Cigna prior authorization, page 4
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 |
|---|---|---|
| 0653U* | Nephrology (inherited kidney disorders), DNA, analysis of approximately 700 genes associated with inherited kidney diseases by exome sequencing, using whole blood, saliva, or nail clipping, reported as an interpretive clinical report classifying pathogenic and likely pathogenic variants | Master Precertification List For Health Care Providers, Pg 12 Original policy |
| 0656T* | Anterior lumbar or thoracolumbar vertebral body tethering; up to 7 vertebral segments | Master Precertification List For Health Care Providers, Pg 12 Original policy |
| 0657T* | Anterior lumbar or thoracolumbar vertebral body tethering; 8 or more vertebral segments | Master Precertification List For Health Care Providers, Pg 12 Original policy |
| 0657U* | Rare diseases (constitutional/heritable disorders), rapid whole genome sequence analysis of comparator nuclear and mitochondrial DNA by next- generation sequencing (NGS), using blood or buccal sample, relevant variants reported with proband results | Master Precertification List For Health Care Providers, Pg 12 Original policy |
| 0658U* | Rare diseases (constitutional/heritable disorders), rapid whole genome sequence analysis of nuclear and mitochondrial DNA by next-generation sequencing (NGS) for single-nucleotide variants (SNVs), insertions/deletions, copy number variants, uniparental disomy, and repeat expansions, using blood or buccal sample, identification and categorization of genetic variants | Master Precertification List For Health Care Providers, Pg 12 Original policy |
| 0659U* | Rare diseases (constitutional/heritable disorders), ultrarapid whole genome sequence analysis of nuclear and mitochondrial DNA by next- generation sequencing (NGS) for single-nucleotide variants (SNVs), insertions/deletions, copy number variants, uniparental disomy, and repeat expansions, using blood or buccal sample, identification and categorization of genetic variants | Master Precertification List For Health Care Providers, Pg 12 Original policy |
| 0663U* | Obstetrics (fetal platelet antigen noninvasive prenatal test [NIPT]), cell- free DNA (cfDNA) sequence analysis for detection of fetal presence or absence of 1 human platelet antigen or more (HPA-1a, HPA-1b, HPA-3a, HPA-5b, and others) when performed, reported as maternal/fetal incompatibility detected or not detected per selected antigen | Master Precertification List For Health Care Providers, Pg 12 Original policy |
| 0664T | Donor hysterectomy (including cold preservation); open, from cadaver donor | Master Precertification List For Health Care Providers, Pg 12 Original policy |
| 0665T | Donor hysterectomy (including cold preservation); open, from living donor | Master Precertification List For Health Care Providers, Pg 12 Original policy |
| 0666T | Donor hysterectomy (including cold preservation); laparoscopic or robotic, from living donor | Master Precertification List For Health Care Providers, Pg 12 Original policy |
| 0667T | Donor hysterectomy (including cold preservation); recipient uterus allograft transplantation from cadaver or living donor | Master Precertification List For Health Care Providers, Pg 12 Original policy |
| 0668T | Backbench standard preparation of cadaver or living donor uterine allograft prior to transplantation, including dissection and removal of surrounding soft tissues and preparation of uterine vein(s) and uterine artery(ies), as necessary | Master Precertification List For Health Care Providers, Pg 12 Original policy |
| 0668U* | Oncology (pancreas), DNA, genome sequence with 5- hydroxymethylcytosine (5hmC) enrichment and glycan biomarker analysis, whole blood or plasma, algorithm reported as cancer detected or not detected | Master Precertification List For Health Care Providers, Pg 12 Original policy |
| 0669T | Backbench reconstruction of cadaver or living donor uterus allograft prior to transplantation; venous anastomosis, each | Master Precertification List For Health Care Providers, Pg 12 Original policy |
| 0670T | Backbench reconstruction of cadaver or living donor uterus allograft prior to transplantation; arterial anastomosis, each | Master Precertification List For Health Care Providers, Pg 12 Original policy |
| 0671T* | Insertion of anterior segment aqueous drainage device into the trabecular meshwork, without external reservoir, and without concomitant cataract removal, one or more | Master Precertification List For Health Care Providers, Pg 13 Original policy |
| 0697T* | 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; multiple organs | Master Precertification List For Health Care Providers, Pg 13 Original policy |
| 0698T* | 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); multiple organs | Master Precertification List For Health Care Providers, Pg 13 Original policy |
| 0678U* | Oncology (hereditary cancer), genome sequence for 117 genes (single- nucleotide variants, deletions/insertions, and characterized intronic variants), copy number variants, duplications/deletions, mobile element insertions and inversions, blood, saliva, cultured skin fibroblasts (skin biopsy) or extracted genomic DNA, diagnostic, identification and categorization of genetic variants | Master Precertification List For Health Care Providers, Pg 13 Original policy |
