Anthem Blue Cross Blue Shield of Georgia prior authorization, page 21
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 |
|---|---|---|
| 81458 | Solid organ neoplasm, genomic sequence analysis panel, interrogation for sequence variants; DNA analysis, copy number variants and microsatellite instability | Standard Local Prior Authorization Code List, Pg 51 Original policy |
| 81459 | Solid organ neoplasm, genomic sequence analysis panel, interrogation for sequence variants; DNA analysis or combined DNA and RNA analysis, copy number variants, microsatellite | Standard Local Prior Authorization Code List, Pg 51 Original policy |
| 81460 | Whole mitochondrial genome (eg, Leigh syndrome, mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes [MELAS], myoclonic epilepsy with ragged-red fibers [MERFF], neuropathy, ataxia, and retinitis pigmentosa [NARP], Leber hereditary optic neuropathy [LHON]), genomic sequence, must include sequence analysis of entire mitochondrial genome with heteroplasmy detection | Standard Local Prior Authorization Code List, Pg 51 Original policy |
| 81462 | Solid organ neoplasm, genomic sequence analysis panel, cell-free nucleic acid (eg, plasma), interrogation for sequence variants; DNA analysis or combined DNA and RNA analysis, copy number variants and rearrangements | Standard Local Prior Authorization Code List, Pg 51 Original policy |
| 81463 | Solid organ neoplasm, genomic sequence analysis panel, cell-free nucleic acid (eg, plasma), interrogation for sequence variants; DNA analysis, copy number variants, and microsatellite instability | Standard Local Prior Authorization Code List, Pg 51 Original policy |
| 81464 | Solid organ neoplasm, genomic sequence analysis panel, cell-free nucleic acid (eg, plasma), interrogation for sequence variants; DNA analysis or combined DNA and RNA analysis, copy number variants, microsatellite instability, tumor mutation burden, and rearrangements | Standard Local Prior Authorization Code List, Pg 52 Original policy |
| 81465 | Whole mitochondrial genome large deletion analysis panel (eg, Kearns-Sayre syndrome, chronic progressive external ophthalmoplegia), including heteroplasmy detection, if performed | Standard Local Prior Authorization Code List, Pg 52 Original policy |
| 81470 | X-linked intellectual disability (XLID) (eg, syndromic and non-syndromic XLID); genomic sequence analysis panel, must include sequencing of at least 60 genes, including ARX, ATRX, CDKL5, FGD1, FMR1, HUWE1, IL1RAPL, KDM5C, L1CAM, MECP2, MED12, MID1, OCRL, RPS6KA3, and SLC16A2 | Standard Local Prior Authorization Code List, Pg 52 Original policy |
| 81471 | X-linked intellectual disability (XLID) (eg, syndromic and non-syndromic XLID); duplication/deletion gene analysis, must include analysis of at least 60 genes, including ARX, ATRX, CDKL5, FGD1, FMR1, HUWE1, IL1RAPL, KDM5C, L1CAM, MECP2, MED12, MID1, OCRL, RPS6KA3, and SLC16A2 | Standard Local Prior Authorization Code List, Pg 52 Original policy |
| 81479 | Unlisted molecular pathology procedure | Standard Local Prior Authorization Code List, Pg 52 Original policy |
| 81493 | Coronary artery disease, mRNA, gene expression profiling by real-time RT-PCR of 23 genes, utilizing whole peripheral blood, algorithm reported as a risk score | Standard Local Prior Authorization Code List, Pg 52 Original policy |
| 81504 | Oncology (tissue of origin), microarray gene expression profiling of• 2000 genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as tissue similarity scores | Standard Local Prior Authorization Code List, Pg 52 Original policy |
| 81518 | Oncology (breast), mRNA, gene expression profiling by real-time RT-PCR of 11 genes (7 content and 4 housekeeping), utilizing formalin- fixed paraffin-embedded tissue, algorithms reported as percentage risk for metastatic recurrence and likelihood of benefit from extended endocrine therapy | Standard Local Prior Authorization Code List, Pg 52 Original policy |
| 81519 | Oncology (breast), mRNA, gene expression profiling by real-time RT-PCR of 21 genes, utilizing formalin-fixed paraffin embedded tissue, algorithm reported as recurrence score | Standard Local Prior Authorization Code List, Pg 52 Original policy |
