Blue Cross Blue Shield Oklahoma prior authorization, page 14
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 |
|---|---|---|
| 0075U | Cyp2D6 (Cytochrome P450 Family 2 Subfamily D Polypeptide 6) (Eg Drug Metabolism) Gene Analysis Targeted Sequence Analysis (Ie 5’ Gene Duplication/Multiplication) (List Separately In Addition To Code For Primary Procedure) | 2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 103 Original policy |
| 0076U | Cyp2D6 (Cytochrome P450 Family 2 Subfamily D Polypeptide 6) (Eg Drug Metabolism) Gene Analysis Targeted Sequence Analysis (Ie 3’ Gene Duplication/ Multiplication) (List Separately In Addition To Code For Primary Procedure) | 2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 103 Original policy |
| 0078U | Pain Management (Opioid-Use Disorder) Genotyping Panel 16 Common Variants (Ie Abcb1 Comt Dat1 Dbh Dor Drd1 Drd2 Drd4 Gaba Gal Htr2A Httlpr Mthfr Muor Oprk1 Oprm1) Buccal Swab Or Other Germline Tissue Sample Algorithm Reported As Positive Or Negative Risk Of Opioid-Use Disorder | 2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 104 Original policy |
| 0079U | Comparative Dna Analysis Using Multiple Selected Single-Nucleotide Polymorphisms (Snps) Urine And Buccal Dna For Specimen Identity Verification | 2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 104 Original policy |
| 0087U | Cardiology (Heart Transplant) Mrna Gene Expression Profiling By Microarray Of 1283 Genes Transplant Biopsy Tissue Allograft Rejection And Injury Algorithm Reported As A Probability Score | 2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 104 Original policy |
| 0088U | Transplantation Medicine (Kidney Allograft Rejection) Microarray Gene Expression Profiling Of 1494 Genes Utilizing Transplant Biopsy Tissue Algorithm Reported As A Probability Score For Rejection | 2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 104 Original policy |
| 0089U | Oncology (Melanoma) Gene Expression Profiling By Rtqpcr Prame And Linc00518 Superficial Collection Using Adhesive Patch(Es) | 2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 104 Original policy |
| 0090U | Oncology (Cutaneous Melanoma) Mrna Gene Expression Profiling By Rt-Pcr Of 23 Genes (14 Content And 9 Housekeeping) Utilizing Formalin- Fixed Paraffin-Embedded Tissue (Ffpe) Algorithm Reported As A Categorical Result (Ie Benign Intermediate Malignant) | 2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 105 Original policy |
| 0094U | Genome (Eg Unexplained Constitutional Or Heritable Disorder Or Syndrome) Rapid Sequence Analysis | 2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 105 Original policy |
| 0101U | Hereditary Colon Cancer Disorders (Eg Lynch Syndrome Pten Hamartoma Syndrome Cowden Syndrome Familial Adenomatosis Polyposis) Genomic Sequence Analysis Panel Utilizing A Combination Of Ngs Sanger Mlpa And Array Cgh With Mrna Analytics To Resolve Variants Of Unknown Significance When Indicated (15 Genes [Sequencing And Deletion/Duplication] Epcam And Grem1 [Deletion/Duplication Only]) | 2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 105 Original policy |
| 0102U | Hereditary Breast Cancer-Related Disorders (Eg Hereditary Breast Cancer Hereditary Ovarian Cancer Hereditary Endometrial Cancer) Genomic Sequence Analysis Panel Utilizing A Combination Of Ngs Sanger Mlpa And Array Cgh With Mrna Analytics To Resolve Variants Of Unknown Significance When Indicated (17 Genes [Sequencing And Deletion/Duplication]) | 2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 105 Original policy |
| 0103U | Hereditary Ovarian Cancer (Eg Hereditary Ovarian Cancer Hereditary Endometrial Cancer) Genomic Sequence Analysis Panel Utilizing A Combination Of Ngs Sanger Mlpa And Array Cgh With Mrna Analytics To Resolve Variants Of Unknown Significance When Indicated (24 Genes [Sequencing And Deletion/Duplication] Epcam [Deletion/Duplication Only]) | 2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 106 Original policy |
| 0111U | Oncology (Colon Cancer) Targeted Kras (Codons 12 13 And 61) And Nras (Codons 12 13 And 61) Gene Analysis Utilizing Formalin-Fixed Paraffin-Embedded Tissue | 2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 106 Original policy |
| 0113U | Oncology (Prostate) Measurement Of Pca3 And Tmprss2-Erg In Urine And Psa In Serum Following Prostatic Massage By Rna Amplification And Fluorescence- Based Detection Algorithm Reported As Risk Score | 2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 106 Original policy |
| 0114U | Gastroenterology (Barrett’S Esophagus) Vim And Ccna1 Methylation Analysis Esophageal Cells Algorithm Reported As Likelihood For Barrett’S Esophagus | 2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 106 Original policy |
