereditary cutaneous melanoma), genomic sequence analysis panel of 88 genes with 20 duplications/deletions using next- generation sequencing (NGS), Sanger sequencing, blood or saliva, reported as positive or negative for germline variants, each gene | California PPO Prior Authorization List, Pg 151 Original policy |
| 0475U | Hereditary prostate cancer-related disorders, genomic sequence analysis panel using next-generation sequencing (NGS), Sanger sequencing, multiplex ligation-dependent probe amplification (MLPA), and array comparative genomic hybridization (CGH), evaluation of 23 genes and duplications/deletions when indicated, pathologic mutations reported with a genetic risk score for prostate cancer | California PPO Prior Authorization List, Pg 151 Original policy |
| 0476U | Drug metabolism, psychiatry (e.g., major depressive disorder, general anxiety disorder, attention deficit hyperactivity disorder [ADHD], schizophrenia), whole blood, buccal swab, and pharmacogenomic genotyping of 14 genes and CYP2D6 copy number variant analysis and reported phenotypes | California PPO Prior Authorization List, Pg 151 Original policy |
| 0477U | Drug metabolism, psychiatry (e.g., major depressive disorder, general anxiety disorder,attention deficit hyperactivity disorder [ADHD], schizophrenia), whole blood, buccal swab, and pharmacogenomic genotyping of 14 genes and CYP2D6 copy number variant analysis, including impacted gene-drug interactions and reported phenotypes | California PPO Prior Authorization List, Pg 151 Original policy |
| 0478U | Oncology (non-small cell lung cancer), DNA and RNA, digital PCR analysis of 9 genes (EGFR, KRAS, BRAF, ALK, ROS1, RET, NTRK 1/2/3, ERBB2, and MET) in formalin-fixed paraffin-embedded (FFPE) tissue, interrogation for single- nucleotide variants, insertions/deletions, gene rearrangements, and reported as actionable detected variants for therapy selection | California PPO Prior Authorization List, Pg 151 Original policy |
| 0485U | Oncology (solid tumor), cell-free DNA and RNA by next- generation sequencing, interpretative report for germline mutations, clonal hematopoiesis of indeterminate potential, and tumor-derived single-nucleotide variants, small insertions/deletions, copy number alterations, fusions, microsatellite instability, and tumor mutational burden | California PPO Prior Authorization List, Pg 151 Original policy |
| 0486U | Oncology (pan-solid tumor), next-generation sequencing analysis of tumor methylation markers present in cell-free circulating tumor DNA, algorithm reported as quantitative measurement of methylation as a correlate of tumor fraction | California PPO Prior Authorization List, Pg 151 Original policy |
| 0487U | Oncology (solid tumor), cell-free circulating DNA, targeted genomic sequence analysis panel of 84 genes, interrogation for sequence variants, aneuploidy corrected, gene copy number amplifications and losses, gene rearrangements, and microsatellite instability | California PPO Prior Authorization List, Pg 151 Original policy |
| 0488U | Obstetrics (fetal antigen noninvasive prenatal test), cell-free DNA sequence analysis for detection of fetal presence or absence of 1 or more of the Rh, C, c, D, E, Duffy (Fya), or Kell (K) antigen in alloimmunized pregnancies, reported as selected antigen(s) detected or not detected | California PPO Prior Authorization List, Pg 151 Original policy |
| 0489U | Obstetrics (single-gene noninvasive prenatal test), cell-free DNA sequence analysis of 1 or more targets (e.g., CFTR, SMN1, HBB, HBA1, HBA2) to identify paternally inherited pathogenic variants, and relative mutation-dosage analysis based on molecular counts to determine fetal inheritance of maternal mutation, algorithm reported as a fetal risk score for the condition (e.g., cystic fibrosis, spinal muscular atrophy, beta hemoglobinopathies [including sickle cell disease], alpha thalassemia) | California PPO Prior Authorization List, Pg 151 Original policy |
| 0493U | Transplantation medicine, quantification of donor-derived cell- free DNA (cfDNA) using next-generation sequencing, plasma, reported as percentage of donor-derived cell-free DNA | California PPO Prior Authorization List, Pg 151 Original policy |
