0117U prior authorization | Anthem Blue Cross Blue Shield of Georgia

0117U, 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, is on the Anthem Blue Cross Blue Shield of Georgia prior authorization list. Not a coverage or referral decision.

Code

0117U

Description

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

Source

Standard Local Prior Authorization Code List, Pg 108 Original policy

Anthem Blue Cross Blue Shield of Georgia prior authorization