Premera Blue Cross of Washington prior authorization, page 2
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 |
|---|---|---|
| 0103U | Hereditary ovarian cancer (eg, 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 [24 genes (sequencing and deletion/duplication); epcam (deletion/duplication only) | Clinical Review by Code List PBCWA, Pg 28 Original policy |
| 0111U | Oncology (colon cancer), targeted KRAS (codons 12, 13, and 61) and NRAS (codons 12, 13, and 61) gene analysis utilizing formalin-fixed paraffin-embedded tissue | Clinical Review by Code List PBCWA, Pg 28 Original policy |
| 0113U | Oncology (prostate), measurement of PCA3 and TMPRSS2-ERG in urine and PSA in serum following prostatic massage, by RNA amplification and fluorescence- based detection, algorithm reported as risk score | Clinical Review by Code List PBCWA, Pg 29 Original policy |
| 0114U | Gastroenterology (Barrett's esophagus), VIM and CCNA1 methylation analysis, esophageal cells, algorithm reported as likelihood for Barrett's esophagus | Clinical Review by Code List PBCWA, Pg 29 Original policy |
| 0118U | Transplantation medicine, quantification of donor-derived cell-free DNA using whole genome next-generation sequencing, plasma, reported as percentage of donor- derived cell-free DNA in the total cell-free DNA These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 29 Original policy |
| 0120U | Oncology (B-cell lymphoma classification), mRNA, gene expression profiling by fluorescent probe hybridization of 58 genes (45 content and 13 housekeeping genes), formalin-fixed paraffin-embedded tissue, algorithm reported as likelihood for primary mediastinal B-cell lymphoma (PMBCL) and diffuse large B-cell lymphoma (DLBCL) with cell of origin subtyping in the latter | Clinical Review by Code List PBCWA, Pg 30 Original policy |
| 0129U | Hereditary breast cancer-related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer), genomic sequence analysis and deletion/duplication analysis panel (ATM, BRCA1, BRCA2, CDH1, CHEK2, PALB2, PTEN, and TP53) | Clinical Review by Code List PBCWA, Pg 30 Original policy |
| 0130U | Hereditary colon cancer disorders (eg, Lynch syndrome, PTEN hamartoma syndrome, Cowden syndrome, familial adenomatosis polyposis), targeted mRNA sequence analysis panel (APC, CDH1, CHEK2, MLH1, MSH2, MSH6, MUTYH, PMS2, PTEN, and TP53) (List separately in addition to code for primary procedure) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 30 Original policy |
| 0133U | Hereditary prostate cancer-related disorders, targeted mRNA sequence analysis panel (11 genes) (List separately in addition to code for primary procedure) | Clinical Review by Code List PBCWA, Pg 31 Original policy |
| 0134U | Hereditary pan cancer (eg, hereditary breast and ovarian cancer, hereditary endometrial cancer, hereditary colorectal cancer), targeted mRNA sequence analysis panel (18 genes) (List separately in addition to code for primary procedure) | Clinical Review by Code List PBCWA, Pg 31 Original policy |
| 0136U | ATM (ataxia telangiectasia mutated) (eg, ataxia telangiectasia) mRNA sequence analysis (List separately in addition to code for primary procedure) | Clinical Review by Code List PBCWA, Pg 31 Original policy |
| 0137U | PALB2 (partner and localizer of BRCA2) (eg, breast and pancreatic cancer) mRNA sequence analysis (List separately in addition to code for primary procedure) | Clinical Review by Code List PBCWA, Pg 31 Original policy |
| 0138U | BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) mRNA sequence analysis (List separately in addition to code for primary procedure) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 31 Original policy |
| 0153U | Oncology (breast), MRNA, gene expression profiling by next-generation sequencing of 101 genes, utilizing formalin-fixed paraffin- embedded tissue, algorithm reported as a triple negative breast cancer clinical subtype(s) with information on immune cell involvement | Clinical Review by Code List PBCWA, Pg 32 Original policy |
| 0154U | Oncology (urothelial cancer) RNA, analysis by real-time rt-pcr of the FGFR3 (fibroblast growth factor receptor 3) gene analysis (IE, P.R248C [C.742C>T], P.S249C [C.746C>G], P.G370C [C.1108G>T], P.Y373C [C.1118A>G], FGFR3-TACC3V1, AND FGFR3-TACC3V3) utilizing formalin- fixed paraffin-embedded (FFPE) urothelial cancer tumor tissue, reported as FGFR gene alteration status | Clinical Review by Code List PBCWA, Pg 32 Original policy |
| 0155U | Oncology (breast cancer) DNA, PIK3CA (PHOSPHATIDYLINOSITOL- 4,5BISPHOSPHATE 3-KINASE, catalytic SUBUNIT ALPHA) gene analysis (IE, P.C420R, P.E542K, P.E545A, P.E545D [G.1635G>T ONLY], P.E545G, P.E545K, P.Q546E, P.Q546R, P.H1047L, P.H1047R, P.H1047Y) utilizing formalin-fixed paraffin- embedded (FFPE) breast tumor tissue, reported as PIK3CA gene mutation status These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 32 Original policy |
