Anthem Blue Cross Blue Shield of Colorado prior authorization, page 44
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 |
|---|---|---|
| 81434 | Hereditary retinal disorders (eg, retinitis pigmentosa, Leber congenital amaurosis, cone-rod dystrophy), genomic sequence analysis panel, must include sequencing of at least 1 | Colorado Prior Authorization List, Pg 105 Original policy |
| 81435 | Hereditary colon cancer-related disorders (eg, Lynch syndrome, PTEN hamartoma syndrome, Cowden syndrome, familial adenomatosis polyposis), genomic sequence analysis panel, 5 o | Colorado Prior Authorization List, Pg 105 Original policy |
| 81437 | Hereditary neuroendocrine tumor-related disorders (eg, medullary thyroid carcinoma, parathyroid carcinoma, malignant pheochromocytoma or paraganglioma), genomic sequence analy | Colorado Prior Authorization List, Pg 105 Original policy |
| 81439 | Hereditary cardiomyopathy (eg, hypertrophic cardiomyopathy, dilated cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy), genomic sequence analysis panel, must inc | Colorado Prior Authorization List, Pg 105 Original policy |
| 81440 | Nuclear encoded mitochondrial genes (eg, neurologic or myopathic phenotypes), genomic sequence panel, must include analysis of at least 100 genes, including BCS1L, C10orf2, CO | Colorado Prior Authorization List, Pg 105 Original policy |
| 81441 | Inherited bone marrow failure syndromes (IBMFS) (eg, Fanconi anemia, dyskeratosis congenita, Diamond-Blackfan anemia, Shwachman-Diamond syndrome, GATA2 deficiency syndrome, co | Colorado Prior Authorization List, Pg 105 Original policy |
| 81442 | Noonan spectrum disorders (eg, Noonan syndrome, cardio-facio-cutaneous syndrome, Costello syndrome, LEOPARD syndrome, Noonan-like syndrome), genomic sequence analysis panel, m | Colorado Prior Authorization List, Pg 105 Original policy |
| 81443 | Genetic testing for severe inherited conditions (eg, cystic fibrosis, Ashkenazi Jewish-associated disorders [eg, Bloom syndrome, Canavan disease, Fanconi anemia type C, mucoli | Colorado Prior Authorization List, Pg 105 Original policy |
| 81445 | Solid organ neoplasm, genomic sequence analysis panel, 5-50 genes, interrogation for sequence variants and copy number variants or rearrangements, if performed; DNA analysis o | Colorado Prior Authorization List, Pg 105 Original policy |
| 81448 | Hereditary peripheral neuropathies (eg, Charcot-Marie-Tooth, spastic paraplegia), genomic sequence analysis panel, must include sequencing of at least 5 peripheral neuropathy | Colorado Prior Authorization List, Pg 105 Original policy |
| 81449 | Solid organ neoplasm, genomic sequence analysis panel, 5-50 genes, interrogation for sequence variants and copy number variants or rearrangements, if performed; RNA analysis | Colorado Prior Authorization List, Pg 105 Original policy |
| 81450 | Hematolymphoid neoplasm or disorder, genomic sequence analysis panel, 5-50 genes, interrogation for sequence variants, and copy number variants or rearrangements, or isoform e | Colorado Prior Authorization List, Pg 105 Original policy |
| 81451 | Hematolymphoid neoplasm or disorder, genomic sequence analysis panel, 5-50 genes, interrogation for sequence variants, and copy number variants or rearrangements, or isoform e | Colorado Prior Authorization List, Pg 105 Original policy |
| 81455 | Solid organ or hematolymphoid neoplasm or disorder, 51 or greater genes, genomic sequence analysis panel, interrogation for sequence variants and copy number variants or rearr | Colorado Prior Authorization List, Pg 105 Original policy |
| 81456 | Solid organ or hematolymphoid neoplasm or disorder, 51 or greater genes, genomic sequence analysis panel, interrogation for sequence variants and copy number variants or rearr | Colorado Prior Authorization List, Pg 105 Original policy |
| 81457 | Solid organ neoplasm, genomic sequence analysis panel, interrogation for sequence variants; DNA analysis, microsatellite instability | Colorado Prior Authorization List, Pg 105 Original policy |
