Premera Blue Cross of Washington prior authorization
CPT code lookup
Each row is one code from the public prior authorization list. The description is the procedure or service name on that source row. This is not a coverage decision.
Prior authorization codes
| Code | Description | Source |
|---|---|---|
| 0001U | Red blood cell antigen typing, DNA, human erythrocyte antigen gene analysis of 35 antigens from 11 blood groups, utilizing whole blood, common RBC alleles reported | Clinical Review by Code List PBCWA, Pg 12 Original policy |
| 0004M | Scoliosis, DNA analysis of 53 single nucleotide polymorphisms (SNPs), using saliva, prognostic algorithm reported as a risk score These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 12 Original policy |
| 0005U | Oncology (prostate) gene expression profile by real-time RT-PCR of 3 genes (ERG, PCA3, and SPDEF), urine, algorithm reported as risk score | Clinical Review by Code List PBCWA, Pg 13 Original policy |
| 0006M | Oncology (hepatic), mRNA expression levels of 161 genes, utilizing fresh hepatocellular carcinoma tumor tissue, with alpha-fetoprotein level, algorithm reported as a risk classifier | Clinical Review by Code List PBCWA, Pg 13 Original policy |
| 0007M | Oncology (gastrointestinal neuroendocrine tumors), real-time PCR expression analysis of 51 genes, utilizing whole peripheral blood, algorithm reported as a nomogram of tumor disease index These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 13 Original policy |
| 0011M | Oncology, prostate cancer, mRNA expression assay of 12 genes (10 content and 2 housekeeping), RT-PCR test utilizing blood plasma and/or urine, algorithms to predict high-grade prostate cancer risk | Clinical Review by Code List PBCWA, Pg 14 Original policy |
| 0012M | Oncology (urothelial), mRNA, gene expression profiling by real-time quantitative PCR of five genes (MDK, HOXA13, CDC2 [CDK1], IGFBP5, and XCR2), utilizing urine, algorithm reported as a risk score for having urothelial carcinoma | Clinical Review by Code List PBCWA, Pg 14 Original policy |
| 0013M | Oncology (urothelial), mRNA, gene expression profiling by real-time quantitative PCR of five genes (MDK, HOXA13, CDC2 [CDK1], IGFBP5, and CXCR2), utilizing urine, algorithm reported as a risk score for having recurrent urothelial carcinoma These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 14 Original policy |
| 0015M | Adrenal cortical tumor, biochemical assay of 25 steroid markers, utilizing 24-hour urine specimen and clinical parameters, prognostic algorithm reported as a clinical risk and integrated clinical steroid risk for adrenal cortical carcinoma, adenoma or other adrenal malignancy | Clinical Review by Code List PBCWA, Pg 15 Original policy |
| 0016U | Oncology (hematolymphoid neoplasia), RNA, BCR/ABL1 major and minor breakpoint fusion transcripts, quantitative PCR amplification, blood or bone marrow, report of fusion not detected or detected with quantitation These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 15 Original policy |
| 0017M | Oncology (diffuse large B-cell lymphoma [DLBCL]), mRNA, gene expression profiling by fluorescent probe hybridization of 20 genes, formalin-fixed paraffin-embedded tissue, algorithm reported as cell of origin | Clinical Review by Code List PBCWA, Pg 16 Original policy |
| 0017U | Oncology (hematolymphoid neoplasia), JAK2 mutation, DNA, PCR amplification of exons 12-14 and sequence analysis, blood or bone marrow, report of JAK2 mutation not detected or detected | Clinical Review by Code List PBCWA, Pg 16 Original policy |
| 0018U | Oncology (Thyroid), microRNA profiling by RT-PCR of 10 microRNA sequences, utilizing fine needle aspirate, algorithm reported as a positive or negative result for moderate to high risk of malignancy | Clinical Review by Code List PBCWA, Pg 16 Original policy |
| 0019U | Oncology, RNA, gene expression by whole transcriptome sequencing, formalin-fixed paraffin embedded tissue or fresh frozen tissue, predictive algorithm reported as potential targets for therapeutic agents | Clinical Review by Code List PBCWA, Pg 17 Original policy |
| 0020M | Oncology (central nervous system), analysis of 30000 DNA methylation loci by methylation array, utilizing DNA extracted from tumor tissue, diagnostic algorithm reported as probability of matching a reference tumor subclass | Clinical Review by Code List PBCWA, Pg 17 Original policy |