| 0156U | Copy number (EG, intellectual disability, dysmorphology), sequence analysis | Clinical Review by Code List PBCWA, Pg 33 Original policy |
| 0157U | APC (APC regulator of WNT signaling pathway) (EG, familial adenomatosis polyposis [FAP]) MRNA sequence analysis (list separately in addition to code for primary procedure | Clinical Review by Code List PBCWA, Pg 33 Original policy |
| 0158U | MLH1 (MUTL HOMOLOG 1) (EG, hereditary non-polyposis colorectal cancer, lynch syndrome) mrna sequence analysis (list separately in addition to code for primary procedure) | Clinical Review by Code List PBCWA, Pg 33 Original policy |
| 0159U | MSH2 (MUTS HOMOLOG 2) (EG, hereditary colon cancer, lynch syndrome) MRNA sequence analysis (list separately in addition to code for primary procedure) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 33 Original policy |
| 0160U | MSH6 (MUTS HOMOLOG 6) (EG, hereditary colon cancer, lynch syndrome) MRNA sequence analysis (list separately in addition to code for primary procedure) | Clinical Review by Code List PBCWA, Pg 34 Original policy |
| 0161U | PMS2 (PMS1 HOMOLOG 2, mismatch repair system component) (eg, hereditary nonpolyposis colorectal cancer, lynch syndrome) MRNA sequence analysis (list separately in addition to code for primary procedure) | Clinical Review by Code List PBCWA, Pg 34 Original policy |
| 0162U | Hereditary colon cancer (lynch syndrome), targeted MRNA sequence analysis panel (MLH1, MSH2, MSH6, PMS2) (list separately in addition to code for primary procedure) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 34 Original policy |
| 0164T | Removal of total disc arthroplasty, anterior approach, lumbar, each additional interspace (List separately in addition to code for primary procedure | Clinical Review by Code List PBCWA, Pg 35 Original policy |
| 0165T | Revision of total disc arthroplasty (artificial disc),, anterior approach, lumbar, each additional interspace | Clinical Review by Code List PBCWA, Pg 35 Original policy |
| 0169U | NUDT15 (nudix hydrolase 15) and TPMT (thiopurine S-methyltransferase) (eg, drug metabolism) gene analysis, common variants | Clinical Review by Code List PBCWA, Pg 35 Original policy |
| 0170U | Neurology (autism spectrum disorder [ASD]), RNA, next-generation sequencing, saliva, algorithmic analysis, and results reported as predictive probability of ASD diagnosis These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 35 Original policy |
| 0171U | Targeted genomic sequence analysis panel, acute myeloid leukemia, myelodysplastic syndrome, and myeloproliferative neoplasms, DNA analysis, 23 genes, interrogation for sequence variants, rearrangements and minimal residual disease, reported as presence/absence | Clinical Review by Code List PBCWA, Pg 36 Original policy |
| 0172U | Oncology (solid tumor as indicated by the label), somatic mutation analysis of BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) and analysis of homologous recombination deficiency pathways, DNA, formalin-fixed paraffin-embedded tissue, algorithm quantifying tumor genomic instability score | Clinical Review by Code List PBCWA, Pg 36 Original policy |
| 0173U | Psychiatry (ie, depression, anxiety), genomic analysis panel, includes variant analysis of 14 genes | Clinical Review by Code List PBCWA, Pg 36 Original policy |
| 0175U | Psychiatry (eg, depression, anxiety), genomic analysis panel, variant analysis of 15 genes | Clinical Review by Code List PBCWA, Pg 37 Original policy |
| 0177U | Oncology (breast cancer), DNA, PIK3CA (phosphatidylinositol-4,5-bisphosphate 3- kinase catalytic subunit alpha) gene analysis of 11 gene variants utilizing plasma, reported as PIK3CA gene mutation status | Clinical Review by Code List PBCWA, Pg 37 Original policy |
| 0179U | Oncology (non-small cell lung cancer), cell- free DNA, targeted sequence analysis of 23 genes (single nucleotide variations, insertions and deletions, fusions without prior knowledge of partner/breakpoint, copy number variations), with report of significant mutation(s) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 37 Original policy |
| 0200T | Percutaneous sacral augmentation (sacroplasty), unilateral injection(s), including the use of a balloon or mechanical device, when used, 1 or more needles | Clinical Review by Code List PBCWA, Pg 41 Original policy |
| 0201T | Percutaneous sacral augmentation (sacroplasty), bilateral injections, including the use of a balloon or mechanical device, when used, 2 or more needles | Clinical Review by Code List PBCWA, Pg 41 Original policy |
| 0203U | Autoimmune (inflammatory bowel disease), mRNA, gene expression profiling by quantitative RT-PCR, 17 genes (15 target and 2 reference genes), whole blood, reported as a continuous risk score and classification of inflammatory bowel disease aggressiveness These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 41 Original policy |
