Blue Cross and Blue Shield of Montana prior authorization, page 18
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 |
|---|---|---|
| 81434 | Hereditary Retinal Disorders (Eg Retinitis Pigmentosa Leber Congenital Amaurosis Cone-Rod Dystrophy) Genomic Sequence Analysis Panel Must Include Sequencing Of At Least 15 Genes Including Abca4 Cnga1 Crb1 Eys Pde6A Pde6B Prpf31 Prph2 Rdh12 Rho Rp1 Rp2 Rpe65 Rpgr And Ush2A | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 144 Original policy |
| 81435 | Hereditary Colon Cancer Disorders (Eg Lynch Syndrome Pten Hamartoma Syndrome Cowden Syndrome Familial Adenomatosis Polyposis); Genomic Sequence Analysis Panel Must Include Sequencing Of At Least 10 Genes Including Apc Bmpr1A Cdh1 Mlh1 Msh2 Msh6 Mutyh Pten Smad4 And Stk11 | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 144 Original policy |
| 81437 | Hereditary Neuroendocrine Tumor Disorders (Eg Medullary Thyroid Carcinoma Parathyroid Carcinoma Malignant Pheochromocytoma Or Paraganglioma); Genomic Sequence Analysis Panel Must Include Sequencing Of At Least 6 Genes Including Max Sdhb Sdhc Sdhd Tmem127 And Vhl | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 145 Original policy |
| 81439 | Hereditary Cardiomyopathy (Eg Hypertrophic Cardiomyopathy Dilated Cardiomyopathy Arrhythmogenic Right Ventricular Cardiomyopathy) Genomic Sequence Analysis Panel Must Include Sequencing Of At Least 5 Cardiomyopathy- Related Genes (Eg Dsg2 Mybpc3 Myh7 Pkp2 Ttn) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 145 Original policy |
| 81440 | Nuclear Encoded Mitochondrial Genes (Eg Neurologic Or Myopathic Phenotypes) Genomic Sequence Panel Must Include Analysis Of At Least 100 Genes Including Bcs1L C10Orf2 Coq2 Cox10 Dguok Mpv17 Opa1 Pdss2 Polg Polg2 Rrm2B Sco1 Sco2 Slc25A4 Sucla2 Suclg1 Taz Tk2 And Tymp | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 145 Original policy |
| 81441 | Inherited Bone Marrow Failure Syndromes (Ibmfs) (Eg Fanconi Anemia Dyskeratosis Congenita Diamond-Blackfan Anemia Shwachman-Diamond Syndrome Gata2 Deficiency Syndrome Congenital Amegakaryocytic Thrombocytopenia) Sequence Analysis Panel Must Include Sequencing Of At Least 30 Genes Including Brca2 Brip1 Dkc1 Fanca Fancb Fancc Fancd2 Fance Fancf Fancg Fanci Fancl Gata1 Gata2 Mpl Nhp2 Nop10 Palb2 Rad51C Rpl11 Rpl35A Rpl5 Rps10 Rps19 Rps24 Rps26 Rps7 Sbds Tert And Tinf2 | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 146 Original policy |
| 81442 | Noonan Spectrum Disorders (Eg Noonan Syndrome Cardio-Facio-Cutaneous Syndrome Costello Syndrome Leopard Syndrome Noonan-Like Syndrome) Genomic Sequence Analysis Panel Must Include Sequencing Of At Least 12 Genes Including Braf Cbl Hras Kras Map2K1 Map2K2 Nras Ptpn11 Raf1 Rit1 Shoc2 And Sos1 | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 146 Original policy |
| 81443 | Genetic Testing For Severe Inherited Conditions (Eg Cystic Fibrosis Ashkenazi Jewish-Associated Disorders [Eg Bloom Syndrome Canavan Disease Fanconi Anemia Type C Mucolipidosis Type Vi Gaucher Disease Tay-Sachs Disease] Beta Hemoglobinopathies Phenylketonuria Galactosemia) Genomic Sequence Analysis Panel Must Include Sequencing Of At Least 15 Genes (Eg Acadm Arsa Aspa Atp7B Bckdha Bckdhb Blm Cftr Dhcr7 Fancc G6Pc Gaa Galt Gba Gbe1 Hbb Hexa Ikbkap Mcoln1 Pah) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 147 Original policy |
| 81445 | Solid Organ Neoplasm Genomic Sequence Analysis Panel 5-50 Genes Interrogation For Sequence Variants And Copy Number Variants Or Rearrangements If Performed; Dna Analysis Or Combined Dna And Rna Analysis | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 147 Original policy |
| 81448 | Hereditary Peripheral Neuropathies (Eg Charcot-Marie-Tooth Spastic Paraplegia) Genomic Sequence Analysis Panel Must Include Sequencing Of At Least 5 Peripheral Neuropathy-Related Genes (Eg Bscl2 Gjb1 Mfn2 Mpz Reep1 Spast Spg11 Sptlc1) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 147 Original policy |
