Anthem Blue Cross Blue Shield of Georgia prior authorization, page 28
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 |
|---|---|---|
| 0401U | Cardiology (coronary heart disease [CHD]), 9 genes (12 variants), targeted variant genotyping, blood, saliva, or buccal swab, algorithm reported as a genetic risk score for a coronary event | Standard Local Prior Authorization Code List, Pg 75 Original policy |
| 0402T | Collagen cross-linking of cornea, including removal of the corneal epithelium, when performed, and intraoperative pachymetry, when performed | Standard Local Prior Authorization Code List, Pg 75 Original policy |
| 0403U | Oncology (prostate), mRNA, gene expression profiling of 18 genes, first-catch post-digital rectal examination urine (or processed first-catch urine), algorithm reported as percentage of likelihood of detecting clinically significant prostate cancer | Standard Local Prior Authorization Code List, Pg 75 Original policy |
| 0405U | Oncology (pancreatic), 59 methylation haplotype block markers, next-generation sequencing, plasma, reported as cancer signal detected or not detected | Standard Local Prior Authorization Code List, Pg 75 Original policy |
| 0409U | Oncology (solid tumor), DNA (80 genes) and RNA (36 genes), by next-generation sequencing from plasma, including single nucleotide variants, insertions/deletions, copy number alterations, microsatellite instability, and fusions, report showing identified mutations with clinical actionability | Standard Local Prior Authorization Code List, Pg 75 Original policy |
| 0410U | Oncology (pancreatic), DNA, whole genome sequencing with 5-hydroxymethylcytosine enrichment, whole blood or plasma, algorithm reported as cancer detected or not detected | Standard Local Prior Authorization Code List, Pg 75 Original policy |
| 0411U | Psychiatry (eg, depression, anxiety, attention deficit hyperactivity disorder [ADHD]), genomic analysis panel, variant analysis of 15 genes, including deletion/duplication analysis of CYP2D6 | Standard Local Prior Authorization Code List, Pg 75 Original policy |
| 0413U | Oncology (hematolymphoid neoplasm), optical genome mapping for copy number alterations, aneuploidy, and balanced/complex structural rearrangements, DNA from blood or bone marrow, report of clinically significant alterations | Standard Local Prior Authorization Code List, Pg 75 Original policy |
| 0414U | Oncology (lung), augmentative algorithmic analysis of digitized whole slide imaging for 8 genes (ALK, BRAF, EGFR, ERBB2, MET, NTRK1-3, RET, ROS1), and KRAS G12C and PD-L1, if performed, formalin-fixed paraffin-embedded (FFPE) tissue, reported as positive or negative for each biomarker | Standard Local Prior Authorization Code List, Pg 75 Original policy |
| 0417U | Rare diseases (constitutional/heritable disorders), whole mitochondrial genome sequence with heteroplasmy detection and deletion analysis, nuclear-encoded mitochondrial gene analysis of 335 nuclear genes, including sequence changes, deletions, insertions, and copy number variants analysis, blood or saliva, identification and categorization of mitochondrial disorder-associated genetic variants | Standard Local Prior Authorization Code List, Pg 75 Original policy |
| 0419U | Neuropsychiatry (eg, depression, anxiety), genomic sequence analysis panel, variant analysis of 13 genes, saliva or buccal swab, report of each gene phenotype | Standard Local Prior Authorization Code List, Pg 75 Original policy |
| 0420U | Oncology (urothelial), mRNA expression profiling by real-time quantitative PCR of MDK, HOXA13, CDC2, IGFBP5, and CXCR2 in combination with droplet digital PCR (ddPCR) analysis of 6 single- nucleotide polymorphisms (SNPs) genes TERT and FGFR3, urine, algorithm reported as a risk score for urothelial carcinoma | Standard Local Prior Authorization Code List, Pg 76 Original policy |
| 0422U | Oncology (pan-solid tumor), analysis of DNA biomarker response to anti-cancer therapy using cell-free circulating DNA, biomarker comparison to a previous baseline pre-treatment cell-free circulating DNA analysis using next-generation sequencing, algorithm reported as a quantitative change from baseline, including specific alterations, if appropriate | Standard Local Prior Authorization Code List, Pg 76 Original policy |
| 0424U | Oncology (prostate), exosome-based analysis of 53 small noncoding RNAs (sncRNAs) by quantitative reverse transcription polymerase chain reaction (RT-qPCR), urine, reported as no molecular evidence, low-, moderate- or elevated-risk of prostate cancer | Standard Local Prior Authorization Code List, Pg 76 Original policy |
