Anthem Blue Cross Blue Shield of Georgia prior authorization, page 16
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 |
|---|---|---|
| 78468 | Myocardial imaging, infarct avid, planar; with ejection fraction by first pass technique | Standard Local Prior Authorization Code List, Pg 39 Original policy |
| 78469 | Myocardial imaging, infarct avid, planar; tomographic SPECT with or without quantification | Standard Local Prior Authorization Code List, Pg 39 Original policy |
| 78472 | Cardiac blood pool imaging, gated equilibrium; planar, single study at rest or stress (exercise and/or pharmacologic), wall motion study plus ejection fraction, with or without additional quantitative processing | Standard Local Prior Authorization Code List, Pg 39 Original policy |
| 78473 | Cardiac blood pool imaging, gated equilibrium; multiple studies, wall motion study plus ejection fraction, at rest and stress (exercise and/or pharmacologic), with or without additional quantification | Standard Local Prior Authorization Code List, Pg 39 Original policy |
| 78481 | Cardiac blood pool imaging (planar), first pass technique; single study, at rest or with stress (exercise and/or pharmacologic), wall motion study plus ejection fraction, with or without quantification | Standard Local Prior Authorization Code List, Pg 39 Original policy |
| 78483 | Cardiac blood pool imaging (planar), first pass technique; multiple studies, at rest and with stress (exercise and/or pharmacologic), wall motion study plus ejection fraction, with or without quantification | Standard Local Prior Authorization Code List, Pg 39 Original policy |
| 78491 | Myocardial imaging, positron emission tomography (PET), perfusion study (including ventricular wall motion[s] and/or ejection fraction[s], when performed); single study, at rest or stress (exercise or pharmacologic) | Standard Local Prior Authorization Code List, Pg 39 Original policy |
| 78492 | Myocardial imaging, positron emission tomography (PET), perfusion study (including ventricular wall motion[s] and/or ejection fraction[s], when performed); multiple studies at rest and stress (exercise or pharmacologic) | Standard Local Prior Authorization Code List, Pg 39 Original policy |
| 78494 | Cardiac blood pool imaging, gated equilibrium, SPECT, at rest, wall motion study plus ejection fraction, with or without quantitative processing | Standard Local Prior Authorization Code List, Pg 39 Original policy |
| 78608 | Brain imaging, positron emission tomography (PET); metabolic evaluation | Standard Local Prior Authorization Code List, Pg 39 Original policy |
| 78609 | Brain imaging, positron emission tomography (PET); perfusion evaluation | Standard Local Prior Authorization Code List, Pg 39 Original policy |
| 78811 | Positron emission tomography (PET) imaging; limited area (eg, chest, head/neck) | Standard Local Prior Authorization Code List, Pg 39 Original policy |
| 78812 | Positron emission tomography (PET) imaging; skull base to mid-thigh | Standard Local Prior Authorization Code List, Pg 39 Original policy |
| 78813 | Positron emission tomography (PET) imaging; whole body | Standard Local Prior Authorization Code List, Pg 39 Original policy |
| 78814 | Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; limited area (eg, chest, head/neck) | Standard Local Prior Authorization Code List, Pg 39 Original policy |
| 78815 | Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; skull base to mid-thigh | Standard Local Prior Authorization Code List, Pg 39 Original policy |
| 78816 | Positron emission tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; whole body | Standard Local Prior Authorization Code List, Pg 39 Original policy |
| 79101 | Radiopharmaceutical therapy, by intravenous administration | Standard Local Prior Authorization Code List, Pg 39 Original policy |
| 79403 | Radiopharmaceutical therapy, radiolabeled monoclonal antibody by intravenous infusion | Standard Local Prior Authorization Code List, Pg 39 Original policy |
| 81120 | IDH1 (isocitrate dehydrogenase 1 [NADP+], soluble) (eg, glioma), common variants (eg, R132H, R132C) | Standard Local Prior Authorization Code List, Pg 39 Original policy |
| 81121 | IDH2 (isocitrate dehydrogenase 2 [NADP+], mitochondrial) (eg, glioma), common variants (eg, R140W, R172M) | Standard Local Prior Authorization Code List, Pg 39 Original policy |
| 81161 | DMD (dystrophin) (eg, Duchenne/Becker muscular dystrophy) deletion analysis, and duplication analysis, if performed | Standard Local Prior Authorization Code List, Pg 39 Original policy |
| 81162 | BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian, Cancer) gene analysis; full sequence analysis and full duplication/deletion analysis (ie, detection of large gene rearrangements) | Standard Local Prior Authorization Code List, Pg 40 Original policy |
| 81163 | BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian, Cancer) gene analysis; full sequence analysis | Standard Local Prior Authorization Code List, Pg 40 Original policy |
| 81164 | BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian, Cancer) gene analysis; full duplication/deletion analysis (ie, detection of large gene rearrangements) | Standard Local Prior Authorization Code List, Pg 40 Original policy |
