Talk to Us

Blue Cross and Blue Shield of Montana prior authorization, page 25

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

Prior authorization codes
CodeDescriptionSource
0605UAllergy and immunology (hereditary alpha tryptasemia), DNA, analysis of TPSAB1 gene copy number variation using digital PCR, whole blood, results reported with genotype-specific interpretation of alpha- tryptase copy number and algorithmic classification as normal or abnormal2026 Commercial Medical Surgical Prior Authorization Code List, Pg 240 Original policy
0611UOncology (liver), analysis of over 1,000 methylated regions, cell-free DNA from plasma, algorithm reported as a quantitative result2026 Commercial Medical Surgical Prior Authorization Code List, Pg 241 Original policy
0612UOncology (liver), analysis of over 1,000 methylated regions, cell-free DNA from plasma, algorithm reported as a quantitative result2026 Commercial Medical Surgical Prior Authorization Code List, Pg 241 Original policy
0613UOncology (urothelial carcinoma), DNA methylation and mutation analysis of 6 biomarkers (TWIST1, OTX1, ONECUT2, FGFR3, HRAS, TERT promoter region), methylation-specific PCR and targeted next-generation sequencing, urine, algorithm reported as a probability index for bladder cancer and upper tract urothelial carcinoma2026 Commercial Medical Surgical Prior Authorization Code List, Pg 241 Original policy
0628UNephrology (kidney disease-related genetic conditions), genomic analysis, renal disease panel, saliva, DNA, next- generation sequencing of 449 genes, reported as pathogenic or likely pathogenic variants of uncertain significance or risk alleles2026 Commercial Medical Surgical Prior Authorization Code List, Pg 241 Original policy
0630UOncology (breast), mRNA, gene expression profiling by microarray of 80 genes (80 content and 465 housekeeping), utilizing formalin-fixed paraffin-embedded tissue (FFPE), algorithm reported as an index that is diagnostic of a molecular subtype (luminal, basal, Her2)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 242 Original policy
0632URed blood cell antigen, fetal RHD gene analysis using multiplex PCR and next- generation sequencing of circulating cell- free DNA2026 Commercial Medical Surgical Prior Authorization Code List, Pg 242 Original policy
0633TComputed Tomography Breast Including 3D Rendering When Performed Unilateral; Without Contrast Material2026 Commercial Medical Surgical Prior Authorization Code List, Pg 242 Original policy
0633UObstetrics single-gene noninvasive prenatal test using circulating cell-free DNA and next-generation sequencing2026 Commercial Medical Surgical Prior Authorization Code List, Pg 242 Original policy
0634TComputed Tomography Breast Including 3D Rendering When Performed Unilateral; With Contrast Material(S)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 242 Original policy
0635TComputed Tomography Breast Including 3D Rendering When Performed Unilateral; Without Contrast Followed By Contrast Material(S)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 242 Original policy
0635UArtificial intelligence analysis of mRNA gene expression profiling, 487 genes, noninvasive2026 Commercial Medical Surgical Prior Authorization Code List, Pg 242 Original policy
0636TComputed Tomography Breast Including 3D Rendering When Performed Bilateral; Without Contrast Material(S)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 243 Original policy
0637TComputed Tomography Breast Including 3D Rendering When Performed Bilateral; With Contrast Material(S)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 243 Original policy
0638TComputed Tomography Breast Including 3D Rendering When Performed Bilateral; Without Contrast Followed By Contrast Material(S)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 243 Original policy
0641UOncology minimal residual disease tumor DNA analysis using next-generation sequencing of FFPE tissue and blood sample, initial test2026 Commercial Medical Surgical Prior Authorization Code List, Pg 243 Original policy
0642UOncology minimal residual disease tumor DNA analysis using next-generation sequencing of whole blood, comparison to previous analysis2026 Commercial Medical Surgical Prior Authorization Code List, Pg 243 Original policy
0643UOncology genitourinary cancer circulating tumor DNA analysis, 200 genes, NGS interrogation of SNVs and indels2026 Commercial Medical Surgical Prior Authorization Code List, Pg 243 Original policy
0648TQuantitative Magnetic Resonance For Analysis Of Tissue Composition (Eg Fat Iron Water Content) Including Multiparametric Data Acquisition Data Preparation And Transmission Interpretation And Report Obtained Without Diagnostic Mri Examination Of The Same Anatomy (Eg Organ Gland Tissue Target Structure) During The Same Session; Single Organ2026 Commercial Medical Surgical Prior Authorization Code List, Pg 244 Original policy
0649TQuantitative Magnetic Resonance For Analysis Of Tissue Composition (Eg Fat Iron Water Content) Including Multiparametric Data Acquisition Data Preparation And Transmission Interpretation And Report Obtained With Diagnostic Mri Examination Of The Same Anatomy (Eg Organ Gland Tissue Target Structure); Single Organ (List Separately In Addition To Code For Primary Procedure)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 244 Original policy
