Anthem Blue Cross and Blue Shield Nevada policy
Prior Authorization List
Prior Authorization List is a public Anthem Blue Cross and Blue Shield Nevada policy. It lists 3,304 CPT or HCPCS codes, 2853 of them on the Anthem Blue Cross and Blue Shield Nevada prior authorization list. Not a coverage decision; the payer's own document governs.
View the original policy (PDF) ↗
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Codes in this policy
The CPT and HCPCS codes the policy names. A policy can name a code it excludes. Prior authorization status is from the Anthem Blue Cross and Blue Shield Nevada prior authorization list.
| Code | Prior authorization | Description on the prior authorization list | Other Anthem Blue Cross and Blue Shield Nevada policies |
|---|---|---|---|
| 00002 | Not listed | Policies naming 00002 | |
| 00003 | Not listed | Policies naming 00003 | |
| 00004 | Not listed | Policies naming 00004 | |
| 00005 | Not listed | Policies naming 00005 | |
| 00006 | Not listed | Policies naming 00006 | |
| 00007 | Not listed | Policies naming 00007 | |
| 00008 | Not listed | Policies naming 00008 | |
| 00009 | Not listed | Policies naming 00009 | |
| 00010 | Not listed | Policies naming 00010 | |
| 00011 | Not listed | Policies naming 00011 | |
| 00012 | Not listed | Policies naming 00012 | |
| 00013 | Not listed | Policies naming 00013 | |
| 00015 | Not listed | Policies naming 00015 | |
| 00016 | Not listed | Policies naming 00016 | |
| 00017 | Not listed | Policies naming 00017 | |
| 00018 | Not listed | Policies naming 00018 | |
| 00019 | Not listed | Policies naming 00019 | |
| 0001U | On the list | Red blood cell antigen typing, DNA, human erythrocyte antigen gene analysis of 35 antigens from 11 blood groups, utilizing whole blood, common RBC alleles reported | Policies naming 0001U |
| 00020 | Not listed | Policies naming 00020 | |
| 00022 | Not listed | Policies naming 00022 | |
| 00023 | Not listed | Policies naming 00023 | |
| 00024 | Not listed | Policies naming 00024 | |
| 00025 | Not listed | Policies naming 00025 | |
| 00026 | Not listed | Policies naming 00026 | |
| 00027 | Not listed | Policies naming 00027 | |
| 00028 | Not listed | Policies naming 00028 | |
| 00029 | Not listed | Policies naming 00029 | |
| 00030 | Not listed | Policies naming 00030 | |
| 00031 | Not listed | Policies naming 00031 | |
| 00032 | Not listed | Policies naming 00032 | |
| 00033 | Not listed | Policies naming 00033 | |
| 00034 | Not listed | Policies naming 00034 | |
| 00035 | Not listed | Policies naming 00035 | |
| 00036 | Not listed | Policies naming 00036 | |
| 00037 | Not listed | Policies naming 00037 | |
| 00038 | Not listed | Policies naming 00038 | |
| 00039 | Not listed | Policies naming 00039 | |
| 00040 | Not listed | Policies naming 00040 | |
| 00041 | Not listed | Policies naming 00041 | |
| 00042 | Not listed | Policies naming 00042 | |
| 00043 | Not listed | Policies naming 00043 | |
| 00045 | Not listed | Policies naming 00045 | |
| 00046 | Not listed | Policies naming 00046 | |
| 00047 | Not listed | Policies naming 00047 | |
| 00048 | Not listed | Policies naming 00048 | |
| 00049 | Not listed | Policies naming 00049 | |
| 00050 | Not listed | Policies naming 00050 | |
| 00051 | Not listed | Policies naming 00051 | |
| 00052 | Not listed | Policies naming 00052 | |
| 00053 | Not listed | Policies naming 00053 | |
| 00055 | Not listed | Policies naming 00055 | |
| 00056 | Not listed | Policies naming 00056 | |
| 00057 | Not listed | Policies naming 00057 | |
| 00058 | Not listed | Policies naming 00058 | |
| 00059 | Not listed | Policies naming 00059 | |
| 0005U | On the list | Oncology (prostate) gene expression profile by real-time RT-PCR of 3 genes (ERG, PCA3, and SPDEF), urine, algorithm reported as risk score | Policies naming 0005U |
| 00061 | Not listed | Policies naming 00061 | |
| 00062 | Not listed | Policies naming 00062 | |
| 00067 | Not listed | Policies naming 00067 | |
| 00068 | Not listed | Policies naming 00068 | |
| 0006M | On the list | Oncology (hepatic), mRNA expression levels of 161 genes, utilizing fresh hepatocellular carcinoma tumor tissue, with alpha-fetoprotein level, algorithm reported as a risk clas | Policies naming 0006M |
| 00070 | Not listed | Policies naming 00070 | |
| 00071 | Not listed | Policies naming 00071 | |
| 00072 | Not listed | Policies naming 00072 | |
| 00073 | Not listed | Policies naming 00073 | |
| 00076 | Not listed | Policies naming 00076 | |
| 00077 | Not listed | Policies naming 00077 | |
| 00079 | Not listed | Policies naming 00079 | |
| 0007M | On the list | Oncology (gastrointestinal neuroendocrine tumors), real-time PCR expression analysis of 51 genes, utilizing whole peripheral blood, algorithm reported as a nomogram of tumor d | Policies naming 0007M |
| 0007U | On the list | Drug test(s), presumptive, with definitive confirmation of positive results, any number of drug classes, urine, includes specimen verification including DNA authentication in | Policies naming 0007U |