| 0494U | Red blood cell antigen (fetal RhD gene analysis), next- generation sequencing of circulating cell-free DNA (cfDNA) of blood in pregnant individuals known to be RhD negative, reported as positive or negative | California PPO Prior Authorization List, Pg 151 Original policy |
| 0496U | Oncology (colorectal), cell-free DNA, 8 genes for mutations, 7 genes for methylation by real-time RT-PCR, and 4 proteins by enzyme-linked immunosorbent assay, blood, reported positive or negative for colorectal cancer or advanced adenoma risk | California PPO Prior Authorization List, Pg 152 Original policy |
| 0497U | Oncology (prostate), mRNA gene expression profiling by real- time RT-PCR of 6 genes (FOXM1, MCM3, MTUS1, TTC21B, ALAS1, and PPP2CA), utilizing formalin-fixed paraffin- embedded (FFPE) tissue, algorithm reported as a risk score for prostate cancer | California PPO Prior Authorization List, Pg 152 Original policy |
| 0498U | Oncology (colorectal), next-generation sequencing for mutation detection in 43 genes and methylation pattern in 45 genes, blood, and formalin-fixed paraffin-embedded (FFPE) tissue, report of variants and methylation pattern with interpretation | California PPO Prior Authorization List, Pg 152 Original policy |
| 0499U | Oncology (colorectal and lung), DNA from formalin-fixed paraffin-embedded (FFPE) tissue, next-generation sequencing of 8 genes (NRAS, EGFR, CTNNB1, PIK3CA, APC, BRAF, KRAS, and TP53), mutation detection | California PPO Prior Authorization List, Pg 152 Original policy |
| 0500U | Auto-inflammatory disease (VEXAS syndrome), DNA, UBA1 gene mutations, targeted variant analysis (M41T, M41V, M41L, c.118-2A>C, c.118-1G>C, c.118- 9_118-2del, S56F, S621C) | California PPO Prior Authorization List, Pg 152 Original policy |
| 0506U | Gastroenterology (Barrett's esophagus), esophageal cells, DNA methylation analysis by next-generation sequencing of at least 89 differentially methylated genomic regions, algorithm reported as likelihood for Barrett's esophagus | California PPO Prior Authorization List, Pg 152 Original policy |
| 0507U | Oncology (ovarian), DNA, whole genome sequencing with 5- hydroxymethylcytosine (5hmC) enrichment, using whole blood or plasma, algorithm reported as cancer detected or not detected | California PPO Prior Authorization List, Pg 152 Original policy |
| 0516U | Drug metabolism, whole blood, pharmacogenomic genotyping of 40 genes and CYP2D6 copy number variant analysis, reported as metabolizer status | California PPO Prior Authorization List, Pg 152 Original policy |
| 0523U | Oncology (solid tumor), DNA, qualitative, next-generation sequencing (NGS) of single nucleotide variants (SNV) and insertion/deletions in 22 genes utilizing formalin-fixed paraffin embedded tissue, reported as presence or absence of mutation(s), location of mutation(s), nucleotide change, and amino acid change | California PPO Prior Authorization List, Pg 152 Original policy |
| 0529U | Hematology (venous thromboembolism [VTE]), genome-wide single-nucleotide polymorphism variants, including F2 and F5 gene analysis, and Leiden variant, by microarray analysis, saliva, report as risk score for VTE | California PPO Prior Authorization List, Pg 152 Original policy |
| 0530U | Oncology (pan-solid tumor), ctDNA, utilizing plasma, next generation sequencing (NGS) of 77 genes, 8 fusions, microsatellite instability, and tumor mutation burden, interpretative report for single-nucleotide variants, copy number alterations, with therapy association | California PPO Prior Authorization List, Pg 152 Original policy |
| 0532U | Rare diseases (constitutional disease/hereditary disorders), rapid whole genome and mitochondrial DNA sequencing for singlenucleotide variants, insertions/deletions, copy number variations, peripheral blood, buffy coat, saliva, buccal or tissue sample, results reported as positive or negative | California PPO Prior Authorization List, Pg 152 Original policy |
| 0533U | Drug metabolism (adverse drug reactions and drug response), genotyping of 16 genes (i.e., ABCG2, CYP2B6, CYP2C9, CYP2C19, CYP2C, CYP2D6, CYP3A5, CYP4F2, DPYD, G6PD, GGCX, NUDT15, SLCO1B1, TPMT, UGT1A1, VKORC1), reported as metabolizer status and transporter function | California PPO Prior Authorization List, Pg 152 Original policy |
