Anthem Blue Cross Blue Shield of Georgia prior authorization, page 17
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 |
|---|---|---|
| 81192 | NTRK2 (neurotrophic receptor tyrosine kinase 2) (eg, solid tumors) translocation analysis | Standard Local Prior Authorization Code List, Pg 41 Original policy |
| 81193 | NTRK3 (neurotrophic receptor tyrosine kinase 3) (eg, solid tumors) translocation analysis | Standard Local Prior Authorization Code List, Pg 41 Original policy |
| 81194 | NTRK (neurotrophic-tropomyosin receptor tyrosine kinase 1, 2, and 3) (eg, solid tumors) translocation analysis | Standard Local Prior Authorization Code List, Pg 41 Original policy |
| 81195 | Cytogenomic analysis, optical genome mapping | Standard Local Prior Authorization Code List, Pg 41 Original policy |
| 81200 | Aspa (Aspartoacylase) (Eg, Canavan Disease) Gene Analysis, Common Variants (Eg, E285A, Y231X) | Standard Local Prior Authorization Code List, Pg 41 Original policy |
| 81201 | APC (adenomatous polyposis coli) (eg, familial adenomatosis polyposis [FAP], attenuated FAP) gene analysis; full gene sequence | Standard Local Prior Authorization Code List, Pg 41 Original policy |
| 81202 | APC (adenomatous polyposis coli) (eg, familial adenomatosis polyposis [FAP], attenuated FAP) gene analysis; known familial variants | Standard Local Prior Authorization Code List, Pg 41 Original policy |
| 81203 | APC (adenomatous polyposis coli) (eg, familial adenomatosis polyposis [FAP], attenuated FAP) gene analysis; duplication/deletion variants | Standard Local Prior Authorization Code List, Pg 41 Original policy |
| 81204 | AR (androgen receptor) (eg, spinal and bulbar muscular atrophy, Kennedy disease, X chromosome inactivation) gene analysis; characterization of alleles (eg, expanded size or methylation status) | Standard Local Prior Authorization Code List, Pg 41 Original policy |
| 81205 | BCKDHB (branched-chain keto acid dehydrogenase E1, beta polypeptide) (eg, maple syrup urine disease) gene analysis, common variants (eg, R183P, G278S, E422X) | Standard Local Prior Authorization Code List, Pg 41 Original policy |
| 81206 | BCR/ABL1 (t(9;22)) (eg, chronic myelogenous leukemia) translocation analysis; major breakpoint, qualitative or quantitative | Standard Local Prior Authorization Code List, Pg 41 Original policy |
| 81207 | BCR/ABL1 (t(9;22)) (eg, chronic myelogenous leukemia) translocation analysis; minor breakpoint, qualitative or quantitative | Standard Local Prior Authorization Code List, Pg 41 Original policy |
| 81208 | BCR/ABL1 (t(9;22)) (eg, chronic myelogenous leukemia) translocation analysis; other breakpoint, qualitative or quantitative | Standard Local Prior Authorization Code List, Pg 41 Original policy |
| 81209 | BLM (Bloom syndrome, RecQ helicase-like) (eg, Bloom syndrome) gene analysis, 2281del6ins7 variant | Standard Local Prior Authorization Code List, Pg 41 Original policy |
| 81210 | BRAF (B-Raf proto-oncogene, serine/threonine kinase) (eg, colon cancer, melanoma), gene analysis, V600 variant(s) | Standard Local Prior Authorization Code List, Pg 41 Original policy |
| 81212 | BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; 185delAG, 5385insC, 6174delT variants | Standard Local Prior Authorization Code List, Pg 41 Original policy |
| 81215 | BRCA1 (BRCA1, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; known familial variant | Standard Local Prior Authorization Code List, Pg 41 Original policy |
| 81216 | BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis | Standard Local Prior Authorization Code List, Pg 41 Original policy |
