Blue Cross and Blue Shield of Montana prior authorization, page 17
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 |
|---|---|---|
| 81338 | Mpl (Mpl Proto-Oncogene Thrombopoietin Receptor) (Eg Myeloproliferative Disorder) Gene Analysis; Common Variants (Eg W515A W515K W515L W515R) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 126 Original policy |
| 81339 | Mpl (Mpl Proto-Oncogene Thrombopoietin Receptor) (Eg Myeloproliferative Disorder) Gene Analysis; Sequence Analysis Exon 10 | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 126 Original policy |
| 81340 | Trb@ (T Cell Antigen Receptor Beta) (Eg Leukemia And Lymphoma) Gene Rearrangement Analysis To Detect Abnormal Clonal Population(S); Using Amplification Methodology (Eg Polymerase Chain Reaction) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 126 Original policy |
| 81341 | Trb@ (T Cell Antigen Receptor Beta) (Eg Leukemia And Lymphoma) Gene Rearrangement Analysis To Detect Abnormal Clonal Population(S); Using Direct Probe Methodology (Eg Southern Blot) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 126 Original policy |
| 81342 | Trg@ (T Cell Antigen Receptor Gamma) (Eg Leukemia And Lymphoma) Gene Rearrangement Analysis Evaluation To Detect Abnormal Clonal Population(S) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 127 Original policy |
| 81343 | Ppp2R2B (Protein Phosphatase 2 Regulatory Subunit Bbeta) (Eg Spinocerebellar Ataxia) Gene Analysis Evaluation To Detect Abnormal (Eg Expanded) Alleles | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 127 Original policy |
| 81344 | Tbp (Tata Box Binding Protein) (Eg Spinocerebellar Ataxia) Gene Analysis Evaluation To Detect Abnormal (Eg Expanded) Alleles | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 127 Original policy |
| 81345 | Tert (Telomerase Reverse Transcriptase) (Eg Thyroid Carcinoma Glioblastoma Multiforme) Gene Analysis Targeted Sequence Analysis (Eg Promoter Region) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 127 Original policy |
| 81346 | Tyms (Thymidylate Synthetase) (Eg 5- Fluorouracil/5-Fu Drug Metabolism) Gene Analysis Common Variant(S) (Eg Tandem Repeat Variant) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 127 Original policy |
| 81347 | Sf3B1 (Splicing Factor [3B] Subunit B1) (Eg Myelodysplastic Syndrome/Acute Myeloid Leukemia) Gene Analysis Common Variants (Eg A672T E622D L833F R625C R625L) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 127 Original policy |
| 81348 | Srsf2 (Serine And Arginine-Rich Splicing Factor 2) (Eg Myelodysplastic Syndrome Acute Myeloid Leukemia) Gene Analysis Common Variants (Eg P95H P95L) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 128 Original policy |
| 81349 | Cytogenomic (Genome-Wide) Analysis For Constitutional Chromosomal Abnormalities; Interrogation Of Genomic Regions For Copy Number And Loss-Of- Heterozygosity Variants Low-Pass Sequencing Analysis | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 128 Original policy |
| 81350 | Ugt1A1 (Udp Glucuronosyltransferase 1 Family Polypeptide A1) (Eg Drug Metabolism Hereditary Unconjugated Hyperbilirubinemia [Gilbert Syndrome]) Gene Analysis Common Variants (Eg *28 *36 *37) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 128 Original policy |
| 81351 | Tp53 (Tumor Protein 53) (Eg Li-Fraumeni Syndrome) Gene Analysis; Full Gene Sequence | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 128 Original policy |
