Blue Cross Blue Shield Oklahoma prior authorization, page 18
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 |
|---|---|---|
| 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 Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 149 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 Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 149 Original policy |
| 0508U | Transplantation Medicine, Quantification Of Donor-Derived Cell- Free Dna Using 40 Single- Nucleotide Polymorphisms (Snps), Plasma, And Urine, Initial Evaluation Reported As Percentage Of Donor- Derived Cell-Free Dna With Risk For Active Rejection | 2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 149 Original policy |
| 0509U | Transplantation Medicine, Quantification Of Donor-Derived Cell- Free Dna Using Up To 12 Single- Nucleotide Polymorphisms (Snps) Previously Identified, Plasma, Reported As Percentage Of Donor- Derived Cell-Free Dna With Risk For Active Rejection | 2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 149 Original policy |
| 0516U | Drug Metabolism, Whole Blood, Pharmacogenomic Genotyping Of 40 Genes And Cyp2D6 Copy Number Variant Analysis, Reported As Metabolizer Status | 2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 150 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 Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 150 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 Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 150 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 Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 150 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 Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 151 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 Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 151 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 Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 151 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 Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 151 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 Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 152 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 Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 152 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 Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 152 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 Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 152 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 Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 153 Original policy |
| 0544U | Nephrology (Transplant Monitoring), 48 Variants By Digital Pcr, Using Cell-Free Dna From Plasma, Donor- Derived Cell-Free Dna, Percentage Reported As Risk Rejection | 2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 153 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 Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 153 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 Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 153 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 Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 154 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 Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 154 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 Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 155 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 Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 155 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 Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 155 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 Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 156 Original policy |
| 0565U | Oncology (hepatocellular carcinoma), next-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 Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 156 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 Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 156 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 Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 157 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 Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 157 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 Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 157 Original policy |
| G9143 | Warfarin Responsiveness Testing By Genetic Technique Using Any Method Any Number Of Specimen(S) | 2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 158 Original policy |
| S3800 | Genetic Testing For Amyotrophic Lateral Sclerosis (Als) | 2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 158 Original policy |
| S3840 | Dna Analysis For Germline Mutations Of The Ret Proto- Oncogene For Susceptibility To Multiple Endocrine Neoplasia Type 2 | 2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 158 Original policy |
| S3841 | Genetic Testing For Retinoblastoma | 2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 158 Original policy |
| S3842 | Genetic Testing For Von Hippel- Lindau Disease | 2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 158 Original policy |
| S3844 | Dna Analysis Of The Connexin 26 Gene (Gjb2) For Susceptibility To Congenital Profound Deafness | 2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 158 Original policy |
| S3845 | Genetic Testing For Alpha- Thalassemia | 2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 158 Original policy |
| S3846 | Genetic Testing For Hemoglobin E Beta-Thalassemia | 2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 158 Original policy |
| S3849 | Genetic Testing For Niemann-Pick Disease | 2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 158 Original policy |
| S3850 | Genetic Testing For Sickle Cell Anemia | 2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 158 Original policy |
| S3852 | Dna Analysis For Apoe Epsilon 4 Allele For Susceptibility To Alzheimer'S Disease | 2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 158 Original policy |
| S3853 | Genetic Testing For Myotonic Muscular Dystrophy | 2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 158 Original policy |
| S3854 | Gene Expression Profiling Panel For Use In The Management Of Breast Cancer Treatment | 2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 158 Original policy |
| S3861 | Genetic Testing Sodium Channel Voltage-Gated Type V Alpha Subunit (Scn5A) And Variants For Suspected Brugada Syndrome | 2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 158 Original policy |
| S3865 | Comprehensive Gene Sequence Analysis For Hypertrophic Cardiomyopathy | 2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 159 Original policy |
| S3866 | Genetic Analysis For A Specific Gene Mutation For Hypertrophic Cardiomyopathy (Hcm) In An Individual With A Known Hcm Mutation In The Family | 2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 159 Original policy |
| S3870 | Comparative Genomic Hybridization (Cgh) Microarray Testing For Developmental Delay Autism Spectrum Disorder And/Or Intellectual Disability | 2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 159 Original policy |
| 20930 | Allograft Morselized Or Placement Of Osteopromotive Material For Spine Surgery Only (List Separately In Addition To Code For Primary Procedure) | 2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 159 Original policy |
| 20931 | Allograft Structural For Spine Surgery Only (List Separately In Addition To Code For Primary Procedure) | 2026 Commercial Outpatient Medical Surgical Fully Insured Prior Authorization Codes, Pg 159 Original policy |