Blue Cross and Blue Shield of Montana prior authorization, page 24
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 |
|---|---|---|
| 0488U | Obstetrics (Fetal Antigen Noninvasive Prenatal Test), Cell-Free Dna Sequence Analysis For Detection Of Fetal Presence Or Absence Of 1 Or More Of The Rh, C, C, D, E, Duffy (Fya), Or Kell (K) Antigen In Alloimmunized Pregnancies, Reported As Selected Antigen(S) Detected Or Not Detected | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 224 Original policy |
| 0489U | Obstetrics (Single-Gene Noninvasive Prenatal Test), Cell-Free Dna Sequence Analysis Of 1 Or More Targets (Eg, Cftr, Smn1, Hbb, Hba1, Hba2) To Identify Paternally Inherited Pathogenic Variants, And Relative Mutation-Dosage Analysis Based On Molecular Counts To Determine Fetal Inheritance Of Maternal Mutation, Algorithm Reported As A Fetal Risk Score For The Condition (Eg, Cystic Fibrosis, Spinal Muscular Atrophy, Beta Hemoglobinopathies [Including Sickle Cell Disease], Alpha Thalassemia) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 225 Original policy |
| 0493U | Transplantation Medicine, Quantification Of Donor-Derived Cell-Free Dna (Cfdna) Using Next-Generation Sequencing, Plasma, Reported As Percentage Of Donor- Derived Cell-Free Dna | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 225 Original policy |
| 0494U | Red Blood Cell Antigen (Fetal Rhd Gene Analysis), Next-Generation Sequencing Of Circulating Cell-Free Dna (Cfdna) Of Blood In Pregnant Individuals Known To Be Rhd Negative, Reported As Positive Or Negative | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 225 Original policy |
| 0496U | Oncology (Colorectal), Cell-Free Dna, 8 Genes For Mutations, 7 Genes For Methylation By Real-Time Rt-Pcr, And 4 Proteins By Enzyme-Linked Immunosorbent Assay, Blood, Reported Positive Or Negative For Colorectal Cancer Or Advanced Adenoma Risk | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 226 Original policy |
| 0497U | Oncology (Prostate), Mrna Gene- Expression Profiling By Real-Time Rt-Pcr Of 6 Genes (Foxm1, Mcm3, Mtus1, Ttc21B, Alas1, And Ppp2Ca), Utilizing Formalin- Fixed Paraffin-Embedded (Ffpe) Tissue, Algorithm Reported As A Risk Score For Prostate Cancer | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 226 Original policy |
| 0498U | Oncology (Colorectal), Next-Generation Sequencing For Mutation Detection In 43 Genes And Methylation Pattern In 45 Genes, Blood, And Formalin-Fixed Paraffin- Embedded (Ffpe) Tissue, Report Of Variants And Methylation Pattern With Interpretation | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 226 Original policy |
| 0499U | Oncology (Colorectal And Lung), Dna From Formalin-Fixed Paraffin-Embedded (Ffpe) Tissue, Next-Generation Sequencing Of 8 Genes (Nras, Egfr, Ctnnb1, Pik3Ca, Apc, Braf, Kras, And Tp53), Mutation Detection | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 226 Original policy |
| 0500U | Autoinflammatory Disease (Vexas Syndrome), Dna, Uba1 Gene Mutations, Targeted Variant Analysis (M41T, M41V, M41L, C.118-2A>C, C.118-1G>C, C.118- 9_118-2Del, S56F, S621C) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 227 Original policy |
| 0506U | Gastroenterology (Barrett'S Esophagus), Esophageal Cells, Dna Methylation Analysis By Next-Generation Sequencing Of At Least 89 Differentially Methylated Genomic Regions, Algorithm Reported As Likelihood For Barrett'S Esophagus | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 227 Original policy |
| 0507U | Oncology (Ovarian), Dna, Whole-Genome Sequencing With 5-Hydroxymethylcytosine (5Hmc) Enrichment, Using Whole Blood Or Plasma, Algorithm Reported As Cancer Detected Or Not Detected | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 227 Original policy |
| 0516U | Drug Metabolism, Whole Blood, Pharmacogenomic Genotyping Of 40 Genes And Cyp2D6 Copy Number Variant Analysis, Reported As Metabolizer Status | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 228 Original policy |
| 0523U | Oncology (solid tumor), DNA, qualitative, next-generation sequencing (NGS) of singlenucleotide variants (SNV) and insertion/deletions in 22 genes utilizing formalin-fixed paraffinembedded tissue, reported as presence or absence of mutation(s), location of mutation(s), nucleotide change, and amino acid change | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 228 Original policy |