| 00082 | Not listed | Policies naming 00082 | |
| 00084 | Not listed | Policies naming 00084 | |
| 00088 | Not listed | Policies naming 00088 | |
| 00089 | Not listed | Policies naming 00089 | |
| 00090 | Not listed | Policies naming 00090 | |
| 00092 | Not listed | Policies naming 00092 | |
| 00095 | Not listed | Policies naming 00095 | |
| 00096 | Not listed | Policies naming 00096 | |
| 00097 | Not listed | Policies naming 00097 | |
| 00099 | Not listed | Policies naming 00099 | |
| 00100 | Not listed | Policies naming 00100 | |
| 00101 | Not listed | Policies naming 00101 | |
| 00102 | Not listed | Policies naming 00102 | |
| 00103 | Not listed | Policies naming 00103 | |
| 00104 | Not listed | Policies naming 00104 | |
| 00107 | Not listed | Policies naming 00107 | |
| 00110 | Not listed | Policies naming 00110 | |
| 00111 | Not listed | Policies naming 00111 | |
| 00112 | Not listed | Policies naming 00112 | |
| 00115 | Not listed | Policies naming 00115 | |
| 0011M | On the list | Oncology, prostate cancer, mRNA expression assay of 12 genes (10 content and 2 housekeeping), RT-PCR test utilizing blood plasma and urine, algorithms to predict high-grade pr | Policies naming 0011M |
| 00120 | Not listed | Policies naming 00120 | |
| 00121 | Not listed | Policies naming 00121 | |
| 00124 | Not listed | Policies naming 00124 | |
| 00125 | Not listed | Policies naming 00125 | |
| 00126 | Not listed | Policies naming 00126 | |
| 00128 | Not listed | Policies naming 00128 | |
| 00129 | Not listed | Policies naming 00129 | |
| 0012M | On the list | Oncology (urothelial), mRNA, gene expression profiling by real-time quantitative PCR of five genes (MDK, HOXA13, CDC2 [CDK1], IGFBP5, and XCR2), utilizing urine, algorithm rep | Policies naming 0012M |
| 00130 | Not listed | Policies naming 00130 | |
| 00131 | Not listed | Policies naming 00131 | |
| 00132 | Not listed | Policies naming 00132 | |
| 00134 | Not listed | Policies naming 00134 | |
| 00135 | Not listed | Policies naming 00135 | |
| 00137 | Not listed | Policies naming 00137 | |
| 00138 | Not listed | Policies naming 00138 | |
| 00139 | Not listed | Policies naming 00139 | |
| 0013M | On the list | Oncology (urothelial), mRNA, gene expression profiling by real-time quantitative PCR of five genes (MDK, HOXA13, CDC2 [CDK1], IGFBP5, and CXCR2), utilizing urine, algorithm re | Policies naming 0013M |
| 00140 | Not listed | Policies naming 00140 | |
| 00141 | Not listed | Policies naming 00141 | |
| 00142 | Not listed | Policies naming 00142 | |
| 00143 | Not listed | Policies naming 00143 | |
| 00144 | Not listed | Policies naming 00144 | |
| 00145 | Not listed | Policies naming 00145 | |
| 00146 | Not listed | Policies naming 00146 | |
| 00147 | Not listed | Policies naming 00147 | |
| 00150 | Not listed | Policies naming 00150 | |
| 00151 | Not listed | Policies naming 00151 | |
| 00152 | Not listed | Policies naming 00152 | |
| 00153 | Not listed | Policies naming 00153 | |
| 00154 | Not listed | Policies naming 00154 | |
| 00155 | Not listed | Policies naming 00155 | |
| 00156 | Not listed | Policies naming 00156 | |
| 00157 | Not listed | Policies naming 00157 | |
| 00158 | Not listed | Policies naming 00158 | |
| 00159 | Not listed | Policies naming 00159 | |
| 00160 | Not listed | Policies naming 00160 | |
| 00161 | Not listed | Policies naming 00161 | |
| 00162 | Not listed | Policies naming 00162 | |
| 0016M | On the list | Oncology (bladder), mRNA, microarray gene expression profiling of 219 genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as molecular subtype (lumina | Policies naming 0016M |
| 0016U | On the list | Oncology (hematolymphoid neoplasia), RNA, BCR/ABL1 major and minor breakpoint fusion transcripts, quantitative PCR amplification, blood or bone marrow, report of fusion not de | Policies naming 0016U |
| 0017M | On the list | Oncology (diffuse large B-cell lymphoma [DLBCL]), mRNA, gene expression profiling by fluorescent probe hybridization of 20 genes, formalin-fixed paraffin- embedded tissue, algo | Policies naming 0017M |
| 0017U | On the list | Oncology (hematolymphoid neoplasia), JAK2 mutation, DNA, PCR amplification of exons 12-14 and sequence analysis, blood or bone marrow, report of JAK2 mutation not detected or | Policies naming 0017U |
| 0018M | On the list | Transplantation medicine (allograft rejection, renal), measurement of donor and third-party-induced CD154+T-cytotoxic memory cells, utilizing whole peripheral blood, algorithm | Policies naming 0018M |
| 0018U | On the list | Oncology (thyroid), microRNA profiling by RT-PCR of 10 microRNA sequences, utilizing fine needle aspirate, algorithm reported as a positive or negative result for moderate to | Policies naming 0018U |
| 0019U | On the list | Oncology, RNA, gene expression by whole transcriptome sequencing, formalin- fixed paraffin embedded tissue or fresh frozen tissue, predictive algorithm reported as potential ta | Policies naming 0019U |
