Anthem Blue Cross Blue Shield of Georgia prior authorization, page 29
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 |
|---|---|---|
| 0499U | Oncology (colorectal and lung), DNA from formalin- fixed paraffin-embedded (FFPE) tissue, next- generation sequencing of 8 genes (NRAS, EGFR, CTNNB1, PIK3CA, APC, BRAF, KRAS, an | Standard Local Prior Authorization Code List, Pg 78 Original policy |
| 0500U | Autoinflammatory disease (VEXAS syndrome), DNA, UBA1 gene mutations, targeted variant analysis (M41T, M41V, M41L, c.118-2A>C, c.118- 1G>C, c.118-9_118-2del, S56F, S621C) | Standard Local Prior Authorization Code List, Pg 78 Original policy |
| 0506U | Gastroenterology (Barrett's esophagus), esophageal cells, DNA methylation analysis by next- generation sequencing of at least 89 differentially methylated genomic regions, algo | Standard Local Prior Authorization Code List, Pg 78 Original policy |
| 0507U | Oncology (ovarian), DNA, whole-genome sequencing with 5-hydroxymethylcytosine (5hmC) enrichment, using whole blood or plasma, algorithm reported as cancer detected or not dete | Standard Local Prior Authorization Code List, Pg 78 Original policy |
| 0516U | Drug metabolism, whole blood, pharmacogenomic genotyping of 40 genes and CYP2D6 copy number variant analysis, reported as metabolizer status | Standard Local Prior Authorization Code List, Pg 78 Original policy |
| 0523U | Oncology (solid tumor), DNA, qualitative, next- generation sequencing (NGS) of singlenucleotide variants (SNV) and insertion/deletions in 22 genes utilizing formalin-fixed par | Standard Local Prior Authorization Code List, Pg 78 Original policy |
| 0524T | Endovenous catheter directed chemical ablation with balloon isolation of incompetent extremity vein, open or percutaneous, including all vascular access, catheter manipulation, diagnostic imaging, imaging guidance and monitoring | Standard Local Prior Authorization Code List, Pg 78 Original policy |
| 0529U | Hematology (venous thromboembolism [VTE]), genome-wide single-nucleotide polymorphism variants, including F2 and F5 gene analysis, and Leiden variant, by microarray analysis | Standard Local Prior Authorization Code List, Pg 78 Original policy |
| 0530U | Oncology (pan-solid tumor), ctDNA, utilizing plasma, nextgeneration sequencing (NGS) of 77 genes, 8 fusions, microsatellite instability, and tumor mutation burden, interpreta | Standard Local Prior Authorization Code List, Pg 78 Original policy |
| 0532U | Rare diseases (constitutional disease/hereditary disorders), rapid whole genome and mitochondrial DNA sequencing for single-nucleotide variants, insertions/deletions, copy num | Standard Local Prior Authorization Code List, Pg 78 Original policy |
| 0533U | Drug metabolism (adverse drug reactions and drug response), genotyping of 16 genes (ie, ABCG2, CYP2B6, CYP2C9, CYP2C19, CYP2C, CYP2D6, CYP3A5, CYP4F2, DPYD, G6PD, GGCX, NUDT15 | Standard Local Prior Authorization Code List, Pg 78 Original policy |
| 0534U | Oncology (prostate), microRNA, single-nucleotide polymorphisms (SNPs) analysis by RT-PCR of 32 variants, using buccal swab, algorithm reported as a risk score | Standard Local Prior Authorization Code List, Pg 78 Original policy |
| 0536U | Red blood cell antigen (fetal RhD), PCR analysis of exon 4 of RHD gene and housekeeping control gene GAPDH from whole blood in pregnant individuals at 10+ weeks gestation know | Standard Local Prior Authorization Code List, Pg 78 Original policy |
| 0537U | Oncology (colorectal cancer), analysis of cell-free DNA for epigenomic patterns, next-generation sequencing, >2500 differentially methylated regions (DMRs), plasma, algorithm | Standard Local Prior Authorization Code List, Pg 78 Original policy |
| 0538U | Oncology (solid tumor), next-generation targeted sequencing analysis, formalin-fixed paraffin- embedded (FFPE) tumor tissue, DNA analysis of 600 genes, interrogation for single | Standard Local Prior Authorization Code List, Pg 78 Original policy |
| 0539U | Oncology (solid tumor), cell-free circulating tumor DNA (ctDNA), 152 genes, next-generation sequencing, interrogation for single-nucleotide variants, insertions/deletions, gen | Standard Local Prior Authorization Code List, Pg 78 Original policy |
