Anthem Blue Cross Blue Shield of Georgia prior authorization, page 19
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 |
|---|---|---|
| 81305 | MYD88 (myeloid differentiation primary response 88) (eg, Waldenstrom's macroglobulinemia, lymphoplasmacytic leukemia) gene analysis, p.Leu265Pro (L265P) variant | Standard Local Prior Authorization Code List, Pg 45 Original policy |
| 81306 | NUDT15 (nudix hydrolase 15) (eg, drug metabolism) gene analysis, common variant(s) (eg, *2, *3, *4, *5, *6) | Standard Local Prior Authorization Code List, Pg 45 Original policy |
| 81307 | PALB2 (partner and localizer of BRCA2) (eg, breast and pancreatic cancer) gene analysis; full gene sequence | Standard Local Prior Authorization Code List, Pg 45 Original policy |
| 81308 | PALB2 (partner and localizer of BRCA2) (eg, breast and pancreatic cancer) gene analysis; known familial variant | Standard Local Prior Authorization Code List, Pg 45 Original policy |
| 81309 | PIK3CA (phosphatidylinositol-4, 5-biphosphate 3- kinase, catalytic subunit alpha) (eg, colorectal and breast cancer) gene analysis, targeted sequence analysis (eg, exons 7, 9 | Standard Local Prior Authorization Code List, Pg 45 Original policy |
| 81310 | NPM1 (nucleophosmin) (eg, acute myeloid leukemia) gene analysis, exon 12 variants | Standard Local Prior Authorization Code List, Pg 46 Original policy |
| 81311 | NRAS (neuroblastoma RAS viral [v-ras] oncogene homolog) (eg, colorectal carcinoma), gene analysis, variants in exon 2 (eg, codons 12 and 13) and exon 3 (eg, codon 61) | Standard Local Prior Authorization Code List, Pg 46 Original policy |
| 81312 | PABPN1 (poly[A] binding protein nuclear 1) (eg, oculopharyngeal muscular dystrophy) gene analysis, evaluation to detect abnormal (eg, expanded) alleles | Standard Local Prior Authorization Code List, Pg 46 Original policy |
| 81313 | PCA3/KLK3 (prostate, Cancer antigen 3 [non- protein, Coding]/kallikrein-related peptidase 3 [prostate specific antigen]) ratio (eg, prostate, Cancer) | Standard Local Prior Authorization Code List, Pg 46 Original policy |
| 81314 | PDGFRA (platelet-derived growth factor receptor, alpha polypeptide) (eg, gastrointestinal stromal tumor [GIST]), gene analysis, targeted sequence analysis (eg, exons 12, 18) | Standard Local Prior Authorization Code List, Pg 46 Original policy |
| 81315 | PML/RARalpha, (t(15;17)), (promyelocytic leukemia/retinoic acid receptor alpha) (eg, promyelocytic leukemia) translocation analysis; common breakpoints (eg, intron 3 and intron 6), qualitative or quantitative | Standard Local Prior Authorization Code List, Pg 46 Original policy |
| 81316 | PML/RARalpha, (t(15;17)), (promyelocytic leukemia/retinoic acid receptor alpha) (eg, promyelocytic leukemia) translocation analysis; single breakpoint (eg, intron 3, intron 6 or exon 6), qualitative or quantitative | Standard Local Prior Authorization Code List, Pg 46 Original policy |
| 81317 | PMS2 (postmeiotic segregation increased 2 [S. cerevisiae]) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; full sequence analysis | Standard Local Prior Authorization Code List, Pg 46 Original policy |
| 81318 | PMS2 (postmeiotic segregation increased 2 [S. cerevisiae]) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; known familial variants | Standard Local Prior Authorization Code List, Pg 46 Original policy |
| 81319 | PMS2 (postmeiotic segregation increased 2 [S. cerevisiae]) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; duplication/deletion variants | Standard Local Prior Authorization Code List, Pg 46 Original policy |
| 81320 | PLCG2 (phospholipase C gamma 2) (eg, chronic lymphocytic leukemia) gene analysis, common variants (eg, R665W, S707F, L845F) | Standard Local Prior Authorization Code List, Pg 46 Original policy |
