Cigna prior authorization
Requirements
Read the care-management columns separately. Complete, PHS+, Preferred, and Basic Standard do not collapse into one Cigna answer. The long descriptor is blank because no AMA-licensed CPT file was available to copy.
Cigna precertification list
CPT code lookup
Prior authorization codes
| Code | Description | Source |
|---|---|---|
| 0161 | Room & Board–Hospital at Home | Master Precertification List For Health Care Providers, Pg 2 Original policy |
| 0333* | Radiology-Therapeutic and/or Chemotherapy Administration-Radiation Therapy | Master Precertification List For Health Care Providers, Pg 2 Original policy |
| 0342 | Nuclear Medicine-Therapeutic | Master Precertification List For Health Care Providers, Pg 2 Original policy |
| 0344 | Nuclear Medicine-Therapeutic Radiopharmaceuticals | Master Precertification List For Health Care Providers, Pg 2 Original policy |
| 0870 | Cell/Gene Therapy-General Classification | Master Precertification List For Health Care Providers, Pg 2 Original policy |
| 0871 | Cell/Gene Therapy-Cell Collection | Master Precertification List For Health Care Providers, Pg 2 Original policy |
| 0872 | Cell/Gene Therapy-Specialized Biologic Processing And Storage - Prior To Transport | Master Precertification List For Health Care Providers, Pg 2 Original policy |
| 0873 | Cell/Gene Therapy-Storage And Processing After Receipt Of Cells From Manufacturer | Master Precertification List For Health Care Providers, Pg 2 Original policy |
| 0874 | Cell/Gene Therapy-Infusion Of Modified Cells | Master Precertification List For Health Care Providers, Pg 2 Original policy |
| 0875 | Cell/Gene Therapy-Injection Of Modified Cells | Master Precertification List For Health Care Providers, Pg 2 Original policy |
| 0890 | Pharmacy-Extension Of 025X And 063X - Reserved (Use 0250 For General Classification) | Master Precertification List For Health Care Providers, Pg 2 Original policy |
| 0891 | Pharmacy-Extension Of 025X And 063X - Special Processed Drugs – FDA Approved Cell Therapy | Master Precertification List For Health Care Providers, Pg 2 Original policy |
| 0892 | Special Processed Drugs-FDA Approved Gene Therapy | Master Precertification List For Health Care Providers, Pg 2 Original policy |
| 0907 | Community behavioral health program (day treatment) | Master Precertification List For Health Care Providers, Pg 2 Original policy |
| 0020M* | Oncology (central nervous system), analysis of 30000 DNA methylation loci by methylation array, utilizing DNA extracted from tumor tissue, diagnostic algorithm reported as probability of matching a reference tumor subclass | Master Precertification List For Health Care Providers, Pg 2 Original policy |
| 0036U* | Exome (ie, somatic mutations), paired formalin-fixed paraffin-embedded tumor tissue and normal specimen, sequence analyses | Master Precertification List For Health Care Providers, Pg 2 Original policy |
| 0037U* | Targeted genomic sequence analysis, solid organ neoplasm, DNA analysis of 324 genes, interrogation for sequence variants, gene copy number amplifications, gene rearrangements, microsatellite instability and tumor mutational burden | Master Precertification List For Health Care Providers, Pg 2 Original policy |
| 0047U* | Oncology (prostate), mRNA, gene expression profiling by real-time RT- PCR of 17 genes (12 content and 5 housekeeping), utilizing formalin- fixed paraffin-embedded tissue, algorithm reported as a risk score | Master Precertification List For Health Care Providers, Pg 2 Original policy |
| 0048U* | Oncology (solid organ neoplasia), DNA, targeted sequencing of protein- coding exons of 468 cancer-associated genes, including interrogation for somatic mutations and microsatellite instability, matched with normal specimens, utilizing formalin-fixed paraffin-embedded tumor tissue, report of clinically significant mutation(s) | Master Precertification List For Health Care Providers, Pg 2 Original policy |
| 0075T* | Transcatheter placement of extracranial vertebral artery stent(s), including radiologic supervision and interpretation, open or percutaneous; initial vessel | Master Precertification List For Health Care Providers, Pg 2 Original policy |
| 0087U | Cardiology (heart transplant), mRNA gene expression profiling by microarray of 1283 genes, transplant biopsy tissue, allograft rejection and injury algorithm reported as a probability score | Master Precertification List For Health Care Providers, Pg 2 Original policy |
| 0088U | Transplantation medicine (kidney allograft rejection), microarray gene expression profiling of 1494 genes, utilizing transplant biopsy tissue, algorithm reported as a probability score for rejection | Master Precertification List For Health Care Providers, Pg 2 Original policy |
| 0089U* | Oncology (melanoma), gene expression profiling by RTqPCR, PRAME and LINC00518, superficial collection using adhesive patch(es) | Master Precertification List For Health Care Providers, Pg 2 Original policy |
| 0098T* | Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, each additional interspace, cervical | Master Precertification List For Health Care Providers, Pg 2 Original policy |
| 0102U* | Hereditary breast cancer-related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer), genomic sequence analysis panel utilizing a combination of NGS, Sanger, MLPA, and array CGH, with mRNA analytics to resolve variants of unknown significance when indicated (17 genes [sequencing and deletion/duplication]) | Master Precertification List For Health Care Providers, Pg 3 Original policy |
| 0129U* | Hereditary breast cancer-related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer), genomic sequence analysis and deletion/duplication analysis panel (ATM, BRCA1, BRCA2, CDH1, CHEK2, PALB2, PTEN, and TP53) | Master Precertification List For Health Care Providers, Pg 3 Original policy |
