Premera Blue Cross of Washington prior authorization, page 3
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 |
|---|---|---|
| 0232U | CSTB (cystatin B) (eg, progressive myoclonic epilepsy type 1A, Unverricht- Lundborg disease), full gene analysis, including small sequence changes in exonic and intronic regions, deletions, duplications, short tandem repeat (STR) expansions, mobile element insertions, and variants in non-uniquely mappable regions | Clinical Review by Code List PBCWA, Pg 48 Original policy |
| 0233U | FXN (frataxin) (eg, Friedreich ataxia), gene analysis, including small sequence changes in exonic and intronic regions, deletions, duplications, short tandem repeat (STR) expansions, mobile element insertions, and variants in non-uniquely mappable regions These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 48 Original policy |
| 0234U | MECP2 (methyl CpG binding protein 2) (eg, Rett syndrome), full gene analysis, including small sequence changes in exonic and intronic regions, deletions, duplications, mobile element insertions, and variants in non-uniquely mappable regions | Clinical Review by Code List PBCWA, Pg 49 Original policy |
| 0235U | PTEN (phosphatase and tensin homolog) (eg, Cowden syndrome, PTEN hamartoma tumor syndrome), full gene analysis, including small sequence changes in exonic and intronic regions, deletions, duplications, mobile element insertions, and variants in non-uniquely mappable regions | Clinical Review by Code List PBCWA, Pg 49 Original policy |
| 0236U | SMN1 (survival of motor neuron 1, telomeric) and SMN2 (survival of motor neuron 2, centromeric) (eg, spinal muscular atrophy) full gene analysis, including small sequence changes in exonic and intronic regions, duplications and deletions, and mobile element insertions These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 49 Original policy |
| 0237U | Cardiac ion channelopathies (eg, Brugada syndrome, long QT syndrome, short QT syndrome, catecholaminergic polymorphic ventricular tachycardia), genomic sequence analysis panel including ANK2, CASQ2, CAV3, KCNE1, KCNE2, KCNH2, KCNJ2, KCNQ1, RYR2, and SCN5A, including small sequence changes in exonic and intronic regions, deletions, duplications, mobile element insertions, and variants in non-uniquely mappable regions | Clinical Review by Code List PBCWA, Pg 50 Original policy |
| 0238T | Transluminal peripheral atherectomy, open or percutaneous, including radiological supervision and interpretation; iliac artery, each vessel | Clinical Review by Code List PBCWA, Pg 50 Original policy |
| 0238U | Oncology (Lynch syndrome), genomic DNA sequence analysis of MLH1, MSH2, MSH6, PMS2, and EPCAM, including small sequence changes in exonic and intronic regions, deletions, duplications, mobile element insertions, and variants in non- uniquely mappable regions These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 50 Original policy |
| 0239U | Targeted genomic sequence analysis panel, solid organ neoplasm, cell-free DNA, analysis of 311 or more genes, interrogation for sequence variants, including substitutions, insertions, deletions, select rearrangements, and copy number variations | Clinical Review by Code List PBCWA, Pg 51 Original policy |
| 0242U | Targeted genomic seq analysis panel, solid organ neoplasm, cell-free circulating DNA analysis of 55-74 genes, inerrogation for seq variants, gene copy number amplifications | Clinical Review by Code List PBCWA, Pg 51 Original policy |
| 0244U | Oncology DNA, comprehensive genomic profiling, 257 genes, interrogation for single- nucleotide variants, insertions/deletions, copy number alterations, gene rearrangements | Clinical Review by Code List PBCWA, Pg 52 Original policy |
| 0245U | Oncology (thyroid) mutation analysis of 10 genes & 37 rna fusions & expression of 4 mrna markers using next-generation sequencing, fine needle aspirate, report incl associated | Clinical Review by Code List PBCWA, Pg 52 Original policy |
| 0250U | Oncology (solid organ neoplasm), targeted genomic sequence DNA analysis of 505 genes, interrogation for somatic alterations (SNVs [single nucleotide variant], small insertions and deletions, one amplification, and four translocations), microsatellite instability and tumor-mutation burden | Clinical Review by Code List PBCWA, Pg 53 Original policy |
| 0252U | Fetal aneuploidy short tandem-repeat comparative analysis, fetal DNA from products of conception, reported as normal (euploidy), monosomy, trisomy, or partial deletion/duplications, mosaicism, and segmental aneuploidy | Clinical Review by Code List PBCWA, Pg 53 Original policy |
| 0253U | Reproductive medicine (endometrial receptivity analysis), RNA gene expression profile, 238 genes by next-generation sequencing, endometrial tissue, predictive algorithm reported as endometrial window of implantation (eg, pre-receptive, receptive, post-receptive) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 53 Original policy |
