Anthem Blue Cross Blue Shield of Georgia prior authorization, page 26
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 |
|---|---|---|
| 0179U | Oncology (non-small cell lung cancer), cell-free DNA, targeted sequence analysis of 23 genes (single nucleotide variations, insertions and deletions, fusions without prior knowledge of partner/breakpoint, copy number variations), with report of significant mutation(s) | Standard Local Prior Authorization Code List, Pg 68 Original policy |
| 0200T | Percutaneous sacral augmentation (sacroplasty), unilateral injection(s), including the use of a balloon or mechanical device, when used, 1 or more needles | Standard Local Prior Authorization Code List, Pg 68 Original policy |
| 0201T | Percutaneous sacral augmentation (sacroplasty), bilateral injections, including the use of a balloon or mechanical device, when used, 2 or more needles | Standard Local Prior Authorization Code List, Pg 68 Original policy |
| 0203U | Autoimmune (inflammatory bowel disease), mRNA, gene expression profiling by quantitative RT-PCR, 17 genes (15 target and 2 reference genes), whole blood, reported as a continuous risk score and classification of inflammatory bowel disease aggressiveness | Standard Local Prior Authorization Code List, Pg 68 Original policy |
| 0205U | Ophthalmology (age-related macular degeneration), analysis of 3 gene variants (2 CFH gene, 1 ARMS2 gene), using PCR and MALDI- TOF, buccal swab, reported as positive or negative for neovascular age-related macular-degeneration risk associated with zinc supplements | Standard Local Prior Authorization Code List, Pg 68 Original policy |
| 0209U | Cytogenomic constitutional (genome-wide) analysis, interrogation of genomic regions for copy number, structural changes and areas of homozygosity for chromosomal abnormalities | Standard Local Prior Authorization Code List, Pg 68 Original policy |
| 0211U | Oncology (pan-tumor), DNA and RNA by next- generation sequencing, utilizing formalin-fixed paraffin-embedded tissue, interpretative report for single nucleotide variants, copy number alterations, tumor mutational burden, and microsatellite instability, with therapy association | Standard Local Prior Authorization Code List, Pg 68 Original policy |
| 0212U | Rare diseases (constitutional/heritable disorders), whole genome and mitochondrial DNA sequence analysis, including small sequence changes, deletions, duplications, short tandem repeat gene expansions, and variants in non-uniquely mappable regions, blood or saliva, identification and categorization of genetic variants, proband | Standard Local Prior Authorization Code List, Pg 69 Original policy |
| 0213T | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; single level | Standard Local Prior Authorization Code List, Pg 69 Original policy |
| 0213U | Rare diseases (constitutional/heritable disorders), whole genome and mitochondrial DNA sequence analysis, including small sequence changes, deletions, duplications, short tandem repeat gene expansions, and variants in non-uniquely mappable regions, blood or saliva, identification and categorization of genetic variants, each comparator genome (eg, parent, sibling) | Standard Local Prior Authorization Code List, Pg 69 Original policy |
| 0214T | njection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; second level | Standard Local Prior Authorization Code List, Pg 69 Original policy |
| 0214U | Rare diseases (constitutional/heritable disorders), whole exome and mitochondrial DNA sequence analysis, including small sequence changes, deletions, duplications, short tandem repeat gene expansions, and variants in non-uniquely mappable regions, blood or saliva, identification and categorization of genetic variants, proband | Standard Local Prior Authorization Code List, Pg 69 Original policy |
| 0215T | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; third and any additional level(s) | Standard Local Prior Authorization Code List, Pg 69 Original policy |
| 0215U | Rare diseases (constitutional/heritable disorders), whole exome and mitochondrial DNA sequence analysis, including small sequence changes, deletions, duplications, short tandem repeat gene expansions, and variants in non-uniquely mappable regions, blood or saliva, identification and categorization of genetic variants, each comparator exome (eg, parent, sibling) | Standard Local Prior Authorization Code List, Pg 69 Original policy |
| 0216T | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; single level(cid:9) | Standard Local Prior Authorization Code List, Pg 69 Original policy |
| 0216U | Neurology (inherited ataxias), genomic DNA sequence analysis of 12 common genes including small sequence changes, deletions, duplications, short tandem repeat gene expansions, and variants in non-uniquely mappable regions, blood or saliva, identification and categorization of genetic variants | Standard Local Prior Authorization Code List, Pg 69 Original policy |
| 0217T | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; second level | Standard Local Prior Authorization Code List, Pg 69 Original policy |
