Blue Cross and Blue Shield of Montana prior authorization, page 23
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 |
|---|---|---|
| 0389U | Pediatric Febrile Illness (Kawasaki Disease [Kd]) Interferon Alphainducible Protein 27 (Ifi27) And Mast Cell-Expressed Membrane Protein 1 (Mcemp1) Rna Using Reverse Transcription Polymerase Chain Reaction (Rt-Qpcr) Blood Reported As A Risk Score For Kd | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 212 Original policy |
| 0391U | Oncology (Solid Tumor) Dna And Rna By Next-Generation Sequencing Utilizing Formalin-Fixed Paraffin-Embedded (Ffpe) Tissue 437 Genes Interpretive Report For Single Nucleotide Variants Splicesite Variants Insertions/Deletions Copy Number Alterations Gene Fusions Tumor Mutational Burden And Microsatellite Instability With Algorithm Quantifying Immunotherapy Response Score | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 212 Original policy |
| 0392U | Drug Metabolism (Depression Anxiety Attention Deficit Hyperactivity Disorder [Adhd]) Gene-Drug Interactions Variant Analysis Of 16 Genes Including Deletion/Duplication Analysis Of Cyp2D6 Reported As Impact Of Gene-Drug Interaction For Each Drug | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 213 Original policy |
| 0394T | High Dose Rate Electronic Brachytherapy Skin Surface Application Per Fraction Includes Basic Dosimetry When Performed | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 213 Original policy |
| 0395T | High Dose Rate Electronic Brachytherapy Interstitial Or Intracavitary Treatment Per Fraction Includes Basic Dosimetry When Performed | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 213 Original policy |
| 0400U | Obstetrics (Expanded Carrier Screening) 145 Genes By Nextgeneration Sequencing Fragment Analysis And Multiplex Ligationdependent Probe Amplification Dna Reported As Carrier Positive Or Negative | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 213 Original policy |
| 0401U | Cardiology (Coronary Heart Disease [Cad]) 9 Genes (12 Variants) Targeted Variant Genotyping Blood Saliva Or Buccal Swab Algorithm Reported As A Genetic Risk Score For A Coronary Event | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 213 Original policy |
| 0403U | Onc Prst8 Mrna 18 Gen Dre Ur | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 213 Original policy |
| 0405U | Oncology (Pancreatic) 59 Methylation Haplotype Block Markers Next-Generation Sequencing Plasma Reported As Cancer Signal Detected Or Not Detected | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 214 Original policy |
| 0409U | Onc Sld Tum Dna 80 & Rna 36 | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 214 Original policy |
| 0410U | Oncology (Pancreatic) Dna Whole Genome Sequencing With 5- Hydroxymethylcytosine Enrichment Whole Blood Or Plasma Algorithm Reported As Cancer Detected Or Not Detected | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 214 Original policy |
| 0411U | 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 214 Original policy |
| 0413U | Oncology (Hematolymphoid Neoplasm) Optical Genome Mapping For Copy Number Alterations Aneuploidy And Balanced/Complex Structural Rearrangements Dna From Blood Or Bone Marrow Report Of Clinically Significant Alterations | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 214 Original policy |
| 0414U | Onc Lng Aug Alg Aly Whl Sld8 | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 214 Original policy |
| 0417U | Rare Diseases (Constitutional/Heritable Disorders) Whole Mitochondrial Genome Sequence With Heteroplasmy Detection And Deletion Analysis Nuclear-Encoded Mitochondrial Gene Analysis Of 335 Nuclear Genes Including Sequence Changes Deletions Insertions And Copy Number Variants Analysis Blood Or Saliva Identification And Categorization Of Mitochondrial Disorder-Associated Genetic Variants | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 215 Original policy |
| 0419U | Neuropsychiatry (Eg Depression Anxiety) Genomic Sequence Analysis Panel Variant Analysis Of 13 Genes Saliva Or Buccal Swab Report Of Each Gene Phenotype | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 215 Original policy |
| 0420U | Oncology (Urothelial) Mrna Expression Profiling By Real-Time Quantitative Pcr Of Mdk Hoxa13 Cdc2 Igfbp5 And Cxcr2 In Combination With Droplet Digital Pcr (Ddpcr) Analysis Of 6 Single-Nucleotide Polymorphisms (Snps) Genes Tert And Fgfr3 Urine Algorithm Reported As A Risk Score For Urothelial Carcinoma | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 215 Original policy |
| 0422U | Oncology (Pan-Solid Tumor) Analysis Of Dna Biomarker Response To Anti-Cancer Therapy Using Cell-Free Circulating Dna Biomarker Comparison To A Previous Baseline Pre-Treatment Cell-Free Circulating Dna Analysis Using Next- Generation Sequencing Algorithm Reported As A Quantitative Change From Baseline Including Specific Alterations If Appropriate | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 216 Original policy |