| 81321 | PTEN (phosphatase and tensin homolog) (eg, Cowden, Syndrome, PTEN hamartoma tumor syndrome) gene analysis; full sequence analysis | Standard Local Prior Authorization Code List, Pg 46 Original policy |
| 81322 | PTEN (phosphatase and tensin homolog) (eg, Cowden, Syndrome, PTEN hamartoma tumor syndrome) gene analysis; known familial variant | Standard Local Prior Authorization Code List, Pg 46 Original policy |
| 81323 | PTEN (phosphatase and tensin homolog) (eg, Cowden, Syndrome, PTEN hamartoma tumor syndrome) gene analysis; duplication/deletion variant | Standard Local Prior Authorization Code List, Pg 46 Original policy |
| 81324 | PMP22 (peripheral myelin protein 22) (eg, Charcot- Marie-Tooth, hereditary neuropathy with liability to pressure palsies) gene analysis; duplication/deletion analysis | Standard Local Prior Authorization Code List, Pg 46 Original policy |
| 81325 | PMP22 (peripheral myelin protein 22) (eg, Charcot- Marie-Tooth, hereditary neuropathy with liability to pressure palsies) gene analysis; full sequence analysis | Standard Local Prior Authorization Code List, Pg 46 Original policy |
| 81326 | PMP22 (peripheral myelin protein 22) (eg, Charcot- Marie-Tooth, hereditary neuropathy with liability to pressure palsies) gene analysis; known familial variant | Standard Local Prior Authorization Code List, Pg 46 Original policy |
| 81327 | SEPT9 (Septin9) (eg, colorectal cancer) promoter methylation analysis | Standard Local Prior Authorization Code List, Pg 46 Original policy |
| 81328 | SLCO1B1 (solute, Carrier organic anion transporter family, member 1B1) (eg, adverse drug reaction), gene analysis, common variant(s) (eg, *5) | Standard Local Prior Authorization Code List, Pg 46 Original policy |
| 81329 | SMN1 (survival of motor neuron 1, telomeric) (eg, spinal muscular atrophy) gene analysis; dosage/deletion analysis (eg, carrier testing), includes SMN2 (survival of motor neuron 2, centromeric) analysis, if performed | Standard Local Prior Authorization Code List, Pg 46 Original policy |
| 81330 | SMPD1(sphingomyelin phosphodiesterase 1, acid lysosomal) (eg, Niemann-Pick disease, Type A) gene analysis, common variants (eg, R496L, L302P, fsP330) | Standard Local Prior Authorization Code List, Pg 46 Original policy |
| 81331 | SNRPN/UBE3A (small nuclear ribonucleoprotein polypeptide N and ubiquitin protein ligase E3A) (eg, Prader-Willi syndrome and/or Angelman syndrome), methylation analysis | Standard Local Prior Authorization Code List, Pg 46 Original policy |
| 81332 | SERPINA1 (serpin peptidase inhibitor, clade A, alpha-1 antiproteinase, antitrypsin, member 1) (eg, alpha-1-antitrypsin deficiency), gene analysis, common variants (eg, *S and *Z) | Standard Local Prior Authorization Code List, Pg 47 Original policy |
| 81333 | TGFBI (transforming, Growth factor beta-induced) (eg, corneal dystrophy) gene analysis, common variants (eg, R124H, R124C, R124L, R555W, R555Q) | Standard Local Prior Authorization Code List, Pg 47 Original policy |
| 81334 | RUNX1 (runt related transcription factor 1) (eg, acute myeloid leukemia, familial platelet disorder with associated myeloid malignancy), gene analysis, targeted sequence analysis (eg, exons 3- 8) | Standard Local Prior Authorization Code List, Pg 47 Original policy |
| 81335 | TPMT (thiopurine S-methyltransferase) (eg, drug metabolism), gene analysis, common variants (eg, *2, *3) | Standard Local Prior Authorization Code List, Pg 47 Original policy |
| 81336 | SMN1 (survival of motor neuron 1, telomeric) (eg, spinal muscular atrophy) gene analysis; full gene sequence | Standard Local Prior Authorization Code List, Pg 47 Original policy |
| 81337 | SMN1 (survival of motor neuron 1, telomeric) (eg, spinal muscular atrophy) gene analysis; known familial sequence variant(s) | Standard Local Prior Authorization Code List, Pg 47 Original policy |
