Anthem Blue Cross Blue Shield of Georgia policy
SHBP Prior Authorization Requirements
SHBP Prior Authorization Requirements is a public Anthem Blue Cross Blue Shield of Georgia policy. It lists 2,569 CPT or HCPCS codes, 2046 of them on the Anthem Blue Cross Blue Shield of Georgia prior authorization list. Not a coverage decision; the payer's own document governs.
View the original policy (PDF) ↗
- Line of business
- Commercial
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- GA
- 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 Georgia prior authorization list.
| Code | Prior authorization | Description on the prior authorization list | Other Anthem Blue Cross Blue Shield of Georgia policies |
|---|---|---|---|
| 00003 | Not listed | Policies naming 00003 | |
| 00004 | Not listed | Policies naming 00004 | |
| 00005 | Not listed | Policies naming 00005 | |
| 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 | |
| 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 | |
| 00035 | Not listed | Policies naming 00035 | |
| 00037 | Not listed | Policies naming 00037 | |
| 00041 | Not listed | Policies naming 00041 | |
| 00046 | Not listed | Policies naming 00046 | |
| 00047 | Not listed | Policies naming 00047 | |
| 00049 | Not listed | Policies naming 00049 | |
| 00052 | Not listed | Policies naming 00052 | |
| 00053 | Not listed | Policies naming 00053 | |
| 00057 | Not listed | Policies naming 00057 | |
| 00059 | Not listed | Policies naming 00059 | |
| 00061 | Not listed | Policies naming 00061 | |
| 00062 | Not listed | Policies naming 00062 | |
| 00070 | Not listed | Policies naming 00070 | |
| 00071 | Not listed | Policies naming 00071 | |
| 00072 | Not listed | Policies naming 00072 | |
| 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 | |
| 00098 | Not listed | Policies naming 00098 | |
| 00103 | Not listed | Policies naming 00103 | |
| 00104 | Not listed | Policies naming 00104 | |
| 00107 | Not listed | Policies naming 00107 | |
| 00111 | Not listed | Policies naming 00111 | |
| 00115 | Not listed | Policies naming 00115 | |
| 00118 | Not listed | Policies naming 00118 | |
| 00120 | Not listed | Policies naming 00120 | |
| 00121 | Not listed | Policies naming 00121 | |
| 00123 | Not listed | Policies naming 00123 | |
| 00129 | Not listed | Policies naming 00129 | |
| 00131 | Not listed | Policies naming 00131 | |
| 00135 | Not listed | Policies naming 00135 | |
| 00140 | Not listed | Policies naming 00140 | |
| 00141 | Not listed | Policies naming 00141 | |
| 00144 | Not listed | Policies naming 00144 | |
| 00145 | Not listed | Policies naming 00145 | |
| 00150 | Not listed | Policies naming 00150 | |
| 00152 | Not listed | Policies naming 00152 | |
| 00153 | Not listed | Policies naming 00153 | |
| 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 | |
| 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 |
| 00170 | On the list | Anesthesia for intraoral procedures, including biopsy; not otherwise specified | Policies naming 00170 |
| 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 |
| 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 |
| 0027U | On the list | JAK2 (Janus kinase 2) (eg, myeloproliferative disorder) gene analysis, targeted sequence analysis exons 12-15 | Policies naming 0027U |
| 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, microsatellite instability and tumor mutational burden | 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-embedded tissue, algorithm reported as recurrence score | 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 |
| 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) (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 | |
| 00580 | On the list | Anesthesia for heart transplant or heart/lung transplant | Policies naming 00580 |
| 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 |
| 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 |
| 0075T | Not listed | Policies naming 0075T | |
| 0076T | Not listed | Policies naming 0076T | |
| 00796 | On the list | Anesthesia, Intraperitoneal Proc, Upper Abdomen, W/Laparoscopy; Liver Transplant, Recipient | Policies naming 00796 |
| 00797 | Not listed | Policies naming 00797 | |
| 00802 | Not listed | Policies naming 00802 | |
| 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 | Policies naming 0095T |
| 0098T | On the list | Revision including replacement of total disc arthroplasty (artificial disc), anterior approach, each additional interspace, cervical | Policies naming 0098T |
| 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 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 |
| 0102U | On the list | Hereditary breast cancer-related disorders (eg, 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])(cid:9) | 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 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 |