| 81217 | BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; known familial variant | Standard Local Prior Authorization Code List, Pg 41 Original policy |
| 81218 | CEBPA (CCAAT/enhancer binding protein [C/EBP], alpha) (eg, acute myeloid leukemia), gene analysis, full gene sequence | Standard Local Prior Authorization Code List, Pg 42 Original policy |
| 81219 | CALR (calreticulin) (eg, myeloproliferative disorders), gene analysis, common variants in exon 9 | Standard Local Prior Authorization Code List, Pg 42 Original policy |
| 81220 | CFTR (cystic fibrosis transmembrane conductance regulator) (eg, cystic fibrosis) gene analysis; common variants (eg, ACMG/ACOG guidelines) | Standard Local Prior Authorization Code List, Pg 42 Original policy |
| 81221 | CFTR (cystic fibrosis transmembrane conductance regulator) (eg, cystic fibrosis) gene analysis; known familial variants | Standard Local Prior Authorization Code List, Pg 42 Original policy |
| 81222 | CFTR (cystic fibrosis transmembrane conductance regulator) (eg, cystic fibrosis) gene analysis; duplication/deletion variants | Standard Local Prior Authorization Code List, Pg 42 Original policy |
| 81223 | CFTR (cystic fibrosis transmembrane conductance regulator) (eg, cystic fibrosis) gene analysis; full gene sequence | Standard Local Prior Authorization Code List, Pg 42 Original policy |
| 81224 | CFTR (cystic fibrosis transmembrane conductance regulator) (eg, cystic fibrosis) gene analysis; intron 8 poly-T analysis (eg, male infertility) | Standard Local Prior Authorization Code List, Pg 42 Original policy |
| 81225 | CYP2C19 (cytochrome P450, family 2, subfamily C, polypeptide 19) (eg, drug metabolism), gene analysis, common variants (eg, *2, *3, *4, *8, *17) | Standard Local Prior Authorization Code List, Pg 42 Original policy |
| 81226 | CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism), gene analysis, common variants (eg, *2, *3, *4, *5, *6, *9, *10, *17, *19, *29, *35, *41, *1XN, *2XN, *4XN) | Standard Local Prior Authorization Code List, Pg 42 Original policy |
| 81227 | CYP2C9 (cytochrome P450, family 2, subfamily C, polypeptide 9) (eg, drug metabolism), gene analysis, common variants (eg, *2, *3, *5, *6) | Standard Local Prior Authorization Code List, Pg 42 Original policy |
| 81228 | Cytogenomic (genome-wide) analysis for constitutional chromosomal abnormalities; interrogation of genomic regions for copy number variants, comparative genomic hybridization [CGH] microarray analysis | Standard Local Prior Authorization Code List, Pg 42 Original policy |
| 81229 | Cytogenomic (genome-wide) analysis for constitutional chromosomal abnormalities; interrogation of genomic regions for copy number and single nucleotide polymorphism (SNP) variants, comparative genomic hybridization (CGH) microarray analysis | Standard Local Prior Authorization Code List, Pg 42 Original policy |
| 81230 | CYP3A4 (cytochrome P450 family 3 subfamily A member 4) (eg, drug metabolism), gene analysis, common variant(s) (eg, *2, *22) | Standard Local Prior Authorization Code List, Pg 42 Original policy |
| 81231 | CYP3A5 (cytochrome P450 family 3 subfamily A member 5) (eg, drug metabolism), gene analysis, common variants (eg, *2, *3, *4, *5, *6, *7) | Standard Local Prior Authorization Code List, Pg 42 Original policy |
| 81232 | DPYD (dihydropyrimidine dehydrogenase) (eg, 5- fluorouracil/5-FU and capecitabine drug metabolism), gene analysis, common variant(s) (eg, *2A, *4, *5, *6) | Standard Local Prior Authorization Code List, Pg 42 Original policy |
