Blue Cross and Blue Shield of Montana prior authorization, page 21
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 |
|---|---|---|
| 0214T | Injection(S) Diagnostic Or Therapeutic Agent Paravertebral Facet (Zygapophyseal) Joint (Or Nerves Innervating That Joint) With Ultrasound Guidance Cervical Or Thoracic; Second Level (List Separately In Addition To Code For Primary Procedure) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 186 Original policy |
| 0214U | Rare Diseases (Constitutional/Heritable Disorders) Whole Exome And Mitochondrial Dna Sequence Analysis Including Small Sequence Changes Deletions Duplications Short Tandem Repeat Gene Expansions And Variants In Non-Uniquely Mappable Regions Blood Or Saliva Identification And Categorization Of Genetic Variants Proband | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 186 Original policy |
| 0215T | Injection(S) Diagnostic Or Therapeutic Agent Paravertebral Facet (Zygapophyseal) Joint (Or Nerves Innervating That Joint) With Ultrasound Guidance Cervical Or Thoracic; Third And Any Additional Level(S) (List Separately In Addition To Code For Primary Procedure) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 186 Original policy |
| 0215U | Rare Diseases (Constitutional/Heritable Disorders) Whole Exome And Mitochondrial Dna Sequence Analysis Including Small Sequence Changes Deletions Duplications Short Tandem Repeat Gene Expansions And Variants In Non-Uniquely Mappable Regions Blood Or Saliva Identification And Categorization Of Genetic Variants Each Comparator Exome (Eg Parent Sibling) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 187 Original policy |
| 0216T | Injection(S) Diagnostic Or Therapeutic Agent Paravertebral Facet (Zygapophyseal) Joint (Or Nerves Innervating That Joint) With Ultrasound Guidance Lumbar Or Sacral; Single Level | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 187 Original policy |
| 0216U | Neurology (Inherited Ataxias) Genomic Dna Sequence Analysis Of 12 Common Genes Including Small Sequence Changes Deletions Duplications Short Tandem Repeat Gene Expansions And Variants In Non-Uniquely Mappable Regions Blood Or Saliva Identification And Categorization Of Genetic Variants | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 187 Original policy |
| 0217T | Injection(S) Diagnostic Or Therapeutic Agent Paravertebral Facet (Zygapophyseal) Joint (Or Nerves Innervating That Joint) With Ultrasound Guidance Lumbar Or Sacral; Second Level (List Separately In Addition To Code For Primary Procedure) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 188 Original policy |
| 0217U | Neurology (Inherited Ataxias) Genomic Dna Sequence Analysis Of 51 Genes Including Small Sequence Changes Deletions Duplications Short Tandem Repeat Gene Expansions And Variants In Non-Uniquely Mappable Regions Blood Or Saliva Identification And Categorization Of Genetic Variants | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 188 Original policy |
| 0218T | Injection(S) Diagnostic Or Therapeutic Agent Paravertebral Facet (Zygapophyseal) Joint (Or Nerves Innervating That Joint) With Ultrasound Guidance Lumbar Or Sacral; Third And Any Additional Level(S) (List Separately In Addition To Code For Primary Procedure) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 188 Original policy |
| 0218U | Neurology (Muscular Dystrophy) Dmd Gene Sequence Analysis Including Small Sequence Changes Deletions Duplications And Variants In Non-Uniquely Mappable Regions Blood Or Saliva Identification And Characterization Of Genetic Variants | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 188 Original policy |
| 0228U | Oncology (Prostate) Multianalyte Molecular Profile By Photometric Detection Of Macromolecules Adsorbed On Nanosponge Array Slides With Machine Learning Utilizing First Morning Voided Urine Algorithm Reported As Likelihood Of Prostate Cancer | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 189 Original policy |
| 0229U | Bcat1 (Branched Chain Amino Acid Transaminase 1) And Ikzf1 (Ikaros Family Zinc Finger 1) (Eg Colorectal Cancer) Promoter Methylation Analysis | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 189 Original policy |
| 0230U | Ar (Androgen Receptor) (Eg Spinal And Bulbar Muscular Atrophy Kennedy Disease X Chromosome Inactivation) Full Sequence Analysis Including Small Sequence Changes In Exonic And Intronic Regions Deletions Duplications Short Tandem Repeat (Str) Expansions Mobile Element Insertions And Variants In Non- Uniquely Mappable Regions | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 189 Original policy |
| 0231U | Cacna1A (Calcium Voltage-Gated Channel Subunit Alpha 1A) (Eg Spinocerebellar Ataxia) Full Gene Analysis Including Small Sequence Changes In Exonic And Intronic Regions Deletions Duplications Short Tandem Repeat (Str) Gene Expansions Mobile Element Insertions And Variants In Non-Uniquely Mappable Regions | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 189 Original policy |
| 0232U | Cstb (Cystatin B) (Eg Progressive Myoclonic Epilepsy Type 1A Unverricht- Lundborg Disease) Full Gene Analysis Including Small Sequence Changes In Exonic And Intronic Regions Deletions Duplications Short Tandem Repeat (Str) Expansions Mobile Element Insertions And Variants In Non-Uniquely Mappable Regions | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 190 Original policy |
