Premera Blue Cross of Washington prior authorization, page 6
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 |
|---|---|---|
| 0534U | Oncology (prostate), microRNA, single- nucleotide polymorphisms (SNPs) analysis by RT-PCR of 32 variants, using buccal swab, algorithm reported as a risk score | Clinical Review by Code List PBCWA, Pg 108 Original policy |
| 0536U | Red blood cell antigen (fetal RhD), PCR analysis of exon 4 of RHD gene and housekeeping control gene GAPDH from whole blood in pregnant individuals at 10+ weeks gestation known to be RhD negative, reported as fetal RhD status | Clinical Review by Code List PBCWA, Pg 108 Original policy |
| 0537U | Oncology (colorectal cancer), analysis of cell-free DNA for epigenomic patterns, next- generation sequencing, >2500 differentially methylated regions (DMRs), plasma, algorithm reported as positive or negative | Clinical Review by Code List PBCWA, Pg 108 Original policy |
| 0538U | Oncology (solid tumor), next-generation targeted sequencing analysis, formalin- fixed paraffin-embedded (FFPE) tumor tissue, DNA analysis of 600 genes, interrogation for single-nucleotide variants, insertions/deletions, gene rearrangements, and copy number alterations, microsatellite instability, tumor mutation burden, reported as actionable variant These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 108 Original policy |
| 0539U | Oncology (solid tumor), cell-free circulating tumor DNA (ctDNA), 152 genes, next- generation sequencing, interrogation for single-nucleotide variants, insertions/deletions, gene rearrangements, copy number alterations, and microsatellite instability, using whole-blood samples, mutations with clinical actionability reported as actionable variant | Clinical Review by Code List PBCWA, Pg 109 Original policy |
| 0540U | Transplantation medicine, quantification of donor-derived cell-free DNA using next- generation sequencing analysis of plasma, reported as percentage of donor-derived cell-free DNA to determine probability of rejection | Clinical Review by Code List PBCWA, Pg 109 Original policy |
| 0543U | Oncology (solid tumor), next-generation sequencing of DNA from formalin-fixed paraffin-embedded (FFPE) tissue of 517 genes, interrogation for single-nucleotide variants, multi-nucleotide variants, insertions and deletions from DNA, fusions in 24 genes and splice variants in 1 gene from RNA, and tumor mutation burden | Clinical Review by Code List PBCWA, Pg 110 Original policy |
| 0544T | Transcatheter mitral valve annulus reconstruction, with implantation of adjustable annulus reconstruction device, percutaneous approach including transseptal puncture | Clinical Review by Code List PBCWA, Pg 110 Original policy |
| 0549U | Oncology (urothelial), DNA, quantitative methylated real-time PCR of TRNA-Cys, SIM2, and NKX1-1, using urine, diagnostic algorithm reported as a probability index for bladder cancer and/or upper tract urothelial carcinoma (UTUC) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 110 Original policy |
| 0552U | Reproductive medicine (preimplantation genetic assessment), analysis for known genetic disorders from trophectoderm biopsy, linkage analysis of disease-causing locus, and when possible, targeted mutation analysis for known familial variant, reported as low-risk or high-risk for familial genetic disorder These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 111 Original policy |
| 0553U | Reproductive medicine (preimplantation genetic assessment), analysis of 24 chromosomes using DNA genomic sequence analysis from embryonic trophectoderm for structural rearrangements, aneuploidy, and a mitochondrial DNA score, results reported as normal/balanced (euploidy/balanced), unbalanced structural rearrangement, monosomy, trisomy, segmental aneuploidy, or mosaic, per embryo tested | Clinical Review by Code List PBCWA, Pg 112 Original policy |
| 0554U | Reproductive medicine (preimplantation genetic assessment), analysis of 24 chromosomes using DNA genomic sequence analysis from trophectoderm biopsy for aneuploidy, ploidy, a mitochondrial DNA score, and embryo quality control, results reported as normal (euploidy), monosomy, trisomy, segmental aneuploidy, triploid, haploid, or mosaic, with quality control results reported as contamination detected or inconsistent cohort when applicable, per embryo tested These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 112 Original policy |
