Premera Blue Cross of Washington prior authorization, page 5
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 |
|---|---|---|
| 0425U | Genome (eg, unexplained constitutional or heritable disorder or syndrome), rapid sequence analysis, each comparator genome (eg parents, siblings) | Clinical Review by Code List PBCWA, Pg 83 Original policy |
| 0426U | Genome (eg, unexplained constitutional or heritable disorder or syndrome), ultra-rapid sequence analysis These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 83 Original policy |
| 0433U | Oncology (prostate), 5 DNA regulatory markers by quantitative PCR, whole blood, algorithm, including prostate-specific antigen, reported as likelihood of cancer | Clinical Review by Code List PBCWA, Pg 84 Original policy |
| 0434U | Drug metabolism (adverse drug reactions and drug response), genomic analysis panel, variant analysis of 25 genes with reported phenotypes | Clinical Review by Code List PBCWA, Pg 84 Original policy |
| 0437U | Psychiatry (anxiety disorders), MRNA, gene expression profiling by RNA sequencing of 15 biomarkers, whole blood, algorithm reported as predictive risk score These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 84 Original policy |
| 0439U | Cardiology (coronary heart disease [CHD]), DNA, analysis of 5 single-nucleotide polymorphisms (SNPs) (rs11716050 [LOC105376934], rs6560711 [WDR37], rs3735222 [SCIN/LOC107986769], rs6820447 [intergenic], and rs9638144 [ESYT2]) and 3 DNA methylation markers (cg00300879 [transcription start site {TSS200} of CNKSR1], cg09552548 [intergenic], and cg14789911 [body of SPATC1L]), qPCR and digital PCR, whole blood, algorithm reported as a 4-tiered risk score for a 3-year risk of symptomatic CHD These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 85 Original policy |
| 0440U | Cardiology (coronary heart disease) DNA analysis of 10 single-nucleotide polymorphisms (rs710987[LINC010019],rs1333048[CDKN2 B-AS1],rs12129789 [KCND3],rs942317 [KTN1-AS1],rs1441433 [PPP3CA],rs2869675 [PREX1],rs4639796 [ZBTB41],rs4376434 [LINC00972],rs12714414 [TMEM18],rs7585056 [TMEM18]) & 6 DNA methylation markers (cg03725309 [SARS1],cg12586707 [CXCL1,cg04988978 [MPO],cg17901584 [DHCR24- DT],cg21161138 [AHRR],cg12655112 [EHD4]),qPCR, digital PCR, whole blood, algorithm reported as detected or not | Clinical Review by Code List PBCWA, Pg 86 Original policy |
| 0444U | Oncology (solid organ neoplasia), targeted genomic sequence analysis panel of 361 genes, interrogation for gene fusions, translocations, or other rearrangements, using DNA from formalin fixed paraffin- embedded (FFPE) tumor tissue, report of clinically significant variant(s) | Clinical Review by Code List PBCWA, Pg 87 Original policy |
| 0449U | Carrier screening for severe inherited conditions (eg, cystic fibrosis, spinal muscular atrophy, beta hemoglobinopathies [including sickle cell disease], alpha thalassemia), regardless of race or self-identified ancestry, genomic sequence analysis panel, must include analysis of 5 genes (CFTR, SMN1, HBB, HBA1, HBA2) | Clinical Review by Code List PBCWA, Pg 88 Original policy |
| 0452U | Oncology (bladder), methylated PENK DNA detection by linear target enrichment- quantitative methylation-specific real-time PCR (LTE-qMSP), urine, reported as likelihood of bladder cancer | Clinical Review by Code List PBCWA, Pg 88 Original policy |
| 0453U | Oncology (colorectal cancer), cell-free DNA (cfDNA), methylation-based quantitative PCR assay (SEPTIN9, IKZF1, BCAT1, Septin9-2, VAV3, BCAN), plasma, reported as presence or absence of circulating tumor DNA (ctDNA) | Clinical Review by Code List PBCWA, Pg 88 Original policy |
| 0454U | 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 88 Original policy |
| 0460U | Oncology, whole blood or buccal, DNA single-nucleotide polymorphism (SNP) genotyping by real-time PCR of 24 genes, with variant analysis and reported phenotypes | Clinical Review by Code List PBCWA, Pg 89 Original policy |
| 0461U | Oncology, pharmacogenomic analysis of single-nucleotide polymorphism (SNP) genotyping by real-time PCR of 24 genes, whole blood or buccal swab, with variant analysis, including impacted gene-drug interactions and reported phenotypes | Clinical Review by Code List PBCWA, Pg 89 Original policy |
