Blue Cross and Blue Shield of Montana prior authorization, page 19
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 |
|---|---|---|
| 95810 | Polysomnography; Age 6 Years Or Older Sleep Staging With 4 Or More Additional Parameters Of Sleep Attended By A Technologist | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 158 Original policy |
| 95811 | Polysomnography; Age 6 Years Or Older Sleep Staging With 4 Or More Additional Parameters Of Sleep With Initiation Of Continuous Positive Airway Pressure Therapy Or Bilevel Ventilation Attended By A Technologist | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 158 Original policy |
| 95965 | Magnetoencephalography (MEG), recording and analysis; for spontaneous brain magnetic activity (e.g., epileptic cerebral cortex localization) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 158 Original policy |
| 95966 | Magnetoencephalography (MEG), recording and analysis; for evoked magnetic fields, single modality (e.g., sensory, motor, language, or visual cortex localization) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 159 Original policy |
| 95972 | Electronic Analysis Of Implanted Neurostimulator Pulse Generator/Transmitter (Eg Contact Group[S] Interleaving Amplitude Pulse Width Frequency [Hz] On/Off Cycling Burst Magnet Mode Dose Lockout Patient Selectable Parameters Responsive Neurostimulation Detection Algorithms Closed Loop Parameters And Passive Parameters) By Physician Or Other Qualified Health Care Professional; With Complex Spinal Cord Or Peripheral Nerve (Eg Sacral Nerve) Neurostimulator Pulse Generator/Transmitter Programming By Physician Or Other Qualified Health Care Professional | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 161 Original policy |
| 95980 | Electronic Analysis Of Implanted Neurostimulator Pulse Generator System (Eg Rate Pulse Amplitude And Duration Configuration Of Wave Form Battery Status Electrode Selectability Output Modulation Cycling Impedance And Patient Measurements) Gastric Neurostimulator Pulse Generator/Transmitter; Intraoperative With Programming | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 161 Original policy |
| 97533 | Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands, direct (one-on-one) patient contact, each 15 minutes | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 162 Original policy |
| 99183 | Physician Or Other Qualified Health Care Professional Attendance And Supervision Of Hyperbaric Oxygen Therapy Per Session | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 162 Original policy |
| 99601 | Home Infusion/Visit 2 Hrs | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 162 Original policy |
| 99602 | Home Infusion Each Addtl Hr | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 163 Original policy |
| 0001U | Red Blood Cell Antigen Typing Dna Human Erythrocyte Antigen Gene Analysis Of 35 Antigens From 11 Blood Groups Utilizing Whole Blood Common Rbc Alleles Reported | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 163 Original policy |
| 0004M | Scoliosis Dna Analysis Of 53 Single Nucleotide Polymorphisms (Snps) Using Saliva Prognostic Algorithm Reported As Risk Score | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 163 Original policy |
| 0005U | Oncology (Prostate) Gene Expression Profile By Real-Time Rt-Pcr Of 3 Genes (Erg Pca3 And Spdef) Urine Algorithm Reported As Risk Score | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 163 Original policy |
| 0006M | Oncology (Hepatic) Mrna Expression Levels Of 161 Genes Utilizing Fresh Hepatocellular Carcinoma Tumor Tissue With Alpha-Fetoprotein Level Algorithm Reported As A Risk Classifier | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 163 Original policy |
| 0007M | Oncology (Gastrointestinal Neuroendocrine Tumors) Real-Time Pcr Expression Analysis Of 51 Genes Utilizing Whole Peripheral Blood Algorithm Reported As A Nomogram Of Tumor Disease Index | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 163 Original policy |
| 0011M | Oncology Prostate Cancer Mrna Expression Assay Of 12 Genes (10 Content And 2 Housekeeping) Rt-Pcr Test Utilizing Blood Plasma And Urine Algorithms To Predict High-Grade Prostate Cancer Risk | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 164 Original policy |
