Blue Cross and Blue Shield of Montana prior authorization, page 16
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 |
|---|---|---|
| 81287 | Mgmt (O-6-Methylguanine-Dna Methyltransferase) (Eg Glioblastoma Multiforme) Promoter Methylation Analysis | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 118 Original policy |
| 81288 | Mlh1 (Mutl Homolog 1 Colon Cancer Nonpolyposis Type 2) (Eg Hereditary Non- Polyposis Colorectal Cancer Lynch Syndrome) Gene Analysis; Promoter Methylation Analysis | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 118 Original policy |
| 81289 | Fxn (Frataxin) (Eg Friedreich Ataxia) Gene Analysis; Known Familial Variant(S) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 118 Original policy |
| 81290 | Mcoln1 (Mucolipin 1) (Eg Mucolipidosis Type Iv) Gene Analysis Common Variants (Eg Ivs3-2A>G Del6.4Kb) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 118 Original policy |
| 81291 | Mthfr (5 10-Methylenetetrahydrofolate Reductase) (Eg Hereditary Hypercoagulability) Gene Analysis Common Variants (Eg 677T 1298C) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 118 Original policy |
| 81292 | Mlh1 (Mutl Homolog 1 Colon Cancer Nonpolyposis Type 2) (Eg Hereditary Non- Polyposis Colorectal Cancer Lynch Syndrome) Gene Analysis; Full Sequence Analysis | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 119 Original policy |
| 81293 | Mlh1 (Mutl Homolog 1 Colon Cancer Nonpolyposis Type 2) (Eg Hereditary Non- Polyposis Colorectal Cancer Lynch Syndrome) Gene Analysis; Known Familial Variants | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 119 Original policy |
| 81294 | Mlh1 (Mutl Homolog 1 Colon Cancer Nonpolyposis Type 2) (Eg Hereditary Non- Polyposis Colorectal Cancer Lynch Syndrome) Gene Analysis; Duplication/Deletion Variants | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 119 Original policy |
| 81295 | Msh2 (Muts Homolog 2 Colon Cancer Nonpolyposis Type 1) (Eg Hereditary Non- Polyposis Colorectal Cancer Lynch Syndrome) Gene Analysis; Full Sequence Analysis | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 119 Original policy |
| 81296 | Msh2 (Muts Homolog 2 Colon Cancer Nonpolyposis Type 1) (Eg Hereditary Non- Polyposis Colorectal Cancer Lynch Syndrome) Gene Analysis; Known Familial Variants | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 119 Original policy |
| 81297 | Msh2 (Muts Homolog 2 Colon Cancer Nonpolyposis Type 1) (Eg Hereditary Non- Polyposis Colorectal Cancer Lynch Syndrome) Gene Analysis; Duplication/Deletion Variants | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 120 Original policy |
| 81298 | Msh6 (Muts Homolog 6 [E. Coli]) (Eg Hereditary Non-Polyposis Colorectal Cancer Lynch Syndrome) Gene Analysis; Full Sequence Analysis | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 120 Original policy |
| 81299 | Msh6 (Muts Homolog 6 [E. Coli]) (Eg Hereditary Non-Polyposis Colorectal Cancer Lynch Syndrome) Gene Analysis; Known Familial Variants | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 120 Original policy |
| 81300 | Msh6 (Muts Homolog 6 [E. Coli]) (Eg Hereditary Non-Polyposis Colorectal Cancer Lynch Syndrome) Gene Analysis; Duplication/Deletion Variants | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 120 Original policy |
| 81301 | Microsatellite Instability Analysis (Eg Hereditary Non-Polyposis Colorectal Cancer Lynch Syndrome) Of Markers For Mismatch Repair Deficiency (Eg Bat25 Bat26) Includes Comparison Of Neoplastic And Normal Tissue If Performed | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 120 Original policy |
| 81302 | Mecp2 (Methyl Cpg Binding Protein 2) (Eg Rett Syndrome) Gene Analysis; Full Sequence Analysis | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 120 Original policy |