| 0465U | Oncology (urothelial carcinoma), DNA, quantitative methylation-specific PCR of 2 genes (ONECUT2, VIM), algorithmic analysis reported as positive or negative | Clinical Review by Code List PBCWA, Pg 90 Original policy |
| 0466U | Cardiology (coronary artery disease [CAD]), DNA, genome-wide association studies (564856 single-nucleotide polymorphisms [SNPs], targeted variant genotyping), patient lifestyle and clinical data, buccal swab, algorithm reported as polygenic risk to acquired heart disease | Clinical Review by Code List PBCWA, Pg 90 Original policy |
| 0467U | Oncology (bladder), DNA, next-generation sequencing (NGS) of 60 genes and whole genome aneuploidy, urine, algorithms reported as minimal residual disease (MRD) status positive or negative and quantitative disease burden These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 90 Original policy |
| 0469U | Rare diseases (constitutional/heritable disorders), whole genome sequence analysis for chromosomal abnormalities, copy number variants, duplications/deletions, inversions, unbalanced translocations, regions of homozygosity (ROH), inheritance pattern that indicate uniparental disomy (UPD), and aneuploidy, fetal sample (amniotic fluid, chorionic villus sample, or products of conception), identification | Clinical Review by Code List PBCWA, Pg 91 Original policy |
| 0471U | Oncology (colorectal cancer), qualitative real-time PCR of 35 variants of KRAS and NRAS genes (exons 2, 3, 4), formalin-fixed paraffin-embedded (FFPE), predictive, identification of detected mutations These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 91 Original policy |
| 0473U | Oncology (solid tumor), next-generation sequencing (NGS) of DNA from formalin- fixed paraffin-embedded (FFPE) tissue with comparative sequence analysis from a matched normal specimen (blood or saliva), 648 genes, interrogation for sequence variants, insertion and deletion alterations, copy number variants, rearrangements, microsatellite instability, and tumor-mutation burden | Clinical Review by Code List PBCWA, Pg 93 Original policy |
| 0474U | Hereditary pan-cancer (eg, hereditary sarcomas, hereditary endocrine tumors, hereditary neuroendocrine tumors, hereditary cutaneous melanoma), genomic sequence analysis panel of 88 genes with 20 duplications/deletions using next- generation sequencing (NGS), Sanger sequencing, blood or saliva, reported as positive or negative for germline variants, each gene | Clinical Review by Code List PBCWA, Pg 93 Original policy |
| 0475U | Hereditary prostate cancer-related disorders, genomic sequence analysis panel using next-generation sequencing (NGS), Sanger sequencing, multiplex ligation-dependent probe amplification (MLPA), and array comparative genomic hybridization (CGH), evaluation of 23 genes and duplications/deletions when indicated, pathologic mutations reported with a genetic risk score for prostate cancer These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 93 Original policy |
| 0476U | Drug metabolism, psychiatry (eg, major depressive disorder, general anxiety disorder, attention deficit hyperactivity disorder [ADHD], schizophrenia), whole blood, buccal swab, and pharmacogenomic genotyping of 14 genes and CYP2D6 copy number variant analysis and reported phenotypes | Clinical Review by Code List PBCWA, Pg 94 Original policy |
| 0477U | Drug metabolism, psychiatry (eg, major depressive disorder, general anxiety disorder, attention deficit hyperactivity disorder [ADHD], schizophrenia), whole blood, buccal swab, and pharmacogenomic genotyping of 14 genes and CYP2D6 copy number variant analysis, including impacted gene-drug interactions and reported phenotypes | Clinical Review by Code List PBCWA, Pg 94 Original policy |
| 0478U | Oncology (non-small cell lung cancer), DNA and RNA, digital PCR analysis of 9 genes (EGFR, KRAS, BRAF, ALK, ROS1, RET, NTRK 1/2/3, ERBB2, and MET) in formalin- fixed paraffin-embedded (FFPE) tissue, interrogation for single-nucleotide variants, insertions/deletions, gene rearrangements, and reported as actionable detected variants for therapy selection | Clinical Review by Code List PBCWA, Pg 94 Original policy |
