Anthem Blue Cross Blue Shield of Colorado prior authorization, page 51
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 |
|---|---|---|
| 0171U | Targeted genomic sequence analysis panel, acute myeloid leukemia, myelodysplastic syndrome, and myeloproliferative neoplasms, DNA analysis, 23 genes, interrogation for sequenc | Colorado Prior Authorization List, Pg 121 Original policy |
| 0172U | Oncology (solid tumor as indicated by the label), somatic mutation analysis of BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) and analysis of homol | Colorado Prior Authorization List, Pg 121 Original policy |
| 0173U | Psychiatry (ie, depression, anxiety), genomic analysis panel, includes variant analysis of 14 gene | Colorado Prior Authorization List, Pg 121 Original policy |
| 0174U | Oncology (solid tumor), mass spectrometric 30 protein targets, formalin-fixed paraffin-embedded tissue, prognostic and predictive algorithm reported as likely, unlikely, or un | Colorado Prior Authorization List, Pg 121 Original policy |
| 0175U | Psychiatry (eg, depression, anxiety), genomic analysis panel, variant analysis of 15 genes | Colorado Prior Authorization List, Pg 121 Original policy |
| 0176U | Cytolethal distending toxin B (CdtB) and vinculin IgG antibodies by immunoassay (ie, ELISA) | Colorado Prior Authorization List, Pg 121 Original policy |
| 0177U | Oncology (breast cancer), DNA, PIK3CA (phosphatidylinositol-4,5-bisphosphate 3-kinase catalytic subunit alpha) gene analysis of 11 gene variants utilizing plasma, reported as | Colorado Prior Authorization List, Pg 121 Original policy |
| 0179U | Oncology (non-small cell lung cancer), cell-free DNA, targeted sequence analysis of 23 genes (single nucleotide variations, insertions and deletions, fusions without prior kno | Colorado Prior Authorization List, Pg 121 Original policy |
| 0186T | Suprachoroidal delivery of pharmacologic agent (does not include supply of medication) | Colorado Prior Authorization List, Pg 121 Original policy |
| 0191T | Insertion of anterior segment aqueous drainage device, without extraocular reservoir; internal approach, into the trabecular meshwork | Colorado Prior Authorization List, Pg 121 Original policy |
| 0192T | Insertion of anterior segment aqueous drainage device, without extraocular reservoir; external approach | Colorado Prior Authorization List, Pg 121 Original policy |
| 0200T | Percutaneous sacral augmentation (sacroplasty), unilateral injection(s), including the use of a balloon or mechanical device, when used, 1 or more needles | Colorado Prior Authorization List, Pg 121 Original policy |
| 0201T | Percutaneous sacral augmentation (sacroplasty), bilateral injections, including the use of a balloon or mechanical device, when used, 2 or more needles | Colorado Prior Authorization List, Pg 121 Original policy |
| 0202T | Posterior vertebral joint(s) arthroplasty (e.g., facet joint[s] replacement) including facetectomy, laminectomy, foramin | Colorado Prior Authorization List, Pg 121 Original policy |
| 0203U | Autoimmune (inflammatory bowel disease), mRNA, gene expression profiling by quantitative RT-PCR, 17 genes (15 target and 2 reference genes), whole blood, reported as a continu | Colorado Prior Authorization List, Pg 121 Original policy |
| 0205U | Ophthalmology (age-related macular degeneration), analysis of 3 gene variants (2 CFH gene, 1 ARMS2 gene), using PCR and MALDI-TOF, buccal swab, reported as positive or negativ | Colorado Prior Authorization List, Pg 121 Original policy |
| 0206U | Neurology (Alzheimer disease); cell aggregation using morphometric imaging and protein kinase C-epsilon (PKCe) concentration in response to amylospheroid treatment by ELISA, c | Colorado Prior Authorization List, Pg 121 Original policy |
| 0207T | Evacuation of meibomian glands, automated, using heat and intermittent pressure, unilateral | Colorado Prior Authorization List, Pg 122 Original policy |
| 0209U | Cytogenomic constitutional (genome-wide) analysis, interrogation of genomic regions for copy number, structural changes and areas of homozygosity for chromosomal abnormalities | Colorado Prior Authorization List, Pg 122 Original policy |
| 0211U | Oncology (pan-tumor), DNA and RNA by next-generation sequencing, utilizing formalin-fixed paraffin-embedded tissue, interpretative report for single nucleotide variants, copy | Colorado Prior Authorization List, Pg 122 Original policy |
| 0212U | Rare diseases (constitutional/heritable disorders), whole genome and mitochondrial DNA sequence analysis, including small sequence changes, deletions, duplications, short tand | Colorado Prior Authorization List, Pg 122 Original policy |
| 0213T | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joi | Colorado Prior Authorization List, Pg 122 Original policy |
| 0213U | Rare diseases (constitutional/heritable disorders), whole genome and mitochondrial DNA sequence analysis, including small sequence changes, deletions, duplications, short tand | Colorado Prior Authorization List, Pg 122 Original policy |
| 0214T | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joi | Colorado Prior Authorization List, Pg 122 Original policy |