| 0233U | Fxn (Frataxin) (Eg Friedreich Ataxia) Gene Analysis Including Small Sequence Changes In Exonic And Intronic Regions Deletions Duplications Short Tandem Repeat (Str) Expansions Mobile Element Insertions And Variants In Non-Uniquely Mappable Regions | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 190 Original policy |
| 0234U | Mecp2 (Methyl Cpg Binding Protein 2) (Eg Rett Syndrome) Full Gene Analysis Including Small Sequence Changes In Exonic And Intronic Regions Deletions Duplications Mobile Element Insertions And Variants In Non-Uniquely Mappable Regions | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 190 Original policy |
| 0235U | Pten (Phosphatase And Tensin Homolog) (Eg Cowden Syndrome Pten Hamartoma Tumor Syndrome) Full Gene Analysis Including Small Sequence Changes In Exonic And Intronic Regions Deletions Duplications Mobile Element Insertions And Variants In Non-Uniquely Mappable Regions | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 191 Original policy |
| 0236U | Smn1 (Survival Of Motor Neuron 1 Telomeric) And Smn2 (Survival Of Motor Neuron 2 Centromeric) (Eg Spinal Muscular Atrophy) Full Gene Analysis Including Small Sequence Changes In Exonic And Intronic Regions Duplications Deletions And Mobile Element Insertions | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 191 Original policy |
| 0237U | Cardiac Ion Channelopathies (Eg Brugada Syndrome Long Qt Syndrome Short Qt Syndrome Catecholaminergic Polymorphic Ventricular Tachycardia) Genomic Sequence Analysis Panel Including Ank2 Casq2 Cav3 Kcne1 Kcne2 Kcnh2 Kcnj2 Kcnq1 Ryr2 And Scn5A Including Small Sequence Changes In Exonic And Intronic Regions Deletions Duplications Mobile Element Insertions And Variants In Non-Uniquely Mappable Regions | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 191 Original policy |
| 0238U | Oncology (Lynch Syndrome) Genomic Dna Sequence Analysis Of Mlh1 Msh2 Msh6 Pms2 And Epcam Including Small Sequence Changes In Exonic And Intronic Regions Deletions Duplications Mobile Element Insertions And Variants In Non- Uniquely Mappable Regions | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 192 Original policy |
| 0239U | Targeted Genomic Sequence Analysis Panel Solid Organ Neoplasm Cell-Free Dna Analysis Of 311 Or More Genes Interrogation For Sequence Variants Including Substitutions Insertions Deletions Select Rearrangements And Copy Number Variations | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 192 Original policy |
| 0242U | Targeted Genomic Sequence Analysis Panel Solid Organ Neoplasm Cell-Free Circulating Dna Analysis Of 55-74 Genes Interrogation For Sequence Variants Gene Copy Number Amplifications And Gene Rearrangements | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 192 Original policy |
| 0244U | Oncology (Solid Organ) Dna Comprehensive Genomic Profiling 257 Genes Interrogation For Single-Nucleotide Variants Insertions/Deletions Copy Number Alterations Gene Rearrangements Tumor-Mutational Burden And Microsatellite Instability Utilizing Formalin- Fixed Paraffin-Embedded Tumor Tissue | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 193 Original policy |
| 0245U | Oncology (Thyroid) Mutation Analysis Of 10 Genes And 37 Rna Fusions And Expression Of 4 Mrna Markers Using Next- Generation Sequencing Fine Needle Aspirate Report Includes Associated Risk Of Malignancy Expressed As A Percentage | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 193 Original policy |
| 0250U | Oncology (Solid Organ Neoplasm) Targeted Genomic Sequence Dna Analysis Of 505 Genes Interrogation For Somatic Alterations (Snvs [Single Nucleotide Variant] Small Insertions And Deletions One Amplification And Four Translocations) Microsatellite Instability And Tumor-Mutation Burden | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 193 Original policy |
| 0252U | Fetal Aneuploidy Short Tandem-Repeat Comparative Analysis Fetal Dna From Products Of Conception Reported As Normal (Euploidy) Monosomy Trisomy Or Partial Deletion/Duplication Mosaicism And Segmental Aneuploidy | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 194 Original policy |
| 0253T | Insertion of anterior segment aqueous drainage device, without extraocular reservoir, internal approach, into the suprachoroidal space | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 194 Original policy |
| 0253U | Reproductive Medicine (Endometrial Receptivity Analysis) Rna Gene Expression Profile 238 Genes By Next-Generation Sequencing Endometrial Tissue Predictive Algorithm Reported As Endometrial Window Of Implantation (Eg Pre-Receptive Receptive Post-Receptive) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 194 Original policy |
| 0254U | Reproductive Medicine (Preimplantation Genetic Assessment) Analysis Of 24 Chromosomes Using Embryonic Dna Genomic Sequence Analysis For Aneuploidy And A Mitochondrial Dna Score In Euploid Embryos Results Reported As Normal (Euploidy) Monosomy Trisomy Or Partial Deletion/Duplication Mosaicism And Segmental Aneuploidy Per Embryo Tested | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 194 Original policy |
