Blue Shield of California Promise Health Plan prior authorization, page 7
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 |
|---|---|---|
| 0480U | Infectious disease (bacteria, viruses, fungi and parasites), cerebrospinal fluid (csf), metagenomic next-generation sequencing (dna and rna), bioinformatic analysis, with positive pathogen identification | Medi-Cal Prior Authorization List, Pg 14 Original policy |
| 0481U | Idh1 (isocitrate dehydrogenase 1 [nadp+]), idh2 (isocitrate dehydrogenase 2 [nadp+]) and tert (telomerase reverse transcriptase) promoter (eg, central nervous system [cns] tumors), next-generation sequencing (single-nucleotide variants [snv], deletions, and insertions) | Medi-Cal Prior Authorization List, Pg 14 Original policy |
| 0485U | Oncology (solid tumor), cell-free dna and rna by next-generation sequencing, interpretative report for germline mutations, clonal hematopoiesis of indeterminate potential and tumor- derived single-nucleotide variants, small insertions/deletions, copy number alterations, fusions, microsatellite instability and tumor mutational burden | Medi-Cal Prior Authorization List, Pg 14 Original policy |
| 0486U | Oncology (pan-solid tumor), next-generation sequencing analysis of tumor methylation markers present in cell-free circulating tumor dna, algorithm reported as quantitative measurement of methylation as a correlate of tumor fraction | Medi-Cal Prior Authorization List, Pg 15 Original policy |
| 0487U | Oncology (solid tumor), cell-free circulating dna, targeted genomic sequence analysis panel of 84 genes, interrogation for sequence variants, aneuploidy-corrected gene copy number amplifications and losses, gene rearrangements and microsatellite instability | Medi-Cal Prior Authorization List, Pg 15 Original policy |
| 0490U | Oncology (cutaneous or uveal melanoma), circulating tumor cell selection, morphological characterization and enumeration based on differential cd146, high molecular-weight melanoma-associated antigen, cd34 and cd45 protein biomarkers, peripheral blood | Medi-Cal Prior Authorization List, Pg 15 Original policy |
| 0491U | Oncology (solid tumor), circulating tumor cell selection, morphological characterization and enumeration based on differential epithelial cell adhesion molecule (epcam), cytokeratins 8, 18 and 19, cd45 protein biomarkers and quantification of estrogen receptor (er) protein biomarker-expressing cells, peripheral blood | Medi-Cal Prior Authorization List, Pg 15 Original policy |
| 0492U | Oncology (solid tumor), circulating tumor cell selection, morphological characterization and enumeration based on differential epithelial cell adhesion molecule (epcam), cytokeratins 8, 18, and 19, cd45 protein biomarkers, and quantification of pd-l1 protein biomarker- expressing cells, peripheral blood | Medi-Cal Prior Authorization List, Pg 15 Original policy |
| 0493U | Transplantation medicine, quantification of donor-derived cell-free dna (cfdna) using next- generation sequencing, plasma, reported as percentage of donor-derived cell-free dna | Medi-Cal Prior Authorization List, Pg 15 Original policy |
| 0495U | Oncology (prostate), analysis of circulating plasma proteins (tpsa, fpsa, klk2, psp94, and gdf15), germline polygenic risk score (60 variants), clinical information (age, family history of prostate cancer, prior negative prostate biopsy), algorithm reported as risk of likelihood of detecting clinically significant prostate cancer | Medi-Cal Prior Authorization List, Pg 15 Original policy |
| 0496U | Oncology (colorectal), cell-free dna, 8 genes for mutations, 7 genes for methylation by real- time rt-pcr and 4 proteins by enzyme-linked immunosorbent assay, blood, reported positive or negative for colorectal cancer or advanced adenoma risk | Medi-Cal Prior Authorization List, Pg 15 Original policy |
| 0497U | Oncology (prostate), mrna gene-expression profiling by real-time rt-pcr of 6 genes (foxm1, mcm3, mtus1, ttc21b, alas1 and ppp2ca), utilizing formalin-fixed paraffin-embedded (ffpe) tissue, algorithm reported as a risk score for prostate cancer | Medi-Cal Prior Authorization List, Pg 15 Original policy |