| 0540U | Transplantation medicine, quantification of donor- derived cell-free DNA using next-generation sequencing analysis of plasma, reported as percentage of donor-derived cell-free | Standard Local Prior Authorization Code List, Pg 78 Original policy |
| 0543U | Oncology (solid tumor), next-generation sequencing of DNA from formalin-fixed paraffin- embedded (FFPE) tissue of 517 genes, interrogation for single-nucleotide variants, multi | Standard Local Prior Authorization Code List, Pg 78 Original policy |
| 0549U | Oncology (urothelial), DNA, quantitative methylated real-time PCR of TRNA-Cys, SIM2, and NKX1-1, using urine, diagnostic algorithm reported as a probability index for bladder | Standard Local Prior Authorization Code List, Pg 78 Original policy |
| 0552T | Low-level laser therapy, dynamic photonic and dynamic thermokinetic energies, provided by a physician or other qualified health care professional | Standard Local Prior Authorization Code List, Pg 79 Original policy |
| 0552U | Reproductive medicine (preimplantation genetic assessment), analysis for known genetic disorders from trophectoderm biopsy, linkage analysis of disease-causing locus, and when | Standard Local Prior Authorization Code List, Pg 79 Original policy |
| 0553U | Reproductive medicine (preimplantation genetic assessment), analysis of 24 chromosomes using DNA genomic sequence analysis from embryonic trophectoderm for structural rearrang | Standard Local Prior Authorization Code List, Pg 79 Original policy |
| 0554U | Reproductive medicine (preimplantation genetic assessment), analysis of 24 chromosomes using DNA genomic sequence analysis from trophectoderm biopsy for aneuploidy, ploidy, a | Standard Local Prior Authorization Code List, Pg 79 Original policy |
| 0555U | Reproductive medicine (preimplantation genetic assessment), analysis of 24 chromosomes using DNA genomic sequence analysis from embryonic trophectoderm for structural rearrang | Standard Local Prior Authorization Code List, Pg 79 Original policy |
| 0560U | Oncology (minimal residual disease [MRD]), genomic sequence analysis, cell-free DNA, whole blood and tumor tissue, baseline assessment for design and construction of a persona | Standard Local Prior Authorization Code List, Pg 79 Original policy |
| 0561U | Oncology (minimal residual disease [MRD]), genomic sequence analysis, cell-free DNA, whole blood, subsequent assessment with comparison to initial assessment to evaluate for M | Standard Local Prior Authorization Code List, Pg 79 Original policy |
| 0562U | Oncology (solid tumor), targeted genomic sequence analysis, 33 genes, detection of single- nucleotide variants (SNVs), insertions and deletions, copy-number amplifications, and | Standard Local Prior Authorization Code List, Pg 79 Original policy |
| 0565U | Oncology (hepatocellular carcinoma), next- generation sequencing methylation pattern assay to detect 6626 epigenetic alterations, cell-free DNA, plasma, algorithm reported as c | Standard Local Prior Authorization Code List, Pg 79 Original policy |
| 0566U | Oncology (lung), qPCR-based analysis of 13 differentially methylated regions (CCDC181, HOXA7, LRRC8A, MARCHF11, MIR129-2, NCOR2, PANTR1, PRKCB, SLC9A3, TBR1_2, TRAP1, VWC2, ZN | Standard Local Prior Authorization Code List, Pg 79 Original policy |
| 0567U | Rare diseases (constitutional/heritable disorders), whole-genome sequence analysis combination of short and long reads, for single-nucleotide variants, insertions/deletions an | Standard Local Prior Authorization Code List, Pg 79 Original policy |
| 0569U | Oncology (solid tumor), next-generation sequencing analysis of tumor methylation markers (>20000 differentially methylated regions) present in cell-free circulating tumor DNA | Standard Local Prior Authorization Code List, Pg 79 Original policy |
| 0571T | Insertion or replacement of implantable cardioverter- defibrillator system with substernal electrode(s), including all imaging guidance and electrophysiological evaluation (inc | Standard Local Prior Authorization Code List, Pg 79 Original policy |
