Blue Cross and Blue Shield of Montana prior authorization, page 15
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 |
|---|---|---|
| 81228 | Cytogenomic (Genome-Wide) Analysis For Constitutional Chromosomal Abnormalities; Interrogation Of Genomic Regions For Copy Number Variants Comparative Genomic Hybridization [Cgh] Microarray Analysis | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 109 Original policy |
| 81229 | Cytogenomic (Genome-Wide) Analysis For Constitutional Chromosomal Abnormalities; Interrogation Of Genomic Regions For Copy Number And Single Nucleotide Polymorphism (Snp) Variants Comparative Genomic Hybridization (Cgh) Microarray Analysis | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 109 Original policy |
| 81230 | Cyp3A4 (Cytochrome P450 Family 3 Subfamily A Member 4) (Eg Drug Metabolism) Gene Analysis Common Variant(S) (Eg *2 *22) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 110 Original policy |
| 81231 | Cyp3A5 (Cytochrome P450 Family 3 Subfamily A Member 5) (Eg Drug Metabolism) Gene Analysis Common Variants (Eg *2 *3 *4 *5 *6 *7) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 110 Original policy |
| 81232 | Dpyd (Dihydropyrimidine Dehydrogenase) (Eg 5-Fluorouracil/5-Fu And Capecitabine Drug Metabolism) Gene Analysis Common Variant(S) (Eg *2A *4 *5 *6) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 110 Original policy |
| 81233 | Btk (Bruton'S Tyrosine Kinase) (Eg Chronic Lymphocytic Leukemia) Gene Analysis Common Variants (Eg C481S C481R C481F) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 110 Original policy |
| 81234 | Dmpk (Dm1 Protein Kinase) (Eg Myotonic Dystrophy Type 1) Gene Analysis; Evaluation To Detect Abnormal (Expanded) Alleles | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 110 Original policy |
| 81235 | Egfr (Epidermal Growth Factor Receptor) (Eg Non-Small Cell Lung Cancer) Gene Analysis Common Variants (Eg Exon 19 Lrea Deletion L858R T790M G719A G719S L861Q) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 110 Original policy |
| 81236 | Ezh2 (Enhancer Of Zeste 2 Polycomb Repressive Complex 2 Subunit) (Eg Myelodysplastic Syndrome Myeloproliferative Neoplasms) Gene Analysis Full Gene Sequence | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 111 Original policy |
| 81237 | Ezh2 (Enhancer Of Zeste 2 Polycomb Repressive Complex 2 Subunit) (Eg Diffuse Large B-Cell Lymphoma) Gene Analysis Common Variant(S) (Eg Codon 646) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 111 Original policy |
| 81238 | F9 (Coagulation Factor Ix) (Eg Hemophilia B) Full Gene Sequence | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 111 Original policy |
| 81239 | Dmpk (Dm1 Protein Kinase) (Eg Myotonic Dystrophy Type 1) Gene Analysis; Characterization Of Alleles (Eg Expanded Size) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 111 Original policy |
| 81240 | F2 (Prothrombin Coagulation Factor Ii) (Eg Hereditary Hypercoagulability) Gene Analysis 20210G>A Variant | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 111 Original policy |
| 81242 | Fancc (Fanconi Anemia Complementation Group C) (Eg Fanconi Anemia Type C) Gene Analysis Common Variant (Eg Ivs4+4A>T) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 111 Original policy |
| 81244 | Fmr1 (Fragile X Messenger Ribonucleoprotein 1) (Eg Fragile X Syndrome X-Linked Intellectual Disability [Xlid]) Gene Analysis; Characterization Of Alleles (Eg Expanded Size And Promoter Methylation Status) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 112 Original policy |
| 81245 | Flt3 (Fms-Related Tyrosine Kinase 3) (Eg Acute Myeloid Leukemia) Gene Analysis; Internal Tandem Duplication (Itd) Variants (Ie Exons 14 15) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 112 Original policy |
