Premera Blue Cross of Washington prior authorization, page 4
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 |
|---|---|---|
| 0314U | Oncology (cutaneous melanoma), mRNA gene expression profiling by RT-PCR of 35 genes (32 content and 3 housekeeping), utilizing formalin-fixed paraffin-embedded (FFPE) tissue, algorithm reported as a categorical result (ie, benign, intermediate, malignant) | Clinical Review by Code List PBCWA, Pg 64 Original policy |
| 0315U | Oncology (cutaneous squamous cell carcinoma), mRNA gene expression profiling by RT-PCR of 40 genes (34 content and 6 housekeeping), utilizing formalin-fixed paraffin-embedded (FFPE) tissue, algorithm reported as a categorical risk result (ie, Class 1, Class 2A, Class 2B) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 64 Original policy |
| 0317U | Oncology (lung cancer), four-probe FISH (3q29, 3p22.1, 10q22.3, 10cen) assay, whole blood, predictive algorithm-generated evaluation reported as decreased or increased risk for lung cancer | Clinical Review by Code List PBCWA, Pg 65 Original policy |
| 0318U | Pediatrics (congenital epigenetic disorders), whole genome methylation analysis by microarray for 50 or more genes, blood | Clinical Review by Code List PBCWA, Pg 65 Original policy |
| 0319U | Nephrology (renal transplant), RNA expression by select transcriptome sequencing, using pretransplant peripheral blood, algorithm reported as a risk score for early acute rejection | Clinical Review by Code List PBCWA, Pg 65 Original policy |
| 0320U | Nephrology (renal transplant), RNA expression by select transcriptome sequencing, using posttransplant peripheral blood, algorithm reported as a risk score for acute cellular rejection These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 65 Original policy |
| 0326U | Targeted genomic sequence analysis panel, solid organ neoplasm, cell-free circulating DNA analysis of 83 or more genes, interrogation for sequence variants, gene copy number amplifications, gene rearrangements, microsatellite instability and tumor mutational burden | Clinical Review by Code List PBCWA, Pg 66 Original policy |
| 0327U | Fetal aneuploidy (trisomy 13, 18, and 21), DNA sequence analysis of selected regions using maternal plasma, algorithm reported as a risk score for each trisomy, includes sex reporting, if performed | Clinical Review by Code List PBCWA, Pg 66 Original policy |
| 0329U | Oncology (neoplasia), exome and transcriptome sequence analysis for sequence variants, gene copy number amplifications and deletions, gene rearrangements, microsatellite instability and tumor mutational burden utilizing DNA and RNA from tumor with DNA from normal blood or saliva for subtraction, report of clinically significant mutation(s) with therapy associations These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 66 Original policy |
| 0331U | Oncology (hematolymphoid neoplasia), optical genome mapping for copy number alterations and gene rearrangements utilizing DNA from blood or bone marrow, report of clinically significant alterations | Clinical Review by Code List PBCWA, Pg 67 Original policy |
| 0333U | Oncology (liver), surveillance for hepatocellular carcinoma (HCC) in high-risk patients, analysis of methylation patterns on circulating cell-free DNA (cfDNA) plus measurement of serum of AFP/AFP-L3 and oncoprotein des-gamma-carboxy- prothrombin (DCP), algorithm reported as normal or abnormal result These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 67 Original policy |
| 0334U | Oncology (solid organ), targeted genomic sequence analysis, formalin-fixed paraffin- embedded (FFPE) tumor tissue, DNA analysis, 84 or more genes, interrogation for sequence variants, gene copy number amplifications, gene rearrangements, microsatellite instability and tumor mutational burden | Clinical Review by Code List PBCWA, Pg 68 Original policy |
| 0335U | Rare diseases (constitutional/heritable disorders), whole genome sequence analysis, including small sequence changes, copy number variants, deletions, duplications, mobile element insertions, uniparental disomy (UPD), inversions, aneuploidy, mitochondrial genome sequence analysis with heteroplasmy and large deletions, short tandem repeat (STR) gene expansions, fetal sample, identification and categorization of genetic variants These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 68 Original policy |
| 0336U | Rare diseases (constitutional/heritable disorders), whole genome sequence analysis, including small sequence changes, copy number variants, deletions, duplications, mobile element insertions, uniparental disomy (UPD), inversions, aneuploidy, mitochondrial genome sequence analysis with heteroplasmy and large deletions, short tandem repeat (STR) gene expansions, blood or saliva, identification and categorization of genetic variants, each comparator genome (eg, parent) | Clinical Review by Code List PBCWA, Pg 69 Original policy |
| 0339U | Oncology (prostate), mRNA expression profiling of HOXC6 and DLX1, reverse transcription polymerase chain reaction (RT- PCR), first-void urine following digital rectal examination, algorithm reported as probability of high-grade cancer | Clinical Review by Code List PBCWA, Pg 70 Original policy |
