Blue Cross and Blue Shield of Montana prior authorization, page 22
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 |
|---|---|---|
| 0288U | Oncology (Lung) Mrna Quantitative Pcr Analysis Of 11 Genes (Bag1 Brca1 Cdc6 Cdk2Ap1 Erbb3 Fut3 Il11 Lck Rnd3 Sh3Bgr Wnt3A) And 3 Reference Genes (Esd Tbp Yap1) Formalin-Fixed Paraffin- Embedded (Ffpe) Tumor Tissue Algorithmic Interpretation Reported As A Recurrence Risk Score | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 199 Original policy |
| 0289U | Neurology (Alzheimer Disease) Mrna Gene Expression Profiling By Rna Sequencing Of 24 Genes Whole Blood Algorithm Reported As Predictive Risk Score | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 199 Original policy |
| 0290U | Pain Management Mrna Gene Expression Profiling By Rna Sequencing Of 36 Genes Whole Blood Algorithm Reported As Predictive Risk Score | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 199 Original policy |
| 0291U | Psychiatry (Mood Disorders) Mrna Gene Expression Profiling By Rna Sequencing Of 144 Genes Whole Blood Algorithm Reported As Predictive Risk Score | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 199 Original policy |
| 0292U | Psychiatry (Stress Disorders) Mrna Gene Expression Profiling By Rna Sequencing Of 72 Genes Whole Blood Algorithm Reported As Predictive Risk Score | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 199 Original policy |
| 0293U | Psychiatry (Suicidal Ideation) Mrna Gene Expression Profiling By Rna Sequencing Of 54 Genes Whole Blood Algorithm Reported As Predictive Risk Score | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 200 Original policy |
| 0294U | Longevity And Mortality Risk Mrna Gene Expression Profiling By Rna Sequencing Of 18 Genes Whole Blood Algorithm Reported As Predictive Risk Score | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 200 Original policy |
| 0296U | Oncology (Oral And/Or Oropharyngeal Cancer) Gene Expression Profiling By Rna Sequencing At Least 20 Molecular Features (Eg Human And/Or Microbial Mrna) Saliva Algorithm Reported As Positive Or Negative For Signature Associated With Malignancy | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 200 Original policy |
| 0297U | Oncology (Pan Tumor) Whole Genome Sequencing Of Paired Malignant And Normal Dna Specimens Fresh Or Formalin- Fixed Paraffin-Embedded (Ffpe) Tissue Blood Or Bone Marrow Comparative Sequence Analyses And Variant Identification | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 200 Original policy |
| 0298U | Oncology (Pan Tumor) Whole Transcriptome Sequencing Of Paired Malignant And Normal Rna Specimens Fresh Or Formalin-Fixed Paraffin- Embedded (Ffpe) Tissue Blood Or Bone Marrow Comparative Sequence Analyses And Expression Level And Chimeric Transcript Identification | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 201 Original policy |
| 0299U | Oncology (Pan Tumor) Whole Genome Optical Genome Mapping Of Paired Malignant And Normal Dna Specimens Fresh Frozen Tissue Blood Or Bone Marrow Comparative Structural Variant Identification | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 201 Original policy |
| 0300U | Oncology (Pan Tumor) Whole Genome Sequencing And Optical Genome Mapping Of Paired Malignant And Normal Dna Specimens Fresh Tissue Blood Or Bone Marrow Comparative Sequence Analyses And Variant Identification | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 201 Original policy |
| 0306U | Oncology (Minimal Residual Disease [Mrd]) Next-Generation Targeted Sequencing Analysis Cell-Free Dna Initial (Baseline) Assessment To Determine A Patient Specific Panel For Future Comparisons To Evaluate For Mrd | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 201 Original policy |
| 0307U | Oncology (Minimal Residual Disease [Mrd]) Next-Generation Targeted Sequencing Analysis Of A Patient-Specific Panel Cell- Free Dna Subsequent Assessment With Comparison To Previously Analyzed Patient Specimens To Evaluate For Mrd | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 202 Original policy |
| 0308T | Insertion of ocular telescope prosthesis including removal of crystalline lens or intraocular lens prosthesis | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 202 Original policy |
| 0313U | Oncology (Pancreas) Dna And Mrna Next- Generation Sequencing Analysis Of 74 Genes And Analysis Of Cea (Ceacam5) Gene Expression Pancreatic Cyst Fluid Algorithm Reported As A Categorical Result (Ie Negative Low Probability Of Neoplasia Or Positive High Probability Of Neoplasia) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 202 Original policy |
| 0314U | Oncology (Cutaneous Melanoma) Mrna Gene Expression Profiling By Rt-Pcr Of 35 Genes (32 Content And 3 Housekeeping) Utilizing Formalin-Fixed Paraffin- Embedded (Ffpe) Tissue Algorithm Reported As A Categorical Result (Ie Benign Intermediate Malignant) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 202 Original policy |
