Cigna prior authorization, page 27
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 |
|---|---|---|
| 81440* | Nuclear encoded mitochondrial genes (eg, neurologic or myopathic phenotypes), genomic sequence panel, must include analysis of at least 100 genes, including BCS1L, C10orf2, COQ2, COX10, DGUOK, MPV17, OPA1, PDSS2, POLG, POLG2, RRM2B, SCO1, SCO2, SLC25A4, SUCLA2, SUCLG1, TAZ, TK2, and TYMP | Master Precertification List For Health Care Providers, Pg 64 Original policy |
| 81442* | Noonan spectrum disorders (eg, Noonan syndrome, cardio-facio- cutaneous syndrome, Costello syndrome, LEOPARD syndrome, Noonan- like syndrome), genomic sequence analysis panel, must include sequencing of at least 12 genes, including BRAF, CBL, HRAS, KRAS, MAP2K1, MAP2K2, NRAS, PTPN11, RAF1, RIT1, SHOC2, and SOS1 | Master Precertification List For Health Care Providers, Pg 64 Original policy |
| 81445* | Solid organ neoplasm, genomic sequence analysis panel, 5-50 genes, interrogation for sequence variants and copy number variants or rearrangements, if performed; DNA analysis or combined DNA and RNA analysis | Master Precertification List For Health Care Providers, Pg 64 Original policy |
| 81448* | Hereditary peripheral neuropathies (eg, Charcot-Marie-Tooth, spastic paraplegia), genomic sequence analysis panel, must include sequencing of at least 5 peripheral neuropathy-related genes (eg, BSCL2, GJB1, MFN2, MPZ, REEP1, SPAST, SPG11, SPTLC1) | Master Precertification List For Health Care Providers, Pg 64 Original policy |
| 81449* | Solid organ neoplasm, genomic sequence analysis panel, 5-50 genes, interrogation for sequence variants and copy number variants or rearrangements, if performed; RNA analysis | Master Precertification List For Health Care Providers, Pg 64 Original policy |
| 81450* | Hematolymphoid neoplasm or disorder, genomic sequence analysis panel, 5-50 genes, interrogation for sequence variants, and copy number variants or rearrangements, or isoform expression or mRNA expression levels, if performed; DNA analysis or combined DNA and RNA analysis | Master Precertification List For Health Care Providers, Pg 64 Original policy |
| 81451* | Hematolymphoid neoplasm or disorder, genomic sequence analysis panel, 5-50 genes, interrogation for sequence variants, and copy number variants or rearrangements, or isoform expression or mRNA expression levels, if performed; RNA analysis | Master Precertification List For Health Care Providers, Pg 64 Original policy |
| 81455* | Solid organ or hematolymphoid neoplasm or disorder, 51 or greater genes, genomic sequence analysis panel, interrogation for sequence variants and copy number variants or rearrangements, or isoform expression or mRNA expression levels, if performed; DNA analysis or combined DNA and RNA analysis | Master Precertification List For Health Care Providers, Pg 64 Original policy |
| 81456* | Solid organ or hematolymphoid neoplasm or disorder, 51 or greater genes, genomic sequence analysis panel, interrogation for sequence variants and copy number variants or rearrangements, or isoform expression or mRNA expression levels, if performed; RNA analysis | Master Precertification List For Health Care Providers, Pg 64 Original policy |
| 81457* | Solid organ neoplasm, genomic sequence analysis panel, interrogation for sequence variants; DNA analysis, microsatellite instability | Master Precertification List For Health Care Providers, Pg 64 Original policy |
| 81458* | Solid organ neoplasm, genomic sequence analysis panel, interrogation for sequence variants; DNA analysis, copy number variants and microsatellite instability | Master Precertification List For Health Care Providers, Pg 65 Original policy |
| 81459* | Solid organ neoplasm, genomic sequence analysis panel, interrogation for sequence variants; DNA analysis or combined DNA and RNA analysis, copy number variants, microsatellite instability, tumor mutation burden, and rearrangements | Master Precertification List For Health Care Providers, Pg 65 Original policy |
| 81460* | Whole mitochondrial genome (eg, Leigh syndrome, mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes [MELAS], myoclonic epilepsy with ragged-red fibers [MERFF], neuropathy, ataxia, and retinitis pigmentosa [NARP], Leber hereditary optic neuropathy [LHON]), genomic sequence, must include sequence analysis of entire mitochondrial genome with heteroplasmy detection | Master Precertification List For Health Care Providers, Pg 65 Original policy |
