Cigna prior authorization, page 2
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 |
|---|---|---|
| 0373T | Adaptive behavior treatment with protocol modification, each 15 minutes of technicians' time face-to-face with a patient, requiring the following components: administration by the physician or other qualified health care professional who is on site; with the assistance of two or more technicians; for a patient who exhibits destructive behavior; completion in an environment that is customized to the patient's behavior. | Master Precertification List For Health Care Providers, Pg 4 Original policy |
| 0379U* | Targeted genomic sequence analysis panel, solid organ neoplasm, DNA (523 genes) and RNA (55 genes) by next-generation sequencing, 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 |
| 0388U* | Oncology (non-small cell lung cancer), next-generation sequencing with identification of single nucleotide variants, copy number variants, insertions and deletions, and structural variants in 37 cancer-related genes, plasma, with report for alteration detection | Master Precertification List For Health Care Providers, Pg 4 Original policy |
| 0395T* | High dose rate electronic brachytherapy, interstitial or intracavitary treatment, per fraction, includes basic dosimetry, when performed | Master Precertification List For Health Care Providers, Pg 5 Original policy |
| 0425U* | Genome (eg, unexplained constitutional or heritable disorder or syndrome), rapid sequence analysis, each comparator genome (eg, parents, siblings) | Master Precertification List For Health Care Providers, Pg 5 Original policy |
| 0426U* | Genome (eg, unexplained constitutional or heritable disorder or syndrome), ultra-rapid sequence analysis | Master Precertification List For Health Care Providers, Pg 5 Original policy |
| 0444U* | Oncology (solid organ neoplasia), targeted genomic sequence analysis panel of 361 genes, interrogation for gene fusions, translocations, or other rearrangements, using DNA from formalin-fixed paraffin- embedded (FFPE) tumor tissue, report of clinically significant variant(s) | Master Precertification List For Health Care Providers, Pg 5 Original policy |
| 0449T* | Insertion of aqueous drainage device, without extraocular reservoir, internal approach, into the subconjunctival space; initial device | Master Precertification List For Health Care Providers, Pg 5 Original policy |
| 0452U* | Oncology (bladder), methylated PENK DNA detection by linear target enrichment-quantitative methylation-specific real-time PCR (LTE-qMSP), urine, reported as likelihood of bladder cancer | Master Precertification List For Health Care Providers, Pg 5 Original policy |
| 0453U* | Oncology (colorectal cancer), cell-free DNA (cfDNA), methylation-based quantitative PCR assay (SEPTIN9, IKZF1, BCAT1, Septin9-2, VAV3, BCAN), plasma, reported as presence or absence of circulating tumor DNA (ctDNA) | Master Precertification List For Health Care Providers, Pg 5 Original policy |
| 0454U* | Rare diseases (constitutional/heritable disorders), identification of copy number variations, inversions, insertions, translocations, and other structural variants by optical genome mapping | Master Precertification List For Health Care Providers, Pg 5 Original policy |
| 0465U* | Oncology (urothelial carcinoma), DNA, quantitative methylation-specific PCR of 2 genes (ONECUT2, VIM), algorithmic analysis reported as positive or negative | Master Precertification List For Health Care Providers, Pg 5 Original policy |
| 0466U* | Cardiology (coronary artery disease [CAD]), DNA, genome-wide association studies (564856 single-nucleotide polymorphisms [SNPs], targeted variant genotyping), patient lifestyle and clinical data, buccal swab, algorithm reported as polygenic risk to acquired heart disease | Master Precertification List For Health Care Providers, Pg 5 Original policy |
| 0467U* | Oncology (bladder), DNA, next-generation sequencing (NGS) of 60 genes and whole genome aneuploidy, urine, algorithms reported as minimal residual disease (MRD) status positive or negative and quantitative disease burden | Master Precertification List For Health Care Providers, Pg 5 Original policy |
| 0469U* | Rare diseases (constitutional/heritable disorders), whole genome sequence analysis for chromosomal abnormalities, copy number variants, duplications/deletions, inversions, unbalanced translocations, regions of homozygosity (ROH), inheritance pattern that indicate uniparental disomy (UPD), and aneuploidy, fetal sample (amniotic fluid, chorionic villus sample, or products of conception), identification and categorization of genetic variants, diagnostic report of fetal results based on phenotype with maternal sample and paternal sample, if performed, as comparators and/or maternal cell contamination | Master Precertification List For Health Care Providers, Pg 5 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 | Master Precertification List For Health Care Providers, Pg 5 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 | Master Precertification List For Health Care Providers, Pg 5 Original policy |