| 81352 | Tp53 (Tumor Protein 53) (Eg Li-Fraumeni Syndrome) Gene Analysis; Targeted Sequence Analysis (Eg 4 Oncology) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 128 Original policy |
| 81353 | Tp53 (Tumor Protein 53) (Eg Li-Fraumeni Syndrome) Gene Analysis; Known Familial Variant | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 128 Original policy |
| 81354 | Cytogenomic (genome-wide) analysis for constitutional chromosomal abnormalities; interrogation of structural and copy number variants, optical genome mapping (OGM) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 129 Original policy |
| 81355 | Vkorc1 (Vitamin K Epoxide Reductase Complex Subunit 1) (Eg Warfarin Metabolism) Gene Analysis Common Variant(S) (Eg -1639G>A C.173+1000C>T) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 129 Original policy |
| 81357 | U2Af1 (U2 Small Nuclear Rna Auxiliary Factor 1) (Eg Myelodysplastic Syndrome Acute Myeloid Leukemia) Gene Analysis Common Variants (Eg S34F S34Y Q157R Q157P) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 129 Original policy |
| 81360 | Zrsr2 (Zinc Finger Ccch-Type Rna Binding Motif And Serine/Arginine-Rich 2) (Eg Myelodysplastic Syndrome Acute Myeloid Leukemia) Gene Analysis Common Variant(S) (Eg E65Fs E122Fs R448Fs) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 129 Original policy |
| 81361 | Hbb (Hemoglobin Subunit Beta) (Eg Sickle Cell Anemia Beta Thalassemia Hemoglobinopathy); Common Variant(S) (Eg Hbs Hbc Hbe) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 129 Original policy |
| 81362 | Hbb (Hemoglobin Subunit Beta) (Eg Sickle Cell Anemia Beta Thalassemia Hemoglobinopathy); Known Familial Variant(S) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 129 Original policy |
| 81363 | Hbb (Hemoglobin Subunit Beta) (Eg Sickle Cell Anemia Beta Thalassemia Hemoglobinopathy); Duplication/Deletion Variant(S) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 130 Original policy |
| 81364 | Hbb (Hemoglobin Subunit Beta) (Eg Sickle Cell Anemia Beta Thalassemia Hemoglobinopathy); Full Gene Sequence | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 130 Original policy |
| 81400 | Molecular Pathology Procedure Level 1 (Eg Identification Of Single Germline Variant [Eg Snp] By Techniques Such As Restriction Enzyme Digestion Or Melt Curve Analysis) Acadm (Acyl-Coa Dehydrogenase C-4 To C-12 Straight Chain Mcad) (Eg Medium Chain Acyl Dehydrogenase Deficiency) K304E Variant Ace (Angiotensin Converting Enzyme) (Eg Hereditary Blood Pressure Regulation) Insertion/Deletion Variant Agtr1 (Angiotensin Ii Receptor Type 1) (Eg Essential Hypertension) 1166A>C Variant Bckdha (Branched Chain Keto Acid Dehydrogenase E1 Alpha Polypeptide) (Eg Maple Syrup Urine Disease Type 1A) Y438N Variant Ccr5 (Chemokine C-C Motif Receptor 5) (Eg Hiv Resistance) 32-Bp Deletion Mutation/794 825Del32 Deletion Clrn1 (Clarin 1) (Eg Usher Syndrome Type 3) N48K Variant F2 (Coagulation Factor 2) (Eg Hereditary Hypercoagulability) 1199G>A Variant F5 (Coagulation Factor (Eg Hereditary Hypercoagulability) Hr2 Variant F7 (Coagulation Factor Vii [Serum Prothrombin Conversion Accelerator]) (Eg Hereditary Hypercoagulability) R353Q Variant F13B (Coagulation Factor Xiii B | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 131 Original policy |
