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Blue Cross and Blue Shield of Montana prior authorization, page 14

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

Prior authorization codes
CodeDescriptionSource
81167Brca2 (Brca2 Dna Repair Associated) (Eg Hereditary Breast And Ovarian Cancer) Gene Analysis; Full Duplication/Deletion Analysis (Ie Detection Of Large Gene Rearrangements)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 102 Original policy
81168Ccnd1/Igh (T(11;14)) (Eg Mantle Cell Lymphoma) Translocation Analysis Major Breakpoint Qualitative And Quantitative Performed2026 Commercial Medical Surgical Prior Authorization Code List, Pg 102 Original policy
81170Abl1 (Abl Proto-Oncogene 1 Non-Receptor Tyrosine Kinase) (Eg Acquired Imatinib Tyrosine Kinase Inhibitor Resistance) Gene Analysis Variants In The Kinase Domain2026 Commercial Medical Surgical Prior Authorization Code List, Pg 102 Original policy
81171Aff2 (Alf Transcription Elongation Factor 2 [Fmr2]) (Eg Fragile X Intellectual Disability 2 [Fraxe]) Gene Analysis; Evaluation To Detect Abnormal (Eg Expanded) Alleles2026 Commercial Medical Surgical Prior Authorization Code List, Pg 102 Original policy
81172Aff2 (Alf Transcription Elongation Factor 2 [Fmr2]) (Eg Fragile X Intellectual Disability 2 [Fraxe]) Gene Analysis; Characterization Of Alleles (Eg Expanded Size And Methylation Status)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 102 Original policy
81173Ar (Androgen Receptor) (Eg Spinal And Bulbar Muscular Atrophy Kennedy Disease X Chromosome Inactivation) Gene Analysis; Full Gene Sequence2026 Commercial Medical Surgical Prior Authorization Code List, Pg 102 Original policy
81174Ar (Androgen Receptor) (Eg Spinal And Bulbar Muscular Atrophy Kennedy Disease X Chromosome Inactivation) Gene Analysis; Known Familial Variant2026 Commercial Medical Surgical Prior Authorization Code List, Pg 103 Original policy
81175Asxl1 (Additional Sex Combs Like 1 Transcriptional Regulator) (Eg Myelodysplastic Syndrome Myeloproliferative Neoplasms Chronic Myelomonocytic Leukemia) Gene Analysis; Full Gene Sequence2026 Commercial Medical Surgical Prior Authorization Code List, Pg 103 Original policy
81176Asxl1 (Additional Sex Combs Like 1 Transcriptional Regulator) (Eg Myelodysplastic Syndrome Myeloproliferative Neoplasms Chronic Myelomonocytic Leukemia) Gene Analysis; Targeted Sequence Analysis (Eg Exon 12)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 103 Original policy
81177Atn1 (Atrophin 1) (Eg Dentatorubral- Pallidoluysian Atrophy) Gene Analysis Evaluation To Detect Abnormal (Eg Expanded) Alleles2026 Commercial Medical Surgical Prior Authorization Code List, Pg 103 Original policy
81178Atxn1 (Ataxin 1) (Eg Spinocerebellar Ataxia) Gene Analysis Evaluation To Detect Abnormal (Eg Expanded) Alleles2026 Commercial Medical Surgical Prior Authorization Code List, Pg 103 Original policy
81179Atxn2 (Ataxin 2) (Eg Spinocerebellar Ataxia) Gene Analysis Evaluation To Detect Abnormal (Eg Expanded) Alleles2026 Commercial Medical Surgical Prior Authorization Code List, Pg 103 Original policy
81180Atxn3 (Ataxin 3) (Eg Spinocerebellar Ataxia Machado-Joseph Disease) Gene Analysis Evaluation To Detect Abnormal (Eg Expanded) Alleles2026 Commercial Medical Surgical Prior Authorization Code List, Pg 104 Original policy
81181Atxn7 (Ataxin 7) (Eg Spinocerebellar Ataxia) Gene Analysis Evaluation To Detect Abnormal (Eg Expanded) Alleles2026 Commercial Medical Surgical Prior Authorization Code List, Pg 104 Original policy
81182Atxn8Os (Atxn8 Opposite Strand [Non- Protein Coding]) (Eg Spinocerebellar Ataxia) Gene Analysis Evaluation To Detect Abnormal (Eg Expanded) Alleles2026 Commercial Medical Surgical Prior Authorization Code List, Pg 104 Original policy
81183Atxn10 (Ataxin 10) (Eg Spinocerebellar Ataxia) Gene Analysis Evaluation To Detect Abnormal (Eg Expanded) Alleles2026 Commercial Medical Surgical Prior Authorization Code List, Pg 104 Original policy
