Cigna prior authorization, page 26
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 |
|---|---|---|
| 81215* | BRCA1 (BRCA1, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; known familial variant | Master Precertification List For Health Care Providers, Pg 61 Original policy |
| 81216* | BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis | Master Precertification List For Health Care Providers, Pg 61 Original policy |
| 81217* | BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; known familial variant | Master Precertification List For Health Care Providers, Pg 61 Original policy |
| 81223* | CFTR (cystic fibrosis transmembrane conductance regulator) (eg, cystic fibrosis) gene analysis; full gene sequence | Master Precertification List For Health Care Providers, Pg 61 Original policy |
| 81226* | CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism), gene analysis, common variants (eg, *2, *3, *4, *5, *6, *9, *10, *17, *19, *29, *35, *41, *1XN, *2XN, *4XN) | Master Precertification List For Health Care Providers, Pg 61 Original policy |
| 81228* | Cytogenomic (genome-wide) analysis for constitutional chromosomal abnormalities; interrogation of genomic regions for copy number variants, comparative genomic hybridization [CGH] microarray analysis | Master Precertification List For Health Care Providers, Pg 61 Original policy |
| 81277* | Cytogenomic neoplasia (genome-wide) microarray analysis, interrogation of genomic regions for copy number and loss-of- heterozygosity variants for chromosomal abnormalities | Master Precertification List For Health Care Providers, Pg 61 Original policy |
| 81292* | MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; full sequence analysis | Master Precertification List For Health Care Providers, Pg 61 Original policy |
| 81293* | MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; known familial variants | Master Precertification List For Health Care Providers, Pg 61 Original policy |
| 81294* | MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; duplication/deletion variants | Master Precertification List For Health Care Providers, Pg 62 Original policy |
| 81295* | MSH2 (mutS homolog 2, colon cancer, nonpolyposis type 1) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; full sequence analysis | Master Precertification List For Health Care Providers, Pg 62 Original policy |
| 81296* | MSH2 (mutS homolog 2, colon cancer, nonpolyposis type 1) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; known familial variants | Master Precertification List For Health Care Providers, Pg 62 Original policy |
| 81297* | MSH2 (mutS homolog 2, colon cancer, nonpolyposis type 1) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; duplication/deletion variants | Master Precertification List For Health Care Providers, Pg 62 Original policy |
| 81298* | MSH6 (mutS homolog 6 [E. coli]) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; full sequence analysis | Master Precertification List For Health Care Providers, Pg 62 Original policy |
| 81299* | MSH6 (mutS homolog 6 [E. coli]) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; known familial variants | Master Precertification List For Health Care Providers, Pg 62 Original policy |
| 81300* | MSH6 (mutS homolog 6 [E. coli]) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; duplication/deletion variants | Master Precertification List For Health Care Providers, Pg 62 Original policy |
| 81307* | PALB2 (partner and localizer of BRCA2) (eg, breast and pancreatic cancer) gene analysis; full gene sequence | Master Precertification List For Health Care Providers, Pg 62 Original policy |
| 81308* | PALB2 (partner and localizer of BRCA2) (eg, breast and pancreatic cancer) gene analysis; known familial variant | Master Precertification List For Health Care Providers, Pg 62 Original policy |
| 81313* | PCA3/KLK3 (prostate cancer antigen 3 [non-protein coding]/kallikrein- related peptidase 3 [prostate specific antigen]) ratio (eg, prostate cancer) | Master Precertification List For Health Care Providers, Pg 62 Original policy |
| 81317* | PMS2 (postmeiotic segregation increased 2 [S. cerevisiae]) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; full sequence analysis | Master Precertification List For Health Care Providers, Pg 62 Original policy |
