Anthem Blue Cross Blue Shield of Colorado prior authorization, page 56
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 |
|---|---|---|
| 0490T | Autologous adipose-derived regenerative cell therapy for scleroderma in the hands; multiple injections in one or both hands | Colorado Prior Authorization List, Pg 132 Original policy |
| 0490U | Oncology (cutaneous or uveal melanoma), circulating tumor cell selection, morphological characterization and enumeration based on differential CD146, high molecular-weight mel | Colorado Prior Authorization List, Pg 132 Original policy |
| 0491U | Oncology (solid tumor), circulating tumor cell selection, morphological characterization and enumeration based on differential epithelial cell adhesion molecule (EpCAM), cytok | Colorado Prior Authorization List, Pg 132 Original policy |
| 0492U | Oncology (solid tumor), circulating tumor cell selection, morphological characterization and enumeration based on differential epithelial cell adhesion molecule (EpCAM), cytok | Colorado Prior Authorization List, Pg 132 Original policy |
| 0493U | Transplantation medicine, quantification of donor-derived cell-free DNA (cfDNA) using next-generation sequencing, plasma, reported as percentage of donor- derived cell-free DNA | Colorado Prior Authorization List, Pg 132 Original policy |
| 0494T | Surgical preparation and cannulation of marginal (extended) cadaver donor lung(s) to ex vivo organ perfusion system, including decannulation, separation from the perfusion sys | Colorado Prior Authorization List, Pg 132 Original policy |
| 0494U | Red blood cell antigen (fetal RhD gene analysis), next-generation sequencing of circulating cell-free DNA (cfDNA) of blood in pregnant individuals known to be RhD negative, re | Colorado Prior Authorization List, Pg 132 Original policy |
| 0495T | Initiation and monitoring marginal (extended) cadaver donor lung(s) organ perfusion system by physician or qualified health care professional, including physiological and labo | Colorado Prior Authorization List, Pg 133 Original policy |
| 0495U | Oncology (prostate), analysis of circulating plasma proteins (tPSA, fPSA, KLK2, PSP94, and GDF15), germline polygenic risk score (60 variants), clinical information (age, fami | Colorado Prior Authorization List, Pg 133 Original policy |
| 0496U | Oncology (colorectal), cell-free DNA, 8 genes for mutations, 7 genes for methylation by real-time RT-PCR, and 4 proteins by enzyme-linked immunosorbent assay, blood, reported | Colorado Prior Authorization List, Pg 133 Original policy |
| 0497U | Oncology (prostate), mRNA gene-expression profiling by real-time RT-PCR of 6 genes (FOXM1, MCM3, MTUS1, TTC21B, ALAS1, and PPP2CA), utilizing formalin-fixed paraffin-embedded | Colorado Prior Authorization List, Pg 133 Original policy |
| 0498U | Oncology (colorectal), next-generation sequencing for mutation detection in 43 genes and methylation pattern in 45 genes, blood, and formalin-fixed paraffin- embedded (FFPE) ti | Colorado Prior Authorization List, Pg 133 Original policy |
| 0499U | Oncology (colorectal and lung), DNA from formalin-fixed paraffin-embedded (FFPE) tissue, next-generation sequencing of 8 genes (NRAS, EGFR, CTNNB1, PIK3CA, APC, BRAF, KRAS, an | Colorado Prior Authorization List, Pg 133 Original policy |
| 0500U | Autoinflammatory disease (VEXAS syndrome), DNA, UBA1 gene mutations, targeted variant analysis (M41T, M41V, M41L, c.118-2A>C, c.118-1G>C, c.118- 9_118-2del, S56F, S621C) | Colorado Prior Authorization List, Pg 133 Original policy |
| 0503U | Neurology (Alzheimer disease), beta amyloid (AB40, AB42, AB42/40 ratio) and tau-protein (ptau217, np-tau217, ptau217/np-tau217 ratio), blood, immunoprecipitation with quantita | Colorado Prior Authorization List, Pg 133 Original policy |
| 0505T | Endovenous femoral-popliteal arterial revascularization, with transcatheter placement of intravascular stent graft(s) and closure by any method, including percutaneous or open | Colorado Prior Authorization List, Pg 133 Original policy |
| 0506U | Gastroenterology (Barrett's esophagus), esophageal cells, DNA methylation analysis by next-generation sequencing of at least 89 differentially methylated genomic regions, algo | Colorado Prior Authorization List, Pg 133 Original policy |
| 0507U | Oncology (ovarian), DNA, whole-genome sequencing with 5- hydroxymethylcytosine (5hmC) enrichment, using whole blood or plasma, algorithm reported as cancer detected or not dete | Colorado Prior Authorization List, Pg 133 Original policy |
| 0510T | Removal of sinus tarsi implant | Colorado Prior Authorization List, Pg 133 Original policy |
| 0511T | Removal and reinsertion of sinus tarsi implant | Colorado Prior Authorization List, Pg 133 Original policy |
| 0511U | Oncology (solid tumor), tumor cell culture in 3D microenvironment, 36 or more drug panel, reported as tumor-response prediction for each drug | Colorado Prior Authorization List, Pg 133 Original policy |
| 0512T | Extracorporeal shock wave for integumentary wound healing, including topical application and dressing care; initial wound | Colorado Prior Authorization List, Pg 133 Original policy |
| 0515T | Insertion of wireless cardiac stimulator for left ventricular pacing, including device interrogation and programming, and imaging supervision and interpretation, when performe | Colorado Prior Authorization List, Pg 133 Original policy |
| 0516T | Insertion of wireless cardiac stimulator for left ventricular pacing, including device interrogation and programming, and imaging supervision and interpretation, when performe | Colorado Prior Authorization List, Pg 133 Original policy |