| 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 |
| 0129U | On the list | Hereditary breast cancer-related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer), genomic sequence analysis and deletion/duplication analysis panel (ATM, BRCA1, BRCA2, CDH1, CHEK2, PALB2, PTEN, and TP53) | Policies naming 0129U |
| 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 (ie, p.R248C [c.742C>T], p.S249C [c.746C>G], p.G370C [c.1108G>T], p.Y373C [c.1118A>G], FGFR3- TACC3v1, and FGFR3-TACC3v3) 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) (eg, breast cancer) gene analysis (ie, 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 |
| 0163T | Not listed | Policies naming 0163T | |
| 0164T | Not listed | Policies naming 0164T | |
| 0165T | Not listed | Policies naming 0165T | |
| 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 |
| 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 |
| 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 (eg, facet joint[s] replacement), including facetectomy, laminectomy, foraminotomy, and vertebral column fixation, injection of bone cement, when performed, including fluoroscopy, single level, lumbar spine | Policies naming 0202T |
| 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 |
| 0207U | Not listed | 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 (eg, parent, sibling) | Policies naming 0213U |
| 0214T | On the list | njection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; second level | 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) | 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 (eg, 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(cid:9) | 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 | 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 |
| 0228T | Not listed | Policies naming 0228T | |
| 0229T | Not listed | Policies naming 0229T | |
| 0229U | On the list | BCAT1 (Branched chain amino acid transaminase 1) or IKZF1 (IKAROS family zinc finger 1) (eg, colorectal cancer) promoter methylation analysis | Policies naming 0229U |
| 0230T | Not listed | Policies naming 0230T | |
| 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 and intronic regions, deletions, duplications, short tandem repeat (STR) expansions, mobile element insertions, and variants in non-uniquely mappable regions | Policies naming 0230U |
| 0231T | Not listed | Policies naming 0231T | |
| 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, deletions, duplications, short tandem repeat (STR) gene expansions, mobile element insertions, and variants in non- uniquely mappable regions | Policies naming 0231U |
| 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 regions, deletions, duplications, short tandem repeat (STR) expansions, mobile element insertions, and variants in non-uniquely mappable regions | 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) expansions, mobile element insertions, and variants in non-uniquely mappable regions | 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 element insertions, and variants in non-uniquely mappable regions | 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, deletions, duplications, mobile element insertions, and variants in non-uniquely mappable 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 changes in exonic and intronic regions, duplications, deletions, and mobile element insertions | 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 including ANK2, CASQ2, CAV3, KCNE1, KCNE2, KCNH2, KCNJ2, KCNQ1, RYR2, and SCN5A, including small sequence changes in exonic and intronic regions, deletions, duplications, mobile element insertions, and variants in non-uniquely mappable regions | 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, duplications, mobile element insertions, and variants in non- uniquely mappable regions | 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, insertions, deletions, select rearrangements, and copy number variations | 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 amplifications, and gene rearrangements | 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 rearrangements, tumor-mutational burden and microsatellite instability, utilizing formalin-fixed paraffin-embedded tumor tissue | Policies naming 0244U |
| 0250U | On the list | Oncology (solid organ neoplasm), targeted genomic sequence DNA analysis of 505 genes, interrogation for somatic alterations (SNVs [single nucleotide variant], small insertions and deletions, one amplification, and four translocations), microsatellite instability and tumor-mutation burden | 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 |
| 0260U | On the list | Rare diseases (constitutional/heritable disorders), identification of copy number variations, inversions, insertions, translocations, and other structural variants by optical genome mapping | Policies naming 0260U |
