Cigna prior authorization, page 3
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 |
|---|---|---|
| 0565U* | Oncology (hepatocellular carcinoma), next-generation sequencing methylation pattern assay to detect 6626 epigenetic alterations, cell- free DNA, plasma, algorithm reported as cancer signal detected or not detected | Master Precertification List For Health Care Providers, Pg 8 Original policy |
| 0566U* | Oncology (lung), qPCR- based analysis of 13 differentially methylated regions (CCDC181, HOXA7, LRRC8A, MARCHF11, MIR129-2, NCOR2, PANTR1, PRKCB, SLC9A3, TBR1_2, TRAP1, VWC2, ZNF781), pleural fluid, algorithm reported as a qualitative result | Master Precertification List For Health Care Providers, Pg 8 Original policy |
| 0567U* | Rare diseases (constitutional/heritable disorders), whole-genome sequence analysis combination of short and long reads, for single- nucleotide variants, insertions/deletions and characterized intronic variants, copy-number variants, duplications/deletions, mobile element insertions, runs of homozygosity, aneuploidy, and inversions, mitochondrial DNA sequence and deletions, short tandem repeat genes, methylation status of selected regions, blood, saliva, amniocentesis, chorionic villus sample or tissue, identification and categorization of genetic variants | Master Precertification List For Health Care Providers, Pg 9 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 | Master Precertification List For Health Care Providers, Pg 9 Original policy |
| 0571T* | Insertion or replacement of implantable cardioverter-defibrillator system with substernal electrode(s), including all imaging guidance and electrophysiological evaluation (includes defibrillation threshold evaluation, induction of arrhythmia, evaluation of sensing for arrhythmia termination, and programming or reprogramming of sensing or therapeutic parameters), when performed | Master Precertification List For Health Care Providers, Pg 9 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 | Master Precertification List For Health Care Providers, Pg 9 Original policy |
| 0572U* | Oncology (prostate), high- throughput telomere length quantification by FISH, whole blood, diagnostic algorithm reported as risk of prostate cancer | Master Precertification List For Health Care Providers, Pg 9 Original policy |
| 0575U | Transplantation medicine (liver allograft rejection), miRNA gene expression profiling by RT-PCR of 4 genes (miR-122, miR-885, miR-23a, spike-in control), serum, plasma, or blood, algorithm reported as risk of liver allograft rejection | Master Precertification List For Health Care Providers, Pg 9 Original policy |
| 0576U | Transplantation medicine (liver allograft rejection), quantitative donor- derived cell-free DNA (cfDNA) by whole genome next- generation sequencing, plasma and mRNA gene expression profiling by multiplex real-time PCR of 56 genes, whole blood, combined algorithm reported as a rejection risk score | Master Precertification List For Health Care Providers, Pg 9 Original policy |
| 0578U* | Oncology (cutaneous melanoma), RNA, gene expression profiling by real- time qPCR of 10 genes (8 content and 2 housekeeping), utilizing formalin-fixed paraffin-embedded (FFPE) tissue, algorithm reports a binary result, either low-risk or high-risk for sentinel lymph node metastasis and recurrence | Master Precertification List For Health Care Providers, Pg 9 Original policy |
| 0581U | Transplantation medicine, antibody to non-human leukocyte antigens (non- HLA), blood specimen, flow cytometry, single-antigen bead technology, 39 targets, individual positive antibodies reported | Master Precertification List For Health Care Providers, Pg 9 Original policy |
| 0582U* | Rare diseases (constitutional disease/hereditary disorders), rapid whole genome DNA sequencing for single- nucleotide variants, insertions/deletions, copy number variations, blood, saliva, tissue sample, variants reported | Master Precertification List For Health Care Providers, Pg 9 Original policy |
| 0583U* | Rare diseases (constitutional disease/hereditary disorders), rapid whole genome comparator DNA sequencing for single-nucleotide variants, insertions/deletions, copy number variations, blood, saliva, tissue sample, variants reported with proband results | Master Precertification List For Health Care Providers, Pg 9 Original policy |
| 0584T | Islet cell transplant, includes portal vein catheterization and infusion, including all imaging, including guidance, and radiological supervision and interpretation, when performed; percutaneous | Master Precertification List For Health Care Providers, Pg 9 Original policy |
| 0585T | Islet cell transplant, includes portal vein catheterization and infusion, including all imaging, including guidance, and radiological supervision and interpretation, when performed; laparoscopic | Master Precertification List For Health Care Providers, Pg 9 Original policy |