| 0118U | Transplantation Medicine Quantification Of Donor-Derived Cell- Free Dna Using Whole Genome Next-Generation Sequencing Plasma Reported As Percentage Of Donor-Derived Cell-Free Dna In The Total Cell-Free Dna | 2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 106 Original policy |
| 0120U | Oncology (B-Cell Lymphoma Classification) Mrna Gene Expression Profiling By Fluorescent Probe Hybridization Of 58 Genes (45 Content And 13 Housekeeping Genes) Formalin-Fixed Paraffin- Embedded Tissue Algorithm Reported As Likelihood For Primary Mediastinal B-Cell Lymphoma (Pmbcl) And Diffuse Large B-Cell Lymphoma (Dlbcl) With Cell Of Origin Subtyping In The Latter | 2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 107 Original policy |
| 0129U | Hereditary Breast Cancer-Related Disorders (Eg Hereditary Breast Cancer Hereditary Ovarian Cancer Hereditary Endometrial Cancer) Genomic Sequence Analysis And Deletion/Duplication Analysis Panel (Atm Brca1 Brca2 Cdh1 Chek2 Palb2 Pten And Tp53) | 2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 107 Original policy |
| 0130U | Hereditary Colon Cancer Disorders (Eg Lynch Syndrome Pten Hamartoma Syndrome Cowden Syndrome Familial Adenomatosis Polyposis) Targeted Mrna Sequence Analysis Panel (Apc Cdh1 Chek2 Mlh1 Msh2 Msh6 Mutyh Pms2 Pten And Tp53) (List Separately In Addition To Code For Primary Procedure) | 2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 107 Original policy |
| 0131U | Hereditary Breast Cancer-Related Disorders (Eg Hereditary Breast Cancer Hereditary Ovarian Cancer Hereditary Endometrial Cancer) Targeted Mrna Sequence Analysis Panel (13 Genes) (List Separately In Addition To Code For Primary Procedure) | 2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 108 Original policy |
| 0132U | Hereditary Ovarian Cancer-Related Disorders (Eg Hereditary Breast Cancer Hereditary Ovarian Cancer Hereditary Endometrial Cancer) Targeted Mrna Sequence Analysis Panel (17 Genes) (List Separately In Addition To Code For Primary Procedure) | 2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 108 Original policy |
| 0133U | Hereditary Prostate Cancer-Related Disorders Targeted Mrna Sequence Analysis Panel (11 Genes) (List Separately In Addition To Code For Primary Procedure) | 2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 108 Original policy |
| 0134U | Hereditary Pan Cancer (Eg Hereditary Breast And Ovarian Cancer Hereditary Endometrial Cancer Hereditary Colorectal Cancer) Targeted Mrna Sequence Analysis Panel (18 Genes) (List Separately In Addition To Code For Primary Procedure) | 2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 108 Original policy |
| 0135U | Hereditary Gynecological Cancer (Eg Hereditary Breast And Ovarian Cancer Hereditary Endometrial Cancer Hereditary Colorectal Cancer) Targeted Mrna Sequence Analysis Panel (12 Genes) (List Separately In Addition To Code For Primary Procedure) | 2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 108 Original policy |
| 0136U | Atm (Ataxia Telangiectasia Mutated) (Eg Ataxia Telangiectasia) Mrna Sequence Analysis (List Separately In Addition To Code For Primary Procedure) | 2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 109 Original policy |
| 0137U | Palb2 (Partner And Localizer Of Brca2) (Eg Breast And Pancreatic Cancer) Mrna Sequence Analysis (List Separately In Addition To Code For Primary Procedure) | 2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 109 Original policy |
| 0138U | Brca1 (Brca1 Dna Repair Associated) Brca2 (Brca2 Dna Repair Associated) (Eg Hereditary Breast And Ovarian Cancer) Mrna Sequence Analysis (List Separately In Addition To Code For Primary Procedure) | 2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 109 Original policy |
| 0153U | Oncology (Breast) Mrna Gene Expression Profiling By Next- Generation Sequencing Of 101 Genes Utilizing Formalin-Fixed Paraffin-Embedded Tissue Algorithm Reported As A Triple Negative Breast Cancer Clinical Subtype(S) With Information On Immune Cell Involvement | 2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 109 Original policy |
| 0154U | Oncology (Urothelial Cancer) Rna Analysis By Real-Time Rt-Pcr Of The Fgfr3 (Fibroblast Growth Factor Receptor 3) Gene Analysis (Ie P.R248C [C.742C>T] P.S249C [C.746C>G] P.G370C [C.1108G>T] P.Y373C [C.1118A>G] Fgfr3- Tacc3V1 And Fgfr3-Tacc3V3) Utilizing Formalin-Fixed Paraffin- Embedded Urothelial Cancer Tumor Tissue Reported As Fgfr Gene Alteration Status | 2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 109 Original policy |
| 0155U | Oncology (Breast Cancer) Dna Pik3Ca (Phosphatidylinositol-4 5- Bisphosphate 3-Kinase Catalytic Subunit Alpha) (Eg Breast Cancer) Gene Analysis (Ie P.C420R P.E542K P.E545A P.E545D [G.1635G>T Only] P.E545G P.E545K P.Q546E P.Q546R P.H1047L P.H1047R P.H1047Y) Utilizing Formalin-Fixed Paraffin- Embedded Breast Tumor Tissue Reported As Pik3Ca Gene Mutation Status | 2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 110 Original policy |