| 0022U | Targeted genomic sequence analysis panel, non-small cell lung neoplasia, DNA and RNA analysis, 23 genes, interrogation for sequence variants and rearrangements, reported as presence or absence of variants and associated therapy(ies) to consider These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 17 Original policy |
| 0023U | Oncology (acute myelogenous leukemia), DNA, genotyping of internal tandem duplication, p.D835, p.I836, using mononuclear cells, reported as detection or nondetection of FLT3 mutation and indication for or against the use of midostaurin | Clinical Review by Code List PBCWA, Pg 18 Original policy |
| 0026U | Oncology (thyroid), DNA and mRNA of 112 genes, next-generation sequencing, fine needle aspirate of thyroid nodule, algorithmic analysis reported as a categorical result ("Positive, high probability of malignancy" or "Negative, low probability of malignancy") | Clinical Review by Code List PBCWA, Pg 18 Original policy |
| 0027U | JAK2 (Janus kinase 2) (eg, myeloproliferative disorder) gene analysis, targeted sequence analysis exons 12-15 | Clinical Review by Code List PBCWA, Pg 18 Original policy |
| 0030U | Drug metabolism (warfarin drug response), targeted sequence analysis (ie, CYP2C9, CYP4F2, VKORC1, rs12777823) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 18 Original policy |
| 0032U | COMT (catechol-O-methyltransferase)(drug metabolism) gene analysis, c.472G>A (rs4680) variant | Clinical Review by Code List PBCWA, Pg 19 Original policy |
| 0034U | TPMT (thiopurine S-methyltransferase), NUDT15 (nudix hydroxylase 15)(eg, thiopurine metabolism), gene analysis, common variants (ie, TPMT *2, *3A, *3B, *3C, *4, *5, *6, *8, *12; NUDT15 *3, *4, *5) | Clinical Review by Code List PBCWA, Pg 19 Original policy |
| 0036U | Exome (ie, somatic mutations), paired formalin-fixed paraffin-embedded tumor tissue and normal specimen, sequence analyses | Clinical Review by Code List PBCWA, Pg 19 Original policy |
| 0037U | Targeted genomic sequence analysis, solid organ neoplasm, DNA analysis of 324 genes, interrogation for sequence variants, gene copy number amplifications, gene rearrangements, microsatellite instability and tumor mutational burden These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 19 Original policy |
| 0040U | BCR/ABL1 (t(9;22)) (eg, chronic myelogenous leukemia) translocation analysis, major breakpoint, quantitative | Clinical Review by Code List PBCWA, Pg 20 Original policy |
| 0045U | Oncology (breast ductal carcinoma in situ), mRNA, gene expression profiling by real- time RT-PCR of 12 genes (7 content and 5 housekeeping) | Clinical Review by Code List PBCWA, Pg 20 Original policy |
| 0046U | FLT3 (fms-related tyrosine kinase 3) (eg, acute myeloid leukemia) internal tandem duplication (ITD) variants, quantitative These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 20 Original policy |
| 0047U | Oncology (prostate), mRNA, gene expression profiling by real-time RT-PCR of 17 genes (12 content and 5 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a risk score | Clinical Review by Code List PBCWA, Pg 21 Original policy |
| 0048U | Oncology (solid organ neoplasia), DNA, targeted sequencing of protein-coding exons of 468 cancer-associated genes, including interrogation for somatic mutations and microsatellite instability, matched with normal specimens | Clinical Review by Code List PBCWA, Pg 21 Original policy |
| 0049U | NPM1 (nucleophosmin) (eg, acute myeloid leukemia) gene analysis, quantitative These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 21 Original policy |
| 0050U | Targeted genomic sequence analysis panel, acute myelogenous leukemia, DNA analysis, 194 genes, interrogation for sequence variants or rearrangements | Clinical Review by Code List PBCWA, Pg 22 Original policy |
| 0055U | Cardiology (heart transplant), cell-free DNA, PCR assay of 96 DNA target sequences (94 single nucleotide polymorphism targets and two control targets), plasma | Clinical Review by Code List PBCWA, Pg 22 Original policy |
| 0060U | Twin zygosity, genomic targeted sequence analysis of chromosome 2, using circulating cell-free DNA in maternal blood | Clinical Review by Code List PBCWA, Pg 22 Original policy |
| 0069U | Oncology (colorectal), microRNA, RT-PCR expression profiling of miR-31-3p, formalin- fixed paraffin-embedded tissue, algorithm reported as an expression score These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 22 Original policy |
