Anthem Blue Cross Blue Shield of Colorado prior authorization, page 41
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 |
|---|---|---|
| 81233 | BTK (Bruton's tyrosine kinase) (eg, chronic lymphocytic leukemia) gene analysis, common variants (eg, C481S, C481R, C481F) | Colorado Prior Authorization List, Pg 97 Original policy |
| 81234 | DMPK (DM1 protein kinase) (eg, myotonic dystrophy type 1) gene analysis; evaluation to detect abnormal (expanded) alleles | Colorado Prior Authorization List, Pg 97 Original policy |
| 81235 | EGFR (epidermal growth factor receptor) (eg, non-small cell lung cancer) gene analysis, common variants (eg, exon 19 LREA deletion, L858R, T790M, G719A, G719S, L861Q) | Colorado Prior Authorization List, Pg 97 Original policy |
| 81236 | EZH2 (enhancer of zeste 2 polycomb repressive complex 2 subunit) (eg, myelodysplastic syndrome, myeloproliferative neoplasms) gene analysis, full gene sequence | Colorado Prior Authorization List, Pg 97 Original policy |
| 81237 | EZH2 (enhancer of zeste 2 polycomb repressive complex 2 subunit) (eg, diffuse large B-cell lymphoma) gene analysis, common variant(s) (eg, codon 646) | Colorado Prior Authorization List, Pg 97 Original policy |
| 81239 | DMPK (DM1 protein kinase) (eg, myotonic dystrophy type 1) gene analysis; characterization of alleles (eg, expanded size) | Colorado Prior Authorization List, Pg 97 Original policy |
| 81240 | F2 (Prothrombin, Coagulation Factor Ii) (Eg, Hereditary Hypercoagulability) Gene Analysis, 20210G>A Variant | Colorado Prior Authorization List, Pg 97 Original policy |
| 81241 | F5 (Coagulation Factor V) (Eg, Hereditary Hypercoagulability) Gene Analysis, Leiden Variant | Colorado Prior Authorization List, Pg 98 Original policy |
| 81242 | Fancc (Fanconi Anemia, Complementation Group C) (Eg, Fanconi Anemia, Type C) Gene Analysis, Common Variant (Eg, Ivs4+4A>T) | Colorado Prior Authorization List, Pg 98 Original policy |
| 81243 | FMR1 (fragile X messenger ribonucleoprotein 1) (eg, fragile X syndrome, X-linked intellectual disability [XLID]) gene analysis; evaluation to detect abnormal (eg, expanded) al | Colorado Prior Authorization List, Pg 98 Original policy |
| 81244 | FMR1 (fragile X messenger ribonucleoprotein 1) (eg, fragile X syndrome, X-linked intellectual disability [XLID]) gene analysis; characterization of alleles (eg, expanded size | Colorado Prior Authorization List, Pg 98 Original policy |
| 81245 | Flt3 (Fms-Related Tyrosine Kinase 3) (Eg, Acute Myeloid Leukemia), Gene Analysis, Internal Tandem Duplication (Itd) Variants (Ie, Exons 14, 15) | Colorado Prior Authorization List, Pg 98 Original policy |
| 81246 | FLT3 (fms-related tyrosine kinase 3) (eg, acute myeloid leukemia), gene analysis; tyrosine kinase domain (TKD) variants (eg, D835, I836) | Colorado Prior Authorization List, Pg 98 Original policy |
| 81247 | G6PD (glucose-6-phosphate dehydrogenase) (eg, hemolytic anemia, jaundice), gene analysis; common variant(s) (eg, A, A-) | Colorado Prior Authorization List, Pg 98 Original policy |
| 81248 | G6PD (glucose-6-phosphate dehydrogenase) (eg, hemolytic anemia, jaundice), gene analysis; known familial variant(s) | Colorado Prior Authorization List, Pg 98 Original policy |
| 81249 | G6PD (glucose-6-phosphate dehydrogenase) (eg, hemolytic anemia, jaundice), gene analysis; full gene sequence | Colorado Prior Authorization List, Pg 98 Original policy |
