Premera Blue Cross of Washington prior authorization, page 26
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 |
|---|---|---|
| 81332 | SERPINA1 (serpin peptidase inhibitor, clade A, alpha-1 antiproteinase, antitrypsin, member 1) (eg, alpha-1-antitrypsin deficiency), gene analysis, common variants (eg, *S and *Z) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 471 Original policy |
| 81333 | TGFBI (transforming growth factor beta- induced) (eg, corneal dystrophy) gene analysis, common variants (eg, R124H, R124C, R124L, R555W, R555Q) | Clinical Review by Code List PBCWA, Pg 472 Original policy |
| 81334 | RUNX1 (runt related transcription factor 1) (eg, acute myeloid leukemia, familial platelet disorder with associated myeloid malignancy), gene analysis, targeted sequence analysis (eg, exons 3-8) | Clinical Review by Code List PBCWA, Pg 472 Original policy |
| 81335 | TPMT (thiopurine S-methyltransferase) (eg, drug metabolism), gene analysis, common variants (eg, *2, *3) | Clinical Review by Code List PBCWA, Pg 472 Original policy |
| 81336 | SMN1 (survival of motor neuron 1, telomeric) (eg, spinal muscular atrophy) gene analysis; full gene sequence | Clinical Review by Code List PBCWA, Pg 472 Original policy |
| 81337 | SMN1 (survival of motor neuron 1, telomeric) (eg, spinal muscular atrophy) gene analysis; known familial sequence variant(s) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 472 Original policy |
| 81338 | MPL (MPL proto-oncogene, thrombopoietin receptor) (eg, myeloproliferative disorder) gene analysis; common variants (eg, W515A, W515K, W515L, W515R) | Clinical Review by Code List PBCWA, Pg 473 Original policy |
| 81339 | MPL (MPL proto-oncogene, thrombopoietin receptor) (eg, myeloproliferative disorder) gene analysis; sequence analysis, exon 10 | Clinical Review by Code List PBCWA, Pg 473 Original policy |
| 81340 | TRB@ (T cell antigen receptor, beta) (eg, leukemia and lymphoma), gene rearrangement analysis to detect abnormal clonal population(s); using amplification methodology (eg, polymerase chain reaction) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 473 Original policy |
| 81341 | TRB@ (T cell antigen receptor, beta) (eg, leukemia and lymphoma), gene rearrangement analysis to detect abnormal clonal population(s); using direct probe methodology (eg, Southern blot) | Clinical Review by Code List PBCWA, Pg 474 Original policy |
| 81342 | TRG@ (T cell antigen receptor, gamma) (eg, leukemia and lymphoma), gene rearrangement analysis, evaluation to detect abnormal clonal population(s) | Clinical Review by Code List PBCWA, Pg 474 Original policy |
| 81343 | PPP2R2B (protein phosphatase 2 regulatory subunit Bbeta) (eg, spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (eg, expanded) alleles | Clinical Review by Code List PBCWA, Pg 474 Original policy |
| 81344 | TBP (TATA box binding protein) (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 474 Original policy |
| 81345 | TERT (telomerase reverse transcriptase) (eg, thyroid carcinoma, glioblastoma multiforme) gene analysis, targeted sequence analysis (eg, promoter region) | Clinical Review by Code List PBCWA, Pg 475 Original policy |
| 81346 | TYMS (thymidylate synthetase) (eg, 5- fluorouracil/5-FU drug metabolism), gene analysis, common variant(s) (eg, tandem repeat variant) | Clinical Review by Code List PBCWA, Pg 475 Original policy |
| 81347 | SF3B1 (splicing factor [3b] subunit B1) (eg, myelodysplastic syndrome/acute myeloid leukemia) gene analysis, common variants (eg, A672T, E622D, L833F, R625C, R625L) | Clinical Review by Code List PBCWA, Pg 475 Original policy |
| 81348 | SRSF2 (serine and arginine-rich splicing factor 2) (eg, myelodysplastic syndrome, acute myeloid leukemia) gene analysis, common variants (eg, P95H, P95L) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 475 Original policy |
| 81349 | Cytogenomic (genome-wide) analysis for constitutional chromosomal abnormalities; interrogation of genomic regions for copy number and loss-of-heterozygosity variants, low-pass sequencing analysis | Clinical Review by Code List PBCWA, Pg 476 Original policy |