| 0340U | Oncology (pan-cancer), analysis of minimal residual disease (MRD) from plasma, with assays personalized to each patient based on prior next-generation sequencing of the patient’s tumor and germline DNA, reported as absence or presence of MRD, with disease-burden correlation, if appropriate | Clinical Review by Code List PBCWA, Pg 70 Original policy |
| 0341U | Fetal aneuploidy DNA sequencing comparative analysis, fetal DNA from products of conception, reported as normal (euploidy), monosomy, trisomy, or partial deletion/duplication, mosaicism, and segmental aneuploid | Clinical Review by Code List PBCWA, Pg 70 Original policy |
| 0343U | Oncology (prostate), exosome-based analysis of 442 small noncoding RNAs (sncRNAs) by quantitative reverse transcription polymerase chain reaction (RT- qPCR), urine, reported as molecular evidence of no-, low-, intermediate- or high- risk of prostate cancer | Clinical Review by Code List PBCWA, Pg 71 Original policy |
| 0345T | Transcatheter mitral valve repair percutaneous approach via the coronary sinus | Clinical Review by Code List PBCWA, Pg 71 Original policy |
| 0345U | Psychiatry (eg, depression, anxiety, attention deficit hyperactivity disorder [ADHD]), genomic analysis panel, variant analysis of 15 genes, including deletion/duplication analysis of CYP2D6 | Clinical Review by Code List PBCWA, Pg 71 Original policy |
| 0347U | Drug metabolism or processing (multiple conditions), whole blood or buccal specimen, DNA analysis, 16 gene report, with variant analysis and reported phenotypes These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 71 Original policy |
| 0348U | Drug metabolism or processing (multiple conditions), whole blood or buccal specimen, DNA analysis, 25 gene report, with variant analysis and reported phenotypes | Clinical Review by Code List PBCWA, Pg 72 Original policy |
| 0349U | Drug metabolism or processing (multiple conditions), whole blood or buccal specimen, DNA analysis, 27 gene report, with variant analysis, including reported phenotypes and impacted gene-drug interactions | Clinical Review by Code List PBCWA, Pg 72 Original policy |
| 0350U | Drug metabolism or processing (multiple conditions), whole blood or buccal specimen, DNA analysis, 27 gene report, with variant analysis and reported phenotypes | Clinical Review by Code List PBCWA, Pg 72 Original policy |
| 0355U | APOL1 (apolipoprotein L1) (eg, chronic kidney disease), risk variants (G1, G2) | Clinical Review by Code List PBCWA, Pg 72 Original policy |
| 0356U | Oncology (oropharyngeal or anal), evaluation of 17 DNA biomarkers using droplet digital PCR (ddPCR), cell-free DNA, algorithm reported as a prognostic risk score for cancer recurrence | Clinical Review by Code List PBCWA, Pg 72 Original policy |
| 0362U | Oncology (papillary thyroid cancer), gene- expression profiling via targeted hybrid capture-enrichment RNA sequencing of 82 content genes and 10 housekeeping genes, fine needle aspirate or formalin- fixed paraffin embedded (FFPE) tissue, algorithm reported as one of three molecular subtypes | Clinical Review by Code List PBCWA, Pg 73 Original policy |
| 0363U | Oncology (urothelial), mRNA, geneexpression profiling by real-time quantitative PCR of 5 genes (MDK, HOXA13, CDC2 [CDK1], IGFBP5, and CXCR2), utilizing urine, algorithm incorporates age, sex, smoking history, and macrohematuria frequency, reported as a risk score for having urothelial carcinoma These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 73 Original policy |
| 0364U | Oncology (hematolymphoid neoplasm), genomic sequence analysis using multiplex (PCR) and next-generation sequencing with algorithm, quantification of dominant clonal sequence(s), reported as presence or absence of minimal residual disease (MRD) with quantitation of disease burden, when appropriate | Clinical Review by Code List PBCWA, Pg 74 Original policy |
| 0368U | Oncology (colorectal cancer), evaluation for mutations of APC, BRAF, CTNNB1, KRAS, NRAS, PIK3CA, SMAD4, and TP53, and methylation markers (MYO1G, KCNQ5, C9ORF50, FLI1, CLIP4, ZNF132 and TWIST1), multiplex quantitative polymerase chain reaction (qPCR), circulating cell-free DNA (cfDNA), plasma, report of risk score for advanced adenoma or colorectal cancer | Clinical Review by Code List PBCWA, Pg 75 Original policy |
| 0378U | RFC1 (replication factor C subunit 1), repeat expansion variant analysis by traditional and repeat-primed PCR, blood, saliva, or buccal swab These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 76 Original policy |
| 0379U | Targeted genomic sequence analysis panel, solid organ neoplasm, DNA (523 genes) and RNA (55 genes) by next- generation sequencing, interrogation for sequence variants, gene copy number amplifications, gene rearrangements, microsatellite instability, and tumor mutational burden | Clinical Review by Code List PBCWA, Pg 77 Original policy |