| 81458 | Solid organ neoplasm, genomic sequence analysis panel, interrogation for sequence variants; DNA analysis, copy number variants and microsatellite instability | Colorado Prior Authorization List, Pg 105 Original policy |
| 81459 | Solid organ neoplasm, genomic sequence analysis panel, interrogation for sequence variants; DNA analysis or combined DNA and RNA analysis, copy number variants, microsatellite | Colorado Prior Authorization List, Pg 105 Original policy |
| 81460 | Whole mitochondrial genome (eg, Leigh syndrome, mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes [MELAS], myoclonic epilepsy with ragged-red fibers [ | Colorado Prior Authorization List, Pg 105 Original policy |
| 81462 | Solid organ neoplasm, genomic sequence analysis panel, cell-free nucleic acid (eg, plasma), interrogation for sequence variants; DNA analysis or combined DNA and RNA analysis | Colorado Prior Authorization List, Pg 105 Original policy |
| 81463 | Solid organ neoplasm, genomic sequence analysis panel, cell-free nucleic acid (eg, plasma), interrogation for sequence variants; DNA analysis, copy number variants, and micros | Colorado Prior Authorization List, Pg 106 Original policy |
| 81464 | Solid organ neoplasm, genomic sequence analysis panel, cell-free nucleic acid (eg, plasma), interrogation for sequence variants; DNA analysis or combined DNA and RNA analysis | Colorado Prior Authorization List, Pg 106 Original policy |
| 81465 | Whole mitochondrial genome large deletion analysis panel (eg, Kearns-Sayre syndrome, chronic progressive external ophthalmoplegia), including heteroplasmy detection, if perfor | Colorado Prior Authorization List, Pg 106 Original policy |
| 81470 | X-linked intellectual disability (XLID) (eg, syndromic and non-syndromic XLID); genomic sequence analysis panel, must include sequencing of at least 60 genes, including ARX, A | Colorado Prior Authorization List, Pg 106 Original policy |
| 81471 | X-linked intellectual disability (XLID) (eg, syndromic and non-syndromic XLID); duplication/deletion gene analysis, must include analysis of at least 60 genes, including ARX | Colorado Prior Authorization List, Pg 106 Original policy |
| 81479 | Unlisted molecular pathology procedure | Colorado Prior Authorization List, Pg 106 Original policy |
| 81490 | Autoimmune (rheumatoid arthritis), analysis of 12 biomarkers using immunoassays, utilizing serum, prognostic algorithm reported as a disease activity score | Colorado Prior Authorization List, Pg 106 Original policy |
| 81493 | Coronary artery disease, mRNA, gene expression profiling by real-time RT-PCR of 23 genes, utilizing whole peripheral blood, algorithm reported as a risk score | Colorado Prior Authorization List, Pg 106 Original policy |
| 81504 | Oncology (tissue of origin), microarray gene expression profiling of > 2000 genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as tissue similarity s | Colorado Prior Authorization List, Pg 106 Original policy |
| 81506 | Endocrinology, Biochemical Assays Of Seven Analytes Utilizing Serum Or Plasma, Algorithm Reporting A Risk Score | Colorado Prior Authorization List, Pg 106 Original policy |
| 81517 | Liver disease, analysis of 3 biomarkers (hyaluronic acid [HA], procollagen III amino terminal peptide [PIIINP], tissue inhibitor of metalloproteinase 1 [TIMP-1]), using immuno | Colorado Prior Authorization List, Pg 106 Original policy |
| 81518 | Oncology (breast), mRNA, gene expression profiling by real-time RT-PCR of 11 genes (7 content and 4 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm | Colorado Prior Authorization List, Pg 106 Original policy |
| 81519 | Oncology (breast), mRNA, gene expression profiling by real-time RT-PCR of 21 genes, utilizing formalin-fixed paraffin embedded tissue, algorithm reported as recurrence score | Colorado Prior Authorization List, Pg 106 Original policy |
