Blue Shield of California Promise Health Plan prior authorization, page 6
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 |
|---|---|---|
| 93898 | Venous-arterial shunt detection with 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 |
| 95965 | MAGNETOENCEPHALOGRAPHY SPON BRAIN ACTIVITY | Medi-Cal Prior Authorization List, Pg 10 Original policy |
| 95966 | MAGNETOENCEPHALOGRAPY EVOKED FIELDS 1 MODALITY | Medi-Cal Prior Authorization List, Pg 10 Original policy |
| 95967 | MAGNETOENCEPHALOGRAPY EVOKED FIELDS EACH ADDL | Medi-Cal Prior Authorization List, Pg 10 Original policy |
| 95999 | Unlisted neurological or neuromuscular diagnostic procedure | Medi-Cal Prior Authorization List, Pg 11 Original policy |
| 96549 | UNLIS CHEMOTX PX | Medi-Cal Prior Authorization List, Pg 11 Original policy |
| 97007 | Mechanical scalp cooling, including individual cap supply with head measurement, fitting, and patient education | Medi-Cal Prior Authorization List, Pg 11 Original policy |
| 97008 | Mechanical scalp cooling; including hair preparation, individual cap placement, therapy initiation, and precooling period | Medi-Cal Prior Authorization List, Pg 11 Original policy |
| 97009 | Mechanical scalp cooling; provided after discontinuation of chemotherapy, each 30 minutes (List separately in addition to code for primary procedure) | Medi-Cal Prior Authorization List, Pg 11 Original policy |
| 0029U | Drug metabolism (adverse drug reactions and drug response), targeted sequence analysis (ie, CYP1A2, CYP2C19, CYP2C9, CYP2D6, CYP3A4, CYP3A5, CYP4F2, SLCO1B1, VKORC1 and rs12777823). | Medi-Cal Prior Authorization List, Pg 11 Original policy |
| 0037U | DNA GENE ANALYSIS OF 324 GENES | Medi-Cal Prior Authorization List, Pg 11 Original policy |
| 0046U | GENE ANALYSIS FOR INTERNAL TANDEM DUP VARIANTS | Medi-Cal Prior Authorization List, Pg 11 Original policy |
| 0049U | GENE ANALYSIS (NUCLEOPHOSMIN) | Medi-Cal Prior Authorization List, Pg 11 Original policy |
| 0070U | CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, common and select rare variants (ie, *2, *3, *4, *4N, *5, *6, *7, *8, *9, *10, *11, *12, *13, *14A, *14B, *15, *17, *29, *35, *36, *41, *57, *61, *63, *68, *83, *xN) | Medi-Cal Prior Authorization List, Pg 11 Original policy |
| 0071U | CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, full gene sequence (List separately in addition to code for primary procedure) | Medi-Cal Prior Authorization List, Pg 11 Original policy |
| 0072U | CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, targeted sequence analysis (ie, CYP2D6-2D7 hybrid gene) (List separately in addition to code for primary procedure) | Medi-Cal Prior Authorization List, Pg 11 Original policy |
| 0073U | CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, targeted sequence analysis (ie, CYP2D7-2D6 hybrid gene) (List separately in addition to code for primary procedure) | Medi-Cal Prior Authorization List, Pg 11 Original policy |
| 0074U | CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, targeted sequence analysis (ie, nonduplicated gene when duplication/multiplication is trans) (List separately in addition to code for primary procedure) | Medi-Cal Prior Authorization List, Pg 11 Original policy |
| 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) | Medi-Cal Prior Authorization List, Pg 11 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) | Medi-Cal Prior Authorization List, Pg 12 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 | Medi-Cal Prior Authorization List, Pg 12 Original policy |
| 0173U | Psychiatry (ie, depression, anxiety), genomic analysis panel, includes variant analysis of 14 genes | Medi-Cal Prior Authorization List, Pg 12 Original policy |
