Anthem Blue Cross Blue Shield of Colorado prior authorization, page 54
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 |
|---|---|---|
| 0359U | Oncology (prostate cancer), analysis of all prostate-specific antigen (PSA) structural isoforms by phase separation and immunoassay, plasma, algorithm reports risk of cancer | Colorado Prior Authorization List, Pg 128 Original policy |
| 0360U | Oncology (lung), enzyme-linked immunosorbent assay (ELISA) of 7 autoantibodies (p53, NY-ESO-1, CAGE, GBU4-5, SOX2, MAGE A4, and HuD), plasma, algorithm reported as a categoric | Colorado Prior Authorization List, Pg 128 Original policy |
| 0362U | Oncology (papillary thyroid cancer), gene-expression profiling via targeted hybrid captureenrichment RNA sequencing of 82 content genes and 10 housekeeping genes, formalin-fi | Colorado Prior Authorization List, Pg 128 Original policy |
| 0363U | Oncology (urothelial), mRNA, gene-expression profiling by real-time quantitative PCR of 5 genes (MDK, HOXA13, CDC2 [CDK1], IGFBP5, and CXCR2), utilizing urine, algorithm incor | Colorado Prior Authorization List, Pg 128 Original policy |
| 0364U | Oncology (hematolymphoid neoplasm), genomic sequence analysis using multiplex (PCR) and next-generation sequencing with algorithm, quantification of dominant clonal sequence(s | Colorado Prior Authorization List, Pg 128 Original policy |
| 0368U | Oncology (colorectal cancer), evaluation for mutations of APC, BRAF, CTNNB1, KRAS, NRAS, PIK3CA, SMAD4, and TP53, and methylation markers (MYO1G, KCNQ5, C9ORF50, FLI1, CLIP4 | Colorado Prior Authorization List, Pg 128 Original policy |
| 0375T | Total disc arthroplasty (artificial disc), anterior approach, including discectomy with end plate preparation (includes osteophytectomy for nerve root or spinal cord decompres | Colorado Prior Authorization List, Pg 128 Original policy |
| 0376U | Oncology (prostate cancer), image analysis of at least 128 histologic features and clinical factors, prognostic algorithm determining the risk of distant metastases, and prost | Colorado Prior Authorization List, Pg 128 Original policy |
| 0377U | Cardiovascular disease, quantification of advanced serum or plasma lipoprotein profile, by nuclear magnetic resonance (NMR) spectrometry with report of a lipoprotein profile ( | Colorado Prior Authorization List, Pg 128 Original policy |
| 0378T | Visual field assessment, with concurrent real time data analysis and accessible data storage with patient initiated data transmitted to a remote surveillance center for up to | Colorado Prior Authorization List, Pg 128 Original policy |
| 0378U | RFC1 (replication factor C subunit 1), repeat expansion variant analysis by traditional and repeat-primed PCR, blood, saliva, or buccal swab | Colorado Prior Authorization List, Pg 128 Original policy |
| 0379T | Visual field assessment, with concurrent real time data analysis and accessible data storage with patient initiated data transmitted to a remote surveillance center for up to | Colorado Prior Authorization List, Pg 128 Original policy |
| 0379U | Targeted genomic sequence analysis panel, solid organ neoplasm, DNA (523 genes) and RNA (55 genes) by next-generation sequencing, interrogation for sequence variants, gene cop | Colorado Prior Authorization List, Pg 128 Original policy |
| 0388U | Oncology (non-small cell lung cancer), next-generation sequencing with identification of single nucleotide variants, copy number variants, insertions and deletions, and struct | Colorado Prior Authorization List, Pg 128 Original policy |
| 0389U | Pediatric febrile illness (Kawasaki disease [KD]), interferon alpha-inducible protein 27 (IFI27) and mast cell-expressed membrane protein 1 (MCEMP1), RNA, using reverse transc | Colorado Prior Authorization List, Pg 128 Original policy |
| 0390U | Obstetrics (preeclampsia), kinase insert domain receptor (KDR), Endoglin (ENG), and retinol-binding protein 4 (RBP4), by immunoassay, serum, algorithm reported as a risk score | Colorado Prior Authorization List, Pg 128 Original policy |
| 0391U | Oncology (solid tumor), DNA and RNA by next-generation sequencing, utilizing formalin-fixed paraffin-embedded (FFPE) tissue, 437 genes, interpretive report for single nucleoti | Colorado Prior Authorization List, Pg 128 Original policy |
| 0392U | Drug metabolism (depression, anxiety, attention deficit hyperactivity disorder [ADHD]), gene-drug interactions, variant analysis of 16 genes, including deletion/duplication an | Colorado Prior Authorization List, Pg 128 Original policy |
| 0394U | Perfluoroalkyl substances (PFAS) (eg, perfluorooctanoic acid, perfluorooctane sulfonic acid), 16 PFAS compounds by liquid chromatography with tandem mass spectrometry (LC-MS/M | Colorado Prior Authorization List, Pg 129 Original policy |
| 0400U | Obstetrics (expanded carrier screening), 145 genes by nextgeneration sequencing, fragment analysis and multiplex ligationdependent probe amplification, DNA, reported as carrie | Colorado Prior Authorization List, Pg 129 Original policy |
| 0401U | Cardiology (coronary heart disease [CAD]), 9 genes (12 variants), targeted variant genotyping, blood, saliva, or buccal swab, algorithm reported as a genetic risk score for a | Colorado Prior Authorization List, Pg 129 Original policy |
| 0402T | Collagen cross-linking of cornea, including removal of the corneal epithelium, when performed, and intraoperative pachymetry, when performed | Colorado Prior Authorization List, Pg 129 Original policy |
| 0403U | Oncology (prostate), mRNA, gene expression profiling of 18 genes, first-catch urine, algorithm reported as percentage of likelihood of detecting clinically significant prostat | Colorado Prior Authorization List, Pg 129 Original policy |