| 81246 | Flt3 (Fms-Related Tyrosine Kinase 3) (Eg Acute Myeloid Leukemia) Gene Analysis; Tyrosine Kinase Domain (Tkd) Variants (Eg D835 I836) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 112 Original policy |
| 81247 | G6Pd (Glucose-6-Phosphate Dehydrogenase) (Eg Hemolytic Anemia Jaundice) Gene Analysis; Common Variant(S) (Eg A A-) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 112 Original policy |
| 81248 | G6Pd (Glucose-6-Phosphate Dehydrogenase) (Eg Hemolytic Anemia Jaundice) Gene Analysis; Known Familial Variant(S) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 112 Original policy |
| 81249 | G6Pd (Glucose-6-Phosphate Dehydrogenase) (Eg Hemolytic Anemia Jaundice) Gene Analysis; Full Gene Sequence | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 112 Original policy |
| 81250 | G6Pc (Glucose-6-Phosphatase Catalytic Subunit) (Eg Glycogen Storage Disease Type 1A Von Gierke Disease) Gene Analysis Common Variants (Eg R83C Q347X) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 113 Original policy |
| 81251 | Gba (Glucosidase Beta Acid) (Eg Gaucher Disease) Gene Analysis Common Variants (Eg N370S 84Gg L444P Ivs2+1G>A) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 113 Original policy |
| 81252 | Gjb2 (Gap Junction Protein Beta 2 26Kda Connexin 26) (Eg Nonsyndromic Hearing Loss) Gene Analysis; Full Gene Sequence | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 113 Original policy |
| 81253 | Gjb2 (Gap Junction Protein Beta 2 26Kda Connexin 26) (Eg Nonsyndromic Hearing Loss) Gene Analysis; Known Familial Variants | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 113 Original policy |
| 81254 | Gjb6 (Gap Junction Protein Beta 6 30Kda Connexin 30) (Eg Nonsyndromic Hearing Loss) Gene Analysis Common Variants (Eg 309Kb [Del(Gjb6-D13S1830)] And 232Kb [Del(Gjb6-D13S1854)]) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 113 Original policy |
| 81255 | Hexa (Hexosaminidase A [Alpha Polypeptide]) (Eg Tay-Sachs Disease) Gene Analysis Common Variants (Eg 1278Instatc 1421+1G>C G269S) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 113 Original policy |
| 81256 | Hfe (Hemochromatosis) (Eg Hereditary Hemochromatosis) Gene Analysis Common Variants (Eg C282Y H63D) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 113 Original policy |
| 81257 | Hba1/Hba2 (Alpha Globin 1 And Alpha Globin 2) (Eg Alpha Thalassemia Hb Bart Hydrops Fetalis Syndrome Hbh Disease) Gene Analysis; Common Deletions Or Variant (Eg Southeast Asian Thai Filipino Mediterranean Alpha3.7 Alpha4.2 Alpha20.5 Constant Spring) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 114 Original policy |
| 81258 | Hba1/Hba2 (Alpha Globin 1 And Alpha Globin 2) (Eg Alpha Thalassemia Hb Bart Hydrops Fetalis Syndrome Hbh Disease) Gene Analysis; Known Familial Variant | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 114 Original policy |
| 81259 | Hba1/Hba2 (Alpha Globin 1 And Alpha Globin 2) (Eg Alpha Thalassemia Hb Bart Hydrops Fetalis Syndrome Hbh Disease) Gene Analysis; Full Gene Sequence | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 114 Original policy |
| 81260 | Ikbkap (Inhibitor Of Kappa Light Polypeptide Gene Enhancer In B-Cells Kinase Complex-Associated Protein) (Eg Familial Dysautonomia) Gene Analysis Common Variants (Eg 2507+6T>C R696P) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 114 Original policy |
| 81261 | Igh@ (Immunoglobulin Heavy Chain Locus) (Eg Leukemias And Lymphomas B-Cell) Gene Rearrangement Analysis To Detect Abnormal Clonal Population(S); Amplified Methodology (Eg Polymerase Chain Reaction) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 114 Original policy |