| 0479T* | Fractional ablative laser fenestration of burn and traumatic scars for functional improvement; first 100 cm2 or part thereof, or 1% of body surface area of infants and children | Master Precertification List For Health Care Providers, Pg 6 Original policy |
| 0480T* | Fractional ablative laser fenestration of burn and traumatic scars for functional improvement; each additional 100 cm2, or each additional 1% of body surface area of infants and children, or part thereof | Master Precertification List For Health Care Providers, Pg 6 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) | Master Precertification List For Health Care Providers, Pg 6 Original policy |
| 0483T* | Transcatheter mitral valve implantation/replacement (TMVI) with prosthetic valve; percutaneous approach, including transseptal puncture, when performed | Master Precertification List For Health Care Providers, Pg 6 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 | Master Precertification List For Health Care Providers, Pg 6 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 | Master Precertification List For Health Care Providers, Pg 6 Original policy |
| 0488U* | Obstetrics (fetal antigen noninvasive prenatal test), cell-free DNA sequence analysis for detection of fetal presence or absence of 1 or more of the Rh, C, c, D, E, Duffy (Fya), or Kell (K) antigen in alloimmunized pregnancies, reported as selected antigen(s) detected or not detected | Master Precertification List For Health Care Providers, Pg 6 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 | Master Precertification List For Health Care Providers, Pg 6 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 | Master Precertification List For Health Care Providers, Pg 6 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 | Master Precertification List For Health Care Providers, Pg 6 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.118-9_118-2del, S56F, S621C) | Master Precertification List For Health Care Providers, Pg 6 Original policy |
| 0501U* | Oncology (colorectal), blood, quantitative measurement of cell-free DNA (cfDNA) | Master Precertification List For Health Care Providers, Pg 6 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 | Master Precertification List For Health Care Providers, Pg 6 Original policy |
| 0507U* | Oncology (ovarian), DNA, whole-genome sequencing with 5- hydroxymethylcytosine (5hmC) enrichment, using whole blood or plasma, algorithm reported as cancer detected or not detected | Master Precertification List For Health Care Providers, Pg 6 Original policy |
| 0523U* | Oncology (solid tumor), DNA, qualitative, next-generation sequencing (NGS) of single-nucleotide variants (SNV) and insertion/deletions in 22 genes utilizing formalin-fixed paraffin-embedded tissue, reported as presence or absence of mutation(s), location of mutation(s), nucleotide change, and amino acid change | Master Precertification List For Health Care Providers, Pg 7 Original policy |
| 0529U* | Hematology (venous thromboembolism [VTE]), genome-wide single- nucleotide polymorphism variants, including F2 and F5 gene analysis, and Leiden variant, by microarray analysis, saliva, report as risk score for VTE | Master Precertification List For Health Care Providers, Pg 7 Original policy |
| 0530U* | Oncology (pan-solid tumor), ctDNA, utilizing plasma, next-generation sequencing (NGS) of 77 genes, 8 fusions, microsatellite instability, and tumor mutation burden, interpretative report for single-nucleotide variants, copy-number alterations, with therapy association | Master Precertification List For Health Care Providers, Pg 7 Original policy |
| 0532U* | Rare diseases (constitutional disease/hereditary disorders), rapid whole genome and mitochondrial DNA sequencing for single- nucleotide variants, insertions/deletions, copy number variations, peripheral blood, buffy coat, saliva, buccal or tissue sample, results reported as positive or negative | Master Precertification List For Health Care Providers, Pg 7 Original policy |
| 0533U* | Drug metabolism (adverse drug reactions and drug response), genotyping of 16 genes (ie, ABCG2, CYP2B6, CYP2C9, CYP2C19, CYP2C, CYP2D6, CYP3A5, CYP4F2, DPYD, G6PD, GGCX, NUDT15, SLCO1B1, TPMT, UGT1A1, VKORC1), reported as metabolizer status and transporter function | Master Precertification List For Health Care Providers, Pg 7 Original policy |
| 0534U* | Oncology (prostate), microRNA, single-nucleotide polymorphisms (SNPs) analysis by RT-PCR of 32 variants, using buccal swab, algorithm reported as a risk score | Master Precertification List For Health Care Providers, Pg 7 Original policy |
