Anthem Blue Cross Blue Shield of Colorado prior authorization, page 52
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 |
|---|---|---|
| 0238U | Oncology (Lynch syndrome), genomic DNA sequence analysis of MLH1, MSH2, MSH6, PMS2, and EPCAM, including small sequence changes in exonic and intronic regions, deletions, dupl | Colorado Prior Authorization List, Pg 123 Original policy |
| 0239U | Targeted genomic sequence analysis panel, solid organ neoplasm, cell-free DNA, analysis of 311 or more genes, interrogation for sequence variants, including substitutions, ins | Colorado Prior Authorization List, Pg 123 Original policy |
| 0242U | Targeted genomic sequence analysis panel, solid organ neoplasm, cell-free circulating DNA analysis of 55-74 genes, interrogation for sequence variants, gene copy number amplif | Colorado Prior Authorization List, Pg 123 Original policy |
| 0243U | Obstetrics (preeclampsia), biochemical assay of placental-growth factor, time- resolved fluorescence immunoassay, maternal serum, predictive algorithm reported as a risk score | Colorado Prior Authorization List, Pg 123 Original policy |
| 0244U | Oncology (solid organ), DNA, comprehensive genomic profiling, 257 genes, interrogation for single-nucleotide variants, insertions/deletions, copy number alterations, gene rear | Colorado Prior Authorization List, Pg 123 Original policy |
| 0245U | Oncology (thyroid), mutation analysis of 10 genes and 37 RNA fusions and expression of 4 mRNA markers using next-generation sequencing, fine needle aspirate, report includes a | Colorado Prior Authorization List, Pg 123 Original policy |
| 0247U | Obstetrics (preterm birth), insulin-like growth factor-binding protein 4 (IBP4), sex hormone-binding globulin (SHBG), quantitative measurement by LC-MS/MS, utilizing maternal | Colorado Prior Authorization List, Pg 124 Original policy |
| 0248U | Oncology, spheroid cell culture in 3D microenvironment, 12-drug panel, brain- or brain metastasis-response prediction for each drug | Colorado Prior Authorization List, Pg 124 Original policy |
| 0249U | Oncology (breast), semiquantitative analysis of 32 phosphoproteins and | Colorado Prior Authorization List, Pg 124 Original policy |
| 0250U | Oncology (solid organ neoplasm), targeted genomic sequence DNA analysi | Colorado Prior Authorization List, Pg 124 Original policy |
| 0253T | Insertion of anterior segment aqueous drainage device, without extraocular reservoir; internal approach, into the suprachoroidal space | Colorado Prior Authorization List, Pg 124 Original policy |
| 0254U | Reproductive medicine (preimplantation genetic assessment), analysis o | Colorado Prior Authorization List, Pg 124 Original policy |
| 0255U | Andrology (infertility), sperm-capacitation assessment of ganglioside GM1 distribution patterns, fluorescence microscopy, fresh or frozen specimen, reported as percentage of c | Colorado Prior Authorization List, Pg 124 Original policy |
| 0258U | Autoimmune (psoriasis), mRNA, next-generation sequencing, gene expression profiling of 50-100 genes, skin-surface collection using adhesive patch, algorithm reported as likeli | Colorado Prior Authorization List, Pg 124 Original policy |
| 0260U | Rare diseases (constitutional/heritable disorders), identification of copy number variations, inversions, insertions, translocations, and other structural variants by optical | Colorado Prior Authorization List, Pg 124 Original policy |
| 0262U | Oncology (solid tumor), gene expression profiling by real-time RT-PCR of 7 gene pathways (ER, AR, PI3K, MAPK, HH, TGFB, Notch), formalin-fixed paraffin- embedded (FFPE), algori | Colorado Prior Authorization List, Pg 124 Original policy |
| 0263T | Intramuscular autologous bone marrow cell therapy, with preparation of harvested cells, multiple injections, one leg, including ultrasound guidance, if performed; complete pro | Colorado Prior Authorization List, Pg 124 Original policy |
| 0264T | Intramuscular autologous bone marrow cell therapy, with preparation of harvested cells, multiple injections, one leg, including ultrasound guidance, if performed; complete pro | Colorado Prior Authorization List, Pg 124 Original policy |
| 0264U | Rare diseases (constitutional/heritable disorders), identification of copy number variations, inversions, insertions, translocations, and other structural variants by optical | Colorado Prior Authorization List, Pg 124 Original policy |
| 0265T | Intramuscular autologous bone marrow cell therapy, with preparation of harvested cells, multiple injections, one leg, including ultrasound guidance, if performed; unilateral o | Colorado Prior Authorization List, Pg 124 Original policy |
| 0265U | Rare constitutional and other heritable disorders, whole genome and mitochondrial DNA sequence analysis, blood, frozen and formalin-fixed paraffin- embedded (FFPE) tissue, sali | Colorado Prior Authorization List, Pg 124 Original policy |
| 0266U | Unexplained constitutional or other heritable disorders or syndromes, tissue- specific gene expression by whole-transcriptome and next-generation sequencing, blood, formalin-fi | Colorado Prior Authorization List, Pg 124 Original policy |
| 0267U | Rare constitutional and other heritable disorders, identification of copy number variations, inversions, insertions, translocations, and other structural variants by optical g | Colorado Prior Authorization List, Pg 124 Original policy |
| 0268U | Hematology (atypical hemolytic uremic syndrome [aHUS]), genomic sequence analysis of 15 genes, blood, buccal swab, or amniotic fluid | Colorado Prior Authorization List, Pg 124 Original policy |