| 0423U | Psychiatry (Eg Depression Anxiety) Genomic Analysis Panel Including Variant Analysis Of 26 Genes Buccal Swab Report Including Metabolizer Status And Risk Of Drug Toxicity By Condition | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 216 Original policy |
| 0424U | Oncology (Prostate) Exosomebased Analysis Of 53 Small Noncoding Rnas (Sncrnas) By Quantitative Reverse Transcription Polymerase Chain Reaction (Rtqpcr) Urine Reported As No Molecular Evidence Low- Moderate- Or Elevated-Risk Of Prostate Cancer | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 216 Original policy |
| 0425U | Genome (Eg Unexplained Constitutional Or Heritable Disorder Or Syndrome) Rapid Sequence Analysis Each Comparator Genome (Eg Parents Siblings) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 216 Original policy |
| 0426U | Genome (Eg Unexplained Constitutional Or Heritable Disorder Or Syndrome) Ultra- Rapid Sequence Analysis | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 217 Original policy |
| 0433U | Oncology (Prostate) 5 Dna Regulatory Markers By Quantitative Pcr Whole Blood Algorithm Including Prostate-Specific Antigen Reported As Likelihood Of Cancer | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 217 Original policy |
| 0434U | Drug Metabolism (Adverse Drug Reactions And Drug Response) Genomic Analysis Panel Variant Analysis Of 25 Genes With Reported Phenotypes | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 217 Original policy |
| 0437U | Psychiatry (Anxiety Disorders) Mrna Gene Expression Profiling By Rna Sequencing Of 15 Biomarkers Whole Blood Algorithm Reported As Predictive Risk Score | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 217 Original policy |
| 0438U | Drug Metabolism (Adverse Drug Reactions And Drug Response) Buccal Specimen Gene-Drug Interactions Variant Analysis 33 Genes Including Deletion/Duplication Analysis Of Cyp2D6 Including Reported Phenotypes And Impacted Genedrug Interactions | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 217 Original policy |
| 0439U | Crd Chd Dna Alys 5 Snp 3 Dna | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 217 Original policy |
| 0440U | Crd Chd Dna Alys 10 Snp 6Dna | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 217 Original policy |
| 0444U | Oncology (Solid Organ Neoplasia) Targeted Genomic Sequence Analysis Panel Of 361 Genes Interrogation For Gene Fusions Translocations Or Other Rearrangements Using Dna From Formalin- Fixed Paraffin-Embedded (Ffpe) Tumor Tissue Report Of Clinically Significant Variant(S) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 218 Original policy |
| 0449U | Carrier Screening For Severe Inherited Conditions (Eg Cystic Fibrosis Spinal Muscular Atrophy Beta Hemoglobinopathies [Including Sickle Cell Disease] Alpha Thalassemia) Regardless Of Race Or Self-Identified Ancestry Genomic Sequence Analysis Panel Must Include Analysis Of 5 Genes (Cftr Smn1 Hbb Hba1 Hba2) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 218 Original policy |
| 0452U | Oncology (bladder), methylated PENK DNA detection by linear target enrichment- quantitative methylation-specific real-time PCR (LTE-qMSP), urine, reported as likelihood of bladder cancer | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 218 Original policy |
| 0453U | Oncology (colorectal cancer), cellfree DNA (cfDNA), methylation-based quantitative PCR assay (SEPTIN9, IKZF1, BCAT1, Septin9-2, VAV3, BCAN), plasma, reported as presence or absence of circulating tumor DNA (ctDNA) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 218 Original policy |
| 0454U | 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 219 Original policy |
| 0460U | Oncology, whole blood or buccal, DNA single-nucleotide polymorphism (SNP) genotyping by real-time PCR of 24 genes, with variant analysis and reported phenotypes | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 219 Original policy |
| 0461U | Oncology, pharmacogenomic analysis of single-nucleotide polymorphism (SNP) genotyping by real-time PCR of 24 genes, whole blood or buccal swab, with variant analysis, including impacted gene-drug interactions and reported phenotypes | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 219 Original policy |
| 0465U | Oncology (urothelial carcinoma), DNA, quantitative methylation-specific PCR of genes (ONECUT2, VIM), algorithmic analysis reported as positive or negative | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 219 Original policy |
| 0466U | Cardiology (coronary artery disease [CAD]), DNA, genome-wide association studies (564856 single-nucleotide polymorphisms [SNPs], targeted variant genotyping), patient lifestyle and clinical data, buccal swab, algorithm reported as polygenic risk to acquired heart disease | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 219 Original policy |
| 0467U | Oncology (bladder), DNA, next-generation sequencing (NGS) of 60 genes and whole genome aneuploidy, urine, algorithms reported as minimal residual disease (MRD) status positive or negative and quantitative disease burden | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 220 Original policy |