| 81303 | Mecp2 (Methyl Cpg Binding Protein 2) (Eg Rett Syndrome) Gene Analysis; Known Familial Variant | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 121 Original policy |
| 81304 | Mecp2 (Methyl Cpg Binding Protein 2) (Eg Rett Syndrome) Gene Analysis; Duplication/Deletion Variants | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 121 Original policy |
| 81305 | Myd88 (Myeloid Differentiation Primary Response 88) (Eg Waldenstrom'S Macroglobulinemia Lymphoplasmacytic Leukemia) Gene Analysis P.Leu265Pro (L265P) Variant | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 121 Original policy |
| 81306 | Nudt15 (Nudix Hydrolase 15) (Eg Drug Metabolism) Gene Analysis Common Variant(S) (Eg *2 *3 *4 *5 *6) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 121 Original policy |
| 81307 | Palb2 (Partner And Localizer Of Brca2) (Eg Breast And Pancreatic Cancer) Gene Analysis; Full Gene Sequence | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 121 Original policy |
| 81308 | Palb2 (Partner And Localizer Of Brca2) (Eg Breast And Pancreatic Cancer) Gene Analysis; Known Familial Variant | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 121 Original policy |
| 81309 | Pik3Ca (Phosphatidylinositol-4 5- Biphosphate 3-Kinase Catalytic Subunit Alpha) (Eg Colorectal And Breast Cancer) Gene Analysis Targeted Sequence Analysis (Eg Exons 7 9 20) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 121 Original policy |
| 81310 | Npm1 (Nucleophosmin) (Eg Acute Myeloid Leukemia) Gene Analysis Exon 12 Variants | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 121 Original policy |
| 81311 | Nras (Neuroblastoma Ras Viral [V-Ras] Oncogene Homolog) (Eg Colorectal Carcinoma) Gene Analysis Variants In Exon 2 (Eg Codons 12 And 13) And Exon 3 (Eg Codon 61) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 122 Original policy |
| 81312 | Pabpn1 (Poly[A] Binding Protein Nuclear 1) (Eg Oculopharyngeal Muscular Dystrophy) Gene Analysis Evaluation To Detect Abnormal (Eg Expanded) Alleles | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 122 Original policy |
| 81313 | Pca3/Klk3 (Prostate Cancer Antigen 3 [Non-Carelon Protein Coding]/Kallikrein-Related Peptidase 3 [Prostate Specific Antigen]) Ratio (Eg Prostate Cancer) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 122 Original policy |
| 81314 | Pdgfra (Platelet-Derived Growth Factor Receptor Alpha Polypeptide) (Eg Gastrointestinal Stromal Tumor [Gist]) Gene Analysis Targeted Sequence Analysis (Eg Exons 12 18) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 122 Original policy |
| 81315 | Pml/Raralpha (T(15;17)) (Promyelocytic Leukemia/Retinoic Acid Receptor Alpha) (Eg Promyelocytic Leukemia) Translocation Analysis; Common Breakpoints (Eg Intron 3 And Intron 6) Qualitative Or Quantitative | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 122 Original policy |
| 81316 | Pml/Raralpha (T(15;17)) (Promyelocytic Leukemia/Retinoic Acid Receptor Alpha) (Eg Promyelocytic Leukemia) Translocation Analysis; Single Breakpoint (Eg Intron 3 Intron 6 Or Exon 6) Qualitative Or Quantitative | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 123 Original policy |
| 81317 | Pms2 (Postmeiotic Segregation Increased 2 [S. Cerevisiae]) (Eg Hereditary Non- Polyposis Colorectal Cancer Lynch Syndrome) Gene Analysis; Full Sequence Analysis | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 123 Original policy |
| 81318 | Pms2 (Postmeiotic Segregation Increased 2 [S. Cerevisiae]) (Eg Hereditary Non- Polyposis Colorectal Cancer Lynch Syndrome) Gene Analysis; Known Familial Variants | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 123 Original policy |
| 81319 | Pms2 (Postmeiotic Segregation Increased 2 [S. Cerevisiae]) (Eg Hereditary Non- Polyposis Colorectal Cancer Lynch Syndrome) Gene Analysis; Duplication/Deletion Variants | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 123 Original policy |