| 0537U* | Oncology (colorectal cancer), analysis of cell-free DNA for epigenomic patterns, next- generation sequencing, >2500 differentially methylated regions (DMRs), plasma, algorithm reported as positive or negative | Master Precertification List For Health Care Providers, Pg 7 Original policy |
| 0538U* | Oncology (solid tumor), next- generation targeted sequencing analysis, formalin-fixed paraffin- embedded (FFPE) tumor tissue, DNA analysis of 600 genes, interrogation for single-nucleotide variants, insertions/deletions, gene rearrangements, and copy number alterations, microsatellite instability, tumor mutation burden, reported as actionable variant | Master Precertification List For Health Care Providers, Pg 7 Original policy |
| 0539U* | Oncology (solid tumor), cell- free circulating tumor DNA (ctDNA), 152 genes, next- generation sequencing, interrogation for single- nucleotide variants, insertions/deletions, gene rearrangements, copy number alterations, and microsatellite instability, using whole-blood samples, mutations with clinical actionability reported as actionable variant | Master Precertification List For Health Care Providers, Pg 7 Original policy |
| 0540U | Transplantation medicine, quantification of donor- derived cell-free DNA using next-generation sequencing analysis of plasma, reported as percentage of donor- derived cell-free DNA to determine probability of rejection | Master Precertification List For Health Care Providers, Pg 7 Original policy |
| 0543U* | Oncology (solid tumor), next- generation sequencing of DNA from formalin-fixed paraffin-embedded (FFPE) tissue of 517 genes, interrogation for single- nucleotide variants, multi- nucleotide variants, insertions and deletions from DNA, fusions in 24 genes and splice variants in 1 gene from RNA, and tumor mutation burden | Master Precertification List For Health Care Providers, Pg 7 Original policy |
| 0549U* | Oncology (urothelial), DNA, quantitative methylated real- time PCR of TRNA-Cys, SIM2, and NKX1-1, using urine, diagnostic algorithm reported as a probability index for bladder cancer and/or upper tract urothelial carcinoma (UTUC) | Master Precertification List For Health Care Providers, Pg 7 Original policy |
| 0552U* | Reproductive medicine (preimplantation genetic assessment), analysis for known genetic disorders from trophectoderm biopsy, linkage analysis of disease- causing locus, and when possible, targeted mutation analysis for known familial variant, reported as low-risk or high-risk for familial genetic disorder | Master Precertification List For Health Care Providers, Pg 8 Original policy |
| 0553U* | Reproductive medicine (preimplantation genetic assessment), analysis of 24 chromosomes using DNA genomic sequence analysis from embryonic trophectoderm for structural rearrangements, aneuploidy, and a mitochondrial DNA score, results reported as normal/balanced (euploidy/balanced), unbalanced structural rearrangement, monosomy, trisomy, segmental aneuploidy, or mosaic, per embryo tested | Master Precertification List For Health Care Providers, Pg 8 Original policy |
| 0554U* | Reproductive medicine (preimplantation genetic assessment), analysis of 24 chromosomes using DNA genomic sequence analysis from trophectoderm biopsy for aneuploidy, ploidy, a mitochondrial DNA score, and embryo quality control, results reported as normal (euploidy), monosomy, trisomy, segmental aneuploidy, triploid, haploid, or mosaic, with quality control results reported as contamination detected or inconsistent cohort when applicable, per embryo tested | Master Precertification List For Health Care Providers, Pg 8 Original policy |
| 0555U* | Reproductive medicine (preimplantation genetic assessment), analysis of 24 chromosomes using DNA genomic sequence analysis from embryonic trophectoderm for structural rearrangements, aneuploidy, ploidy, a mitochondrial DNA score, and embryo quality control, results reported as normal/balanced (euploidy/balanced), unbalanced structural rearrangement, monosomy, trisomy, segmental aneuploidy, triploid, haploid, or mosaic, with quality control results reported as contamination detected or inconsistent cohort when applicable, per embryo tested | Master Precertification List For Health Care Providers, Pg 8 Original policy |
| 0560U* | Oncology (minimal residual disease [MRD]), genomic sequence analysis, cell-free DNA, whole blood and tumor tissue, baseline assessment for design and construction of a personalized variant panel to evaluate current MRD and for comparison to subsequent MRD assessments | Master Precertification List For Health Care Providers, Pg 8 Original policy |
| 0561U* | Oncology (minimal residual disease [MRD]), genomic sequence analysis, cell-free DNA, whole blood, subsequent assessment with comparison to initial assessment to evaluate for MRD | Master Precertification List For Health Care Providers, Pg 8 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 | Master Precertification List For Health Care Providers, Pg 8 Original policy |