Anthem Blue Cross Blue Shield of Colorado prior authorization, page 39
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 |
|---|---|---|
| 77770 | Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; 1 channel | Colorado Prior Authorization List, Pg 93 Original policy |
| 77771 | Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; 2-12 channels | Colorado Prior Authorization List, Pg 93 Original policy |
| 77772 | Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy, includes basic dosimetry, when performed; over 12 channels | Colorado Prior Authorization List, Pg 93 Original policy |
| 77778 | Interstitial Radioelement Application; Complex | Colorado Prior Authorization List, Pg 93 Original policy |
| 77790 | Supervision, Handling, Loading, Radiation Source | Colorado Prior Authorization List, Pg 93 Original policy |
| 78429 | Myocardial imaging, positron emission tomography (PET), metabolic evaluation study (including ventricular wall motion[s] and/or ejection fraction[s], when performed), single s | Colorado Prior Authorization List, Pg 93 Original policy |
| 78430 | Myocardial imaging, positron emission tomography (PET), perfusion study (including ventricular wall motion[s] and/or ejection fraction[s], when performed); single study, at re | Colorado Prior Authorization List, Pg 93 Original policy |
| 78431 | Myocardial imaging, positron emission tomography (PET), perfusion study (including ventricular wall motion[s] and/or ejection fraction[s], when performed); multiple studies at | Colorado Prior Authorization List, Pg 93 Original policy |
| 78432 | Myocardial imaging, positron emission tomography (PET), combined perfusion with metabolic evaluation study (including ventricular wall motion[s] and/or ejection fraction[s], w | Colorado Prior Authorization List, Pg 93 Original policy |
| 78433 | Myocardial imaging, positron emission tomography (PET), combined perfusion with metabolic evaluation study (including ventricular wall motion[s] and/or ejection fraction[s], w | Colorado Prior Authorization List, Pg 93 Original policy |
| 78451 | Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall mo | Colorado Prior Authorization List, Pg 93 Original policy |
| 78452 | Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall mo | Colorado Prior Authorization List, Pg 93 Original policy |
| 78453 | Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall mo | Colorado Prior Authorization List, Pg 93 Original policy |
| 78454 | Myocardial perfusion imaging, tomographic (SPECT) (including attenuation correction, qualitative or quantitative wall mo | Colorado Prior Authorization List, Pg 93 Original policy |
| 78459 | Myocardial imaging, positron emission tomography (PET), metabolic evaluation study (including ventricular wall motion[s] and/or ejection fraction[s], when performed), single s | Colorado Prior Authorization List, Pg 94 Original policy |
| 78466 | Myocardial Imaging, Infarct Avid, Planar; Qualitative/Quantitative | Colorado Prior Authorization List, Pg 94 Original policy |
| 78468 | Myocardial Imaging, Infarct Avid, Planar; W/Ejection Fraction, 1st Pass Technique | Colorado Prior Authorization List, Pg 94 Original policy |
| 78469 | Myocardial Imaging, Infarct Avid, Planar; Tomographic Spect W/Wo Quantification | Colorado Prior Authorization List, Pg 94 Original policy |
| 78472 | Cardiac Blood Pool Imaging, Gated Equilibrium; Planar, Single Study, Rest/Stress | Colorado Prior Authorization List, Pg 94 Original policy |
| 78473 | Cardiac Blood Pool Imaging, Gated Equilibrium; Planar, Multiple Studies, Rest/Stress | Colorado Prior Authorization List, Pg 94 Original policy |
| 78481 | Cardiac Blood Pool Imaging, Planar, 1st Pass; Single Study & Ejection Fraction W/Wo Quantification | Colorado Prior Authorization List, Pg 94 Original policy |
| 78483 | Cardiac Blood Pool Imaging, Planar, 1st Pass; Mult Studies, Rest & Stress & Eject Fractn W/Wo Quant | Colorado Prior Authorization List, Pg 94 Original policy |
| 78491 | Myocardial imaging, positron emission tomography (PET), perfusion study (including ventricular wall motion[s] and/or ejection fraction[s], when performed); single study, at re | Colorado Prior Authorization List, Pg 94 Original policy |
| 78492 | Myocardial imaging, positron emission tomography (PET), perfusion study (including ventricular wall motion[s] and/or ejection fraction[s], when performed); multiple studies at | Colorado Prior Authorization List, Pg 94 Original policy |