| 81449 | Solid Organ Neoplasm Genomic Sequence Analysis Panel 5-50 Genes Interrogation For Sequence Variants And Copy Number Variants Or Rearrangements If Performed; Rna Analysis | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 148 Original policy |
| 81450 | Hematolymphoid Neoplasm Or Disorder Genomic Sequence Analysis Panel 5-50 Genes Interrogation For Sequence Variants And Copy Number Variants Or Rearrangements Or Isoform Expression Or Mrna Expression Levels If Performed; Dna Analysis Or Combined Dna And Rna Analysis | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 148 Original policy |
| 81451 | Hematolymphoid Neoplasm Or Disorder Genomic Sequence Analysis Panel 5-50 Genes Interrogation For Sequence Variants And Copy Number Variants Or Rearrangements Or Isoform Expression Or Mrna Expression Levels If Performed; Rna Analysis | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 148 Original policy |
| 81455 | Solid Organ Or Hematolymphoid Neoplasm Or Disorder 51 Or Greater Genes Genomic Sequence Analysis Panel Interrogation For Sequence Variants And Copy Number Variants Or Rearrangements Or Isoform Expression Or Mrna Expression Levels If Performed; Dna Analysis Or Combined Dna And Rna Analysis | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 149 Original policy |
| 81456 | Solid Organ Or Hematolymphoid Neoplasm Or Disorder 51 Or Greater Genes Genomic Sequence Analysis Panel Interrogation For Sequence Variants And Copy Number Variants Or Rearrangements Or Isoform Expression Or Mrna Expression Levels If Performed; Rna Analysis | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 149 Original policy |
| 81457 | Solid Organ Neoplasm Genomic Sequence Analysis Panel Interrogation For Sequence Variants; Dna Analysis Microsatellite Instability | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 149 Original policy |
| 81458 | Solid Organ Neoplasm Genomic Sequence Analysis Panel Interrogation For Sequence Variants; Dna Analysis Copy Number Variants And Microsatellite Instability | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 149 Original policy |
| 81459 | Solid Organ Neoplasm Genomic Sequence Analysis Panel Interrogation For Sequence Variants; Dna Analysis Or Combined Dna And Rna Analysis Copy Number Variants Microsatellite Instability Tumor Mutation Burden And Rearrangements | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 150 Original policy |
| 81460 | Whole Mitochondrial Genome (Eg Leigh Syndrome Mitochondrial Encephalomyopathy Lactic Acidosis And Stroke-Like Episodes [Melas] Myoclonic Epilepsy With Ragged-Red Fibers [Merff] Neuropathy Ataxia And Retinitis Pigmentosa [Narp] Leber Hereditary Optic Neuropathy [Lhon]) Genomic Sequence Must Include Sequence Analysis Of Entire Mitochondrial Genome With Heteroplasmy Detection | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 150 Original policy |
| 81462 | Solid Organ Neoplasm Genomic Sequence Analysis Panel Cell-Free Nucleic Acid (Eg Plasma) Interrogation For Sequence Variants; Dna Analysis Or Combined Dna And Rna Analysis Copy Number Variants And Rearrangements | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 150 Original policy |
| 81463 | Solid Organ Neoplasm Genomic Sequence Analysis Panel Cell-Free Nucleic Acid (Eg Plasma) Interrogation For Sequence Variants; Dna Analysis Copy Number Variants And Microsatellite Instability | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 151 Original policy |
| 81464 | Solid Organ Neoplasm Genomic Sequence Analysis Panel Cell-Free Nucleic Acid (Eg Plasma) Interrogation For Sequence Variants; Dna Analysis Or Combined Dna And Rna Analysis Copy Number Variants Microsatellite Instability Tumor Mutation Burden And Rearrangements | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 151 Original policy |
| 81465 | Whole Mitochondrial Genome Large Deletion Analysis Panel (Eg Kearns-Sayre Syndrome Chronic Progressive External Ophthalmoplegia) Including Heteroplasmy Detection If Performed | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 151 Original policy |
