Premera Blue Cross of Washington prior authorization, page 27
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 |
|---|---|---|
| 81426 | Genome (eg, unexplained constitutional or heritable disorder or syndrome); sequence analysis, each comparator genome (eg, parents, siblings) (List separately in addition to code for primary procedure) | Clinical Review by Code List PBCWA, Pg 484 Original policy |
| 81427 | Genome (eg, unexplained constitutional or heritable disorder or syndrome); re- evaluation of previously obtained genome sequence (eg, updated knowledge or unrelated condition/syndrome) | Clinical Review by Code List PBCWA, Pg 484 Original policy |
| 81430 | Hearing loss (eg, nonsyndromic hearing loss, Usher syndrome, Pendred syndrome); genomic sequence analysis panel, must include sequencing of at least 60 genes, including CDH23, CLRN1, GJB2, GPR98, MTRNR1, MYO7A, MYO15A, PCDH15, OTOF, SLC26A4, TMC1, TMPRSS3, USH1C, USH1G, USH2A, and WFS1 | Clinical Review by Code List PBCWA, Pg 484 Original policy |
| 81431 | Hearing loss (eg, nonsyndromic hearing loss, Usher syndrome, Pendred syndrome); duplication/deletion analysis panel, must include copy number analyses for STRC and DFNB1 deletions in GJB2 and GJB6 genes These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 484 Original policy |
| 81432 | Hereditary breast cancer-related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer); genomic sequence analysis panel, must include sequencing of at least 14 genes, including ATM, BRCA1, BRCA2, BRIP1, CDH1, MLH1, MSH2, MSH6, NBN, PALB2, PTEN, RAD51C, STK11, and TP53 | Clinical Review by Code List PBCWA, Pg 485 Original policy |
| 81434 | Hereditary retinal disorders (eg, retinitis pigmentosa, Leber congenital amaurosis, cone-rod dystrophy), genomic sequence analysis panel, must include sequencing of at least 15 genes, including ABCA4, CNGA1, CRB1, EYS, PDE6A, PDE6B, PRPF31, PRPH2, RDH12, RHO, RP1, RP2, RPE65, RPGR, and USH2A | Clinical Review by Code List PBCWA, Pg 485 Original policy |
| 81435 | Hereditary colon cancer syndromes (eg, Lynch syndrome, familial adenomatosis polyposis); genomic sequence analysis panel, must include analysis of at least 7 genes, including APC, CHEK2, MLH1, MSH2, MSH6, MUTYH, and PMS2 These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 485 Original policy |
| 81437 | Hereditary neuroendocrine tumor disorders (eg, medullary thyroid carcinoma, parathyroid carcinoma, malignant pheochromocytoma or paraganglioma); genomic sequence analysis panel, must include sequencing of at least 6 genes, including MAX, SDHB, SDHC, SDHD, TMEM127, and VHL | Clinical Review by Code List PBCWA, Pg 486 Original policy |
| 81439 | Inherited cardiomyopathy (eg, hypertrophic cardiomyopathy, dilated cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy) genomic sequence analysis panel, must include sequencing of at least 5 genes, including DSG2, MYBPC3, MYH7, PKP2, and TTN | Clinical Review by Code List PBCWA, Pg 486 Original policy |
| 81440 | Nuclear encoded mitochondrial genes (eg, neurologic or myopathic phenotypes), genomic sequence panel, must include analysis of at least 100 genes, including BCS1L, C10orf2, COQ2, COX10, DGUOK, MPV17, OPA1, PDSS2, POLG, POLG2, RRM2B, SCO1, SCO2, SLC25A4, SUCLA2, SUCLG1, TAZ, TK2, and TYMP These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 486 Original policy |
| 81441 | Inherited bone marrow failure syndromes (IBMFS) (eg, Fanconi anemia, dyskeratosis congenita, Diamond-Blackfan anemia, Shwachman-Diamond syndrome, GATA2 deficiency syndrome, congenital amegakaryocytic thrombocytopenia) sequence analysis panel, must include sequencing of at least 30 genes, including BRCA2.. | Clinical Review by Code List PBCWA, Pg 487 Original policy |
| 81442 | Noonan spectrum disorders (eg, Noonan syndrome, cardio-facio-cutaneous syndrome, Costello syndrome, LEOPARD syndrome, Noonan-like syndrome), genomic sequence analysis panel, must include sequencing of at least 12 genes, including BRAF, CBL, HRAS, KRAS, MAP2K1, MAP2K2, NRAS, PTPN11, RAF1, RIT1, SHOC2, and SOS1 These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 487 Original policy |