| 81462* | Solid organ neoplasm, genomic sequence analysis panel, cell-free nucleic acid (eg, plasma), interrogation for sequence variants; DNA analysis or combined DNA and RNA analysis, copy number variants and rearrangements | Master Precertification List For Health Care Providers, Pg 65 Original policy |
| 81463* | Solid organ neoplasm, genomic sequence analysis panel, cell-free nucleic acid (eg, plasma), interrogation for sequence variants; DNA analysis, copy number variants, and microsatellite instability | Master Precertification List For Health Care Providers, Pg 65 Original policy |
| 81464* | Solid organ neoplasm, genomic sequence analysis panel, cell-free nucleic acid (eg, plasma), interrogation for sequence variants; DNA analysis or combined DNA and RNA analysis, copy number variants, microsatellite instability, tumor mutation burden, and rearrangements | Master Precertification List For Health Care Providers, Pg 65 Original policy |
| 81465* | Whole mitochondrial genome large deletion analysis panel (eg, Kearns- Sayre syndrome, chronic progressive external ophthalmoplegia), including heteroplasmy detection, if performed | Master Precertification List For Health Care Providers, Pg 65 Original policy |
| 81470* | X-linked intellectual disability (XLID) (eg, syndromic and non-syndromic XLID); genomic sequence analysis panel, must include sequencing of at least 60 genes, including ARX, ATRX, CDKL5, FGD1, FMR1, HUWE1, IL1RAPL, KDM5C, L1CAM, MECP2, MED12, MID1, OCRL, RPS6KA3, and SLC16A2 | Master Precertification List For Health Care Providers, Pg 65 Original policy |
| 81471* | X-linked intellectual disability (XLID) (eg, syndromic and non-syndromic XLID); duplication/deletion gene analysis, must include analysis of at least 60 genes, including ARX, ATRX, CDKL5, FGD1, FMR1, HUWE1, IL1RAPL, KDM5C, L1CAM, MECP2, MED12, MID1, OCRL, RPS6KA3, and SLC16A2 | Master Precertification List For Health Care Providers, Pg 65 Original policy |
| 81479* | Unlisted molecular pathology procedure | Master Precertification List For Health Care Providers, Pg 65 Original policy |
| 81518* | Oncology (breast), mRNA, gene expression profiling by real-time RT- PCR of 11 genes (7 content and 4 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithms reported as percentage risk for metastatic recurrence and likelihood of benefit from extended endocrine therapy | Master Precertification List For Health Care Providers, Pg 65 Original policy |
| 81524* | Oncology (central nervous system tumor), DNA methylation analysis of at least 10,000 methylation sites, utilizing DNA extracted from formalin- fixed tumor tissue, algorithm(s) reported as probability of matching a reference tumor family and class, and MGMT (O-6-methylguanine-DNA methyltransferase) promoter methylation status, if performed | Master Precertification List For Health Care Providers, Pg 65 Original policy |
| 81529* | Oncology (cutaneous melanoma), mRNA, gene expression profiling by real-time RT-PCR of 31 genes (28 content and 3 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as recurrence risk, including likelihood of sentinel lymph node metastasis | Master Precertification List For Health Care Providers, Pg 65 Original policy |
| 81538* | Oncology (lung), mass spectrometric 8-protein signature, including amyloid A, utilizing serum, prognostic and predictive algorithm reported as good versus poor overall survival | Master Precertification List For Health Care Providers, Pg 65 Original policy |
| 81541* | Oncology (prostate), mRNA gene expression profiling by real-time RT- PCR of 46 genes (31 content and 15 housekeeping), utilizing formalin- fixed paraffin-embedded tissue, algorithm reported as a disease-specific mortality risk score | Master Precertification List For Health Care Providers, Pg 65 Original policy |
| 81542* | Oncology (prostate), mRNA, microarray gene expression profiling of 22 content genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as metastasis risk score | Master Precertification List For Health Care Providers, Pg 66 Original policy |
| 81552* | Oncology (uveal melanoma), mRNA, gene expression profiling by real- time RT-PCR of 15 genes (12 content and 3 housekeeping), utilizing fine needle aspirate or formalin-fixed paraffin-embedded tissue, algorithm reported as risk of metastasis | Master Precertification List For Health Care Providers, Pg 66 Original policy |
