Anthem Blue Cross Blue Shield of Colorado prior authorization, page 49
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 |
|---|---|---|
| 0001U | Red blood cell antigen typing, DNA, human erythrocyte antigen gene analysis of 35 antigens from 11 blood groups, utilizing whole blood, common RBC alleles reported | Colorado Prior Authorization List, Pg 117 Original policy |
| 0002M | Liver disease, ten biochemical assays (ALT, A2-macroglobulin, apolipoprotein A- 1, total bilirubin, GGT, haptoglobin, AST, glucose, total cholesterol and triglycerides) utilizi | Colorado Prior Authorization List, Pg 117 Original policy |
| 0003M | Liver disease, ten biochemical assays (ALT, A2-macroglobulin, apolipoprotein A- 1, total bilirubin, GGT, haptoglobin, AST, glucose, total cholesterol and triglycerides) utilizi | Colorado Prior Authorization List, Pg 117 Original policy |
| 0005U | Oncology (prostate) gene expression profile by real-time RT-PCR of 3 genes (ERG, PCA3, and SPDEF), urine, algorithm reported as risk score | Colorado Prior Authorization List, Pg 117 Original policy |
| 0006M | Oncology (hepatic), mRNA expression levels of 161 genes, utilizing fresh hepatocellular carcinoma tumor tissue, with alpha-fetoprotein level, algorithm reported as a risk clas | Colorado Prior Authorization List, Pg 117 Original policy |
| 0007M | Oncology (gastrointestinal neuroendocrine tumors), real-time PCR expression analysis of 51 genes, utilizing whole peripheral blood, algorithm reported as a nomogram of tumor d | Colorado Prior Authorization List, Pg 117 Original policy |
| 0007U | Drug test(s), presumptive, with definitive confirmation of positive results, any number of drug classes, urine, includes specimen verification including DNA authentication in | Colorado Prior Authorization List, Pg 117 Original policy |
| 0011M | Oncology, prostate cancer, mRNA expression assay of 12 genes (10 content and 2 housekeeping), RT-PCR test utilizing blood plasma and urine, algorithms to predict high-grade pr | Colorado Prior Authorization List, Pg 117 Original policy |
| 0012M | Oncology (urothelial), mRNA, gene expression profiling by real-time quantitative PCR of five genes (MDK, HOXA13, CDC2 [CDK1], IGFBP5, and XCR2), utilizing urine, algorithm rep | Colorado Prior Authorization List, Pg 117 Original policy |
| 0013M | Oncology (urothelial), mRNA, gene expression profiling by real-time quantitative PCR of five genes (MDK, HOXA13, CDC2 [CDK1], IGFBP5, and CXCR2), utilizing urine, algorithm re | Colorado Prior Authorization List, Pg 117 Original policy |
| 0016M | Oncology (bladder), mRNA, microarray gene expression profiling of 219 genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as molecular subtype (lumina | Colorado Prior Authorization List, Pg 117 Original policy |
| 0016U | Oncology (hematolymphoid neoplasia), RNA, BCR/ABL1 major and minor breakpoint fusion transcripts, quantitative PCR amplification, blood or bone marrow, report of fusion not de | Colorado Prior Authorization List, Pg 117 Original policy |
| 0017M | Oncology (diffuse large B-cell lymphoma [DLBCL]), mRNA, gene expression profiling by fluorescent probe hybridization of 20 genes, formalin-fixed paraffin- embedded tissue, algo | Colorado Prior Authorization List, Pg 117 Original policy |
| 0017U | Oncology (hematolymphoid neoplasia), JAK2 mutation, DNA, PCR amplification of exons 12-14 and sequence analysis, blood or bone marrow, report of JAK2 mutation not detected or | Colorado Prior Authorization List, Pg 117 Original policy |
| 0018M | Transplantation medicine (allograft rejection, renal), measurement of donor and third-party-induced CD154+T-cytotoxic memory cells, utilizing whole peripheral blood, algorithm | Colorado Prior Authorization List, Pg 117 Original policy |
