Anthem Blue Cross Blue Shield of California policy
California PPO Prior Authorization List
California PPO Prior Authorization List is a public Anthem Blue Cross Blue Shield of California policy. It lists 3,545 CPT or HCPCS codes, 2918 of them on the Anthem Blue Cross Blue Shield of California prior authorization list. Not a coverage decision; the payer's own document governs.
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- Line of business
- Commercial
- States
- CA
- Source
- www.anthem.com
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 Blue Shield of California prior authorization list.
| Code | Prior authorization | Description on the prior authorization list | Other Anthem Blue Cross Blue Shield of California 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 | |
| 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 |
| 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 | |
| 0002M | On the list | Liver disease, ten biochemical assays (ALT, A2- macroglobulin, apolipoprotein A-1, total bilirubin, GGT, haptoglobin, AST, glucose, total cholesterol and triglycerides) utilizing serum, prognostic algorithm reported as quantitative scores for fibrosis, steatosis and alcoholic steatohepatitis (ASH) | Policies naming 0002M |
| 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 | |
| 0003M | On the list | Liver disease, ten biochemical assays (ALT, A2- macroglobulin, apolipoprotein A-1, total bilirubin, GGT, haptoglobin, AST, glucose, total cholesterol and triglycerides) utilizing serum, prognostic algorithm reported as quantitative scores for fibrosis, steatosis and nonalcoholic steatohepatitis (NASH) | Policies naming 0003M |
| 00040 | Not listed | Policies naming 00040 | |
| 00041 | Not listed | Policies naming 00041 | |
| 00042 | Not listed | Policies naming 00042 | |
| 00043 | Not listed | Policies naming 00043 | |
| 00044 | Not listed | Policies naming 00044 | |
| 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 | |
| 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 | |
| 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 | |
| 00063 | Not listed | Policies naming 00063 | |
| 00064 | Not listed | Policies naming 00064 | |
| 00065 | Not listed | Policies naming 00065 | |
| 00067 | Not listed | Policies naming 00067 | |
| 00068 | Not listed | Policies naming 00068 | |
| 00069 | Not listed | Policies naming 00069 | |
| 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 classifier. Lab tests for alpha-fetoprotein and for mRNA gene expression profiling for 161 genes using fresh tumor tissue from hepatocellular carcinoma. The test also includes an algorithmic analysis using patient data and the lab test results to report a risk classification score. | Policies naming 0006M |
| 00071 | Not listed | Policies naming 00071 | |
| 00072 | Not listed | Policies naming 00072 | |
| 00073 | Not listed | Policies naming 00073 | |
| 00075 | Not listed | Policies naming 00075 | |
| 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 disease index | Policies naming 0007M |
| 00082 | Not listed | Policies naming 00082 | |
| 00084 | Not listed | Policies naming 00084 | |
| 00087 | Not listed | Policies naming 00087 | |
| 00088 | Not listed | Policies naming 00088 | |
| 00089 | Not listed | Policies naming 00089 | |
| 00090 | Not listed | Policies naming 00090 | |
| 00091 | Not listed | Policies naming 00091 | |
| 00092 | Not listed | Policies naming 00092 | |
| 00095 | Not listed | Policies naming 00095 | |
| 00096 | Not listed | Policies naming 00096 | |
| 00097 | Not listed | Policies naming 00097 | |
| 00098 | Not listed | Policies naming 00098 | |
| 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 | |
| 00105 | Not listed | Policies naming 00105 | |
| 00107 | Not listed | Policies naming 00107 | |
| 00110 | Not listed | Policies naming 00110 | |
| 00111 | Not listed | Policies naming 00111 | |
| 00112 | Not listed | Policies naming 00112 | |
| 00113 | Not listed | Policies naming 00113 | |
| 00114 | Not listed | Policies naming 00114 | |
| 00115 | Not listed | Policies naming 00115 | |
| 00116 | Not listed | Policies naming 00116 | |
| 00118 | Not listed | Policies naming 00118 | |
| 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/or urine, algorithms to predict high-grade prostate cancer risk | Policies naming 0011M |
| 00120 | Not listed | Policies naming 00120 | |
| 00121 | Not listed | Policies naming 00121 | |
| 00123 | Not listed | Policies naming 00123 | |
| 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 CXCR2), utilizing urine, algorithm reported as a risk score for having urothelial carcinoma | Policies naming 0012M |
| 00130 | Not listed | Policies naming 00130 | |
| 00131 | Not listed | Policies naming 00131 | |
| 00132 | Not listed | Policies naming 00132 | |
| 00133 | Not listed | Policies naming 00133 | |