| 0529U | Hematology (venous thromboembolism [VTE]), genome-wide single-nucleotide polymorphism variants, including F2 and F5 gene analysis, and Leiden variant, by microarray analysis, saliva, report as risk score for VTE | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 228 Original policy |
| 0530U | Oncology (pan-solid tumor), ctDNA, utilizing plasma, nextgeneration sequencing (NGS) of 77 genes, 8 fusions, microsatellite instability, and tumor mutation burden, interpretative report for single-nucleotide variants, copynumber alterations, with therapy association | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 229 Original policy |
| 0532U | Rare Diseases (Constitutional Disease/Hereditary Disorders), Rapid Whole Genome And Mitochondrial Dna Sequencing For Single-Nucleotide Variants, Insertions/Deletions, Copy Number Variations, Peripheral Blood, Buffy Coat, Saliva, Buccal Or Tissue Sample, Results Reported As Positive Or Negative | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 229 Original policy |
| 0533U | Drug Metabolism (Adverse Drug Reactions And Drug Response), Genotyping Of 16 Genes (Ie, Abcg2, Cyp2B6, Cyp2C9, Cyp2C19, Cyp2C, Cyp2D6, Cyp3A5, Cyp4F2, Dpyd, G6Pd, Ggcx, Nudt15, Slco1B1, Tpmt, Ugt1A1, Vkorc1), Reported As Metabolizer Status And Transporter Function | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 229 Original policy |
| 0534U | Oncology (Prostate), Microrna, Single- Nucleotide Polymorphisms (Snps) Analysis By Rt-Pcr Of 32 Variants, Using Buccal Swab, Algorithm Reported As A Risk Score | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 230 Original policy |
| 0536U | Red Blood Cell Antigen (Fetal Rhd), Pcr Analysis Of Exon 4 Of Rhd Gene And Housekeeping Control Gene Gapdh From Whole Blood In Pregnant Individuals At 10+ Weeks Gestation Known To Be Rhd Negative, Reported As Fetal Rhd Status | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 230 Original policy |
| 0537U | Oncology (Colorectal Cancer), Analysis Of Cell-Free Dna For Epigenomic Patterns, Next-Generation Sequencing, >2500 Differentially Methylated Regions (Dmrs), Plasma, Algorithm Reported As Positive Or Negative | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 230 Original policy |
| 0538U | Oncology (Solid Tumor), Next-Generation Targeted Sequencing Analysis, Formalin- Fixed Paraffin-Embedded (Ffpe) Tumor Tissue, Dna Analysis Of 600 Genes, Interrogation For Single-Nucleotide Variants, Insertions/Deletions, Gene Rearrangements, And Copy Number Alterations, Microsatellite Instability, Tumor Mutation Burden, Reported As Actionable Variant | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 230 Original policy |
| 0539U | Oncology (Solid Tumor), Cell-Free Circulating Tumor Dna (Ctdna), 152 Genes, Next-Generation Sequencing, Interrogation For Single-Nucleotide Variants, Insertions/Deletions, Gene Rearrangements, Copy Number Alterations, And Microsatellite Instability, Using Whole-Blood Samples, Mutations With Clinical Actionability Reported As Actionable Variant | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 231 Original policy |
| 0540U | Transplantation Medicine, Quantification Of Donor-Derived Cell-Free Dna Using Next- Generation Sequencing Analysis Of Plasma, Reported As Percentage Of Donor- Derived Cell-Free Dna To Determine Probability Of Rejection | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 231 Original policy |
| 0543U | Oncology (Solid Tumor), Next-Generation Sequencing Of Dna From Formalin-Fixed Paraffin-Embedded (Ffpe) Tissue Of 517 Genes, Interrogation For Single-Nucleotide Variants, Multi-Nucleotide Variants, Insertions And Deletions From Dna, Fusions In 24 Genes And Splice Variants In 1 Gene From Rna, And Tumor Mutation Burden | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 231 Original policy |
| 0549U | Oncology (Urothelial), Dna, Quantitative Methylated Real-Time Pcr Of Trna-Cys, Sim2, And Nkx1-1, Using Urine, Diagnostic Algorithm Reported As A Probability Index For Bladder Cancer And/Or Upper Tract Urothelial Carcinoma (Utuc) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 232 Original policy |
| 0552U | Reproductive medicine (preimplantation genetic assessment), analysis for known genetic disorders from trophectoderm biopsy, linkage analysis of disease-causing locus, and when possible, targeted mutation analysis for known familial variant, reported as low-risk or high-risk for familial genetic disorder | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 232 Original policy |