| 0018U | Oncology (thyroid), microRNA profiling by RT-PCR of 10 microRNA sequences, utilizing fine needle aspirate, algorithm reported as a positive or negative result for moderate to | Colorado Prior Authorization List, Pg 117 Original policy |
| 0019U | Oncology, RNA, gene expression by whole transcriptome sequencing, formalin- fixed paraffin embedded tissue or fresh frozen tissue, predictive algorithm reported as potential ta | Colorado Prior Authorization List, Pg 117 Original policy |
| 0020M | Oncology (central nervous system), analysis of 30000 DNA methylation loci by methylation array, utilizing DNA extracted from tumor tissue, diagnostic algorithm reported as pro | Colorado Prior Authorization List, Pg 117 Original policy |
| 0022U | Targeted genomic sequence analysis panel, non-small cell lung neoplasia, DNA and RNA analysis, 23 genes, interrogation for sequence variants and rearrangements, reported as pr | Colorado Prior Authorization List, Pg 117 Original policy |
| 0023U | Oncology (acute myelogenous leukemia), DNA, genotyping of internal tandem duplication, p.D835, p.I836, using mononuclear cells, reported as detection or non-detection of FLT3 | Colorado Prior Authorization List, Pg 117 Original policy |
| 0026U | Oncology (thyroid), DNA and mRNA of 112 genes, next-generation sequencing, fine needle aspirate of thyroid nodule, algorithmic analysis reported as a categorical result ('Posi | Colorado Prior Authorization List, Pg 117 Original policy |
| 0027U | JAK2 (Janus kinase 2) (eg, myeloproliferative disorder) gene analysis, targeted sequence analysis exons 12-15 | Colorado Prior Authorization List, Pg 117 Original policy |
| 0028U | CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, copy number variants, common variants with reflex to targeted sequence anal | Colorado Prior Authorization List, Pg 118 Original policy |
| 0029U | Drug metabolism (adverse drug reactions and drug response), targeted sequence analysis (ie, CYP1A2, CYP2C19, CYP2C9, CYP2D6, CYP3A4, CYP3A5, CYP4F2, SLCO1B1, VKORC1 and rs1277 | Colorado Prior Authorization List, Pg 118 Original policy |
| 0030U | Drug metabolism (warfarin drug response), targeted sequence analysis (ie, CYP2C9, CYP4F2, VKORC1, rs12777823) | Colorado Prior Authorization List, Pg 118 Original policy |
| 0031U | CYP1A2 (cytochrome P450 family 1, subfamily A, member 2)(eg, drug metabolism) gene analysis, common variants (ie, *1F, *1K, *6, *7) | Colorado Prior Authorization List, Pg 118 Original policy |
| 0032U | COMT (catechol-O-methyltransferase)(drug metabolism) gene analysis, c.472G>A (rs4680) variant | Colorado Prior Authorization List, Pg 118 Original policy |
| 0034U | TPMT (thiopurine S-methyltransferase), NUDT15 (nudix hydroxylase 15)(eg, thiopurine metabolism), gene analysis, common variants (ie, TPMT *2, *3A, *3B, *3C, *4, *5, *6, *8, *1 | Colorado Prior Authorization List, Pg 118 Original policy |
| 0036U | Exome (ie, somatic mutations), paired formalin-fixed paraffin-embedded tumor tissue and normal specimen, sequence analyses | Colorado Prior Authorization List, Pg 118 Original policy |
| 0037U | Targeted genomic sequence analysis, solid organ neoplasm, DNA analysis of 324 genes, interrogation for sequence variants, gene copy number amplifications, gene rearrangements | Colorado Prior Authorization List, Pg 118 Original policy |
| 0040U | BCR/ABL1 (t(9;22)) (eg, chronic myelogenous leukemia) translocation analysis, major breakpoint, quantitative | Colorado Prior Authorization List, Pg 118 Original policy |
| 0045U | Oncology (breast ductal carcinoma in situ), mRNA, gene expression profiling by real-time RT-PCR of 12 genes (7 content and 5 housekeeping), utilizing formalin- fixed paraffin-e | Colorado Prior Authorization List, Pg 118 Original policy |