| 0388U | Oncology (non-small cell lung cancer), next generation sequencing with identification of single nucleotide variants, copy number variants, insertions and deletions, and structural variants in 37 cancer related genes, plasma, with report of alterations detected These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 77 Original policy |
| 0389U | Pediatric febrile illness (Kawasaki disease [KD]), interferon alphainducible protein 27 (IFI27) and mast cell-expressed membrane protein 1 (MCEMP1), RNA, using reverse transcription polymerase chain reaction (RT- qPCR), blood, reported as a risk score for KD | Clinical Review by Code List PBCWA, Pg 78 Original policy |
| 0391U | Oncology (solid tumor), DNA and RNA by next-generation sequencing, utilizing formalin-fixed paraffin-embedded (FFPE) tissue, 437 genes, interpretive report for single nucleotide variants, splicesite variants, insertions/deletions, copy number alterations, gene fusions, tumor mutational burden, and microsatellite instability, with algorithm quantifying immunotherapy response score | Clinical Review by Code List PBCWA, Pg 78 Original policy |
| 0392U | Drug metabolism (depression, anxiety, attention deficit hyperactivity disorder [ADHD]), gene-drug interactions, variant analysis of 16 genes, including deletion/duplication analysis of CYP2D6, reported as impact of gene-drug interaction for each drug These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 78 Original policy |
| 0400U | Obstetrics (expanded carrier screening), 145 genes by nextgeneration sequencing, fragment analysis and multiplex ligationdependent probe amplification, DNA, reported as carrier positive or negative | Clinical Review by Code List PBCWA, Pg 79 Original policy |
| 0401U | Cardiology (coronary heart disease [CAD]), 9 genes (12 variants), targeted variant genotyping, blood, saliva, or buccal swab, algorithm reported as a genetic risk score for a coronary event These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 79 Original policy |
| 0403U | Oncology (prostate), MRNA, gene expression profiling of 18 genes, first-catch post-digital rectal exam urine, algorithm reported as percentage of detecting prostate cancer | Clinical Review by Code List PBCWA, Pg 80 Original policy |
| 0405U | Oncology (pancreatic), 59 methylation haplotype block markers, next-generation sequencing, plasma, reported as cancer signal detected or not detected | Clinical Review by Code List PBCWA, Pg 80 Original policy |
| 0409U | Oncology (solid tumor), DNA (80 genes) and RNA (36 genes), by next-generation sequencing from plasma, including single nucleotide variants, insertions/deletions, copy number alterations These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 80 Original policy |
| 0410U | Oncology (pancreatic), DNA, whole genome sequencing with 5- hydroxymethylcytosine enrichment, whole blood or plasma, algorithm reported as cancer detected or not detected | Clinical Review by Code List PBCWA, Pg 81 Original policy |
| 0411U | Psychiatry (depression, anxiety, attention deficit hyperactivity disorder), genomic analysis panel, variant analysis of 15 genes, including deletion/duplication analysis of CYP2D6 | Clinical Review by Code List PBCWA, Pg 81 Original policy |
| 0413U | Oncology optical genome mapping for copy number alterations, aneuploidy & balanced/complex structural rearrangements, DNA from blood or bone marrow, RPT of clinically significance alt | Clinical Review by Code List PBCWA, Pg 81 Original policy |
| 0414U | Oncology (lung), augmentative algorithmic analysis of digitized whole slide imaging for 8 genes & KRAS G12C & PD-L1, if performed, formalin-fixed paraffin- embedded tissue report These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 81 Original policy |
| 0417U | Rare diseases whole mitochondrial genome sequence with heteroplasmy detection & deletion analysis, nuclear- encoded mitochondrial gene analysis of 335 nuclear genes, including sequence changes | Clinical Review by Code List PBCWA, Pg 82 Original policy |
| 0419U | Neuropsychiatry (eg depression, anxiety,) genomic sequence analysis panel, variant analysis of 13 genes, saliva or buccal swab, report of each gene phenotype | Clinical Review by Code List PBCWA, Pg 82 Original policy |
| 0420U | Oncology (urothelial), MRNA expression profiling by real-time quantitative PCR of MDK, HOXA13, CDC2, IGFBP5 & CXCR2 in comb w/ droplet digital PCR analysis of single-nucleotide polymorphisms (SNPS) genes TERT and FGFR3, urine, algorithm reported as a risk score for urothelial carcinoma These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 82 Original policy |
| 0422U | Oncology (pan-solid tumor) analysis of DNA biomarker response to anti-cancer therapy using cell-free circulating DNA, biomarker comparison to a previous baseline pre-treatment | Clinical Review by Code List PBCWA, Pg 83 Original policy |
| 0424U | Oncology (prostate), exosome-based analysis of 53 small noncoding RNAs by quantitative reverse transcription polymerase chain reaction urine, reported as no molecular evidence | Clinical Review by Code List PBCWA, Pg 83 Original policy |