Blue Shield of California Promise Health Plan prior authorization, page 4
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 |
|---|---|---|
| 81223 | CFTR GENE ANALYSIS FULL GENE SEQUENCE | Medi-Cal Prior Authorization List, Pg 7 Original policy |
| 81225 | CYP2C19 (cytochrome P450, family 2, subfamily C, polypeptide 19) (eg, drug metabolism), gene analysis, common variants (eg, *2, *3, *4, *8, *17) | Medi-Cal Prior Authorization List, Pg 7 Original policy |
| 81226 | CYP2D6 gene analysis, common variants | Medi-Cal Prior Authorization List, Pg 7 Original policy |
| 81231 | CYP3A5 (cytochrome P450 family 3 subfamily A member 5), gene analysis, common variants | Medi-Cal Prior Authorization List, Pg 7 Original policy |
| 81232 | DPYD (dihydropyrimidine dehydrogenase) (eg, 5-fluorouracil/5-FU and capecitabine drug metabolism), gene analysis, common variant(s) (eg, *2A, *4, *5, *6) | Medi-Cal Prior Authorization List, Pg 7 Original policy |
| 81233 | GENE ANALYSIS BRUTON'S TYROSINE KINASE COMMON | Medi-Cal Prior Authorization List, Pg 7 Original policy |
| 81234 | GENE ANALYSIS DM1 PROTEIN KINASE ABNORMAL ALLELE | Medi-Cal Prior Authorization List, Pg 7 Original policy |
| 81235 | EGFR (Epidermal Growth Factor Receptor) Gene Analysis, Common Variants | Medi-Cal Prior Authorization List, Pg 7 Original policy |
| 81236 | GENE ANALYSIS ZESTE 2 FULL SEQUENCE | Medi-Cal Prior Authorization List, Pg 7 Original policy |
| 81237 | GENE ANALYSIS ZESTE 2 COMMON VARIANTS | Medi-Cal Prior Authorization List, Pg 7 Original policy |
| 81238 | F9 FULL GENE SEQUENCE | Medi-Cal Prior Authorization List, Pg 7 Original policy |
| 81239 | GENE ANALYSIS DM1 PROTEIN KINASE CHARAC ALLELES | Medi-Cal Prior Authorization List, Pg 7 Original policy |
| 81243 | FMR1 GENE DETECTION | Medi-Cal Prior Authorization List, Pg 7 Original policy |
| 81245 | FLT3 GENE | Medi-Cal Prior Authorization List, Pg 7 Original policy |
| 81246 | FLT3 GENE ANALYSIS | Medi-Cal Prior Authorization List, Pg 7 Original policy |
| 81247 | G6PD (glucose-6-phosphate dehyfrogenase), gene analysis; common variant(s) | Medi-Cal Prior Authorization List, Pg 7 Original policy |
| 81250 | G6PC GENE | Medi-Cal Prior Authorization List, Pg 7 Original policy |
| 81256 | HFE HEMOCHROMATOSIS GENE ANAL COMMON VARIANTS | Medi-Cal Prior Authorization List, Pg 7 Original policy |
| 81257 | HBA1/HBA2 GENE | Medi-Cal Prior Authorization List, Pg 7 Original policy |
| 81258 | HBA1 HBA2 GENE KNOWN VARIANT | Medi-Cal Prior Authorization List, Pg 7 Original policy |
| 81259 | HBA1 HBA2 GENE ANAL FULL GENE SEQ | Medi-Cal Prior Authorization List, Pg 8 Original policy |
| 81260 | IKBKAP GENE | Medi-Cal Prior Authorization List, Pg 8 Original policy |
| 81265 | STR MARKERS SPECIMEN ANAL | Medi-Cal Prior Authorization List, Pg 8 Original policy |
| 81266 | STR MARKERS SPEC ANAL ADDL | Medi-Cal Prior Authorization List, Pg 8 Original policy |