| 81443 | Genetic testing for severe inherited conditions (eg, cystic fibrosis, Ashkenazi Jewish-associated disorders [eg, Bloom syndrome, Canavan disease, Fanconi anemia type C, mucolipidosis type VI, Gaucher disease, Tay-Sachs disease], beta hemoglobinopathies, phenylketonuria, galactosemia), genomic sequence analysis panel, must include sequencing of at least 15 genes (eg, ACADM, ARSA, ASPA, ATP7B, BCKDHA, BCKDHB, BLM, CFTR, DHCR7, FANCC, G6PC, GAA, GALT, GBA, GBE1, HBB, HEXA, IKBKAP, MCOLN1, PAH) | Clinical Review by Code List PBCWA, Pg 488 Original policy |
| 81445 | Solid organ neoplasm, genomic sequence analysis panel, 5-50 genes (eg, ALK, BRAF, CDKN2A, EGFR, ERBB2, KIT, KRAS, MET, NRAS, PDGFRA, PDGFRB, PGR, PIK3CA, PTEN, RET), interrogation for sequence variants and copy number variants or rearrangements, if performed; DNA analysis or combined DNA and RNA analysis | Clinical Review by Code List PBCWA, Pg 488 Original policy |
| 81448 | Hereditary peripheral neuropathies (eg, Charcot-Marie-Tooth, spastic paraplegia), genomic sequence analysis panel, must include sequencing of at least 5 peripheral neuropathy-related genes (eg, BSCL2, GJB1, MFN2, MPZ, REEP1, SPAST, SPG11, SPTLC1) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 488 Original policy |
| 81449 | Solid organ neoplasm, genomic sequence analysis panel, 5-50 genes (eg, ALK, BRAF, CDKN2A, EGFR, ERBB2, KIT, KRAS, MET, NRAS, PDGFRA, PDGFRB, PGR, PIK3CA, PTEN, RET), interrogation for sequence variants and copy number variants or rearrangements, if performed; RNA analysis | Clinical Review by Code List PBCWA, Pg 489 Original policy |
| 81450 | Hematolymphoid neoplasm or disorder, genomic sequence analysis panel, 5-50 genes (eg, BRAF, CEBPA, DNMT3A, EZH2, FLT3, IDH1, IDH2, JAK2, KIT, KRAS, MLL, NOTCH1, NPM1, NRAS), interrogation for sequence variants, and copy number variants or rearrangements, or isoform expression or mRNA expression levels, if performed; DNA analysis or combined DNA and RNA analysis | Clinical Review by Code List PBCWA, Pg 489 Original policy |
| 81451 | Hematolymphoid neoplasm or disorder, genomic sequence analysis panel, 5-50 genes (eg, BRAF, CEBPA, DNMT3A, EZH2, FLT3, IDH1, IDH2, JAK2, KIT, KRAS, MLL, NOTCH1, NPM1, NRAS), interrogation for sequence variants, and copy number variants or rearrangements, or isoform expression or mRNA expression levels, if performed; RNA analysis These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 489 Original policy |
| 81455 | Solid organ or hematolymphoid neoplasm or disorder, 51 or greater genes, genomic sequence analysis panel, interrogation for sequence variants and copy number variants or rearrangements, or isoform expression or mRNA expression levels, if performed; DNA analysis or combined DNA and RNA analysis | Clinical Review by Code List PBCWA, Pg 490 Original policy |
| 81456 | Solid organ or hematolymphoid neoplasm or disorder, 51 or greater genes, genomic sequence analysis panel, interrogation for sequence variants and copy number variants or rearrangements, or isoform expression or mRNA expression levels, if performed; RNA analysis | Clinical Review by Code List PBCWA, Pg 490 Original policy |
| 81457 | Solid organ neoplasm, genomic sequence analysis panel, interrogation for sequence variants, DNA analysis, microsatellite instability | Clinical Review by Code List PBCWA, Pg 490 Original policy |
| 81458 | Solid organ neoplasm, genomic sequence analysis panel, interrogation for sequence variants; DNA analysis, copy number variants and microsatellite instability These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 490 Original policy |
| 81459 | Solid organ neoplasm, genomic sequence analysis panel, interrogation for sequence variants; DNA analysis or combined DNA & RNA analysis, copy number variants, microsatellite instability | Clinical Review by Code List PBCWA, Pg 491 Original policy |