| 0046U | FLT3 (fms-related tyrosine kinase 3) (eg, acute myeloid leukemia) internal tandem duplication (ITD) variants, quantitative | Colorado Prior Authorization List, Pg 118 Original policy |
| 0047U | Oncology (prostate), mRNA, gene expression profiling by real-time RT-PCR of 17 genes (12 content and 5 housekeeping), utilizing formalin-fixed paraffin- embedded tissue, algori | Colorado Prior Authorization List, Pg 118 Original policy |
| 0048T | Implantation of a ventricular assist device, extracorporeal, percutaneous transseptal access, single or dual cannulation | Colorado Prior Authorization List, Pg 118 Original policy |
| 0048U | Oncology (solid organ neoplasia), DNA, targeted sequencing of protein-coding exons of 468 cancer-associated genes, including interrogation for somatic mutations and microsatel | Colorado Prior Authorization List, Pg 118 Original policy |
| 0049U | NPM1 (nucleophosmin) (eg, acute myeloid leukemia) gene analysis, quantitative | Colorado Prior Authorization List, Pg 118 Original policy |
| 0050T | Removal of a ventricular assist device, extracorporeal, percutaneous transseptal access, single or dual cannulation | Colorado Prior Authorization List, Pg 118 Original policy |
| 0050U | Targeted genomic sequence analysis panel, acute myelogenous leukemia, DNA analysis, 194 genes, interrogation for sequence variants, copy number variants or rearrangements | Colorado Prior Authorization List, Pg 118 Original policy |
| 0053U | Oncology (prostate cancer), FISH analysis of 4 genes (ASAP1, HDAC9, CHD1 and PTEN), needle biopsy specimen, algorithm reported as probability of higher tumor grade | Colorado Prior Authorization List, Pg 118 Original policy |
| 0055U | Cardiology (heart transplant), cell-free DNA, PCR assay of 96 DNA target sequences (94 single nucleotide polymorphism targets and two control targets), plasma | Colorado Prior Authorization List, Pg 118 Original policy |
| 0062U | Autoimmune (systemic lupus erythematosus), IgG and IgM analysis of 80 biomarkers, utilizing serum, algorithm reported with a risk score | Colorado Prior Authorization List, Pg 118 Original policy |
| 0069U | Oncology (colorectal), microRNA, RT-PCR expression profiling of miR-31-3p, formalin-fixed paraffin-embedded tissue, algorithm reported as an expression score | Colorado Prior Authorization List, Pg 118 Original policy |
| 0070U | CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, common and select rare variants (ie, *2, *3, *4, *4N, *5, *6, *7, *8, *9, * | Colorado Prior Authorization List, Pg 118 Original policy |
| 0071T | Ultrasound Ablation of Uterine Leioomyomata inc MR Guidance | Colorado Prior Authorization List, Pg 118 Original policy |
| 0071U | CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, full gene sequence (List separately in addition to code for primary procedu | Colorado Prior Authorization List, Pg 118 Original policy |
| 0072T | Ultrasound Ablation of Uterine Leioomyomata inc MR Guidance; Vol>=200 CC | Colorado Prior Authorization List, Pg 118 Original policy |
| 0072U | CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, targeted sequence analysis (ie, CYP2D6-2D7 hybrid gene) (List separately in | Colorado Prior Authorization List, Pg 119 Original policy |
| 0073U | CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, targeted sequence analysis (ie, CYP2D7-2D6 hybrid gene) (List separately in | Colorado Prior Authorization List, Pg 119 Original policy |
| 0074U | CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, targeted sequence analysis (ie, non-duplicated gene when duplication/multip | Colorado Prior Authorization List, Pg 119 Original policy |