Anthem Blue Cross Blue Shield of Colorado prior authorization, page 42
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 |
|---|---|---|
| 81289 | FXN (frataxin) (eg, Friedreich ataxia) gene analysis; known familial variant(s) | Colorado Prior Authorization List, Pg 100 Original policy |
| 81290 | Mcoln1 (Mucolipin 1) (Eg, Mucolipidosis, Type Iv) Gene Analysis, Common Variants (Eg, Ivs3-2A>G, Del6.4Kb) | Colorado Prior Authorization List, Pg 100 Original policy |
| 81291 | Mthfr (5,10-Methylenetetrahydrofolate Reductase) (Eg, Hereditary Hypercoagulability) Gene Analysis, Common Variants (Eg, 677T, 1298C) | Colorado Prior Authorization List, Pg 100 Original policy |
| 81292 | Mlh1 (Mutl Homolog 1, Colon Cancer, Nonpolyposis Type 2) (Eg, Hereditary Non- Polyposis Colorectal Cancer, Lynch Syndrome) Gene Analysis; Full Sequence Analysis | Colorado Prior Authorization List, Pg 100 Original policy |
| 81293 | Mlh1 (Mutl Homolog 1, Colon Cancer, Nonpolyposis Type 2) (Eg, Hereditary Non- Polyposis Colorectal Cancer, Lynch Syndrome) Gene Analysis; Known Familial Variants | Colorado Prior Authorization List, Pg 100 Original policy |
| 81294 | Mlh1 (Mutl Homolog 1, Colon Cancer, Nonpolyposis Type 2) (Eg, Hereditary Non- Polyposis Colorectal Cancer, Lynch Syndrome) Gene Analysis; Duplication/Deletion Variants | Colorado Prior Authorization List, Pg 100 Original policy |
| 81295 | Msh2 (Muts Homolog 2, Colon Cancer, Nonpolyposis Type 1) (Eg, Hereditary Non-Polyposis Colorectal Cancer, Lynch Syndrome) Gene Analysis; Full Sequence Analysis | Colorado Prior Authorization List, Pg 100 Original policy |
| 81296 | Msh2 (Muts Homolog 2, Colon Cancer, Nonpolyposis Type 1) (Eg, Hereditary Non-Polyposis Colorectal Cancer, Lynch Syndrome) Gene Analysis; Known Familial Variants | Colorado Prior Authorization List, Pg 100 Original policy |
| 81297 | Msh2 (Muts Homolog 2, Colon Cancer, Nonpolyposis Type 1) (Eg, Hereditary Non-Polyposis Colorectal Cancer, Lynch Syndrome) Gene Analysis; Duplication/Deletion Variants | Colorado Prior Authorization List, Pg 100 Original policy |
| 81298 | Msh6 (Muts Homolog 6 [E. Coli]) (Eg, Hereditary Non-Polyposis Colorectal Cancer, Lynch Syndrome) Gene Analysis; Full Sequence Analysis | Colorado Prior Authorization List, Pg 100 Original policy |
| 81299 | Msh6 (Muts Homolog 6 [E. Coli]) (Eg, Hereditary Non-Polyposis Colorectal Cancer, Lynch Syndrome) Gene Analysis; Known Familial Variants | Colorado Prior Authorization List, Pg 100 Original policy |
| 81300 | Msh6 (Muts Homolog 6 [E. Coli]) (Eg, Hereditary Non-Polyposis Colorectal Cancer, Lynch Syndrome) Gene Analysis; Duplication/Deletion Variants | Colorado Prior Authorization List, Pg 100 Original policy |
| 81301 | Microsatellite Instability Analysis (Eg, Hereditary Non-Polyposis Colorectal Cancer, Lynch Syndrome) Of Markers For Mismatch Repair Deficiency (Eg, Bat25, Bat26), Includes Com | Colorado Prior Authorization List, Pg 100 Original policy |
| 81302 | Mecp2 (Methyl Cpg Binding Protein 2) (Eg, Rett Syndrome) Gene Analysis; Full Sequence Analysis | Colorado Prior Authorization List, Pg 100 Original policy |
| 81303 | Mecp2 (Methyl Cpg Binding Protein 2) (Eg, Rett Syndrome) Gene Analysis; Known Familial Variant | Colorado Prior Authorization List, Pg 100 Original policy |
| 81304 | Mecp2 (Methyl Cpg Binding Protein 2) (Eg, Rett Syndrome) Gene Analysis; Duplication/Deletion Variants | Colorado Prior Authorization List, Pg 100 Original policy |
| 81305 | MYD88 (myeloid differentiation primary response 88) (eg, Waldenstrom's macroglobulinemia, lymphoplasmacytic leukemia) gene analysis, p.Leu265Pro (L265P) variant | Colorado Prior Authorization List, Pg 100 Original policy |