| 81460 | Whole mitochondrial genome (eg, Leigh syndrome, mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes [MELAS], myoclonic epilepsy with ragged-red fibers [MERFF], neuropathy, ataxia, and retinitis pigmentosa [NARP], Leber hereditary optic neuropathy [LHON]), genomic sequence, must include sequence analysis of entire mitochondrial genome with heteroplasmy detection | Clinical Review by Code List PBCWA, Pg 491 Original policy |
| 81462 | Solid organ neoplasm, genomic sequence analysis panel, cell-free nucleic acid, interrogation for sequence variants; DNA analysis or combined DNA & RNA analysis. copy number variants | Clinical Review by Code List PBCWA, Pg 491 Original policy |
| 81463 | Solid organ neoplasm, genomic sequence analysis panel, cell-free nucleic acid, interrogation for sequence variants; DNA analysis, copy number variants & microsatellite instability These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 491 Original policy |
| 81464 | Solid organ neoplasm, genomic sequence analysis panel, cell-free nucleic acid, interrogation for sequence variants; DNA analysis or combined DNA & RNA analysis, copy number variants | Clinical Review by Code List PBCWA, Pg 492 Original policy |
| 81465 | Whole mitochondrial genome large deletion analysis panel (eg, Kearns-Sayre syndrome, chronic progressive external ophthalmoplegia), including heteroplasmy detection, if performed | Clinical Review by Code List PBCWA, Pg 492 Original policy |
| 81470 | X-linked intellectual disability (XLID) (eg, syndromic and non-syndromic XLID); genomic sequence analysis panel, must include sequencing of at least 60 genes, including ARX, ATRX, CDKL5, FGD1, FMR1, HUWE1, IL1RAPL, KDM5C, L1CAM, MECP2, MED12, MID1, OCRL, RPS6KA3, and SLC16A2 | Clinical Review by Code List PBCWA, Pg 492 Original policy |
| 81471 | X-linked intellectual disability (XLID) (eg, syndromic and non-syndromic XLID); duplication/deletion gene analysis, must include analysis of at least 60 genes, including ARX, ATRX, CDKL5, FGD1, FMR1, HUWE1, IL1RAPL, KDM5C, L1CAM, MECP2, MED12, MID1, OCRL, RPS6KA3, and SLC16A2 These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 492 Original policy |
| 81479 | Unlisted molecular pathology procedure | Clinical Review by Code List PBCWA, Pg 493 Original policy |
| 81493 | Coronary artery disease, mRNA, gene expression profiling by real-time RT-PCR of 23 genes, utilizing whole peripheral blood, algorithm reported as a risk score | Clinical Review by Code List PBCWA, Pg 493 Original policy |
| 81504 | Oncology (tissue of origin), microarray gene expression profiling of > 2000 genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as tissue similarity scores | Clinical Review by Code List PBCWA, Pg 494 Original policy |
| 81518 | Oncology (breast), mRNA, gene expression profiling by real-time RT-PCR of 11 genes (7 content and 4 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithms reported as percentage risk for metastatic recurrence and likelihood of benefit from extended endocrine therapy | Clinical Review by Code List PBCWA, Pg 494 Original policy |
| 81519 | Oncology (breast), mRNA, gene expression profiling by real-time RT-PCR of 21 genes, utilizing formalin-fixed paraffin embedded tissue, algorithm reported as recurrence score These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 494 Original policy |
| 81520 | Oncology (breast), mRNA gene expression profiling by hybrid capture of 58 genes (50 content and 8 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a recurrence risk score | Clinical Review by Code List PBCWA, Pg 495 Original policy |
| 81521 | Oncology (breast), mRNA, microarray gene expression profiling of 70 content genes and 465 housekeeping genes, utilizing fresh frozen or formalin-fixed paraffin- embedded tissue, algorithm reported as index related to risk of distant metastasis | Clinical Review by Code List PBCWA, Pg 495 Original policy |
