Premera Blue Cross of Washington prior authorization, page 24
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 |
|---|---|---|
| 81221 | CFTR (cystic fibrosis transmembrane conductance regulator) (eg, cystic fibrosis) gene analysis; known familial variants | Clinical Review by Code List PBCWA, Pg 449 Original policy |
| 81222 | CFTR (cystic fibrosis transmembrane conductance regulator) (eg, cystic fibrosis) gene analysis; duplication/deletion variants | Clinical Review by Code List PBCWA, Pg 449 Original policy |
| 81223 | CFTR (cystic fibrosis transmembrane conductance regulator) (eg, cystic fibrosis) gene analysis; full gene sequence | Clinical Review by Code List PBCWA, Pg 449 Original policy |
| 81224 | CFTR (cystic fibrosis transmembrane conductance regulator) (eg, cystic fibrosis) gene analysis; intron 8 poly-T analysis (eg, male infertility) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 449 Original policy |
| 81225 | CYP2C19 (cytochrome P450, family 2, subfamily C, polypeptide 19) (eg, drug metabolism), gene analysis, common variants (eg, *2, *3, *4, *8, *17) | Clinical Review by Code List PBCWA, Pg 450 Original policy |
| 81226 | CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism), gene analysis, common variants (eg, *2, *3, *4, *5, *6, *9, *10, *17, *19, *29, *35, *41, *1XN, *2XN, *4XN) | Clinical Review by Code List PBCWA, Pg 450 Original policy |
| 81227 | CYP2C9 (cytochrome P450, family 2, subfamily C, polypeptide 9) (eg, drug metabolism), gene analysis, common variants (eg, *2, *3, *5, *6) | Clinical Review by Code List PBCWA, Pg 450 Original policy |
| 81228 | Cytogenomic constitutional (genome-wide) microarray analysis; interrogation of genomic regions for copy number variants | Clinical Review by Code List PBCWA, Pg 450 Original policy |
| 81229 | Cytogenomic constitutional (genome-wide) microarray analysis; interrogation of genomic regions for copy number and single nucleotide polymorphism (SNP) variants for chromosomal abnormalities | Clinical Review by Code List PBCWA, Pg 450 Original policy |
| 81230 | CYP3A4 (cytochrome P450 family 3 subfamily A member 4) (eg, drug metabolism), gene analysis, common variant(s) (eg, *2, *22) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 450 Original policy |
| 81231 | CYP3A5 (cytochrome P450 family 3 subfamily A member 5) (eg, drug metabolism), gene analysis, common variants (eg, *2, *3, *4, *5, *6, *7) | Clinical Review by Code List PBCWA, Pg 451 Original policy |
| 81232 | DPYD (dihydropyrimidine dehydrogenase) (eg, 5-fluorouracil/5-FU and capecitabine drug metabolism), gene analysis, common variant(s) (eg, *2A, *4, *5, *6) | Clinical Review by Code List PBCWA, Pg 451 Original policy |
| 81233 | BTK (Bruton's tyrosine kinase) (eg, chronic lymphocytic leukemia) gene analysis, common variants (eg, C481S, C481R, C481F) | Clinical Review by Code List PBCWA, Pg 451 Original policy |
| 81234 | DMPK (DM1 protein kinase) (eg, myotonic dystrophy type 1) gene analysis; evaluation to detect abnormal (expanded) alleles These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 451 Original policy |
| 81235 | EGFR (epidermal growth factor receptor) (eg, non-small cell lung cancer) gene analysis, common variants (eg, exon 19 LREA deletion, L858R, T790M, G719A, G719S, L861Q) | Clinical Review by Code List PBCWA, Pg 452 Original policy |
| 81236 | EZH2 (enhancer of zeste 2 polycomb repressive complex 2 subunit) (eg, myelodysplastic syndrome, myeloproliferative neoplasms) gene analysis, full gene sequence | Clinical Review by Code List PBCWA, Pg 452 Original policy |