| 81338 | MPL (MPL proto-oncogene, thrombopoietin receptor) (eg, myeloproliferative disorder) gene analysis; common variants (eg, W515A, W515K, W515L, W515R) | Standard Local Prior Authorization Code List, Pg 47 Original policy |
| 81339 | MPL (MPL proto-oncogene, thrombopoietin receptor) (eg, myeloproliferative disorder) gene analysis; sequence analysis, exon 10 | Standard Local Prior Authorization Code List, Pg 47 Original policy |
| 81340 | TRB@ (T cell antigen receptor, beta) (eg, leukemia and lymphoma), gene rearrangement analysis to detect abnormal clonal population(s); using amplification methodology (eg, polymerase chain reaction) | Standard Local Prior Authorization Code List, Pg 47 Original policy |
| 81341 | TRB@ (T cell antigen receptor, beta) (eg, leukemia and lymphoma), gene rearrangement analysis to detect abnormal clonal population(s); using direct probe methodology (eg, Southern blot) | Standard Local Prior Authorization Code List, Pg 47 Original policy |
| 81342 | TRG@ (T cell antigen receptor, gamma) (eg, leukemia and lymphoma), gene rearrangement analysis, evaluation to detect abnormal clonal population(s) | Standard Local Prior Authorization Code List, Pg 47 Original policy |
| 81343 | PPP2R2B (protein phosphatase 2 regulatory subunit Bbeta) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles | Standard Local Prior Authorization Code List, Pg 47 Original policy |
| 81344 | TBP (TATA box binding protein) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles | Standard Local Prior Authorization Code List, Pg 47 Original policy |
| 81345 | TERT (telomerase reverse transcriptase) (eg, thyroid carcinoma, glioblastoma multiforme) gene analysis, targeted sequence analysis (eg, promoter region) | Standard Local Prior Authorization Code List, Pg 47 Original policy |
| 81346 | TYMS (thymidylate synthetase) (eg, 5-fluorouracil/5- FU drug metabolism), gene analysis, common variant(s) (eg, tandem repeat variant) | Standard Local Prior Authorization Code List, Pg 47 Original policy |
| 81347 | SF3B1 (splicing factor [3b] subunit B1) (eg, myelodysplastic syndrome/acute myeloid leukemia) gene analysis, common variants (eg, A672T, E622D, L833F, R625C, R625L) | Standard Local Prior Authorization Code List, Pg 47 Original policy |
| 81348 | SRSF2 (serine and arginine-rich splicing factor 2) (eg, myelodysplastic syndrome, acute myeloid leukemia) gene analysis, common variants (eg, P95H, P95L) | Standard Local Prior Authorization Code List, Pg 47 Original policy |
| 81349 | Cytogenomic (genome-wide) analysis for constitutional chromosomal abnormalities; interrogation of genomic regions for copy number and loss-of-heterozygosity variants, low-pass | Standard Local Prior Authorization Code List, Pg 47 Original policy |
| 81350 | UGT1A1 (UDP glucuronosyltransferase 1 family, polypeptide A1) (eg, drug metabolism, hereditary unconjugated hyperbilirubinemia [Gilbert syndrome]) gene analysis, common variants (eg, *28, *36, *37) | Standard Local Prior Authorization Code List, Pg 47 Original policy |
| 81351 | TP53 (tumor protein 53) (eg, Li-Fraumeni syndrome) gene analysis; full gene sequence | Standard Local Prior Authorization Code List, Pg 47 Original policy |
| 81352 | TP53 (tumor protein 53) (eg, Li-Fraumeni syndrome) gene analysis; targeted sequence analysis (eg, 4 oncology) | Standard Local Prior Authorization Code List, Pg 47 Original policy |
| 81353 | TP53 (tumor protein 53) (eg, Li-Fraumeni syndrome) gene analysis; known familial variant | Standard Local Prior Authorization Code List, Pg 47 Original policy |
| 81354 | Cytogenomic (genome-wide) analysis for constitutional chromosomal abnormalities; interrogation of structural and copy number variants, optical genome mapping (OGM) | Standard Local Prior Authorization Code List, Pg 48 Original policy |