| 0498U | Oncology (colorectal), next-generation sequencing for mutation detection in 43 genes and methylation pattern in 45 genes, blood and formalin-fixed paraffin-embedded (ffpe) tissue, report of variants and methylation pattern with interpretation | Medi-Cal Prior Authorization List, Pg 15 Original policy |
| 0499U | Oncology (colorectal and lung), dna from formalin-fixed paraffin-embedded (ffpe) tissue, next-generation sequencing of 8 genes (nras, egfr, ctnnb1, pik3ca, apc, braf, kras and tp53), mutation detection | Medi-Cal Prior Authorization List, Pg 16 Original policy |
| 0500U | Autoinflammatory disease (vexas syndrome), dna, uba1 gene mutations, targeted variant analysis (m41t, m41v, m41l, c.118-2a>c, c.118-1g>c, c.1189_118-2del, s56f, s621c) | Medi-Cal Prior Authorization List, Pg 16 Original policy |
| 0501U | Oncology (colorectal), blood, quantitative measurement of cell-free dna (cfdna) | Medi-Cal Prior Authorization List, Pg 16 Original policy |
| 0503U | Neurology (Alzheimer disease), beta amyloid (ab40, ab42, ab42/40 ratio) and tau-protein (ptau217, np-tau217, ptau217/nptau217 ratio), blood, immunoprecipitation with quantitation by liquid chromatography with tandem mass spectrometry (lc-ms/ms), algorithm score reported as likelihood of positive or negative for amyloid plaques | Medi-Cal Prior Authorization List, Pg 16 Original policy |
| 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 | Medi-Cal Prior Authorization List, Pg 16 Original policy |
| 0507U | Oncology (ovarian), dna, whole-genome sequencing with 5hydroxymethylcytosine (5hmc) enrichment, using whole blood or plasma, algorithm reported as cancer detected or not detected | Medi-Cal Prior Authorization List, Pg 16 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 | Medi-Cal Prior Authorization List, Pg 16 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 | Medi-Cal Prior Authorization List, Pg 16 Original policy |
| 0510U | Oncology (pancreatic cancer), augmentative algorithmic analysis of 16 genes from previously sequenced rna whole-transcriptome data, reported as probability of predicted molecular subtype | Medi-Cal Prior Authorization List, Pg 16 Original policy |
| 0511U | Oncology (solid tumor), tumor cell culture in 3d microenvironment, 36 or more drug panel, reported as tumor-response prediction for each drug | Medi-Cal Prior Authorization List, Pg 16 Original policy |
| 0512U | Oncology (prostate), augmentative algorithmic analysis of digitized whole-slide imaging of histologic features for microsatellite instability (msi) status, formalin-fixed paraffin- embedded (ffpe) tissue, reported as increased or decreased probability of msi-high (msi-h) | Medi-Cal Prior Authorization List, Pg 16 Original policy |
| 0513U | Oncology (prostate), augmentative algorithmic analysis of digitized whole-slide imaging of histologic features for microsatellite instability (msi) and homologous recombination deficiency (hrd) status, formalin-fixed paraffin-embedded (ffpe) tissue, reported as increased or decreased probability of each biomarker | Medi-Cal Prior Authorization List, Pg 16 Original policy |
| 0514U | Gastroenterology (irritable bowel disease [ibd]), immunoassay for quantitative determination of adalimumab (adl) levels in venous serum in patients undergoing adalimumab therapy, results reported as a numerical value as micrograms per milliliter (g/ml) | Medi-Cal Prior Authorization List, Pg 17 Original policy |
| 0515U | Gastroenterology (irritable bowel disease [ibd]), immunoassay for quantitative determination of infliximab (ifx) levels in venous serum in patients undergoing infliximab therapy, results reported as a numerical value as micrograms per milliliter (g/ml) | Medi-Cal Prior Authorization List, Pg 17 Original policy |
| 0516U | Drug metabolism, whole blood, pharmacogenomic genotyping of 40 genes and cyp2d6 copy number variant analysis, reported as metabolizer status | Medi-Cal Prior Authorization List, Pg 17 Original policy |
