Anthem Blue Cross Blue Shield of Georgia prior authorization, page 27
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 |
|---|---|---|
| 0276U | Hematology (inherited thrombocytopenia), genomic sequence analysis of 42 genes, blood, buccal swab, or amniotic fluid | Standard Local Prior Authorization Code List, Pg 72 Original policy |
| 0277U | Hematology (genetic platelet function disorder), genomic sequence analysis of 40 genes and duplication/deletion of PLAU, blood, buccal swab, or amniotic fluid | Standard Local Prior Authorization Code List, Pg 72 Original policy |
| 0278U | Hematology (genetic thrombosis), genomic sequence analysis of 14 genes, blood, buccal swab, or amniotic fluid | Standard Local Prior Authorization Code List, Pg 72 Original policy |
| 0285U | Oncology, response to radiation, cell-free DNA, quantitative branched chain DNA amplification, plasma, reported as a radiation toxicity score | Standard Local Prior Authorization Code List, Pg 72 Original policy |
| 0286U | CEP72 (centrosomal protein, 72-KDa), NUDT15 (nudix hydrolase 15) and TPMT (thiopurine S- methyltransferase) (eg, drug metabolism) gene analysis, common variants | Standard Local Prior Authorization Code List, Pg 72 Original policy |
| 0287U | Oncology (thyroid), DNA and mRNA, next- generation sequencing analysis of 112 genes, fine needle aspirate or formalin-fixed paraffin- embedded (FFPE) tissue, algorithmic prediction of cancer recurrence, reported as a categorical risk result (low, intermediate, high) | Standard Local Prior Authorization Code List, Pg 72 Original policy |
| 0288U | Oncology (lung), mRNA, quantitative PCR analysis of 11 genes (BAG1, BRCA1, CDC6, CDK2AP1, ERBB3, FUT3, IL11, LCK, RND3, SH3BGR, WNT3A) and 3 reference genes (ESD, TBP, YAP1), formalin-fixed paraffin-embedded (FFPE) tumor tissue, algorithmic interpretation reported as a recurrence risk score | Standard Local Prior Authorization Code List, Pg 72 Original policy |
| 0289U | Neurology (Alzheimer disease), mRNA, gene expression profiling by RNA sequencing of 24 genes, whole blood, algorithm reported as predictive risk score | Standard Local Prior Authorization Code List, Pg 72 Original policy |
| 0290U | Pain management, mRNA, gene expression profiling by RNA sequencing of 36 genes, whole blood, algorithm reported as predictive risk score | Standard Local Prior Authorization Code List, Pg 72 Original policy |
| 0291U | Psychiatry (mood disorders), mRNA, gene expression profiling by RNA sequencing of 144 genes, whole blood, algorithm reported as predictive risk score | Standard Local Prior Authorization Code List, Pg 72 Original policy |
| 0292U | Psychiatry (stress disorders), mRNA, gene expression profiling by RNA sequencing of 72 genes, whole blood, algorithm reported as predictive risk score | Standard Local Prior Authorization Code List, Pg 72 Original policy |
| 0293U | Psychiatry (suicidal ideation), mRNA, gene expression profiling by RNA sequencing of 54 genes, whole blood, algorithm reported as predictive risk score | Standard Local Prior Authorization Code List, Pg 72 Original policy |
| 0294U | Longevity and mortality risk, mRNA, gene expression profiling by RNA sequencing of 18 genes, whole blood, algorithm reported as predictive risk score | Standard Local Prior Authorization Code List, Pg 72 Original policy |
| 0296U | Oncology (oral and/or oropharyngeal cancer), gene expression profiling by RNA sequencing of at least 20 molecular features (eg, human and/or microbial mRNA), saliva, algorithm reported as positive or negative for signature associated with malignancy | Standard Local Prior Authorization Code List, Pg 72 Original policy |
| 0306U | Oncology (minimal residual disease [MRD]), next- generation targeted sequencing analysis, cell-free DNA, initial (baseline) assessment to determine a patient-specific panel for future comparisons to evaluate for MRD | Standard Local Prior Authorization Code List, Pg 72 Original policy |
| 0307U | Oncology (minimal residual disease [MRD]), next- generation targeted sequencing analysis of a patient-specific panel, cell-free DNA, subsequent assessment with comparison to previously analyzed patient specimens to evaluate for MRD | Standard Local Prior Authorization Code List, Pg 72 Original policy |
| 0313U | Oncology (pancreas), DNA and mRNA next- generation sequencing analysis of 74 genes and analysis of CEA (CEACAM5) gene expression, pancreatic cyst fluid, algorithm reported as a categorical result (ie, negative, low probability of neoplasia or positive, high probability of neoplasia) | Standard Local Prior Authorization Code List, Pg 73 Original policy |
| 0314U | Oncology (cutaneous melanoma), mRNA gene expression profiling by RT-PCR of 35 genes (32 content and 3 housekeeping), utilizing formalin- fixed paraffin-embedded (FFPE) tissue, algorithm reported as a categorical result (ie, benign, intermediate, malignant) | Standard Local Prior Authorization Code List, Pg 73 Original policy |
