Premera Blue Cross of Washington prior authorization, page 25
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 |
|---|---|---|
| 81274 | HTT (huntingtin) (eg, Huntington disease) gene analysis; characterization of alleles (eg, expanded size) | Clinical Review by Code List PBCWA, Pg 460 Original policy |
| 81275 | KRAS (Kirsten rat sarcoma viral oncogene homolog) (eg, carcinoma) gene analysis; variants in exon 2 (eg, codons 12 and 13) | Clinical Review by Code List PBCWA, Pg 460 Original policy |
| 81276 | KRAS (Kirsten rat sarcoma viral oncogene homolog) (eg, carcinoma) gene analysis; additional variant(s) (eg, codon 61, codon 146) | Clinical Review by Code List PBCWA, Pg 460 Original policy |
| 81277 | Cytogenomic neoplasia (genome-wide) microarray analysis, interrogation of genomic regions for copy number and loss- of-heterozygosity variants for chromosomal abnormalities These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 460 Original policy |
| 81278 | IGH@/BCL2 (t(14;18)) (eg, follicular lymphoma) translocation analysis, major breakpoint region (MBR) and minor cluster region (mcr) breakpoints, qualitative or quantitative | Clinical Review by Code List PBCWA, Pg 461 Original policy |
| 81279 | JAK2 (Janus kinase 2) (eg, myeloproliferative disorder) targeted sequence analysis (eg, exons 12 and 13) | Clinical Review by Code List PBCWA, Pg 461 Original policy |
| 81283 | IFNL3 (interferon, lambda 3) (eg, drug response), gene analysis, rs12979860 variant | Clinical Review by Code List PBCWA, Pg 461 Original policy |
| 81284 | FXN (frataxin) (eg, Friedreich ataxia) gene analysis; evaluation to detect abnormal (expanded) alleles These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 461 Original policy |
| 81285 | FXN (frataxin) (eg, Friedreich ataxia) gene analysis; characterization of alleles (eg, expanded size) | Clinical Review by Code List PBCWA, Pg 462 Original policy |
| 81286 | FXN (frataxin) (eg, Friedreich ataxia) gene analysis; full gene sequence | Clinical Review by Code List PBCWA, Pg 462 Original policy |
| 81287 | MGMT (o-6-methylguanine-dna methyltransferase) (eg, glioblastoma multiforme) promoter methylation analysis | Clinical Review by Code List PBCWA, Pg 462 Original policy |
| 81289 | FXN (frataxin) (eg, Friedreich ataxia) gene analysis; known familial variant(s) | Clinical Review by Code List PBCWA, Pg 462 Original policy |
| 81290 | MCOLN1 (mucolipin 1) (eg, Mucolipidosis, type IV) gene analysis, common variants (eg, IVS3-2A>G, del6.4kb) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 462 Original policy |
| 81291 | MTHFR (5,10-methylenetetrahydrofolate reductase) (eg, hereditary hypercoagulability) gene analysis, common variants (eg, 677T, 1298C) | Clinical Review by Code List PBCWA, Pg 463 Original policy |
| 81292 | MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (eg, hereditary non- polyposis colorectal cancer, Lynch syndrome) gene analysis; full sequence analysis | Clinical Review by Code List PBCWA, Pg 463 Original policy |
| 81293 | MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (eg, hereditary non- polyposis colorectal cancer, Lynch syndrome) gene analysis; known familial variants | Clinical Review by Code List PBCWA, Pg 463 Original policy |
| 81294 | MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (eg, hereditary non- polyposis colorectal cancer, Lynch syndrome) gene analysis; duplication/deletion variants | Clinical Review by Code List PBCWA, Pg 463 Original policy |
| 81295 | MSH2 (mutS homolog 2, colon cancer, nonpolyposis type 1) (eg, hereditary non- polyposis colorectal cancer, Lynch syndrome) gene analysis; full sequence analysis | Clinical Review by Code List PBCWA, Pg 463 Original policy |
| 81296 | MSH2 (mutS homolog 2, colon cancer, nonpolyposis type 1) (eg, hereditary non- polyposis colorectal cancer, Lynch syndrome) gene analysis; known familial variants These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 463 Original policy |
| 81297 | MSH2 (mutS homolog 2, colon cancer, nonpolyposis type 1) (eg, hereditary non- polyposis colorectal cancer, Lynch syndrome) gene analysis; duplication/deletion variants | Clinical Review by Code List PBCWA, Pg 464 Original policy |
| 81298 | MSH6 (mutS homolog 6 [E. coli]) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; full sequence analysis | Clinical Review by Code List PBCWA, Pg 464 Original policy |
| 81299 | MSH6 (mutS homolog 6 [E. coli]) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; known familial variants | Clinical Review by Code List PBCWA, Pg 464 Original policy |
| 81300 | MSH6 (mutS homolog 6 [E. coli]) (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) gene analysis; duplication/deletion variants | Clinical Review by Code List PBCWA, Pg 464 Original policy |
| 81301 | Microsatellite instability analysis (eg, hereditary non-polyposis colorectal cancer, Lynch syndrome) of markers for mismatch repair deficiency (eg, BAT25, BAT26), includes comparison of neoplastic and normal tissue, if performed These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 464 Original policy |
| 81302 | MECP2 (methyl CpG binding protein 2) (eg, Rett syndrome) gene analysis; full sequence analysis | Clinical Review by Code List PBCWA, Pg 465 Original policy |