| 81520 | Oncology (breast), mRNA gene expression profiling by hybrid capture of 58 genes (50 content and 8 housekeeping), utilizing formalin-fixed paraffin- embedded tissue, algorithm reported as a recurrence risk score | Standard Local Prior Authorization Code List, Pg 52 Original policy |
| 81521 | Oncology (breast), mRNA, microarray gene expression profiling of 70 content genes and 465 housekeeping, Genes, utilizing fresh frozen or formalin-fixed paraffin-embedded tissue, algorithm reported as index related to risk of distant metastasis | Standard Local Prior Authorization Code List, Pg 52 Original policy |
| 81522 | Oncology (breast), mRNA, gene expression profiling by RT-PCR of 12 genes (8 content and 4 housekeeping), utilizing formalin-fixed paraffin- embedded tissue, algorithm reported | Standard Local Prior Authorization Code List, Pg 52 Original policy |
| 81523 | Oncology (breast), mRNA, next-generation sequencing gene expression profiling of 70 content genes and 31 housekeeping genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as index related to risk to distant metastasis | Standard Local Prior Authorization Code List, Pg 52 Original policy |
| 81524 | Oncology (central nervous system tumor), DNA methylation analysis of at least 10,000 methylation sites, utilizing DNA extracted from formalin-fixed tumor tissue, algorithm(s) reported as probability of matching a reference tumor family and class, and MGMT (O-6-methylguanine-DNA methyltransferase) promoter methylation status, if performed | Standard Local Prior Authorization Code List, Pg 52 Original policy |
| 81525 | Oncology (colon), mRNA, gene expression profiling by real-time RT-PCR of 12 genes (7 content and 5 housekeeping), utilizing formalin-fixed paraffin- embedded tissue, algorithm reported as a recurrence score | Standard Local Prior Authorization Code List, Pg 53 Original policy |
| 81529 | Oncology (cutaneous melanoma), mRNA, gene expression profiling by real-time RT-PCR of 31 genes (28 content and 3 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as recurrence risk, including likelihood of sentinel lymph node metastasis | Standard Local Prior Authorization Code List, Pg 53 Original policy |
| 81540 | Oncology (tumor of unknown origin), mRNA, gene expression profiling by real-time RT-PCR of 92 genes (87 content and 5 housekeeping) to classify tumor into main cancer type and subtype, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a probability of a predicted main cancer type and subtype | Standard Local Prior Authorization Code List, Pg 53 Original policy |
| 81541 | Oncology (prostate), mRNA gene expression profiling by real-time RT-PCR of 46 genes (31 content and 15 housekeeping), utilizing formalin- fixed paraffin-embedded tissue, algorithm reported as a disease-specific mortality risk score | Standard Local Prior Authorization Code List, Pg 53 Original policy |
| 81542 | Oncology (prostate), mRNA, microarray gene expression profiling of 22 content genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as metastasis risk score | Standard Local Prior Authorization Code List, Pg 53 Original policy |
| 81546 | Oncology (thyroid), mRNA, gene expression analysis of 10,196 genes, utilizing fine needle aspirate, algorithm reported as a categorical result (eg, benign or suspicious) | Standard Local Prior Authorization Code List, Pg 53 Original policy |
| 81551 | Oncology (prostate), promoter methylation profiling by real-time PCR of 3 genes (GSTP1, APC, RASSF1), utilizing formalin-fixed paraffin- embedded tissue, algorithm reported as a likelihood of prostate, Cancer detection on repeat biopsy | Standard Local Prior Authorization Code List, Pg 53 Original policy |
| 81552 | Oncology (uveal melanoma), mRNA, gene expression profiling by real-time RT-PCR of 15 genes (12 content and 3 housekeeping), utilizing fine needle aspirate or formalin-fixed paraffin- embedded tissue, algorithm reported as risk of metastasis | Standard Local Prior Authorization Code List, Pg 53 Original policy |