| 81401 | Molecular Pathology Procedure Level 2 (Eg 2-10 Snps 1 Methylated Variant Or 1 Somatic Variant [Typically Using Nonsequencing Target Variant Analysis] Or Detection Of A Dynamic Mutation Disorder/Triplet Repeat) Abcc8 (Atp- Binding Cassette Sub-Family C [Cftr/Mrp] Member 8) (Eg Familial Hyperinsulinism) Common Variants (Eg C.3898-9G>A [C.3992-9G>A] F1388Del) Abl1 (Abl Proto- Oncogene 1 Non-Receptor Tyrosine Kinase) (Eg Acquired Imatinib Resistance) T315I Variant Acadm (Acyl-Coa Dehydrogenase C-4 To C-12 Straight Chain Mcad) (Eg Medium Chain Acyl Dehydrogenase Deficiency) Commons Variants (Eg K304E Y42H) Adrb2 (Adrenergic Beta-2 Receptor Surface) (Eg Drug Metabolism) Common Variants (Eg G16R Q27E) Apob (Apolipoprotein B) (Eg Familial Hypercholesterolemia Type B) Common Variants (Eg R3500Q R3500W) Apoe (Apolipoprotein E) (Eg Hyperlipoproteinemia Type Iii Cardiovascular Disease Alzheimer Disease) Common Variants (Eg *2 *3 *4) Cbfb/Myh11 (Inv(16)) (Eg Acute Myeloid Leukemia) Qualitative And Quantitative | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 132 Original policy |
| 81402 | Molecular Pathology Procedure Level 3 (Eg >10 Snps 2-10 Methylated Variants Or 2- 10 Somatic Variants [Typically Using Non- Sequencing Target Variant Analysis] Immunoglobulin And T-Cell Receptor Gene Rearrangements Duplication/Deletion Variants Of 1 Exon Loss Of Heterozygosity [Loh] Uniparental Disomy [Upd]) Chromosome 1P-/19Q- (Eg Glial Tumors) Deletion Analysis Chromosome 18Q- (Eg D18S55 D18S58 D18S61 D18S64 And D18S69) (Eg Colon Cancer) Allelic Imbalance Assessment (Ie Loss Of Heterozygosity) Col1A1/Pdgfb (T(17;22)) (Eg Dermatofibrosarcoma Protuberans) Translocation Analysis Multiple Breakpoints Qualitative And Quantitative If Performed Cyp21A2 (Cytochrome P450 Family 21 Subfamily A Polypeptide 2) (Eg Congenital Adrenal Hyperplasia 21- Hydroxylase Deficiency) Common Variants (Eg Ivs2-13G P30L I172N Exon 6 Mutation Cluster [I235N V236E M238K] V281L L307Ffsx6 Q318X R356W P453S G110Vfsx21 30-Kb Deletion Variant) Esr1/Pgr (Receptor 1/Progesterone Receptor) Ratio (Eg Breast Cancer) Mefv (Mediterranean Fever) (Eg Familial | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 133 Original policy |
| 81403 | Molecular Pathology Procedure Level 4 (Eg Analysis Of Single Exon By Dna Sequence Analysis Analysis Of >10 Amplicons Using Multiplex Pcr In 2 Or More Independent Reactions Mutation Scanning Or Duplication/Deletion Variants Of 2-5 Exons) Ang (Angiogenin Ribonuclease Rnase A Family 5) (Eg Amyotrophic Lateral Sclerosis) Full Gene Sequence Arx (Aristaless Related Homeobox) (Eg X- Linked Lissencephaly With Ambiguous Genitalia X-Linked Intellectual Disability) Duplication/Deletion Analysis Cel (Carboxyl Ester Lipase [Bile Salt- Stimulated Lipase]) (Eg Maturity-Onset Diabetes Of The Young [Mody]) Targeted Sequence Analysis Of Exon 11 (Eg C.1785Delc C.1686Delt) Ctnnb1 (Catenin [Cadherin-Associated Protein] Beta 1 88Kda) (Eg Desmoid Tumors) Targeted Sequence Analysis (Eg Exon 3) Daz/Sry (Deleted In Azoospermia And Sex Determining Region Y) (Eg Male Infertility) Common Deletions (Eg Azfa Azfb Azfc Azfd) Dnmt3A (Dna [Cytosine-5-]- Methyltransferase 3 Alpha) (Eg Acute Myeloid Leukemia) Targeted Sequence Analysis (Eg Exon 23) Epcam (Epithelial | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 134 Original policy |