| 0022U | On the list | Targeted genomic sequence analysis panel, non-small cell lung neoplasia, DNA and RNA analysis, 23 genes, interrogation for sequence variants and rearrangements, reported as pr | Policies naming 0022U |
| 0023U | On the list | Oncology (acute myelogenous leukemia), DNA, genotyping of internal tandem duplication, p.D835, p.I836, using mononuclear cells, reported as detection or non-detection of FLT3 | Policies naming 0023U |
| 0026U | On the list | Oncology (thyroid), DNA and mRNA of 112 genes, next-generation sequencing, fine needle aspirate of thyroid nodule, algorithmic analysis reported as a categorical result ('Posi | Policies naming 0026U |
| 0027U | On the list | JAK2 (Janus kinase 2) (eg, myeloproliferative disorder) gene analysis, targeted sequence analysis exons 12-15 | Policies naming 0027U |
| 0029U | On the list | Drug metabolism (adverse drug reactions and drug response), targeted sequence analysis (ie, CYP1A2, CYP2C19, CYP2C9, CYP2D6, CYP3A4, CYP3A5, CYP4F2, SLCO1B1, VKORC1 and rs1277 | Policies naming 0029U |
| 0030U | On the list | Drug metabolism (warfarin drug response), targeted sequence analysis (ie, CYP2C9, CYP4F2, VKORC1, rs12777823) | Policies naming 0030U |
| 0031U | On the list | CYP1A2 (cytochrome P450 family 1, subfamily A, member 2)(eg, drug metabolism) gene analysis, common variants (ie, *1F, *1K, *6, *7) | Policies naming 0031U |
| 0032U | On the list | COMT (catechol-O-methyltransferase)(drug metabolism) gene analysis, c.472G>A (rs4680) variant | Policies naming 0032U |
| 0033U | Not listed | Policies naming 0033U | |
| 0034U | On the list | TPMT (thiopurine S-methyltransferase), NUDT15 (nudix hydroxylase 15)(eg, thiopurine metabolism), gene analysis, common variants (ie, TPMT *2, *3A, *3B, *3C, *4, *5, *6, *8, *1 | Policies naming 0034U |
| 0036U | On the list | Exome (ie, somatic mutations), paired formalin-fixed paraffin-embedded tumor tissue and normal specimen, sequence analyses | Policies naming 0036U |
| 0037U | On the list | Targeted genomic sequence analysis, solid organ neoplasm, DNA analysis of 324 genes, interrogation for sequence variants, gene copy number amplifications, gene rearrangements | Policies naming 0037U |
| 0040U | On the list | BCR/ABL1 (t(9;22)) (eg, chronic myelogenous leukemia) translocation analysis, major breakpoint, quantitative | Policies naming 0040U |
| 0045U | On the list | Oncology (breast ductal carcinoma in situ), mRNA, gene expression profiling by real-time RT-PCR of 12 genes (7 content and 5 housekeeping), utilizing formalin- fixed paraffin-e | Policies naming 0045U |
| 0046U | On the list | FLT3 (fms-related tyrosine kinase 3) (eg, acute myeloid leukemia) internal tandem duplication (ITD) variants, quantitative | Policies naming 0046U |
| 0047U | On the list | Oncology (prostate), mRNA, gene expression profiling by real-time RT-PCR of 17 genes (12 content and 5 housekeeping), utilizing formalin-fixed paraffin- embedded tissue, algori | Policies naming 0047U |
| 0048U | On the list | Oncology (solid organ neoplasia), DNA, targeted sequencing of protein-coding exons of 468 cancer-associated genes, including interrogation for somatic mutations and microsatel | Policies naming 0048U |
| 0049U | On the list | NPM1 (nucleophosmin) (eg, acute myeloid leukemia) gene analysis, quantitative | Policies naming 0049U |
| 0050U | On the list | Targeted genomic sequence analysis panel, acute myelogenous leukemia, DNA analysis, 194 genes, interrogation for sequence variants, copy number variants or rearrangements | Policies naming 0050U |
| 00530 | Not listed | Policies naming 00530 | |
| 00534 | Not listed | Policies naming 00534 | |
| 0053U | On the list | Oncology (prostate cancer), FISH analysis of 4 genes (ASAP1, HDAC9, CHD1 and PTEN), needle biopsy specimen, algorithm reported as probability of higher tumor grade | Policies naming 0053U |
| 0055U | On the list | Cardiology (heart transplant), cell-free DNA, PCR assay of 96 DNA target sequences (94 single nucleotide polymorphism targets and two control targets), plasma | Policies naming 0055U |
| 00580 | On the list | Anesthesia, Heart Transplant/Heart & Lung Transplant | Policies naming 00580 |
| 0062U | On the list | Autoimmune (systemic lupus erythematosus), IgG and IgM analysis of 80 biomarkers, utilizing serum, algorithm reported with a risk score | Policies naming 0062U |
| 0069U | On the list | Oncology (colorectal), microRNA, RT-PCR expression profiling of miR-31-3p, formalin-fixed paraffin-embedded tissue, algorithm reported as an expression score | Policies naming 0069U |
| 0070U | On the list | CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, common and select rare variants (ie, *2, *3, *4, *4N, *5, *6, *7, *8, *9, * | Policies naming 0070U |
| 0071T | On the list | Ultrasound Ablation of Uterine Leioomyomata inc MR Guidance | Policies naming 0071T |
| 0071U | On the list | CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, full gene sequence (List separately in addition to code for primary procedu | Policies naming 0071U |
