Anthem Blue Cross Blue Shield of Colorado prior authorization, page 43
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 |
|---|---|---|
| 81339 | MPL (MPL proto-oncogene, thrombopoietin receptor) (eg, myeloproliferative disorder) gene analysis; sequence analysis, exon 10 | Colorado Prior Authorization List, Pg 102 Original policy |
| 81340 | Trb@ (T Cell Antigen Receptor, Beta) (Eg, Leukemia And Lymphoma), Gene Rearrangement Analysis To Detect Abnormal Clonal Population(S); Using Amplification Methodology (Eg, Pol | Colorado Prior Authorization List, Pg 102 Original policy |
| 81341 | Trb@ (T Cell Antigen Receptor, Beta) (Eg, Leukemia And Lymphoma), Gene Rearrangement Analysis To Detect Abnormal Clonal Population(S); Using Direct Probe Methodology (Eg, Sout | Colorado Prior Authorization List, Pg 102 Original policy |
| 81342 | Trg@ (T Cell Antigen Receptor, Gamma) (Eg, Leukemia And Lymphoma), Gene Rearrangement Analysis, Evaluation To Detect Abnormal Clonal Population(S) | Colorado Prior Authorization List, Pg 102 Original policy |
| 81343 | PPP2R2B (protein phosphatase 2 regulatory subunit Bbeta) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles | Colorado Prior Authorization List, Pg 102 Original policy |
| 81344 | TBP (TATA box binding protein) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles | Colorado Prior Authorization List, Pg 102 Original policy |
| 81345 | TERT (telomerase reverse transcriptase) (eg, thyroid carcinoma, glioblastoma multiforme) gene analysis, targeted sequence analysis (eg, promoter region) | Colorado Prior Authorization List, Pg 102 Original policy |
| 81346 | TYMS (thymidylate synthetase) (eg, 5-fluorouracil/5-FU drug metabolism), gene analysis, common variant(s) (eg, tandem repeat variant) | Colorado Prior Authorization List, Pg 102 Original policy |
| 81347 | SF3B1 (splicing factor [3b] subunit B1) (eg, myelodysplastic syndrome/acute myeloid leukemia) gene analysis, common variants (eg, A672T, E622D, L833F, R625C, R625L) | Colorado Prior Authorization List, Pg 102 Original policy |
| 81348 | SRSF2 (serine and arginine-rich splicing factor 2) (eg, myelodysplastic syndrome, acute myeloid leukemia) gene analysis, common variants (eg, P95H, P95L) | Colorado Prior Authorization List, Pg 102 Original policy |
| 81349 | Cytogenomic (genome-wide) analysis for constitutional chromosomal abnormalities; interrogation of genomic regions for copy number and loss-of- heterozygosity variants, low-pass | Colorado Prior Authorization List, Pg 102 Original policy |
| 81350 | UGT1A1 (UDP glucuronosyltransferase 1 family, polypeptide A1) (eg, drug metabolism, hereditary unconjugated hyperbilirubinemia [Gilbert syndrome]) gene analysis, common varian | Colorado Prior Authorization List, Pg 102 Original policy |
| 81351 | TP53 (tumor protein 53) (eg, Li-Fraumeni syndrome) gene analysis; full gene sequence | Colorado Prior Authorization List, Pg 102 Original policy |
| 81352 | TP53 (tumor protein 53) (eg, Li-Fraumeni syndrome) gene analysis; targeted sequence analysis (eg, 4 oncology) | Colorado Prior Authorization List, Pg 103 Original policy |
| 81353 | TP53 (tumor protein 53) (eg, Li-Fraumeni syndrome) gene analysis; known familial variant | Colorado Prior Authorization List, Pg 103 Original policy |
| 81355 | Vkorc1 (Vitamin K Epoxide Reductase Complex, Subunit 1) (Eg, Warfarin Metabolism), Gene Analysis, Common Variants (Eg, -1639/3673) | Colorado Prior Authorization List, Pg 103 Original policy |