| 0315U | Oncology (Cutaneous Squamous Cell Carcinoma) Mrna Gene Expression Profiling By Rt-Pcr Of 40 Genes (34 Content And 6 Housekeeping) Utilizing Formalin- Fixed Paraffin-Embedded (Ffpe) Tissue Algorithm Reported As A Categorical Risk Result (Ie Class 1 Class 2A Class 2B) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 203 Original policy |
| 0317U | Oncology (Lung Cancer) Four-Probe Fish (3Q29 3P22.1 10Q22.3 10Cen) Assay Whole Blood Predictive Algorithmgenerated Evaluation Reported As Decreased Or Increased Risk For Lung Cancer | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 203 Original policy |
| 0318U | Pediatrics (Congenital Epigenetic Disorders) Whole Genome Methylation Analysis By Microarray For 50 Or More Genes Blood | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 203 Original policy |
| 0319U | Nephrology (Renal Transplant) Rna Expression By Select Transcriptome Sequencing Using Pretransplant Peripheral Blood Algorithm Reported As A Risk Score For Early Acute Rejection | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 203 Original policy |
| 0320U | Nephrology (Renal Transplant) Rna Expression By Select Transcriptome Sequencing Using Posttransplant Peripheral Blood Algorithm Reported As A Risk Score For Acute Cellular Rejection | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 203 Original policy |
| 0326U | Targeted Genomic Sequence Analysis Panel Solid Organ Neoplasm Cell-Free Circulating Dna Analysis Of 83 Or More 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 204 Original policy |
| 0327U | Fetal Aneuploidy (Trisomy 13 18 And 21) Dna Sequence Analysis Of Selected Regions Using Maternal Plasma Algorithm Reported As A Risk Score For Each Trisomy Includes Sex Reporting If Performed | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 204 Original policy |
| 0329U | Oncology (Neoplasia) Exome And Transcriptome Sequence Analysis For Sequence Variants Gene Copy Number Amplifications And Deletions Gene Rearrangements Microsatellite Instability And Tumor Mutational Burden Utilizing Dna And Rna From Tumor With Dna From Normal Blood Or Saliva For Subtraction Report Of Clinically Significant Mutation(S) With Therapy Associations | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 204 Original policy |
| 0331U | Oncology (Hematolymphoid Neoplasia) Optical Genome Mapping For Copy Number Alterations And Gene Rearrangements Utilizing Dna From Blood Or Bone Marrow Report Of Clinically Significant Alternations | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 205 Original policy |
| 0332U | Oncology (Pan-Tumor) Genetic Profiling Of 8 Dna-Regulatory (Epigenetic) Markers By Quantitative Polymerase Chain Reaction (Qpcr) Whole Blood Reported As A High Or Low Probability Of Responding To Immune Checkpoint-Inhibitor Therapy | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 205 Original policy |
| 0333U | Oncology (Liver) Surveillance For Hepatocellular Carcinoma (Hcc) In Highrisk Patients Analysis Of Methylation Patterns On Circulating Cell-Free Dna (Cfdna) Plus Measurement Of Serum Of Afp/Afp-L3 And Oncoprotein Des- Gammacarboxy-Prothrombin (Dcp) Algorithm Reported As Normal Or Abnormal Result | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 205 Original policy |
| 0334U | Oncology (Solid Organ) Targeted Genomic Sequence Analysis Formalin-Fixed Paraffinembedded (Ffpe) Tumor Tissue Dna Analysis 84 Or More 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 206 Original policy |
| 0335U | Rare Diseases (Constitutional/Heritable Disorders) Whole Genome Sequence Analysis Including Small Sequence Changes Copy Number Variants Deletions Duplications Mobile Element Insertions Uniparental Disomy (Upd) Inversions Aneuploidy Mitochondrial Genome Sequence Analysis With Heteroplasmy And Large Deletions Short Tandem Repeat (Str) Gene Expansions Fetal Sample Identification And Categorization Of Genetic Variants | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 206 Original policy |
| 0336U | Rare Diseases (Constitutional/Heritable Disorders) Whole Genome Sequence Analysis Including Small Sequence Changes Copy Number Variants Deletions Duplications Mobile Element Insertions Uniparental Disomy (Upd) Inversions Aneuploidy Mitochondrial Genome Sequence Analysis With Heteroplasmy And Large Deletions Short Tandem Repeat (Str) Gene Expansions Blood Or Saliva Identification And Categorization Of Genetic Variants Each Comparator Genome (Eg Parent) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 207 Original policy |
| 0339U | Oncology (Prostate) Mrna Expression Profiling Of Hoxc6 And Dlx1 Reverse Transcription Polymerase Chain Reaction (Rt-Pcr) First-Void Urine Following Digital Rectal Examination Algorithm Reported As Probability Of High-Grade Cancer | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 207 Original policy |
| 0340U | Oncology (Pan-Cancer) Analysis Of Minimal Residual Disease (Mrd) From Plasma With Assays Personalized To Each Patient Based On Prior Next-Generation Sequencing Of The Patient’S Tumor And Germline Dna Reported As Absence Or Presence Of Mrd With Disease-Burden Correlation If Appropriate | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 207 Original policy |