| 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 reported as a risk score for having recurrent urothelial carcinoma | 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 | |
| 00148 | Not listed | Policies naming 00148 | |
| 00149 | Not listed | Policies naming 00149 | |
| 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 209 genes, utilizing formalin-fixed paraffin- embedded tissue, algorithm reported as molecular subtype (luminal, luminal infiltrated, basal, basal claudin-low, neuroendocrine-like) | 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 detected or detected with quantitation | 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, algorithm reported as cell of origin | 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 detected | Policies naming 0017U |
| 0018M | Not listed | 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 high risk of malignancy | 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 targets for therapeutic agents | 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 presence or absence of variants and associated therapy(ies) to consider | 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 mutation and indication for or against the use of midostaurin | 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 ("Positive, high probability of malignancy" or "Negative, low probability of malignancy) | Policies naming 0026U |
| 0027U | On the list | JAK2 (Janus kinase 2) (e.g., myeloproliferative disorder) gene analysis, targeted sequence analysis exons 12-15 | Policies naming 0027U |
| 0029U | Not listed | Policies naming 0029U | |
| 0030U | On the list | Drug metabolism (warfarin drug response), targeted sequence analysis (i.e., CYP2C9, CYP4F2, VKORC1, rs12777823) | Policies naming 0030U |
| 0031U | Not listed | 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)(e.g., thiopurine metabolism), gene analysis, common variants (i.e., TPMT *2, *3A, *3B, *3C, *4, *5, *6, *8, *12; NUDT15 *3, *4, *5) | Policies naming 0034U |
| 0036U | On the list | Exome (i.e., 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, microsatellite instability and tumor mutational burden | Policies naming 0037U |
| 0040U | On the list | BCR/ABL1 (t(9;22)) (e.g., chronic myelogenous leukemia) translocation analysis, major breakpoint, quantitative | Policies naming 0040U |
| 0042T | Not listed | Policies naming 0042T | |
| 0045U | On the list | Oncology (breast ductal carcinoma in situ), mRNA, gene expression profiling by realtime RT-PCR of 12 genes (7 content and 5 housekeeping), utilizing formalin-fixed paraffin- embedded tissue, algorithm reported as recurrence score | Policies naming 0045U |
| 0046U | On the list | FLT3 (fms-related tyrosine kinase 3) (e.g., 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, algorithm reported as a risk score | 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 microsatellite instability, matched with normal specimens, utilizing formalin-fixed paraffin-embedded tumor tissue, report of clinically significant mutation(s) | Policies naming 0048U |
| 0049U | On the list | NPM1 (nucleophosmin) (e.g., 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 |
| 0052U | Not listed | Policies naming 0052U | |
| 00530 | Not listed | Policies naming 00530 | |
| 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 for heart transplant or heart/lung transplant | Policies naming 00580 |
| 0062U | Not listed | 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) (e.g., drug metabolism) gene analysis, common and select rare variants (i.e., *2, *3, *4, *4N, *5, *6, *7, *8, *9, *10, *11, *12, *13, *14A, *14B, *15, *17, *29, *35, *36, *41, *57, *61, *63, *68, *83, *xN) | Policies naming 0070U |
| 0071T | On the list | Focused ultrasound ablation of uterine leiomyomata, including MR guidance; total leiomyomata volume less than 200 cc of tissue | Policies naming 0071T |
| 0071U | On the list | CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (e.g., drug metabolism) gene analysis, full gene sequence (List separately in addition to code for primary procedure) | Policies naming 0071U |
| 0072T | On the list | Focused ultrasound ablation of uterine leiomyomata, including MR guidance; total leiomyomata volume greater or equal to 200 cc of tissue | Policies naming 0072T |
| 0072U | On the list | CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (e.g., drug metabolism) gene analysis, targeted sequence analysis (i.e., CYP2D6-2D7 hybrid gene) (List separately in addition to code for primary procedure) | Policies naming 0072U |
| 00731 | On the list | Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum; not otherwise specified | Policies naming 00731 |
| 00732 | On the list | Anesthesia for upper gastrointestinal endoscopic procedures; endoscopic retrograde cholangiopancreatography [ERCP] | Policies naming 00732 |