| 0555U | Reproductive medicine (preimplantation genetic assessment), analysis of 24 chromosomes using DNA genomic sequence analysis from embryonic trophectoderm for structural rearrangements, aneuploidy, ploidy, a mitochondrial DNA score, and embryo quality control, results reported as normal/balanced (euploidy/balanced), unbalanced structural rearrangement, monosomy, trisomy, segmental aneuploidy, triploid, haploid, or mosaic, with quality control results reported as contamination detected or inconsistent cohort when applicable, per embryo tested | Clinical Review by Code List PBCWA, Pg 113 Original policy |
| 0560U | Oncology (minimal residual disease [MRD]), genomic sequence analysis, cell- free DNA, whole blood and tumor tissue, baseline assessment for design and construction of a personalized variant panel to evaluate current MRD and for comparison to subsequent MRD assessments | Clinical Review by Code List PBCWA, Pg 114 Original policy |
| 0561U | Oncology (minimal residual disease [MRD]), genomic sequence analysis, cell- free DNA, whole blood, subsequent assessment with comparison to initial assessment to evaluate for MRD | Clinical Review by Code List PBCWA, Pg 114 Original policy |
| 0562U | Oncology (solid tumor), targeted genomic sequence analysis, 33 genes, detection of single-nucleotide variants (SNVs), insertions and deletions, copy-number amplifications, and translocations in human genomic circulating cell-free DNA, plasma, reported as presence of actionable variants These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 114 Original policy |
| 0565U | Oncology (hepatocellular carcinoma), next- generation sequencing methylation pattern assay to detect 6626 epigenetic alterations, cell-free DNA, plasma, algorithm reported as cancer signal detected or not detected | Clinical Review by Code List PBCWA, Pg 115 Original policy |
| 0566U | Oncology (lung), qPCR-based analysis of 13 differentially methylated regions (CCDC181, HOXA7, LRRC8A, MARCHF11, MIR129-2, NCOR2, PANTR1, PRKCB, SLC9A3, TBR1_2, TRAP1, VWC2, ZNF781), pleural fluid, algorithm reported as a qualitative result | Clinical Review by Code List PBCWA, Pg 116 Original policy |
| 0567U | Rare diseases (constitutional/heritable disorders), whole-genome sequence analysis combination of short and long reads, for single-nucleotide variants, insertions/deletions and characterized intronic variants, copy-number variants, duplications/deletions, mobile element insertions, runs of homozygosity, aneuploidy, and inversions, mitochondrial DNA sequence and deletions, short tandem repeat genes, methylation status of selected regions, blood, saliva, amniocentesis, chorionic villus sample or tissue, identification and categorization of genetic variants | Clinical Review by Code List PBCWA, Pg 116 Original policy |
| 0569T | Transcatheter tricuspid valve repair, percutaneous approach; initial prosthesis | Clinical Review by Code List PBCWA, Pg 117 Original policy |
| 0569U | Oncology (solid tumor), next-generation sequencing analysis of tumor methylation markers (>20000 differentially methylated regions) present in cell-free circulating tumor DNA (ctDNA), whole blood, algorithm reported as presence or absence of ctDNA with tumor fraction, if appropriate | Clinical Review by Code List PBCWA, Pg 117 Original policy |
| 0570T | Transcatheter tricuspid valve repair, percutaneous approach; each additional prosthesis during same session (List separately in addition to code for primary procedure) | Clinical Review by Code List PBCWA, Pg 117 Original policy |
| 0571T | Insertion or replacement of implantable cardioverter-defibrillator system with substernal electrode(s), including all imaging guidance and electrophysiological evaluation (includes defibrillation threshold evaluation, induction of arrhythmia, evaluation of sensing for arrhythmia termination, and programming or reprogramming of sensing or therapeutic parameters), when performed | Clinical Review by Code List PBCWA, Pg 118 Original policy |