| 0072T | On the list | Ultrasound Ablation of Uterine Leioomyomata inc MR Guidance; Vol>=200 CC | Policies naming 0072T |
| 0072U | On the list | CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, targeted sequence analysis (ie, CYP2D6-2D7 hybrid gene) (List separately in | Policies naming 0072U |
| 0073U | On the list | CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, targeted sequence analysis (ie, CYP2D7-2D6 hybrid gene) (List separately in | Policies naming 0073U |
| 0074U | On the list | CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, targeted sequence analysis (ie, non-duplicated gene when duplication/multip | Policies naming 0074U |
| 0075U | On the list | CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, targeted sequence analysis (ie, 5 gene duplication/multiplication) (List se | Policies naming 0075U |
| 0076U | On the list | CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (eg, drug metabolism) gene analysis, targeted sequence analysis (ie, 3 gene duplication/ multiplication) (List s | Policies naming 0076U |
| 0078U | On the list | Pain management (opioid-use disorder) genotyping panel, 16 common variants (ie, ABCB1, COMT, DAT1, DBH, DOR, DRD1, DRD2, DRD4, GABA, GAL, HTR2A, HTTLPR, MTHFR, MUOR, OPRK1, OP | Policies naming 0078U |
| 00796 | On the list | Anesthesia, Intraperitoneal Proc, Upper Abdomen, W/Laparoscopy; Liver Transplant, Recipient | Policies naming 00796 |
| 00797 | Not listed | Policies naming 00797 | |
| 0079U | On the list | Comparative DNA analysis using multiple selected single-nucleotide polymorphisms(SNPs), urine and buccal DNA, for specimen identity verification | Policies naming 0079U |
| 0080U | On the list | Oncology (lung), mass spectrometric analysis of galectin-3-binding protein and scavenger receptor cysteine-rich type 1 protein M130, with five clinical risk factors (age, smok | Policies naming 0080U |
| 00868 | On the list | Anesthesia, Extraperitoneal Proc, Lower Abdomen, W/Urinary Tract; Renal Transplant, Recipient | Policies naming 00868 |
| 0087U | On the list | Cardiology (heart transplant), mRNA gene expression profiling by microarray of 1283 genes, transplant biopsy tissue, allograft rejection and injury algorithm reported as a pro | Policies naming 0087U |
| 0088U | On the list | Transplantation medicine (kidney allograft rejection), microarray gene expression profiling of 1494 genes, utilizing transplant biopsy tissue, algorithm reported as a probabil | Policies naming 0088U |
| 0089U | On the list | Oncology (melanoma), gene expression profiling by RTqPCR, PRAME and LINC00518, superficial collection using adhesive patch(es) | Policies naming 0089U |
| 0090U | On the list | Oncology (cutaneous melanoma), mRNA gene expression profiling by RT-PCR of 23 genes (14 content and 9 housekeeping), utilizing formalin-fixed paraffin- embedded (FFPE) tissue | Policies naming 0090U |
| 0092U | On the list | Oncology (lung), three protein biomarkers, immunoassay using magnetic nanosensor technology, plasma, algorithm reported as risk score for likelihood of malignancy | Policies naming 0092U |
| 0094U | On the list | Genome (eg, unexplained constitutional or heritable disorder or syndrome), rapid sequence analysis | Policies naming 0094U |
| 0095T | On the list | Removal of total disc arthroplasty (artificial disc), anterior approach, each additional interspace, cervical (List separately in addition to code for primary procedure) | Policies naming 0095T |
| 0098T | On the list | Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, each additional interspace, cervical (List separately in addition to code for p | Policies naming 0098T |
| 0101T | On the list | Extracorporeal shock wave involving musculoskeletal system, not otherwise specified | Policies naming 0101T |
| 0101U | On the list | Hereditary colon cancer disorders (eg, Lynch syndrome, PTEN hamartoma syndrome, Cowden syndrome, familial adenomatosis polyposis), genomic sequence analysis panel utilizing a | Policies naming 0101U |
| 0102T | On the list | Extracorporeal shock wave performed by a physician, requiring anesthesia other than local, and involving the lateral humeral epicondyle | Policies naming 0102T |
| 0102U | On the list | Hereditary breast cancer-related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer), genomic sequence analysis panel utilizing | Policies naming 0102U |
| 0103U | On the list | Hereditary ovarian cancer (eg, hereditary ovarian cancer, hereditary endometrial cancer), genomic sequence analysis panel utilizing a combination of NGS, Sanger, MLPA, and arr | Policies naming 0103U |
| 0105U | On the list | Nephrology (chronic kidney disease), multiplex electrochemiluminescent immunoassay (ECLIA) of tumor necrosis factor receptor 1A, receptor superfamily 2 (TNFR1, TNFR2), and kid | Policies naming 0105U |
| 0111U | On the list | Oncology (colon cancer), targeted KRAS (codons 12, 13, and 61) and NRAS (codons 12, 13, and 61) gene analysis utilizing formalin-fixed paraffin- embedded tissue | Policies naming 0111U |