| 0254U | Reproductive medicine (preimplantation genetic assessment), analysis of 24 chromosomes using embryonic DNA genomic sequence analysis for aneuploidy, and a mitochondrial DNA score in euploid embryos, results reported as normal (euploidy), monosomy, trisomy, or partial deletion/duplications, mosaicism, and segmental aneuploidy, per embryo tested | Clinical Review by Code List PBCWA, Pg 54 Original policy |
| 0258U | Autoimmune (psoriasis), mRNA, next- generation sequencing, gene expression profiling of 50-100 genes, skin-surface collection using adhesive patch, algorithm reported as likelihood of response to psoriasis biologics | Clinical Review by Code List PBCWA, Pg 54 Original policy |
| 0260U | Rare diseases (constitutional/heritable disorders), identification of copy number variations, inversions, insertions, translocations, and other structural variants by optical genome mapping | Clinical Review by Code List PBCWA, Pg 54 Original policy |
| 0262U | Oncology (solid tumor), gene expression profiling by real-time RT-PCR of 7 gene pathways (ER, AR, PI3K, MAPK, HH, TGFB, Notch), formalin-fixed paraffin- embedded (FFPE), algorithm reported as gene pathway activity score These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 54 Original policy |
| 0264U | Rare diseases (constitutional/heritable disorders), identification of copy number variations, inversions, insertions, translocations, and other structural variants by optical genome mapping | Clinical Review by Code List PBCWA, Pg 55 Original policy |
| 0265U | Rare constitutional and other heritable disorders, whole genome and mitochondrial DNA sequence analysis, blood, frozen and formalin-fixed paraffin-embedded (FFPE) tissue, saliva, buccal swabs or cell lines, identification of single nucleotide and copy number variants These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 55 Original policy |
| 0266U | Unexplained constitutional or other heritable disorders or syndromes, tissue- specific gene expression by whole- transcriptome and next-generation sequencing, blood, formalin-fixed paraffin- embedded (FFPE) tissue or fresh frozen tissue, reported as presence or absence of splicing or expression changes | Clinical Review by Code List PBCWA, Pg 56 Original policy |
| 0267U | Rare constitutional and other heritable disorders, identification of copy number variations, inversions, insertions, translocations, and other structural variants by optical genome mapping and whole genome sequencing | Clinical Review by Code List PBCWA, Pg 56 Original policy |
| 0268U | Hematology (atypical hemolytic uremic syndrome [aHUS]), genomic sequence analysis of 15 genes, blood, buccal swab, or amniotic fluid | Clinical Review by Code List PBCWA, Pg 56 Original policy |
| 0269U | Hematology (autosomal dominant congenital thrombocytopenia), genomic sequence analysis of 22 genes, blood, buccal swab, or amniotic fluid | Clinical Review by Code List PBCWA, Pg 56 Original policy |
| 0270U | Hematology (congenital coagulation disorders), genomic sequence analysis of 20 genes, blood, buccal swab, or amniotic fluid These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 56 Original policy |
| 0271U | Hematology (congenital neutropenia), genomic sequence analysis of 24 genes, blood, buccal swab, or amniotic fluid | Clinical Review by Code List PBCWA, Pg 57 Original policy |
| 0272U | Hematology (genetic bleeding disorders), genomic sequence analysis of 60 genes and duplication/deletion of plau, blood, buccal swab, or amniotic fluid, comprehensive | Clinical Review by Code List PBCWA, Pg 57 Original policy |
| 0273U | Hematology (genetic hyperfibrinolysis, delayed bleeding), genomic sequence analysis of 8 genes (F13A1, F13B, FGA, FGB, FGG, SERPINA1, SERPINE1, SERPINF2, PLAU), blood, buccal swab, or amniotic fluid | Clinical Review by Code List PBCWA, Pg 57 Original policy |
| 0274U | Hematology (genetic platelet disorders), genomic sequence analysis of 62 genes and duplication/deletion of plau, blood, buccal swab, or amniotic fluid These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 57 Original policy |
| 0276U | Hematology (inherited thrombocytopenia), genomic sequence analysis of 42 genes, blood, buccal swab, or amniotic fluid | Clinical Review by Code List PBCWA, Pg 58 Original policy |
| 0277U | Hematology (genetic platelet function disorder), genomic sequence analysis of 40 genes and duplication/deletion of plau, blood, buccal swab, or amniotic fluid | Clinical Review by Code List PBCWA, Pg 58 Original policy |
| 0278U | Hematology (genetic thrombosis), genomic sequence analysis of 14 genes, blood, buccal swab, or amniotic fluid | Clinical Review by Code List PBCWA, Pg 58 Original policy |