| 81306 | NUDT15 (nudix hydrolase 15) (eg, drug metabolism) gene analysis, common variant(s) (eg, *2, *3, *4, *5, *6) | Colorado Prior Authorization List, Pg 100 Original policy |
| 81307 | PALB2 (partner and localizer of BRCA2) (eg, breast and pancreatic cancer) gene analysis; full gene sequence | Colorado Prior Authorization List, Pg 100 Original policy |
| 81308 | PALB2 (partner and localizer of BRCA2) (eg, breast and pancreatic cancer) gene analysis; known familial variant | Colorado Prior Authorization List, Pg 100 Original policy |
| 81309 | PIK3CA (phosphatidylinositol-4, 5-biphosphate 3-kinase, catalytic subunit alpha) (eg, colorectal and breast cancer) gene analysis, targeted sequence analysis (eg, exons 7, 9 | Colorado Prior Authorization List, Pg 101 Original policy |
| 81310 | Npm1 (Nucleophosmin) (Eg, Acute Myeloid Leukemia) Gene Analysis, Exon 12 Variants | Colorado Prior Authorization List, Pg 101 Original policy |
| 81311 | NRAS (neuroblastoma RAS viral [v-ras] oncogene homolog) (eg, colorectal carcinoma), gene analysis, variants in exon 2 (eg, codons 12 and 13) and exon 3 (eg, codon 61) | Colorado Prior Authorization List, Pg 101 Original policy |
| 81312 | PABPN1 (poly[A] binding protein nuclear 1) (eg, oculopharyngeal muscular dystrophy) gene analysis, evaluation to detect abnormal (eg, expanded) alleles | Colorado Prior Authorization List, Pg 101 Original policy |
| 81313 | PCA3/KLK3 (prostate cancer antigen 3 [non-protein coding]/kallikrein-related peptidase 3 [prostate specific antigen]) ratio (eg, prostate cancer) | Colorado Prior Authorization List, Pg 101 Original policy |
| 81314 | PDGFRA (platelet-derived growth factor receptor, alpha polypeptide) (eg, gastrointestinal stromal tumor [GIST]), gene analysis, targeted sequence analysis (eg, exons 12, 18) | Colorado Prior Authorization List, Pg 101 Original policy |
| 81315 | Pml/Raralpha, (T(15;17)), (Promyelocytic Leukemia/Retinoic Acid Receptor Alpha) (Eg, Promyelocytic Leukemia) Translocation Analysis; Common Breakpoints (Eg, Intron 3 And Intro | Colorado Prior Authorization List, Pg 101 Original policy |
| 81316 | Pml/Raralpha, (T(15;17)), (Promyelocytic Leukemia/Retinoic Acid Receptor Alpha) (Eg, Promyelocytic Leukemia) Translocation Analysis; Single Breakpoint (Eg, Intron 3, Intron 6 | Colorado Prior Authorization List, Pg 101 Original policy |
| 81317 | Pms2 (Postmeiotic Segregation Increased 2 [S. Cerevisiae]) (Eg, Hereditary Non- Polyposis Colorectal Cancer, Lynch Syndrome) Gene Analysis; Full Sequence Analysis | Colorado Prior Authorization List, Pg 101 Original policy |
| 81318 | Pms2 (Postmeiotic Segregation Increased 2 [S. Cerevisiae]) (Eg, Hereditary Non- Polyposis Colorectal Cancer, Lynch Syndrome) Gene Analysis; Known Familial Variants | Colorado Prior Authorization List, Pg 101 Original policy |
| 81319 | Pms2 (Postmeiotic Segregation Increased 2 [S. Cerevisiae]) (Eg, Hereditary Non- Polyposis Colorectal Cancer, Lynch Syndrome) Gene Analysis; Duplication/Deletion Variants | Colorado Prior Authorization List, Pg 101 Original policy |
| 81320 | PLCG2 (phospholipase C gamma 2) (eg, chronic lymphocytic leukemia) gene analysis, common variants (eg, R665W, S707F, L845F) | Colorado Prior Authorization List, Pg 101 Original policy |
| 81321 | PTEN (phosphatase and tensin homolog) (eg, Cowden syndrome, PTEN hamartoma tumor syndrome) gene analysis; full sequence analysis | Colorado Prior Authorization List, Pg 101 Original policy |