| 81267 | CHIMERISM ANAL NO CELL SELEC | Medi-Cal Prior Authorization List, Pg 8 Original policy |
| 81268 | CHIMERISM ANAL W/CELL SELECT | Medi-Cal Prior Authorization List, Pg 8 Original policy |
| 81269 | HBA1 HBA2 GENE ANAL DUP DEL VARIANT | Medi-Cal Prior Authorization List, Pg 8 Original policy |
| 81271 | GENE ANALYSIS HUNTINGTIN FOR ABNORMAL ALLELES | Medi-Cal Prior Authorization List, Pg 8 Original policy |
| 81272 | KIT GENE TARGETED SEQ ANALYS | Medi-Cal Prior Authorization List, Pg 8 Original policy |
| 81273 | KIT GENE ANALYS D816 VARIANT | Medi-Cal Prior Authorization List, Pg 8 Original policy |
| 81274 | GENE ANALYSIS HUNTINGTIN FOR CHARAC ALLELES | Medi-Cal Prior Authorization List, Pg 8 Original policy |
| 81275 | KRAS GENE VARIANTS EXON 2 | Medi-Cal Prior Authorization List, Pg 8 Original policy |
| 81276 | KRAS GENE ADDL VARIANTS | Medi-Cal Prior Authorization List, Pg 8 Original policy |
| 81277 | CYTOGENOMIC NEOPLASIA GENOME-WIDE MICROARRAY ANALYSIS INTERROGATION | Medi-Cal Prior Authorization List, Pg 8 Original policy |
| 81278 | BREAKPOINT REGION (MBR) AND MINOR CLUSTER REGION (MCR) BREAKPOINTS | Medi-Cal Prior Authorization List, Pg 8 Original policy |
| 81283 | IFNL3 (interferon, lambda 3) (eg, drug response), gene analysis, rs12979860 variant | Medi-Cal Prior Authorization List, Pg 8 Original policy |
| 81284 | GENE ANALYSIS FRATAXIN FOR ABNORMAL ALLELES | Medi-Cal Prior Authorization List, Pg 8 Original policy |
| 81285 | GENE ANALYSIS FRATAXIN FOR CHARACTER ALLELES | Medi-Cal Prior Authorization List, Pg 8 Original policy |
| 81286 | GENE ANALYSIS FRATAXIN OF FULL SEQUENCE | Medi-Cal Prior Authorization List, Pg 8 Original policy |
| 81287 | MGMT PROMOTER METHYLATION ANALYSIS | Medi-Cal Prior Authorization List, Pg 8 Original policy |
| 81288 | MLH1 GENE | Medi-Cal Prior Authorization List, Pg 8 Original policy |
| 81289 | GENE ANALYSIS FRATAXIN FOR KNOWN FAMILIAL VARIANTS | Medi-Cal Prior Authorization List, Pg 8 Original policy |
| 81301 | MICROSATELLITE INSTABILITY | Medi-Cal Prior Authorization List, Pg 8 Original policy |
| 81305 | GENE ANALYSIS FOR P.LEU265PRO VARIANT | Medi-Cal Prior Authorization List, Pg 8 Original policy |
| 81306 | NUDT15 (nudix hydrolase 15) (eg, drug metabolism) gene analysis, common variant(s) (eg, *2, *3, *4, *5, *6) | Medi-Cal Prior Authorization List, Pg 8 Original policy |
| 81309 | PIK3CA PHOSPHATIDYLINOSITOL-4 5-BIPHOSPHATE 3-KINASE CATALYTIC SUBUNIT ALPHA | Medi-Cal Prior Authorization List, Pg 8 Original policy |
| 81310 | NPM1 GENE | Medi-Cal Prior Authorization List, Pg 8 Original policy |
| 81311 | NRAS GENE VARIANTS EXON 2&3 | Medi-Cal Prior Authorization List, Pg 8 Original policy |
| 81312 | GENE ANALYSIS POLY[A] BIND PROTEIN NUCL 1 ABNORM | Medi-Cal Prior Authorization List, Pg 8 Original policy |
| 81314 | PDGFRA GENE | Medi-Cal Prior Authorization List, Pg 8 Original policy |