| 81320 | Plcg2 (Phospholipase C Gamma 2) (Eg Chronic Lymphocytic Leukemia) Gene Analysis Common Variants (Eg R665W S707F L845F) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 123 Original policy |
| 81321 | Pten (Phosphatase And Tensin Homolog) (Eg Cowden Syndrome Pten Hamartoma Tumor Syndrome) Gene Analysis; Full Sequence Analysis | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 123 Original policy |
| 81322 | Pten (Phosphatase And Tensin Homolog) (Eg Cowden Syndrome Pten Hamartoma Tumor Syndrome) Gene Analysis; Known Familial Variant | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 124 Original policy |
| 81323 | Pten (Phosphatase And Tensin Homolog) (Eg Cowden Syndrome Pten Hamartoma Tumor Syndrome) Gene Analysis; Duplication/Deletion Variant | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 124 Original policy |
| 81324 | Pmp22 (Peripheral Myelin Protein 22) (Eg Charcot-Marie-Tooth Hereditary Neuropathy With Liability To Pressure Palsies) Gene Analysis; Duplication/Deletion Analysis | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 124 Original policy |
| 81325 | Pmp22 (Peripheral Myelin Protein 22) (Eg Charcot-Marie-Tooth Hereditary Neuropathy With Liability To Pressure Palsies) Gene Analysis; Full Sequence Analysis | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 124 Original policy |
| 81326 | Pmp22 (Peripheral Myelin Protein 22) (Eg Charcot-Marie-Tooth Hereditary Neuropathy With Liability To Pressure Palsies) Gene Analysis; Known Familial Variant | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 124 Original policy |
| 81327 | Sept9 (Septin9) (Eg Colorectal Cancer) Promoter Methylation Analysis | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 124 Original policy |
| 81328 | Slco1B1 (Solute Carrier Organic Anion Transporter Family Member 1B1) (Eg Adverse Drug Reaction) Gene Analysis Common Variant(S) (Eg *5) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 124 Original policy |
| 81330 | Smpd1 (Sphingomyelin Phosphodiesterase 1 Acid Lysosomal) (Eg Niemann-Pick Disease Type A) Gene Analysis Common Variants (Eg R496L L302P Fsp330) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 125 Original policy |
| 81331 | Snrpn/Ube3A (Small Nuclear Ribonucleoprotein Polypeptide N And Ubiquitin Protein Ligase E3A) (Eg Prader- Willi Syndrome And/Or Angelman Syndrome) Methylation Analysis | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 125 Original policy |
| 81332 | Serpina1 (Serpin Peptidase Inhibitor Clade A Alpha-1 Antiproteinase Antitrypsin Member 1) (Eg Alpha-1-Antitrypsin Deficiency) Gene Analysis Common Variants (Eg *S And *Z) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 125 Original policy |
| 81333 | Tgfbi (Transforming Growth Factor Beta- Induced) (Eg Corneal Dystrophy) Gene Analysis Common Variants (Eg R124H R124C R124L R555W R555Q) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 125 Original policy |
| 81334 | Runx1 (Runt Related Transcription Factor 1) (Eg Acute Myeloid Leukemia Familial Platelet Disorder With Associated Myeloid Malignancy) Gene Analysis Targeted Sequence Analysis (Eg Exons 3-8) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 125 Original policy |
| 81335 | Tpmt (Thiopurine S-Methyltransferase) (Eg Drug Metabolism) Gene Analysis Common Variants (Eg *2 *3) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 125 Original policy |
| 81336 | Smn1 (Survival Of Motor Neuron 1 Telomeric) (Eg Spinal Muscular Atrophy) Gene Analysis; Full Gene Sequence | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 126 Original policy |
| 81337 | Smn1 (Survival Of Motor Neuron 1 Telomeric) (Eg Spinal Muscular Atrophy) Gene Analysis; Known Familial Sequence Variant(S) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 126 Original policy |