| 0073U | On the list | CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (e.g., drug metabolism) gene analysis, targeted sequence analysis (i.e., CYP2D7-2D6 hybrid gene) (List separately in addition to code for primary procedure) | Policies naming 0073U |
| 0074U | On the list | CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (e.g., drug metabolism) gene analysis, targeted sequence analysis (i.e., non-duplicated gene when duplication/multiplication is trans) (List separately in addition to code for primary procedure) | Policies naming 0074U |
| 0075T | Not listed | Policies naming 0075T | |
| 0075U | On the list | CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (e.g., drug metabolism) gene analysis, targeted sequence analysis (i.e., 5’ gene duplication/multiplication) (List separately in addition to code for primary procedure) | Policies naming 0075U |
| 0076T | Not listed | Policies naming 0076T | |
| 0076U | On the list | CYP2D6 (cytochrome P450, family 2, subfamily D, polypeptide 6) (e.g., drug metabolism) gene analysis, targeted sequence analysis (i.e., 3’ gene duplication/ multiplication) (List separately in addition to code for primary procedure) | Policies naming 0076U |
| 00796 | On the list | Anesthesia for intraperitoneal procedures in upper abdomen including laparoscopy; liver transplant (recipient) | Policies naming 00796 |
| 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, smoking status, nodule diameter, nodule-spiculation status and nodule location), utilizing plasma, algorithm reported as a categorical probability of malignancy | Policies naming 0080U |
| 00811 | On the list | Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum; not otherwise specified | Policies naming 00811 |
| 00812 | On the list | Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum; not otherwise specified; screening colonoscopy | Policies naming 00812 |
| 00813 | On the list | Anesthesia for combined upper and lower gastrointestinal endoscopic procedures, endoscope introduced both proximal to and distal to the duodenum | Policies naming 00813 |
| 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 probability score | 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 probability score for rejection. | 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, algorithm reported as a categorical result (i.e., benign, intermediate, malignant) | Policies naming 0090U |
| 0091U | Not listed | Policies naming 0091U | |
| 0092U | Not listed | Policies naming 0092U | |
| 0094U | On the list | Genome (e.g., 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 primary procedure) | Policies naming 0098T |
| 0100T | On the list | Placement of a subconjunctival retinal prosthesis receiver and pulse generator, and implantation of intra-ocular retinal electrode array, with vitrectomy | Policies naming 0100T |
| 0101T | On the list | Extracorporeal shock wave involving musculoskeletal system, not otherwise specified | Policies naming 0101T |
| 0101U | On the list | Hereditary colon cancer disorders (e.g., Lynch syndrome, PTEN hamartoma syndrome, Cowden syndrome, familial adenomatosis polyposis), genomic sequence analysis panel utilizing a combination of NGS, Sanger, MLPA, and array CGH, with MRNA analytics to resolve variants of unknown significance when indicated (15 genes [sequencing and deletion/duplication], EPCAM and GREM1 [deletion/duplication only]) | 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 (e.g., hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer), genomic sequence analysis panel utilizing a combination of NGS, Sanger, MLPA, and array CGH, with MRNA analytics to resolve variants of unknown significance when indicated (17 genes [sequencing and deletion/duplication]) | Policies naming 0102U |
| 0103U | On the list | Hereditary ovarian cancer (e.g., hereditary ovarian cancer, hereditary endometrial cancer), genomic sequence analysis panel utilizing a combination of NGS, Sanger, MLPA, and array CGH, with MRNA analytics to resolve variants of unknown significance when indicated (24 genes [sequencing and deletion/duplication], EPCAM [deletion/duplication only]) | 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 kidney injury molecule-1 (KIM-1) combined with longitudinal clinical data, including APOL1 genotype if available, and plasma (isolated fresh or frozen), algorithm reported as probability score for rapid kidney function decline (RKFD) | Policies naming 0105U |
| 0106T | On the list | Quantitative sensory testing (QST), testing and interpretation per extremity; using touch pressure stimuli to assess large diameter sensation | Policies naming 0106T |
| 0107T | On the list | Quantitative sensory testing (QST), testing and interpretation per extremity; using vibration stimuli to assess large diameter fiber sensation | Policies naming 0107T |
| 0108T | On the list | Quantitative sensory testing (QST), testing and interpretation per extremity; using cooling stimuli to assess small nerve fiber sensation and hyperalgesia | Policies naming 0108T |