81184Cacna1A (Calcium Voltage-Gated Channel Subunit Alpha1 A) (Eg Spinocerebellar Ataxia) Gene Analysis; Evaluation To Detect Abnormal (Eg Expanded) Alleles2026 Commercial Medical Surgical Prior Authorization Code List, Pg 104 Original policy
81185Cacna1A (Calcium Voltage-Gated Channel Subunit Alpha1 A) (Eg Spinocerebellar Ataxia) Gene Analysis; Full Gene Sequence2026 Commercial Medical Surgical Prior Authorization Code List, Pg 104 Original policy
81186Cacna1A (Calcium Voltage-Gated Channel Subunit Alpha1 A) (Eg Spinocerebellar Ataxia) Gene Analysis; Known Familial Variant2026 Commercial Medical Surgical Prior Authorization Code List, Pg 104 Original policy
81187Cnbp (Cchc-Type Zinc Finger Nucleic Acid Binding Protein) (Eg Myotonic Dystrophy Type 2) Gene Analysis Evaluation To Detect Abnormal (Eg Expanded) Alleles2026 Commercial Medical Surgical Prior Authorization Code List, Pg 105 Original policy
81188Cstb (Cystatin B) (Eg Unverricht-Lundborg Disease) Gene Analysis; Evaluation To Detect Abnormal (Eg Expanded) Alleles2026 Commercial Medical Surgical Prior Authorization Code List, Pg 105 Original policy
81189Cstb (Cystatin B) (Eg Unverricht-Lundborg Disease) Gene Analysis; Full Gene Sequence2026 Commercial Medical Surgical Prior Authorization Code List, Pg 105 Original policy
81190Cstb (Cystatin B) (Eg Unverricht-Lundborg Disease) Gene Analysis; Known Familial Variant(S)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 105 Original policy
81191Ntrk1 (Neurotrophic Receptor Tyrosine Kinase 1) (Eg Solid Tumors) Translocation Analysis2026 Commercial Medical Surgical Prior Authorization Code List, Pg 105 Original policy
81192Ntrk2 (Neurotrophic Receptor Tyrosine Kinase 2) (Eg Solid Tumors) Translocation Analysis2026 Commercial Medical Surgical Prior Authorization Code List, Pg 105 Original policy
81193Ntrk3 (Neurotrophic Receptor Tyrosine Kinase 3) (Eg Solid Tumors) Translocation Analysis2026 Commercial Medical Surgical Prior Authorization Code List, Pg 105 Original policy
81194Ntrk (Neurotrophic Receptor Tyrosine Kinase 1 2 And 3) (Eg Solid Tumors) Translocation Analysis2026 Commercial Medical Surgical Prior Authorization Code List, Pg 105 Original policy
81195Cytogenomic (genome-wide) analysis, hematologic malignancy, structural variants and copy number variants, optical genome mapping (OGM)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 106 Original policy
81200Aspa (Aspartoacylase) (Eg Canavan Disease) Gene Analysis Common Variants (Eg E285A Y231X)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 106 Original policy
81201Apc (Adenomatous Polyposis Coli) (Eg Familial Adenomatosis Polyposis [Fap] Attenuated Fap) Gene Analysis; Full Gene Sequence2026 Commercial Medical Surgical Prior Authorization Code List, Pg 106 Original policy
81202Apc (Adenomatous Polyposis Coli) (Eg Familial Adenomatosis Polyposis [Fap] Attenuated Fap) Gene Analysis; Known Familial Variants2026 Commercial Medical Surgical Prior Authorization Code List, Pg 106 Original policy
81203Apc (Adenomatous Polyposis Coli) (Eg Familial Adenomatosis Polyposis [Fap] Attenuated Fap) Gene Analysis; Duplication/Deletion Variants2026 Commercial Medical Surgical Prior Authorization Code List, Pg 106 Original policy
81204Ar (Androgen Receptor) (Eg Spinal And Bulbar Muscular Atrophy Kennedy Disease X Chromosome Inactivation) Gene Analysis; Characterization Of Alleles (Eg Expanded Size Or Methylation Status)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 106 Original policy
81205Bckdhb (Branched-Chain Keto Acid Dehydrogenase E1 Beta Polypeptide) (Eg Maple Syrup Urine Disease) Gene Analysis Common Variants (Eg R183P G278S E422X)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 107 Original policy
81208Bcr/Abl1 (T(9;22)) (Eg Chronic Myelogenous Leukemia) Translocation Analysis; Other Breakpoint Qualitative Or Quantitative2026 Commercial Medical Surgical Prior Authorization Code List, Pg 107 Original policy