| 78494 | Cardiac Blood Pool Imaging, Gated Equilibrium, Rest, Spect, & Ejection Fraction W/Wo Quantification | Colorado Prior Authorization List, Pg 94 Original policy |
| 78608 | Brain Imaging, Positron Emission Tomography (Pet); Metabolic Evaluation | Colorado Prior Authorization List, Pg 94 Original policy |
| 78609 | Brain Imaging, Positron Emission Tomography (Pet); Perfusion Evaluation | Colorado Prior Authorization List, Pg 94 Original policy |
| 78811 | Positron emission tomography (PET) imaging; limited area (eg, chest, head/neck) | Colorado Prior Authorization List, Pg 94 Original policy |
| 78812 | Positron emission tomography (PET) imaging; skull base to mid-thigh | Colorado Prior Authorization List, Pg 94 Original policy |
| 78813 | Positron emission tomography (PET) imaging; whole body | Colorado Prior Authorization List, Pg 94 Original policy |
| 78814 | Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and an | Colorado Prior Authorization List, Pg 94 Original policy |
| 78815 | Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and an | Colorado Prior Authorization List, Pg 94 Original policy |
| 78816 | Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and an | Colorado Prior Authorization List, Pg 94 Original policy |
| 79101 | Radiopharmaceutical Therapy, By Intravenous Administration | Colorado Prior Authorization List, Pg 94 Original policy |
| 79403 | Radiopharmaceutical Therapy, Radiolabeled Monoclonal Antibody By Intravenous Infusion | Colorado Prior Authorization List, Pg 94 Original policy |
| 81120 | IDH1 (isocitrate dehydrogenase 1 [NADP+], soluble) (eg, glioma), common variants (eg, R132H, R132C) | Colorado Prior Authorization List, Pg 94 Original policy |
| 81121 | IDH2 (isocitrate dehydrogenase 2 [NADP+], mitochondrial) (eg, glioma), common variants (eg, R140W, R172M) | Colorado Prior Authorization List, Pg 94 Original policy |
| 81161 | DMD (dystrophin) (eg, Duchenne/Becker muscular dystrophy) deletion analysis, and duplication analysis, if performed | Colorado Prior Authorization List, Pg 94 Original policy |
| 81162 | BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis and full duplicatio | Colorado Prior Authorization List, Pg 95 Original policy |
| 81163 | BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis | Colorado Prior Authorization List, Pg 95 Original policy |
| 81164 | BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full duplication/deletion analysis (ie, de | Colorado Prior Authorization List, Pg 95 Original policy |
| 81165 | BRCA1 (BRCA1, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis | Colorado Prior Authorization List, Pg 95 Original policy |
| 81166 | BRCA1 (BRCA1, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full duplication/deletion analysis (ie, detection of large gene rearrangements) | Colorado Prior Authorization List, Pg 95 Original policy |
| 81167 | BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full duplication/deletion analysis (ie, detection of large gene rearrangements) | Colorado Prior Authorization List, Pg 95 Original policy |
| 81170 | ABL1 (ABL proto-oncogene 1, non-receptor tyrosine kinase) (eg, acquired imatinib tyrosine kinase inhibitor resistance), gene analysis, variants in the kinase domain | Colorado Prior Authorization List, Pg 95 Original policy |
| 81171 | AFF2 (ALF transcription elongation factor 2 [FMR2]) (eg, fragile X intellectual disability 2 [FRAXE]) gene analysis; evaluation to detect abnormal (eg, expanded) alleles | Colorado Prior Authorization List, Pg 95 Original policy |
| 81172 | AFF2 (ALF transcription elongation factor 2 [FMR2]) (eg, fragile X intellectual disability 2 [FRAXE]) gene analysis; characterization of alleles (eg, expanded size and methyla | Colorado Prior Authorization List, Pg 95 Original policy |
| 81173 | AR (androgen receptor) (eg, spinal and bulbar muscular atrophy, Kennedy disease, X chromosome inactivation) gene analysis; full gene sequence | Colorado Prior Authorization List, Pg 95 Original policy |
| 81174 | AR (androgen receptor) (eg, spinal and bulbar muscular atrophy, Kennedy disease, X chromosome inactivation) gene analysis; known familial variant | Colorado Prior Authorization List, Pg 95 Original policy |
| 81175 | ASXL1 (additional sex combs like 1, transcriptional regulator) (eg, myelodysplastic syndrome, myeloproliferative neoplasms, chronic myelomonocytic leukemia), gene analysis; fu | Colorado Prior Authorization List, Pg 95 Original policy |