| 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 genome mapping | 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, saliva, buccal swabs or cell lines, identification of single nucleotide and copy number variants | 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-fixed paraffin-embedded (FFPE) tissue or fresh frozen tissue, reported as presence or absence of splicing or expression changes | 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 genome mapping and whole genome sequencing | 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 22 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 |
| 0272U | On the list | Hematology (genetic bleeding disorders), genomic sequence analysis of 60 genes and duplication/deletion of PLAU, blood, buccal swab, or amniotic fluid, comprehensive | Policies naming 0272U |
| 0273U | On the list | Hematology (genetic hyperfibrinolysis, delayed bleeding), analysis of 9 genes (F13A1, F13B, FGA, FGB, FGG, SERPINA1, SERPINE1, SERPINF2 by next-generation sequencing, and PLAU by array comparative genomic hybridization), blood, buccal swab, or amniotic fluid | 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 foraminotomy), any method, under indirect image guidance (eg, fluoroscopic, CT), single or multiple levels, unilateral or bilateral; cervical or thoracic | Policies naming 0274T |
| 0274U | On the list | Hematology (genetic platelet disorders), genomic sequence analysis of 62 genes and duplication/deletion of PLAU, 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 42 genes, blood, buccal swab, or amniotic fluid | Policies naming 0276U |
| 0277U | On the list | Hematology (genetic platelet function disorder), genomic sequence analysis of 40 genes and duplication/deletion of PLAU, blood, buccal swab, or amniotic fluid | Policies naming 0277U |
| 0278U | On the list | Hematology (genetic thrombosis), genomic sequence analysis of 14 genes, blood, buccal swab, or amniotic fluid | Policies naming 0278U |
| 0297U | On the list | Oncology (pan tumor), whole genome sequencing of paired malignant and normal DNA specimens, fresh or formalin-fixed paraffin-embedded (FFPE) tissue, blood or bone marrow, comp | Policies naming 0297U |
| 0298U | On the list | Oncology (pan tumor), whole transcriptome sequencing of paired malignant and normal RNA specimens, fresh or formalin-fixed paraffin- embedded (FFPE) tissue, blood or bone marro | Policies naming 0298U |
| 0299U | On the list | Oncology (pan tumor), whole genome optical genome mapping of paired malignant and normal DNA specimens, fresh frozen tissue, blood, or bone marrow, comparative structural vari | Policies naming 0299U |
| 0300U | On the list | Oncology (pan tumor), whole genome sequencing and optical genome mapping of paired malignant and normal DNA specimens, fresh tissue, blood, or bone marrow, comparative sequenc | Policies naming 0300U |
| 0306U | On the list | Oncology (minimal residual disease [MRD]), next- generation targeted sequencing analysis, cell-free DNA, initial (baseline) assessment to determine a patient-specific panel for future comparisons to evaluate for MRD | Policies naming 0306U |
| 0307U | On the list | Oncology (minimal residual disease [MRD]), next- generation targeted sequencing analysis of a patient-specific panel, cell-free DNA, subsequent assessment with comparison to previously analyzed patient specimens to evaluate for MRD | Policies naming 0307U |
| 0312T | Not listed | Policies naming 0312T | |
| 0313T | Not listed | Policies naming 0313T | |
| 0314T | Not listed | Policies naming 0314T | |
| 0315T | Not listed | Policies naming 0315T | |
| 0316T | Not listed | Policies naming 0316T | |
| 0317T | Not listed | Policies naming 0317T | |
| 0318U | On the list | Pediatrics (congenital epigenetic disorders), whole genome methylation analysis by microarray for 50 or more genes, blood | Policies naming 0318U |
| 0326U | On the list | Targeted genomic sequence analysis panel, solid organ neoplasm, cell-free circulating DNA analysis of 83 or more genes, interrogation for sequence variants, gene copy number amplifications, gene rearrangements, microsatellite instability and tumor mutational burden | Policies naming 0326U |
| 0329U | On the list | Oncology (neoplasia), exome and transcriptome sequence analysis for sequence variants, gene copy number amplifications and deletions, gene rearrangements, microsatellite instability and tumor mutational burden utilizing DNA and RNA from tumor with DNA from normal blood or saliva for subtraction, report of clinically significant mutation(s) with therapy associations | Policies naming 0329U |
| 0331U | On the list | Oncology (hematolymphoid neoplasia), optical genome mapping for copy number alterations and gene rearrangements utilizing DNA from blood or bone marrow, report of clinically s | Policies naming 0331U |