| 0571U | Oncology (solid tumor), DNA (80 genes) and RNA (10 genes), by next-generation sequencing, plasma, including single- nucleotide variants, insertions/deletions, copy-number alterations, microsatellite instability, and fusions, reported as clinically actionable variants | Clinical Review by Code List PBCWA, Pg 118 Original policy |
| 0572T | Insertion of substernal implantable defibrillator electrode | Clinical Review by Code List PBCWA, Pg 118 Original policy |
| 0575U | TRANSPLANTATION MEDICINE (LIVER ALLOGRAFT REJECTION), MIRNA GENE EXPRESSION PROFILING BY RT-PCR OF 4 GENES (MIR-122, MIR-885, MIR-23A SPIKE-IN CONTROL), SERUM PLASMA, OR BLOOD, ALGORITHM REPORTED AS RISK OF LIVER ALLOGRAFT REJECTION | Clinical Review by Code List PBCWA, Pg 119 Original policy |
| 0576U | Transplantation medicine (liver allograft rejection), quantitative donor-derived cell- free DNA (cfDNA) by whole genome next- generation sequencing, plasma and mRNA gene expression profiling by multiplex real- time PCR of 56 genes, whole blood, combined algorithm reported as a rejection risk score | Clinical Review by Code List PBCWA, Pg 119 Original policy |
| 0578U | Oncology (cutaneous melanoma), RNA, gene expression profiling by real-time qPCR of 10 genes (8 content and 2 housekeeping), utilizing formalin-fixed paraffin-embedded (FFPE) tissue, algorithm reports a binary result, either low- risk or high-risk for sentinel lymph node metastasis and recurrence These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 119 Original policy |
| 0582U | Rare diseases (constitutional disease/hereditary disorders), rapid whole genome DNA sequencing for single- nucleotide variants, insertions/deletions, copy number variations, blood, saliva, tissue sample, variants reported | Clinical Review by Code List PBCWA, Pg 121 Original policy |
| 0583U | Rare diseases (constitutional disease/hereditary disorders), rapid whole genome comparator DNA sequencing for single-nucleotide variants, insertions/deletions, copy number variations, blood, saliva, tissue sample, variants reported with proband results (List separately in addition to code for primary procedure) | Clinical Review by Code List PBCWA, Pg 121 Original policy |
| 0584T | Islet cell transplant, includes portal vein catheterization and infusion, including all imaging, including guidance, and radiological supervision and interpretation, when performed; percutaneous | Clinical Review by Code List PBCWA, Pg 121 Original policy |
| 0585T | Islet cell transplant, includes portal vein catheterization and infusion, including all imaging, including guidance, and radiological supervision and interpretation, when performed; laparoscopic These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 121 Original policy |
| 0586T | Islet cell transplant, includes portal vein catheterization and infusion, including all imaging, including guidance, and radiological supervision and interpretation, when performed; open | Clinical Review by Code List PBCWA, Pg 122 Original policy |
| 0586U | Oncology, mRNA, gene expression profiling of 216 genes (204 targeted and 12 housekeeping genes), RNA expression analysis, formalin-fixed paraffin-embedded (FFPE) tissue, quantitative, reported as log2 ratio per gene | Clinical Review by Code List PBCWA, Pg 122 Original policy |
| 0592U | Oncology (hematolymphoid neoplasms), DNA, targeted genomic sequence of 417 genes, interrogation for gene fusions, translocations, rearrangements, utilizing formalin-fixed paraffin-embedded (FFPE) tumor tissue, results report clinically significant variant(s) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 123 Original policy |
| 0597U | Oncology (breast), RNA expression profiling of 329 genes by targeted next- generation sequencing and 20 proteins by multiplex immunofluorescence, formalin- fixed paraffin-embedded (FFPE) tissue, algorithmic analyses to determine tumor- recurrence risk score | Clinical Review by Code List PBCWA, Pg 125 Original policy |
