Premera Blue Cross of Washington prior authorization, page 7
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 |
|---|---|---|
| 0637T | Computed tomography, breast, including 3D rendering, when performed, bilateral; with contrast material(s) | Clinical Review by Code List PBCWA, Pg 137 Original policy |
| 0638T | Computed tomography, breast, including 3D rendering, when performed, bilateral; without contrast, followed by contrast material(s) | Clinical Review by Code List PBCWA, Pg 137 Original policy |
| 0641U | Oncology (minimal residual disease [MRD]), tumor DNA, next-generation sequencing (NGS), using formalin-fixed paraffin-embedded (FFPE) tissue and blood samples, initial (baseline) assessment | Clinical Review by Code List PBCWA, Pg 138 Original policy |
| 0642U | Oncology (minimal residual disease [MRD]), tumor DNA, next-generation sequencing (NGS), whole blood, comparison to previously performed analyses, reported as trend in circulating tumor DNA (ctDNA) level | Clinical Review by Code List PBCWA, Pg 138 Original policy |
| 0643U | Oncology (genitourinary cancer), cell-free circulating tumor DNA (ctDNA), 200 genes, next-generation sequencing (NGS), interrogation for single-nucleotide variants (SNVs), insertions/deletions, gene rearrangements, copy number alterations, and tumor mutation burden, using urine, identify and report mutations with clinical actionability | Clinical Review by Code List PBCWA, Pg 138 Original policy |
| 0644U | Oncology (leukemia), minimal residual disease (MRD) detection for rearrangements, blood or bone marrow, personalized assay design and baseline quantification | Clinical Review by Code List PBCWA, Pg 138 Original policy |
| 0645U | Oncology (leukemia), minimal residual disease (MRD) detection for rearrangements, based on digital PCR, blood or bone marrow, reported as not detected or detected with estimated abundance These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 138 Original policy |
| 0646T | Transcatheter tricuspid valve implantation (TTVI)/replacement with prosthetic valve, percutaneous approach, including right heart catheterization, temporary pacemaker INSERTion, and selective right ventricular or right atrial angiography, when performed | Clinical Review by Code List PBCWA, Pg 139 Original policy |
| 0646U | Oncology (molecular residual disease), whole genome sequence analysis, cell-free DNA, whole blood, and formalin-fixed paraffin-embedded (FFPE) tumor tissue DNA, baseline assessment | Clinical Review by Code List PBCWA, Pg 139 Original policy |
| 0647U | Oncology (molecular residual disease), whole genome sequence analysis, cell-free DNA (cfDNA), whole blood, assessment utilizing patient-specific tumor information, reported as negative or percent circulating tumor DNA (ctDNA) | Clinical Review by Code List PBCWA, Pg 139 Original policy |
| 0648T | Quantitative magnetic resonance for analysis of tissue composition (eg, fat, iron, water content), including multiparametric data acquisition, data preparation and transmission, interpretation and report, obtained without diagnostic MRI examination of the same anatomy (eg, organ, gland, tissue, target structure) during the same session; single organ These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 139 Original policy |
| 0648U | Oncology (solid tumor), targeted genomic sequencing analysis, to detect deletions, insertions, and substitutions in 42 genes, copy number amplifications in 10 genes, and fusions and splice variants in 18 driver genes from DNA and RNA extracted from formalin-fixed paraffin-embedded (FFPE) tissue | Clinical Review by Code List PBCWA, Pg 140 Original policy |
| 0649T | Quantitative magnetic resonance for analysis of tissue composition (eg, fat, iron, water content), including multiparametric data acquisition, data preparation and transmission, interpretation and report, obtained with diagnostic MRI examination of the same anatomy (eg, organ, gland, tissue, target structure); single organ (List separately in addition to code for primary procedure) | Clinical Review by Code List PBCWA, Pg 140 Original policy |
| 0649U | Neurology (Alzheimer disease), DNA, targeted next-generation sequencing (NGS) of AD-1 and AD-2 target regions, whole blood, prognostic algorithmic analysis, reported as categorization of cognitive status | Clinical Review by Code List PBCWA, Pg 140 Original policy |
| 0650U | Drug metabolism (adverse drug reactions and drug response), genotyping of 9 genes (ie, CYP2D6, CYP2C19, G6PD, SLCO1B1, HLA-B*58:01, NAT2, CYP2C9, VKORC1, ABCG2), reported as metabolizer status and transporter function These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 140 Original policy |
| 0651U | Oncology (hereditary cancer), genomic DNA, 55 hereditary cancer pre- dispositioned genes, next-generation sequencing (NGS) and digital multiplex ligation-dependent probe amplification for variants, small indels (<40 base pairs), using saliva, whole blood or nail clipping, interpretive clinical report with variant classification | Clinical Review by Code List PBCWA, Pg 141 Original policy |