| 0534U | Oncology (prostate), microRNA, single-nucleotide polymorphisms (SNPs) analysis by RT-PCR of 32 variants, using buccal swab, algorithm reported as a risk | California PPO Prior Authorization List, Pg 152 Original policy |
| 0536U | Red blood cell antigen (fetal RhD), PCR analysis of exon 4 of RHD gene and housekeeping control gene GAPDH from whole blood in pregnant individuals at 10+ weeks gestation known to be RhD negative, reported as fetal RhD status | California PPO Prior Authorization List, Pg 152 Original policy |
| 0537U | Oncology (colorectal cancer), analysis of cell-free DNA for epigenomic patterns, next-generation sequencing, >2500 differentially methylated regions (DMRs), plasma, algorithm reported as positive or negative | California PPO Prior Authorization List, Pg 152 Original policy |
| 0538U | Oncology (solid tumor), nextgeneration targeted sequencing analysis, formalin-fixed paraffinembedded (FFPE) tumor tissue, DNA analysis of 600 genes, interrogation for single- nucleotide variants, insertions/deletions, gene rearrangements, and copy number alterations, microsatellite instability, tumor mutation burden, reported as actionable variant | California PPO Prior Authorization List, Pg 153 Original policy |
| 0539U | Oncology (solid tumor), cell-free circulating tumor DNA (ctDNA), 152 genes, next-generation sequencing, interrogation for single-nucleotide variants, insertions/deletions, gene rearrangements, copy number alterations, and microsatellite instability, using whole-blood samples, mutations with clinical actionability reported as actionable variant | California PPO Prior Authorization List, Pg 153 Original policy |
| 0540U | Transplantation medicine, quantification of donorderived cell- free DNA using next-generation sequencing analysis of plasma, reported as percentage of donor derived cell-free DNA to determine probability of rejection | California PPO Prior Authorization List, Pg 153 Original policy |
| 0543U | Oncology (solid tumor), nextgeneration sequencing of DNA from formalin-fixed paraffin-embedded (FFPE) tissue of 517 genes, interrogation for singlenucleotide variants, multinucleotide variants, insertions and deletions from DNA, fusions in 24 genes and splice variants in 1 gene from RNA, and tumor mutation burden | California PPO Prior Authorization List, Pg 153 Original policy |
| 0549U | Oncology (urothelial), DNA, quantitative methylated realtime PCR of TRNA-Cys, SIM2, and NKX1-1, using urine, diagnostic algorithm reported as a probability index for bladder cancer and/or upper tract urothelial carcinoma (UTUC) | California PPO Prior Authorization List, Pg 153 Original policy |
| 0552U | Reproductive medicine (preimplantation genetic assessment), analysis for known genetic disorders from trophectoderm biopsy, linkage analysis of disease-causing locus, and when possible, targeted mutation analysis for known familial variant, reported as low-risk or high-risk for familial genetic disorder | California PPO Prior Authorization List, Pg 153 Original policy |
| 0553U | Reproductive medicine (preimplantation genetic assessment), analysis of 24 chromosomes using DNA genomic sequence analysis from embryonic trophectoderm for structural rearrangements, aneuploidy, and a mitochondrial DNA score, results reported as normal/balanced (euploidy/balanced), unbalanced structural rearrangement, monosomy, trisomy, segmental aneuploidy, or mosaic, per embryo tested | California PPO Prior Authorization List, Pg 153 Original policy |
| 0554U | Reproductive medicine (preimplantation genetic assessment), analysis of 24 chromosomes using DNA genomic sequence analysis from trophectoderm biopsy for aneuploidy, ploidy, a mitochondrial DNA score, and embryo quality control, results reported as normal (euploidy), monosomy, trisomy, segmental aneuploidy, triploid, haploid, or mosaic, with quality control results reported as contamination detected or inconsistent cohort when applicable, per embryo tested | California PPO Prior Authorization List, Pg 153 Original policy |