| 81318* | PMS2 (postmeiotic segregation increased 2 [S. cerevisiae]) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; known familial variants | Master Precertification List For Health Care Providers, Pg 62 Original policy |
| 81319* | PMS2 (postmeiotic segregation increased 2 [S. cerevisiae]) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; duplication/deletion variants | Master Precertification List For Health Care Providers, Pg 62 Original policy |
| 81321* | PTEN (phosphatase and tensin homolog) (eg, Cowden syndrome, PTEN hamartoma tumor syndrome) gene analysis; full sequence analysis | Master Precertification List For Health Care Providers, Pg 62 Original policy |
| 81322* | PTEN (phosphatase and tensin homolog) (eg, Cowden syndrome, PTEN hamartoma tumor syndrome) gene analysis; known familial variant | Master Precertification List For Health Care Providers, Pg 62 Original policy |
| 81323* | PTEN (phosphatase and tensin homolog) (eg, Cowden syndrome, PTEN hamartoma tumor syndrome) gene analysis; duplication/deletion variant | Master Precertification List For Health Care Providers, Pg 62 Original policy |
| 81349* | Cytogenomic (genome-wide) analysis for constitutional chromosomal abnormalities; interrogation of genomic regions for copy number and loss-of-heterozygosity variants, low-pass sequencing analysis | Master Precertification List For Health Care Providers, Pg 62 Original policy |
| 81354* | Cytogenomic (genome-wide) analysis for constitutional chromosomal abnormalities; interrogation of structural and copy number variants, optical genome mapping (OGM) | Master Precertification List For Health Care Providers, Pg 62 Original policy |
| 81400* | Molecular pathology procedure, Level 1 (eg, identification of single germline variant [eg, SNP] by techniques such as restriction enzyme digestion or melt curve analysis) | Master Precertification List For Health Care Providers, Pg 62 Original policy |
| 81401* | Molecular pathology procedure, Level 2 (eg, 2-10 SNPs, 1 methylated variant, or 1 somatic variant [typically using nonsequencing target variant analysis], or detection of a dynamic mutation disorder/triplet repeat) | Master Precertification List For Health Care Providers, Pg 62 Original policy |
| 81402* | Molecular pathology procedure, Level 3 (eg, >10 SNPs, 2-10 methylated variants, or 2-10 somatic variants [typically using non-sequencing target variant analysis], immunoglobulin and T-cell receptor gene rearrangements, duplication/deletion variants of 1 exon, loss of heterozygosity [LOH], uniparental disomy [UPD]) | Master Precertification List For Health Care Providers, Pg 62 Original policy |
| 81403* | Molecular pathology procedure, Level 4 (eg, analysis of single exon by DNA sequence analysis, analysis of >10 amplicons using multiplex PCR in 2 or more independent reactions, mutation scanning or duplication/deletion variants of 2-5 exons) | Master Precertification List For Health Care Providers, Pg 63 Original policy |
| 81404* | Molecular pathology procedure, Level 5 (eg, analysis of 2-5 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of 6-10 exons, or characterization of a dynamic mutation disorder/triplet repeat by Southern blot analysis) | Master Precertification List For Health Care Providers, Pg 63 Original policy |
| 81405* | Molecular pathology procedure, Level 6 (eg, analysis of 6-10 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of 11-25 exons, regionally targeted cytogenomic array analysis) | Master Precertification List For Health Care Providers, Pg 63 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) | Master Precertification List For Health Care Providers, Pg 63 Original policy |
| 81407* | Molecular pathology procedure, Level 8 (eg, analysis of 26-50 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of >50 exons, sequence analysis of multiple genes on one platform) | Master Precertification List For Health Care Providers, Pg 63 Original policy |
| 81408* | Molecular pathology procedure, Level 9 (eg, analysis of >50 exons in a single gene by DNA sequence analysis) | Master Precertification List For Health Care Providers, Pg 63 Original policy |