| 0285U | Oncology, disease progression and response monitoring to radiation, chemotherapy, or other systematic cancer treatments, cell-free DNA, quantitative branched chain DNA amplification, plasma reported in as NG/ML a radiation toxicity score These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 58 Original policy |
| 0286U | CEP72 (centrosomal protein, 72-KDa), NUDT15 (nudix hydrolase 15) and TPMT (thiopurine S-methyltransferase) (eg, drug metabolism) gene analysis, common variants | Clinical Review by Code List PBCWA, Pg 59 Original policy |
| 0287U | Oncology (thyroid), DNA and mRNA, next- generation sequencing analysis of 112 genes, fine needle aspirate or formalin- fixed paraffin-embedded (FFPE) tissue, algorithmic prediction of cancer recurrence, reported as a categorical risk result (low, intermediate, high) | Clinical Review by Code List PBCWA, Pg 59 Original policy |
| 0288U | Oncology (lung), mRNA, quantitative PCR analysis of 11 genes (BAG1, BRCA1, CDC6, CDK2AP1, ERBB3, FUT3, IL11, LCK, RND3, SH3BGR, WNT3A) and 3 reference genes (ESD, TBP, YAP1), formalin-fixed paraffin-embedded (FFPE) tumor tissue, algorithmic interpretation reported as a recurrence risk score | Clinical Review by Code List PBCWA, Pg 59 Original policy |
| 0289U | Neurology (Alzheimer disease), mRNA, gene expression profiling by RNA sequencing of 24 genes, whole blood, algorithm reported as predictive risk score These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 59 Original policy |
| 0290U | Pain management, mRNA, gene expression profiling by RNA sequencing of 36 genes, whole blood, algorithm reported as predictive risk score | Clinical Review by Code List PBCWA, Pg 60 Original policy |
| 0291U | Psychiatry (mood disorders), mRNA, gene expression profiling by RNA sequencing of 144 genes, whole blood, algorithm reported as predictive risk score | Clinical Review by Code List PBCWA, Pg 60 Original policy |
| 0292U | Psychiatry (stress disorders), mRNA, gene expression profiling by RNA sequencing of 72 genes, whole blood, algorithm reported as predictive risk score | Clinical Review by Code List PBCWA, Pg 60 Original policy |
| 0293U | Psychiatry (suicidal ideation), mRNA, gene expression profiling by RNA sequencing of 54 genes, whole blood, algorithm reported as predictive risk score | Clinical Review by Code List PBCWA, Pg 60 Original policy |
| 0294U | Longevity and mortality risk, mRNA, gene expression profiling by RNA sequencing of 18 genes, whole blood, algorithm reported as predictive risk score These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 60 Original policy |
| 0296U | Oncology (oral and/or oropharyngeal cancer), gene expression profiling by RNA sequencing of at least 20 molecular features (eg, human and/or microbial mRNA), saliva, algorithm reported as positive or negative for signature associated with malignancy | Clinical Review by Code List PBCWA, Pg 61 Original policy |
| 0297U | Oncology (pan tumor), whole genome sequencing of paired malignant and normal DNA specimens, fresh or formalin-fixed paraffin-embedded (FFPE) tissue, blood or bone marrow, comparative sequence analyses and variant identification These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 61 Original policy |
| 0298U | Oncology (pan tumor), whole transcriptome sequencing of paired malignant and normal RNA specimens, fresh or formalin-fixed paraffin-embedded (FFPE) tissue, blood or bone marrow, comparative sequence analyses and expression level and chimeric transcript identification | Clinical Review by Code List PBCWA, Pg 62 Original policy |
| 0299U | Oncology (pan tumor), whole genome optical genome mapping of paired malignant and normal DNA specimens, fresh frozen tissue, blood, or bone marrow, comparative structural variant identification | Clinical Review by Code List PBCWA, Pg 62 Original policy |
| 0300U | Oncology (pan tumor), whole genome sequencing and optical genome mapping of paired malignant and normal DNA specimens, fresh tissue, blood, or bone marrow, comparative sequence analyses and variant identification These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 62 Original policy |
| 0306U | Oncology (minimal residual disease [MRD]), next-generation targeted sequencing analysis, cell-free DNA, initial (baseline) assessment to determine a patient specific panel for future comparisons to evaluate for MRD | Clinical Review by Code List PBCWA, Pg 63 Original policy |
| 0307U | Oncology (minimal residual disease [MRD]), next-generation targeted sequencing analysis of a patient-specific panel, cell-free DNA, subsequent assessment with comparison to previously analyzed patient specimens to evaluate for MRD | Clinical Review by Code List PBCWA, Pg 63 Original policy |