| 81233 | BTK (Bruton's tyrosine kinase) (eg, chronic lymphocytic leukemia) gene analysis, common variants (eg, C481S, C481R, C481F) | Standard Local Prior Authorization Code List, Pg 42 Original policy |
| 81234 | DMPK (DM1 protein kinase) (eg, myotonic dystrophy type 1) gene analysis; evaluation to detect abnormal (expanded) alleles | Standard Local Prior Authorization Code List, Pg 42 Original policy |
| 81235 | EGFR (epidermal growth factor receptor) (eg, non- small cell lung cancer) gene analysis, common variants (eg, exon 19 LREA deletion, L858R, T790M, G719A, G719S, L861Q) | Standard Local Prior Authorization Code List, Pg 42 Original policy |
| 81236 | EZH2 (enhancer of zeste 2 polycomb repressive complex 2 subunit) (eg, myelodysplastic syndrome, myeloproliferative neoplasms) gene analysis, full gene sequence | Standard Local Prior Authorization Code List, Pg 42 Original policy |
| 81237 | EZH2 (enhancer of zeste 2 polycomb repressive complex 2 subunit) (eg, diffuse large B-cell lymphoma) gene analysis, common variant(s) (eg, codon 646) | Standard Local Prior Authorization Code List, Pg 42 Original policy |
| 81239 | DMPK (DM1 protein kinase) (eg, myotonic dystrophy type 1) gene analysis; characterization of alleles (eg, expanded size) | Standard Local Prior Authorization Code List, Pg 42 Original policy |
| 81240 | F2 (prothrombin, coagulation factor II) (eg, hereditary hypercoagulability) gene analysis, 20210G>A variant | Standard Local Prior Authorization Code List, Pg 42 Original policy |
| 81241 | F5 (coagulation factor V) (eg, hereditary hypercoagulability) gene analysis, Leiden variant | Standard Local Prior Authorization Code List, Pg 43 Original policy |
| 81242 | FANCC (Fanconi anemia, complementation group C) (eg, Fanconi anemia, type C) gene analysis, common variant (eg, IVS4+4A>T) | Standard Local Prior Authorization Code List, Pg 43 Original policy |
| 81243 | FMR1 (fragile X messenger ribonucleoprotein 1) (eg, fragile X syndrome, X-linked intellectual disability [XLID]) gene analysis; evaluation to detect abnormal (eg, expanded) alleles | Standard Local Prior Authorization Code List, Pg 43 Original policy |
| 81244 | FMR1 (fragile X messenger ribonucleoprotein 1) (eg, fragile X syndrome, X-linked intellectual disability [XLID]) gene analysis; characterization of alleles (eg, expanded size and promoter methylation status) | Standard Local Prior Authorization Code List, Pg 43 Original policy |
| 81245 | FLT3 (fms-related tyrosine kinase 3) (eg, acute myeloid leukemia), gene analysis; internal tandem duplication (ITD) variants (ie, exons 14, 15) | Standard Local Prior Authorization Code List, Pg 43 Original policy |
| 81246 | FLT3 (fms-related tyrosine kinase 3) (eg, acute myeloid leukemia), gene analysis; tyrosine kinase domain (TKD) variants (eg, D835, I836) | Standard Local Prior Authorization Code List, Pg 43 Original policy |
| 81247 | G6PD (glucose-6-phosphate dehydrogenase) (eg, hemolytic anemia, jaundice), gene analysis; common variant(s) (eg, A, A-) | Standard Local Prior Authorization Code List, Pg 43 Original policy |
| 81248 | G6PD (glucose-6-phosphate dehydrogenase) (eg, hemolytic anemia, jaundice), gene analysis; known familial variant(s) | Standard Local Prior Authorization Code List, Pg 43 Original policy |
| 81249 | G6PD (glucose-6-phosphate dehydrogenase) (eg, hemolytic anemia, jaundice), gene analysis; full gene sequence | Standard Local Prior Authorization Code List, Pg 43 Original policy |