| 81357 | U2AF1 (U2 small nuclear RNA auxiliary factor 1) (eg, myelodysplastic syndrome, acute myeloid leukemia) gene analysis, common variants (eg, S34F, S34Y, Q157R, Q157P) | Colorado Prior Authorization List, Pg 103 Original policy |
| 81360 | ZRSR2 (zinc finger CCCH-type, RNA binding motif and serine/arginine-rich 2) (eg, myelodysplastic syndrome, acute myeloid leukemia) gene analysis, common variant(s) (eg, E65fs | Colorado Prior Authorization List, Pg 103 Original policy |
| 81361 | HBB (hemoglobin, subunit beta) (eg, sickle cell anemia, beta thalassemia, hemoglobinopathy); common variant(s) (eg, HbS, HbC, HbE) | Colorado Prior Authorization List, Pg 103 Original policy |
| 81362 | HBB (hemoglobin, subunit beta) (eg, sickle cell anemia, beta thalassemia, hemoglobinopathy); known familial variant(s) | Colorado Prior Authorization List, Pg 103 Original policy |
| 81363 | HBB (hemoglobin, subunit beta) (eg, sickle cell anemia, beta thalassemia, hemoglobinopathy); duplication/deletion variant(s) | Colorado Prior Authorization List, Pg 103 Original policy |
| 81364 | HBB (hemoglobin, subunit beta) (eg, sickle cell anemia, beta thalassemia, hemoglobinopathy); full gene sequence | Colorado Prior Authorization List, Pg 103 Original policy |
| 81379 | Hla Class I Typing, High Resolution (Ie, Alleles Or Allele Groups); Complete (Ie, Hla-A, -B, And -C) | Colorado Prior Authorization List, Pg 103 Original policy |
| 81380 | Hla Class I Typing, High Resolution (Ie, Alleles Or Allele Groups); One Locus (Eg, Hla-A, -B, Or -C), Each | Colorado Prior Authorization List, Pg 103 Original policy |
| 81381 | Hla Class I Typing, High Resolution (Ie, Alleles Or Allele Groups); One Allele Or Allele Group (Eg, B*57:01P), Each | Colorado Prior Authorization List, Pg 103 Original policy |
| 81400 | MOLECULAR PATHOLOGY PROCEDURE LEVEL 1 | Colorado Prior Authorization List, Pg 103 Original policy |
| 81401 | MOLECULAR PATHOLOGY PROCEDURE LEVEL 2 | Colorado Prior Authorization List, Pg 103 Original policy |
| 81402 | MOLECULAR PATHOLOGY PROCEDURE LEVEL 3 | Colorado Prior Authorization List, Pg 103 Original policy |
| 81403 | MOLECULAR PATHOLOGY PROCEDURE LEVEL 4 | Colorado Prior Authorization List, Pg 103 Original policy |
| 81404 | MOLECULAR PATHOLOGY PROCEDURE LEVEL 5 | Colorado Prior Authorization List, Pg 103 Original policy |
| 81405 | MOLECULAR PATHOLOGY PROCEDURE LEVEL 6 | Colorado Prior Authorization List, Pg 104 Original policy |
| 81406 | MOLECULAR PATHOLOGY PROCEDURE LEVEL 7 | Colorado Prior Authorization List, Pg 104 Original policy |
| 81407 | MOLECULAR PATHOLOGY PROCEDURE LEVEL 8 | Colorado Prior Authorization List, Pg 104 Original policy |
| 81408 | Molecular pathology procedure, Level 9 (eg, analysis of >50 exons in a single gene by DNA sequence analysis) ABCA4 (ATP-binding cassette, sub-family A [ABC1], member 4) (eg, S | Colorado Prior Authorization List, Pg 104 Original policy |
| 81410 | Aortic dysfunction or dilation (eg, Marfan syndrome, Loeys Dietz syndrome, Ehler Danlos syndrome type IV, arterial tortuosity syndrome); genomic sequence analysis panel, must | Colorado Prior Authorization List, Pg 104 Original policy |