| 81404 | Molecular Pathology Procedure Level 5 (Eg Analysis Of 2-5 Exons By Dna Sequence Analysis Mutation Scanning Or Duplication/Deletion Variants Of 6-10 Exons Or Characterization Of A Dynamic Mutation Disorder/Triplet Repeat By Southern Blot Analysis) Acads (Acyl-Coa Dehydrogenase C-2 To C-3 Short Chain) (Eg Short Chain Acyl-Coa Dehydrogenase Deficiency) Targeted Sequence Analysis (Eg Exons 5 And 6) Aqp2 (Aquaporin 2 [Collecting Duct]) (Eg Nephrogenic Diabetes Insipidus) Full Gene Sequence Arx (Aristaless Related Homeobox) (Eg X- Linked Lissencephaly With Ambiguous Genitalia X-Linked Intellectual Disability) Full Gene Sequence Avpr2 (Arginine Vasopressin Receptor 2) (Eg Nephrogenic Diabetes Insipidus) Full Gene Sequence Bbs10 (Bardet-Biedl Syndrome 10) (Eg Bardet-Biedl Syndrome) Full Gene Sequence Btd (Biotinidase) (Eg Biotinidase Deficiency) Full Gene Sequence C10Orf2 (Chromosome 10 Open Reading Frame 2) (Eg Mitochondrial Dna Depletion Syndrome) Full Gene Sequence Cav3 (Caveolin 3) (Eg Cav3-Related Distal Myopathy Limb-Girdle Muscular Dystrophy | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 135 Original policy |
| 81405 | Molecular Pathology Procedure Level 6 (Eg Analysis Of 6-10 Exons By Dna Sequence Analysis Mutation Scanning Or Duplication/Deletion Variants Of 11-25 Exons Regionally Targeted Cytogenomic Array Analysis) Abcd1 (Atp-Binding Cassette Sub-Family D [Ald] Member 1) (Eg Adrenoleukodystrophy) Full Gene Sequence Acads (Acyl-Coa Dehydrogenase C-2 To C-3 Short Chain) (Eg Short Chain Acyl-Coa Dehydrogenase Deficiency) Full Gene Sequence Acta2 (Actin Alpha 2 Smooth Muscle Aorta) (Eg Thoracic Aortic Aneurysms And Aortic Dissections) Full Gene Sequence Actc1 (Actin Alpha Cardiac Muscle 1) (Eg Familial Hypertrophic Cardiomyopathy) Full Gene Sequence Ankrd1 (Ankyrin Repeat Domain 1) (Eg Dilated Cardiomyopathy) Full Gene Sequence Aptx (Aprataxin) (Eg Ataxia With Oculomotor Apraxia 1) Full Gene Sequence Arsa (Arylsulfatase A) (Eg Arylsulfatase A Deficiency) Full Gene Sequence Bckdha (Branched Chain Keto Acid Dehydrogenase E1 Alpha Polypeptide) (Eg Maple Syrup Urine Disease Type 1A) Full Gene Sequence Bcs1L (Bcs1-Like [S. Cerevisiae]) (Eg Leigh | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 136 Original policy |
| 81406 | Molecular Pathology Procedure Level 7 (Eg Analysis Of 11-25 Exons By Dna Sequence Analysis Mutation Scanning Or Duplication/Deletion Variants Of 26-50 Exons) Acadvl (Acyl-Coa Dehydrogenase Very Long Chain) (Eg Very Long Chain Acyl- Coenzyme A Dehydrogenase Deficiency) Full Gene Sequence Actn4 (Actinin Alpha 4) (Eg Focal Segmental Glomerulosclerosis) Full Gene Sequence Afg3L2 (Afg3 Atpase Family Gene 3-Like 2 [S. Cerevisiae]) (Eg Spinocerebellar Ataxia) Full Gene Sequence Aire (Autoimmune Regulator) (Eg Autoimmune Polyendocrinopathy Syndrome Type 1) Full Gene Sequence Aldh7A1 (Aldehyde Dehydrogenase 7 Family Member A1) (Eg Pyridoxine-Dependent Epilepsy) Full Gene Sequence Ano5 (Anoctamin 5) (Eg Limb- Girdle Muscular Dystrophy) Full Gene Sequence Anos1 (Anosmin-1) (Eg Kallmann Syndrome 1) Full Gene Sequence App (Amyloid Beta [A4] Precursor Protein) (Eg Alzheimer Disease) Full Gene Sequence Ass1 (Argininosuccinate Synthase 1) (Eg Citrullinemia Type I) Full Gene Sequence Atl1 (Atlastin Gtpase 1) (Eg Spastic | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 137 Original policy |