| 0332U | On the list | Oncology (pan-tumor), genetic profiling of 8 DNA- regulatory (epigenetic) markers by quantitative polymerase chain reaction (qPCR), whole blood, reported as a high or low probability of responding to immune checkpoint-inhibitor therapy | Policies naming 0332U |
| 0333U | On the list | Oncology (liver), surveillance for hepatocellular carcinoma (HCC) in high-risk patients, analysis of methylation patterns on circulating cell-free DNA (cfDNA) plus measurement of serum of AFP/AFP- L3 and oncoprotein des-gamma-carboxy- prothrombin (DCP), algorithm reported as normal or abnormal result | Policies naming 0333U |
| 0334U | On the list | Oncology (solid organ), targeted genomic sequence analysis, formalin-fixed paraffin- embedded (FFPE) tumor tissue, DNA analysis, 84 or more genes, interrogation for sequence va | Policies naming 0334U |
| 0335T | On the list | Insertion of sinus tarsi implant | Policies naming 0335T |
| 0335U | On the list | Rare diseases (constitutional/heritable disorders), whole genome sequence analysis, including small sequence changes, copy number variants, deletions, duplications, mobile element insertions, uniparental disomy (UPD), inversions, aneuploidy, mitochondrial genome sequence analysis with heteroplasmy and large deletions, short tandem repeat (STR) gene expansions, fetal sample, identification and categorization of genetic variants | Policies naming 0335U |
| 0336U | On the list | Rare diseases (constitutional/heritable disorders), whole genome sequence analysis, including small sequence changes, copy number variants, deletions, duplications, mobile element insertions, uniparental disomy (UPD), inversions, aneuploidy, mitochondrial genome sequence analysis with heteroplasmy and large deletions, short tandem repeat (STR) gene expansions, blood or saliva, identification and categorization of genetic variants, each comparator genome (eg, parent) | Policies naming 0336U |
| 0342T | On the list | Therapeutic apheresis with selective HDL delipidation and plasma reinfusion | Policies naming 0342T |
| 0343U | On the list | Oncology (prostate), exosome-based analysis of 442 small noncoding RNAs (sncRNAs) by quantitative reverse transcription polymerase chain reaction (RT-qPCR), urine, reported as molecular evidence of no-, low-, intermediate- or high-risk of prostate cancer | Policies naming 0343U |
| 0345T | On the list | Transcatheter mitral valve repair percutaneous approach via the coronary sinus | Policies naming 0345T |
| 0346U | Not listed | Policies naming 0346U | |
| 0355T | Not listed | Policies naming 0355T | |
| 0356U | On the list | Oncology (oropharyngeal or anal), evaluation of 17 DNA biomarkers using droplet digital PCR (ddPCR), cell-free DNA, algorithm reported as a prognostic risk score for cancer recurrence | Policies naming 0356U |
| 0358U | On the list | Neurology (mild cognitive impairment), analysis of β- amyloid 1-42 and 1-40, chemiluminescence enzyme immunoassay, cerebral spinal fluid, reported as positive, likely positive, or negative | Policies naming 0358U |
| 0361U | Not listed | Policies naming 0361U | |
| 0368U | On the list | Oncology (colorectal cancer), evaluation for mutations of APC, BRAF, CTNNB1, KRAS, NRAS, PIK3CA, SMAD4, and TP53, and methylation markers (MYO1G, KCNQ5, C9ORF50, FLI1, CLIP4, ZNF132 and TWIST1), multiplex quantitative polymerase chain reaction (qPCR), circulating cell-free DNA (cfDNA), plasma, report of risk score for advanced adenoma or colorectal cancer | Policies naming 0368U |
| 0379U | On the list | Targeted genomic sequence analysis panel, solid organ neoplasm, DNA (523 genes) and RNA (55 genes) by next-generation sequencing, interrogation for sequence variants, gene copy number amplifications, gene rearrangements, microsatellite instability, and tumor mutational burden | Policies naming 0379U |
| 0388U | On the list | Oncology (non-small cell lung cancer), next- generation sequencing with identification of single nucleotide variants, copy number variants, insertions and deletions, and structural variants in 37 cancer-related genes, plasma, with report for alteration detection | Policies naming 0388U |
| 0391U | On the list | Oncology (solid tumor), DNA and RNA by next- generation sequencing, utilizing formalin-fixed paraffin-embedded (FFPE) tissue, 437 genes, interpretive report for single nucleotide variants, splice-site variants, insertions/deletions, copy number alterations, gene fusions, tumor mutational burden, and microsatellite instability, with algorithm quantifying immunotherapy response score | Policies naming 0391U |
| 0397U | Not listed | Policies naming 0397U | |
| 0398T | Not listed | Policies naming 0398T | |