| 0112U | On the list | Infectious agent detection and identification, targeted sequence analysis (16S and 18S rRNA genes) with drug-resistance gene | Policies naming 0112U |
| 0113U | On the list | Oncology (prostate), measurement of PCA3 and TMPRSS2-ERG in urine and PSA in serum following prostatic massage, by RNA amplification and fluorescence- based detection, algorith | Policies naming 0113U |
| 0118U | On the list | Transplantation medicine, quantification of donor-derived cell-free DNA using whole genome next-generation sequencing, plasma, reported as percentage of donor-derived cell-fre | Policies naming 0118U |
| 0120U | On the list | Oncology (B-cell lymphoma classification), mRNA, gene expression profiling by fluorescent probe hybridization of 58 genes (45 content and 13 housekeeping genes), formalin-fixe | Policies naming 0120U |
| 0129U | On the list | Hereditary breast cancer-related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer), genomic sequence analysis and deletion/dup | Policies naming 0129U |
| 0130U | On the list | Hereditary colon cancer disorders (eg, Lynch syndrome, PTEN hamartoma syndrome, Cowden syndrome, familial adenomatosis polyposis), targeted mRNA sequence analysis panel (APC | Policies naming 0130U |
| 0131U | Not listed | Policies naming 0131U | |
| 0132U | Not listed | Policies naming 0132U | |
| 0134U | On the list | Hereditary pan cancer (eg, hereditary breast and ovarian cancer, hereditary endometrial cancer, hereditary colorectal cancer), targeted mRNA sequence analysis panel (18 genes) | Policies naming 0134U |
| 0135U | Not listed | Policies naming 0135U | |
| 0141U | Not listed | Policies naming 0141U | |
| 0142U | Not listed | Policies naming 0142U | |
| 0152U | On the list | Infectious disease (bacteria, fungi, parasites, and DNA viruses), microbial cell- free DNA, plasma, untargeted next-generation sequencing, report for significant positive patho | Policies naming 0152U |
| 0153U | On the list | Oncology (breast), mRNA, gene expression profiling by next-generation sequencing of 101 genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a tripl | Policies naming 0153U |
| 0154U | On the list | Oncology (urothelial cancer), RNA, analysis by real-time RT-PCR of the FGFR3 (fibroblast growth factor receptor 3) gene analysis (ie, p.R248C [c.742C>T], p.S249C [c.746C>G], p | Policies naming 0154U |
| 0155U | On the list | Oncology (breast cancer), DNA, PIK3CA (phosphatidylinositol-4,5-bisphosphate 3-kinase, catalytic subunit alpha) (eg, breast cancer) gene analysis (ie, p.C420R, p.E542K, p.E545 | Policies naming 0155U |
| 0156U | On the list | Copy number (eg, intellectual disability, dysmorphology), sequence analysis | Policies naming 0156U |
| 0163T | On the list | Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression), each additional interspace, lumbar (Li | Policies naming 0163T |
| 0164T | On the list | Removal of total disc arthroplasty, (artificial disc), anterior approach, each additional interspace, lumbar (List separ | Policies naming 0164T |
| 0164U | On the list | Gastroenterology (irritable bowel syndrome [IBS]), immunoassay for anti-CdtB and anti-vinculin antibodies, utilizing plasma, algorithm for elevated or not elevated qualitative | Policies naming 0164U |
| 0165T | On the list | Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, each additional interspa | Policies naming 0165T |
| 0166U | On the list | Liver disease, 10 biochemical assays (+2-macroglobulin, haptoglobin, apolipoprotein A1, bilirubin, GGT, ALT, AST, triglycerides, cholesterol, fasting glucose) and biometric a | Policies naming 0166U |
| 0169U | On the list | NUDT15 (nudix hydrolase 15) and TPMT (thiopurine S-methyltransferase) (eg, drug metabolism) gene analysis, common variants | Policies naming 0169U |
| 0170U | On the list | Neurology (autism spectrum disorder [ASD]), RNA, next-generation sequencing, saliva, algorithmic analysis, and results reported as predictive probability of ASD diagnosis | Policies naming 0170U |
| 0171U | On the list | Targeted genomic sequence analysis panel, acute myeloid leukemia, myelodysplastic syndrome, and myeloproliferative neoplasms, DNA analysis, 23 genes, interrogation for sequenc | Policies naming 0171U |
| 0172U | On the list | Oncology (solid tumor as indicated by the label), somatic mutation analysis of BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) and analysis of homol | Policies naming 0172U |
| 0173U | On the list | Psychiatry (ie, depression, anxiety), genomic analysis panel, includes variant analysis of 14 gene | Policies naming 0173U |
| 0174U | On the list | Oncology (solid tumor), mass spectrometric 30 protein targets, formalin-fixed paraffin-embedded tissue, prognostic and predictive algorithm reported as likely, unlikely, or un | Policies naming 0174U |
| 0175U | On the list | Psychiatry (eg, depression, anxiety), genomic analysis panel, variant analysis of 15 genes | Policies naming 0175U |