| 81350 | UGT1A1 (UDP glucuronosyltransferase 1 family, polypeptide A1) (eg, drug metabolism, hereditary unconjugated hyperbilirubinemia [gilbert syndrome]) gene analysis, common variants (eg, *28, *36, *37) | Clinical Review by Code List PBCWA, Pg 476 Original policy |
| 81351 | TP53 (tumor protein 53) (eg, Li-Fraumeni syndrome) gene analysis; full gene sequence | Clinical Review by Code List PBCWA, Pg 476 Original policy |
| 81352 | TP53 (tumor protein 53) (eg, Li-Fraumeni syndrome) gene analysis; targeted sequence analysis (eg, 4 oncology) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 476 Original policy |
| 81353 | TP53 (tumor protein 53) (eg, Li-Fraumeni syndrome) gene analysis; known familial variant | Clinical Review by Code List PBCWA, Pg 477 Original policy |
| 81354 | Cytogenomic (genome-wide) analysis for constitutional chromosomal abnormalities; interrogation of structural and copy number variants, optical genome mapping (OGM) | Clinical Review by Code List PBCWA, Pg 477 Original policy |
| 81355 | VKORC1 (vitamin K epoxide reductase complex, subunit 1) (e.g., warfarin metabolism), gene analysis, common variants (e.g., -1639/3673)* | Clinical Review by Code List PBCWA, Pg 477 Original policy |
| 81357 | U2AF1 (U2 small nuclear RNA auxiliary factor 1) (eg, myelodysplastic syndrome, acute myeloid leukemia) gene analysis, common variants (eg, S34F, S34Y, Q157R, Q157P) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 477 Original policy |
| 81360 | ZRSR2 (zinc finger CCCH-type, RNA binding motif and serine/arginine-rich 2) (eg, myelodysplastic syndrome, acute myeloid leukemia) gene analysis, common variant(s) (eg, E65fs, E122fs, R448fs) | Clinical Review by Code List PBCWA, Pg 478 Original policy |
| 81362 | HBB (hemoglobin, subunit beta) (eg, sickle cell anemia, beta thalassemia, hemoglobinopathy); known familial variant(s) | Clinical Review by Code List PBCWA, Pg 478 Original policy |
| 81363 | HBB (hemoglobin, subunit beta) (eg, sickle cell anemia, beta thalassemia, hemoglobinopathy); duplication/deletion variant(s) | Clinical Review by Code List PBCWA, Pg 478 Original policy |
| 81364 | HBB (hemoglobin, subunit beta) (eg, sickle cell anemia, beta thalassemia, hemoglobinopathy); full gene sequence | Clinical Review by Code List PBCWA, Pg 478 Original policy |
| 81400 | Molecular pathology procedure, Level 1(eg, identification of single germline variant [eg, SNP] by techniques such as restriction enzyme digestion or melt curve analysis) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 478 Original policy |
| 81401 | Molecular pathology procedure, Level 2 (eg, 2-10 SNPs, 1 methylated variant, or 1 somatic variant [typically using nonsequencing target variant analysis], or detection of a dynamic mutation disorder/triplet repeat | Clinical Review by Code List PBCWA, Pg 479 Original policy |
| 81402 | Molecular pathology procedure, Level 3 (eg, >10 SNPs, 2-10 methylated variants, or 2-10 somatic variants [typically using non-sequencing target variant analysis], immunoglobulin and T-cell receptor gene rearrangements, duplication/deletion variants of 1 exon, loss of heterozygosity [LOH], uniparental disomy [UPD]) | Clinical Review by Code List PBCWA, Pg 479 Original policy |
| 81403 | Molecular pathology procedure, Level 4 (eg, analysis of single exon by DNA sequence analysis, analysis of >10 amplicons using multiplex PCR in 2 or more independent reactions, mutation scanning or duplication/deletion variants of 2-5 exons) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 479 Original policy |
| 81404 | Molecular pathology procedure, Level 5 (eg, analysis of 2-5 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of 6-10 exons, or characterization of a dynamic mutation disorder/triplet repeat by Southern blot analysis | Clinical Review by Code List PBCWA, Pg 480 Original policy |
| 81405 | Molecular pathology procedure, Level 6 (eg, analysis of 6-10 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of 11-25 exons) | Clinical Review by Code List PBCWA, Pg 480 Original policy |