| 0205U | Ophthalmology (age-related macular degeneration), analysis of 3 gene variants (2 CFH gene, 1 ARMS2 gene), using PCR and MALDI-TOF, buccal swab, reported as positive or negative for neovascular age- related macular-degeneration risk associated with zinc supplements | Clinical Review by Code List PBCWA, Pg 42 Original policy |
| 0209U | Cytogenomic constitutional (genome-wide) analysis, interrogation of genomic regions for copy number, structural changes and areas of homozygosity for chromosomal abnormalities | Clinical Review by Code List PBCWA, Pg 42 Original policy |
| 0211U | Oncology (pan-tumor), DNA and RNA by next-generation sequencing, utilizing formalin-fixed paraffin-embedded tissue, interpretative report for single nucleotide variants, copy number alterations, tumor mutational burden, and microsatellite instability, with therapy association | Clinical Review by Code List PBCWA, Pg 43 Original policy |
| 0212U | Oncology (pan-tumor), DNA and RNA by next-generation sequencing, utilizing formalin-fixed paraffin-embedded tissue, interpretative report for single nucleotide variants, copy number alterations, tumor mutational burden, and microsatellite instability, with therapy association | Clinical Review by Code List PBCWA, Pg 43 Original policy |
| 0213U | Rare diseases (constitutional/heritable disorders), whole genome and mitochondrial DNA sequence analysis, including small sequence changes, deletions, duplications, short tandem repeat gene expansions, and variants in non- uniquely mappable regions, blood or saliva, identification and categorization of genetic variants, each comparator genome (eg, parent, sibling) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 43 Original policy |
| 0214U | Rare diseases (constitutional/heritable disorders), whole exome and mitochondrial DNA sequence analysis, including small sequence changes, deletions, duplications, short tandem repeat gene expansions, and variants in non-uniquely mappable regions, blood or saliva, identification and categorization of genetic variants, proband | Clinical Review by Code List PBCWA, Pg 44 Original policy |
| 0215U | Rare diseases (constitutional/heritable disorders), whole exome and mitochondrial DNA sequence analysis, including small sequence changes, deletions, duplications, short tandem repeat gene expansions, and variants in non-uniquely mappable regions, blood or saliva, identification and categorization of genetic variants, each comparator exome (eg, parent, sibling) | Clinical Review by Code List PBCWA, Pg 44 Original policy |
| 0216U | Neurology (inherited ataxias), genomic DNA sequence analysis of 12 common genes including small sequence changes, deletions, duplications, short tandem repeat gene expansions, and variants in non- uniquely mappable regions, blood or saliva, identification and categorization of genetic variants These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 44 Original policy |
| 0217U | Neurology (inherited ataxias), genomic DNA sequence analysis of 51 genes including small sequence changes, deletions, duplications, short tandem repeat gene expansions, and variants in non- uniquely mappable regions, blood or saliva, identification and categorization of genetic variants | Clinical Review by Code List PBCWA, Pg 45 Original policy |
| 0218U | Neurology (muscular dystrophy), DMD gene sequence analysis, including small sequence changes, deletions, duplications, and variants in non-uniquely mappable regions, blood or saliva, identification and characterization of genetic variants | Clinical Review by Code List PBCWA, Pg 45 Original policy |
| 0228U | Oncology (prostate), multianalyte molecular profile by photometric detection of macromolecules adsorbed on nanosponge array slides with machine learning, utilizing first morning voided urine, algorithm reported as likelihood of prostate cancer | Clinical Review by Code List PBCWA, Pg 47 Original policy |
| 0229U | BCAT1 (Branched chain amino acid transaminase 1) or IKZF1 (IKAROS family zinc finger 1) (eg, colorectal cancer) promoter methylation analysis | Clinical Review by Code List PBCWA, Pg 47 Original policy |
| 0230U | AR (androgen receptor) (eg, spinal and bulbar muscular atrophy, Kennedy disease, X chromosome inactivation), full sequence analysis, including small sequence changes in exonic and intronic regions, deletions, duplications, short tandem repeat (STR) expansions, mobile element insertions, and variants in non-uniquely mappable regions These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 47 Original policy |
| 0231U | CACNA1A (calcium voltage-gated channel subunit alpha 1A) (eg, spinocerebellar ataxia), full gene analysis, including small sequence changes in exonic and intronic regions, deletions, duplications, short tandem repeat (STR) gene expansions, mobile element insertions, and variants in non-uniquely mappable regions | Clinical Review by Code List PBCWA, Pg 48 Original policy |