| 0425U | Genome (eg, unexplained constitutional or heritable disorder or syndrome), rapid sequence analysis, each comparator genome (eg, parents, siblings) | Standard Local Prior Authorization Code List, Pg 76 Original policy |
| 0426U | Genome (eg, unexplained constitutional or heritable disorder or syndrome), ultra-rapid sequence analysis | Standard Local Prior Authorization Code List, Pg 76 Original policy |
| 0433U | Oncology (prostate), 5 DNA regulatory markers by quantitative PCR, whole blood, algorithm, including prostate-specific antigen, reported as likelihood of cancer | Standard Local Prior Authorization Code List, Pg 76 Original policy |
| 0434U | Drug metabolism (adverse drug reactions and drug response), genomic analysis panel, variant analysis of 25 genes with reported phenotypes | Standard Local Prior Authorization Code List, Pg 76 Original policy |
| 0437U | Psychiatry (anxiety disorders), mRNA, gene expression profiling by RNA sequencing of 15 biomarkers, whole blood, algorithm reported as predictive risk score | Standard Local Prior Authorization Code List, Pg 76 Original policy |
| 0438U | Drug metabolism (adverse drug reactions and drug response), buccal specimen, gene-drug interactions, variant analysis of 33 genes, including deletion/duplication analysis of CYP2D6, including reported phenotypes and impacted gene-drug interactions | Standard Local Prior Authorization Code List, Pg 76 Original policy |
| 0439U | Cardiology (coronary heart disease [CHD]), DNA, analysis of 5 single-nucleotide polymorphisms (SNPs) (rs11716050 [LOC105376934], rs6560711 [WDR37], rs3735222 [SCIN/LOC10798676 | Standard Local Prior Authorization Code List, Pg 76 Original policy |
| 0440U | Cardiology (coronary heart disease [CHD]), DNA, analysis of 10 single-nucleotide polymorphisms (SNPs) (rs710987 [LINC010019], rs1333048 [CDKN2B-AS1], rs12129789 [KCND3], rs942 | Standard Local Prior Authorization Code List, Pg 76 Original policy |
| 0444U | Oncology (solid organ neoplasia), targeted genomic sequence analysis panel of 361 genes, interrogation for gene fusions, translocations, or other rearrangements, using DNA fro | Standard Local Prior Authorization Code List, Pg 76 Original policy |
| 0449U | Carrier screening for severe inherited conditions (eg, cystic fibrosis, spinal muscular atrophy, beta hemoglobinopathies [including sickle cell disease], alpha thalassemia), r | Standard Local Prior Authorization Code List, Pg 76 Original policy |
| 0452U | Oncology (bladder), methylated PENK DNA detection by linear target enrichment-quantitative methylation-specific real-time PCR (LTE-qMSP), urine, reported as likelihood of blad | Standard Local Prior Authorization Code List, Pg 76 Original policy |
| 0453U | Oncology (colorectal cancer), cell-free DNA (cfDNA), methylation-based quantitative PCR assay (SEPTIN9, IKZF1, BCAT1, Septin9-2, VAV3, BCAN), plasma, reported as presence or a | Standard Local Prior Authorization Code List, Pg 76 Original policy |
| 0454U | Rare diseases (constitutional/heritable disorders), identification of copy number variations, inversions, insertions, translocations, and other structural variants by optical | Standard Local Prior Authorization Code List, Pg 76 Original policy |
| 0460U | Oncology, whole blood or buccal, DNA single- nucleotide polymorphism (SNP) genotyping by real- time PCR of 24 genes, with variant analysis and reported phenotypes | Standard Local Prior Authorization Code List, Pg 76 Original policy |
| 0461U | Oncology, pharmacogenomic analysis of single- nucleotide polymorphism (SNP) genotyping by real- time PCR of 24 genes, whole blood or buccal swab, with variant analysis, includin | Standard Local Prior Authorization Code List, Pg 76 Original policy |
| 0465U | Oncology (urothelial carcinoma), DNA, quantitative methylation-specific PCR of 2 genes (ONECUT2, VIM), algorithmic analysis reported as positive or negative | Standard Local Prior Authorization Code List, Pg 77 Original policy |
| 0466U | Cardiology (coronary artery disease [CAD]), DNA, genome-wide association studies (564856 single- nucleotide polymorphisms [SNPs], targeted variant genotyping), patient lifestyl | Standard Local Prior Authorization Code List, Pg 77 Original policy |
| 0467U | Oncology (bladder), DNA, next-generation sequencing (NGS) of 60 genes and whole genome aneuploidy, urine, algorithms reported as minimal residual disease (MRD) status positive | Standard Local Prior Authorization Code List, Pg 77 Original policy |