| 0156U | Copy Number (Eg Intellectual Disability Dysmorphology) Sequence Analysis | 2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 110 Original policy |
| 0157U | Apc (Apc Regulator Of Wnt Signaling Pathway) (Eg Familial Adenomatosis Polyposis [Fap]) Mrna Sequence Analysis (List Separately In Addition To Code For Primary Procedure) | 2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 110 Original policy |
| 0158U | Mlh1 (Mutl Homolog 1) (Eg Hereditary Non-Polyposis Colorectal Cancer Lynch Syndrome) Mrna Sequence Analysis (List Separately In Addition To Code For Primary Procedure) | 2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 110 Original policy |
| 0159U | Msh2 (Muts Homolog 2) (Eg Hereditary Colon Cancer Lynch Syndrome) Mrna Sequence Analysis (List Separately In Addition To Code For Primary Procedure) | 2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 110 Original policy |
| 0160U | Msh6 (Muts Homolog 6) (Eg Hereditary Colon Cancer Lynch Syndrome) Mrna Sequence Analysis (List Separately In Addition To Code For Primary Procedure) | 2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 110 Original policy |
| 0161U | Pms2 (Pms1 Homolog 2 Mismatch Repair System Component) (Eg Hereditary Non-Polyposis Colorectal Cancer Lynch Syndrome) Mrna Sequence Analysis (List Separately In Addition To Code For Primary Procedure) | 2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 111 Original policy |
| 0162U | Hereditary Colon Cancer (Lynch Syndrome) Targeted Mrna Sequence Analysis Panel (Mlh1 Msh2 Msh6 Pms2) (List Separately In Addition To Code For Primary Procedure) | 2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 111 Original policy |
| 0169U | Nudt15 (Nudix Hydrolase 15) And Tpmt (Thiopurine S- Methyltransferase) (Eg Drug Metabolism) Gene Analysis Common Variants | 2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 111 Original policy |
| 0170U | Neurology (Autism Spectrum Disorder [Asd]) Rna Next- Generation Sequencing Saliva Algorithmic Analysis And Results Reported As Predictive Probability Of Asd Diagnosis | 2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 111 Original policy |
| 0171U | Targeted Genomic Sequence Analysis Panel Acute Myeloid Leukemia Myelodysplastic Syndrome And Myeloproliferative Neoplasms Dna Analysis 23 Genes Interrogation For Sequence Variants Rearrangements And Minimal Residual Disease Reported As Presence/Absence | 2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 111 Original policy |
| 0203U | Autoimmune (Inflammatory Bowel Disease) Mrna Gene Expression Profiling By Quantitative Rt-Pcr 17 Genes (15 Target And 2 Reference Genes) Whole Blood Reported As A Continuous Risk Score And Classification Of Inflammatory Bowel Disease Aggressiveness | 2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 112 Original policy |
| 0205U | Ophthalmology (Age-Related Macular Degeneration) Analysis Of 3 Gene Variants (2 Cfh Gene 1 Arms2 Gene) Using Pcr And Maldi- Tof Buccal Swab Reported As Positive Or Negative For Neovascular Age-Related Macular- Degeneration Risk Associated With Zinc Supplements | 2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 112 Original policy |
| 0209U | Cytogenomic Constitutional (Genome-Wide) Analysis Interrogation Of Genomic Regions For Copy Number Structural Changes And Areas Of Homozygosity For Chromosomal Abnormalities | 2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 112 Original policy |
| 0211U | Oncology (Pan-Tumor) Dna And Rna By Next-Generation Sequencing Utilizing Formalin-Fixed Paraffin- Embedded Tissue Interpretative Report For Single Nucleotide Variants Copy Number Alterations Tumor Mutational Burden And Microsatellite Instability With Therapy Association | 2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 112 Original policy |
| 0212U | Rare Diseases (Constitutional/Heritable Disorders) Whole Genome 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 Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 113 Original policy |
| 0213U | Rare Diseases (Constitutional/Heritable Disorders) Whole Genome 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 Genome (Eg Parent Sibling) | 2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 113 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 Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 113 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 Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 114 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 Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 114 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 Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 114 Original policy |