81209Blm (Bloom Syndrome Recq Helicase- Like) (Eg Bloom Syndrome) Gene Analysis 2281Del6Ins7 Variant2026 Commercial Medical Surgical Prior Authorization Code List, Pg 107 Original policy
81210Braf (B-Raf Proto-Oncogene Serine/Threonine Kinase) (Eg Colon Cancer Melanoma) Gene Analysis V600 Variant(S)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 107 Original policy
81212Brca1 (Brca1 Dna Repair Associated) Brca2 (Brca2 Dna Repair Associated) (Eg Hereditary Breast And Ovarian Cancer) Gene Analysis; 185Delag 5385Insc 6174Delt Variants2026 Commercial Medical Surgical Prior Authorization Code List, Pg 107 Original policy
81215Brca1 (Brca1 Dna Repair Associated) (Eg Hereditary Breast And Ovarian Cancer) Gene Analysis; Known Familial Variant2026 Commercial Medical Surgical Prior Authorization Code List, Pg 107 Original policy
81216Brca2 (Brca2 Dna Repair Associated) (Eg Hereditary Breast And Ovarian Cancer) Gene Analysis; Full Sequence Analysis2026 Commercial Medical Surgical Prior Authorization Code List, Pg 107 Original policy
81217Brca2 (Brca2 Dna Repair Associated) (Eg Hereditary Breast And Ovarian Cancer) Gene Analysis; Known Familial Variant2026 Commercial Medical Surgical Prior Authorization Code List, Pg 108 Original policy
81218Cebpa (Ccaat/Enhancer Binding Protein [C/Ebp] Alpha) (Eg Acute Myeloid Leukemia) Gene Analysis Full Gene Sequence2026 Commercial Medical Surgical Prior Authorization Code List, Pg 108 Original policy
81219Calr (Calreticulin) (Eg Myeloproliferative Disorders) Gene Analysis Common Variants In Exon 92026 Commercial Medical Surgical Prior Authorization Code List, Pg 108 Original policy
81221Cftr (Cystic Fibrosis Transmembrane Conductance Regulator) (Eg Cystic Fibrosis) Gene Analysis; Known Familial Variants2026 Commercial Medical Surgical Prior Authorization Code List, Pg 108 Original policy
81222Cftr (Cystic Fibrosis Transmembrane Conductance Regulator) (Eg Cystic Fibrosis) Gene Analysis; Duplication/Deletion Variants2026 Commercial Medical Surgical Prior Authorization Code List, Pg 108 Original policy
81223Cftr (Cystic Fibrosis Transmembrane Conductance Regulator) (Eg Cystic Fibrosis) Gene Analysis; Full Gene Sequence2026 Commercial Medical Surgical Prior Authorization Code List, Pg 108 Original policy
81224Cftr (Cystic Fibrosis Transmembrane Conductance Regulator) (Eg Cystic Fibrosis) Gene Analysis; Intron 8 Poly-T Analysis (Eg Male Infertility)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 108 Original policy
81225Cyp2C19 (Cytochrome P450 Family 2 Subfamily C Polypeptide 19) (Eg Drug Metabolism) Gene Analysis Common Variants (Eg *2 *3 *4 *8 *17)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 109 Original policy
81226Cyp2D6 (Cytochrome P450 Family 2 Subfamily D Polypeptide 6) (Eg Drug Metabolism) Gene Analysis Common Variants (Eg *2 *3 *4 *5 *6 *9 *10 *17 *19 *29 *35 *41 *1Xn *2Xn *4Xn)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 109 Original policy
81227Cyp2C9 (Cytochrome P450 Family 2 Subfamily C Polypeptide 9) (Eg Drug Metabolism) Gene Analysis Common Variants (Eg *2 *3 *5 *6)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 109 Original policy

Sources

Disclaimer

The information provided on this page is for general informational purposes only and does not constitute billing, coding, or reimbursement advice. Nothing on this page should be relied upon as a substitute for clinician assessment, professional billing guidance, or as a definitive statement of any payor's billing requirements or policies.

Payor agreements, fee schedules, and billing policies vary and are subject to change. Before submitting any claims related to maternity care services, including claims affected by the 2027 CPT code revisions, please consult the applicable payor agreements, coverage policies, and billing guidelines to confirm current requirements for their specific payor contracts.

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