| 81410* | Aortic dysfunction or dilation (eg, Marfan syndrome, Loeys Dietz syndrome, Ehler Danlos syndrome type IV, arterial tortuosity syndrome); genomic sequence analysis panel, must include sequencing of at least 9 genes, including FBN1, TGFBR1, TGFBR2, COL3A1, MYH11, ACTA2, SLC2A10, SMAD3, and MYLK | Master Precertification List For Health Care Providers, Pg 63 Original policy |
| 81411* | Aortic dysfunction or dilation (eg, Marfan syndrome, Loeys Dietz syndrome, Ehler Danlos syndrome type IV, arterial tortuosity syndrome); duplication/deletion analysis panel, must include analyses for TGFBR1, TGFBR2, MYH11, and COL3A1 | Master Precertification List For Health Care Providers, Pg 63 Original policy |
| 81413* | Cardiac ion channelopathies (eg, Brugada syndrome, long QT syndrome, short QT syndrome, catecholaminergic polymorphic ventricular tachycardia); genomic sequence analysis panel, must include sequencing of at least 10 genes, including ANK2, CASQ2, CAV3, KCNE1, KCNE2, KCNH2, KCNJ2, KCNQ1, RYR2, and SCN5A | Master Precertification List For Health Care Providers, Pg 63 Original policy |
| 81414* | Cardiac ion channelopathies (eg, Brugada syndrome, long QT syndrome, short QT syndrome, catecholaminergic polymorphic ventricular tachycardia); duplication/deletion gene analysis panel, must include analysis of at least 2 genes, including KCNH2 and KCNQ1 | Master Precertification List For Health Care Providers, Pg 63 Original policy |
| 81415* | Exome (eg, unexplained constitutional or heritable disorder or syndrome); sequence analysis | Master Precertification List For Health Care Providers, Pg 63 Original policy |
| 81416* | Exome (eg, unexplained constitutional or heritable disorder or syndrome); sequence analysis, each comparator exome (eg, parents, siblings) | Master Precertification List For Health Care Providers, Pg 63 Original policy |
| 81417* | Exome (eg, unexplained constitutional or heritable disorder or syndrome); re-evaluation of previously obtained exome sequence (eg, updated knowledge or unrelated condition/syndrome) | Master Precertification List For Health Care Providers, Pg 63 Original policy |
| 81425* | Genome (eg, unexplained constitutional or heritable disorder or syndrome); sequence analysis | Master Precertification List For Health Care Providers, Pg 63 Original policy |
| 81426* | Genome (eg, unexplained constitutional or heritable disorder or syndrome); sequence analysis, each comparator genome (eg, parents, siblings) | Master Precertification List For Health Care Providers, Pg 63 Original policy |
| 81430* | Hearing loss (eg, nonsyndromic hearing loss, Usher syndrome, Pendred syndrome); genomic sequence analysis panel, must include sequencing of at least 60 genes, including CDH23, CLRN1, GJB2, GPR98, MTRNR1, MYO7A, MYO15A, PCDH15, OTOF, SLC26A4, TMC1, TMPRSS3, USH1C, USH1G, USH2A, and WFS1 | Master Precertification List For Health Care Providers, Pg 63 Original policy |
| 81431* | Hearing loss (eg, nonsyndromic hearing loss, Usher syndrome, Pendred syndrome); duplication/deletion analysis panel, must include copy number analyses for STRC and DFNB1 deletions in GJB2 and GJB6 genes | Master Precertification List For Health Care Providers, Pg 64 Original policy |
| 81434* | Hereditary retinal disorders (eg, retinitis pigmentosa, Leber congenital amaurosis, cone-rod dystrophy), genomic sequence analysis panel, must include sequencing of at least 15 genes, including ABCA4, CNGA1, CRB1, EYS, PDE6A, PDE6B, PRPF31, PRPH2, RDH12, RHO, RP1, RP2, RPE65, RPGR, and USH2A | Master Precertification List For Health Care Providers, Pg 64 Original policy |
| 81437* | Hereditary neuroendocrine tumor-related disorders (eg, medullary thyroid carcinoma, parathyroid carcinoma, malignant pheochromocytoma or paraganglioma), genomic sequence analysis panel, 5 or more genes, interrogation for sequence variants and copy number variants | Master Precertification List For Health Care Providers, Pg 64 Original policy |
| 81439* | Hereditary cardiomyopathy (eg, hypertrophic cardiomyopathy, dilated cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy), genomic sequence analysis panel, must include sequencing of at least 5 cardiomyopathy-related genes (eg, DSG2, MYBPC3, MYH7, PKP2, TTN) | Master Precertification List For Health Care Providers, Pg 64 Original policy |