| 0516U | Drug metabolism, whole blood, pharmacogenomic genotyping of 40 genes and CYP2D6 copy number variant analysis, reported as metabolizer status | Colorado Prior Authorization List, Pg 133 Original policy |
| 0517T | Insertion of wireless cardiac stimulator for left ventricular pacing, including device interrogation and programming, and imaging supervision and interpretation, when performe | Colorado Prior Authorization List, Pg 133 Original policy |
| 0518T | Removal of pulse generator for wireless cardiac stimulator for left ventricular pacing; battery component only | Colorado Prior Authorization List, Pg 133 Original policy |
| 0519T | Removal and replacement of pulse generator for wireless cardiac stimulator for left ventricular pacing, including device interrogation and programming; both components (batter | Colorado Prior Authorization List, Pg 133 Original policy |
| 0520T | Removal and replacement of pulse generator for wireless cardiac stimulator for left ventricular pacing, including device interrogation and programming; battery component only | Colorado Prior Authorization List, Pg 134 Original policy |
| 0521T | Interrogation device evaluation (in person) with analysis, review and report, includes connection, recording, and disconnection per patient encounter, wireless cardiac stimula | Colorado Prior Authorization List, Pg 134 Original policy |
| 0521U | Rheumatoid factor IgA and IgM, cyclic citrullinated peptide (CCP) antibodies, and scavenger receptor A (SR-A) by immunoassay, blood | Colorado Prior Authorization List, Pg 134 Original policy |
| 0522T | 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 134 Original policy |
| 0523U | Oncology (solid tumor), DNA, qualitative, next-generation sequencing (NGS) of singlenucleotide variants (SNV) and insertion/deletions in 22 genes utilizing formalin-fixed par | Colorado Prior Authorization List, Pg 134 Original policy |
| 0524T | Endovenous catheter directed chemical ablation with balloon isolation of incompetent extremity vein, open or percutaneous, including all vascular access, catheter manipulation | Colorado Prior Authorization List, Pg 134 Original policy |
| 0524U | Obstetrics (preeclampsia), sFlt1/PlGF ratio, immunoassay, utilizing serum or plasma, reported as a value | Colorado Prior Authorization List, Pg 134 Original policy |
| 0525T | Insertion or replacement of intracardiac ischemia monitoring system, including testing of the lead and monitor, initial system programming, and imaging supervision and interpr | Colorado Prior Authorization List, Pg 134 Original policy |
| 0525U | Oncology, spheroid cell culture, 11-drug panel (carboplatin, docetaxel, doxorubicin, etoposide, gemcitabine, niraparib, olaparib, paclitaxel, rucaparib, topotecan, veliparib) | Colorado Prior Authorization List, Pg 134 Original policy |
| 0526T | Insertion or replacement of intracardiac ischemia monitoring system, including testing of the lead and monitor, initial system programming, and imaging supervision and interpr | Colorado Prior Authorization List, Pg 134 Original policy |
| 0527T | Insertion or replacement of intracardiac ischemia monitoring system, including testing of the lead and monitor, initial system programming, and imaging supervision and interpr | Colorado Prior Authorization List, Pg 134 Original policy |
| 0528T | Programming device evaluation (in person) of intracardiac ischemia monitoring system with iterative adjustment of programmed values, with analysis, review, and report | Colorado Prior Authorization List, Pg 134 Original policy |
| 0529T | Interrogation device evaluation (in person) of intracardiac ischemia monitoring system with analysis, review, and report | Colorado Prior Authorization List, Pg 134 Original policy |
| 0529U | Hematology (venous thromboembolism [VTE]), genome-wide single-nucleotide polymorphism variants, including F2 and F5 gene analysis, and Leiden variant, by microarray analysis | Colorado Prior Authorization List, Pg 134 Original policy |
| 0530T | Removal of intracardiac ischemia monitoring system, including all imaging supervision and interpretation; complete system (electrode and implantable monitor) | Colorado Prior Authorization List, Pg 134 Original policy |
| 0530U | Oncology (pan-solid tumor), ctDNA, utilizing plasma, nextgeneration sequencing (NGS) of 77 genes, 8 fusions, microsatellite instability, and tumor mutation burden, interpreta | Colorado Prior Authorization List, Pg 134 Original policy |
| 0531T | Removal of intracardiac ischemia monitoring system, including all imaging supervision and interpretation; electrode only | Colorado Prior Authorization List, Pg 134 Original policy |
| 0532T | Removal of intracardiac ischemia monitoring system, including all imaging supervision and interpretation; implantable monitor only | Colorado Prior Authorization List, Pg 134 Original policy |
| 0532U | Rare diseases (constitutional disease/hereditary disorders), rapid whole genome and mitochondrial DNA sequencing for single-nucleotide variants, insertions/deletions, copy num | Colorado Prior Authorization List, Pg 134 Original policy |
| 0533U | Drug metabolism (adverse drug reactions and drug response), genotyping of 16 genes (ie, ABCG2, CYP2B6, CYP2C9, CYP2C19, CYP2C, CYP2D6, CYP3A5, CYP4F2, DPYD, G6PD, GGCX, NUDT15 | Colorado Prior Authorization List, Pg 134 Original policy |
| 0534U | Oncology (prostate), microRNA, single-nucleotide polymorphisms (SNPs) analysis by RT-PCR of 32 variants, using buccal swab, algorithm reported as a risk score | Colorado Prior Authorization List, Pg 134 Original policy |
| 0535U | Perfluoroalkyl substances (PFAS) (eg, perfluorooctanoic acid, perfluorooctane sulfonic acid), by liquid chromatography with tandem mass spectrometry (LC- MS/MS), plasma or seru | Colorado Prior Authorization List, Pg 134 Original policy |