| 0571U | Oncology (solid tumor), DNA (80 genes) and RNA (10 genes), by next-generation sequencing, plasma, including single-nucleotide variants, insertions/deletions, copy-number alter | Standard Local Prior Authorization Code List, Pg 79 Original policy |
| 0572T | Insertion of substernal implantable defibrillator electrode | Standard Local Prior Authorization Code List, Pg 79 Original policy |
| 0573T | Removal of substernal implantable defibrillator electrode | Standard Local Prior Authorization Code List, Pg 79 Original policy |
| 0574T | Repositioning of previously implanted substernal implantable defibrillator-pacing electrode | Standard Local Prior Authorization Code List, Pg 79 Original policy |
| 0575U | Transplantation medicine (liver allograft rejection), miRNA gene expression profiling by RT-PCR of 4 genes (miR-122, miR-885, miR-23a housekeeping, spike-in control), serum, a | Standard Local Prior Authorization Code List, Pg 79 Original policy |
| 0576U | Transplantation medicine (liver allograft rejection), quantitative donor-derived cell-free DNA (cfDNA) by whole genome next-generation sequencing, plasma and mRNA gene express | Standard Local Prior Authorization Code List, Pg 80 Original policy |
| 0578U | Oncology (cutaneous melanoma), RNA, gene expression profiling by real-time qPCR of 10 genes (8 content and 2 housekeeping), utilizing formalin- fixed paraffin-embedded (FFPE) t | Standard Local Prior Authorization Code List, Pg 80 Original policy |
| 0580T | Removal of substernal implantable defibrillator pulse generator only | Standard Local Prior Authorization Code List, Pg 80 Original policy |
| 0581T | Ablation, malignant breast tumor(s), percutaneous, cryotherapy, including imaging guidance when performed, unilateral | Standard Local Prior Authorization Code List, Pg 80 Original policy |
| 0582U | Rare diseases (constitutional disease/hereditary disorders), rapid whole genome DNA sequencing for single-nucleotide variants, insertions/deletions, copy number variations, bl | Standard Local Prior Authorization Code List, Pg 80 Original policy |
| 0583U | Rare diseases (constitutional disease/hereditary disorders), rapid whole genome comparator DNA sequencing for single-nucleotide variants, insertions/deletions, copy number var | Standard Local Prior Authorization Code List, Pg 80 Original policy |
| 0585U | Targeted genomic sequence analysis panel, solid organ neoplasm, circulating cell-free DNA (cfDNA) analysis from plasma of 521 genes, interrogation for sequence variants, gene | Standard Local Prior Authorization Code List, Pg 80 Original policy |
| 0586U | Oncology, mRNA, gene expression profiling of 216 genes (204 targeted and 12 housekeeping genes), RNA expression analysis, formalin-fixed paraffin- embedded (FFPE) tissue, quant | Standard Local Prior Authorization Code List, Pg 80 Original policy |
| 0592U | Oncology (hematolymphoid neoplasms), DNA, targeted genomic sequence of 417 genes, interrogation for gene fusions, translocations, rearrangements, utilizing formalin-fixed para | Standard Local Prior Authorization Code List, Pg 80 Original policy |
| 0597U | Oncology (breast), RNA expression profiling of 329 genes by targeted next-generation sequencing and 20 proteins by multiplex immunofluorescence, formalin-fixed paraffin-embedd | Standard Local Prior Authorization Code List, Pg 80 Original policy |
| 0605U | Allergy and immunology (hereditary alpha tryptasemia), DNA, analysis of TPSAB1 gene copy number variation using digital PCR, whole blood, results reported with genotype-specific interpretation of alpha-tryptase copy number and algorithmic classification as normal or abnormal | Standard Local Prior Authorization Code List, Pg 80 Original policy |
| 0611U | Oncology (liver), analysis of over 1,000 methylated regions, cell-free DNA from plasma, algorithm reported as a quantitative result | Standard Local Prior Authorization Code List, Pg 80 Original policy |
| 0612U | Oncology (liver), analysis of over 1,000 methylated regions, cell-free DNA from plasma, algorithm reported as a quantitative result | Standard Local Prior Authorization Code List, Pg 80 Original policy |