| 81250 | G6Pc (Glucose-6-Phosphatase, Catalytic Subunit) (Eg, Glycogen Storage Disease, Type 1A, Von Gierke Disease) Gene Analysis, Common Variants (Eg, R83C, Q347X) | Colorado Prior Authorization List, Pg 98 Original policy |
| 81251 | Gba (Glucosidase, Beta, Acid) (Eg, Gaucher Disease) Gene Analysis, Common Variants (Eg, N370S, 84Gg, L444P, Ivs2+1G>A) | Colorado Prior Authorization List, Pg 98 Original policy |
| 81252 | GJB2 (gap junction protein, beta 2, 26kDa, connexin 26) (eg, nonsyndromic hearing loss) gene analysis; full gene sequence | Colorado Prior Authorization List, Pg 98 Original policy |
| 81253 | GJB2 (gap junction protein, beta 2, 26kDa; connexin 26) (eg, nonsyndromic hearing loss) gene analysis; known familial variants | Colorado Prior Authorization List, Pg 98 Original policy |
| 81254 | GJB6 (gap junction protein, beta 6, 30kDa, connexin 30) (eg, nonsyndromic hearing loss) gene analysis, common variants (eg, 309kb [del(GJB6-D13S1830)] and 232kb [del(GJB6-D13S | Colorado Prior Authorization List, Pg 98 Original policy |
| 81255 | Hexa (Hexosaminidase A [Alpha Polypeptide]) (Eg, Tay-Sachs Disease) Gene Analysis, Common Variants (Eg, 1278Instatc, 1421+1G>C, G269S) | Colorado Prior Authorization List, Pg 98 Original policy |
| 81256 | Hfe (Hemochromatosis) (Eg, Hereditary Hemochromatosis) Gene Analysis, Common Variants (Eg, C282Y, H63D) | Colorado Prior Authorization List, Pg 98 Original policy |
| 81257 | HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia, Hb Bart hydrops fetalis syndrome, HbH disease), gene analysis; common deletions or variant (eg, Southeast | Colorado Prior Authorization List, Pg 98 Original policy |
| 81258 | HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia, Hb Bart hydrops fetalis syndrome, HbH disease), gene analysis; known familial variant | Colorado Prior Authorization List, Pg 98 Original policy |
| 81259 | HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia, Hb Bart hydrops fetalis syndrome, HbH disease), gene analysis; full gene sequence | Colorado Prior Authorization List, Pg 99 Original policy |
| 81260 | Ikbkap (Inhibitor Of Kappa Light Polypeptide Gene Enhancer In B-Cells, Kinase Complex-Associated Protein) (Eg, Familial Dysautonomia) Gene Analysis, Common Variants (Eg, 2507+ | Colorado Prior Authorization List, Pg 99 Original policy |
| 81261 | Igh@ (Immunoglobulin Heavy Chain Locus) (Eg, Leukemias And Lymphomas, B- Cell), Gene Rearrangement Analysis To Detect Abnormal Clonal Population(S); Amplified Methodology (Eg | Colorado Prior Authorization List, Pg 99 Original policy |
| 81262 | Igh@ (Immunoglobulin Heavy Chain Locus) (Eg, Leukemias And Lymphomas, B- Cell), Gene Rearrangement Analysis To Detect Abnormal Clonal Population(S); Direct Probe Methodology (E | Colorado Prior Authorization List, Pg 99 Original policy |
| 81263 | Igh@ (Immunoglobulin Heavy Chain Locus) (Eg, Leukemia And Lymphoma, B- Cell), Variable Region Somatic Mutation Analysis | Colorado Prior Authorization List, Pg 99 Original policy |
| 81264 | Igk@ (Immunoglobulin Kappa Light Chain Locus) (Eg, Leukemia And Lymphoma, B-Cell), Gene Rearrangement Analysis, Evaluation To Detect Abnormal Clonal Population(S) | Colorado Prior Authorization List, Pg 99 Original policy |
| 81265 | Comparative Analysis Using Short Tandem Repeat (Str) Markers; Patient And Comparative Specimen (Eg, Pre-Transplant Recipient And Donor Germline Testing, Post-Transplant Non-He | Colorado Prior Authorization List, Pg 99 Original policy |