| 0258U | Autoimmune (Psoriasis) Mrna Next- Generation Sequencing Gene Expression Profiling Of 50-100 Genes Skin-Surface Collection Using Adhesive Patch Algorithm Reported As Likelihood Of Response To Psoriasis Biologics | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 195 Original policy |
| 0260U | Rare Diseases (Constitutional/Heritable Disorders) Identification Of Copy Number Variations Inversions Insertions Translocations And Other Structural Variants By Optical Genome Mapping | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 195 Original policy |
| 0262U | Oncology (Solid Tumor) Gene Expression Profiling By Real-Time Rt-Pcr Of 7 Gene Pathways (Er Ar Pi3K Mapk Hh Tgfb Notch) Formalin-Fixed Paraffin-Embedded (Ffpe) Algorithm Reported As Gene Pathway Activity Score | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 195 Original policy |
| 0264U | Rare Diseases (Constitutional/Heritable Disorders) Identification Of Copy Number Variations Inversions Insertions Translocations And Other Structural Variants By Optical Genome Mapping | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 195 Original policy |
| 0265U | Rare Constitutional And Other Heritable Disorders Whole Genome And Mitochondrial Dna Sequence Analysis Blood Frozen And Formalin-Fixed Paraffin- Embedded (Ffpe) Tissue Saliva Buccal Swabs Or Cell Lines Identification Of Single Nucleotide And Copy Number Variants | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 196 Original policy |
| 0266U | Unexplained Constitutional Or Other Heritable Disorders Or Syndromes Tissue- Specific Gene Expression By Whole- Transcriptome And Next-Generation Sequencing Blood Formalin-Fixed Paraffin- Embedded (Ffpe) Tissue Or Fresh Frozen Tissue Reported As Presence Or Absence Of Splicing Or Expression Changes | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 196 Original policy |
| 0267U | Rare Constitutional And Other Heritable Disorders Identification Of Copy Number Variations Inversions Insertions Translocations And Other Structural Variants By Optical Genome Mapping And Whole Genome Sequencing | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 196 Original policy |
| 0268U | Hematology (Atypical Hemolytic Uremic Syndrome [Ahus]) Genomic Sequence Analysis Of 15 Genes Blood Buccal Swab Or Amniotic Fluid | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 196 Original policy |
| 0269U | Hematology (Autosomal Dominant Congenital Thrombocytopenia) Genomic Sequence Analysis Of 22 Genes Blood Buccal Swab Or Amniotic Fluid | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 197 Original policy |
| 0270U | Hematology (Congenital Coagulation Disorders) Genomic Sequence Analysis Of 20 Genes Blood Buccal Swab Or Amniotic Fluid | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 197 Original policy |
| 0271U | Hematology (Congenital Neutropenia) Genomic Sequence Analysis Of 24 Genes Blood Buccal Swab Or Amniotic Fluid | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 197 Original policy |
| 0272U | Hematology (Genetic Bleeding Disorders) Genomic Sequence Analysis Of 60 Genes And Duplication/Deletion Of Plau Blood Buccal Swab Or Amniotic Fluid Comprehensive | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 197 Original policy |
| 0273U | Hematology (Genetic Hyperfibrinolysis Delayed Bleeding) Genomic Sequence Analysis Of 8 Genes (F13A1 F13B Fga Fgb Fgg Serpina1 Serpine1 Serpinf2 Plau) Blood Buccal Swab Or Amniotic Fluid | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 197 Original policy |
| 0274U | Hematology (Genetic Platelet Disorders) Genomic Sequence Analysis Of 62 Genes And Duplication/Deletion Of Plau Blood Buccal Swab Or Amniotic Fluid | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 197 Original policy |
| 0276U | Hematology (Inherited Thrombocytopenia) Genomic Sequence Analysis Of 42 Genes Blood Buccal Swab Or Amniotic Fluid | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 198 Original policy |
| 0277U | Hematology (Genetic Platelet Function Disorder) Genomic Sequence Analysis Of 40 Genes And Duplication/Deletion Of Plau Blood Buccal Swab Or Amniotic Fluid | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 198 Original policy |
| 0278U | Hematology (Genetic Thrombosis) Genomic Sequence Analysis Of 14 Genes Blood Buccal Swab Or Amniotic Fluid | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 198 Original policy |
| 0285U | Oncology Response To Radiation Cell- Free Dna Quantitative Branched Chain Dna Amplification Plasma Reported As A Radiation Toxicity Score | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 198 Original policy |
| 0286U | Cep72 (Centrosomal Protein 72-Kda) Nudt15 (Nudix Hydrolase 15) And Tpmt (Thiopurine S-Methyltransferase) (Eg Drug Metabolism) Gene Analysis Common Variants | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 198 Original policy |
| 0287U | Oncology (Thyroid) Dna And Mrna Next- Generation Sequencing Analysis Of 112 Genes Fine Needle Aspirate Or Formalin- Fixed Paraffin-Embedded (Ffpe) Tissue Algorithmic Prediction Of Cancer Recurrence Reported As A Categorical Risk Result (Low Intermediate High) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 198 Original policy |