Premera Blue Cross of Washington prior authorization, page 23
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 |
|---|---|---|
| 81162 | BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis and full duplication/deletion analysis (ie, detection of large gene rearrangements) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 437 Original policy |
| 81163 | BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis | Clinical Review by Code List PBCWA, Pg 438 Original policy |
| 81164 | BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full duplication/deletion analysis (ie, detection of large gene rearrangements) | Clinical Review by Code List PBCWA, Pg 438 Original policy |
| 81165 | BRCA1 (BRCA1, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 438 Original policy |
| 81166 | BRCA1 (BRCA1, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full duplication/deletion analysis (ie, detection of large gene rearrangements) | Clinical Review by Code List PBCWA, Pg 439 Original policy |
| 81167 | BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full duplication/deletion analysis (ie, detection of large gene rearrangements) | Clinical Review by Code List PBCWA, Pg 439 Original policy |
| 81168 | CCND1/IGH (t(11;14)) (eg, mantle cell lymphoma) translocation analysis, major breakpoint, qualitative and quantitative, if performed These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 439 Original policy |
| 81170 | ABL1 (ABL proto-oncogene 1, non-receptor tyrosine kinase) (eg, acquired imatinib tyrosine kinase inhibitor resistance), gene analysis, variants in the kinase domain | Clinical Review by Code List PBCWA, Pg 440 Original policy |
| 81171 | AFF2 (ALF transcription elongation factor 2 (FMR2) (EF, Fragile X intellectual disability 2 (FRAXE) gene analysis; evaluation to detect abnormal (eg, expanded) alleles | Clinical Review by Code List PBCWA, Pg 440 Original policy |
| 81172 | AFF2 (ALF transcription elongation factor 2 (FMR2) (EF, fragile X intellectual disability 2 (FRAXE) gene analysis; characterization of alleles (eg, expanded size and methylation status) | Clinical Review by Code List PBCWA, Pg 440 Original policy |
| 81173 | AR (androgen receptor) (eg, spinal and bulbar muscular atrophy, Kennedy disease, X chromosome inactivation) gene analysis; full gene sequence | Clinical Review by Code List PBCWA, Pg 440 Original policy |
| 81174 | AR (androgen receptor) (eg, spinal and bulbar muscular atrophy, Kennedy disease, X chromosome inactivation) gene analysis; known familial variant These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 440 Original policy |
| 81175 | ASXL1 (additional sex combs like 1, transcriptional regulator) (eg, myelodysplastic syndrome, myeloproliferative neoplasms, chronic myelomonocytic leukemia), gene analysis; full gene sequence | Clinical Review by Code List PBCWA, Pg 441 Original policy |
| 81176 | ASXL1 (additional sex combs like 1, transcriptional regulator) (eg, myelodysplastic syndrome, myeloproliferative neoplasms, chronic myelomonocytic leukemia), gene analysis; targeted sequence analysis (eg, exon 12) | Clinical Review by Code List PBCWA, Pg 441 Original policy |
| 81177 | ATN1 (atrophin 1) (eg, dentatorubral- pallidoluysian atrophy) gene analysis, evaluation to detect abnormal (eg, expanded) alleles | Clinical Review by Code List PBCWA, Pg 441 Original policy |
| 81178 | ATXN1 (ataxin 1) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 441 Original policy |
| 81179 | ATXN2 (ataxin 2) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles | Clinical Review by Code List PBCWA, Pg 442 Original policy |
| 81180 | ATXN3 (ataxin 3) (eg, spinocerebellar ataxia, Machado-Joseph disease) gene analysis, evaluation to detect abnormal (eg, expanded) alleles | Clinical Review by Code List PBCWA, Pg 442 Original policy |
| 81181 | ATXN7 (ataxin 7) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles | Clinical Review by Code List PBCWA, Pg 442 Original policy |
| 81182 | ATXN8OS (ATXN8 opposite strand [non- protein coding]) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles | Clinical Review by Code List PBCWA, Pg 442 Original policy |
| 81183 | ATXN10 (ataxin 10) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles | Clinical Review by Code List PBCWA, Pg 442 Original policy |
| 81184 | CACNA1A (calcium voltage-gated channel subunit alpha1 A) (eg, spinocerebellar ataxia) gene analysis; evaluation to detect abnormal (eg, expanded) alleles These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 442 Original policy |
| 81185 | CACNA1A (calcium voltage-gated channel subunit alpha1 A) (eg, spinocerebellar ataxia) gene analysis; full gene sequence | Clinical Review by Code List PBCWA, Pg 443 Original policy |
| 81186 | CACNA1A (calcium voltage-gated channel subunit alpha1 A) (eg, spinocerebellar ataxia) gene analysis; known familial variant | Clinical Review by Code List PBCWA, Pg 443 Original policy |