| 81407 | Molecular Pathology Procedure Level 8 (Eg Analysis Of 26-50 Exons By Dna Sequence Analysis Mutation Scanning Or Duplication/Deletion Variants Of >50 Exons Sequence Analysis Of Multiple Genes On One Platform) Abcc8 (Atp- Binding Cassette Sub-Family C [Cftr/Mrp] Member 8) (Eg Familial Hyperinsulinism) Full Gene Sequence Agl (Amylo-Alpha-1 6- Glucosidase 4-Alpha-Glucanotransferase) (Eg Glycogen Storage Disease Type Iii) Full Gene Sequence Ahi1 (Abelson Helper Integration Site 1) (Eg Joubert Syndrome) Full Gene Sequence Apob (Apolipoprotein B) (Eg Familial Hypercholesterolemia Type B) Full Gene Sequence Aspm (Asp [Abnormal Spindle] Homolog Microcephaly Associated [Drosophila]) (Eg Primary Microcephaly) Full Gene Sequence Chd7 (Chromodomain Helicase Dna Binding Protein 7) (Eg Charge Syndrome) Full Gene Sequence Col4A4 (Collagen Type Iv Alpha 4) (Eg Alport Syndrome) Full Gene Sequence Col4A5 (Collagen Type Iv Alpha 5) (Eg Alport Syndrome) Duplication/Deletion Analysis Col6A1 (Collagen Type Vi Alpha 1) (Eg Collagen Type Vi-Related Disorders) Full Gene | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 138 Original policy |
| 81408 | Molecular Pathology Procedure Level 9 (Eg Analysis Of >50 Exons In A Single Gene By Dna Sequence Analysis) Abca4 (Atp- Binding Cassette Sub-Family A [Abc1] Member 4) (Eg Stargardt Disease Age- Related Macular Degeneration) Full Gene Sequence Atm (Ataxia Telangiectasia Mutated) (Eg Ataxia Telangiectasia) Full Gene Sequence Cdh23 (Cadherin-Related 23) (Eg Usher Syndrome Type 1) Full Gene Sequence Cep290 (Centrosomal Protein 290Kda) (Eg Joubert Syndrome) Full Gene Sequence Col1A1 (Collagen Type I Alpha 1) (Eg Osteogenesis Imperfecta Type I) Full Gene Sequence Col1A2 (Collagen Type I Alpha 2) (Eg Osteogenesis Imperfecta Type I) Full Gene Sequence Col4A1 (Collagen Type Iv Alpha 1) (Eg Brain Small-Vessel Disease With Hemorrhage) Full Gene Sequence Col4A3 (Collagen Type Iv Alpha 3 [Goodpasture Antigen]) (Eg Alport Syndrome) Full Gene Sequence Col4A5 (Collagen Type Iv Alpha 5) (Eg Alport Syndrome) Full Gene Sequence Dmd (Dystrophin) (Eg Duchenne/Becker Muscular Dystrophy) Full Gene Sequence Dysf (Dysferlin Limb Girdle Muscular Dystrophy 2B [Autosomal | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 139 Original policy |
| 81410 | Aortic Dysfunction Or Dilation (Eg Marfan Syndrome Loeys Dietz Syndrome Ehler Danlos Syndrome Type Iv Arterial Tortuosity Syndrome); Genomic Sequence Analysis Panel Must Include Sequencing Of At Least 9 Genes Including Fbn1 Tgfbr1 Tgfbr2 Col3A1 Myh11 Acta2 Slc2A10 Smad3 And Mylk | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 140 Original policy |
| 81411 | Aortic Dysfunction Or Dilation (Eg Marfan Syndrome Loeys Dietz Syndrome Ehler Danlos Syndrome Type Iv Arterial Tortuosity Syndrome); Duplication/Deletion Analysis Panel Must Include Analyses For Tgfbr1 Tgfbr2 Myh11 And Col3A1 | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 140 Original policy |
| 81412 | Ashkenazi Jewish Associated Disorders (Eg Bloom Syndrome Canavan Disease Cystic Fibrosis Familial Dysautonomia Fanconi Anemia Group C Gaucher Disease Tay- Sachs Disease) Genomic Sequence Analysis Panel Must Include Sequencing Of At Least 9 Genes Including Aspa Blm Cftr Fancc Gba Hexa Ikbkap Mcoln1 And Smpd1 | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 140 Original policy |
| 81413 | Cardiac Ion Channelopathies (Eg Brugada Syndrome Long Qt Syndrome Short Qt Syndrome Catecholaminergic Polymorphic Ventricular Tachycardia); Genomic Sequence Analysis Panel Must Include Sequencing Of At Least 10 Genes Including Ank2 Casq2 Cav3 Kcne1 Kcne2 Kcnh2 Kcnj2 Kcnq1 Ryr2 And Scn5A | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 141 Original policy |