| 0481U | IDH1 (isocitrate dehydrogenase 1 [NADP+]), IDH2 (isocitrate dehydrogenase 2 [NADP+]), and TERT (telomerase reverse transcriptase) promoter (eg, central nervous system [CNS] tumors), next- generation sequencing (single-nucleotide variants [SNV], deletions, and insertions) | Clinical Review by Code List PBCWA, Pg 95 Original policy |
| 0483T | Transcatheter mitral valve implantation/replacement (TMVI) with prosthetic valve; percutaneous approach, including transseptal puncture, when performed These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 95 Original policy |
| 0484T | Transcatheter mitral valve implantation/replacement (TMVI) with prosthetic valve; transthoracic exposure (eg, thoracotomy, transapical) | Clinical Review by Code List PBCWA, Pg 96 Original policy |
| 0485U | Oncology (solid tumor), cell-free DNA and RNA by next-generation sequencing, interpretative report for germline mutations, clonal hematopoiesis of indeterminate potential, and tumor-derived single- nucleotide variants, small insertions/deletions, copy number alterations, fusions, microsatellite instability, and tumor mutational burden | Clinical Review by Code List PBCWA, Pg 96 Original policy |
| 0486U | Oncology (pan-solid tumor), next- generation sequencing analysis of tumor methylation markers present in cell-free circulating tumor DNA, algorithm reported as quantitative measurement of methylation as a correlate of tumor fraction These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 96 Original policy |
| 0487U | Oncology (solid tumor), cell-free circulating DNA, targeted genomic sequence analysis panel of 84 genes, interrogation for sequence variants, aneuploidy-corrected gene copy number amplifications and losses, gene rearrangements, and microsatellite instability | Clinical Review by Code List PBCWA, Pg 97 Original policy |
| 0488U | Obstetrics (fetal antigen noninvasive prenatal test), cell-free DNA sequence analysis for detection of fetal presence or absence of 1 or more of the Rh, C, c, D, E, Duffy (Fya), or Kell (K) antigen in alloimmunized pregnancies, reported as selected antigen(s) detected or not detected | Clinical Review by Code List PBCWA, Pg 97 Original policy |
| 0489U | Obstetrics (single-gene noninvasive prenatal test), cell-free DNA sequence analysis of 1 or more targets (eg, CFTR, SMN1, HBB, HBA1, HBA2) to identify paternally inherited pathogenic variants, and relative mutation-dosage analysis based on molecular counts to determine fetal inheritance of maternal mutation, algorithm reported as a fetal risk score for the condition (eg, cystic fibrosis, spinal muscular atrophy, beta hemoglobinopathies [including sickle cell disease], alpha thalassemia) | Clinical Review by Code List PBCWA, Pg 98 Original policy |
| 0493U | Transplantation medicine, quantification of donor-derived cell-free DNA (cfDNA) using next-generation sequencing, plasma, reported as percentage of donor-derived cell-free DNA | Clinical Review by Code List PBCWA, Pg 99 Original policy |
| 0494U | Red blood cell antigen (fetal RhD gene analysis), next-generation sequencing of circulating cell-free DNA (cfDNA) of blood in pregnant individuals known to be RhD negative, reported as positive or negative These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 99 Original policy |
| 0496U | Oncology (colorectal), cell-free DNA, 8 genes for mutations, 7 genes for methylation by real-time RT-PCR, and 4 proteins by enzyme-linked immunosorbent assay, blood, reported positive or negative for colorectal cancer or advanced adenoma risk | Clinical Review by Code List PBCWA, Pg 100 Original policy |
| 0497U | Oncology (prostate), mRNA gene- expression profiling by real-time RT-PCR of 6 genes (FOXM1, MCM3, MTUS1, TTC21B, ALAS1, and PPP2CA), utilizing formalin-fixed paraffin-embedded (FFPE) tissue, algorithm reported as a risk score for prostate cancer | Clinical Review by Code List PBCWA, Pg 100 Original policy |