| 81522 | Oncology (breast), MRNA, gene expression profiling by RT-PCR OF 12 genes (8 content and 4 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as recurrence risk score These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 495 Original policy |
| 81523 | Oncology (breast), mRNA, next-generation sequencing gene expression profiling of 70 content genes and 31 housekeeping genes, utilizing formalin-fixed paraffin- embedded tissue, algorithm reported as index related to risk to distant metastasis | Clinical Review by Code List PBCWA, Pg 496 Original policy |
| 81524 | Oncology (central nervous system tumor), DNA methylation analysis of at least 10,000 methylation sites, utilizing DNA extracted from formalin-fixed tumor tissue, algorithm(s) reported as probability of matching a reference tumor family and class, and MGMT (0-6-methyfuanine-DNA methyltransferase) promoter methylation status, if performed | Clinical Review by Code List PBCWA, Pg 496 Original policy |
| 81525 | Oncology (colon), mRNA, gene expression profiling by real-time RT-PCR of 12 genes (7 content and 5 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a recurrence score These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 496 Original policy |
| 81529 | Oncology (cutaneous melanoma), mRNA, gene expression profiling by real-time RT- PCR of 31 genes (28 content and 3 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as recurrence risk, including likelihood of sentinel lymph node metastasis | Clinical Review by Code List PBCWA, Pg 497 Original policy |
| 81540 | Oncology (tumor of unknown origin), mRNA, gene expression profiling by real- time RT-PCR of 92 genes (87 content and 5 housekeeping) to classify tumor into main cancer type and subtype, utilizing formalin- fixed paraffin-embedded tissue, algorithm reported as a probability of a predicted main cancer type and subtype These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 497 Original policy |
| 81541 | Oncology (prostate), mRNA gene expression profiling by real-time RT-PCR of 46 genes (31 content and 15 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a disease-specific mortality risk score | Clinical Review by Code List PBCWA, Pg 498 Original policy |
| 81542 | Oncology (prostate), mRNA, microarray gene expression profiling of 22 content genes, utilizing formalin-fixed paraffin- embedded tissue, algorithm reported as metastasis risk score | Clinical Review by Code List PBCWA, Pg 498 Original policy |
| 81546 | Oncology (thyroid), mRNA, gene expression analysis of 10,196 genes, utilizing fine needle aspirate, algorithm reported as a categorical result (eg, benign or suspicious) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 498 Original policy |
| 81551 | Oncology (prostate), promoter methylation profiling by real-time PCR of 3 genes (GSTP1, APC, RASSF1), utilizing formalin- fixed paraffin-embedded tissue, algorithm reported as a likelihood of prostate cancer detection on repeat biopsy | Clinical Review by Code List PBCWA, Pg 499 Original policy |
| 81552 | Oncology (uveal melanoma), MRNA, gene expression profiling by real-time RT-PCR of 15 genes (12 content and 3 housekeeping), utilizing fine needle aspirate or formalin- fixed paraffin-embedded tissue, algorithm reported as risk of metastasis | Clinical Review by Code List PBCWA, Pg 499 Original policy |
| 81554 | Pulmonary disease (idiopathic pulmonary fibrosis [IPF]), mRNA, gene expression analysis of 190 genes, utilizing transbronchial biopsies, diagnostic algorithm reported as categorical result (eg, positive or negative for high probability of usual interstitial pneumonia [UIP]) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 499 Original policy |
| 81558 | Transplantation medicine (allograft rejection, kidney), mRNA, gene expression profiling by quantitative polymerase chain reaction (qPCR) of 139 genes, utilizing whole blood, algorithm reported as a binary categorization as transplant excellence, which indicates immune quiescence, or not transplant excellence, indicating subclinical rejection | Clinical Review by Code List PBCWA, Pg 500 Original policy |