| 0555U | Reproductive medicine (preimplantation genetic assessment), analysis of 24 chromosomes using DNA genomic sequence analysis from embryonic trophectoderm for structural rearrangements, aneuploidy, ploidy, a mitochondrial DNA score, and embryo quality control, results reported as normal/balanced (euploidy/balanced), unbalanced structural rearrangement, monosomy, trisomy, segmental aneuploidy, triploid, haploid, or mosaic, with quality control results reported as contamination detected or inconsistent cohort when applicable, per embryo tested | California PPO Prior Authorization List, Pg 153 Original policy |
| 0560U | Oncology (minimal residual disease [MRD]), genomic sequence analysis, cell-free DNA, whole blood and tumor tissue, baseline assessment for design and construction of a personalized variant panel to evaluate current MRD and for comparison to subsequent MRD assessments | California PPO Prior Authorization List, Pg 153 Original policy |
| 0561U | Oncology (minimal residual disease [MRD]), genomic sequence analysis, cell-free DNA, whole blood, subsequent assessment with comparison to initial assessment to evaluate for MRD | California PPO Prior Authorization List, Pg 153 Original policy |
| 0562U | Oncology (solid tumor), targeted genomic sequence analysis, 33 genes, detection of single-nucleotide variants (SNVs), insertions and deletions, copy-number amplifications, and translocations in human genomic circulating cell-free DNA, plasma, reported as presence of actionable variants | California PPO Prior Authorization List, Pg 153 Original policy |
| 0565U | Oncology (hepatocellular carcinoma), next-generation sequencing methylation pattern assay to detect 6626 epigenetic alterations, cell-free DNA, plasma, algorithm reported as cancer signal detected or not detected | California PPO Prior Authorization List, Pg 154 Original policy |
| 0566U | Oncology (lung), qPCR-based analysis of 13 differentially methylated regions (CCDC181, HOXA7, LRRC8A, MARCHF11, MIR129-2, NCOR2, PANTR1, PRKCB, SLC9A3, TBR1_2, TRAP1, VWC2, ZNF781), pleural fluid, algorithm reported as a qualitative result | California PPO Prior Authorization List, Pg 154 Original policy |
| 0567U | Rare diseases (constitutional/heritable disorders), whole- genome sequence analysis combination of short and long reads, for single-nucleotide variants, insertions/deletions and characterized intronic variants, copy-number variants, duplications/deletions, mobile element insertions, runs of homozygosity, aneuploidy, and inversions, mitochondrial DNA sequence and deletions, short tandem repeat genes, methylation status of selected regions, blood, saliva, amniocentesis, chorionic villus sample or tissue, identification and categorization of genetic variants | California PPO Prior Authorization List, Pg 154 Original policy |
| 0569U | Oncology (solid tumor), next generation sequencing analysis of tumor methylation markers (>20000 differentially methylated regions) present in cell-free circulating tumor DNA (ctDNA), whole blood, algorithm reported as presence or absence of ctDNA with tumor fraction, if appropriate | California PPO Prior Authorization List, Pg 154 Original policy |
| 0571U | Oncology (solid tumor), DNA (80 genes) and RNA (10 genes), by next-generation sequencing, plasma, including single- nucleotide variants, insertions/deletions, copy-number alterations, microsatellite instability, and fusions, reported as clinically actionable variants | California PPO Prior Authorization List, Pg 154 Original policy |
| 0575U | Transplantation medicine (liver allograft rejection), miRNA gene expression profiling by RT-PCR of 4 genes (miR-122, miR-885, miR-23a, spike-in control), serum, plasma or blood, algorithm reported as risk of liver allograft rejection | California PPO Prior Authorization List, Pg 154 Original policy |
| 0576U | Transplantation medicine (liver allograft rejection), quantitative donor-derived cell-free DNA (cfDNA) by whole genome next generation sequencing, plasma and mRNA gene expression profiling by multiplex real-time PCR of 56 genes, whole blood, combined algorithm reported as a rejection risk score | California PPO Prior Authorization List, Pg 154 Original policy |
| 0578U | Oncology (cutaneous melanoma), RNA, gene expression profiling by real time qPCR of 10 genes (8 content and 2 housekeeping), utilizing formalin-fixed paraffin-embedded (FFPE) tissue, algorithm reports a binary result, either low-risk or high-risk for sentinel lymph node metastasis and recurrence | California PPO Prior Authorization List, Pg 154 Original policy |