| 0269U | Hematology (autosomal dominant congenital thrombocytopenia), genomic sequence analysis of 14 genes, blood, buccal swab, or amniotic fluid | Colorado Prior Authorization List, Pg 124 Original policy |
| 0270U | Hematology (congenital coagulation disorders), genomic sequence analysis of 20 genes, blood, buccal swab, or amniotic fluid | Colorado Prior Authorization List, Pg 124 Original policy |
| 0271U | Hematology (congenital neutropenia), genomic sequence analysis of 23 genes, blood, buccal swab, or amniotic fluid | Colorado Prior Authorization List, Pg 124 Original policy |
| 0272U | Hematology (genetic bleeding disorders), genomic sequence analysis of 51 genes, blood, buccal swab, or amniotic fluid, comprehensive | Colorado Prior Authorization List, Pg 124 Original policy |
| 0273U | Hematology (genetic hyperfibrinolysis, delayed bleeding), genomic sequence analysis of 8 genes (F13A1, F13B, FGA, FGB, FGG, SERPINA1, SERPINE1, SERPINF2, PLAU), blood, buccal | Colorado Prior Authorization List, Pg 124 Original policy |
| 0274T | Percutaneous laminotomy/laminectomy (interlaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or forami | Colorado Prior Authorization List, Pg 124 Original policy |
| 0274U | Hematology (genetic platelet disorders), genomic sequence analysis of 43 genes, blood, buccal swab, or amniotic fluid | Colorado Prior Authorization List, Pg 124 Original policy |
| 0276U | Hematology (inherited thrombocytopenia), genomic sequence analysis of 23 genes, blood, buccal swab, or amniotic fluid | Colorado Prior Authorization List, Pg 125 Original policy |
| 0277U | Hematology (genetic platelet function disorder), genomic sequence analysis of 31 genes, blood, buccal swab, or amniotic fluid | Colorado Prior Authorization List, Pg 125 Original policy |
| 0278T | Transcutaneous Electrical Modulation Pain Reprocessing (Eg, Scrambler Therapy), Each Treatment Session (Includes Placement Of Electrodes) | Colorado Prior Authorization List, Pg 125 Original policy |
| 0278U | Hematology (genetic thrombosis), genomic sequence analysis of 12 genes, blood, buccal swab, or amniotic fluid | Colorado Prior Authorization List, Pg 125 Original policy |
| 0282T | Percutaneous or open implantation of neurostimulator electrode array(s), subcutaneous (peripheral subcutaneous field stimulation), including imaging guidance, when performed | Colorado Prior Authorization List, Pg 125 Original policy |
| 0283T | Percutaneous or open implantation of neurostimulator electrode array(s), subcutaneous (peripheral subcutaneous field stimulation), including imaging guidance, when performed | Colorado Prior Authorization List, Pg 125 Original policy |
| 0284T | Revision or removal of pulse generator or electrodes, including imaging guidance, when performed, including addition of new electrodes, when performed | Colorado Prior Authorization List, Pg 125 Original policy |
| 0285T | Electronic analysis of implanted peripheral subcutaneous field stimulation pulse generator, with reprogramming when performed | Colorado Prior Authorization List, Pg 125 Original policy |
| 0285U | Oncology, disease progression and response monitoring to radiation, chemotherapy, or other systematic cancer treatments, cell-free DNA, quantitative branched chain DNA amplifi | Colorado Prior Authorization List, Pg 125 Original policy |
| 0286U | CEP72 (centrosomal protein, 72-KDa), NUDT15 (nudix hydrolase 15) and TPMT (thiopurine S-methyltransferase) (eg, drug metabolism) gene analysis, common variants | Colorado Prior Authorization List, Pg 125 Original policy |
| 0287U | Oncology (thyroid), DNA and mRNA, next-generation sequencing analysis of 112 genes, fine needle aspirate or formalin-fixed paraffin-embedded (FFPE) tissue, algorithmic predict | Colorado Prior Authorization List, Pg 125 Original policy |
| 0288U | Oncology (lung), mRNA, quantitative PCR analysis of 11 genes (BAG1, BRCA1, CDC6, CDK2AP1, ERBB3, FUT3, IL11, LCK, RND3, SH3BGR, WNT3A) and 3 reference genes (ESD, TBP, YAP1) | Colorado Prior Authorization List, Pg 125 Original policy |
| 0289U | Neurology (Alzheimer disease), mRNA, gene expression profiling by RNA sequencing of 24 genes, whole blood, algorithm reported as predictive risk score | Colorado Prior Authorization List, Pg 125 Original policy |
| 0290U | Pain management, mRNA, gene expression profiling by RNA sequencing of 36 genes, whole blood, algorithm reported as predictive risk score | Colorado Prior Authorization List, Pg 125 Original policy |
| 0291U | Psychiatry (mood disorders), mRNA, gene expression profiling by RNA sequencing of 144 genes, whole blood, algorithm reported as predictive risk score | Colorado Prior Authorization List, Pg 125 Original policy |
| 0292U | Psychiatry (stress disorders), mRNA, gene expression profiling by RNA sequencing of 72 genes, whole blood, algorithm reported as predictive risk score | Colorado Prior Authorization List, Pg 125 Original policy |
| 0293U | Psychiatry (suicidal ideation), mRNA, gene expression profiling by RNA sequencing of 54 genes, whole blood, algorithm reported as predictive risk score | Colorado Prior Authorization List, Pg 125 Original policy |
| 0294U | Longevity and mortality risk, mRNA, gene expression profiling by RNA sequencing of 18 genes, whole blood, algorithm reported as predictive risk score | Colorado Prior Authorization List, Pg 125 Original policy |
| 0296U | Oncology (oral and/or oropharyngeal cancer), gene expression profiling by RNA sequencing at least 20 molecular features (eg, human and/or microbial mRNA), saliva, algorithm re | Colorado Prior Authorization List, Pg 125 Original policy |