| 0605U | Allergy and immunology (hereditary alpha tryptasemia), DNA, analysis of TPSAB1 gene copy number variation using digital PCR, whole blood, results reported with genotypespecific interpretation of alpha- tryptase copy number and algorithmic classification as normal or abnormal | Clinical Review by Code List PBCWA, Pg 128 Original policy |
| 0611U | Oncology (liver), analysis of over 1,000 methylated regions, cell-free DNA from plasma, algorithm reported as a quantitative result (For additional PLA code with identical clinical descriptor, see 0612U. See Appendix O or the most current listing on the AMA CPT website to determine appropriate code assignment) | Clinical Review by Code List PBCWA, Pg 131 Original policy |
| 0612U | Oncology (liver), analysis of over 1,000 methylated regions, cell-free DNA from plasma, algorithm reported as a quantitative result (For additional PLA code with identical clinical descriptor, see 0611U. See Appendix O or the most current listing on the AMA CPT website to determine appropriate code assignment) | Clinical Review by Code List PBCWA, Pg 131 Original policy |
| 0613U | Oncology (urothelial carcinoma), DNA methylation and mutation analysis of 6 biomarkers (TWIST1, OTX1, ONECUT2, FGFR3, HRAS, TERT promoter region), methylation-specific PCR and targeted next- generation sequencing, urine, algorithm reported as a probability index for bladder cancer and upper tract urothelial carcinoma | Clinical Review by Code List PBCWA, Pg 132 Original policy |
| 0628U | Nephrology (kidney disease related genetic conditions), genomic analysis, renal disease panel, saliva, DNA, next- generation sequencing of 449 genes, reported as pathogenic or likely pathogenic variants of uncertain significance or risk alleles These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 134 Original policy |
| 0630U | Oncology (breast), MRNA, gene expression profiling by microarray of 80 genes (80 content and 465 housekeeping), utilizing formalin-fixed paraffin embedded tissue (FFPE). algorithm reports as an index that is diagnostic of a molecular subtype (luminal, basal, HER2) | Clinical Review by Code List PBCWA, Pg 135 Original policy |
| 0631U | Oncology (solid tumor), DNA, sequence analysis of 15 genes including BRCA1 and BRCA2 for identification of clonal hematopoiesis, blood, reported as tumor- derived or nontumor-derived | Clinical Review by Code List PBCWA, Pg 135 Original policy |
| 0632U | Red blood cell antigen (fetal RhD gene analysis), multiplex polymerase chain reaction (PCR) and next-generation sequencing (NGS) of circulating cell-free DNA (cfDNA), plasma from pregnant individuals known to be RhD negative, reported as detected or not detected | Clinical Review by Code List PBCWA, Pg 136 Original policy |
| 0633T | Computed tomography, breast, including 3D rendering, when performed, unilateral; without contrast material | Clinical Review by Code List PBCWA, Pg 136 Original policy |
| 0633U | Obstetrics (single-gene noninvasive prenatal test), cell-free DNA (cfDNA), next- generation sequencing (NGS) analysis of 1 or more targets (eg, CFTR, SMN1, HBB, HBA1, HBA2) to identify paternally inherited pathogenic variants and to determine fetal inheritance of maternal mutation, using maternal blood sample, algorithm reported as a fetal risk score | Clinical Review by Code List PBCWA, Pg 136 Original policy |
| 0634T | Computed tomography, breast, including 3D rendering, when performed, unilateral; with contrast material(s) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 136 Original policy |
| 0634U | Oncology (breast cancer), cell-free DNA (cfDNA), evaluation of 11 ESR1 variants (E380Q, S463P, L536R, Y537C, Y537N, Y537S, D538G, V422del, L536H, L536P, Y537D) using droplet digital PCR (ddPCR), plasma, reported as positive or negative | Clinical Review by Code List PBCWA, Pg 137 Original policy |
| 0635T | Computed tomography, breast, including 3D rendering, when performed, unilateral; without contrast, followed by contrast material(s) | Clinical Review by Code List PBCWA, Pg 137 Original policy |
| 0636T | Computed tomography, breast, including 3D rendering, when performed, bilateral; without contrast material(s) | Clinical Review by Code List PBCWA, Pg 137 Original policy |