| 0469U | Rare diseases (constitutional/heritable disorders), whole genome sequence analysis for chromosomal abnormalities, copy number variants, duplications/deletions, inversions, unb | Standard Local Prior Authorization Code List, Pg 77 Original policy |
| 0471U | Oncology (colorectal cancer), qualitative real-time PCR of 35 variants of KRAS and NRAS genes (exons 2, 3, 4), formalin-fixed paraffin-embedded (FFPE), predictive, identificat | Standard Local Prior Authorization Code List, Pg 77 Original policy |
| 0473U | Oncology (solid tumor), next-generation sequencing (NGS) of DNA from formalin-fixed paraffin-embedded (FFPE) tissue with comparative sequence analysis from a matched normal sp | Standard Local Prior Authorization Code List, Pg 77 Original policy |
| 0474U | Hereditary pan-cancer (eg, hereditary sarcomas, hereditary endocrine tumors, hereditary neuroendocrine tumors, hereditary cutaneous melanoma), genomic sequence analysis panel | Standard Local Prior Authorization Code List, Pg 77 Original policy |
| 0475U | Hereditary prostate cancer-related disorders, genomic sequence analysis panel using next- generation sequencing (NGS), Sanger sequencing, multiplex ligation-dependent probe amp | Standard Local Prior Authorization Code List, Pg 77 Original policy |
| 0476U | Drug metabolism, psychiatry (eg, major depressive disorder, general anxiety disorder, attention deficit hyperactivity disorder [ADHD], schizophrenia), whole blood, buccal swab | Standard Local Prior Authorization Code List, Pg 77 Original policy |
| 0477U | Drug metabolism, psychiatry (eg, major depressive disorder, general anxiety disorder, attention deficit hyperactivity disorder [ADHD], schizophrenia), whole blood, buccal swab | Standard Local Prior Authorization Code List, Pg 77 Original policy |
| 0478U | Oncology (non-small cell lung cancer), DNA and RNA, digital PCR analysis of 9 genes (EGFR, KRAS, BRAF, ALK, ROS1, RET, NTRK 1/2/3, ERBB2, and MET) in formalin-fixed paraffin-e | Standard Local Prior Authorization Code List, Pg 77 Original policy |
| 0485U | Oncology (solid tumor), cell-free DNA and RNA by next-generation sequencing, interpretative report for germline mutations, clonal hematopoiesis of indeterminate potential, and | Standard Local Prior Authorization Code List, Pg 77 Original policy |
| 0486U | Oncology (pan-solid tumor), next-generation sequencing analysis of tumor methylation markers present in cell-free circulating tumor DNA, algorithm reported as quantitative mea | Standard Local Prior Authorization Code List, Pg 77 Original policy |
| 0487U | Oncology (solid tumor), cell-free circulating DNA, targeted genomic sequence analysis panel of 84 genes, interrogation for sequence variants, aneuploidy-corrected gene copy nu | Standard Local Prior Authorization Code List, Pg 77 Original policy |
| 0488U | Obstetrics (fetal antigen noninvasive prenatal test), cell-free DNA sequence analysis for detection of fetal presence or absence of 1 or more of the Rh, C, c, D, E, Duffy (Fya | Standard Local Prior Authorization Code List, Pg 77 Original policy |
| 0489U | Obstetrics (single-gene noninvasive prenatal test), cell-free DNA sequence analysis of 1 or more targets (eg, CFTR, SMN1, HBB, HBA1, HBA2) to identify paternally inherited pat | Standard Local Prior Authorization Code List, Pg 77 Original policy |
| 0493U | Transplantation medicine, quantification of donor- derived cell-free DNA (cfDNA) using next- generation sequencing, plasma, reported as percentage of donor-derived cell-free DNA | Standard Local Prior Authorization Code List, Pg 77 Original policy |
| 0494U | Red blood cell antigen (fetal RhD gene analysis), next-generation sequencing of circulating cell-free DNA (cfDNA) of blood in pregnant individuals known to be RhD negative, re | Standard Local Prior Authorization Code List, Pg 77 Original policy |
| 0496U | Oncology (colorectal), cell-free DNA, 8 genes for mutations, 7 genes for methylation by real-time RT- PCR, and 4 proteins by enzyme-linked immunosorbent assay, blood, reported | Standard Local Prior Authorization Code List, Pg 77 Original policy |
| 0497U | Oncology (prostate), mRNA gene-expression profiling by real-time RT-PCR of 6 genes (FOXM1, MCM3, MTUS1, TTC21B, ALAS1, and PPP2CA), utilizing formalin-fixed paraffin-embedded | Standard Local Prior Authorization Code List, Pg 77 Original policy |
| 0498U | Oncology (colorectal), next-generation sequencing for mutation detection in 43 genes and methylation pattern in 45 genes, blood, and formalin-fixed paraffin-embedded (FFPE) ti | Standard Local Prior Authorization Code List, Pg 78 Original policy |