| 81411 | Aortic dysfunction or dilation (eg, Marfan syndrome, Loeys Dietz syndrome, Ehler Danlos syndrome type IV, arterial tortuosity syndrome); duplication/deletion analysis panel, m | Colorado Prior Authorization List, Pg 104 Original policy |
| 81412 | Ashkenazi Jewish associated disorders (eg, Bloom syndrome, Canavan disease, cystic fibrosis, familial dysautonomia, Fanconi anemia group C, Gaucher disease, Tay-Sachs disease) | Colorado Prior Authorization List, Pg 104 Original policy |
| 81413 | Cardiac ion channelopathies (eg Brugada syndrome, long QT syndrome, short QT syndrome, catecholaminergic polymorphic ventricular tachycardia); genomic sequence analysis panel | Colorado Prior Authorization List, Pg 104 Original policy |
| 81414 | Cardiac ion channelopathies (eg Brugada syndrome, long QT syndrome, short QT syndrome, catecholaminergic polymorphic ventricular tachycardia); duplication/deletion gene analys | Colorado Prior Authorization List, Pg 104 Original policy |
| 81415 | Exome (eg, unexplained constitutional or heritable disorder or syndrome); sequence analysis | Colorado Prior Authorization List, Pg 104 Original policy |
| 81416 | Exome (eg, unexplained constitutional or heritable disorder or syndrome); sequence analysis, each comparator exome (eg, parents, siblings) (List separately in addition to code | Colorado Prior Authorization List, Pg 104 Original policy |
| 81417 | Exome (eg, unexplained constitutional or heritable disorder or syndrome); re- evaluation of previously obtained exome sequence (eg, updated knowledge or unrelated condition/syn | Colorado Prior Authorization List, Pg 104 Original policy |
| 81418 | Drug metabolism (eg, pharmacogenomics) genomic sequence analysis panel, must include testing of at least 6 genes, including CYP2C19, CYP2D6, and CYP2D6 duplication/deletion an | Colorado Prior Authorization List, Pg 104 Original policy |
| 81419 | Epilepsy genomic sequence analysis panel, must include analyses for ALDH7A1, CACNA1A, CDKL5, CHD2, GABRG2, GRIN2A, KCNQ2, MECP2, PCDH19, POLG, PRRT2, SCN1A, SCN1B, SCN2A, SCN8 | Colorado Prior Authorization List, Pg 104 Original policy |
| 81425 | Genome (eg, unexplained constitutional or heritable disorder or syndrome); sequence analysis | Colorado Prior Authorization List, Pg 104 Original policy |
| 81426 | Genome (eg, unexplained constitutional or heritable disorder or syndrome); sequence analysis, each comparator genome (eg, parents, siblings) (List separately in addition to co | Colorado Prior Authorization List, Pg 104 Original policy |
| 81427 | Genome (eg, unexplained constitutional or heritable disorder or syndrome); re- evaluation of previously obtained genome sequence (eg, updated knowledge or unrelated condition/s | Colorado Prior Authorization List, Pg 104 Original policy |
| 81430 | Hearing loss (eg, nonsyndromic hearing loss, Usher syndrome, Pendred syndrome); genomic sequence analysis panel, must include sequencing of at least 60 genes, including CDH23 | Colorado Prior Authorization List, Pg 104 Original policy |
| 81431 | Hearing loss (eg, nonsyndromic hearing loss, Usher syndrome, Pendred syndrome); duplication/deletion analysis panel, must include copy number analyses for STRC and DFNB1 delet | Colorado Prior Authorization List, Pg 105 Original policy |
| 81432 | Hereditary breast cancer-related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer, hereditary pancreatic cancer, hereditary pr | Colorado Prior Authorization List, Pg 105 Original policy |