| 0315U | Oncology (cutaneous squamous cell carcinoma), mRNA gene expression profiling by RT-PCR of 40 genes (34 content and 6 housekeeping), utilizing formalin-fixed paraffin-embedded (FFPE) tissue, algorithm reported as a categorical risk result (ie, Class 1, Class 2A, Class 2B) | Standard Local Prior Authorization Code List, Pg 73 Original policy |
| 0318U | Pediatrics (congenital epigenetic disorders), whole genome methylation analysis by microarray for 50 or more genes, blood | Standard Local Prior Authorization Code List, Pg 73 Original policy |
| 0319U | Nephrology (renal transplant), RNA expression by select transcriptome sequencing, using pretransplant peripheral blood, algorithm reported as a risk score for early acute rejection | Standard Local Prior Authorization Code List, Pg 73 Original policy |
| 0320U | Nephrology (renal transplant), RNA expression by select transcriptome sequencing, using posttransplant peripheral blood, algorithm reported as a risk score for acute cellular rejection | Standard Local Prior Authorization Code List, Pg 73 Original policy |
| 0326U | Targeted genomic sequence analysis panel, solid organ neoplasm, cell-free circulating DNA analysis of 83 or more genes, interrogation for sequence variants, gene copy number amplifications, gene rearrangements, microsatellite instability and tumor mutational burden | Standard Local Prior Authorization Code List, Pg 73 Original policy |
| 0329T | Monitoring of intraocular pressure for 24 hours or longer, unilateral or bilateral, with interpretation and report | Standard Local Prior Authorization Code List, Pg 73 Original policy |
| 0329U | Oncology (neoplasia), exome and transcriptome sequence analysis for sequence variants, gene copy number amplifications and deletions, gene rearrangements, microsatellite instability and tumor mutational burden utilizing DNA and RNA from tumor with DNA from normal blood or saliva for subtraction, report of clinically significant mutation(s) with therapy associations | Standard Local Prior Authorization Code List, Pg 73 Original policy |
| 0332U | Oncology (pan-tumor), genetic profiling of 8 DNA- regulatory (epigenetic) markers by quantitative polymerase chain reaction (qPCR), whole blood, reported as a high or low probability of responding to immune checkpoint-inhibitor therapy | Standard Local Prior Authorization Code List, Pg 73 Original policy |
| 0333U | Oncology (liver), surveillance for hepatocellular carcinoma (HCC) in high-risk patients, analysis of methylation patterns on circulating cell-free DNA (cfDNA) plus measurement of serum of AFP/AFP- L3 and oncoprotein des-gamma-carboxy- prothrombin (DCP), algorithm reported as normal or abnormal result | Standard Local Prior Authorization Code List, Pg 73 Original policy |
| 0335U | Rare diseases (constitutional/heritable disorders), whole genome sequence analysis, including small sequence changes, copy number variants, deletions, duplications, mobile element insertions, uniparental disomy (UPD), inversions, aneuploidy, mitochondrial genome sequence analysis with heteroplasmy and large deletions, short tandem repeat (STR) gene expansions, fetal sample, identification and categorization of genetic variants | Standard Local Prior Authorization Code List, Pg 73 Original policy |
| 0336U | Rare diseases (constitutional/heritable disorders), whole genome sequence analysis, including small sequence changes, copy number variants, deletions, duplications, mobile element insertions, uniparental disomy (UPD), inversions, aneuploidy, mitochondrial genome sequence analysis with heteroplasmy and large deletions, short tandem repeat (STR) gene expansions, blood or saliva, identification and categorization of genetic variants, each comparator genome (eg, parent) | Standard Local Prior Authorization Code List, Pg 73 Original policy |
| 0339U | Oncology (prostate), mRNA expression profiling of HOXC6 and DLX1, reverse transcription polymerase chain reaction (RT-PCR), first-void urine following digital rectal examinati | Standard Local Prior Authorization Code List, Pg 74 Original policy |
| 0340U | Oncology (pan-cancer), analysis of minimal residual disease (MRD) from plasma, with assays personalized to each patient based on prior next- generation sequencing of the patien | Standard Local Prior Authorization Code List, Pg 74 Original policy |
| 0343U | Oncology (prostate), exosome-based analysis of 442 small noncoding RNAs (sncRNAs) by quantitative reverse transcription polymerase chain reaction (RT-qPCR), urine, reported as molecular evidence of no-, low-, intermediate- or high-risk of prostate cancer | Standard Local Prior Authorization Code List, Pg 74 Original policy |
| 0345U | Psychiatry (eg, depression, anxiety, attention deficit hyperactivity disorder [ADHD]), genomic analysis panel, variant analysis of 15 genes, including deletion/duplication ana | Standard Local Prior Authorization Code List, Pg 74 Original policy |
| 0347U | Drug metabolism or processing (multiple conditions), whole blood or buccal specimen, DNA analysis, 16 gene report, with variant analysis and reported phenotypes | Standard Local Prior Authorization Code List, Pg 74 Original policy |