| 0012M | Oncology (Urothelial) Mrna Gene Expression Profiling By Real-Time Quantitative Pcr Of Five Genes (Mdk Hoxa13 Cdc2 [Cdk1] Igfbp5 And Cxcr2) Utilizing Urine Algorithm Reported As A Risk Score For Having Urothelial Carcinoma | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 164 Original policy |
| 0013M | Oncology (Urothelial) Mrna Gene Expression Profiling By Real-Time Quantitative Pcr Of Five Genes (Mdk Hoxa13 Cdc2 [Cdk1] Igfbp5 And Cxcr2) Utilizing Urine Algorithm Reported As A Risk Score For Having Recurrent Urothelial Carcinoma | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 164 Original policy |
| 0016M | Oncology (Bladder) Mrna Microarray Gene Expression Profiling Of 219 Genes Utilizing Formalin-Fixed Paraffin-Embedded Tissue Algorithm Reported As Molecular Subtype (Luminal Luminal Infiltrated Basal Basal Claudin-Low Neuroendocrine-Like) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 164 Original policy |
| 0016U | Oncology (Hematolymphoid Neoplasia) Rna Bcr/Abl1 Major And Minor Breakpoint Fusion Transcripts Quantitative Pcr Amplification Blood Or Bone Marrow Report Of Fusion Not Detected Or Detected With Quantitation | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 165 Original policy |
| 0017M | Oncology (Diffuse Large B-Cell Lymphoma [Dlbcl]) Mrna Gene Expression Profiling By Fluorescent Probe Hybridization Of 20 Genes Formalin-Fixed Paraffin-Embedded Tissue Algorithm Reported As Cell Of Origin | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 165 Original policy |
| 0017U | Oncology (Hematolymphoid Neoplasia) Jak2 Mutation Dna Pcr Amplification Of Exons 12-14 And Sequence Analysis Blood Or Bone Marrow Report Of Jak2 Mutation Not Detected Or Detected | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 165 Original policy |
| 0018U | Oncology (Thyroid) Microrna Profiling By Rt-Carelon Pcr Of 10 Microrna Sequences Utilizing Fine Needle Aspirate Algorithm Reported As A Positive Or Negative Result For Moderate To High Risk Of Malignancy | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 165 Original policy |
| 0019U | Oncology Rna Gene Expression By Whole Transcriptome Sequencing Formalin-Fixed Paraffin Embedded Tissue Or Fresh Frozen Tissue Predictive Algorithm Reported As Potential Targets For Therapeutic Agents | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 166 Original policy |
| 0020M | Oncology (central nervous system), analysis of 30000 DNA methylation loci by methylation array, utilizing DNA extracted from tumor tissue, diagnostic algorithm reported as probability of matching a reference tumor subclass | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 166 Original policy |
| 0022U | Targeted Genomic Sequence Analysis Panel Nonsmall Cell Lung Neoplasia Dna And Rna Analysis 23 Genes Interrogation For Sequence Variants And Rearrangements Reported As Presence/- Or Absence Of Variants And Associated Therapy(Ies) To Consider | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 166 Original policy |
| 0023U | Oncology (Acute Myelogenous Leukemia) Dna Genotyping Of Internal Tandem Duplication P.D835 P.I836 Using Mononuclear Cells Reported As Detection Or Non-Detection Of Flt3 Mutation And Indication For Or Against The Use Of Midostaurin | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 166 Original policy |
| 0026U | Oncology (Thyroid) Dna And Mrna Of 112 Genes Next-Generation Sequencing Fine Needle Aspirate Of Thyroid Nodule Algorithmic Analysis Reported As A Categorical Result (Positive High Probability Of Malignancy Or Negative Low Probability Of Malignancy) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 167 Original policy |
| 0027U | Jak2 (Janus Kinase 2) (Eg Myeloproliferative Disorder) Gene Analysis Targeted Sequence Analysis Exons 12-15 | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 167 Original policy |
| 0029U | Drug Metabolism (Adverse Drug Reactions And Drug Response) Targeted Sequence Analysis (Ie Cyp1A2 Cyp2C19 Cyp2C9 Cyp2D6 Cyp3A4 Cyp3A5 Cyp4F2 Slco1B1 Vkorc1 And Rs12777823) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 167 Original policy |
| 0030U | Drug Metabolism (Warfarin Drug Response) Targeted Sequence Analysis (Ie Cyp2C9 Cyp4F2 Vkorc1 Rs12777823) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 167 Original policy |
| 0031U | Cyp1A2 (Cytochrome P450 Family 1 Subfamily A Member 2)(Eg Drug Metabolism) Gene Analysis Common Variants (Ie *1F *1K *6 *7) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 167 Original policy |