| 0175U | Psychiatry (eg, depression, anxiety), genomic analysis panel, variant analysis of 15 genes | Medi-Cal Prior Authorization List, Pg 12 Original policy |
| 0193U | Red cell antigen (JR blood group) genotyping (JR), gene analysis, ABCG2 (ATP binding cassette subfamily G member 2 [Junior blood group]) exons 2-26 | Medi-Cal Prior Authorization List, Pg 12 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 | Medi-Cal Prior Authorization List, Pg 12 Original policy |
| 0242U | Targeted Genomic Sequence Analysis (Guardant360) | Medi-Cal Prior Authorization List, Pg 12 Original policy |
| 0286U | CEP72 (centrosomal protein, 72-KDa), NUDT15 (nudix hydrolase 15) and TPMT (thiopurine S-methyltransferase) (eg, drug metabolism) gene analysis, common variants | Medi-Cal Prior Authorization List, Pg 12 Original policy |
| 0290U | Pain management, mRNA, gene expression profiling by RNA sequencing of 36 genes, whole blood, algorithm reported as predictive risk score | Medi-Cal Prior Authorization List, Pg 12 Original policy |
| 0292U | Psychiatry (stress disorders), mRNA, gene expression profiling by RNA sequencing of 72 genes, whole blood, algorithm reported as predictive risk score | Medi-Cal Prior Authorization List, Pg 12 Original policy |
| 0293U | Psychiatry (suicidal ideation), mRNA, gene expression profiling by RNA sequencing of 54 genes, whole blood, algorithm reported as predictive risk score | Medi-Cal Prior Authorization List, Pg 12 Original policy |
| 0326U | Targeted genomic sequence analysis panel, solid organ neoplasm, cell-free circulating DNA analysis of 83 or more genes, interrogation for sequence variants, gene copy number amplifications, gene rearrangements, microsatellite instability and tumor mutational burden. | Medi-Cal Prior Authorization List, Pg 12 Original policy |
| 0347U | Drug metabolism or processing (multiple conditions), whole blood or buccal specimen, DNA analysis, 16 gene report, with variant analysis and reported phenotypes | Medi-Cal Prior Authorization List, Pg 12 Original policy |
| 0348U | Drug metabolism or processing (multiple conditions), whole blood or buccal specimen, DNA analysis, 25 gene report, with variant analysis and reported phenotypes | Medi-Cal Prior Authorization List, Pg 12 Original policy |
| 0349U | Drug metabolism or processing (multiple conditions), whole blood or buccal specimen, DNA analysis, 27 gene report, with variant analysis, including reported phenotypes and impacted gene-drug interactions | Medi-Cal Prior Authorization List, Pg 12 Original policy |
| 0350U | Drug metabolism or processing (multiple conditions), whole blood or buccal specimen, DNA analysis, 27 gene report, with variant analysis and reported phenotypes | Medi-Cal Prior Authorization List, Pg 13 Original policy |
| 0380U | Drug metabolism (adverse drug reactions and drug response), targeted sequence analysis, 20 gene variants and cyp2d6 deletion or duplication analysis with reported genotype and phenotype | Medi-Cal Prior Authorization List, Pg 13 Original policy |
| 0392U | Drug metabolism (depression, anxiety, attention deficit hyperactivity disorder [ADHD]), gene-drug interactions, variant analysis of 16 genes, including deletion/duplication analysis of CYP2D6, reported as impact of gene-drug interaction for each drug | Medi-Cal Prior Authorization List, Pg 13 Original policy |
| 0409U | Oncology (solid tumor), DNA (80 genes) and RNA (36 genes), by next-generation sequencing from plasma, including single nucleotide variants, insertions/deletions, copy number alterations, microsatellite instability, and fusions, report showing identified mutations with clinical actionability | Medi-Cal Prior Authorization List, Pg 13 Original policy |
