Anthem Blue Cross Blue Shield of California prior authorization, page 59
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 |
|---|---|---|
| 0582U | Rare diseases (constitutional disease/hereditary disorders), rapid whole genome DNA sequencing for single nucleotide variants, insertions/deletions, copy number variations, blood, saliva, tissue sample, variants reported | California PPO Prior Authorization List, Pg 154 Original policy |
| 0583U | Rare diseases (constitutional disease/hereditary disorders), rapid whole genome comparator DNA sequencing for single- nucleotide variants, insertions/deletions, copy number variations, blood, saliva, tissue sample, variants reported with proband results | California PPO Prior Authorization List, Pg 154 Original policy |
| 0586U | Oncology, mRNA, gene expression profiling of 216 genes (204 targeted and 12 housekeeping genes), RNA expression analysis, formalin-fixed paraffin-embedded (FFPE) tissue, quantitative, reported as log2 ratio per gene | California PPO Prior Authorization List, Pg 154 Original policy |
| 0592U | Oncology (hematolymphoid neoplasms), DNA, targeted genomic sequence of 417 genes, interrogation for gene fusions, translocations, rearrangements, utilizing formalin- fixed paraffin-embedded (FFPE) tumor tissue, results report clinically significant variant(s) | California PPO Prior Authorization List, Pg 154 Original policy |
| 0597U | Oncology (breast), RNA expression profiling of 329 genes by targeted nextgeneration sequencing and 20 proteins by multiplex immunofluorescence, formalin-fixed paraffin- embedded (FFPE) tissue, algorithmic analyses to determine tumor-recurrence risk score | California PPO Prior Authorization List, Pg 154 Original policy |
| 0605U | Allergy and immunology (hereditary alpha tryptasemia), DNA, analysis of TPSAB1 gene copy number variation using digital PCR, whole blood, results reported with genotype specific interpretation of alpha-tryptase copy number and algorithmic classification as normal or abnormal | California PPO Prior Authorization List, Pg 154 Original policy |
| 0611U | Oncology (liver), analysis of over 1,000 methylated regions, cell-free DNA from plasma, algorithm reported as a quantitative result | California PPO Prior Authorization List, Pg 155 Original policy |
| 0612U | Oncology (liver), analysis of over 1,000 methylated regions, cell-free DNA from plasma, algorithm reported as a quantitative result | California PPO Prior Authorization List, Pg 155 Original policy |
| 0613U | Oncology (urothelial carcinoma), DNA methylation and mutation analysis of 6 biomarkers (TWIST1, OTX1, ONECUT2, FGFR3, HRAS, TERT promoter region), methylation-specific PCR and targeted next-generation sequencing, urine, algorithm reported as a probability index for bladder cancer and upper tract urothelial carcinoma | California PPO Prior Authorization List, Pg 155 Original policy |
| 0628U | Nephrology (kidney disease-related genetic conditions), genomic analysis, renal disease panel, saliva, DNA, next- generation sequencing of 449 genes, reported as pathogenic or likely pathogenic variants of uncertain significance or risk alleles | California PPO Prior Authorization List, Pg 155 Original policy |
| 0630U | Oncology (breast), mRNA, gene expression profiling by microarray of 80 genes (80 content and 465 housekeeping), utilizing formalin-fixed paraffin-embedded tissue (FFPE), algorithm reported as an index that is diagnostic of a molecular subtype (luminal, basal, Her2) | California PPO Prior Authorization List, Pg 155 Original policy |
| A4544 | Electrode for external lower extremity nerve stimulator for restless legs syndrome | California PPO Prior Authorization List, Pg 155 Original policy |
| A4545 | Supplies and accessories for external tibial nerve stimulator (e.g., socks, gel pads, electrodes, etc.), needed for one month [e.g., supplies for Vivally and ZIDA systems] | California PPO Prior Authorization List, Pg 155 Original policy |
| A4604 | Tubing with heating element | California PPO Prior Authorization List, Pg 155 Original policy |
| A7027 | Combination Oral/Nasal Mask used with positive airway pressure device, each | California PPO Prior Authorization List, Pg 155 Original policy |
| A7028 | Oral Cushion, Replacement for Combination Oral/Nasal Mask, each | California PPO Prior Authorization List, Pg 155 Original policy |
| A7029 | Nasal Pillows, Replacement for Combination Oral/Nasal Mask, pair | California PPO Prior Authorization List, Pg 155 Original policy |
