Anthem Blue Cross Blue Shield of Colorado prior authorization, page 50
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 |
|---|---|---|
| 0075U | CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, targeted sequence analysis (ie, 5 gene duplication/multiplication) (List se | Colorado Prior Authorization List, Pg 119 Original policy |
| 0076U | CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, targeted sequence analysis (ie, 3 gene duplication/ multiplication) (List s | Colorado Prior Authorization List, Pg 119 Original policy |
| 0078U | Pain management (opioid-use disorder) genotyping panel, 16 common variants (ie, ABCB1, COMT, DAT1, DBH, DOR, DRD1, DRD2, DRD4, GABA, GAL, HTR2A, HTTLPR, MTHFR, MUOR, OPRK1, OP | Colorado Prior Authorization List, Pg 119 Original policy |
| 0079U | Comparative DNA analysis using multiple selected single-nucleotide polymorphisms(SNPs), urine and buccal DNA, for specimen identity verification | Colorado Prior Authorization List, Pg 119 Original policy |
| 0080U | Oncology (lung), mass spectrometric analysis of galectin-3-binding protein and scavenger receptor cysteine-rich type 1 protein M130, with five clinical risk factors (age, smok | Colorado Prior Authorization List, Pg 119 Original policy |
| 0085T | Breath test for heart transplant rejection | Colorado Prior Authorization List, Pg 119 Original policy |
| 0087U | Cardiology (heart transplant), mRNA gene expression profiling by microarray of 1283 genes, transplant biopsy tissue, allograft rejection and injury algorithm reported as a pro | Colorado Prior Authorization List, Pg 119 Original policy |
| 0088U | Transplantation medicine (kidney allograft rejection), microarray gene expression profiling of 1494 genes, utilizing transplant biopsy tissue, algorithm reported as a probabil | Colorado Prior Authorization List, Pg 119 Original policy |
| 0089U | Oncology (melanoma), gene expression profiling by RTqPCR, PRAME and LINC00518, superficial collection using adhesive patch(es) | Colorado Prior Authorization List, Pg 119 Original policy |
| 0090U | Oncology (cutaneous melanoma), mRNA gene expression profiling by RT-PCR of 23 genes (14 content and 9 housekeeping), utilizing formalin-fixed paraffin- embedded (FFPE) tissue | Colorado Prior Authorization List, Pg 119 Original policy |
| 0092U | Oncology (lung), three protein biomarkers, immunoassay using magnetic nanosensor technology, plasma, algorithm reported as risk score for likelihood of malignancy | Colorado Prior Authorization List, Pg 119 Original policy |
| 0094U | Genome (eg, unexplained constitutional or heritable disorder or syndrome), rapid sequence analysis | Colorado Prior Authorization List, Pg 119 Original policy |
| 0095T | Removal of total disc arthroplasty (artificial disc), anterior approach, each additional interspace, cervical (List separately in addition to code for primary procedure) | Colorado Prior Authorization List, Pg 119 Original policy |
| 0098T | Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, each additional interspace, cervical (List separately in addition to code for p | Colorado Prior Authorization List, Pg 119 Original policy |
| 0100T | Placement of a subconjunctival retinal prosthesis receiver and pulse generator, and implantation of intra-ocular retinal electrode array, with vitrectomy | Colorado Prior Authorization List, Pg 119 Original policy |
| 0101T | Extracorporeal shock wave involving musculoskeletal system, not otherwise specified | Colorado Prior Authorization List, Pg 119 Original policy |
| 0101U | Hereditary colon cancer disorders (eg, Lynch syndrome, PTEN hamartoma syndrome, Cowden syndrome, familial adenomatosis polyposis), genomic sequence analysis panel utilizing a | Colorado Prior Authorization List, Pg 119 Original policy |
| 0102T | Extracorporeal shock wave performed by a physician, requiring anesthesia other than local, and involving the lateral humeral epicondyle | Colorado Prior Authorization List, Pg 119 Original policy |
| 0102U | Hereditary breast cancer-related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer), genomic sequence analysis panel utilizing | Colorado Prior Authorization List, Pg 119 Original policy |
| 0103U | Hereditary ovarian cancer (eg, hereditary ovarian cancer, hereditary endometrial cancer), genomic sequence analysis panel utilizing a combination of NGS, Sanger, MLPA, and arr | Colorado Prior Authorization List, Pg 119 Original policy |
| 0105U | Nephrology (chronic kidney disease), multiplex electrochemiluminescent immunoassay (ECLIA) of tumor necrosis factor receptor 1A, receptor superfamily 2 (TNFR1, TNFR2), and kid | Colorado Prior Authorization List, Pg 120 Original policy |
| 0106T | QST TST-EXT; TOUCH PRESS LG DIAM SENSATION | Colorado Prior Authorization List, Pg 120 Original policy |
| 0107T | QST TST-EXT; VIBRATION LG DIAM FIBER SENSATION | Colorado Prior Authorization List, Pg 120 Original policy |
| 0108T | QST-EXT; COOL SM NRV FIBR SENSATION&HYPERALGESIA | Colorado Prior Authorization List, Pg 120 Original policy |
| 0108U | Gastroenterology (Barrett's esophagus), whole slide-digital imaging, including morphometric analysis, computer-assisted quantitative immunolableing of 9 protein biomarkers (p1 | Colorado Prior Authorization List, Pg 120 Original policy |