| 0032U | Comt (Catechol-O- Methyltransferase)(Drug Metabolism) Gene Analysis C.472G>A (Rs4680) Variant | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 167 Original policy |
| 0034U | Tpmt (Thiopurine S-Methyltransferase) Nudt15 (Nudix Hydroxylase 15)(Eg Thiopurine Metabolism) Gene Analysis Common Variants (Ie Tpmt *2 *3A *3B *3C *4 *5 *6 *8 *12; Nudt15 *3 *4 *5) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 168 Original policy |
| 0036U | Exome (Ie Somatic Mutations) Paired Formalin-Fixed Paraffin-Embedded Tumor Tissue And Normal Specimen Sequence Analyses | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 168 Original policy |
| 0037U | Targeted Genomic Sequence Analysis Solid Organ Neoplasm Dna Analysis Of 324 Genes Interrogation For Sequence Variants Gene Copy Number Amplifications Gene Rearrangements Microsatellite Instability And Tumor Mutational Burden | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 168 Original policy |
| 0040U | Bcr/Abl1 (T(9;22)) (Eg Chronic Myelogenous Leukemia) Translocation Analysis Major Breakpoint Quantitative | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 168 Original policy |
| 0045U | Oncology (Breast Ductal Carcinoma In Situ) 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 Recurrence Score | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 169 Original policy |
| 0046U | Flt3 (Fms-Related Tyrosine Kinase 3) (Eg Acute Myeloid Leukemia) Internal Tandem Duplication (Itd) Variants Quantitative | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 169 Original policy |
| 0047U | Oncology (Prostate) Mrna Gene Expression Profiling By Real-Time Rt-Pcr Of 17 Genes (12 Content And 5 Housekeeping) Utilizing Formalin-Fixed Paraffin-Embedded Tissue Algorithm Reported As A Risk Score | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 169 Original policy |
| 0048U | Oncology (Solid Organ Neoplasia) Dna Targeted Sequencing Of Protein-Coding Exons Of 468 Cancer-Associated Genes Including Interrogation For Somatic Mutations And Microsatellite Instability Matched With Normal Specimens Utilizing Formalin-Fixed Paraffin-Embedded Tumor Tissue Report Of Clinically Significant Mutation(S) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 170 Original policy |
| 0049U | Npm1 (Nucleophosmin) (Eg Acute Myeloid Leukemia) Gene Analysis Quantitative | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 170 Original policy |
| 0050U | Targeted Genomic Sequence Analysis Panel Acute Myelogenous Leukemia Dna Analysis 194 Genes Interrogation For Sequence Variants Copy Number Variants Or Rearrangements | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 170 Original policy |
| 0055U | Cardiology (Heart Transplant) Cell-Free Dna Pcr Assay Of 96 Dna Target Sequences (94 Single Nucleotide Polymorphism Targets And Two Control Targets) Plasma | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 170 Original policy |
| 0060U | Twin Zygosity Genomic Targeted Sequence Analysis Of Chromosome 2 Using Circulating Cell-Free Fetal Dna In Maternal Blood | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 170 Original policy |
| 0069U | Oncology (Colorectal) Microrna Rt-Pcr Expression Profiling Of Mir-31-3P Formalin- Fixed Paraffin-Embedded Tissue Algorithm Reported As An Expression Score | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 171 Original policy |
| 0070U | Cyp2D6 (Cytochrome P450 Family 2 Subfamily D Polypeptide 6) (Eg Drug Metabolism) Gene Analysis Common And Select Rare Variants (Ie *2 *3 *4 *4N *5 *6 *7 *8 *9 *10 *11 *12 *13 *14A *14B *15 *17 *29 *35 *36 *41 *57 *61 *63 *68 *83 *Xn) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 171 Original policy |
| 0071T | Focused ultrasound ablation of uterine leiomyomata, including MR guidance; total leiomyomata volume less than 200 cc of tissue | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 171 Original policy |
| 0071U | Cyp2D6 (Cytochrome P450 Family 2 Subfamily D Polypeptide 6) (Eg Drug Metabolism) Gene Analysis Full Gene Sequence (List Separately In Addition To Code For Primary Procedure) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 171 Original policy |
| 0072T | Focused ultrasound ablation of uterine leiomyomata, including MR guidance; total leiomyomata volume greater or equal to 200 cc of tissue | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 171 Original policy |