| 81266 | Comparative Analysis Using Short Tandem Repeat (Str) Markers; Each Additional Specimen (Eg, Additional Cord Blood Donor, Additional Fetal Samples From Different Cultures, Or A | Colorado Prior Authorization List, Pg 99 Original policy |
| 81269 | HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia, Hb Bart hydrops fetalis syndrome, HbH disease), gene analysis; duplication/deletion variants | Colorado Prior Authorization List, Pg 99 Original policy |
| 81270 | Jak2 (Janus Kinase 2) (Eg, Myeloproliferative Disorder) Gene Analysis, P.Val617Phe (V617F) Variant | Colorado Prior Authorization List, Pg 99 Original policy |
| 81271 | HTT (huntingtin) (eg, Huntington disease) gene analysis; evaluation to detect abnormal (eg, expanded) alleles | Colorado Prior Authorization List, Pg 99 Original policy |
| 81272 | KIT (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog) (eg, gastrointestinal stromal tumor [GIST], acute myeloid leukemia, melanoma), gene analysis, targeted sequ | Colorado Prior Authorization List, Pg 99 Original policy |
| 81273 | KIT (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog) (eg, mastocytosis), gene analysis, D816 variant(s) | Colorado Prior Authorization List, Pg 99 Original policy |
| 81274 | HTT (huntingtin) (eg, Huntington disease) gene analysis; characterization of alleles (eg, expanded size) | Colorado Prior Authorization List, Pg 99 Original policy |
| 81275 | Kras (V-Ki-Ras2 Kirsten Rat Sarcoma Viral Oncogene) (Eg, Carcinoma) Gene Analysis, Variants In Codons 12 And 13 | Colorado Prior Authorization List, Pg 99 Original policy |
| 81276 | KRAS (Kirsten rat sarcoma viral oncogene homolog) (eg, carcinoma) gene analysis; additional variant(s) (eg, codon 61, codon 146) | Colorado Prior Authorization List, Pg 99 Original policy |
| 81277 | Cytogenomic neoplasia (genome-wide) microarray analysis, interrogation of genomic regions for copy number and loss-of-heterozygosity variants for chromosomal abnormalities | Colorado Prior Authorization List, Pg 99 Original policy |
| 81278 | IGH@/BCL2 (t(14;18)) (eg, follicular lymphoma) translocation analysis, major breakpoint region (MBR) and minor cluster region (mcr) breakpoints, qualitative or quantitative | Colorado Prior Authorization List, Pg 99 Original policy |
| 81279 | JAK2 (Janus kinase 2) (eg, myeloproliferative disorder) targeted sequence analysis (eg, exons 12 and 13) | Colorado Prior Authorization List, Pg 99 Original policy |
| 81283 | IFNL3 (interferon, lambda 3) (eg, drug response), gene analysis, rs12979860 variant | Colorado Prior Authorization List, Pg 99 Original policy |
| 81284 | FXN (frataxin) (eg, Friedreich ataxia) gene analysis; evaluation to detect abnormal (expanded) alleles | Colorado Prior Authorization List, Pg 99 Original policy |
| 81285 | FXN (frataxin) (eg, Friedreich ataxia) gene analysis; characterization of alleles (eg, expanded size) | Colorado Prior Authorization List, Pg 99 Original policy |
| 81286 | FXN (frataxin) (eg, Friedreich ataxia) gene analysis; full gene sequence | Colorado Prior Authorization List, Pg 99 Original policy |
| 81287 | MGMT (O-6-methylguanine-DNA methyltransferase) (eg, glioblastoma multiforme) promoter methylation analysis | Colorado Prior Authorization List, Pg 99 Original policy |
| 81288 | MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (eg, hereditary non- polyposis colorectal cancer, Lynch syndrome) gene analysis; promoter methylation analysis | Colorado Prior Authorization List, Pg 100 Original policy |