| 81322 | PTEN (phosphatase and tensin homolog) (eg, Cowden syndrome, PTEN hamartoma tumor syndrome) gene analysis; known familial variant | Colorado Prior Authorization List, Pg 101 Original policy |
| 81323 | PTEN (phosphatase and tensin homolog) (eg, Cowden syndrome, PTEN hamartoma tumor syndrome) gene analysis; duplication/deletion variant | Colorado Prior Authorization List, Pg 101 Original policy |
| 81324 | PMP22 (peripheral myelin protein 22) (eg, Charcot-Marie-Tooth, hereditary neuropathy with liability to pressure palsies) gene analysis; duplication/deletion analysis | Colorado Prior Authorization List, Pg 101 Original policy |
| 81325 | PMP22 (peripheral myelin protein 22) (eg, Charcot-Marie-Tooth, hereditary neuropathy with liability to pressure palsies) gene analysis; full sequence analysis | Colorado Prior Authorization List, Pg 101 Original policy |
| 81326 | PMP22 (peripheral myelin protein 22) (eg, Charcot-Marie-Tooth, hereditary neuropathy with liability to pressure palsies) gene analysis; known familial variant | Colorado Prior Authorization List, Pg 101 Original policy |
| 81327 | SEPT9 (Septin9) (eg, colorectal cancer) promoter methylation analysis | Colorado Prior Authorization List, Pg 101 Original policy |
| 81328 | SLCO1B1 (solute carrier organic anion transporter family, member 1B1) (eg, adverse drug reaction), gene analysis, common variant(s) (eg, *5) | Colorado Prior Authorization List, Pg 101 Original policy |
| 81329 | SMN1 (survival of motor neuron 1, telomeric) (eg, spinal muscular atrophy) gene analysis; dosage/deletion analysis (eg, carrier testing), includes SMN2 (survival of motor neur | Colorado Prior Authorization List, Pg 101 Original policy |
| 81330 | Smpd1(Sphingomyelin Phosphodiesterase 1, Acid Lysosomal) (Eg, Niemann- Pick Disease, Type A) Gene Analysis, Common Variants (Eg, R496L, L302P, Fsp330) | Colorado Prior Authorization List, Pg 101 Original policy |
| 81331 | Snrpn/Ube3A (Small Nuclear Ribonucleoprotein Polypeptide N And Ubiquitin Protein Ligase E3A) (Eg, Prader-Willi Syndrome And/Or Angelman Syndrome), Methylation Analysis | Colorado Prior Authorization List, Pg 102 Original policy |
| 81332 | Serpina1 (Serpin Peptidase Inhibitor, Clade A, Alpha-1 Antiproteinase, Antitrypsin, Member 1) (Eg, Alpha-1-Antitrypsin Deficiency), Gene Analysis, Common Variants (Eg, *S And | Colorado Prior Authorization List, Pg 102 Original policy |
| 81333 | TGFBI (transforming growth factor beta-induced) (eg, corneal dystrophy) gene analysis, common variants (eg, R124H, R124C, R124L, R555W, R555Q) | Colorado Prior Authorization List, Pg 102 Original policy |
| 81334 | RUNX1 (runt related transcription factor 1) (eg, acute myeloid leukemia, familial platelet disorder with associated myeloid malignancy), gene analysis, targeted sequence analy | Colorado Prior Authorization List, Pg 102 Original policy |
| 81335 | TPMT (thiopurine S-methyltransferase) (eg, drug metabolism), gene analysis, common variants (eg, *2, *3) | Colorado Prior Authorization List, Pg 102 Original policy |
| 81336 | SMN1 (survival of motor neuron 1, telomeric) (eg, spinal muscular atrophy) gene analysis; full gene sequence | Colorado Prior Authorization List, Pg 102 Original policy |
| 81337 | SMN1 (survival of motor neuron 1, telomeric) (eg, spinal muscular atrophy) gene analysis; known familial sequence variant(s) | Colorado Prior Authorization List, Pg 102 Original policy |
| 81338 | MPL (MPL proto-oncogene, thrombopoietin receptor) (eg, myeloproliferative disorder) gene analysis; common variants (eg, W515A, W515K, W515L, W515R) | Colorado Prior Authorization List, Pg 102 Original policy |