| 0400U | On the list | Obstetrics (expanded carrier screening), 145 genes by next-generation sequencing, fragment analysis and multiplex ligation-dependent probe amplification, DNA, reported as carrier positive or negative | Policies naming 0400U |
| 0401U | On the list | Cardiology (coronary heart disease [CHD]), 9 genes (12 variants), targeted variant genotyping, blood, saliva, or buccal swab, algorithm reported as a genetic risk score for a coronary event | Policies naming 0401U |
| 0402T | On the list | Collagen cross-linking of cornea, including removal of the corneal epithelium, when performed, and intraoperative pachymetry, when performed | Policies naming 0402T |
| 0408T | On the list | Insertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic parameters; pulse generator with transvenous electrodes | Policies naming 0408T |
| 0409T | On the list | Insertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic parameters; pulse generator only | Policies naming 0409T |
| 0410T | On the list | Insertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic parameters; atrial electrode only | Policies naming 0410T |
| 0411T | On the list | Insertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic parameters; ventricular electrode only | Policies naming 0411T |
| 0412T | On the list | Removal of permanent cardiac contractility modulation system; pulse generator only | Policies naming 0412T |
| 0413T | On the list | Removal of permanent cardiac contractility modulation system; transvenous electrode (atrial or ventricular) | Policies naming 0413T |
| 0414T | On the list | Removal and replacement of permanent cardiac contractility modulation system pulse generator only | Policies naming 0414T |
| 0415T | On the list | Repositioning of previously implanted cardiac contractility modulation transvenous electrode, (atrial or ventricular lead) | Policies naming 0415T |
| 0416T | On the list | Relocation of skin pocket for implanted cardiac contractility modulation pulse generator | Policies naming 0416T |
| 0417T | On the list | Programming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, including review and report, implantable cardiac contractility modulation system | Policies naming 0417T |
| 0418T | On the list | Interrogation device evaluation (in person) with analysis, review and report, includes connection, recording and disconnection per patient encounter, implantable cardiac contractility modulation system | Policies naming 0418T |
| 0421T | Not listed | Policies naming 0421T | |
| 0424T | Not listed | Policies naming 0424T | |
| 0425T | Not listed | Policies naming 0425T | |
| 0426T | Not listed | Policies naming 0426T | |
| 0427T | Not listed | Policies naming 0427T | |
| 0428T | Not listed | Policies naming 0428T | |
| 0429T | Not listed | Policies naming 0429T | |
| 0430T | Not listed | Policies naming 0430T | |
| 0431T | Not listed | Policies naming 0431T | |
| 0432T | Not listed | Policies naming 0432T | |
| 0433T | Not listed | Policies naming 0433T | |
| 0434T | Not listed | Policies naming 0434T | |
| 0435T | Not listed | Policies naming 0435T | |
| 0436T | Not listed | Policies naming 0436T | |
| 0449T | On the list | Insertion of aqueous drainage device, without extraocular reservoir, internal approach, into the subconjunctival space; initial device | Policies naming 0449T |
| 0450T | Not listed | Policies naming 0450T | |
| 0468T | Not listed | Policies naming 0468T | |
| 0474T | On the list | Insertion of anterior segment aqueous drainage device, with creation of intraocular reservoir, internal approach, into the supraciliary space | Policies naming 0474T |
| 0483T | On the list | Transcatheter mitral valve implantation/replacement (TMVI) with prosthetic valve; percutaneous approach, including transseptal puncture, when performed | Policies naming 0483T |
| 0484T | On the list | Transcatheter mitral valve implantation/replacement (TMVI) with prosthetic valve; transthoracic exposure (eg, thoracotomy, transapical) | Policies naming 0484T |
| 0494T | On the list | Surgical preparation and cannulation of marginal (extended) cadaver donor lung(s) to ex vivo organ perfusion system, including decannulation, separation from the perfusion system, and cold preservation of the allograft prior to implantation, when performed | Policies naming 0494T |
| 0495T | On the list | Initiation and monitoring marginal (extended) cadaver donor lung(s) organ perfusion system by physician or qualified health care professional, including physiological and laboratory assessment (eg, pulmonary artery flow, pulmonary artery pressure, left atrial pressure, pulmonary vascular resistance, mean/peak and plateau airway pressure, dynamic compliance and perfusate gas analysis), including bronchoscopy and X ray when performed; first two hours in sterile field | Policies naming 0495T |
| 0496T | Not listed | Policies naming 0496T | |