| 81554* | Pulmonary disease (idiopathic pulmonary fibrosis [IPF]), mRNA, gene expression analysis of 190 genes, utilizing transbronchial biopsies, diagnostic algorithm reported as categorical result (eg, positive or negative for high probability of usual interstitial pneumonia [UIP]) | Master Precertification List For Health Care Providers, Pg 66 Original policy |
| 81558 | Transplantation medicine (allograft rejection, kidney), mRNA, gene expression profiling by quantitative polymerase chain reaction (qPCR) of 139 genes, utilizing whole blood, algorithm reported as a binary categorization as transplant excellence, which indicates immune quiescence, or not transplant excellence, indicating subclinical rejection | Master Precertification List For Health Care Providers, Pg 66 Original policy |
| 81595 | Cardiology (heart transplant), mRNA, gene expression profiling by real- time quantitative PCR of 20 genes (11 content and 9 housekeeping), utilizing subfraction of peripheral blood, algorithm reported as a rejection risk score | Master Precertification List For Health Care Providers, Pg 66 Original policy |
| 81599* | Unlisted multianalyte assay with algorithmic analysis | Master Precertification List For Health Care Providers, Pg 66 Original policy |
| 89251 | Culture of oocyte(s)/embryo(s), less than 4 days; with co-culture of oocyte(s)/embryos | Master Precertification List For Health Care Providers, Pg 66 Original policy |
| 89335 | Cryopreservation, reproductive tissue, testicular | Master Precertification List For Health Care Providers, Pg 66 Original policy |
| 89344 | Storage (per year); reproductive tissue, testicular/ovarian | Master Precertification List For Health Care Providers, Pg 66 Original policy |
| 89346 | Storage (per year); oocyte(s) | Master Precertification List For Health Care Providers, Pg 66 Original policy |
| 89354 | Thawing of cryopreserved; reproductive tissue, testicular/ovarian | Master Precertification List For Health Care Providers, Pg 66 Original policy |
| 89356 | Thawing of cryopreserved; oocytes, each aliquot | Master Precertification List For Health Care Providers, Pg 66 Original policy |
| 90283 | Immune globulin (IgIV), human, for intravenous use | Master Precertification List For Health Care Providers, Pg 66 Original policy |
| 90284 | Immune globulin (SCIg), human, for use in subcutaneous infusions, 100 mg, each | Master Precertification List For Health Care Providers, Pg 66 Original policy |
| 90378 | Respiratory syncytial virus, monoclonal antibody, recombinant, for intramuscular use, 50 mg, each | Master Precertification List For Health Care Providers, Pg 66 Original policy |
| 90399 | Unlisted immune globulin | Master Precertification List For Health Care Providers, Pg 66 Original policy |
| 90867 | Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; initial, including cortical mapping, motor threshold determination, delivery and management | Master Precertification List For Health Care Providers, Pg 66 Original policy |
| 90868 | Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; subsequent delivery and management, per session | Master Precertification List For Health Care Providers, Pg 66 Original policy |
| 90869 | Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; subsequent motor threshold re-determination with delivery and management | Master Precertification List For Health Care Providers, Pg 66 Original policy |
| 90899 | Unlisted psychiatric service or procedure | Master Precertification List For Health Care Providers, Pg 66 Original policy |
| 91299* | Unlisted diagnostic gastroenterology procedure | Master Precertification List For Health Care Providers, Pg 66 Original policy |
| 93451* | Right heart catheterization including measurement(s) of oxygen saturation and cardiac output, when performed | Master Precertification List For Health Care Providers, Pg 66 Original policy |
| 93452* | Left heart catheterization including intraprocedural injection(s) for left ventriculography, imaging supervision and interpretation, when performed | Master Precertification List For Health Care Providers, Pg 66 Original policy |
| 93453* | Combined right and left heart catheterization including intraprocedural injection(s) for left ventriculography, imaging supervision and interpretation, when performed | Master Precertification List For Health Care Providers, Pg 66 Original policy |
| 93454* | Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; | Master Precertification List For Health Care Providers, Pg 67 Original policy |