| 0411U | Psychiatry (eg, depression, anxiety, attention deficit hyperactivity disorder [ADHD]), genomic analysis panel, variant analysis of 15 genes, including deletion/duplication analysis of CYP2D6 | Medi-Cal Prior Authorization List, Pg 13 Original policy |
| 0419U | Neuropsychiatry (eg, depression, anxiety), genomic sequence analysis panel, variant analysis of 13 genes, saliva or buccal swab, report of each gene phenotype | Medi-Cal Prior Authorization List, Pg 13 Original policy |
| 0421U | (Oncology [colorectal] screening, quantitative real-time target and signal amplification of 8 RNA markers [GAPDH, SMAD4, ACY1, AREG, CDH1, KRAS, TNFRSF10B, EGLN2] and fecal hemoglobin, algorithm reported as a positive or negative for colorectal cancer risk) is a Medi-Cal benefit for members who are ages 45 through 75 | Medi-Cal Prior Authorization List, Pg 13 Original policy |
| 0423U | Psychiatry (eg, depression, anxiety), genomic analysis panel, including variant analysis of 26 genes, buccal swab, report including metabolizer status and risk of drug toxicity by conditio | Medi-Cal Prior Authorization List, Pg 13 Original policy |
| 0424T | PHRENIC NERVE STIMULATION SYSTEM PROCEDURES | Medi-Cal Prior Authorization List, Pg 13 Original policy |
| 0438U | Drug metabolism (adverse drug reactions and drug response), buccal specimen, gene-drug interactions, variant analysis of 33 genes, including deletion/duplication analysis of CYP2D6, including reported phenotypes and impacted gene-drug interactions | Medi-Cal Prior Authorization List, Pg 13 Original policy |
| 0471U | Oncology (colorectal cancer), qualitative real-time PCR of 35 variants of KRAS and NRAS genes (exons 2, 3, 4), formalin-fixed paraffin-embedded (FFPE), predictive, identification of detected mutations | Medi-Cal Prior Authorization List, Pg 13 Original policy |
| 0473U | Oncology (solid tumor), next-generation sequencing (NGS) of DNA from formalin-fixed paraffin-embedded (FFPE) tissue with comparative sequence analysis from a matched normal specimen (blood or saliva), 648 genes, interrogation for sequence variants, insertion and deletion alterations, copy number variants, rearrangements, microsatellite instability, and tumor-mutation burden | Medi-Cal Prior Authorization List, Pg 14 Original policy |
| 0475U | Hereditary prostate cancer-related disorders, genomic sequence analysis panel using next- generation sequencing (NGS), Sanger sequencing, multiplex ligation-dependent probe amplification (MLPA), and array comparative genomic hybridization (CGH), evaluation of 23 genes and duplications/deletions when indicated, pathologic mutations reported with a genetic risk score for prostate cancer | Medi-Cal Prior Authorization List, Pg 14 Original policy |
| 0476U | Drug metabolism, psychiatry (eg, major depressive disorder, general anxiety disorder, attention deficit hyperactivity disorder [adhd], schizophrenia), whole blood, buccal swab and pharmacogenomic genotyping of 14 genes and cyp2d6 copy number variant analysis and reported phenotypes | Medi-Cal Prior Authorization List, Pg 14 Original policy |
| 0477U | Drug metabolism, psychiatry (eg, major depressive disorder, general anxiety disorder, attention deficit hyperactivity disorder [adhd], schizophrenia), whole blood, buccal swab and pharmacogenomic genotyping of 14 genes and cyp2d6 copy number variant analysis, including impacted gene-drug interactions and reported phenotypes | Medi-Cal Prior Authorization List, Pg 14 Original policy |
| 0478U | Oncology (non-small cell lung cancer), dna and rna, digital pcr analysis of 9 genes (egfr, kras, braf, alk, ros1, ret, ntrk 1/2/3, erbb2, and met) in formalin-fixed paraffin-embedded (ffpe) tissue, interrogation for single-nucleotide variants, insertions/deletions, gene rearrangements and reported as actionable detected variants for therapy selection | Medi-Cal Prior Authorization List, Pg 14 Original policy |