| 0109T | On the list | Quantitative sensory testing (QST), testing and interpretation per extremity; using heat-pain stimuli to assess small nerve fiber sensation and hyperalgesia | Policies naming 0109T |
| 0110T | On the list | Quantitative sensory testing (QST), testing and interpretation per extremity; using other stimuli to assess sensation | Policies naming 0110T |
| 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, algorithm reported as risk score | Policies naming 0113U |
| 0117U | On the list | Pain management, analysis of 11 endogenous analytes (methylmalonic acid, xanthurenic acid, homocysteine, pyroglutamic acid, vanilmandelate, 5-hydroxyindoleacetic acid, hydroxymethylglutarate, ethylmalonate, 3-hydroxypropyl mercapturic acid (3-HPMA), quinolinic acid, kynurenic acid), LC-MS/MS, urine, algorithm reported as a pain-index score with likelihood of atypical biochemical function associated with pain | Policies naming 0117U |
| 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-free DNA in the total cell-free DNA [when specified for heart transplant rejection] | 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- fixed paraffin-embedded tissue, algorithm reported as likelihood for primary mediastinal B-cell lymphoma (PMBCL) and diffuse large B-cell lymphoma (DLBCL) with cell of origin subtyping in the latter | Policies naming 0120U |
| 0130U | On the list | Hereditary colon cancer disorders (e.g., Lynch syndrome, PTEN hamartoma syndrome, Cowden syndrome, familial adenomatosis polyposis), targeted mRNA sequence analysis panel (APC, CDH1, CHEK2, MLH1, MSH2, MSH6, MUTYH, PMS2, PTEN, and TP53) | Policies naming 0130U |
| 0131U | Not listed | Policies naming 0131U | |
| 0132U | Not listed | Policies naming 0132U | |
| 0133U | On the list | Hereditary prostate cancer-related disorders, targeted mRNA sequence analysis panel (11 genes) | Policies naming 0133U |
| 0134U | On the list | Hereditary pan cancer (e.g., hereditary breast and ovarian cancer, hereditary endometrial cancer, hereditary colorectal cancer), targeted mRNA sequence analysis panel (18 genes) (List separately in addition to code for primary procedure) | Policies naming 0134U |
| 0135U | Not listed | Policies naming 0135U | |
| 0136U | On the list | ATM (ataxia telangiectasia mutated) (e.g., ataxia telangiectasia) mRNA sequence analysis | Policies naming 0136U |
| 0137U | On the list | PALB2 (partner and localizer of BRCA2) (e.g., breast and pancreatic cancer) mRNA sequence analysis | Policies naming 0137U |
| 0138U | On the list | BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (e.g., hereditary breast and ovarian cancer) mRNA sequence analysis | Policies naming 0138U |
| 0141U | Not listed | Policies naming 0141U | |
| 0142U | Not listed | Policies naming 0142U | |
| 0152U | On the list | Infectious disease (bacteria, fungi, parasites, and DNA viruses), DNA, plasma, untargeted next-generation sequencing, report for significant positive pathogens | 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 triple negative breast cancer clinical subtype(s) with information on immune cell involvement | 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 (i.e., p.R248C [c.742C>T], p.S249C [c.746C>G], p.G370C [c.1108G>T], p.Y373C [c.1118A>G], FGFR3- TACC3v1, and FGFR3-TACC3 v3), utilizing formalin-fixed paraffin-embedded urothelial cancer tumor tissue, reported as FGFR gene alteration status | Policies naming 0154U |
| 0155U | On the list | Oncology (breast cancer), DNA, PIK3CA (phosphatidylinositol- 4,5- bisphosphate 3-kinase, catalytic subunit alpha) (e.g., breast cancer) gene analysis (i.e., p.C420R, p.E542K, p.E545A, p.E545D [g.1635G>T only], p.E545G, p.E545K, p.Q546E, p.Q546R, p.H1047L, p.H1047R, p.H1047Y), utilizing formalin-fixed paraffin-embedded breast tumor tissue, reported as PIK3CA gene mutation status | Policies naming 0155U |
| 0156U | On the list | Copy number (e.g., intellectual disability, dysmorphology), sequence analysis | Policies naming 0156U |
| 0157U | On the list | APC (APC regulator of WNT signaling pathway) (e.g., familial adenomatosis polyposis [FAP]) mRNA sequence analysis | Policies naming 0157U |
| 0158U | On the list | MLH1 (mutL homolog 1) (e.g., hereditary non-polyposis colorectal cancer, Lynch syndrome) mRNA sequence analysis | Policies naming 0158U |
| 0159U | On the list | MSH2 (mutS homolog 2) (e.g., hereditary colon cancer, Lynch syndrome) mRNA sequence analysis | Policies naming 0159U |
| 0160U | On the list | MSH6 (mutS homolog 6) (e.g., hereditary colon cancer, Lynch syndrome) mRNA sequence analysis | Policies naming 0160U |
| 0161U | On the list | PMS2 (PMS1 homolog 2, mismatch repair system component) (e.g., hereditary non-polyposis colorectal cancer, Lynch syndrome) mRNA sequence analysis | Policies naming 0161U |