| 0217U | Neurology (inherited ataxias), genomic DNA sequence analysis of 51 genes including small sequence changes, deletions, duplications, short tandem repeat gene expansions, and variants in non-uniquely mappable regions, blood or saliva, identification and categorization of genetic variants | Standard Local Prior Authorization Code List, Pg 69 Original policy |
| 0218U | Neurology (muscular dystrophy), DMD gene sequence analysis, including small sequence changes, deletions, duplications, and variants in non-uniquely mappable regions, blood or saliva, identification and characterization of genetic variants | Standard Local Prior Authorization Code List, Pg 69 Original policy |
| 0229U | BCAT1 (Branched chain amino acid transaminase 1) or IKZF1 (IKAROS family zinc finger 1) (eg, colorectal cancer) promoter methylation analysis | Standard Local Prior Authorization Code List, Pg 69 Original policy |
| 0230U | AR (androgen receptor) (eg, spinal and bulbar muscular atrophy, Kennedy disease, X chromosome inactivation), full sequence analysis, including small sequence changes in exonic and intronic regions, deletions, duplications, short tandem repeat (STR) expansions, mobile element insertions, and variants in non-uniquely mappable regions | Standard Local Prior Authorization Code List, Pg 70 Original policy |
| 0231U | CACNA1A (calcium voltage-gated channel subunit alpha 1A) (eg, spinocerebellar ataxia), full gene analysis, including small sequence changes in exonic and intronic regions, deletions, duplications, short tandem repeat (STR) gene expansions, mobile element insertions, and variants in non- uniquely mappable regions | Standard Local Prior Authorization Code List, Pg 70 Original policy |
| 0232U | CSTB (cystatin B) (eg, progressive myoclonic epilepsy type 1A, Unverricht-Lundborg disease), full gene analysis, including small sequence changes in exonic and intronic regions, deletions, duplications, short tandem repeat (STR) expansions, mobile element insertions, and variants in non-uniquely mappable regions | Standard Local Prior Authorization Code List, Pg 70 Original policy |
| 0233U | FXN (frataxin) (eg, Friedreich ataxia), gene analysis, including small sequence changes in exonic and intronic regions, deletions, duplications, short tandem repeat (STR) expansions, mobile element insertions, and variants in non-uniquely mappable regions | Standard Local Prior Authorization Code List, Pg 70 Original policy |
| 0234U | MECP2 (methyl CpG binding protein 2) (eg, Rett syndrome), full gene analysis, including small sequence changes in exonic and intronic regions, deletions, duplications, mobile element insertions, and variants in non-uniquely mappable regions | Standard Local Prior Authorization Code List, Pg 70 Original policy |
| 0235U | PTEN (phosphatase and tensin homolog) (eg, Cowden syndrome, PTEN hamartoma tumor syndrome), full gene analysis, including small sequence changes in exonic and intronic regions, deletions, duplications, mobile element insertions, and variants in non-uniquely mappable regions | Standard Local Prior Authorization Code List, Pg 70 Original policy |
| 0236U | SMN1 (survival of motor neuron 1, telomeric) and SMN2 (survival of motor neuron 2, centromeric) (eg, spinal muscular atrophy) full gene analysis, including small sequence changes in exonic and intronic regions, duplications, deletions, and mobile element insertions | Standard Local Prior Authorization Code List, Pg 70 Original policy |
| 0237U | Cardiac ion channelopathies (eg, Brugada syndrome, long QT syndrome, short QT syndrome, catecholaminergic polymorphic ventricular tachycardia), genomic sequence analysis panel including ANK2, CASQ2, CAV3, KCNE1, KCNE2, KCNH2, KCNJ2, KCNQ1, RYR2, and SCN5A, including small sequence changes in exonic and intronic regions, deletions, duplications, mobile element insertions, and variants in non-uniquely mappable regions | Standard Local Prior Authorization Code List, Pg 70 Original policy |
| 0238U | Oncology (Lynch syndrome), genomic DNA sequence analysis of MLH1, MSH2, MSH6, PMS2, and EPCAM, including small sequence changes in exonic and intronic regions, deletions, duplications, mobile element insertions, and variants in non- uniquely mappable regions | Standard Local Prior Authorization Code List, Pg 70 Original policy |
| 0239U | Targeted genomic sequence analysis panel, solid organ neoplasm, cell-free DNA, analysis of 311 or more genes, interrogation for sequence variants, including substitutions, insertions, deletions, select rearrangements, and copy number variations | Standard Local Prior Authorization Code List, Pg 70 Original policy |
| 0242U | Targeted genomic sequence analysis panel, solid organ neoplasm, cell-free circulating DNA analysis of 55-74 genes, interrogation for sequence variants, gene copy number amplifications, and gene rearrangements | Standard Local Prior Authorization Code List, Pg 70 Original policy |
| 0244U | Oncology (solid organ), DNA, comprehensive genomic profiling, 257 genes, interrogation for single-nucleotide variants, insertions/deletions, copy number alterations, gene rearrangements, tumor-mutational burden and microsatellite instability, utilizing formalin-fixed paraffin-embedded tumor tissue | Standard Local Prior Authorization Code List, Pg 70 Original policy |
