Blue Shield of California Promise Health Plan prior authorization, page 3
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 |
|---|---|---|
| 76018 | MR safety implant electronics preparation under supervision of physician or other qualified health care professional, including MR-specific programming of pulse generator and/or transmitter to verify device integrity, protection of device internal circuitry from MR electromagnetic fields, and protection of patient from risks of unintended stimulation or heating while in the MR room, with written report | Medi-Cal Prior Authorization List, Pg 5 Original policy |
| 76019 | MR safety implant positioning and/or immobilization under supervision of physician or other qualified health care professional, including application of physical protections to secure implanted medical device from MR-induced translational or vibrational forces, magnetically induced functional changes, and/or prevention of radiofrequency burns from inadvertent tissue contact while in the MR room, with written report | Medi-Cal Prior Authorization List, Pg 5 Original policy |
| 77299 | UNLIS PX THER RAD CLINICAL TX PLNNING | Medi-Cal Prior Authorization List, Pg 5 Original policy |
| 78429 | MYOCARDIAL IMAGING POSITRON EMISSION TOMOGRAPHY | Medi-Cal Prior Authorization List, Pg 5 Original policy |
| 78430 | MYOCARDIAL IMAGING POSITRON EMISSION TOMOGRAPHY | Medi-Cal Prior Authorization List, Pg 6 Original policy |
| 78431 | MYOCARDIAL IMAGING POSITRON EMISSION TOMOGRAPHY | Medi-Cal Prior Authorization List, Pg 6 Original policy |
| 78432 | MYOCARDIAL IMAGING POSITRON EMISSION TOMOGRAPHY | Medi-Cal Prior Authorization List, Pg 6 Original policy |
| 78433 | MYOCARDIAL IMAGING POSITRON EMISSION TOMOGRAPHY | Medi-Cal Prior Authorization List, Pg 6 Original policy |
| 78434 | TOMOGRAPHY PET REST AND PHARMACOLOGIC STRES | Medi-Cal Prior Authorization List, Pg 6 Original policy |
| 78811 | PET IMAGING LIMITED AREA CHEST HEAD/NECK | Medi-Cal Prior Authorization List, Pg 6 Original policy |
| 78812 | PET IMAGING SKULL BASE TO MID-THIGH | Medi-Cal Prior Authorization List, Pg 6 Original policy |
| 78813 | PET IMAGING WHOLE BODY | Medi-Cal Prior Authorization List, Pg 6 Original policy |
| 78814 | PET IMAGING CT FOR ATTENUATION LIMITED AREA | Medi-Cal Prior Authorization List, Pg 6 Original policy |
| 78815 | PET IMAGING CT ATTENUATION SKULL BASE MID-THIGH | Medi-Cal Prior Authorization List, Pg 6 Original policy |
| 78816 | PET IMAGING FOR CT ATTENUATION WHOLE BODY | Medi-Cal Prior Authorization List, Pg 6 Original policy |
| 78835 | ADD TO CODE FOR PRIMARY PROC) | Medi-Cal Prior Authorization List, Pg 6 Original policy |
| 81162 | BRCA1/BRCA2 Gene Analysis | Medi-Cal Prior Authorization List, Pg 6 Original policy |
| 81170 | ABL1 GENE | Medi-Cal Prior Authorization List, Pg 6 Original policy |
| 81171 | GENE ANALYSIS FRAGILE X MENTAL RETARDATION | Medi-Cal Prior Authorization List, Pg 6 Original policy |
| 81172 | GENE ANALYSIS FRAGILE X MENTAL RETARDATION | Medi-Cal Prior Authorization List, Pg 6 Original policy |
| 81173 | GENE ANALYSIS ANDROGEN RECEPTOR FULL SEQUENCE | Medi-Cal Prior Authorization List, Pg 6 Original policy |