| 0176U | On the list | Cytolethal distending toxin B (CdtB) and vinculin IgG antibodies by immunoassay (ie, ELISA) | Policies naming 0176U |
| 0177U | On the list | Oncology (breast cancer), DNA, PIK3CA (phosphatidylinositol-4,5-bisphosphate 3-kinase catalytic subunit alpha) gene analysis of 11 gene variants utilizing plasma, reported as | Policies naming 0177U |
| 0179U | On the list | Oncology (non-small cell lung cancer), cell-free DNA, targeted sequence analysis of 23 genes (single nucleotide variations, insertions and deletions, fusions without prior kno | Policies naming 0179U |
| 0201T | On the list | Percutaneous sacral augmentation (sacroplasty), bilateral injections, including the use of a balloon or mechanical device, when used, 2 or more needles | Policies naming 0201T |
| 0202T | On the list | Posterior vertebral joint(s) arthroplasty (e.g., facet joint[s] replacement) including facetectomy, laminectomy, foramin | Policies naming 0202T |
| 0203U | On the list | Autoimmune (inflammatory bowel disease), mRNA, gene expression profiling by quantitative RT-PCR, 17 genes (15 target and 2 reference genes), whole blood, reported as a continu | Policies naming 0203U |
| 0204U | Not listed | Policies naming 0204U | |
| 0205U | On the list | Ophthalmology (age-related macular degeneration), analysis of 3 gene variants (2 CFH gene, 1 ARMS2 gene), using PCR and MALDI-TOF, buccal swab, reported as positive or negativ | Policies naming 0205U |
| 0209U | On the list | Cytogenomic constitutional (genome-wide) analysis, interrogation of genomic regions for copy number, structural changes and areas of homozygosity for chromosomal abnormalities | Policies naming 0209U |
| 0211U | On the list | Oncology (pan-tumor), DNA and RNA by next-generation sequencing, utilizing formalin-fixed paraffin-embedded tissue, interpretative report for single nucleotide variants, copy | Policies naming 0211U |
| 0212U | On the list | Rare diseases (constitutional/heritable disorders), whole genome and mitochondrial DNA sequence analysis, including small sequence changes, deletions, duplications, short tand | Policies naming 0212U |
| 0213T | On the list | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joi | Policies naming 0213T |
| 0213U | On the list | Rare diseases (constitutional/heritable disorders), whole genome and mitochondrial DNA sequence analysis, including small sequence changes, deletions, duplications, short tand | Policies naming 0213U |
| 0214T | On the list | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joi | Policies naming 0214T |
| 0214U | On the list | Rare diseases (constitutional/heritable disorders), whole exome and mitochondrial DNA sequence analysis, including small sequence changes, deletions, duplications, short tande | Policies naming 0214U |
| 0215T | On the list | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joi | Policies naming 0215T |
| 0215U | On the list | Rare diseases (constitutional/heritable disorders), whole exome and mitochondrial DNA sequence analysis, including small sequence changes, deletions, duplications, short tande | Policies naming 0215U |
| 0216T | On the list | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joi | Policies naming 0216T |
| 0216U | On the list | Neurology (inherited ataxias), genomic DNA sequence analysis of 12 common genes including small sequence changes, deletions, duplications, short tandem repeat gene expansions | Policies naming 0216U |
| 0217T | On the list | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joi | Policies naming 0217T |
| 0217U | On the list | Neurology (inherited ataxias), genomic DNA sequence analysis of 51 genes including small sequence changes, deletions, duplications, short tandem repeat gene expansions, and va | Policies naming 0217U |
| 0218T | On the list | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joi | Policies naming 0218T |
| 0218U | On the list | Neurology (muscular dystrophy), DMD gene sequence analysis, including small sequence changes, deletions, duplications, and variants in non-uniquely mappable regions, blood or | Policies naming 0218U |
| 0228U | On the list | Oncology (prostate), multianalyte molecular profile by photometric detection of macromolecules adsorbed on nanosponge array slides with machine learning, utilizing first morni | Policies naming 0228U |
| 0229U | On the list | BCAT1 (Branched chain amino acid transaminase 1) and IKZF1 (IKAROS family zinc finger 1) (eg, colorectal cancer) promoter methylation analysis | Policies naming 0229U |
| 0230U | On the list | AR (androgen receptor) (eg, spinal and bulbar muscular atrophy, Kennedy disease, X chromosome inactivation), full sequence analysis, including small sequence changes in exonic | Policies naming 0230U |
| 0231U | On the list | CACNA1A (calcium voltage-gated channel subunit alpha 1A) (eg, spinocerebellar ataxia), full gene analysis, including small sequence changes in exonic and intronic regions, del | Policies naming 0231U |