| 0214U | Rare diseases (constitutional/heritable disorders), whole exome and mitochondrial DNA sequence analysis, including small sequence changes, deletions, duplications, short tande | Colorado Prior Authorization List, Pg 122 Original policy |
| 0215T | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joi | Colorado Prior Authorization List, Pg 122 Original policy |
| 0215U | Rare diseases (constitutional/heritable disorders), whole exome and mitochondrial DNA sequence analysis, including small sequence changes, deletions, duplications, short tande | Colorado Prior Authorization List, Pg 122 Original policy |
| 0216T | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joi | Colorado Prior Authorization List, Pg 122 Original policy |
| 0216U | Neurology (inherited ataxias), genomic DNA sequence analysis of 12 common genes including small sequence changes, deletions, duplications, short tandem repeat gene expansions | Colorado Prior Authorization List, Pg 122 Original policy |
| 0217T | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joi | Colorado Prior Authorization List, Pg 122 Original policy |
| 0217U | Neurology (inherited ataxias), genomic DNA sequence analysis of 51 genes including small sequence changes, deletions, duplications, short tandem repeat gene expansions, and va | Colorado Prior Authorization List, Pg 122 Original policy |
| 0218T | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joi | Colorado Prior Authorization List, Pg 122 Original policy |
| 0218U | Neurology (muscular dystrophy), DMD gene sequence analysis, including small sequence changes, deletions, duplications, and variants in non-uniquely mappable regions, blood or | Colorado Prior Authorization List, Pg 122 Original policy |
| 0221T | Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; lumbar | Colorado Prior Authorization List, Pg 122 Original policy |
| 0222T | Placement of a posterior intrafacet implant(s), unilateral or bilateral, including imaging and placement of bone graft(s) or synthetic device(s), single level; each additional | Colorado Prior Authorization List, Pg 122 Original policy |
| 0228T | Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, cervical or thoracic; single level | Colorado Prior Authorization List, Pg 122 Original policy |
| 0228U | Oncology (prostate), multianalyte molecular profile by photometric detection of macromolecules adsorbed on nanosponge array slides with machine learning, utilizing first morni | Colorado Prior Authorization List, Pg 123 Original policy |
| 0229T | Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, cervical or thoracic; each additional level (List separately in addition to c | Colorado Prior Authorization List, Pg 123 Original policy |
| 0229U | BCAT1 (Branched chain amino acid transaminase 1) and IKZF1 (IKAROS family zinc finger 1) (eg, colorectal cancer) promoter methylation analysis | Colorado Prior Authorization List, Pg 123 Original policy |
| 0230T | Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, lumbar or sacral; single level | Colorado Prior Authorization List, Pg 123 Original policy |
| 0230U | AR (androgen receptor) (eg, spinal and bulbar muscular atrophy, Kennedy disease, X chromosome inactivation), full sequence analysis, including small sequence changes in exonic | Colorado Prior Authorization List, Pg 123 Original policy |
| 0231T | Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, lumbar or sacral; each additional level (List separately in addition to code | Colorado Prior Authorization List, Pg 123 Original policy |
| 0231U | CACNA1A (calcium voltage-gated channel subunit alpha 1A) (eg, spinocerebellar ataxia), full gene analysis, including small sequence changes in exonic and intronic regions, del | Colorado Prior Authorization List, Pg 123 Original policy |
| 0232T | Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed | Colorado Prior Authorization List, Pg 123 Original policy |
| 0232U | CSTB (cystatin B) (eg, progressive myoclonic epilepsy type 1A, Unverricht- Lundborg disease), full gene analysis, including small sequence changes in exonic and intronic region | Colorado Prior Authorization List, Pg 123 Original policy |
| 0233U | FXN (frataxin) (eg, Friedreich ataxia), gene analysis, including small sequence changes in exonic and intronic regions, deletions, duplications, short tandem repeat (STR) expa | Colorado Prior Authorization List, Pg 123 Original policy |
| 0234U | MECP2 (methyl CpG binding protein 2) (eg, Rett syndrome), full gene analysis, including small sequence changes in exonic and intronic regions, deletions, duplications, mobile | Colorado Prior Authorization List, Pg 123 Original policy |
| 0235U | PTEN (phosphatase and tensin homolog) (eg, Cowden syndrome, PTEN hamartoma tumor syndrome), full gene analysis, including small sequence changes in exonic and intronic regions | Colorado Prior Authorization List, Pg 123 Original policy |
| 0236U | SMN1 (survival of motor neuron 1, telomeric) and SMN2 (survival of motor neuron 2, centromeric) (eg, spinal muscular atrophy) full gene analysis, including small sequence chan | Colorado Prior Authorization List, Pg 123 Original policy |
| 0237U | 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 123 Original policy |