Blue Shield of California Promise Health Plan prior authorization, page 5
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 |
|---|---|---|
| 81315 | PML/RARALPHA COM BREAKPOINTS | Medi-Cal Prior Authorization List, Pg 8 Original policy |
| 81316 | PML/RARALPHA 1 BREAKPOINT | Medi-Cal Prior Authorization List, Pg 8 Original policy |
| 81320 | GENE ANALYSIS PHOSPHO C GAMMA 2 COMMON VARIANTS | Medi-Cal Prior Authorization List, Pg 8 Original policy |
| 81321 | PTEN (Phosphatase And Tensin Homolog) Gene Analysis; Full Sequence Analysis | Medi-Cal Prior Authorization List, Pg 8 Original policy |
| 81322 | PTEN (Phosphatase And Tensin Homolog) Gene Analysis; Known Familial Variant | Medi-Cal Prior Authorization List, Pg 9 Original policy |
| 81323 | PTEN (Phosphatase And Tensin Homolog) Gene Analysis; Duplication/Deletion Variant | Medi-Cal Prior Authorization List, Pg 9 Original policy |
| 81328 | SLCO1B1 (solute carrier organic anion transporter family, member 1B1), gene analysis, common variant(s) | Medi-Cal Prior Authorization List, Pg 9 Original policy |
| 81331 | SNRPN/UBE3A GENE | Medi-Cal Prior Authorization List, Pg 9 Original policy |
| 81334 | RUNX1 GENE ANALYSIS TARGET SEQ ANAL | Medi-Cal Prior Authorization List, Pg 9 Original policy |
| 81335 | TPMT (thiopurine S-methyltransferase) (eg, drug metabolism), gene analysis, common variants (eg, *2, *3) | Medi-Cal Prior Authorization List, Pg 9 Original policy |
| 81336 | GENE ANALYSIS MOTOR NEURON 1 TELOMERIC | Medi-Cal Prior Authorization List, Pg 9 Original policy |
| 81337 | GENE ANALYSIS MOTOR NEURON 1 TELOMERIC | Medi-Cal Prior Authorization List, Pg 9 Original policy |
| 81343 | GENE ANALYSIS PROTEIN PHOSPH2 ABNORMAL ALLELES | Medi-Cal Prior Authorization List, Pg 9 Original policy |
| 81344 | GENE ANALYSIS TATA BOX BINDING PROTEIN ABNORMAL | Medi-Cal Prior Authorization List, Pg 9 Original policy |
| 81345 | GENE ANALYSIS TELOMERASE REVERSE SEQ ANALYSIS | Medi-Cal Prior Authorization List, Pg 9 Original policy |
| 81347 | Genetic Analysis Procedures | Medi-Cal Prior Authorization List, Pg 9 Original policy |
| 81348 | GENE ANALYSIS (E.G., Srsf2 GENE COMMON VARIANTS) | Medi-Cal Prior Authorization List, Pg 9 Original policy |
| 81350 | UGT1A1 gene analysis | Medi-Cal Prior Authorization List, Pg 9 Original policy |
| 81351 | SEQUENCE | Medi-Cal Prior Authorization List, Pg 9 Original policy |
| 81352 | SEQUENCE ANALYSIS (EG, 4 ONCOLOGY) | Medi-Cal Prior Authorization List, Pg 9 Original policy |
| 81353 | TP53 (tumor protein 53) (eg, Li-Fraumeni syndrome) gene analysis; known familial variant | Medi-Cal Prior Authorization List, Pg 9 Original policy |
| 81355 | VKORC1 gene analysis | Medi-Cal Prior Authorization List, Pg 9 Original policy |
| 81357 | Genetic Analysis Procedures | Medi-Cal Prior Authorization List, Pg 9 Original policy |
| 81360 | GENE ANALYSIS (E.G., Zrsr2 GENE COMMON VARIANTS) | Medi-Cal Prior Authorization List, Pg 9 Original policy |
| 81374 | HLA Class I typing, low resolution (eg, antigen equivalents); one antigen equivalent (eg, B*27), each | Medi-Cal Prior Authorization List, Pg 9 Original policy |
| 81381 | HLA Class I typing, high resolution (ie, alleles or allele groups); one allele or allele group (eg, B*57:01P), each | Medi-Cal Prior Authorization List, Pg 9 Original policy |