| 0172U* | Oncology (solid tumor as indicated by the label), somatic mutation analysis of BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) and analysis of homologous recombination deficiency pathways, DNA, formalin-fixed paraffin-embedded tissue, algorithm quantifying tumor genomic instability score | Master Precertification List For Health Care Providers, Pg 3 Original policy |
| 0200T* | Percutaneous sacral augmentation (sacroplasty), unilateral injection(s), including the use of a balloon or mechanical device, when used, 1 or more needles, includes imaging guidance and bone biopsy, when performed | Master Precertification List For Health Care Providers, Pg 3 Original policy |
| 0201T* | Percutaneous sacral augmentation (sacroplasty), bilateral injections, including the use of a balloon or mechanical device, when used, 2 or more needles, includes imaging guidance and bone biopsy, when performed | Master Precertification List For Health Care Providers, Pg 3 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 | Master Precertification List For Health Care Providers, Pg 3 Original policy |
| 0213T* | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; single level | Master Precertification List For Health Care Providers, Pg 3 Original policy |
| 0214T* | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; second level | Master Precertification List For Health Care Providers, Pg 3 Original policy |
| 0215T* | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; third and any additional level(s) | Master Precertification List For Health Care Providers, Pg 3 Original policy |
| 0216T* | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; single level | Master Precertification List For Health Care Providers, Pg 3 Original policy |
| 0217T* | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; second level | Master Precertification List For Health Care Providers, Pg 3 Original policy |
| 0218T* | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; third and any additional level(s) | Master Precertification List For Health Care Providers, Pg 3 Original policy |
| 0232T* | Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed | Master Precertification List For Health Care Providers, Pg 3 Original policy |
| 0239U* | Targeted genomic sequence analysis panel, solid organ neoplasm, cell- free DNA, analysis of 311 or more genes, interrogation for sequence variants, including substitutions, insertions, deletions, select rearrangements, and copy number variations | Master Precertification List For Health Care Providers, Pg 3 Original policy |
| 0242U* | Targeted genomic sequence analysis panel, solid organ neoplasm, cell- free circulating DNA analysis of 55-74 genes, interrogation for sequence variants, gene copy number amplifications, and gene rearrangements | Master Precertification List For Health Care Providers, Pg 3 Original policy |
| 0244U* | Oncology (solid organ), DNA, comprehensive genomic profiling, 257 genes, interrogation for single-nucleotide variants, insertions/deletions, copy number alterations, gene rearrangements, tumor-mutational burden and microsatellite instability, utilizing formalin-fixed paraffin- embedded tumor tissue | Master Precertification List For Health Care Providers, Pg 4 Original policy |
| 0250U* | Oncology (solid organ neoplasm), targeted genomic sequence DNA analysis of 505 genes, interrogation for somatic alterations (SNVs [single nucleotide variant], small insertions and deletions, one amplification, and four translocations), microsatellite instability and tumor-mutation burden | Master Precertification List For Health Care Providers, Pg 4 Original policy |
| 0318U* | Pediatrics (congenital epigenetic disorders), whole genome methylation analysis by microarray for 50 or more genes, blood | Master Precertification List For Health Care Providers, Pg 4 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 | Master Precertification List For Health Care Providers, Pg 4 Original policy |
| 0329U* | Oncology (neoplasia), exome and transcriptome sequence analysis for sequence variants, gene copy number amplifications and deletions, gene rearrangements, microsatellite instability and tumor mutational burden utilizing DNA and RNA from tumor with DNA from normal blood or saliva for subtraction, report of clinically significant mutation(s) with therapy associations | Master Precertification List For Health Care Providers, Pg 4 Original policy |
| 0331T* | Myocardial sympathetic innervation imaging, planar qualitative and quantitative assessment; | Master Precertification List For Health Care Providers, Pg 4 Original policy |
| 0332T* | Myocardial sympathetic innervation imaging, planar qualitative and quantitative assessment; with tomographic SPECT | Master Precertification List For Health Care Providers, Pg 4 Original policy |
| 0334U* | Oncology (solid organ), targeted genomic sequence analysis, formalin- fixed paraffin-embedded (FFPE) tumor tissue, DNA analysis, 84 or more genes, interrogation for sequence variants, gene copy number amplifications, gene rearrangements, microsatellite instability and tumor mutational burden | Master Precertification List For Health Care Providers, Pg 4 Original policy |
| 0335T* | Insertion of sinus tarsi implant | Master Precertification List For Health Care Providers, Pg 4 Original policy |
| 0340U* | Oncology (pan-cancer), analysis of minimal residual disease (MRD) from plasma, with assays personalized to each patient based on prior next- generation sequencing of the patient's tumor and germline DNA, reported as absence or presence of MRD, with disease-burden correlation, if appropriate | Master Precertification List For Health Care Providers, Pg 4 Original policy |
| 0364U* | Oncology (hematolymphoid neoplasm), genomic sequence analysis using multiplex (PCR) and next-generation sequencing with algorithm, quantification of dominant clonal sequence(s), reported as presence or absence of minimal residual disease (MRD) with quantitation of disease burden, when appropriate | Master Precertification List For Health Care Providers, Pg 4 Original policy |