| 0162U | On the list | Hereditary colon cancer (Lynch syndrome), targeted mRNA sequence analysis panel (MLH1, MSH2, MSH6, PMS2) | Policies naming 0162U |
| 0164T | Not listed | Policies naming 0164T | |
| 0164U | On the list | Gastroenterology (irritable bowel syndrome [IBS]), immunoassay for antiCdtB and anti-vinculin antibodies, utilizing plasma, algorithm for elevated or not elevated qualitative results | Policies naming 0164U |
| 0165T | Not listed | Policies naming 0165T | |
| 0166U | On the list | Liver disease, 10 biochemical assays (α2-macroglobulin, haptoglobin, apolipoprotein A1, bilirubin, GGT, ALT, AST, triglycerides, cholesterol, fasting glucose) and biometric and demographic data, utilizing serum, algorithm reported as scores for fibrosis, necroinflammatory activity, and steatosis with a summary interpretation | Policies naming 0166U |
| 0169U | On the list | NUDT15 (nudix hydrolase 15) and TPMT (thiopurine S- methyltransferase) (e.g., 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 sequence variants, rearrangements and minimal residual disease, reported as presence/absence | 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 homologous recombination deficiency pathways, DNA, formalin-fixed paraffin-embedded tissue, algorithm quantifying tumor genomic instability score | Policies naming 0172U |
| 0173U | On the list | Psychiatry (i.e., depression, anxiety), genomic analysis panel, includes variant analysis of 14 genes | Policies naming 0173U |
| 0174U | Not listed | Policies naming 0174U | |
| 0175U | On the list | Psychiatry (e.g., depression, anxiety), genomic analysis panel, variant analysis of 15 genes | Policies naming 0175U |
| 0176U | Not listed | 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 PIK3CA gene mutation status | 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 knowledge of partner/breakpoint, copy number variations), with report of significant mutation(s) | Policies naming 0179U |
| 01937 | On the list | Anesthesia for percutaneous image-guided injection, drainage or aspiration procedures on the spine or spinal cord; cervical or thoracic | Policies naming 01937 |
| 01938 | On the list | Anesthesia for percutaneous image-guided injection, drainage or aspiration procedures on the spine or spinal cord; lumbar or sacral | Policies naming 01938 |
| 01939 | On the list | Anesthesia for percutaneous image-guided destruction procedures by neurolytic agent on the spine or spinal cord; cervical or thoracic | Policies naming 01939 |
| 01940 | On the list | Anesthesia for percutaneous image-guided destruction procedures by neurolytic agent on the spine or spinal cord; lumbar or sacral | Policies naming 01940 |
| 01941 | On the list | Anesthesia for percutaneous image-guided neuromodulation or intravertebral procedures (e.g., kyphoplasty, vertebroplasty) on the spine or spinal cord; cervical or thoracic | Policies naming 01941 |
| 01942 | On the list | Anesthesia for percutaneous image-guided neuromodulation or intravertebral procedures (e.g., kyphoplasty, vertebroplasty) on the spine or spinal cord; lumbar or sacral | Policies naming 01942 |
| 01991 | On the list | Anesthesia for diagnostic or therapeutic nerve blocks and injections (when block or injection is performed by a different physician or other qualified health care professional); other than the prone position | Policies naming 01991 |
| 01992 | On the list | Anesthesia for diagnostic or therapeutic nerve blocks and injections (when block or injection is performed by a different physician or other qualified health care professional); prone position | Policies naming 01992 |
| 0200T | On the list | Percutaneous sacral augmentation (sacroplasty), unilateral injection(s), including the use of a balloon or mechanical device, when used, 1 or more needles | Policies naming 0200T |
| 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, foraminotomy and vertebral column fixation, with or without injection of bone cement, including fluoroscopy, single level, lumbar spine | 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 continuous risk score and classification of inflammatory bowel disease aggressiveness | Policies naming 0203U |
| 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 negative for neovascular age-related macular-degeneration risk associated with zinc supplements | Policies naming 0205U |
| 0206U | Not listed | Policies naming 0206U | |
| 0207T | On the list | Evacuation of meibomian glands, automated, using heat and intermittent pressure, unilateral | Policies naming 0207T |
| 0207U | On the list | Neurology (Alzheimer disease); quantitative imaging of phosphorylated ERK1 and ERK2 in response to bradykinin treatment by in situ immunofluorescence, using cultured skin fibroblasts, reported as a probability index for Alzheimer disease | Policies naming 0207U |