| 81165 | BRCA1 (BRCA1, DNA repair associated) (eg, hereditary breast and ovarian, Cancer) gene analysis; full sequence analysis | Standard Local Prior Authorization Code List, Pg 40 Original policy |
| 81166 | BRCA1 (BRCA1, DNA repair associated) (eg, hereditary breast and ovarian, Cancer) gene analysis; full duplication/deletion analysis (ie, detection of large gene rearrangements) | Standard Local Prior Authorization Code List, Pg 40 Original policy |
| 81167 | BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian, Cancer) gene analysis; full duplication/deletion analysis (ie, detection of large gene rearrangements) | Standard Local Prior Authorization Code List, Pg 40 Original policy |
| 81170 | ABL1 (ABL proto-oncogene 1, non-receptor tyrosine kinase) (eg, acquired imatinib tyrosine kinase inhibitor resistance), gene analysis, variants in the kinase domain | Standard Local Prior Authorization Code List, Pg 40 Original policy |
| 81171 | AFF2 (AF4/FMR2 family, member 2 [FMR2]) (eg, fragile X mental retardation 2 [FRAXE]) gene analysis; evaluation to detect abnormal (eg, expanded) alleles | Standard Local Prior Authorization Code List, Pg 40 Original policy |
| 81172 | AFF2 (AF4/FMR2 family, member 2 [FMR2]) (eg, fragile X mental retardation 2 [FRAXE]) gene analysis; characterization of alleles (eg, expanded size and methylation status) | Standard Local Prior Authorization Code List, Pg 40 Original policy |
| 81173 | AR (androgen receptor) (eg, spinal and bulbar muscular atrophy, Kennedy disease, X chromosome inactivation) gene analysis; full gene sequence | Standard Local Prior Authorization Code List, Pg 40 Original policy |
| 81174 | AR (androgen receptor) (eg, spinal and bulbar muscular atrophy, Kennedy disease, X chromosome inactivation) gene analysis; known familial variant | Standard Local Prior Authorization Code List, Pg 40 Original policy |
| 81175 | ASXL1 (additional sex combs like 1, transcriptional regulator) (eg, myelodysplastic syndrome, myeloproliferative neoplasms, chronic myelomonocytic leukemia), gene analysis; full gene sequence | Standard Local Prior Authorization Code List, Pg 40 Original policy |
| 81176 | ASXL1 (additional sex combs like 1, transcriptional regulator) (eg, myelodysplastic syndrome, myeloproliferative neoplasms, chronic myelomonocytic leukemia), gene analysis; targeted sequence analysis (eg, exon 12) | Standard Local Prior Authorization Code List, Pg 40 Original policy |
| 81177 | ATN1 (atrophin 1) (eg, dentatorubral-pallidoluysian atrophy) gene analysis, evaluation to detect abnormal (eg, expanded) alleles | Standard Local Prior Authorization Code List, Pg 40 Original policy |
| 81178 | ATXN1 (ataxin 1) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles | Standard Local Prior Authorization Code List, Pg 40 Original policy |
| 81179 | ATXN2 (ataxin 2) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles | Standard Local Prior Authorization Code List, Pg 40 Original policy |
| 81180 | ATXN3 (ataxin 3) (eg, spinocerebellar ataxia, Machado-Joseph disease) gene analysis, evaluation to detect abnormal (eg, expanded) alleles | Standard Local Prior Authorization Code List, Pg 40 Original policy |
| 81181 | ATXN7 (ataxin 7) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles | Standard Local Prior Authorization Code List, Pg 40 Original policy |
| 81182 | ATXN8OS (ATXN8 opposite strand [non-protein, Coding]) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles | Standard Local Prior Authorization Code List, Pg 40 Original policy |
| 81183 | ATXN10 (ataxin 10) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles | Standard Local Prior Authorization Code List, Pg 40 Original policy |
| 81184 | CACNA1A (calcium voltage-gated channel subunit alpha1 A) (eg, spinocerebellar ataxia) gene analysis; evaluation to detect abnormal (eg, expanded) alleles | Standard Local Prior Authorization Code List, Pg 40 Original policy |
| 81185 | CACNA1A (calcium voltage-gated channel subunit alpha1 A) (eg, spinocerebellar ataxia) gene analysis; full gene sequence | Standard Local Prior Authorization Code List, Pg 40 Original policy |
| 81186 | CACNA1A (calcium voltage-gated channel subunit alpha1 A) (eg, spinocerebellar ataxia) gene analysis; known familial variant | Standard Local Prior Authorization Code List, Pg 41 Original policy |
| 81187 | CNBP (CCHC-type zinc finger nucleic acid binding protein) (eg, myotonic dystrophy type 2) gene analysis, evaluation to detect abnormal (eg, expanded) alleles | Standard Local Prior Authorization Code List, Pg 41 Original policy |
| 81188 | CSTB (cystatin B) (eg, Unverricht-Lundborg disease) gene analysis; evaluation to detect abnormal (eg, expanded) alleles | Standard Local Prior Authorization Code List, Pg 41 Original policy |
| 81189 | CSTB (cystatin B) (eg, Unverricht-Lundborg disease) gene analysis; full gene sequence | Standard Local Prior Authorization Code List, Pg 41 Original policy |
| 81190 | CSTB (cystatin B) (eg, Unverricht-Lundborg disease) gene analysis; known familial variant(s) | Standard Local Prior Authorization Code List, Pg 41 Original policy |
| 81191 | NTRK1 (neurotrophic receptor tyrosine kinase 1) (eg, solid tumors) translocation analysis | Standard Local Prior Authorization Code List, Pg 41 Original policy |