| 0245U | Oncology (thyroid), mutation analysis of 10 genes and 37 RNA fusions and expression of 4 mRNA markers using next-generation sequencing, fine needle aspirate, report includes associated risk of malignancy expressed as a percentage | Standard Local Prior Authorization Code List, Pg 71 Original policy |
| 0250U | Oncology (solid organ neoplasm), targeted genomic sequence DNA analysis of 505 genes, interrogation for somatic alterations (SNVs [single nucleotide variant], small insertions and deletions, one amplification, and four translocations), microsatellite instability and tumor-mutation burden | Standard Local Prior Authorization Code List, Pg 71 Original policy |
| 0253U | Reproductive medicine (endometrial receptivity analysis), RNA gene exp | Standard Local Prior Authorization Code List, Pg 71 Original policy |
| 0254U | Reproductive medicine (preimplantation genetic assessment), analysis of 24 chromosomes using embryonic DNA genomic sequence analysis for aneuploidy, and a mitochondrial DNA score in euploid embryos, results reported as normal (euploidy), monosomy, trisomy, or partial deletion/duplication, mosaicism, and segmental aneuploidy, per embryo tested | Standard Local Prior Authorization Code List, Pg 71 Original policy |
| 0258U | Autoimmune (psoriasis), mRNA, next-generation sequencing, gene expression profiling of 50-100 genes, skin-surface collection using adhesive patch, algorithm reported as likelihood of response to psoriasis biologics | Standard Local Prior Authorization Code List, Pg 71 Original policy |
| 0260U | Rare diseases (constitutional/heritable disorders), identification of copy number variations, inversions, insertions, translocations, and other structural variants by optical genome mapping | Standard Local Prior Authorization Code List, Pg 71 Original policy |
| 0262U | Oncology (solid tumor), gene expression profiling by real-time RT-PCR of 7 gene pathways (ER, AR, PI3K, MAPK, HH, TGFB, Notch), formalin-fixed paraffin-embedded (FFPE), algorithm reported as gene pathway activity score | Standard Local Prior Authorization Code List, Pg 71 Original policy |
| 0264U | Rare diseases (constitutional/heritable disorders), identification of copy number variations, inversions, insertions, translocations, and other structural variants by optical genome mapping | Standard Local Prior Authorization Code List, Pg 71 Original policy |
| 0265U | Rare constitutional and other heritable disorders, whole genome and mitochondrial DNA sequence analysis, blood, frozen and formalin-fixed paraffin- embedded (FFPE) tissue, saliva, buccal swabs or cell lines, identification of single nucleotide and copy number variants | Standard Local Prior Authorization Code List, Pg 71 Original policy |
| 0266U | Unexplained constitutional or other heritable disorders or syndromes, tissue-specific gene expression by whole-transcriptome and next- generation sequencing, blood, formalin-fixed paraffin-embedded (FFPE) tissue or fresh frozen tissue, reported as presence or absence of splicing or expression changes | Standard Local Prior Authorization Code List, Pg 71 Original policy |
| 0267U | Rare constitutional and other heritable disorders, identification of copy number variations, inversions, insertions, translocations, and other structural variants by optical genome mapping and whole genome sequencing | Standard Local Prior Authorization Code List, Pg 71 Original policy |
| 0268U | Hematology (atypical hemolytic uremic syndrome [aHUS]), genomic sequence analysis of 15 genes, blood, buccal swab, or amniotic fluid | Standard Local Prior Authorization Code List, Pg 71 Original policy |
| 0269U | Hematology (autosomal dominant congenital thrombocytopenia), genomic sequence analysis of 22 genes, blood, buccal swab, or amniotic fluid | Standard Local Prior Authorization Code List, Pg 71 Original policy |
| 0270U | Hematology (congenital coagulation disorders), genomic sequence analysis of 20 genes, blood, buccal swab, or amniotic fluid | Standard Local Prior Authorization Code List, Pg 71 Original policy |
| 0271U | Hematology (congenital neutropenia), genomic sequence analysis of 24 genes, blood, buccal swab, or amniotic fluid | Standard Local Prior Authorization Code List, Pg 71 Original policy |
| 0272U | Hematology (genetic bleeding disorders), genomic sequence analysis of 60 genes and duplication/deletion of PLAU, blood, buccal swab, or amniotic fluid, comprehensive | Standard Local Prior Authorization Code List, Pg 71 Original policy |
| 0273U | Hematology (genetic hyperfibrinolysis, delayed bleeding), analysis of 9 genes (F13A1, F13B, FGA, FGB, FGG, SERPINA1, SERPINE1, SERPINF2 by next-generation sequencing, and PLAU by array comparative genomic hybridization), blood, buccal swab, or amniotic fluid | Standard Local Prior Authorization Code List, Pg 72 Original policy |
| 0274U | Hematology (genetic platelet disorders), genomic sequence analysis of 62 genes and duplication/deletion of PLAU, blood, buccal swab, or amniotic fluid | Standard Local Prior Authorization Code List, Pg 72 Original policy |