| A7030 | Full Face Mask used with positive airway pressure device, each | California PPO Prior Authorization List, Pg 155 Original policy |
| A7031 | Face Mask Cushion, Replacement for Full Face Mask | California PPO Prior Authorization List, Pg 155 Original policy |
| A7032 | Replacement Cushion for Nasal Application Device | California PPO Prior Authorization List, Pg 155 Original policy |
| A7033 | Replacement Pillows for Nasal Application Device, pair | California PPO Prior Authorization List, Pg 155 Original policy |
| A7034 | Nasal Interface (mask or cannula type), used with positive airway pressure device, with/without head strap | California PPO Prior Authorization List, Pg 155 Original policy |
| A7035 | Headgear | California PPO Prior Authorization List, Pg 155 Original policy |
| A7036 | Chinstrap | California PPO Prior Authorization List, Pg 155 Original policy |
| A7037 | Tubing | California PPO Prior Authorization List, Pg 156 Original policy |
| A7038 | Filter, disposable | California PPO Prior Authorization List, Pg 156 Original policy |
| A7039 | Filter, non-disposable | California PPO Prior Authorization List, Pg 156 Original policy |
| A7044 | Oral Interface for Positive Airway Pressure Therapy | California PPO Prior Authorization List, Pg 156 Original policy |
| A7045 | Replacement Exhalation Port for PAP Therapy | California PPO Prior Authorization List, Pg 156 Original policy |
| A7046 | Water chamber for humidifier, replacement, each | California PPO Prior Authorization List, Pg 156 Original policy |
| A9513 | Lutetium Lu 177, dotatate, therapeutic, 1 mCi (Lutathera) | California PPO Prior Authorization List, Pg 156 Original policy |
| A9543 | Yttrium Y-90 ibritumomab tiuxetan, therapeutic, per treatment dose, up to 40mCi (Zevalin) | California PPO Prior Authorization List, Pg 156 Original policy |
| A9552 | Fluorodeoxyglucose f-18 fdg, diagnostic, per study dose, up to 45 millicuries | California PPO Prior Authorization List, Pg 156 Original policy |
| A9586 | Florbetapir f18, diagnostic, per study dose, up to 10 millicuries | California PPO Prior Authorization List, Pg 156 Original policy |
| A9601 | Flortaucipir f 18 injection, diagnostic, 1 millicurie | California PPO Prior Authorization List, Pg 156 Original policy |
| A9602 | Fluorodopa f-18, diagnostic, per millicurie | California PPO Prior Authorization List, Pg 156 Original policy |
| A9606 | Radium ra-223 dichloride, therapeutic (Xofigo) | California PPO Prior Authorization List, Pg 156 Original policy |
| A9515 | Choline c-11, diagnostic, per study dose up to 20 millicuries | California PPO Prior Authorization List, Pg 156 Original policy |
| A9580 | Sodium fluoride f-18, diagnostic, per study dose, up to 30 millicuries | California PPO Prior Authorization List, Pg 156 Original policy |
| A9587 | Gallium ga-68, dotatate, diagnostic, 0.1 millicurie (Gallium dotatate) | California PPO Prior Authorization List, Pg 157 Original policy |
| A9588 | Fluciclovine f-18, diagnostic, 1 millicurie (Axumin) | California PPO Prior Authorization List, Pg 157 Original policy |
| A9591 | Fluoroestradiol f 18, diagnostic, 1 millicurie (Cerianna) | California PPO Prior Authorization List, Pg 157 Original policy |
| A9592 | Copper cu-64, dotatate, diagnostic, 1 millicurie (Copper dotatate) | California PPO Prior Authorization List, Pg 157 Original policy |
| A9593 | Gallium ga-68 psma-11, diagnostic, (ucsf), 1 millicurie (PSMA) | California PPO Prior Authorization List, Pg 157 Original policy |
| A9594 | Gallium ga-68 psma-11, diagnostic, (ucla), 1 millicurie (PSMA) | California PPO Prior Authorization List, Pg 157 Original policy |
| A9595 | Piflufolastat f-18, diagnostic, 1 millicurie (Pylarify) | California PPO Prior Authorization List, Pg 157 Original policy |
| A9596 | Gallium ga-68 gozetotide, diagnostic, (illuccix), 1 millicurie (Illuccix) | California PPO Prior Authorization List, Pg 157 Original policy |
| A9597 | Positron emission tomography radiopharmaceutical, diagnostic, for tumor identification, NOC | California PPO Prior Authorization List, Pg 157 Original policy |
| A9598 | Positron emission tomography radiopharmaceutical, diagnostic, for tumor identification, NOC | California PPO Prior Authorization List, Pg 157 Original policy |
| A9608 | Flotufolastat f 18, diagnostic, 1 millicurie (Posluma) | California PPO Prior Authorization List, Pg 157 Original policy |