| 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 number alterations, tumor mutational burden, and microsatellite instability, with therapy association | 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 tandem repeat gene expansions, and variants in non-uniquely mappable regions, blood or saliva, identification and categorization of genetic variants, proband | Policies naming 0212U |
| 0213T | On the list | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; single level | 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 tandem repeat gene expansions, and variants in non-uniquely mappable regions, blood or saliva, identification and categorization of genetic variants, each comparator genome (e.g., parent, sibling) | Policies naming 0213U |
| 0214T | On the list | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; second level (List separately in addition to code for primary procedure) | 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 tandem repeat gene expansions, and variants in non-uniquely mappable regions, blood or saliva, identification and categorization of genetic variants, proband | Policies naming 0214U |
| 0215T | On the list | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; third and any additional level(s) (List separately in addition to code for primary procedure) | 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 tandem repeat gene expansions, and variants in non-uniquely mappable regions, blood or saliva, identification and categorization of genetic variants, each comparator exome (e.g., parent, sibling) | Policies naming 0215U |
| 0216T | On the list | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; single level | 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, and variants in non-uniquely mappable regions, blood or saliva, identification and categorization of genetic variants | Policies naming 0216U |
| 0217T | On the list | Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; second level (List separately in addition to code for primary procedure) | 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 variants in non-uniquely mappable regions, blood or saliva, identification and categorization of genetic variants | Policies naming 0217U |
| 0218T | Not listed | 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 saliva, identification and characterization of genetic variants | Policies naming 0218U |
| 0219T | Not listed | Policies naming 0219T | |
| 0220T | Not listed | Policies naming 0220T | |
| 0221T | Not listed | Policies naming 0221T | |
| 0222T | Not listed | Policies naming 0222T | |
| 0228T | On the list | Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, cervical or thoracic; single level | Policies naming 0228T |
| 0228U | Not listed | Policies naming 0228U | |
| 0229T | On the list | Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, cervical or thoracic; each additional level (List separately in addition to code for primary procedure) | Policies naming 0229T |
| 0229U | On the list | BCAT1 (Branched chain amino acid transaminase 1) or IKZF1 (IKAROS family zinc finger 1) (e.g., colorectal cancer) promoter methylation analysis | Policies naming 0229U |
| 0230T | On the list | Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, lumbar or sacral; single level | Policies naming 0230T |
| 0230U | On the list | AR (androgen receptor) (e.g., spinal and bulbar muscular atrophy, Kennedy disease, X chromosome inactivation), full sequence analysis, including small sequence changes in exonic and intronic regions, deletions, duplications, short tandem repeat (STR) expansions, mobile element insertions, and variants in non-uniquely mappable regions | Policies naming 0230U |
| 0231T | On the list | Injection(s), anesthetic agent and/or steroid, transforaminal epidural, with ultrasound guidance, lumbar or sacral; each additional level (List separately in addition to code for primary procedure) | Policies naming 0231T |
| 0231U | On the list | CACNA1A (calcium voltage-gated channel subunit alpha 1A) (e.g., spinocerebellar ataxia), full gene analysis, including small sequence changes in exonic and intronic regions, deletions, duplications, short tandem repeat (STR) gene expansions, mobile element insertions, and variants in non- uniquely mappable regions | Policies naming 0231U |
| 0232T | On the list | Injection(s), platelet rich plasma, any tissue, including image guidance, harvesting and preparation when performed | Policies naming 0232T |
| 0232U | On the list | CSTB (cystatin B) (e.g., progressive myoclonic epilepsy type 1A, Unverricht-Lundborg disease), full gene analysis, including small sequence changes in exonic and intronic regions, deletions, duplications, short tandem repeat (STR) expansions, mobile element insertions, and variants in non- uniquely mappable regions | Policies naming 0232U |
And 3,245 more in the original policy.
All Anthem Blue Cross Blue Shield of California policies · Anthem Blue Cross Blue Shield of California prior authorization CPT list