| 0501T | Not listed | Policies naming 0501T | |
| 0502T | Not listed | Policies naming 0502T | |
| 0503T | Not listed | Policies naming 0503T | |
| 0504T | Not listed | Policies naming 0504T | |
| 0505T | On the list | Endovenous femoral-popliteal arterial revascularization, with transcatheter placement of intravascular stent graft(s) and closure by any method, including percutaneous or open vascular access, ultrasound guidance for vascular access when performed, all catheterization(s) and intraprocedural roadmapping and imaging guidance necessary to complete the intervention, all associated radiological supervision and interpretation, when performed, with crossing of the occlusive lesion in an extraluminal fashion | Policies naming 0505T |
| 0510T | On the list | Removal of sinus tarsi implant | Policies naming 0510T |
| 0511T | On the list | Removal and reinsertion of sinus tarsi implant | Policies naming 0511T |
| 0515T | On the list | Insertion of wireless cardiac stimulator for left ventricular pacing, including device interrogation and programming, and imaging supervision and interpretation, when performed; complete system (includes electrode and generator [transmitter and battery]) | Policies naming 0515T |
| 0516T | On the list | Insertion of wireless cardiac stimulator for left ventricular pacing, including device interrogation and programming, and imaging supervision and interpretation, when performed; electrode only | Policies naming 0516T |
| 0517T | On the list | Insertion of wireless cardiac stimulator for left ventricular pacing, including device interrogation and programming, and imaging supervision and interpretation, when performed; pulse generator component(s) (battery and/or transmitter) only | Policies naming 0517T |
| 0518T | Not listed | Policies naming 0518T | |
| 0519T | On the list | Removal and replacement of pulse generator for wireless cardiac stimulator for left ventricular pacing, including device interrogation and programming; both components (battery and transmitter) | Policies naming 0519T |
| 0520T | On the list | Removal and replacement of pulse generator for wireless cardiac stimulator for left ventricular pacing, including device interrogation and programming; battery component only | Policies naming 0520T |
| 0521T | Not listed | Policies naming 0521T | |
| 0522T | Not listed | Policies naming 0522T | |
| 0524T | On the list | Endovenous catheter directed chemical ablation with balloon isolation of incompetent extremity vein, open or percutaneous, including all vascular access, catheter manipulation, diagnostic imaging, imaging guidance and monitoring | Policies naming 0524T |
| 0525T | On the list | Insertion or replacement of intracardiac ischemia monitoring system, including testing of the lead and monitor, initial system programming, and imaging supervision and interpretation; complete system (electrode and implantable monitor) | Policies naming 0525T |
| 0526T | On the list | Insertion or replacement of intracardiac ischemia monitoring system, including testing of the lead and monitor, initial system programming, and imaging supervision and interpretation; electrode only | Policies naming 0526T |
| 0527T | On the list | Insertion or replacement of intracardiac ischemia monitoring system, including testing of the lead and monitor, initial system programming, and imaging supervision and interpretation; implantable monitor only | Policies naming 0527T |
| 0528T | On the list | Programming device evaluation (in person) of intracardiac ischemia monitoring system with iterative adjustment of programmed values, with analysis, review, and report | Policies naming 0528T |
| 0529T | On the list | Interrogation device evaluation (in person) of intracardiac ischemia monitoring system with analysis, review, and report | Policies naming 0529T |
| 0530T | On the list | Removal of intracardiac ischemia monitoring system, including all imaging supervision and interpretation; complete system (electrode and implantable monitor) | Policies naming 0530T |
| 0531T | On the list | Removal of intracardiac ischemia monitoring system, including all imaging supervision and interpretation; electrode only | Policies naming 0531T |
| 0532T | On the list | Removal of intracardiac ischemia monitoring system, including all imaging supervision and interpretation; implantable monitor only | Policies naming 0532T |
| 0537T | Not listed | Policies naming 0537T | |
| 0538T | Not listed | Policies naming 0538T | |
| 0539T | Not listed | Policies naming 0539T | |
| 0540T | Not listed | Policies naming 0540T | |
| 0544T | On the list | Transcatheter mitral valve annulus reconstruction, with implantation of adjustable annulus reconstruction device, percutaneous approach including transseptal puncture | Policies naming 0544T |