| 81470 | X-Linked Intellectual Disability (Xlid) (Eg Syndromic And Non-Syndromic Xlid); Genomic Sequence Analysis Panel Must Include Sequencing Of At Least 60 Genes Including Arx Atrx Cdkl5 Fgd1 Fmr1 Huwe1 Il1Rapl Kdm5C L1Cam Mecp2 Med12 Mid1 Ocrl Rps6Ka3 And Slc16A2 | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 151 Original policy |
| 81471 | X-Linked Intellectual Disability (Xlid) (Eg Syndromic And Non-Syndromic Xlid); Duplication/Deletion Gene Analysis Must Include Analysis Of At Least 60 Genes Including Arx Atrx Cdkl5 Fgd1 Fmr1 Huwe1 Il1Rapl Kdm5C L1Cam Mecp2 Med12 Mid1 Ocrl Rps6Ka3 And Slc16A2 | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 152 Original policy |
| 81479 | Unlisted Molecular Pathology Procedure | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 152 Original policy |
| 81493 | Coronary Artery Disease Mrna Gene Expression Profiling By Real-Time Rt-Pcr Of 23 Genes Utilizing Whole Peripheral Blood Algorithm Reported As A Risk Score | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 152 Original policy |
| 81504 | Oncology (Tissue Of Origin) Microarray Gene Expression Profiling Of > 2000 Genes Utilizing Formalin-Fixed Paraffin- Embedded Tissue Algorithm Reported As Tissue Similarity Scores | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 152 Original policy |
| 81518 | Oncology (Breast) Mrna Gene Expression Profiling By Real-Time Rt-Pcr Of 11 Genes (7 Content And 4 Housekeeping) Utilizing Formalin-Fixed Paraffin-Embedded Tissue Algorithms Reported As Percentage Risk For Metastatic Recurrence And Likelihood Of Benefit From Extended Endocrine Therapy | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 152 Original policy |
| 81519 | Oncology (Breast) Mrna Gene Expression Profiling By Real-Time Rt-Pcr Of 21 Genes Utilizing Formalin-Fixed Paraffin- Embedded Tissue Algorithm Reported As Recurrence Score | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 153 Original policy |
| 81520 | Oncology (Breast) Mrna Gene Expression Profiling By Hybrid Capture Of 58 Genes (50 Content And 8 Housekeeping) Utilizing Formalin-Fixed Paraffin-Embedded Tissue Algorithm Reported As A Recurrence Risk Score | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 153 Original policy |
| 81521 | Oncology (Breast) Mrna Microarray Gene Expression Profiling Of 70 Content Genes And 465 Housekeeping Genes Utilizing Fresh Frozen Or Formalin-Fixed Paraffin- Embedded Tissue Algorithm Reported As Index Related To Risk Of Distant Metastasis | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 153 Original policy |
| 81522 | Oncology (Breast) Mrna Gene Expression Profiling By Rt-Pcr Of 12 Genes (8 Content And 4 Housekeeping) Utilizing Formalin- Fixed Paraffin-Embedded Tissue Algorithm Reported As Recurrence Risk Score | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 153 Original policy |
| 81523 | Oncology (Breast) Mrna Next-Generation Sequencing Gene Expression Profiling Of 70 Content Genes And 31 Housekeeping Genes Utilizing Formalin-Fixed Paraffin- Embedded Tissue Algorithm Reported As Index Related To Risk To Distant Metastasis | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 154 Original policy |
| 81524 | Oncology (central nervous system tumor), DNA methylation analysis of at least 10,000 methylation sites, utilizing DNA extracted from formalin-fixed tumor tissue, algorithm(s) reported as probability of matching a reference tumor family and class, and MGMT (O-6-methylguanine-DNA methyltransferase) promoter methylation status, if performed | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 154 Original policy |
| 81525 | Oncology (Colon) Mrna Gene Expression Profiling By Real-Time Rt-Pcr Of 12 Genes (7 Content And 5 Housekeeping) Utilizing Formalin-Fixed Paraffin-Embedded Tissue Algorithm Reported As A Recurrence Score | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 154 Original policy |