| 81237 | EZH2 (enhancer of zeste 2 polycomb repressive complex 2 subunit) (eg, diffuse large B-cell lymphoma) gene analysis, common variant(s) (eg, codon 646) | Clinical Review by Code List PBCWA, Pg 452 Original policy |
| 81238 | F9 (coagulation factor IX) (eg, hemophilia B), full gene sequence These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 452 Original policy |
| 81239 | DMPK (DM1 protein kinase) (eg, myotonic dystrophy type 1) gene analysis; characterization of alleles (eg, expanded size) | Clinical Review by Code List PBCWA, Pg 453 Original policy |
| 81240 | F2 (prothrombin, coagulation factor II) (eg, hereditary hypercoagulability) gene analysis, 20210G>A variant | Clinical Review by Code List PBCWA, Pg 453 Original policy |
| 81241 | F5 (coagulation factor V) (eg, hereditary hypercoagulability) gene analysis, Leiden variant | Clinical Review by Code List PBCWA, Pg 453 Original policy |
| 81242 | FANCC (Fanconi anemia, complementation group C) (eg, Fanconi anemia, type C) gene analysis, common variant (eg, IVS4+4A>T) | Clinical Review by Code List PBCWA, Pg 453 Original policy |
| 81243 | FMR1 (fragile X messenger ribonucleoprotein 1) (EG, fragile X syndrome, X-linked intellectual disability (XLID)) gene analysis; evaluation to detect abnormal (eg, expanded) alleles | Clinical Review by Code List PBCWA, Pg 453 Original policy |
| 81244 | FMR1 (fragile X messenger ribonucleoprotein 1) (eg, fragile X syndrome, X-linked intellectual disability (XLID)) gene analysis; characterization of alleles (eg, expanded size and promoter methylation status) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 453 Original policy |
| 81245 | FLT3 (fms-related tyrosine kinase 3) (eg, acute myeloid leukemia), gene analysis; internal tandem duplication (ITD) variants (ie, exons 14, 15) | Clinical Review by Code List PBCWA, Pg 454 Original policy |
| 81246 | FLT3 (fms-related tyrosine kinase 3) (eg, acute myeloid leukemia), gene analysis; tyrosine kinase domain (TKD) variants (eg, D835, I836) | Clinical Review by Code List PBCWA, Pg 454 Original policy |
| 81247 | G6PD (glucose-6-phosphate dehydrogenase) (eg, hemolytic anemia, jaundice), gene analysis; common variant(s) (eg, A, A-) | Clinical Review by Code List PBCWA, Pg 454 Original policy |
| 81248 | G6PD (glucose-6-phosphate dehydrogenase) (eg, hemolytic anemia, jaundice), gene analysis; known familial variant(s) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 454 Original policy |
| 81249 | G6PD (glucose-6-phosphate dehydrogenase) (eg, hemolytic anemia, jaundice), gene analysis; full gene sequence | Clinical Review by Code List PBCWA, Pg 455 Original policy |
| 81250 | G6PC (glucose-6-phosphatase, catalytic subunit) (eg, Glycogen storage disease, type 1a, von Gierke disease) gene analysis, common variants (eg, R83C, Q347X) | Clinical Review by Code List PBCWA, Pg 455 Original policy |
| 81251 | GBA (glucosidase, beta, acid) (eg, Gaucher disease) gene analysis, common variants (eg, N370S, 84GG, L444P, IVS2+1G>A) | Clinical Review by Code List PBCWA, Pg 455 Original policy |
| 81252 | GJB2 (gap junction protein, beta 2, 26kDa, connexin 26) (eg, nonsyndromic hearing loss) gene analysis; full gene sequence | Clinical Review by Code List PBCWA, Pg 455 Original policy |
| 81253 | GJB2 (gap junction protein, beta 2, 26kDa, connexin 26) (eg, nonsyndromic hearing loss) gene analysis; known familial variants | Clinical Review by Code List PBCWA, Pg 455 Original policy |
| 81254 | GJB6 (gap junction protein, beta 6, 30kDa, connexin 30) (eg, nonsyndromic hearing loss) gene analysis, common variants (eg, 309kb [del(GJB6-D13S1830)] and 232kb [del(GJB6-D13S1854)]) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 455 Original policy |