| 0498U | Oncology (colorectal), next-generation sequencing for mutation detection in 43 genes and methylation pattern in 45 genes, blood, and formalin-fixed paraffin- embedded (FFPE) tissue, report of variants and methylation pattern with interpretation These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 100 Original policy |
| 0499U | Oncology (colorectal and lung), DNA from formalin-fixed paraffin-embedded (FFPE) tissue, next-generation sequencing of 8 genes (NRAS, EGFR, CTNNB1, PIK3CA, APC, BRAF, KRAS, and TP53), mutation detection | Clinical Review by Code List PBCWA, Pg 101 Original policy |
| 0500U | Autoinflammatory disease (VEXAS syndrome), DNA, UBA1 gene mutations, targeted variant analysis (M41T, M41V, M41L, c.118-2A>C, c.118-1G>C, c.118- 9_118-2del, S56F, S621C) | Clinical Review by Code List PBCWA, Pg 101 Original policy |
| 0505T | Endovenous femoral-popliteal arterial revascularization, with transcatheter placement of intravascular stent graft(s) and closure by any method, including percutaneous or open vascular access, ultrasound guidance for vascular access when performed, all catheterization(s) and intraprocedural roadmapping and imaging guidance necessary to complete the intervention, all associated radiological supervision and interpretation, when performed, with crossing of the occlusive lesion in an extraluminal fashion | Clinical Review by Code List PBCWA, Pg 102 Original policy |
| 0506U | Gastroenterology (Barrett's esophagus), esophageal cells, DNA methylation analysis by next-generation sequencing of at least 89 differentially methylated genomic regions, algorithm reported as likelihood for Barrett's esophagus | Clinical Review by Code List PBCWA, Pg 102 Original policy |
| 0507U | Oncology (ovarian), DNA, whole-genome sequencing with 5-hydroxymethylcytosine (5hmC) enrichment, using whole blood or plasma, algorithm reported as cancer detected or not detected | Clinical Review by Code List PBCWA, Pg 102 Original policy |
| 0516U | Drug metabolism, whole blood, pharmacogenomic genotyping of 40 genes and CYP2D6 copy number variant analysis, reported as metabolizer status | Clinical Review by Code List PBCWA, Pg 104 Original policy |
| 0523U | Oncology (solid tumor), DNA, qualitative, next-generation sequencing (NGS) of single-nucleotide variants (SNV) and insertion/deletions in 22 genes utilizing formalin-fixed paraffin-embedded tissue, reported as presence or absence of mutation(s), location of mutation(s), nucleotide change, and amino acid change | Clinical Review by Code List PBCWA, Pg 105 Original policy |
| 0524T | Endovenous catheter directed chemical ablation with balloon isolation of incompetent extremity vein, open or percutaneous, including all vascular access, catheter manipulation, diagnostic imaging, imaging guidance and monitoring | Clinical Review by Code List PBCWA, Pg 105 Original policy |
| 0529U | Hematology (venous thromboembolism [VTE]), genome-wide single-nucleotide polymorphism variants, including F2 and F5 gene analysis, and Leiden variant, by microarray analysis, saliva, report as risk score for VTE These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 106 Original policy |
| 0530U | Oncology (pan-solid tumor), ctDNA, utilizing plasma, next-generation sequencing (NGS) of 77 genes, 8 fusions, microsatellite instability, and tumor mutation burden, interpretative report for single-nucleotide variants, copy-number alterations, with therapy association | Clinical Review by Code List PBCWA, Pg 107 Original policy |
| 0532U | Rare diseases (constitutional disease/hereditary disorders), rapid whole genome and mitochondrial DNA sequencing for single-nucleotide variants, insertions/deletions, copy number variations, peripheral blood, buffy coat, saliva, buccal or tissue sample, results reported as positive or negative | Clinical Review by Code List PBCWA, Pg 107 Original policy |
| 0533U | Drug metabolism (adverse drug reactions and drug response), genotyping of 16 genes (ie, ABCG2, CYP2B6, CYP2C9, CYP2C19, CYP2C, CYP2D6, CYP3A5, CYP4F2, DPYD, G6PD, GGCX, NUDT15, SLCO1B1, TPMT, UGT1A1, VKORC1), reported as metabolizer status and transporter function These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 107 Original policy |