| 0109T | QST-EXT;HEAT-PAIN SM NRV FIBR SENSATN&HYPRALGSIA | Colorado Prior Authorization List, Pg 120 Original policy |
| 0110T | QST TST-EXT; OTHER STIMULI ASSESS SENSATION | Colorado Prior Authorization List, Pg 120 Original policy |
| 0111U | Oncology (colon cancer), targeted KRAS (codons 12, 13, and 61) and NRAS (codons 12, 13, and 61) gene analysis utilizing formalin-fixed paraffin-embedded tissue | Colorado Prior Authorization List, Pg 120 Original policy |
| 0112U | Infectious agent detection and identification, targeted sequence analysis (16S and 18S rRNA genes) with drug-resistance gene | Colorado Prior Authorization List, Pg 120 Original policy |
| 0113U | Oncology (prostate), measurement of PCA3 and TMPRSS2-ERG in urine and PSA in serum following prostatic massage, by RNA amplification and fluorescence-based detection, algorith | Colorado Prior Authorization List, Pg 120 Original policy |
| 0117U | Pain management, analysis of 11 endogenous analytes (methylmalonic acid, xanthurenic acid, homocysteine, pyroglutamic acid, vanilmandelate, 5- hydroxyindoleacetic acid, hydroxy | Colorado Prior Authorization List, Pg 120 Original policy |
| 0118U | Transplantation medicine, quantification of donor-derived cell-free DNA using whole genome next-generation sequencing, plasma, reported as percentage of donor-derived cell-fre | Colorado Prior Authorization List, Pg 120 Original policy |
| 0120U | Oncology (B-cell lymphoma classification), mRNA, gene expression profiling by fluorescent probe hybridization of 58 genes (45 content and 13 housekeeping genes), formalin-fixe | Colorado Prior Authorization List, Pg 120 Original policy |
| 0129U | Hereditary breast cancer-related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer), genomic sequence analysis and deletion/dup | Colorado Prior Authorization List, Pg 120 Original policy |
| 0130U | Hereditary colon cancer disorders (eg, Lynch syndrome, PTEN hamartoma syndrome, Cowden syndrome, familial adenomatosis polyposis), targeted mRNA sequence analysis panel (APC | Colorado Prior Authorization List, Pg 120 Original policy |
| 0134U | Hereditary pan cancer (eg, hereditary breast and ovarian cancer, hereditary endometrial cancer, hereditary colorectal cancer), targeted mRNA sequence analysis panel (18 genes) | Colorado Prior Authorization List, Pg 120 Original policy |
| 0136U | ATM (ataxia telangiectasia mutated) (eg, ataxia telangiectasia) mRNA sequence analysis (List separately in addition to code for primary procedure) | Colorado Prior Authorization List, Pg 120 Original policy |
| 0138U | BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) mRNA sequence analysis (List separately in addition to co | Colorado Prior Authorization List, Pg 120 Original policy |
| 0152U | Infectious disease (bacteria, fungi, parasites, and DNA viruses), microbial cell- free DNA, plasma, untargeted next-generation sequencing, report for significant positive patho | Colorado Prior Authorization List, Pg 120 Original policy |
| 0153U | Oncology (breast), mRNA, gene expression profiling by next-generation sequencing of 101 genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a tripl | Colorado Prior Authorization List, Pg 120 Original policy |
| 0154U | Oncology (urothelial cancer), RNA, analysis by real-time RT-PCR of the FGFR3 (fibroblast growth factor receptor 3) gene analysis (ie, p.R248C [c.742C>T], p.S249C [c.746C>G], p | Colorado Prior Authorization List, Pg 120 Original policy |
| 0155U | Oncology (breast cancer), DNA, PIK3CA (phosphatidylinositol-4,5-bisphosphate 3-kinase, catalytic subunit alpha) (eg, breast cancer) gene analysis (ie, p.C420R, p.E542K, p.E545 | Colorado Prior Authorization List, Pg 120 Original policy |
| 0156U | Copy number (eg, intellectual disability, dysmorphology), sequence analysis | Colorado Prior Authorization List, Pg 120 Original policy |
| 0163T | Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), each additional interspace, lumbar (Li | Colorado Prior Authorization List, Pg 120 Original policy |
| 0164T | Removal of total disc arthroplasty, (artificial disc), anterior approach, each additional interspace, lumbar (List separ | Colorado Prior Authorization List, Pg 121 Original policy |
| 0164U | Gastroenterology (irritable bowel syndrome [IBS]), immunoassay for anti-CdtB and anti-vinculin antibodies, utilizing plasma, algorithm for elevated or not elevated qualitative | Colorado Prior Authorization List, Pg 121 Original policy |
| 0165T | Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, each additional interspa | Colorado Prior Authorization List, Pg 121 Original policy |
| 0166U | Liver disease, 10 biochemical assays (+2-macroglobulin, haptoglobin, apolipoprotein A1, bilirubin, GGT, ALT, AST, triglycerides, cholesterol, fasting glucose) and biometric a | Colorado Prior Authorization List, Pg 121 Original policy |
| 0169U | NUDT15 (nudix hydrolase 15) and TPMT (thiopurine S-methyltransferase) (eg, drug metabolism) gene analysis, common variants | Colorado Prior Authorization List, Pg 121 Original policy |
| 0170U | Neurology (autism spectrum disorder [ASD]), RNA, next-generation sequencing, saliva, algorithmic analysis, and results reported as predictive probability of ASD diagnosis | Colorado Prior Authorization List, Pg 121 Original policy |