| 81187 | CNBP (CCHC-type zinc finger nucleic acid binding protein) (eg, myotonic dystrophy type 2) gene analysis, evaluation to detect abnormal (eg, expanded) alleles | Clinical Review by Code List PBCWA, Pg 443 Original policy |
| 81188 | CSTB (cystatin B) (eg, Unverricht-Lundborg disease) gene analysis; evaluation to detect abnormal (eg, expanded) alleles | Clinical Review by Code List PBCWA, Pg 443 Original policy |
| 81189 | CSTB (cystatin B) (eg, Unverricht-Lundborg disease) gene analysis; full gene sequence | Clinical Review by Code List PBCWA, Pg 443 Original policy |
| 81190 | CSTB (cystatin B) (eg, Unverricht-Lundborg disease) gene analysis; known familial variant(s) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 443 Original policy |
| 81191 | NTRK1 (neurotrophic receptor tyrosine kinase 1) (eg, solid tumors) translocation analysis | Clinical Review by Code List PBCWA, Pg 444 Original policy |
| 81192 | NTRK2 (neurotrophic receptor tyrosine kinase 2) (eg, solid tumors) translocation analysis | Clinical Review by Code List PBCWA, Pg 444 Original policy |
| 81193 | NTRK3 (neurotrophic receptor tyrosine kinase 3) (eg, solid tumors) translocation analysis These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 444 Original policy |
| 81194 | NTRK (neurotrophic-tropomyosin receptor tyrosine kinase 1, 2, and 3) (eg, solid tumors) translocation analysis | Clinical Review by Code List PBCWA, Pg 445 Original policy |
| 81195 | Cytogenomic (genome-wide) analysis, hematologic malignancy, structural variants and copy number variants, optical genome mapping (OGM) | Clinical Review by Code List PBCWA, Pg 445 Original policy |
| 81200 | ASPA (aspartoacylase) (eg, Canavan disease) gene analysis, common variants (eg, E285A, Y231X) | Clinical Review by Code List PBCWA, Pg 445 Original policy |
| 81201 | APC (adenomatous polyposis coli) (eg, familial adenomatosis polyposis [FAP], attenuated FAP) gene analysis; full gene sequence | Clinical Review by Code List PBCWA, Pg 445 Original policy |
| 81202 | APC (adenomatous polyposis coli) (eg, familial adenomatosis polyposis [FAP], attenuated FAP) gene analysis; known familial variants These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 445 Original policy |
| 81203 | APC (adenomatous polyposis coli) (eg, familial adenomatosis polyposis [FAP], attenuated FAP) gene analysis; duplication/deletion variants | Clinical Review by Code List PBCWA, Pg 446 Original policy |
| 81204 | AR (androgen receptor) (eg, spinal and bulbar muscular atrophy, Kennedy disease, X chromosome inactivation) gene analysis; characterization of alleles (eg, expanded size or methylation status) | Clinical Review by Code List PBCWA, Pg 446 Original policy |
| 81205 | BCKDHB (branched-chain keto acid dehydrogenase E1, beta polypeptide) (eg, maple syrup urine disease) gene analysis, common variants (eg, R183P, G278S, E422X) | Clinical Review by Code List PBCWA, Pg 446 Original policy |
| 81206 | BCR/ABL1 (t(9;22)) (eg, chronic myelogenous leukemia) translocation analysis; major breakpoint, qualitative or quantitative These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 446 Original policy |
| 81207 | BCR/ABL1 (t(9;22)) (eg, chronic myelogenous leukemia) translocation analysis; minor breakpoint, qualitative or quantitative | Clinical Review by Code List PBCWA, Pg 447 Original policy |
| 81208 | BCR/ABL1 (t(9;22)) (eg, chronic myelogenous leukemia) translocation analysis; other breakpoint, qualitative or quantitative | Clinical Review by Code List PBCWA, Pg 447 Original policy |
| 81209 | BLM (Bloom syndrome, RecQ helicase-like) (eg, Bloom syndrome) gene analysis, 2281del6ins7 variant | Clinical Review by Code List PBCWA, Pg 447 Original policy |
| 81210 | BRAF (v-raf murine sarcoma viral oncogene homolog B1) (eg, colon cancer), gene analysis, V600E variant These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 447 Original policy |
| 81212 | BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; 185delag, 5385insc, 6174delt variants | Clinical Review by Code List PBCWA, Pg 448 Original policy |
| 81215 | BRCA1 (BRCA1, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; known familial variant | Clinical Review by Code List PBCWA, Pg 448 Original policy |
| 81216 | BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; full sequence analysis | Clinical Review by Code List PBCWA, Pg 448 Original policy |
| 81217 | BRCA2 (BRCA2, DNA repair associated) (eg, hereditary breast and ovarian cancer) gene analysis; known familial variant | Clinical Review by Code List PBCWA, Pg 448 Original policy |
| 81218 | CEBPA (CCAAT/enhancer binding protein [C/EBP], alpha) (eg, acute myeloid leukemia), gene analysis, full gene sequence These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 448 Original policy |
| 81219 | CALR (calreticulin) (eg, myeloproliferative disorders), gene analysis, common variants in exon 9 | Clinical Review by Code List PBCWA, Pg 449 Original policy |