| 0652U | Drug metabolism (adverse drug reactions), DNA analysis of 13 genes by targeted genotyping, using saliva or buccal swab, reported as diplotype and metabolizer status | Clinical Review by Code List PBCWA, Pg 141 Original policy |
| 0653U | Nephrology (inherited kidney disorders), DNA, analysis of approximately 700 genes associated with inherited kidney diseases by exome sequencing, using whole blood, saliva, or nail clipping, reported as an interpretive clinical report classifying pathogenic and likely pathogenic variants | Clinical Review by Code List PBCWA, Pg 141 Original policy |
| 0657U | Rare diseases (constitutional/heritable disorders), rapid whole genome sequence analysis of comparator nuclear and mitochondrial DNA by next-generation sequencing (NGS), using blood or buccal sample, relevant variants reported with proband results | Clinical Review by Code List PBCWA, Pg 142 Original policy |
| 0658U | Rare diseases (constitutional/heritable disorders), rapid whole genome sequence analysis of nuclear and mitochondrial DNA by next-generation sequencing (NGS) for single-nucleotide variants (SNVs), insertions/deletions, copy number variants, uniparental disomy, and repeat expansions, using blood or buccal sample, identification and categorization of genetic variants | Clinical Review by Code List PBCWA, Pg 142 Original policy |
| 0659U | Rare diseases (constitutional/heritable disorders), ultrarapid whole genome sequence analysis of nuclear and mitochondrial DNA by next-generation sequencing (NGS) for single-nucleotide variants (SNVs), insertions/deletions, copy number variants, uniparental disomy, and repeat expansions, using blood or buccal sample, identification and categorization of genetic variants | Clinical Review by Code List PBCWA, Pg 142 Original policy |
| 0665U | Hepatology (metabolic dysfunction- associated steatohepatitis [MASH]), enzyme-linked immunosorbent assay (ELISA) for YKL40 and quantitative reverse transcription polymerase chain reaction (RT- qPCR) for miR-34a-5p, serum, algorithm reported as a single score for MASH activity and fibrosis | Clinical Review by Code List PBCWA, Pg 144 Original policy |
| 0666U | Human papillomavirus (HPV), genotypes 18, 31, 33, and 35, cell-free DNA (cfDNA), whole blood, multiplex digital droplet PCR (ddPCR), quantitative | Clinical Review by Code List PBCWA, Pg 144 Original policy |
| 0667U | Inborn error of metabolism (primary mitochondrial disease), determination of fibroblast growth factor 21 (FGF21) concentration by enzyme-linked immunosorbent assay (ELISA), serum or plasma, diagnostic quantitative result These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 144 Original policy |
| 0668U | Oncology (pancreas), DNA, genome sequence with 5-hydroxymethylcytosine (5hmC) enrichment and glycan biomarker analysis, whole blood or plasma, algorithm reported as cancer detected or not detected | Clinical Review by Code List PBCWA, Pg 145 Original policy |
| 0669U | Infectious disease (Bartonella species, Borrelia species, and Babesia species), multiplex digital PCR for detection of DNA at the genus level for each species, blood, qualitative reporting of presence or absence of each pathogen at the genus level | Clinical Review by Code List PBCWA, Pg 145 Original policy |
| 0672U | Rare diseases (constitutional/heritable disorders), whole exome and mitochondrial DNA sequence analysis, including small sequence changes, deletions, duplications, short tandem repeat (STR) gene expansions, and variants in nonuniquely mappable regions, blood or saliva, identification and categorization of genetic variants, proband and comparator | Clinical Review by Code List PBCWA, Pg 146 Original policy |
| 0673U | Rare diseases (constitutional/heritable disorders), whole exome and mitochondrial DNA sequence analysis, including small sequence changes, deletions, duplications, short tandem repeat (STR) gene expansions, and variants in nonuniquely mappable regions, blood or saliva, identification and categorization of genetic variants, proband and 2 comparators | Clinical Review by Code List PBCWA, Pg 146 Original policy |
| 0679U | Oncology (hereditary hematologic cancer), genomic DNA, whole genome sequence (single-nucleotide variants, deletions/insertions, and characterized intronic variants), copy number variants, duplications/deletions, mobile element insertions and inversions, analysis of over 105 genes, genomic DNA isolated from blood, saliva, cultured skin fibroblasts (skin biopsy), identification and categorization of genetic variants | Clinical Review by Code List PBCWA, Pg 148 Original policy |
| 0780T | Instillation of fecal microbiota suspension via rectal enema into lower gastrointestinal tract | Clinical Review by Code List PBCWA, Pg 167 Original policy |
| 0784T | Insertion or replacement of percutaneous electrode array, spinal. with integrated neurostimulator, including imaging guidance. when performed These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 167 Original policy |
| 0785T | Revision or removal of neurostimulator electrode array, spinal, with integrated neurostimulator | Clinical Review by Code List PBCWA, Pg 168 Original policy |