| 0553U | Reproductive medicine (preimplantation genetic assessment), analysis of 24 chromosomes using DNA genomic sequence analysis from embryonic trophectoderm for structural rearrangements, aneuploidy, and a mitochondrial DNA score, results reported as normal/balanced (euploidy/balanced), unbalanced structural rearrangement, monosomy, trisomy, segmental aneuploidy, or mosaic, per embryo tested | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 233 Original policy |
| 0554U | Reproductive medicine (preimplantation genetic assessment), analysis of 24 chromosomes using DNA genomic sequence analysis from trophectoderm biopsy for aneuploidy, ploidy, a mitochondrial DNA score, and embryo quality control, results reported as normal (euploidy), monosomy, trisomy, segmental aneuploidy, triploid, haploid, or mosaic, with quality control results reported as contamination detected or inconsistent cohort when applicable, per embryo tested | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 233 Original policy |
| 0555U | Reproductive medicine (preimplantation genetic assessment), analysis of 24 chromosomes using DNA genomic sequence analysis from embryonic trophectoderm for structural rearrangements, aneuploidy, ploidy, a mitochondrial DNA score, and embryo quality control, results reported as normal/balanced (euploidy/balanced), unbalanced structural rearrangement, monosomy, trisomy, segmental aneuploidy, triploid, haploid, or mosaic, with quality control results reported as contamination detected or inconsistent cohort when applicable, per embryo tested | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 234 Original policy |
| 0560U | Oncology (minimal residual disease [MRD]), genomic sequence analysis, cell- free DNA, whole blood and tumor tissue, baseline assessment for design and construction of a personalized variant panel to evaluate current MRD and for comparison to subsequent MRD assessments | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 234 Original policy |
| 0561U | Oncology (minimal residual disease [MRD]), genomic sequence analysis, cell- free DNA, whole blood, subsequent assessment with comparison to initial assessment to evaluate for MRD | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 234 Original policy |
| 0562U | Oncology (solid tumor), targeted genomic sequence analysis, 33 genes, detection of single-nucleotide variants (SNVs), insertions and deletions, copy-number amplifications, and translocations in human genomic circulating cell-free DNA, plasma, reported as presence of actionable variants | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 235 Original policy |
| 0565U | Oncology (hepatocellular carcinoma), next-Carelon generation sequencing methylation pattern assay to detect 6626 epigenetic alterations, cell-free DNA, plasma, algorithm reported as cancer signal detected or not detected | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 235 Original policy |
| 0566U | Oncology (lung), qPCR-based analysis of 13 differentially methylated regions (CCDC181, HOXA7, LRRC8A, MARCHF11, MIR129-2, NCOR2, PANTR1, PRKCB, SLC9A3, TBR1_2, TRAP1, VWC2, ZNF781), pleural fluid, algorithm reported as a qualitative result | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 235 Original policy |
| 0567U | Rare diseases (constitutional/heritable disorders), whole-genome sequence analysis combination of short and long reads, for single-nucleotide variants, insertions/deletions and characterized intronic variants, copy-number variants, duplications/deletions, mobile element insertions, runs of homozygosity, aneuploidy, and inversions, mitochondrial DNA sequence and deletions, short tandem repeat genes, methylation status of selected regions, blood, saliva, amniocentesis, chorionic villus sample or tissue, identification and categorization of genetic variants | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 236 Original policy |
| 0569U | Oncology (solid tumor), next-generation sequencing analysis of tumor methylation markers (>20000 differentially methylated regions) present in cell-free circulating tumor DNA (ctDNA), whole blood, algorithm reported as presence or absence of ctDNA with tumor fraction, if appropriate | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 236 Original policy |