| 81400 | MOLECULAR PATH PROC LEVEL 1 | Medi-Cal Prior Authorization List, Pg 9 Original policy |
| 81401 | Molecular pathology procedure, Level 2 (eg, 2-10 SNPs, 1 methylated variant, or 1 somatic variant [typically using non-sequencing target variant analysis], or detection of a dynamic mutation disorder/triplet repeat) | Medi-Cal Prior Authorization List, Pg 9 Original policy |
| 81402 | MOLECULAR PATHOLOGY PROCEDURE LEVEL 3 | Medi-Cal Prior Authorization List, Pg 9 Original policy |
| 81404 | MOLECULAR PATHOLOGY PROCEDURE LEVEL 5 | Medi-Cal Prior Authorization List, Pg 9 Original policy |
| 81405 | MOLECULAR PATHOLOGY PROCEDURE LEVEL 6 | Medi-Cal Prior Authorization List, Pg 9 Original policy |
| 81406 | Molecular pathology procedure, Level 7 (eg, analysis of 11-25 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of 26-50 exons) | Medi-Cal Prior Authorization List, Pg 10 Original policy |
| 81407 | MOPATH PROCEDURE LEVEL 8 | Medi-Cal Prior Authorization List, Pg 10 Original policy |
| 81408 | MOPATH PROCEDURE LEVEL 9 | Medi-Cal Prior Authorization List, Pg 10 Original policy |
| 81418 | Drug metabolism (e.g., pharmacogenomics) genomic sequence analysis panel, must include testing of at least 6 genes, including CYP2C19, CYP2D6, and CYP2D6 duplication/deletion analysis | Medi-Cal Prior Authorization List, Pg 10 Original policy |
| 81419 | EPILEPSY GENOMIC SEQ ANALYSIS PANEL | Medi-Cal Prior Authorization List, Pg 10 Original policy |
| 81455 | Genomic Sequence Analysis, 51+ Genes | Medi-Cal Prior Authorization List, Pg 10 Original policy |
| 81479 | Unlisted molecular pathology procedure | Medi-Cal Prior Authorization List, Pg 10 Original policy |
| 81541 | ONCO GENE EXPRESS PROFILING | Medi-Cal Prior Authorization List, Pg 10 Original policy |
| 81542 | CONTENT GENES | Medi-Cal Prior Authorization List, Pg 10 Original policy |
| 81546 | MULTIANALYTE ASSAYS WITH ALGORITHMIC ANALYSES | Medi-Cal Prior Authorization List, Pg 10 Original policy |
| 81599 | Unlisted Multianalyte Assay | Medi-Cal Prior Authorization List, Pg 10 Original policy |
| 82233 | Beta-amyloid; 1-40 (Abeta 40) | Medi-Cal Prior Authorization List, Pg 10 Original policy |
| 82234 | Beta-amyloid; 1-42 (Abeta 42) | Medi-Cal Prior Authorization List, Pg 10 Original policy |
| 84393 | Tau, phosphorylated (eg, pTau 181, pTau 217), each | Medi-Cal Prior Authorization List, Pg 10 Original policy |
| 84394 | Tau, total (tTau) | Medi-Cal Prior Authorization List, Pg 10 Original policy |
| 86813 | HLA TYPING A B OR C | Medi-Cal Prior Authorization List, Pg 10 Original policy |
| 86817 | HLA TYPING DR/DQ | Medi-Cal Prior Authorization List, Pg 10 Original policy |
| 93896 | Vasoreactivity study performed with transcranial Doppler study of intracranial arteries, complete (List separately in addition to code for primary procedure) | Medi-Cal Prior Authorization List, Pg 10 Original policy |
| 93897 | Emboli detection without intravenous microbubble injection performed with transcranial Doppler study of intracranial arteries, complete (List separately in addition to code for primary procedure) | Medi-Cal Prior Authorization List, Pg 10 Original policy |