| 0786T | Insertion or replacement of percutaneous electrode array, sacral, with integrated neurostimulator, including imaging guidance, when performed | Clinical Review by Code List PBCWA, Pg 168 Original policy |
| 0795T | Transcatheter insertion of permanent dual- chamber leadless pacemaker, including imaging guidance (eg, fluoroscopy, venous ultrasound, right atrial angiography, right ventriculography, femoral venography) and device evaluation (eg, interrogation or programming), when performed; complete system (ie, right atrial and right ventricular pacemaker components) | Clinical Review by Code List PBCWA, Pg 169 Original policy |
| 0796T | Transcatheter insertion of permanent dual- chamber leadless pacemaker, including imaging guidance (e.g., fluoroscopy, venous ultrasound, right atrial angiography, right ventriculography, femoral venography) and device evaluation (e.g., interrogation or programming), when performed; right atrial pacemaker component (when an existing right ventricular single leadless pacemaker exists to create a dual-chamber leadless pacemaker system) These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 169 Original policy |
| 0797T | Transcatheter insertion of permanent dual- chamber leadless pacemaker, including imaging guidance (e.g., fluoroscopy, venous ultrasound, right atrial angiography, right ventriculography, femoral venography) and device evaluation (e.g., interrogation or programming), when performed; right ventricular pacemaker component (when part of a dual-chamber leadless pacemaker system) | Clinical Review by Code List PBCWA, Pg 170 Original policy |
| 0801T | Transcatheter removal and replacement of permanent dual-chamber leadless pacemaker, including imaging?guidance (eg, fluoroscopy, venous ultrasound, right atrial angiography, right ventriculography, femoral venography) and device evaluation (eg, interrogation or programming), when performed; dual-chamber system (ie, right atrial and right ventricular pacemaker components) | Clinical Review by Code List PBCWA, Pg 171 Original policy |
| 0802T | Transcatheter removal and replacement of permanent dual-chamber leadless pacemaker, including imaging?guidance (eg, fluoroscopy, venous ultrasound, right atrial angiography, right ventriculography, femoral venography) and device evaluation (eg, interrogation or programming), when performed; right atrial pacemaker component These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 171 Original policy |
| 0803T | Transcatheter removal and replacement of permanent dual-chamber leadless pacemaker, including imaging?guidance (eg, fluoroscopy, venous ultrasound, right atrial angiography, right ventriculography, femoral venography) and device evaluation (eg, interrogation or programming), when performed; right ventricular pacemaker component (when part of a dual-chamber leadless pacemaker system) | Clinical Review by Code List PBCWA, Pg 172 Original policy |
| 0824T | Transcatheter removal of permanent single- chamber leadless pacemaker, right atrial, including imaging guidance when performed | Clinical Review by Code List PBCWA, Pg 175 Original policy |
| 0825T | Transcatheter removal and replacement of permanent single-chamber, leadless pacemaker, right atrial, including imaging guidance and device evaluation, when performed | Clinical Review by Code List PBCWA, Pg 175 Original policy |
| 0826T | Programming device evaluation with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis | Clinical Review by Code List PBCWA, Pg 175 Original policy |
| 0964T | Impression and custom preparation of jaw expansion oral prosthesis for obstructive sleep apnea, including initial adjustment; single arch, without mandibular advancement mechanism These criteria do not imply or guarantee approval. | Clinical Review by Code List PBCWA, Pg 199 Original policy |
| 0965T | Impression and custom preparation of jaw expansion oral prosthesis for obstructive sleep apnea, including initial adjustment; dual arch, with additional mandibular advancement, non-fixed hinge mechanism | Clinical Review by Code List PBCWA, Pg 200 Original policy |
| 0966T | Impression and custom preparation of jaw expansion oral prosthesis for obstructive sleep apnea, including initial adjustment; dual arch, with additional mandibular advancement, fixed hinge mechanism | Clinical Review by Code List PBCWA, Pg 200 Original policy |
| 1081T | Microvascular anastomosis between a lymph node and a vein, including robot assistance, when performed; initial anastomosis | Clinical Review by Code List PBCWA, Pg 224 Original policy |
| 1082T | Microvascular anastomosis between a lymph node and a vein, including robot assistance, when performed; each additional anastomosis (List separately in addition to code for primary procedure) | Clinical Review by Code List PBCWA, Pg 224 Original policy |
| 11970 | Replacement of tissue expander with permanent implant | Clinical Review by Code List PBCWA, Pg 231 Original policy |
| 11971 | Removal of tissue expander without insertion of implant | Clinical Review by Code List PBCWA, Pg 231 Original policy |
| 15788 | Chemical peel, facial; epidermal | Clinical Review by Code List PBCWA, Pg 235 Original policy |