| 0679U* | Oncology (hereditary hematologic cancer), genomic DNA, whole genome sequence (single-nucleotide variants, deletions/insertions, and characterized intronic variants), copy number variants, duplications/deletions, mobile element insertions and inversions, analysis of over 105 genes, genomic DNA isolated from blood, saliva, cultured skin fibroblasts (skin biopsy), identification and categorization of genetic variants | Master Precertification List For Health Care Providers, Pg 13 Original policy |
| 0686U* | Oncology (prostate), mRNA, next-generation sequencing (NGS) gene expression profiling of 22 genes, formalin-fixed paraffin-embedded (FFPE) tissue, algorithm reported as risk score | Master Precertification List For Health Care Providers, Pg 13 Original policy |
| 0695U* | Oncology (central nervous system), low-pass whole genome sequence analysis of cerebrospinal fluid, interrogation for chromosome arm-level and focal losses and gains | Master Precertification List For Health Care Providers, Pg 13 Original policy |
| 0696U* | Oncology (solid organ), targeted genomic sequence analysis, formalin- fixed paraffin-embedded (FFPE) tumor tissue, RNA analysis, 350 or more genes for RNA alterations (eg, gene rearrangements and splice isoforms) | Master Precertification List For Health Care Providers, Pg 13 Original policy |
| 0707T* | Injection(s), bone-substitute material (eg, calcium phosphate) into subchondral bone defect (ie, bone marrow lesion, bone bruise, stress injury, microtrabecular fracture), including imaging guidance and arthroscopic assistance for joint visualization | Master Precertification List For Health Care Providers, Pg 13 Original policy |
| 0710T* | Noninvasive arterial plaque analysis using software processing of data from non-coronary computerized tomography angiography; including data preparation and transmission, quantification of the structure and composition of the vessel wall and assessment for lipid-rich necrotic core plaque to assess atherosclerotic plaque stability, data review, interpretation and report | Master Precertification List For Health Care Providers, Pg 13 Original policy |
| 0711T* | Noninvasive arterial plaque analysis using software processing of data from non-coronary computerized tomography angiography; data preparation and transmission | Master Precertification List For Health Care Providers, Pg 13 Original policy |
| 0712T* | Noninvasive arterial plaque analysis using software processing of data from non-coronary computerized tomography angiography; quantification of the structure and composition of the vessel wall and assessment for lipid-rich necrotic core plaque to assess atherosclerotic plaque stability | Master Precertification List For Health Care Providers, Pg 13 Original policy |
| 0713T* | Noninvasive arterial plaque analysis using software processing of data from non-coronary computerized tomography angiography; data review, interpretation and report | Master Precertification List For Health Care Providers, Pg 13 Original policy |
| 0717T* | Autologous adipose-derived regenerative cell (ADRC) therapy for partial thickness rotator cuff tear; adipose tissue harvesting, isolation and preparation of harvested cells, including incubation with cell dissociation enzymes, filtration, washing, and concentration of ADRCs | Master Precertification List For Health Care Providers, Pg 14 Original policy |
| 0718T* | Autologous adipose-derived regenerative cell (ADRC) therapy for partial thickness rotator cuff tear; injection into supraspinatus tendon including ultrasound guidance, unilateral | Master Precertification List For Health Care Providers, Pg 14 Original policy |
| 0745T* | Cardiac focal ablation utilizing radiation therapy for arrhythmia; noninvasive arrhythmia localization and mapping of arrhythmia site (nidus), derived from anatomical image data (eg, CT, MRI, or myocardial perfusion scan) and electrical data (eg, 12-lead ECG data), and identification of areas of avoidance | Master Precertification List For Health Care Providers, Pg 14 Original policy |
| 0746T* | Cardiac focal ablation utilizing radiation therapy for arrhythmia; conversion of arrhythmia localization and mapping of arrhythmia site (nidus) into a multidimensional radiation treatment plan | Master Precertification List For Health Care Providers, Pg 14 Original policy |
| 0747T* | Cardiac focal ablation utilizing radiation therapy for arrhythmia; delivery of radiation therapy, arrhythmia | Master Precertification List For Health Care Providers, Pg 14 Original policy |
| 0805T* | Transcatheter superior and/or inferior vena cava prosthetic valve implantation (ie, caval valve implantation [CAVI]); percutaneous femoral vein approach | Master Precertification List For Health Care Providers, Pg 14 Original policy |
| 0806T* | Transcatheter superior and/or inferior vena cava prosthetic valve implantation (ie, caval valve implantation [CAVI]); open femoral vein approach | Master Precertification List For Health Care Providers, Pg 14 Original policy |