| 0586T | Islet cell transplant, includes portal vein catheterization and infusion, including all imaging, including guidance, and radiological supervision and interpretation, when performed; open | Master Precertification List For Health Care Providers, Pg 10 Original policy |
| 0586U* | Oncology, mRNA, gene expression profiling of 216 geOncology, mRNA, gene expression profiling of 216 genes (204 targeted and 12 housekeeping genes), RNA expression analysis, formalin- fixed paraffin- embedded (FFPE) tissue, quantitative, reported as log2 ratio per gene | Master Precertification List For Health Care Providers, Pg 10 Original policy |
| 0592U* | Oncology (hematolymphoid neoplasms), DNA, targeted genomic sequence of 417 genes, interrogation for gene fusions, translocations, rearrangements, utilizing formalin-fixed paraffin- embedded (FFPE) tumor tissue, results report clinically significant variant(s) | Master Precertification List For Health Care Providers, Pg 10 Original policy |
| 0597U* | Oncology (breast), RNA expression profiling of 329 genes by targeted next- generation sequencing and 20 proteins by multiplex immunofluorescence, formalin-fixed paraffin- embedded (FFPE) tissue, algorithmic analyses to determine tumor-recurrence risk score | Master Precertification List For Health Care Providers, Pg 10 Original policy |
| 0600T* | Ablation, irreversible electroporation; 1 or more tumors per organ, other than liver or prostate, including imaging guidance, when performed, percutaneous | Master Precertification List For Health Care Providers, Pg 10 Original policy |
| 0601T* | Ablation, irreversible electroporation; 1 or more tumors per organ, including fluoroscopic and ultrasound guidance, when performed, open | Master Precertification List For Health Care Providers, Pg 10 Original policy |
| 0602U* | Endocrinology (diabetes), insulin (INS) gene methylation using digital droplet PCR, insulin, and C-peptide immunoassay, serum, Hemoglobin A1c immunoassay, whole blood, algorithm reported as diabetes-risk score | Master Precertification List For Health Care Providers, Pg 10 Original policy |
| 0609T* | Magnetic resonance spectroscopy, determination and localization of discogenic pain (cervical, thoracic, or lumbar); acquisition of single voxel data, per disc, on biomarkers (ie, lactic acid, carbohydrate, alanine, laal, propionic acid, proteoglycan, and collagen) in at least 3 discs | Master Precertification List For Health Care Providers, Pg 10 Original policy |
| 0610T* | Magnetic resonance spectroscopy, determination and localization of discogenic pain (cervical, thoracic, or lumbar); transmission of biomarker data for software analysis | Master Precertification List For Health Care Providers, Pg 10 Original policy |
| 0611T* | Magnetic resonance spectroscopy, determination and localization of discogenic pain (cervical, thoracic, or lumbar); postprocessing for algorithmic analysis of biomarker data for determination of relative chemical differences between discs | Master Precertification List For Health Care Providers, Pg 10 Original policy |
| 0611U* | Oncology (liver), analysis of over 1,000 methylated regions, cell-free DNA from plasma, algorithm reported as a quantitative result | Master Precertification List For Health Care Providers, Pg 10 Original policy |
| 0612T* | Magnetic resonance spectroscopy, determination and localization of discogenic pain (cervical, thoracic, or lumbar); interpretation and report | Master Precertification List For Health Care Providers, Pg 10 Original policy |
| 0612U* | Oncology (liver), analysis of over 1,000 methylated regions, cell-free DNA from plasma, algorithm reported as a quantitative result | Master Precertification List For Health Care Providers, Pg 10 Original policy |
| 0613U* | Oncology (urothelial carcinoma), DNA methylation and mutation analysis of 6 biomarkers (TWIST1, OTX1, ONECUT2, FGFR3, HRAS, TERT promoter region), methylation-specific PCR and targeted next- generation sequencing, urine, algorithm reported as a probability index for bladder cancer and upper tract urothelial carcinoma | Master Precertification List For Health Care Providers, Pg 10 Original policy |
| 0627T* | Percutaneous injection of allogeneic cellular and/or tissue-based product, intervertebral disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar; first level | Master Precertification List For Health Care Providers, Pg 10 Original policy |
| 0628T* | Percutaneous injection of allogeneic cellular and/or tissue-based product, intervertebral disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar; each additional level | Master Precertification List For Health Care Providers, Pg 11 Original policy |
| 0629T* | Percutaneous injection of allogeneic cellular and/or tissue-based product, intervertebral disc, unilateral or bilateral injection, with CT guidance, lumbar; first level | Master Precertification List For Health Care Providers, Pg 11 Original policy |
| 0631U* | Oncology (solid tumor), DNA, sequence analysis of 15 genes including BRCA1 and BRCA2 for identification of clonal hematopoiesis, blood, reported as tumor-derived or nontumor-derived | Master Precertification List For Health Care Providers, Pg 11 Original policy |