| 0469U | Rare diseases (constitutional/heritable disorders), whole genome sequence analysis for chromosomal abnormalities, copy number variants, duplications/deletions, inversions, unbalanced translocations, regions of homozygosity (ROH), inheritance pattern that indicate uniparental disomy (UPD), and aneuploidy, fetal sample (amniotic fluid, chorionic villus sample, or products of conception), identification and categorization of genetic variants, diagnostic report of fetal results based on phenotype with maternal sample and paternal sample, if performed, as comparators and/or maternal cell contamination | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 220 Original policy |
| 0471U | Oncology (colorectal cancer), qualitative real-time PCR of 35 variants of KRAS and NRAS genes (exons 2, 3, 4), formalin-fixed paraffin-embedded (FFPE), predictive, identification of detected mutations | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 220 Original policy |
| 0473U | Oncology (solid tumor), next-generation sequencing (NGS) of DNA from formalin- fixed paraffin-embedded (FFPE) tissue with comparative sequence analysis from a matched normal specimen (blood or saliva), 648 genes, interrogation for sequence variants, insertion and deletion alterations, copy number variants, rearrangements, microsatellite instability, and tumor-mutation burden | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 221 Original policy |
| 0474U | Hereditary pan-cancer (eg, hereditary sarcomas, hereditary endocrine tumors, hereditary neuroendocrine tumors, hereditary cutaneous melanoma), genomic sequence analysis panel of 88 genes with 20 duplications/deletions using next- generation sequencing (NGS), Sanger sequencing, blood or saliva, reported as positive or negative for germline variants, each gene | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 221 Original policy |
| 0475U | Hereditary prostate cancer-related disorders, genomic sequence analysis panel using next-generation sequencing (NGS), Sanger sequencing, multiplex ligation-dependent probe amplification (MLPA), and array comparative genomic hybridization (CGH), evaluation of 23 genes and duplications/deletions when indicated, pathologic mutations reported with a genetic risk score for prostate cancer | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 222 Original policy |
| 0476U | Drug Metabolism, Psychiatry (Eg, Major Depressive Disorder, General Anxiety Disorder, Attention Deficit Hyperactivity Disorder [Adhd], Schizophrenia), Whole Blood, Buccal Swab, And Pharmacogenomic Genotyping Of 14 Genes And Cyp2D6 Copy Number Variant Analysis And Reported Phenotypes | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 222 Original policy |
| 0477U | Drug Metabolism, Psychiatry (Eg, Major Depressive Disorder, General Anxiety Disorder, Attention Deficit Hyperactivity Disorder [Adhd], Schizophrenia), Whole Blood, Buccal Swab, And Pharmacogenomic Genotyping Of 14 Genes And Cyp2D6 Copy Number Variant Analysis, Including Impacted Gene-Drug Interactions And Reported Phenotypes | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 222 Original policy |
| 0478U | Oncology (Non-Small Cell Lung Cancer), Dna And Rna, Digital Pcr Analysis Of 9 Genes (Egfr, Kras, Braf, Alk, Ros1, Ret, Ntrk 1/2/3, Erbb2, And Met) In Formalin-Fixed Paraffin-Embedded (Ffpe) Tissue, Interrogation For Single-Nucleotide Variants, Insertions/Deletions, Gene Rearrangements, And Reported As Actionable Detected Variants For Therapy Selection | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 223 Original policy |
| 0481U | Idh1 (Isocitrate Dehydrogenase 1 [Nadp+]), Idh2 (Isocitrate Dehydrogenase 2 [Nadp+]), And Tert (Telomerase Reverse Transcriptase) Promoter (Eg, Central Nervous System [Cns] Tumors), Next- Generation Sequencing (Single-Nucleotide Variants [Snv], Deletions, And Insertions) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 223 Original policy |
| 0485U | Oncology (Solid Tumor), Cell-Free Dna And Rna By Next-Generation Sequencing, Interpretative Report For Germline Mutations, Clonal Hematopoiesis Of Indeterminate Potential, And Tumor- Derived Single-Nucleotide Variants, Small Insertions/Deletions, Copy Number Alterations, Fusions, Microsatellite Instability, And Tumor Mutational Burden | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 223 Original policy |
| 0486U | Oncology (Pan-Solid Tumor), Next- Generation Sequencing Analysis Of Tumor Methylation Markers Present In Cell-Free Circulating Tumor Dna, Algorithm Reported As Quantitative Measurement Of Methylation As A Correlate Of Tumor Fraction | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 224 Original policy |
| 0487U | Oncology (Solid Tumor), Cell-Free Circulating Dna, Targeted Genomic Sequence Analysis Panel Of 84 Genes, Interrogation For Sequence Variants, Aneuploidy-Corrected Gene Copy Number Amplifications And Losses, Gene Rearrangements, And Microsatellite Instability | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 224 Original policy |