| 81554 | Pulmonary disease (idiopathic pulmonary fibrosis [IPF]), mRNA, gene expression analysis of 190 genes, utilizing transbronchial biopsies, diagnostic algorithm reported as categorical result (eg, positive or negative for high probability of usual interstitial pneumonia [UIP]) | Standard Local Prior Authorization Code List, Pg 53 Original policy |
| 81558 | Transplantation medicine (allograft rejection, kidney), mRNA, gene expression profiling | Standard Local Prior Authorization Code List, Pg 53 Original policy |
| 89280 | Assisted oocyte fertilization, microtechnique; less than or equal to 10 oocytes | Standard Local Prior Authorization Code List, Pg 53 Original policy |
| 89281 | Assisted oocyte fertilization, microtechnique; greater than 10 oocytes | Standard Local Prior Authorization Code List, Pg 53 Original policy |
| 89290 | Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); less than or equal to 5 embryos | Standard Local Prior Authorization Code List, Pg 53 Original policy |
| 89291 | Biopsy, oocyte polar body or embryo blastomere, microtechnique (for pre-implantation genetic diagnosis); greater than 5 embryos | Standard Local Prior Authorization Code List, Pg 53 Original policy |
| 89337 | Cryopreservation, mature oocyte(s) | Standard Local Prior Authorization Code List, Pg 53 Original policy |
| 89344 | Storage (per year); reproductive tissue, testicular/ovarian | Standard Local Prior Authorization Code List, Pg 53 Original policy |
| 89346 | Storage (per year); oocyte(s) | Standard Local Prior Authorization Code List, Pg 53 Original policy |
| 89354 | Thawing of cryopreserved; reproductive tissue, testicular/ovarian | Standard Local Prior Authorization Code List, Pg 53 Original policy |
| 89356 | Thawing of cryopreserved; oocytes, each aliquot | Standard Local Prior Authorization Code List, Pg 53 Original policy |
| 90913 | Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry, when performed; each additional 15 minutes of one-on-one physician or other qualified health care professional contact with the patient (List separately in addition to code for primary procedure) | Standard Local Prior Authorization Code List, Pg 53 Original policy |
| 92507 | Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual | Standard Local Prior Authorization Code List, Pg 54 Original policy |
| 92508 | Treatment of speech, language, voice, communication, and/or auditory processing disorder; group, 2 or more individuals | Standard Local Prior Authorization Code List, Pg 54 Original policy |
| 92521 | Evaluation of speech fluency (eg, stuttering, cluttering) | Standard Local Prior Authorization Code List, Pg 54 Original policy |
| 92522 | Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria) | Standard Local Prior Authorization Code List, Pg 54 Original policy |
| 92523 | Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria); with evaluation of language, Comprehension and expression (eg, receptive and expressive language) | Standard Local Prior Authorization Code List, Pg 54 Original policy |
| 92524 | Behavioral and qualitative analysis of voice and resonance | Standard Local Prior Authorization Code List, Pg 54 Original policy |
| 92526 | Treatment of swallowing dysfunction and/or oral function for feeding | Standard Local Prior Authorization Code List, Pg 54 Original policy |
| 92605 | Evaluation for prescription of non-speech- generating augmentative and alternative communication device, face-to-face with the patient; first hour | Standard Local Prior Authorization Code List, Pg 54 Original policy |
| 92606 | Therapeutic service(s) for the use of non-speech- generating device, including programming and modification | Standard Local Prior Authorization Code List, Pg 54 Original policy |
| 92607 | Evaluation for prescription for speech-generating augmentative and alternative communication device, face-to-face with the patient; first hour | Standard Local Prior Authorization Code List, Pg 54 Original policy |
| 92608 | Evaluation for prescription for speech-generating augmentative and alternative communication device, face-to-face with the patient; each additional 30 minutes (List separately in addition to code for primary procedure) | Standard Local Prior Authorization Code List, Pg 54 Original policy |