81504 prior authorization | Premera Blue Cross of Washington

81504, Oncology (tissue of origin), microarray gene expression profiling of > 2000 genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as tissue similarity scores, is on the Premera Blue Cross of Washington prior authorization list. Not a coverage or referral decision.

Code: 81504
Description: Oncology (tissue of origin), microarray gene expression profiling of > 2000 genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as tissue similarity scores
Source: Clinical Review by Code List PBCWA, Pg 494 Original policy

Premera Blue Cross of Washington prior authorization

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