| 0517U | Therapeutic drug monitoring, 80 or more psychoactive drugs or substances, lc-ms/ms, plasma, qualitative and quantitative therapeutic minimally and maximally effective dose of prescribed and non-prescribed medications | Medi-Cal Prior Authorization List, Pg 17 Original policy |
| 0518U | Therapeutic drug monitoring, 90 or more pain and mental health drugs or substances, lc- ms/ms, plasma, qualitative and quantitative therapeutic minimally effective range of prescribed and non-prescribed medications | Medi-Cal Prior Authorization List, Pg 17 Original policy |
| 0519U | Therapeutic drug monitoring, medications specific to pain, depression and anxiety, lcms/ms, plasma, 110 or more drugs or substances, qualitative and quantitative therapeutic minimally effective range of prescribed, non-prescribed and illicit medications in circulation | Medi-Cal Prior Authorization List, Pg 17 Original policy |
| 0520U | Therapeutic drug monitoring, 200 or more drugs or substances, lcms/ms, plasma, qualitative and quantitative therapeutic minimally effective range of prescribed and non- prescribed medications | Medi-Cal Prior Authorization List, Pg 17 Original policy |
| 0541T | Myocardial Imaging by Magnetocardiography (MCG) | Medi-Cal Prior Authorization List, Pg 17 Original policy |
| 0542T | Myocardial Imaging by Magnetocardiography (MCG) | Medi-Cal Prior Authorization List, Pg 17 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 | Medi-Cal Prior Authorization List, Pg 17 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 | Medi-Cal Prior Authorization List, Pg 17 Original policy |
| 0570U | Neurology (traumatic brain injury), analysis of glial fibrillary acidic protein (GFAP) and ubiquitin carboxyl-terminal hydrolase L1 (UCH-L1), immunoassay, whole blood or plasma, individual components reported with the overall result of elevated or non-elevated based on threshold comparison | Medi-Cal Prior Authorization List, Pg 18 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 | Medi-Cal Prior Authorization List, Pg 18 Original policy |
| 0606U | Hematology (red cell membrane disorders), RBCs, osmotic gradient ektacytometry, whole blood, quantitative | Medi-Cal Prior Authorization List, Pg 18 Original policy |
| 0609T | Magnetic Resonance Spectroscopy | Medi-Cal Prior Authorization List, Pg 18 Original policy |
| 0610T | Magnetic Resonance Spectroscopy | Medi-Cal Prior Authorization List, Pg 18 Original policy |
| 0611T | Magnetic Resonance Spectroscopy | Medi-Cal Prior Authorization List, Pg 18 Original policy |
| 0612T | Magnetic Resonance Spectroscopy | Medi-Cal Prior Authorization List, Pg 18 Original policy |
| 0716T | CORONARY ARTERY DISEASE (CAD) RISK SCORE ANALYSIS | Medi-Cal Prior Authorization List, Pg 18 Original policy |
| 0722T | TISSUE CHARACTERIZATION BY QUANTITATIVE CT | Medi-Cal Prior Authorization List, Pg 18 Original policy |
| 0723T | OMEZA COLLAGEN MATRIX | Medi-Cal Prior Authorization List, Pg 18 Original policy |
| 0742T | PHOENIX WOUND MATRIX | Medi-Cal Prior Authorization List, Pg 18 Original policy |
| 0815T | Ultrasound-based radiofrequency echographic multi-spectrometry (REMS), bone-density study and fracture-risk assessment, 1 or more sites, hips, pelvis, or spine. | Medi-Cal Prior Authorization List, Pg 18 Original policy |
| 0889T | Personalized target development for accelerated, repetitive high-dose functional connectivity MRI-guided theta-burst stimulation derived from a structural and resting-state functional MRI, including data preparation and transmission, generation of the target, motor threshold-starting location, neuronavigation files and target report, review and interpretation | Medi-Cal Prior Authorization List, Pg 18 Original policy |
| 0906T | Concurrent optical and magnetic stimulation (COMS) therapy, wound assessment and dressing care; first application, total wound(s) surface area less than or equal to 50 sq cm | Medi-Cal Prior Authorization List, Pg 18 Original policy |