| 81174 | GENE ANALYSIS ANDROGEN RECEPTOR KNOWN VARIANT | Medi-Cal Prior Authorization List, Pg 6 Original policy |
| 81175 | ASXL1 | Medi-Cal Prior Authorization List, Pg 6 Original policy |
| 81176 | ASXL1 | Medi-Cal Prior Authorization List, Pg 6 Original policy |
| 81177 | GENE ANALYSIS ATROPIN 1 FOR ABNORMAL ALLELES | Medi-Cal Prior Authorization List, Pg 6 Original policy |
| 81178 | GENE ANALYSIS ATAXIN 1 FOR ABNORMAL ALLELES | Medi-Cal Prior Authorization List, Pg 6 Original policy |
| 81179 | GENE ANALYSIS ATAXIN 2 FOR ABNORMAL ALLELES | Medi-Cal Prior Authorization List, Pg 6 Original policy |
| 81180 | GENE ANALYSIS ATAXIN 3 FOR ABNORMAL ALLELES | Medi-Cal Prior Authorization List, Pg 6 Original policy |
| 81181 | GENE ANALYSIS ATAXIN 7 FOR ABNORMAL ALLELES | Medi-Cal Prior Authorization List, Pg 6 Original policy |
| 81182 | GENE ANALYSIS ATAXIN 8 OPPOSITE STRAND | Medi-Cal Prior Authorization List, Pg 6 Original policy |
| 81183 | GENE ANALYSIS ATAXIN 10 FOR ABNORMAL ALLELES | Medi-Cal Prior Authorization List, Pg 6 Original policy |
| 81184 | GENE ANALYSIS CALCIUM VOLTAGE-GATED CHANNEL | Medi-Cal Prior Authorization List, Pg 6 Original policy |
| 81185 | GENE ANALYSIS CALCIUM VOLTAGE-GATED CHANNEL | Medi-Cal Prior Authorization List, Pg 6 Original policy |
| 81186 | GENE ANALYSIS CALCIUM VOLTAGE-GATED CHANNEL | Medi-Cal Prior Authorization List, Pg 6 Original policy |
| 81187 | GENE ANALYSIS CCH-TYPE ZINC FINGER NUCLEIC ACID | Medi-Cal Prior Authorization List, Pg 6 Original policy |
| 81188 | GENE ANALYSIS CYSTATIN B FOR ABNORMAL ALLELES | Medi-Cal Prior Authorization List, Pg 6 Original policy |
| 81189 | GENE ANALYSIS CYSTATIN B OF FULL SEQUENCE | Medi-Cal Prior Authorization List, Pg 6 Original policy |
| 81190 | GENE ANALYSIS CYSTATIN B KNOWN FAMILIAL VARIANTS | Medi-Cal Prior Authorization List, Pg 6 Original policy |
| 81191 | TRANSLOCATION ANALYSIS | Medi-Cal Prior Authorization List, Pg 6 Original policy |
| 81192 | TRANSLOCATION ANALYSIS | Medi-Cal Prior Authorization List, Pg 7 Original policy |
| 81193 | TRANSLOCATION ANALYSIS | Medi-Cal Prior Authorization List, Pg 7 Original policy |
| 81194 | SOLID TUMORS) TRANSLOCATION ANALYSIS | Medi-Cal Prior Authorization List, Pg 7 Original policy |
| 81204 | GENE ANALYSIS ANDROGEN RECEPTOR | Medi-Cal Prior Authorization List, Pg 7 Original policy |
| 81206 | BCR/ABL1 GENE MAJOR BP | Medi-Cal Prior Authorization List, Pg 7 Original policy |
| 81207 | BCR/ABL1 GENE MINOR BP | Medi-Cal Prior Authorization List, Pg 7 Original policy |
| 81208 | BCR/ABL1 GENE OTHER BP | Medi-Cal Prior Authorization List, Pg 7 Original policy |
| 81218 | CEBPA GENE FULL SEQUENCE | Medi-Cal Prior Authorization List, Pg 7 Original policy |
| 81220 | CFTR (cystic fibrosis transmembrane conductance regulator) (eg, cystic fibrosis) gene analysis; common variants (eg, ACMG/ACOG guidelines) | Medi-Cal Prior Authorization List, Pg 7 Original policy |
| 81221 | CFTR GENE ANALYSIS KNOWN FAMILIAL VARIANTS | Medi-Cal Prior Authorization List, Pg 7 Original policy |
| 81222 | CFTR GENE DUP/DELET VARIANTS | Medi-Cal Prior Authorization List, Pg 7 Original policy |