| 81255 | HEXA (hexosaminidase A [alpha polypeptide]) (e.g., Tay-Sachs disease) gene analysis, common variants (e.g., 1278insTATC, 1421+1G>C, G269S) | Clinical Review by Code List PBCWA, Pg 456 Original policy |
| 81256 | HFE (hemochromatosis) (eg, hereditary hemochromatosis) gene analysis, common variants (eg, C282Y, H63D) | Clinical Review by Code List PBCWA, Pg 456 Original policy |
| 81258 | HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia, Hb Bart hydrops fetalis syndrome, HbH disease), gene analysis; known familial variant | Clinical Review by Code List PBCWA, Pg 456 Original policy |
| 81259 | HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia, Hb Bart hydrops fetalis syndrome, HbH disease), gene analysis; full gene sequence | Clinical Review by Code List PBCWA, Pg 456 Original policy |
| 81260 | IKBKAP (inhibitor of kappa light polypeptide gene enhancer in B-cells, kinase complex- associated protein) (eg, familial dysautonomia) gene analysis, common variants (eg, 2507+6T>C, R696P) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 456 Original policy |
| 81261 | IGH@ (Immunoglobulin heavy chain locus) (eg, leukemias and lymphomas, B-cell), gene rearrangement analysis to detect abnormal clonal population(s); amplified methodology (eg, polymerase chain reaction) | Clinical Review by Code List PBCWA, Pg 457 Original policy |
| 81262 | IGH@ (Immunoglobulin heavy chain locus) (eg, leukemias and lymphomas, B-cell), gene rearrangement analysis to detect abnormal clonal population(s); direct probe methodology (eg, Southern blot) | Clinical Review by Code List PBCWA, Pg 457 Original policy |
| 81263 | IGH@ (Immunoglobulin heavy chain locus) (eg, leukemia and lymphoma, B-cell), variable region somatic mutation analysis These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 457 Original policy |
| 81264 | IGK@ (Immunoglobulin kappa light chain locus) (eg, leukemia and lymphoma, B- cell), gene rearrangement analysis, evaluation to detect abnormal clonal population(s) | Clinical Review by Code List PBCWA, Pg 458 Original policy |
| 81265 | Comparative analysis using Short Tandem Repeat (STR) markers; patient and comparative specimen (eg, pre-transplant recipient and donor germline testing, post- transplant non-hematopoietic recipient germlin | Clinical Review by Code List PBCWA, Pg 458 Original policy |
| 81266 | Comparative analysis using Short Tandem Repeat (STR) markers; each additional specimen (eg, additional cord blood donor, additional fetal samples from different cultures, or additional zygosity in multiple birth pregnancies | Clinical Review by Code List PBCWA, Pg 458 Original policy |
| 81269 | HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia, Hb Bart hydrops fetalis syndrome, HbH disease), gene analysis; duplication/deletion variants These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 458 Original policy |
| 81270 | JAK2 (Janus kinase 2) (eg, myeloproliferative disorder) gene analysis, p.Val617Phe (V617F) variant | Clinical Review by Code List PBCWA, Pg 459 Original policy |
| 81271 | HTT (huntingtin) (eg, Huntington disease) gene analysis; evaluation to detect abnormal (eg, expanded) alleles | Clinical Review by Code List PBCWA, Pg 459 Original policy |
| 81272 | KIT (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog) (eg, gastrointestinal stromal tumor [GIST], acute myeloid leukemia, melanoma), gene analysis, targeted sequence analysis (eg, exons 8, 11, 13, 17, 18) | Clinical Review by Code List PBCWA, Pg 459 Original policy |
| 81273 | KIT (v-kit Hardy-Zuckerman 4 feline sarcoma viral oncogene homolog) (eg, mastocytosis), gene analysis, D816 variant(s) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 459 Original policy |