| 81262 | Igh@ (Immunoglobulin Heavy Chain Locus) (Eg Leukemias And Lymphomas B-Cell) Gene Rearrangement Analysis To Detect Abnormal Clonal Population(S); Direct Probe Methodology (Eg Southern Blot) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 115 Original policy |
| 81263 | Igh@ (Immunoglobulin Heavy Chain Locus) (Eg Leukemia And Lymphoma B-Cell) Variable Region Somatic Mutation Analysis | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 115 Original policy |
| 81264 | Igk@ (Immunoglobulin Kappa Light Chain Locus) (Eg Leukemia And Lymphoma B- Cell) Gene Rearrangement Analysis Evaluation To Detect Abnormal Clonal Population(S) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 115 Original policy |
| 81269 | Hba1/Hba2 (Alpha Globin 1 And Alpha Globin 2) (Eg Alpha Thalassemia Hb Bart Hydrops Fetalis Syndrome Hbh Disease) Gene Analysis; Duplication/Deletion Variants | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 116 Original policy |
| 81270 | Jak2 (Janus Kinase 2) (Eg Myeloproliferative Disorder) Gene Analysis P.Val617Phe (V617F) Variant | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 116 Original policy |
| 81271 | Htt (Huntingtin) (Eg Huntington Disease) Gene Analysis; Evaluation To Detect Abnormal (Eg Expanded) Alleles | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 116 Original policy |
| 81272 | Kit (V-Kit Hardy-Zuckerman 4 Feline Sarcoma Viral Oncogene Homolog) (Eg Gastrointestinal Stromal Tumor [Gist] Acute Myeloid Leukemia Melanoma) Gene Analysis Targeted Sequence Analysis (Eg Exons 8 11 13 17 18) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 116 Original policy |
| 81273 | Kit (V-Kit Hardy-Zuckerman 4 Feline Sarcoma Viral Oncogene Homolog) (Eg Mastocytosis) Gene Analysis D816 Variant(S) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 116 Original policy |
| 81274 | Htt (Huntingtin) (Eg Huntington Disease) Gene Analysis; Characterization Of Alleles (Eg Expanded Size) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 117 Original policy |
| 81275 | Kras (Kirsten Rat Sarcoma Viral Oncogene Homolog) (Eg Carcinoma) Gene Analysis; Variants In Exon 2 (Eg Codons 12 And 13) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 117 Original policy |
| 81276 | Kras (Kirsten Rat Sarcoma Viral Oncogene Homolog) (Eg Carcinoma) Gene Analysis; Additional Variant(S) (Eg Codon 61 Codon 146) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 117 Original policy |
| 81277 | Cytogenomic Neoplasia (Genome-Wide) Microarray Analysis Interrogation Of Genomic Regions For Copy Number And Loss-Of-Heterozygosity Variants For Chromosomal Abnormalities | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 117 Original policy |
| 81278 | Igh@/Bcl2 (T(14;18)) (Eg Follicular Lymphoma) Translocation Analysis Major Breakpoint Region (Mbr) And Minor Cluster Region (Mcr) Breakpoints Qualitative Or Quantitative | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 117 Original policy |
| 81279 | Jak2 (Janus Kinase 2) (Eg Myeloproliferative Disorder) Targeted Sequence Analysis (Eg Exons 12 And 13) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 117 Original policy |
| 81283 | Ifnl3 (Interferon Lambda 3) (Eg Drug Response) Gene Analysis Rs12979860 Variant | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 117 Original policy |
| 81284 | Fxn (Frataxin) (Eg Friedreich Ataxia) Gene Analysis; Evaluation To Detect Abnormal (Expanded) Alleles | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 118 Original policy |
| 81285 | Fxn (Frataxin) (Eg Friedreich Ataxia) Gene Analysis; Characterization Of Alleles (Eg Expanded Size) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 118 Original policy |
| 81286 | Fxn (Frataxin) (Eg Friedreich Ataxia) Gene Analysis; Full Gene Sequence | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 118 Original policy |