| 81414 | Cardiac Ion Channelopathies (Eg Brugada Syndrome Long Qt Syndrome Short Qt Syndrome Catecholaminergic Polymorphic Ventricular Tachycardia); Duplication/Deletion Gene Analysis Panel Must Include Analysis Of At Least 2 Genes Including Kcnh2 And Kcnq1 | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 141 Original policy |
| 81415 | Exome (Eg Unexplained Constitutional Or Heritable Disorder Or Syndrome); Sequence Analysis | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 141 Original policy |
| 81416 | Exome (Eg Unexplained Constitutional Or Heritable Disorder Or Syndrome); Sequence Analysis Each Comparator Exome (Eg Parents Siblings) (List Separately In Addition To Code For Primary Procedure) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 141 Original policy |
| 81417 | Exome (Eg Unexplained Constitutional Or Heritable Disorder Or Syndrome); Re- Evaluation Of Previously Obtained Exome Sequence (Eg Updated Knowledge Or Unrelated Condition/Syndrome) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 142 Original policy |
| 81418 | Drug Metabolism (Eg Pharmacogenomics) Genomic Sequence Analysis Panel Must Include Testing Of At Least 6 Genes Including Cyp2C19 Cyp2D6 And Cyp2D6 Duplication/Deletion Analysis | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 142 Original policy |
| 81419 | Epilepsy Genomic Sequence Analysis Panel Must Include Analyses For Aldh7A1 Cacna1A Cdkl5 Chd2 Gabrg2 Grin2A Kcnq2 Mecp2 Pcdh19 Polg Prrt2 Scn1A Scn1B Scn2A Scn8A Slc2A1 Slc9A6 Stxbp1 Syngap1 Tcf4 Tpp1 Tsc1 Tsc2 And Zeb2 | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 142 Original policy |
| 81422 | Fetal Chromosomal Microdeletion(S) Genomic Sequence Analysis (Eg Digeorge Syndrome Cri-Du-Chat Syndrome) Circulating Cell-Free Fetal Dna In Maternal Blood | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 142 Original policy |
| 81425 | Genome (Eg Unexplained Constitutional Or Heritable Disorder Or Syndrome); Sequence Analysis | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 142 Original policy |
| 81426 | Genome (Eg Unexplained Constitutional Or Heritable Disorder Or Syndrome); Sequence Analysis Each Comparator Genome (Eg Parents Siblings) (List Separately In Addition To Code For Primary Procedure) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 143 Original policy |
| 81427 | Genome (Eg Unexplained Constitutional Or Heritable Disorder Or Syndrome); Re- Evaluation Of Previously Obtained Genome Sequence (Eg Updated Knowledge Or Unrelated Condition/Syndrome) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 143 Original policy |
| 81430 | Hearing Loss (Eg Nonsyndromic Hearing Loss Usher Syndrome Pendred Syndrome); Genomic Sequence Analysis Panel Must Include Sequencing Of At Least 60 Genes Including Cdh23 Clrn1 Gjb2 Gpr98 Mtrnr1 Myo7A Myo15A Pcdh15 Otof Slc26A4 Tmc1 Tmprss3 Ush1C Ush1G Ush2A And Wfs1 | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 143 Original policy |
| 81431 | Hearing Loss (Eg Nonsyndromic Hearing Loss Usher Syndrome Pendred Syndrome); Duplication/Deletion Analysis Panel Must Include Copy Number Analyses For Strc And Dfnb1 Deletions In Gjb2 And Gjb6 Genes | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 143 Original policy |
| 81432 | Hereditary Breast Cancer-Related Disorders (Eg Hereditary Breast Cancer Hereditary Ovarian Cancer Hereditary Endometrial Cancer); Genomic Sequence Analysis Panel Must Include Sequencing Of At Least 10 Genes Always Including Brca1 Brca2 Cdh1 Mlh1 Msh2 Msh6 Palb2 Pten Stk11 And Tp53 | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 144 Original policy |