| 0807T* | Pulmonary tissue ventilation analysis using software-based processing of data from separately captured cinefluorograph images; in combination with previously acquired computed tomography (CT) images, including data preparation and transmission, quantification of pulmonary tissue ventilation, data review, interpretation and report | Master Precertification List For Health Care Providers, Pg 14 Original policy |
| 0808T* | Pulmonary tissue ventilation analysis using software-based processing of data from separately captured cinefluorograph images; in combination with computed tomography (CT) images taken for the purpose of pulmonary tissue ventilation analysis, including data preparation and transmission, quantification of pulmonary tissue ventilation, data review, interpretation and report | Master Precertification List For Health Care Providers, Pg 14 Original policy |
| 0813T* | Esophagogastroduodenoscopy, flexible, transoral, with volume adjustment of intragastric bariatric balloon | Master Precertification List For Health Care Providers, Pg 14 Original policy |
| 0865T* | Quantitative magnetic resonance image (MRI) analysis of the brain with comparison to prior magnetic resonance (MR) study(ies), including lesion identification, characterization, and quantification, with brain volume(s) quantification and/or severity score, when performed, data preparation and transmission, interpretation and report, obtained without diagnostic MRI examination of the brain during the same session | Master Precertification List For Health Care Providers, Pg 14 Original policy |
| 0866T* | Quantitative magnetic resonance image (MRI) analysis of the brain with comparison to prior magnetic resonance (MR) study(ies), including lesion detection, characterization, and quantification, with brain volume(s) quantification and/or severity score, when performed, data preparation and transmission, interpretation and report, obtained with diagnostic MRI examination of the brain | Master Precertification List For Health Care Providers, Pg 14 Original policy |
| 0869T* | Injection(s), bone-substitute material for bone and/or soft tissue hardware fixation augmentation, including intraoperative imaging guidance, when performed | Master Precertification List For Health Care Providers, Pg 14 Original policy |
| 0889T | Personalized target development for accelerated, repetitive high-dose functional connectivity MRI-guided theta-burst stimulation derived from a structural and resting-state functional MRI, including data preparation and transmission, generation of the target, motor threshold-starting location, neuronavigation files and target report, review and interpretation | Master Precertification List For Health Care Providers, Pg 14 Original policy |
| 0890T | Accelerated, repetitive high-dose functional connectivity MRI-guided theta-burst stimulation, including target assessment, initial motor threshold determination, neuronavigation, delivery and management, initial treatment day | Master Precertification List For Health Care Providers, Pg 15 Original policy |
| 0891T | Accelerated, repetitive high-dose functional connectivity MRI-guided theta-burst stimulation, including neuronavigation, delivery and management, subsequent treatment day | Master Precertification List For Health Care Providers, Pg 15 Original policy |
| 0892T | Accelerated, repetitive high-dose functional connectivity MRI-guided theta-burst stimulation, including neuronavigation, delivery and management, subsequent motor threshold redetermination with delivery and management, per treatment day | Master Precertification List For Health Care Providers, Pg 15 Original policy |
| 0899T* | Noninvasive determination of absolute quantitation of myocardial blood flow (AQMBF), derived from augmentative algorithmic analysis of the dataset acquired via contrast cardiac magnetic resonance (CMR), pharmacologic stress, with interpretation and report by a physician or other qualified health care professional | Master Precertification List For Health Care Providers, Pg 15 Original policy |
| 0900T* | Noninvasive estimate of absolute quantitation of myocardial blood flow (AQMBF), derived from assistive algorithmic analysis of the dataset acquired via contrast cardiac magnetic resonance (CMR), pharmacologic stress, with interpretation and report by a physician or other qualified health care professional | Master Precertification List For Health Care Providers, Pg 15 Original policy |
| 0908T* | Open implantation of integrated neurostimulation system, vagus nerve, including analysis and programming, when performed | Master Precertification List For Health Care Providers, Pg 15 Original policy |
| 0933T* | Transcatheter implantation of wireless left atrial pressure sensor for long- term left atrial pressure monitoring, including sensor calibration and deployment, right heart catheterization, transseptal puncture, imaging guidance, and radiological supervision and interpretation | Master Precertification List For Health Care Providers, Pg 15 Original policy |
| 0947T* | Magnetic resonance image guided low intensity focused ultrasound (MRgFUS), stereotactic blood-brain barrier disruption using microbubble resonators to increase the concentration of blood-based biomarkers of target, intracranial, including stereotactic navigation and frame placement, when performed | Master Precertification List For Health Care Providers, Pg 15 Original policy |