| 0571U | Oncology (solid tumor), DNA (80 genes) and RNA (10 genes), by next-generation sequencing, plasma, including single- nucleotide variants, insertions/deletions, copy-number alterations, microsatellite instability, and fusions, reported as clinically actionable variants | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 237 Original policy |
| 0575U | Transplantation medicine (liver allograft rejection), miRNA gene expression profiling by RT-PCR of 4 genes (miR-122, miR-885, miR-23a housekeeping, spike-in control), serum, algorithm reported as risk of liver allograft rejection | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 237 Original policy |
| 0576U | Transplantation medicine (liver allograft rejection), quantitative donor-derived cell- free DNA (cfDNA) by whole genome nextgeneration sequencing, plasma and mRNA gene expression profiling by multiplex real-time PCR of 56 genes, whole blood, combined algorithm reported as a rejection risk score | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 237 Original policy |
| 0578U | Oncology (cutaneous melanoma), RNA, gene expression profiling by realtime qPCR of 10 genes (8 content and 2 housekeeping), utilizing formalin-fixed paraffin-embedded (FFPE) tissue, algorithm reports a binary result, either low- risk or high-risk for sentinel lymph node metastasis and recurrence | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 238 Original policy |
| 0582U | Rare diseases (constitutional disease/hereditary disorders), rapid whole genome DNA sequencing for singlenucleotide variants, insertions/deletions, copy number variations, blood, saliva, tissue sample, variants reported | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 238 Original policy |
| 0583U | Rare diseases (constitutional disease/hereditary disorders), rapid whole genome comparator DNA sequencing for single-nucleotide variants, insertions/deletions, copy number variations, blood, saliva, tissue sample, variants reported with proband results | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 238 Original policy |
| 0584T | Islet Cell Transplant Includes Portal Vein Catheterization And Infusion Including All Imaging Including Guidance And Radiological Supervision And Interpretation When Performed; Percutaneous | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 238 Original policy |
| 0585T | Islet Cell Transplant Includes Portal Vein Catheterization And Infusion Including All Imaging Including Guidance And Radiological Supervision And Interpretation When Performed; Laparoscopic | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 239 Original policy |
| 0586T | Islet Cell Transplant Includes Portal Vein Catheterization And Infusion Including All Imaging Including Guidance And Radiological Supervision And Interpretation When Performed; Open | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 239 Original policy |
| 0586U | Oncology, mRNA, gene expression profiling of 216 genes (204 targeted and 12 housekeeping genes), RNA expression analysis, formalin-fixed paraffin-embedded (FFPE) tissue, quantitative, reported as log2 ratio per gene | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 239 Original policy |
| 0592U | Oncology (hematolymphoid neoplasms), DNA, targeted genomic sequence of 417 genes, interrogation for gene fusions, translocations, rearrangements, utilizing formalin-fixed paraffin-embedded (FFPE) tumor tissue, results report clinically significant variant(s) | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 240 Original policy |
| 0596T | Temporary female intraurethral valve- pump (ie, voiding prosthesis); initial insertion, including urethral measurement | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 240 Original policy |
| 0597T | Temporary female intraurethral valve- pump (ie, voiding prosthesis); replacement | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 240 Original policy |
| 0597U | Oncology (breast), RNA expression profiling of 329 genes by targeted nextgeneration sequencing and 20 proteins by multiplex immunofluorescence, formalin-fixed paraffin-embedded (FFPE) tissue, algorithmic analyses to determine tumor-recurrence risk score | 2026 Commercial Medical Surgical Prior Authorization Code List, Pg 240 Original policy |