| 0405U | Oncology (pancreatic), 59 methylation haplotype block markers, next-generation sequencing, plasma, reported as cancer signal detected or not detected | Colorado Prior Authorization List, Pg 129 Original policy |
| 0407U | Nephrology (diabetic chronic kidney disease [CKD]), multiplex electrochemiluminescent immunoassay (ECLIA) of soluble tumor necrosis factor receptor 1 (sTNFR1), soluble tumor n | Colorado Prior Authorization List, Pg 129 Original policy |
| 0408T | Insertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic pa | Colorado Prior Authorization List, Pg 129 Original policy |
| 0409T | Insertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic pa | Colorado Prior Authorization List, Pg 129 Original policy |
| 0409U | Oncology (solid tumor), DNA (80 genes) and RNA (36 genes), by next-generation sequencing from plasma, including single nucleotide variants, insertions/deletions, copy number a | Colorado Prior Authorization List, Pg 129 Original policy |
| 0410T | Insertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic pa | Colorado Prior Authorization List, Pg 129 Original policy |
| 0410U | Oncology (pancreatic), DNA, whole genome sequencing with 5- hydroxymethylcytosine enrichment, whole blood or plasma, algorithm reported as cancer detected or not detected | Colorado Prior Authorization List, Pg 129 Original policy |
| 0411T | Insertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic pa | Colorado Prior Authorization List, Pg 129 Original policy |
| 0411U | Psychiatry (eg, depression, anxiety, attention deficit hyperactivity disorder [ADHD]), genomic analysis panel, variant analysis of 15 genes, including deletion/duplication ana | Colorado Prior Authorization List, Pg 129 Original policy |
| 0412T | Removal of permanent cardiac contractility modulation system; pulse generator only | Colorado Prior Authorization List, Pg 129 Original policy |
| 0412U | Beta amyloid, AB42/40 ratio, immunoprecipitation with quantitation by liquid chromatography with tandem mass spectrometry (LC-MS/MS) and qualitative ApoE isoform-specific prot | Colorado Prior Authorization List, Pg 129 Original policy |
| 0413T | Removal of permanent cardiac contractility modulation system; transvenous electrode (atrial or ventricular) | Colorado Prior Authorization List, Pg 129 Original policy |
| 0413U | Oncology (hematolymphoid neoplasm), optical genome mapping for copy number alterations, aneuploidy, and balanced/complex structural rearrangements, DNA from blood or bone marr | Colorado Prior Authorization List, Pg 129 Original policy |
| 0414T | Removal and replacement of permanent cardiac contractility modulation system pulse generator only | Colorado Prior Authorization List, Pg 129 Original policy |
| 0414U | Oncology (lung), augmentative algorithmic analysis of digitized whole slide imaging for 8 genes (ALK, BRAF, EGFR, ERBB2, MET, NTRK1-3, RET, ROS1), and KRAS G12C and PD-L1, if | Colorado Prior Authorization List, Pg 129 Original policy |
| 0415T | Repositioning of previously implanted cardiac contractility modulation transvenous electrode, (atrial or ventricular lead) | Colorado Prior Authorization List, Pg 129 Original policy |
| 0416T | Relocation of skin pocket for implanted cardiac contractility modulation pulse generator | Colorado Prior Authorization List, Pg 129 Original policy |
| 0417T | Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values | Colorado Prior Authorization List, Pg 129 Original policy |
| 0417U | Rare diseases (constitutional/heritable disorders), whole mitochondrial genome sequence with heteroplasmy detection and deletion analysis, nuclear-encoded mitochondrial gene a | Colorado Prior Authorization List, Pg 130 Original policy |
| 0418T | Interrogation device evaluation (in person) with analysis, review and report, includes connection, recording and disconnection per patient encounter, implantable cardiac contr | Colorado Prior Authorization List, Pg 130 Original policy |
| 0419U | Neuropsychiatry (eg, depression, anxiety), genomic sequence analysis panel, variant analysis of 13 genes, saliva or buccal swab, report of each gene phenotype | Colorado Prior Authorization List, Pg 130 Original policy |
| 0420U | Oncology (urothelial), mRNA expression profiling by real-time quantitative PCR of MDK, HOXA13, CDC2, IGFBP5, and CXCR2 in combination with droplet digital PCR (ddPCR) analysis | Colorado Prior Authorization List, Pg 130 Original policy |
| 0422U | Oncology (pan-solid tumor), analysis of DNA biomarker response to anti-cancer therapy using cell-free circulating DNA, biomarker comparison to a previous baseline pre-treatmen | Colorado Prior Authorization List, Pg 130 Original policy |
| 0423U | Psychiatry (eg, depression, anxiety), genomic analysis panel, including variant analysis of 26 genes, buccal swab, report including metabolizer status and risk of drug toxicit | Colorado Prior Authorization List, Pg 130 Original policy |
| 0424U | Oncology (prostate), exosome-based analysis of 53 small noncoding RNAs (sncRNAs) by quantitative reverse transcription polymerase chain reaction (RT- qPCR), urine, reported as | Colorado Prior Authorization List, Pg 130 Original policy |
| 0425U | Genome (eg, unexplained constitutional or heritable disorder or syndrome), rapid sequence analysis, each comparator genome (eg, parents, siblings) | Colorado Prior Authorization List, Pg 130 Original policy |
| 0426U | Genome (eg, unexplained constitutional or heritable disorder or syndrome), ultra- rapid sequence analysis | Colorado Prior Authorization List, Pg 130 Original policy |