| 81520 | Oncology (breast), mRNA gene expression profiling by hybrid capture of 58 genes (50 content and 8 housekeeping), utilizing formalin-fixed paraffin- embedded tissue, algorithm r | Colorado Prior Authorization List, Pg 106 Original policy |
| 81521 | Oncology (breast), mRNA, microarray gene expression profiling of 70 content genes and 465 housekeeping genes, utilizing fresh frozen or formalin-fixed paraffin-embedded tissue | Colorado Prior Authorization List, Pg 106 Original policy |
| 81522 | Oncology (breast), mRNA, gene expression profiling by RT-PCR of 12 genes (8 content and 4 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported | Colorado Prior Authorization List, Pg 106 Original policy |
| 81523 | Oncology (breast), mRNA, next-generation sequencing gene expression profiling of 70 content genes and 31 housekeeping genes, utilizing formalin-fixed paraffin- embedded tissue | Colorado Prior Authorization List, Pg 106 Original policy |
| 81525 | Oncology (colon), mRNA, gene, expression profiling by real-time RT-PCR of 12 genes (7 content and 5 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm | Colorado Prior Authorization List, Pg 106 Original policy |
| 81529 | Oncology (cutaneous melanoma), mRNA, gene expression profiling by real-time RT-PCR of 31 genes (28 content and 3 housekeeping), utilizing formalin-fixed paraffin-embedded tiss | Colorado Prior Authorization List, Pg 106 Original policy |
| 81535 | Oncology (gynecologic), live tumor cell culture and chemotherapeutic response by DAPI stain and morphology, predictive algorithm reported as a drug response score; first singl | Colorado Prior Authorization List, Pg 107 Original policy |
| 81538 | Oncology (lung), mass spectrometric 8-protein signature, including amyloid A, utilizing serum, prognostic and predictive algorithm reported as good versus poor overall surviva | Colorado Prior Authorization List, Pg 107 Original policy |
| 81539 | Oncology (high-grade prostate cancer), biochemical assay of four proteins (Total PSA, Free PSA, Intact PSA, and human kallikrein-2 hK2), utilizing plasma or serum, prognostic | Colorado Prior Authorization List, Pg 107 Original policy |
| 81540 | Oncology (tumor of unknown origin), mRNA, gene expression profiling by real- time RT-PCR of 92 genes (87 content and 5 housekeeping) to classify tumor into main cancer type and | Colorado Prior Authorization List, Pg 107 Original policy |
| 81541 | Oncology (prostate), mRNA gene expression profiling by real-time RT-PCR of 46 genes (31 content and 15 housekeeping), utilizing formalin-fixed paraffin- embedded tissue, algori | Colorado Prior Authorization List, Pg 107 Original policy |
| 81542 | Oncology (prostate), mRNA, microarray gene expression profiling of 22 content genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as metastasis risk s | Colorado Prior Authorization List, Pg 107 Original policy |
| 81546 | Oncology (thyroid), mRNA, gene expression analysis of 10,196 genes, utilizing fine needle aspirate, algorithm reported as a categorical result (eg, benign or suspicious) | Colorado Prior Authorization List, Pg 107 Original policy |
| 81551 | Oncology (prostate), promoter methylation profiling by real-time PCR of 3 genes (GSTP1, APC, RASSF1), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as | Colorado Prior Authorization List, Pg 107 Original policy |
| 81552 | Oncology (uveal melanoma), mRNA, gene expression profiling by real-time RT- PCR of 15 genes (12 content and 3 housekeeping), utilizing fine needle aspirate or formalin-fixed pa | Colorado Prior Authorization List, Pg 107 Original policy |
| 81554 | Pulmonary disease (idiopathic pulmonary fibrosis [IPF]), mRNA, gene expression analysis of 190 genes, utilizing transbronchial biopsies, diagnostic algorithm reported as categ | Colorado Prior Authorization List, Pg 107 Original policy |
| 81558 | Transplantation medicine (allograft rejection, kidney), mRNA, gene expression profiling | Colorado Prior Authorization List, Pg 107 Original policy |