| 0341U | Fetal Aneuploidy Dna Sequencing Comparative Analysis Fetal Dna From Products Of Conception Reported As Normal (Euploidy) Monosomy Trisomy Or Partial Deletion/Duplication Mosaicism And Segmental Aneuploid | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 208 Original policy |
| 0343U | Oncology (Prostate) Exosome-Based Analysis Of 442 Small Noncoding Rnas (Sncrnas) By Quantitative Reverse Transcription Polymerase Chain Reaction (Rt-Qpcr) Urine Reported As Molecular Evidence Of No- Low- Intermediate- Or High-Risk Of Prostate Cancer | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 208 Original policy |
| 0345T | Transcatheter mitral valve repair percutaneous approach via the coronary sinus | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 208 Original policy |
| 0345U | Psychiatry (Eg Depression Anxiety Attention Deficit Hyperactivity Disorder [Adhd]) Genomic Analysis Panel Variant Analysis Of 15 Genes Including Deletion/Duplication Analysis Of Cyp2D6 | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 208 Original policy |
| 0347U | Drug Metabolism Or Processing (Multiple Conditions) Whole Blood Or Buccal Specimen Dna Analysis 16 Gene Report With Variant Analysis And Reported Phenotypes | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 208 Original policy |
| 0348U | Drug Metabolism Or Processing (Multiple Conditions) Whole Blood Or Buccal Specimen Dna Analysis 25 Gene Report With Variant Analysis And Reported Phenotypes | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 209 Original policy |
| 0349U | Drug Metabolism Or Processing (Multiple Conditions) Whole Blood Or Buccal Specimen Dna Analysis 27 Gene Report With Variant Analysis Including Reported Phenotypes And Impacted Gene-Drug Interactions | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 209 Original policy |
| 0350U | Drug Metabolism Or Processing (Multiple Conditions) Whole Blood Or Buccal Specimen Dna Analysis 27 Gene Report With Variant Analysis And Reported Phenotypes | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 209 Original policy |
| 0355U | Apol1 (Apolipoprotein L1) (Eg Chronic Kidney Disease) Risk Variants (G1 G2) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 209 Original policy |
| 0356U | Oncology (Oropharyngeal Or Anal) Evaluation Of 17 Dna Biomarkers Using Droplet Digital Pcr (Ddpcr) Cell-Free Dna Algorithm Reported As A Prognostic Risk Score For Cancer Recurrence | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 209 Original policy |
| 0362U | Oncology (Papillary Thyroid Cancer) Gene- Expression Profiling Via Targeted Hybrid Capture- Enrichment Rna Sequencing Of 82 Content Genes And 10 Housekeeping Genes Fine Needle Aspirate Or Formalin- Fixed Paraffinembedded (Ffpe) Tissue Algorithm Reported As One Of Three Molecular Subtypes | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 210 Original policy |
| 0363U | Oncology (Urothelial) Mrna Gene- Expression Profiling By Real-Time Quantitative Pcr Of 5 Genes (Mdk Hoxa13 Cdc2 [Cdk1] Igfbp5 And Cxcr2) Utilizing Urine Algorithm Incorporates Age Sex Smoking History And Macrohematuria Frequency Reported As A Risk Score For Having Urothelial Carcinoma | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 210 Original policy |
| 0364U | Oncology (Hematolymphoid Neoplasm) Genomic Sequence Analysis Using Multiplex (Pcr) And Next-Generation Sequencing With Algorithm Quantification Of Dominant Clonal Sequence(S) Reported As Presence Or Absence Of Minimal Residual Disease (Mrd) With Quantitation Of Disease Burden When Appropriate | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 210 Original policy |
| 0368U | Oncology (Colorectal Cancer) Evaluation For Mutations Of Apc Braf Ctnnb1 Kras Nras Pik3Ca Smad4 And Tp53 And Methylation Markers (Myo1G Kcnq5 C9Orf50 Fli1 Clip4 Znf132 And Twist1) Multiplex Quantitative Polymerase Chain Reaction (Qpcr) Circulating Cell-Free Dna (Cfdna) Plasma Report Of Risk Score For Advanced Adenoma Or Colorectal Cancer | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 211 Original policy |
| 0378U | Rfc1 (Replication Factor C Subunit 1) Repeat Expansion Variant Analysis By Traditional And Repeat-Primed Pcr Blood Saliva Or Buccal Swab | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 211 Original policy |
| 0379U | Targeted Genomic Sequence Analysis Panel Solid Organ Neoplasm Dna (523 Genes) And Rna (55 Genes) By Nextgeneration Sequencing 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 211 Original policy |
| 0388U | Oncology (Non-Small Cell Lung Cancer) Next-Generation Sequencing With Identification Of Single Nucleotide Variants Copy Number Variants Insertions And Deletions And Structural Variants In 37 Cancer-Related Genes Plasma With Report For Alteration Detection | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 212 Original policy |