| 0348U | Drug metabolism or processing (multiple conditions), whole blood or buccal specimen, DNA analysis, 25 gene report, with variant analysis and reported phenotypes | Standard Local Prior Authorization Code List, Pg 74 Original policy |
| 0349U | Drug metabolism or processing (multiple conditions), whole blood or buccal specimen, DNA analysis, 27 gene report, with variant analysis, including reported phenotypes and imp | Standard Local Prior Authorization Code List, Pg 74 Original policy |
| 0350U | Drug metabolism or processing (multiple conditions), whole blood or buccal specimen, DNA analysis, 27 gene report, with variant analysis and reported phenotypes | Standard Local Prior Authorization Code List, Pg 74 Original policy |
| 0355U | APOL1 (apolipoprotein L1) (eg, chronic kidney disease), risk variants (G1, G2) | Standard Local Prior Authorization Code List, Pg 74 Original policy |
| 0356U | Oncology (oropharyngeal or anal), evaluation of 17 DNA biomarkers using droplet digital PCR (ddPCR), cell-free DNA, algorithm reported as a prognostic risk score for cancer recurrence | Standard Local Prior Authorization Code List, Pg 74 Original policy |
| 0362U | Oncology (papillary thyroid cancer), gene- expression profiling via targeted hybrid capture- enrichment RNA sequencing of 82 content genes and 10 housekeeping genes, fine needle aspirate or formalin-fixed paraffin-embedded (FFPE) tissue, algorithm reported as one of three molecular subtypes | Standard Local Prior Authorization Code List, Pg 74 Original policy |
| 0363U | Oncology (urothelial), mRNA, gene-expression profiling by real-time quantitative PCR of 5 genes (MDK, HOXA13, CDC2 [CDK1], IGFBP5, and CXCR2), utilizing urine, algorithm incor | Standard Local Prior Authorization Code List, Pg 74 Original policy |
| 0364U | Oncology (hematolymphoid neoplasm), genomic sequence analysis using multiplex (PCR) and next- generation sequencing with algorithm, quantification of dominant clonal sequence(s), reported as presence or absence of minimal residual disease (MRD) with quantitation of disease burden, when appropriate | Standard Local Prior Authorization Code List, Pg 74 Original policy |
| 0368U | Oncology (colorectal cancer), evaluation for mutations of APC, BRAF, CTNNB1, KRAS, NRAS, PIK3CA, SMAD4, and TP53, and methylation markers (MYO1G, KCNQ5, C9ORF50, FLI1, CLIP4, ZNF132 and TWIST1), multiplex quantitative polymerase chain reaction (qPCR), circulating cell-free DNA (cfDNA), plasma, report of risk score for advanced adenoma or colorectal cancer | Standard Local Prior Authorization Code List, Pg 74 Original policy |
| 0378U | RFC1 (replication factor C subunit 1), repeat expansion variant analysis by traditional and repeat- primed PCR, blood, saliva, or buccal swab | Standard Local Prior Authorization Code List, Pg 74 Original policy |
| 0379U | Targeted genomic sequence analysis panel, solid organ neoplasm, DNA (523 genes) and RNA (55 genes) by next-generation sequencing, interrogation for sequence variants, gene copy number amplifications, gene rearrangements, microsatellite instability, and tumor mutational burden | Standard Local Prior Authorization Code List, Pg 74 Original policy |
| 0388U | Oncology (non-small cell lung cancer), next- generation sequencing with identification of single nucleotide variants, copy number variants, insertions and deletions, and structural variants in 37 cancer-related genes, plasma, with report for alteration detection | Standard Local Prior Authorization Code List, Pg 74 Original policy |
| 0389U | Pediatric febrile illness (Kawasaki disease [KD]), interferon alpha-inducible protein 27 (IFI27) and mast cell-expressed membrane protein 1 (MCEMP1), RNA, using quantitative reverse transcription polymerase chain reaction (RT- qPCR), blood, reported as a risk score for KD | Standard Local Prior Authorization Code List, Pg 75 Original policy |
| 0391U | Oncology (solid tumor), DNA and RNA by next- generation sequencing, utilizing formalin-fixed paraffin-embedded (FFPE) tissue, 437 genes, interpretive report for single nucleotide variants, splice-site variants, insertions/deletions, copy number alterations, gene fusions, tumor mutational burden, and microsatellite instability, with algorithm quantifying immunotherapy response score | Standard Local Prior Authorization Code List, Pg 75 Original policy |
| 0392U | Drug metabolism (depression, anxiety, attention deficit hyperactivity disorder [ADHD]), gene-drug interactions, variant analysis of 16 genes, including deletion/duplication analysis of CYP2D6, reported as impact of gene-drug interaction for each drug | Standard Local Prior Authorization Code List, Pg 75 Original policy |
| 0400U | Obstetrics (expanded carrier screening), 145 genes by next-generation sequencing, fragment analysis and multiplex ligation-dependent probe amplification, DNA, reported as carrier positive or negative | Standard Local Prior Authorization Code List, Pg 75 Original policy |