| 0545T | On the list | Transcatheter tricuspid valve annulus reconstruction with implantation of adjustable annulus reconstruction device, percutaneous approach | Policies naming 0545T |
| 0569T | On the list | Transcatheter tricuspid valve repair, percutaneous approach; initial prosthesis | Policies naming 0569T |
| 0570T | Not listed | Policies naming 0570T | |
| 0581T | On the list | Ablation, malignant breast tumor(s), percutaneous, cryotherapy, including imaging guidance when performed, unilateral | Policies naming 0581T |
| 0584T | On the list | Islet cell transplant, includes portal vein catheterization and infusion, including all imaging, including guidance, and radiological supervision and interpretation, when performed; percutaneous | Policies naming 0584T |
| 0585T | On the list | Islet cell transplant, includes portal vein catheterization and infusion, including all imaging, including guidance, and radiological supervision and interpretation, when performed; laparoscopic | Policies naming 0585T |
| 0586T | On the list | Islet cell transplant, includes portal vein catheterization and infusion, including all imaging, including guidance, and radiological supervision and interpretation, when performed; open | Policies naming 0586T |
| 0587T | Not listed | Policies naming 0587T | |
| 0588T | Not listed | Policies naming 0588T | |
| 0589T | Not listed | Policies naming 0589T | |
| 0590T | Not listed | Policies naming 0590T | |
| 0596T | On the list | Temporary female intraurethral valve-pump (ie, voiding prosthesis); initial insertion, including urethral measurement | Policies naming 0596T |
| 0597T | On the list | Temporary female intraurethral valve-pump (ie, voiding prosthesis); replacement | Policies naming 0597T |
| 0616T | Not listed | Policies naming 0616T | |
| 0617T | Not listed | Policies naming 0617T | |
| 0618T | Not listed | Policies naming 0618T | |
| 0620T | On the list | Endovascular venous arterialization, tibial or peroneal vein, with transcatheter placement of intravascular stent graft(s) and closure by any method, including percutaneous or open vascular access, ultrasound guidance for vascular access when performed, all catheterization(s) and intraprocedural roadmapping and imaging guidance necessary to complete the intervention, all associated radiological supervision and interpretation, when performed | Policies naming 0620T |
| 0627T | On the list | Percutaneous injection of allogeneic cellular and/or tissue-based product, intervertebral disc, unilateral or bilateral injection, with fluoroscopic guidance, lumbar; first level [VAST, Via Disc] | Policies naming 0627T |
| 0628T | Not listed | Policies naming 0628T | |
| 0629T | On the list | Percutaneous injection of allogeneic cellular and/or tissue-based product, intervertebral disc, unilateral or bilateral injection, with CT guidance, lumbar; first level [VAST, Via Disc] | Policies naming 0629T |
| 0630T | Not listed | Policies naming 0630T | |
| 0655T | On the list | Transperineal focal laser ablation of malignant prostate tissue, including transrectal imaging guidance, with MR-fused images or other enhanced ultrasound imaging | Policies naming 0655T |
| 0672T | On the list | Endovaginal cryogen-cooled, monopolar radiofrequency remodeling of the tissues surrounding the female bladder neck and proximal urethra for urinary incontinence | Policies naming 0672T |
| 0686T | On the list | Histotripsy (ie, non-thermal ablation via acoustic energy delivery) of malignant hepatocellular tissue, including image guidance | Policies naming 0686T |
| 0745T | On the list | Cardiac focal ablation utilizing radiation therapy for arrhythmia; noninvasive arrhythmia localization and mapping of arrhythmia site (nidus), derived from anatomical image data (eg, CT, MRI, or myocardial perfusion scan) and electrical data (eg, 12-lead ECG data), and identification of areas of avoidance | Policies naming 0745T |
| 0746T | On the list | Cardiac focal ablation utilizing radiation therapy for arrhythmia; conversion of arrhythmia localization and mapping of arrhythmia site (nidus) into a multidimensional radiation treatment plan | Policies naming 0746T |
| 0747T | On the list | Cardiac focal ablation utilizing radiation therapy for arrhythmia; delivery of radiation therapy, arrhythmia | Policies naming 0747T |
| 1108G | Not listed | Policies naming 1108G | |
| 1118A | Not listed | Policies naming 1118A | |
| 11920 | On the list | Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.0 sq cm or less | Policies naming 11920 |
| 11921 | On the list | Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation; 6.1 to 20.0 sq cm | Policies naming 11921 |
| 11922 | Not listed | Policies naming 11922 |
And 2,269 more in the original policy.
All Anthem Blue Cross Blue Shield of Georgia policies · Anthem Blue Cross Blue Shield of Georgia prior authorization CPT list