0417U prior authorization | Premera Blue Cross of Washington

0417U, Rare diseases whole mitochondrial genome sequence with heteroplasmy detection & deletion analysis, nuclear- encoded mitochondrial gene analysis of 335 nuclear genes, including sequence changes, is on the Premera Blue Cross of Washington prior authorization list. Not a coverage or referral decision.

Code: 0417U
Description: Rare diseases whole mitochondrial genome sequence with heteroplasmy detection & deletion analysis, nuclear- encoded mitochondrial gene analysis of 335 nuclear genes, including sequence changes
Source: Clinical Review by Code List PBCWA, Pg 82 Original policy

Premera Blue Cross of Washington prior authorization

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