| 0232T | On the list | Injection(s), platelet rich plasma, any site, including image guidance, harvesting and preparation when performed | Policies naming 0232T |
| 0232U | On the list | CSTB (cystatin B) (eg, progressive myoclonic epilepsy type 1A, Unverricht- Lundborg disease), full gene analysis, including small sequence changes in exonic and intronic region | Policies naming 0232U |
| 0233U | On the list | FXN (frataxin) (eg, Friedreich ataxia), gene analysis, including small sequence changes in exonic and intronic regions, deletions, duplications, short tandem repeat (STR) expa | Policies naming 0233U |
| 0234U | On the list | MECP2 (methyl CpG binding protein 2) (eg, Rett syndrome), full gene analysis, including small sequence changes in exonic and intronic regions, deletions, duplications, mobile | Policies naming 0234U |
| 0235U | On the list | PTEN (phosphatase and tensin homolog) (eg, Cowden syndrome, PTEN hamartoma tumor syndrome), full gene analysis, including small sequence changes in exonic and intronic regions | Policies naming 0235U |
| 0236U | On the list | 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 chan | Policies naming 0236U |
| 0237U | On the list | Cardiac ion channelopathies (eg, Brugada syndrome, long QT syndrome, short QT syndrome, catecholaminergic polymorphic ventricular tachycardia), genomic sequence analysis panel | Policies naming 0237U |
| 0238U | On the list | Oncology (Lynch syndrome), genomic DNA sequence analysis of MLH1, MSH2, MSH6, PMS2, and EPCAM, including small sequence changes in exonic and intronic regions, deletions, dupl | Policies naming 0238U |
| 0239U | On the list | Targeted genomic sequence analysis panel, solid organ neoplasm, cell-free DNA, analysis of 311 or more genes, interrogation for sequence variants, including substitutions, ins | Policies naming 0239U |
| 0242U | On the list | Targeted genomic sequence analysis panel, solid organ neoplasm, cell-free circulating DNA analysis of 55-74 genes, interrogation for sequence variants, gene copy number amplif | Policies naming 0242U |
| 0244U | On the list | Oncology (solid organ), DNA, comprehensive genomic profiling, 257 genes, interrogation for single-nucleotide variants, insertions/deletions, copy number alterations, gene rear | Policies naming 0244U |
| 0245U | On the list | Oncology (thyroid), mutation analysis of 10 genes and 37 RNA fusions and expression of 4 mRNA markers using next-generation sequencing, fine needle aspirate, report includes a | Policies naming 0245U |
| 0247U | On the list | Obstetrics (preterm birth), insulin-like growth factor-binding protein 4 (IBP4), sex hormone-binding globulin (SHBG), quantitative measurement by LC-MS/MS, utilizing maternal | Policies naming 0247U |
| 0249U | On the list | Oncology (breast), semiquantitative analysis of 32 phosphoproteins and | Policies naming 0249U |
| 0250U | On the list | Oncology (solid organ neoplasm), targeted genomic sequence DNA analysi | Policies naming 0250U |
| 0253T | On the list | Insertion of anterior segment aqueous drainage device, without extraocular reservoir; internal approach, into the suprachoroidal space | Policies naming 0253T |
| 0253U | Not listed | Policies naming 0253U | |
| 0254U | On the list | Reproductive medicine (preimplantation genetic assessment), analysis o | Policies naming 0254U |
| 0255U | On the list | Andrology (infertility), sperm-capacitation assessment of ganglioside GM1 distribution patterns, fluorescence microscopy, fresh or frozen specimen, reported as percentage of c | Policies naming 0255U |
| 0258U | On the list | Autoimmune (psoriasis), mRNA, next-generation sequencing, gene expression profiling of 50-100 genes, skin-surface collection using adhesive patch, algorithm reported as likeli | Policies naming 0258U |
| 0260U | On the list | Rare diseases (constitutional/heritable disorders), identification of copy number variations, inversions, insertions, translocations, and other structural variants by optical | Policies naming 0260U |
| 0262U | On the list | 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), algori | Policies naming 0262U |
| 0263T | On the list | Intramuscular autologous bone marrow cell therapy, with preparation of harvested cells, multiple injections, one leg, including ultrasound guidance, if performed; complete pro | Policies naming 0263T |
| 0264T | On the list | Intramuscular autologous bone marrow cell therapy, with preparation of harvested cells, multiple injections, one leg, including ultrasound guidance, if performed; complete pro | Policies naming 0264T |
| 0264U | On the list | Rare diseases (constitutional/heritable disorders), identification of copy number variations, inversions, insertions, translocations, and other structural variants by optical | Policies naming 0264U |
| 0265T | On the list | Intramuscular autologous bone marrow cell therapy, with preparation of harvested cells, multiple injections, one leg, including ultrasound guidance, if performed; unilateral o | Policies naming 0265T |