0649UNeurology Alzheimer’s disease DNA targeted analysis using next-generation sequencing of AD-related genes from whole blood2026 Commercial Medical Surgical Prior Authorization Code List, Pg 244 Original policy
0651UOncology hereditary cancer genomic DNA analysis of 55 genes using NGS and deletion/duplication analysis (MLPA)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 244 Original policy
0660UHPV GNOTYP 18/31/33/35 CFDNA2026 Commercial Medical Surgical Prior Authorization Code List, Pg 244 Original policy
0661UHPV GENOTYPE 16 CFDNA DDPCR2026 Commercial Medical Surgical Prior Authorization Code List, Pg 245 Original policy
0662UTRNSPLJ MED KAR RTQPCR 12GEN2026 Commercial Medical Surgical Prior Authorization Code List, Pg 245 Original policy
0663UOB FETAL PLTLT AG NIPT CFDNA2026 Commercial Medical Surgical Prior Authorization Code List, Pg 245 Original policy
0664UTRNSPLJ MED KAF NGS 13 GENES2026 Commercial Medical Surgical Prior Authorization Code List, Pg 245 Original policy
0668UONC PNCRS DNA 5HMC & GLYCAN2026 Commercial Medical Surgical Prior Authorization Code List, Pg 245 Original policy
0670URARE DS WGSA S/L READ CMPRTR2026 Commercial Medical Surgical Prior Authorization Code List, Pg 245 Original policy
0671URARE DS WGSA S/L RD 2CMPRTRS2026 Commercial Medical Surgical Prior Authorization Code List, Pg 245 Original policy
0672URARE DS WHOLE EXOME CMPRTR2026 Commercial Medical Surgical Prior Authorization Code List, Pg 245 Original policy
0673URARE DS WHOLE EXOME 2CMPRTRS2026 Commercial Medical Surgical Prior Authorization Code List, Pg 245 Original policy
0674URARE DS MTDNA BLD/SLV/GENDNA2026 Commercial Medical Surgical Prior Authorization Code List, Pg 245 Original policy
0675URARE DS MTDNA PRBND&2CMPRTRS2026 Commercial Medical Surgical Prior Authorization Code List, Pg 245 Original policy
0676URARE DS WGSA MATERNAL CMPRTR2026 Commercial Medical Surgical Prior Authorization Code List, Pg 245 Original policy
0677URARE DS WGSA FETAL SAMPLE2026 Commercial Medical Surgical Prior Authorization Code List, Pg 245 Original policy
0678UONC HHM GENOME SEQ 117 GENES2026 Commercial Medical Surgical Prior Authorization Code List, Pg 245 Original policy
0679UONC HHM DNA ALYS >105 GENES2026 Commercial Medical Surgical Prior Authorization Code List, Pg 245 Original policy
0686UONC PRST8 MRNA GENE XPRSN 222026 Commercial Medical Surgical Prior Authorization Code List, Pg 245 Original policy
0688UONC CLRCT CA ALYS MRD CTDNA2026 Commercial Medical Surgical Prior Authorization Code List, Pg 245 Original policy
0689UONC CLRT CA ALYS MRD PT-SPEC2026 Commercial Medical Surgical Prior Authorization Code List, Pg 245 Original policy
0690UTRNSPLJ MED AR DPCR ALYS 452026 Commercial Medical Surgical Prior Authorization Code List, Pg 245 Original policy
0691UCARRIER SCREENING GSAP 6GENS2026 Commercial Medical Surgical Prior Authorization Code List, Pg 245 Original policy
0693UONC H&N CTDNA 699 GENES VRNT2026 Commercial Medical Surgical Prior Authorization Code List, Pg 245 Original policy
0696UONC SO TGSA RNA ALYS 350/>2026 Commercial Medical Surgical Prior Authorization Code List, Pg 245 Original policy
A0430Ambulance Service Conventional Air Services Transport One Way (Fixed Wing)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 245 Original policy
A0431Ambulance service, conventional air services, transport, one way (rotary wing)2026 Commercial Medical Surgical Prior Authorization Code List, Pg 246 Original policy
A0435Fixed Wing Air Mileage, per statute Mile2026 Commercial Medical Surgical Prior Authorization Code List, Pg 246 Original policy
A0436Rotary wing air mileage, per statute mile2026 Commercial Medical Surgical Prior Authorization Code List, Pg 246 Original policy
A9508Iodine I-131 Iobenguane Sulfate Diagnostic Per 0.5 Millicurie2026 Commercial Medical Surgical Prior Authorization Code List, Pg 246 Original policy

Sources

Disclaimer

The information provided on this page is for general informational purposes only and does not constitute billing, coding, or reimbursement advice. Nothing on this page should be relied upon as a substitute for clinician assessment, professional billing guidance, or as a definitive statement of any payor's billing requirements or policies.

Payor agreements, fee schedules, and billing policies vary and are subject to change. Before submitting any claims related to maternity care services, including claims affected by the 2027 CPT code revisions, please consult the applicable payor agreements, coverage policies, and billing guidelines to confirm current requirements for their specific payor contracts.

Substrate makes no representation or warranty regarding the accuracy, completeness, or timeliness of the payor-specific information presented here. Providers are solely responsible for ensuring that all claims are submitted in accordance with applicable payor requirements, and Substrate assumes no liability for claim denials, underpayments, or other adverse outcomes arising from reliance on this information.

This website uses cookies to ensure you get the best experience on our website. Learn more