| 81303 | MECP2 (methyl CpG binding protein 2) (eg, Rett syndrome) gene analysis; known familial variant | Clinical Review by Code List PBCWA, Pg 465 Original policy |
| 81304 | MECP2 (methyl CpG binding protein 2) (eg, Rett syndrome) gene analysis; duplication/deletion variants | Clinical Review by Code List PBCWA, Pg 465 Original policy |
| 81305 | MYD88 (myeloid differentiation primary response 88) (eg, Waldenstrom's macroglobulinemia, lymphoplasmacytic leukemia) gene analysis, p.Leu265Pro (L265P) variant | Clinical Review by Code List PBCWA, Pg 465 Original policy |
| 81306 | NUDT15 (nudix hydrolase 15) (eg, drug metabolism) gene analysis, common variant(s) (eg, *2, *3, *4, *5, *6) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 465 Original policy |
| 81307 | PALB2 (partner and localizer of BRCA2) (EG, breast and pancreatic cancer) gene analysis; full gene sequence | Clinical Review by Code List PBCWA, Pg 466 Original policy |
| 81308 | PALB2 (partner and localizer of BRCA2) (EG, breast and pancreatic cancer) gene analysis; known familial variant | Clinical Review by Code List PBCWA, Pg 466 Original policy |
| 81309 | PIK3CA (phosphatidylinositol-4, 5- biphosphate 3-kinase, catalytic subunit alpha) (eg, colorectal and breast cancer) gene analysis, targeted sequence analysis (eg, exons 7, 9, 20) | Clinical Review by Code List PBCWA, Pg 466 Original policy |
| 81310 | NPM1 (nucleophosmin) (eg, acute myeloid leukemia) gene analysis, exon 12 variants These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 466 Original policy |
| 81311 | NRAS (neuroblastoma RAS viral [v-ras] oncogene homolog) (eg, colorectal carcinoma), gene analysis, variants in exon 2 (eg, codons 12 and 13) and exon 3 (eg, codon 61) | Clinical Review by Code List PBCWA, Pg 467 Original policy |
| 81312 | PABPN1 (poly[A] binding protein nuclear 1) (eg, oculopharyngeal muscular dystrophy) gene analysis, evaluation to detect abnormal (eg, expanded) alleles | Clinical Review by Code List PBCWA, Pg 467 Original policy |
| 81313 | PCA3/KLK3 (prostate cancer antigen 3 [non-protein coding]/kallikrein-related peptidase 3 [prostate specific antigen]) ratio (eg, prostate cancer) | Clinical Review by Code List PBCWA, Pg 467 Original policy |
| 81314 | PDGFRA (platelet-derived growth factor receptor, alpha polypeptide) (eg, gastrointestinal stromal tumor [GIST]), gene analysis, targeted sequence analysis (eg, exons 12, 18) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 467 Original policy |
| 81315 | PML/RARalpha, (t(15;17)), (promyelocytic leukemia/retinoic acid receptor alpha) (eg, promyelocytic leukemia) translocation analysis; common breakpoints (eg, intron 3 and intron 6), qualitative or quantitative | Clinical Review by Code List PBCWA, Pg 468 Original policy |
| 81316 | PML/RARalpha, (t(15;17)), (promyelocytic leukemia/retinoic acid receptor alpha) (eg, promyelocytic leukemia) translocation analysis; single breakpoint (eg, intron 3, intron 6 or exon 6), qualitative or quantitative | Clinical Review by Code List PBCWA, Pg 468 Original policy |
| 81320 | PLCG2 (phospholipase C gamma 2) (eg, chronic lymphocytic leukemia) gene analysis, common variants (eg, R665W, S707F, L845F) | Clinical Review by Code List PBCWA, Pg 469 Original policy |
| 81321 | PTEN (phosphatase and tensin homolog) (eg, Cowden syndrome, PTEN hamartoma tumor syndrome) gene analysis; full sequence analysis | Clinical Review by Code List PBCWA, Pg 469 Original policy |
| 81322 | PTEN (phosphatase and tensin homolog) (eg, Cowden syndrome, PTEN hamartoma tumor syndrome) gene analysis; known familial variant These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 469 Original policy |
| 81323 | PTEN (phosphatase and tensin homolog) (eg, Cowden syndrome, PTEN hamartoma tumor syndrome) gene analysis; duplication/deletion variant | Clinical Review by Code List PBCWA, Pg 470 Original policy |
| 81324 | PMP22 (peripheral myelin protein 22) (eg, Charcot-Marie-Tooth, hereditary neuropathy with liability to pressure palsies) gene analysis; duplication/deletion analysis | Clinical Review by Code List PBCWA, Pg 470 Original policy |
| 81325 | PMP22 (peripheral myelin protein 22) (eg, Charcot-Marie-Tooth, hereditary neuropathy with liability to pressure palsies) gene analysis; full sequence analysis | Clinical Review by Code List PBCWA, Pg 470 Original policy |
| 81326 | PMP22 (peripheral myelin protein 22) (eg, Charcot-Marie-Tooth, hereditary neuropathy with liability to pressure palsies) gene analysis; known familial variant These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 470 Original policy |
| 81327 | SEPT9 (Septin9) (eg, colorectal cancer) promoter methylation analysis | Clinical Review by Code List PBCWA, Pg 471 Original policy |
| 81328 | SLCO1B1 (solute carrier organic anion transporter family, member 1B1) (eg, adverse drug reaction), gene analysis, common variant(s) (eg, *5) | Clinical Review by Code List PBCWA, Pg 471 Original policy |
| 81330 | SMPD1(sphingomyelin phosphodiesterase 1, acid lysosomal) (eg, Niemann-Pick disease, Type A) gene analysis, common variants (eg, R496L, L302P, fsP330) | Clinical Review by Code List PBCWA, Pg 471 Original policy |
| 81331 | SNRPN/UBE3A (small nuclear ribonucleoprotein polypeptide N and ubiquitin protein ligase E3A) (eg, Prader- Willi syndrome and/or Angelman syndrome), methylation analysis | Clinical Review by Code List PBCWA, Pg 471 Original policy |