Anthem Blue Cross Blue Shield of Georgia prior authorization, page 18
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 |
|---|---|---|
| 81250 | G6PC (glucose-6-phosphatase, catalytic subunit) (eg, Glycogen storage disease, type 1a, von Gierke disease) gene analysis, common variants (eg, R83C, Q347X) | Standard Local Prior Authorization Code List, Pg 43 Original policy |
| 81251 | GBA (glucosidase, beta, acid) (eg, Gaucher disease) gene analysis, common variants (eg, N370S, 84GG, L444P, IVS2+1G>A) | Standard Local Prior Authorization Code List, Pg 43 Original policy |
| 81252 | GJB2 (gap junction protein, beta 2, 26kDa, connexin 26) (eg, nonsyndromic hearing loss) gene analysis; full gene sequence | Standard Local Prior Authorization Code List, Pg 43 Original policy |
| 81253 | GJB2 (gap junction protein, beta 2, 26kDa; connexin 26) (eg, nonsyndromic hearing loss) gene analysis; known familial variants | Standard Local Prior Authorization Code List, Pg 43 Original policy |
| 81254 | GJB6 (gap junction protein, beta 6, 30kDa, connexin 30) (eg, nonsyndromic hearing loss) gene analysis, common variants (eg, 309kb [del(GJB6- D13S1830)] and 232kb [del(GJB6-D13S1854)]) | Standard Local Prior Authorization Code List, Pg 43 Original policy |
| 81255 | HEXA (hexosaminidase A [alpha polypeptide]) (eg, Tay-Sachs disease) gene analysis, common variants (eg, 1278insTATC, 1421+1G>C, G269S) | Standard Local Prior Authorization Code List, Pg 43 Original policy |
| 81256 | HFE (hemochromatosis) (eg, hereditary hemochromatosis) gene analysis, common variants (eg, C282Y, H63D) | Standard Local Prior Authorization Code List, Pg 43 Original policy |
| 81257 | HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia, Hb Bart hydrops fetalis syndrome, HbH disease), gene analysis; common deletions or variant (eg, Southeast Asian, Thai, Filipino, Mediterranean, alpha3.7, alpha4.2, alpha20.5, Constant Spring) | Standard Local Prior Authorization Code List, Pg 43 Original policy |
| 81258 | HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia, Hb Bart hydrops fetalis syndrome, HbH disease), gene analysis; known familial variant | Standard Local Prior Authorization Code List, Pg 43 Original policy |
| 81259 | HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia, Hb Bart hydrops fetalis syndrome, HbH disease), gene analysis; full gene sequence | Standard Local Prior Authorization Code List, Pg 43 Original policy |
| 81260 | IKBKAP (inhibitor of kappa light polypeptide gene enhancer in B-cells, kinase, Complex-associated protein) (eg, familial dysautonomia) gene analysis, common variants (eg, 2507+6T>C, R696P) | Standard Local Prior Authorization Code List, Pg 43 Original policy |
| 81261 | IGH@ (Immunoglobulin heavy chain locus) (eg, leukemias and lymphomas, B-cell), gene rearrangement analysis to detect abnormal clonal population(s); amplified methodology (eg, polymerase chain reaction) | Standard Local Prior Authorization Code List, Pg 44 Original policy |
| 81262 | IGH@ (Immunoglobulin heavy chain locus) (eg, leukemias and lymphomas, B-cell), gene rearrangement analysis to detect abnormal clonal population(s); direct probe methodology (eg, Southern blot) | Standard Local Prior Authorization Code List, Pg 44 Original policy |
| 81263 | IGH@ (Immunoglobulin heavy chain locus) (eg, leukemia and lymphoma, B-cell), variable region somatic mutation analysis | Standard Local Prior Authorization Code List, Pg 44 Original policy |
| 81264 | IGK@ (Immunoglobulin kappa light chain locus) (eg, leukemia and lymphoma, B-cell), gene rearrangement analysis, evaluation to detect abnormal clonal population(s) | Standard Local Prior Authorization Code List, Pg 44 Original policy |
| 81265 | Comparative analysis using Short Tandem Repeat (STR) markers; patient and comparative specimen (eg, pre-transplant recipient and donor germline testing, post-transplant non-hematopoietic recipient germline [eg, buccal swab or other germline tissue sample] and donor testing, twin zygosity testing, or maternal cell contamination of fetal cells) | Standard Local Prior Authorization Code List, Pg 44 Original policy |
| 81266 | Comparative Analysis Using Short Tandem Repeat (Str) Markers; Each Additional Specimen (Eg, Additional Cord Blood Donor, Additional Fetal Samples From Different Cultures, Or A | Standard Local Prior Authorization Code List, Pg 44 Original policy |
| 81269 | HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia, Hb Bart hydrops fetalis syndrome, HbH disease), gene analysis; duplication/deletion variants | Standard Local Prior Authorization Code List, Pg 44 Original policy |
| 81270 | JAK2 (Janus kinase 2) (eg, myeloproliferative disorder) gene analysis, p.Val617Phe (V617F) variant | Standard Local Prior Authorization Code List, Pg 44 Original policy |
| 81271 | HTT (huntingtin) (eg, Huntington disease) gene analysis; evaluation to detect abnormal (eg, expanded) alleles | Standard Local Prior Authorization Code List, Pg 44 Original policy |
| 81272 | KIT (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog) (eg, gastrointestinal stromal tumor [GIST], acute myeloid leukemia, melanoma), gene analysis, targeted sequence analysis (eg, exons 8, 11, 13, 17, 18) | Standard Local Prior Authorization Code List, Pg 44 Original policy |
| 81273 | KIT (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog) (eg, mastocytosis), gene analysis, D816 variant(s) | Standard Local Prior Authorization Code List, Pg 44 Original policy |