| 81529 | Oncology (Cutaneous Melanoma) Mrna Gene Expression Profiling By Real-Time Rt- Pcr Of 31 Genes (28 Content And 3 Housekeeping) Utilizing Formalin-Fixed Paraffin-Embedded Tissue Algorithm Reported As Recurrence Risk Including Likelihood Of Sentinel Lymph Node Metastasis | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 155 Original policy |
| 81540 | Oncology (Tumor Of Unknown Origin) Mrna Gene Expression Profiling By Real-Time Rt- Pcr Of 92 Genes (87 Content And 5 Housekeeping) To Classify Tumor Into Main Cancer Type And Subtype Utilizing Formalin-Fixed Paraffin-Embedded Tissue Algorithm Reported As A Probability Of A Predicted Main Cancer Type And Subtype | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 155 Original policy |
| 81541 | Oncology (Prostate) Mrna Gene Expression Profiling By Real-Time Rt-Pcr Of 46 Genes (31 Content And 15 Housekeeping) Utilizing Formalin-Fixed Paraffin- Embedded Tissue Algorithm Reported As Disease-Specific Mortality Risk Score | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 155 Original policy |
| 81542 | Oncology (Prostate) Mrna Microarray Gene Expression Profiling Of 22 Content Genes Utilizing Formalin-Fixed Paraffin- Embedded Tissue Algorithm Reported As Metastasis Risk Score | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 155 Original policy |
| 81546 | Oncology (Thyroid) Mrna Gene Expression Analysis Of 10 196 Genes Utilizing Fine Needle Aspirate Algorithm Reported As A Categorical Result (Eg Benign Or Suspicious) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 156 Original policy |
| 81551 | Oncology (Prostate) Promoter Methylation Profiling By Real-Time Pcr Of 3 Genes (Gstp1 Apc Rassf1) Utilizing Formalin- Fixed Paraffin-Embedded Tissue Algorithm Reported As A Likelihood Of Prostate Cancer Detection On Repeat Biopsy | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 156 Original policy |
| 81554 | Pulmonary Disease (Idiopathic Pulmonary Fibrosis [Ipf]) Mrna Gene Expression Analysis Of 190 Genes Utilizing Transbronchial Biopsies Diagnostic Algorithm Reported As Categorical Result (Eg Positive Or Negative For High Probability Of Usual Interstitial Pneumonia [Uip]) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 156 Original policy |
| 81558 | Transplantation medicine (allograft rejection, kidney), mRNA, gene expression profiling by quantitative polymerase chain reaction (qPCR) of 139 genes, utilizing whole blood, algorithm reported as a binary categorization as transplant excellence, which indicates immune quiescence, or not transplant excellence, indicating subclinical rejection | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 157 Original policy |
| 81595 | Cardiology (Heart Transplant) Mrna Gene Expression Profiling By Real-Time Quantitative Pcr Of 20 Genes (11 Content And 9 Housekeeping) Utilizing Subfraction Of Peripheral Blood Algorithm Reported As A Rejection Risk Score | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 157 Original policy |
| 91110 | Gastrointestinal tract imaging intraluminal (eg capsule endoscopy) esophagus through ileum with interpretation and report | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 157 Original policy |
| 93580 | Percutaneous transcatheter closure of congenital interatrial communication (ie, Fontan fenestration, atrial septal defect) with implant | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 157 Original policy |
| 93660 | Evaluation of cardiovascular function with tilt table evaluation, with continuous ECG monitoring and intermittent blood pressure monitoring, with or without pharmacological intervention | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 158 Original policy |
| 95807 | Sleep Study Simultaneous Recording Of Ventilation Respiratory Effort Ecg Or Heart Rate And Oxygen Saturation Attended By Technologist | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 158 Original policy |
| 95808 | Polysomnography; Any Age Sleep Staging With 1-3 Additional Parameters Of Sleep Attended By A Technologist | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 158 Original policy |