| 0265U | On the list | Rare constitutional and other heritable disorders, whole genome and mitochondrial DNA sequence analysis, blood, frozen and formalin-fixed paraffin- embedded (FFPE) tissue, sali | Policies naming 0265U |
| 0266U | On the list | Unexplained constitutional or other heritable disorders or syndromes, tissue- specific gene expression by whole-transcriptome and next-generation sequencing, blood, formalin-fi | Policies naming 0266U |
| 0267U | On the list | Rare constitutional and other heritable disorders, identification of copy number variations, inversions, insertions, translocations, and other structural variants by optical g | Policies naming 0267U |
| 0268U | On the list | Hematology (atypical hemolytic uremic syndrome [aHUS]), genomic sequence analysis of 15 genes, blood, buccal swab, or amniotic fluid | Policies naming 0268U |
| 0269U | On the list | Hematology (autosomal dominant congenital thrombocytopenia), genomic sequence analysis of 14 genes, blood, buccal swab, or amniotic fluid | Policies naming 0269U |
| 0270U | On the list | Hematology (congenital coagulation disorders), genomic sequence analysis of 20 genes, blood, buccal swab, or amniotic fluid | Policies naming 0270U |
| 0271U | On the list | Hematology (congenital neutropenia), genomic sequence analysis of 23 genes, blood, buccal swab, or amniotic fluid | Policies naming 0271U |
| 0272U | On the list | Hematology (genetic bleeding disorders), genomic sequence analysis of 51 genes, blood, buccal swab, or amniotic fluid, comprehensive | Policies naming 0272U |
| 0273U | On the list | Hematology (genetic hyperfibrinolysis, delayed bleeding), genomic sequence analysis of 8 genes (F13A1, F13B, FGA, FGB, FGG, SERPINA1, SERPINE1, SERPINF2, PLAU), blood, buccal | Policies naming 0273U |
| 0274T | On the list | Percutaneous laminotomy/laminectomy (interlaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or forami | Policies naming 0274T |
| 0274U | On the list | Hematology (genetic platelet disorders), genomic sequence analysis of 43 genes, blood, buccal swab, or amniotic fluid | Policies naming 0274U |
| 0275T | Not listed | Policies naming 0275T | |
| 0276U | On the list | Hematology (inherited thrombocytopenia), genomic sequence analysis of 23 genes, blood, buccal swab, or amniotic fluid | Policies naming 0276U |
| 0277U | On the list | Hematology (genetic platelet function disorder), genomic sequence analysis of 31 genes, blood, buccal swab, or amniotic fluid | Policies naming 0277U |
| 0278U | On the list | Hematology (genetic thrombosis), genomic sequence analysis of 12 genes, blood, buccal swab, or amniotic fluid | Policies naming 0278U |
| 0285U | On the list | Oncology, disease progression and response monitoring to radiation, chemotherapy, or other systematic cancer treatments, cell-free DNA, quantitative branched chain DNA amplifi | Policies naming 0285U |
| 0286U | On the list | CEP72 (centrosomal protein, 72-KDa), NUDT15 (nudix hydrolase 15) and TPMT (thiopurine S-methyltransferase) (eg, drug metabolism) gene analysis, common variants | Policies naming 0286U |
| 0287U | On the list | Oncology (thyroid), DNA and mRNA, next-generation sequencing analysis of 112 genes, fine needle aspirate or formalin-fixed paraffin-embedded (FFPE) tissue, algorithmic predict | Policies naming 0287U |
| 0288U | On the list | 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) | Policies naming 0288U |
| 0289U | On the list | Neurology (Alzheimer disease), mRNA, gene expression profiling by RNA sequencing of 24 genes, whole blood, algorithm reported as predictive risk score | Policies naming 0289U |
| 0290U | On the list | Pain management, mRNA, gene expression profiling by RNA sequencing of 36 genes, whole blood, algorithm reported as predictive risk score | Policies naming 0290U |
| 0291U | On the list | Psychiatry (mood disorders), mRNA, gene expression profiling by RNA sequencing of 144 genes, whole blood, algorithm reported as predictive risk score | Policies naming 0291U |
| 0292U | On the list | Psychiatry (stress disorders), mRNA, gene expression profiling by RNA sequencing of 72 genes, whole blood, algorithm reported as predictive risk score | Policies naming 0292U |
| 0293U | On the list | Psychiatry (suicidal ideation), mRNA, gene expression profiling by RNA sequencing of 54 genes, whole blood, algorithm reported as predictive risk score | Policies naming 0293U |
| 0294U | On the list | Longevity and mortality risk, mRNA, gene expression profiling by RNA sequencing of 18 genes, whole blood, algorithm reported as predictive risk score | Policies naming 0294U |
| 0296U | On the list | Oncology (oral and/or oropharyngeal cancer), gene expression profiling by RNA sequencing at least 20 molecular features (eg, human and/or microbial mRNA), saliva, algorithm re | Policies naming 0296U |
And 3,004 more in the original policy.
All Anthem Blue Cross and Blue Shield Nevada policies · Anthem Blue Cross and Blue Shield Nevada prior authorization CPT list