| 0070U | CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, common and select rare variants (ie, *2, *3, *4, *4N, *5, *6, *7, *8, *9, *10, *11, *12, *13, *14A, *14B, *15, *17, *29, *35, *36, *41, *57, *61, *63, *68, *83, *xN) | Clinical Review by Code List PBCWA, Pg 23 Original policy |
| 0071U | CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, full gene sequence (List separately in addition to code for primary procedure) | Clinical Review by Code List PBCWA, Pg 23 Original policy |
| 0072U | CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, targeted sequence analysis (ie, CYP2D6-2D7 hybrid gene) (List separately in addition to code for primary procedure) | Clinical Review by Code List PBCWA, Pg 23 Original policy |
| 0073U | CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, targeted sequence analysis (ie, CYP2D7-2D6 hybrid gene) (List separately in addition to code for primary procedure) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 23 Original policy |
| 0074U | CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, targeted sequence analysis (ie, non-duplicated gene when duplication/multiplication is trans) (List separately in addition to code for primary procedure) | Clinical Review by Code List PBCWA, Pg 24 Original policy |
| 0075U | CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, targeted sequence analysis (ie, 5’ gene duplication/multiplication) (List separately in addition to code for primary procedure) | Clinical Review by Code List PBCWA, Pg 24 Original policy |
| 0076U | CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, targeted sequence analysis (ie, 3’ gene duplication/ multiplication) (List separately in addition to code for primary procedure) | Clinical Review by Code List PBCWA, Pg 24 Original policy |
| 0079U | Comparative DNA analysis using multiple selected single-nucleotide polymorphisms (SNPs), urine and buccal DNA, for specimen identity verification These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 24 Original policy |
| 0087U | Cardiology (heart transplant), mRNA gene expression profiling by microarray of 1283 genes, transplant biopsy tissue, allograft rejection and injury algorithm reported as a probability score | Clinical Review by Code List PBCWA, Pg 25 Original policy |
| 0088U | Transplantation medicine (kidney allograft rejection), microarray gene expression profiling of 1494 genes, utilizing transplant biopsy tissue, algorithm reported as a probability score for rejection | Clinical Review by Code List PBCWA, Pg 25 Original policy |
| 0089U | Oncology (melanoma), gene expression profiling by RTqPCR, PRAME and LINC00518, superficial collection using adhesive patch(es) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 25 Original policy |
| 0090U | Oncology (cutaneous melanoma), mRNA gene expression profiling by RT-PCR of 23 genes (14 content and 9 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a categorical result (ie, benign, indeterminate, malignant) | Clinical Review by Code List PBCWA, Pg 26 Original policy |
| 0094U | Genome (eg, unexplained constitutional or heritable disorder or syndrome), rapid sequence analysis | Clinical Review by Code List PBCWA, Pg 26 Original policy |
| 0098T | Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, each additional interspace, cervical (List separately in addition to code for primary procedure) | Clinical Review by Code List PBCWA, Pg 26 Original policy |
| 0101U | Hereditary colon cancer disorders (eg, lynch syndrome, pten hamartoma syndrome, cowden syndrome, familial adenomatosis polyposis); genomic sequence analysis panel utilizing a combination of ngs, sanger, mlpa and array cgh, with mrna analytics to resolve variants of unknown significance when indicated [15 genes (sequencing and deletion/duplication), epcam and grem1 (deletion/duplication only) | Clinical Review by Code List PBCWA, Pg 27 Original policy |
| 0102U | Hereditary breast cancer-related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer); genomic sequence analysis panel utilizing a combination of ngs, sanger, mlpa and array cgh, with mrna analytics to resolve variants of unknown significance when indicated [17 genes (sequencing and deletion/duplication) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 27 Original policy |