| 81406 | Molecular pathology procedure, Level 7 (eg, analysis of 11-25 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of 26-50 exons, cytogenomic array analysis for neoplasia) | Clinical Review by Code List PBCWA, Pg 480 Original policy |
| 81407 | Molecular pathology procedure, Level 8 (eg, analysis of 26-50 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of >50 exons, sequence analysis of multiple genes on one platform) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 480 Original policy |
| 81408 | Molecular pathology procedure, Level 9 (eg, analysis of >50 exons in a single gene by DNA sequence analysis) | Clinical Review by Code List PBCWA, Pg 481 Original policy |
| 81410 | Aortic dysfunction or dilation (eg, Marfan syndrome, Loeys Dietz syndrome, Ehler Danlos syndrome type IV, arterial tortuosity syndrome); genomic sequence analysis panel, must include sequencing of at least 9 genes, including FBN1, TGFBR1, TGFBR2, COL3A1, MYH11, ACTA2, SLC2A10, SMAD3, and MYLK | Clinical Review by Code List PBCWA, Pg 481 Original policy |
| 81411 | Aortic dysfunction or dilation (eg, Marfan syndrome, Loeys Dietz syndrome, Ehler Danlos syndrome type IV, arterial tortuosity syndrome); duplication/deletion analysis panel, must include analyses for TGFBR1, TGFBR2, MYH11, and COL3A1 These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 481 Original policy |
| 81412 | Ashkenazi Jewish associated disorders (eg, Bloom syndrome, Canavan disease, cystic fibrosis, familial dysautonomia, Fanconi anemia group C, Gaucher disease, Tay-Sachs disease), genomic sequence analysis panel, must include sequencing of at least 9 genes, including ASPA, BLM, CFTR, FANCC, GBA, HEXA, IKBKAP, MCOLN1, and SMPD1 | Clinical Review by Code List PBCWA, Pg 482 Original policy |
| 81413 | Cardiac ion channelopathies (eg, Brugada syndrome, long QT syndrome, short QT syndrome, catecholaminergic polymorphic ventricular tachycardia); genomic sequence analysis panel, must include sequencing of at least 10 genes, including ANK2, CASQ2, CAV3, KCNE1, KCNE2, KCNH2, KCNJ2, KCNQ1, RYR2, and SCN5A | Clinical Review by Code List PBCWA, Pg 482 Original policy |
| 81414 | Cardiac ion channelopathies (eg, Brugada syndrome, long QT syndrome, short QT syndrome, catecholaminergic polymorphic ventricular tachycardia); duplication/deletion gene analysis panel, must include analysis of at least 2 genes, including KCNH2 and KCNQ1 | Clinical Review by Code List PBCWA, Pg 482 Original policy |
| 81415 | Exome (eg, unexplained constitutional or heritable disorder or syndrome); sequence analysis These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 482 Original policy |
| 81416 | Exome (eg, unexplained constitutional or heritable disorder or syndrome); sequence analysis, each comparator exome (eg, parents, siblings) (List separately in addition to code for primary procedure) | Clinical Review by Code List PBCWA, Pg 483 Original policy |
| 81417 | Exome (eg, unexplained constitutional or heritable disorder or syndrome); re- evaluation of previously obtained exome sequence (eg, updated knowledge or unrelated condition/syndrome) | Clinical Review by Code List PBCWA, Pg 483 Original policy |
| 81418 | Drug metabolism (eg, pharmacogenomics) genomic sequence analysis panel, must include testing of at least 6 genes, including CYP2C19, CYP2D6, and CYP2D6 duplication/deletion analysis | Clinical Review by Code List PBCWA, Pg 483 Original policy |
| 81419 | Epilepsy genomic sequence analysis panel, must include analyses for ALDH7A1, CACNA1A, CDKL5, CHD2, GABRG2, GRIN2A, KCNQ2, MECP2, PCDH19, POLG, PRRT2, SCN1A, SCN1B, SCN2A, SCN8A, SLC2A1, SLC9A6, STXBP1, SYNGAP1, TCF4, TPP1, TSC1, TSC2, and ZEB2 | Clinical Review by Code List PBCWA, Pg 483 Original policy |
| 81422 | Fetal chromosomal microdeletion(s) genomic sequence analysis (eg, DiGeorge syndrome, Cri-du-chat syndrome), circulating cell-free fetal DNA in maternal blood These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 483 Original policy |
| 81425 | Genome (eg, unexplained constitutional or heritable disorder or syndrome); sequence analysis | Clinical Review by Code List PBCWA, Pg 484 Original policy |