| 0632U* | Red blood cell antigen (fetal RhD gene analysis), multiplex polymerase chain reaction (PCR) and next-generation sequencing (NGS) of circulating cell-free DNA (cfDNA), plasma from pregnant individuals known to be RhD negative, reported as detected or not detected | Master Precertification List For Health Care Providers, Pg 11 Original policy |
| 0633T* | Computed tomography, breast, including 3D rendering, when performed, unilateral; without contrast material | Master Precertification List For Health Care Providers, Pg 11 Original policy |
| 0634T* | Computed tomography, breast, including 3D rendering, when performed, unilateral; with contrast material(s) | Master Precertification List For Health Care Providers, Pg 11 Original policy |
| 0634U* | Oncology (breast cancer), cell-free DNA (cfDNA), evaluation of 11 ESR1 variants (E380Q, S463P, L536R, Y537C, Y537N, Y537S, D538G, V422del, L536H, L536P, Y537D) using droplet digital PCR (ddPCR), plasma, reported as positive or negative | Master Precertification List For Health Care Providers, Pg 11 Original policy |
| 0635T* | Computed tomography, breast, including 3D rendering, when performed, unilateral; without contrast, followed by contrast material(s) | Master Precertification List For Health Care Providers, Pg 11 Original policy |
| 0636T* | Computed tomography, breast, including 3D rendering, when performed, bilateral; without contrast material(s) | Master Precertification List For Health Care Providers, Pg 11 Original policy |
| 0637T* | Computed tomography, breast, including 3D rendering, when performed, bilateral; with contrast material(s) | Master Precertification List For Health Care Providers, Pg 11 Original policy |
| 0638T* | Computed tomography, breast, including 3D rendering, when performed, bilateral; without contrast, followed by contrast material(s) | Master Precertification List For Health Care Providers, Pg 11 Original policy |
| 0641U* | Oncology (minimal residual disease [MRD]), tumor DNA, next- generation sequencing (NGS), using formalin-fixed paraffin-embedded (FFPE) tissue and blood samples, initial (baseline) assessment | Master Precertification List For Health Care Providers, Pg 11 Original policy |
| 0642U* | Oncology (minimal residual disease [MRD]), tumor DNA, next- generation sequencing (NGS), whole blood, comparison to previously performed analyses, reported as trend in circulating tumor DNA (ctDNA) level | Master Precertification List For Health Care Providers, Pg 11 Original policy |
| 0644U* | Oncology (leukemia), minimal residual disease (MRD) detection for rearrangements, blood or bone marrow, personalized assay design and baseline quantification | Master Precertification List For Health Care Providers, Pg 11 Original policy |
| 0645U* | Oncology (leukemia), minimal residual disease (MRD) detection for rearrangements, based on digital PCR, blood or bone marrow, reported as not detected or detected with estimated abundance | Master Precertification List For Health Care Providers, Pg 11 Original policy |
| 0646U* | Oncology (molecular residual disease), whole genome sequence analysis, cell-free DNA, whole blood, and formalin-fixed paraffin- embedded (FFPE) tumor tissue DNA, baseline assessment | Master Precertification List For Health Care Providers, Pg 11 Original policy |
| 0647U* | Oncology (molecular residual disease), whole genome sequence analysis, cell-free DNA (cfDNA), whole blood, assessment utilizing patient-specific tumor information, reported as negative or percent circulating tumor DNA (ctDNA) | Master Precertification List For Health Care Providers, Pg 11 Original policy |
| 0648T* | Quantitative magnetic resonance for analysis of tissue composition (eg, fat, iron, water content), including multiparametric data acquisition, data preparation and transmission, interpretation and report, obtained without diagnostic MRI examination of the same anatomy (eg, organ, gland, tissue, target structure) during the same session; single organ | Master Precertification List For Health Care Providers, Pg 11 Original policy |
| 0649T* | Quantitative magnetic resonance for analysis of tissue composition (eg, fat, iron, water content), including multiparametric data acquisition, data preparation and transmission, interpretation and report, obtained with diagnostic MRI examination of the same anatomy (eg, organ, gland, tissue, target structure); single organ | Master Precertification List For Health Care Providers, Pg 12 Original policy |
| 0651U* | Oncology (hereditary cancer), genomic DNA, 55 hereditary cancer pre- dispositioned genes, next-generation sequencing (NGS) and digital multiplex ligation-dependent probe amplification for variants, small indels (<40 base pairs), using saliva, whole blood or nail clipping, interpretive clinical report with variant classification | Master Precertification List For Health Care Providers, Pg 12 Original policy |