| 81274 | HTT (huntingtin) (eg, Huntington disease) gene analysis; characterization of alleles (eg, expanded size) | Standard Local Prior Authorization Code List, Pg 44 Original policy |
| 81275 | Kras (V-Ki-Ras2 Kirsten Rat Sarcoma Viral Oncogene) (Eg, Carcinoma) Gene Analysis, Variants In, Codons 12 And 13 | Standard Local Prior Authorization Code List, Pg 44 Original policy |
| 81276 | KRAS (Kirsten rat sarcoma viral oncogene homolog) (eg, carcinoma) gene analysis; additional variant(s) (eg, codon 61, codon 146) | Standard Local Prior Authorization Code List, Pg 44 Original policy |
| 81277 | Cytogenomic neoplasia (genome-wide) microarray analysis, interrogation of genomic regions for copy number and loss-of-heterozygosity variants for chromosomal abnormalities | Standard Local Prior Authorization Code List, Pg 44 Original policy |
| 81278 | IGH@/BCL2 (t(14;18)) (eg, follicular lymphoma) translocation analysis, major breakpoint region (MBR) and minor cluster region (mcr) breakpoints, qualitative or quantitative | Standard Local Prior Authorization Code List, Pg 44 Original policy |
| 81279 | JAK2 (Janus kinase 2) (eg, myeloproliferative disorder) targeted sequence analysis (eg, exons 12 and 13) | Standard Local Prior Authorization Code List, Pg 44 Original policy |
| 81283 | IFNL3 (interferon, lambda 3) (eg, drug response), gene analysis, rs12979860 variant | Standard Local Prior Authorization Code List, Pg 44 Original policy |
| 81284 | FXN (frataxin) (eg, Friedreich ataxia) gene analysis; evaluation to detect abnormal (expanded) alleles | Standard Local Prior Authorization Code List, Pg 44 Original policy |
| 81285 | FXN (frataxin) (eg, Friedreich ataxia) gene analysis; characterization of alleles (eg, expanded size) | Standard Local Prior Authorization Code List, Pg 44 Original policy |
| 81286 | FXN (frataxin) (eg, Friedreich ataxia) gene analysis; full gene sequence | Standard Local Prior Authorization Code List, Pg 44 Original policy |
| 81287 | MGMT (O-6-methylguanine-DNA methyltransferase) (eg, glioblastoma multiforme) promoter methylation analysis | Standard Local Prior Authorization Code List, Pg 44 Original policy |
| 81288 | MLH1 (mutL homolog 1, colon, Cancer, nonpolyposis type 2) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; promoter methylation analysis | Standard Local Prior Authorization Code List, Pg 45 Original policy |
| 81289 | FXN (frataxin) (eg, Friedreich ataxia) gene analysis; known familial variant(s) | Standard Local Prior Authorization Code List, Pg 45 Original policy |
| 81290 | MCOLN1 (mucolipin 1) (eg, Mucolipidosis, type IV) gene analysis, common variants (eg, IVS3-2A>G, del6.4kb) | Standard Local Prior Authorization Code List, Pg 45 Original policy |
| 81291 | MTHFR (5,10-methylenetetrahydrofolate reductase) (eg, hereditary hypercoagulability) gene analysis, common variants (eg, 677T, 1298C) | Standard Local Prior Authorization Code List, Pg 45 Original policy |
| 81292 | MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; full sequence analysis | Standard Local Prior Authorization Code List, Pg 45 Original policy |
| 81293 | MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; known familial variants | Standard Local Prior Authorization Code List, Pg 45 Original policy |
| 81294 | MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; duplication/deletion variants | Standard Local Prior Authorization Code List, Pg 45 Original policy |
| 81295 | MSH2 (mutS homolog 2, colon cancer, nonpolyposis type 1) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; full sequence analysis | Standard Local Prior Authorization Code List, Pg 45 Original policy |
| 81296 | MSH2 (mutS homolog 2, colon cancer, nonpolyposis type 1) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; known familial variants | Standard Local Prior Authorization Code List, Pg 45 Original policy |
| 81297 | MSH2 (mutS homolog 2, colon cancer, nonpolyposis type 1) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; duplication/deletion variants | Standard Local Prior Authorization Code List, Pg 45 Original policy |
| 81298 | MSH6 (mutS homolog 6 [E. coli]) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; full sequence analysis | Standard Local Prior Authorization Code List, Pg 45 Original policy |
| 81299 | MSH6 (mutS homolog 6 [E. coli]) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; known familial variants | Standard Local Prior Authorization Code List, Pg 45 Original policy |
| 81300 | MSH6 (mutS homolog 6 [E. coli]) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; duplication/deletion variants | Standard Local Prior Authorization Code List, Pg 45 Original policy |
| 81301 | Microsatellite instability analysis (eg, hereditary non- polyposis colorectal cancer, Lynch syndrome) of markers for mismatch repair deficiency (eg, BAT25, BAT26), includes comparison of neoplastic and normal tissue, if performed | Standard Local Prior Authorization Code List, Pg 45 Original policy |
| 81302 | MECP2 (methyl CpG binding protein 2) (eg, Rett syndrome) gene analysis; full sequence analysis | Standard Local Prior Authorization Code List, Pg 45 Original policy |
| 81303 | MECP2 (methyl CpG binding protein 2) (eg, Rett syndrome) gene analysis; known familial variant | Standard Local Prior Authorization Code List, Pg 45 Original policy |
| 81304 | MECP2 (methyl CpG binding protein 2) (eg, Rett syndrome) gene analysis; duplication/deletion variants | Standard Local Prior Authorization Code List, Pg 45 Original policy |