THE PRIOR AUTHORIZATION LIST - FOR BLUECROSS BLUESHIELD OF SOUTH CAROLINA AND BLUECHOICE HEALTHPLAN 2018
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ADVANCING CLINICALLY APPROPRIATE LAB TECHNOLOGY AND SERVICES
The Prior Authorization List
For BlueCross BlueShield of South Carolina and
BlueChoice HealthPlan 2018
Visit us at Avalonhcs.com
BlueCross® BlueShield® of South Carolina is an independent licensee of the Blue Cross and Blue Shield Association.
About Prior Authorization
BlueCross Blue Shield of South Carolina and BlueChoice HealthPlan have delegated prior authorization for outpatient lab
services to Avalon Healthcare Solutions (Avalon). Avalon is an independent company that performs outpatient lab
services on behalf of BlueCross and BlueChoice®. Avalon does not review requests for services provided in an emergency
room, surgery center or hospital inpatient place of service.
Avalon, BlueCross and BlueChoice have determined that certain lab services require prior authorization and require that
you request that Avalon review these services prior to performing the services. You may submit requests for prior
authorization to Avalon by fax (888‐791‐2181) or by phone (844‐227‐5769), 8 a.m. – 8 p.m., Eastern Time. Once Avalon
receives your request, it will be reviewed by Avalon’s clinical staff and they will notify you of their determination.
An authorization does not guarantee payment. As always, payment is subject to the member’s plan coverage and
benefits at the time the service is performed.
2018 Code Revision Legend
New codes for 2018
Existing code now requiring PA
Existing code that will no longer require PA, not intended to imply coverage
Codes Requiring Prior Authorization
Procedure Required PA Requires PA
Code Description 1/1/2017 2/1/2018
IDH1 (isocitrate dehydrogenase 1 [NADP+], soluble) (eg, glioma), common
81120 N/A Yes
variants (eg, R132H, R132C)
IDH2 (isocitrate dehydrogenase 2 [NADP+], mitochondrial) (eg, glioma),
81121 N/A Yes
common variants (eg, R140W, R172M)
Dmd (dystrophin) (e.g., duchenne/becker muscular dystrophy) deletion
81161 Yes Yes
analysis, and duplication analysis
BRCA1, BRCA2 (breast cancer 1 and 2) (e.g., hereditary breast and ovarian
81162 cancer) gene analysis; full sequence analysis and full duplication/deletion Yes Yes
analysis
ABL1 (ABL proto‐oncogene 1, non‐receptor tyrosine kinase) (e.g., acquired
81170 imatinib tyrosine kinase inhibitor resistance), gene analysis, variants in the Yes Yes
kinase domain
ASXL1 (additional sex combs like 1, transcriptional regulator) (eg,
81175 myelodysplastic syndrome, myeloproliferative neoplasms, chronic N/A Yes
myelomonocytic leukemia) gene analysis; full gene sequence
ASXL1 (additional sex combs like 1, transcriptional regulator) (eg,
myelodysplastic syndrome, myeloproliferative neoplasms, chronic
81176 N/A Yes
myelomonocytic leukemia) gene analysis; targeted sequence analysis (eg,
exon 12)
ASPA (aspartoacylase) (e.g., Canavan disease) gene analysis, common
81200 Yes Yes
variants (e.g., E285A, Y231X)
APC (adenomatous polyposis coli) (e.g., familial adenomatosis polyposis
81201 Yes Yes
[FAP], attenuated FAP) gene analysis; full gene sequence
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PA‐TOOL‐6032‐V02‐20170124‐Prior Authorization List 1Procedure Required PA Requires PA
Code Description 1/1/2017 2/1/2018
APC (adenomatous polyposis coli) (e.g., familial adenomatosis polyposis
81202 Yes Yes
[FAP], attenuated FAP) gene analysis; known familial variants
APC (adenomatous polyposis coli) (e.g., familial adenomatosis polyposis
81203 Yes Yes
[FAP], attenuated FAP) gene analysis; duplication/deletion variants
BCKDHB (branched‐chain keto acid dehydrogenase E1, beta polypeptide)
81205 (e.g., Maple syrup urine disease) gene analysis, common variants (e.g., Yes Yes
R183P, G278S, E422X)
BCR/ABL1 (t(9:22)) (e.g., chronic myelogenous leukemia) translocation
81206 Yes Yes
analysis; major breakpoint, qualitative or quantitative
81207 minor breakpoint, qualitative or quantitative Yes Yes
81208 other breakpoint, qualitative or quantitative Yes Yes
BLM (Bloom Syndrome, RecQ helicase‐like) (e.g., Bloom Syndrome) gene
81209 Yes Yes
analysis, 2281del6ins7 variant
BRAF (v‐raf murine sarcoma viral oncogene homolog b1) (e.g., colon cancer),
81210 Yes Yes
gene analysis, v600e variant
BRCA1, BRCA2 (breast cancer 1 and 2) e.g., hereditary breast and ovarian
cancer) gene analysis; full sequence analysis and common
81211 Yes Yes
duplication/deletion variants in BRCA1 (ie, exon 13 del 3.835kb, exon 13 dup
6kb, exon 14‐20 del 26kb, exon 22 del 510bp, exon 8‐9 del 7.1 kb)
81212 185delAG, 5385insC, 6174delT variants Yes Yes
81213 Uncommon duplication/deletion variants (BRCA1, BRCA2 ) Yes Yes
BRCA1 (breast cancer 1 e.g., hereditary breast and ovarian cancer) gene
analysis; full sequence analysis and common duplication/deletion variants
81214 (i.e., exon 13 del 3.835kb, exon 13 dup 6kb, exon 14‐20 del 26kb, exon 22 Yes Yes
del 510bp, exon 8‐9 del 7.1kb) *Note: when performing BRCA1 full sequence
analysis with BRCA2 full sequence analysis, use procedure code 81211
81215 Known familial variant. Note BRCA 1 or BRCA 2 Specific Site Analysis. Yes Yes
BRCA2 (breast cancer 2) (e.g., hereditary breast and ovarian cancer) gene
analysis, full sequence analysis **Note: when performing BRCA2 full
81216 Yes Yes
sequence analysis with BRCA1 full sequence analysis, use procedure code
81211
81217 Known familial variant Yes Yes
CEBPA (CCAAT/enhancer binding protein [C/EBP], alpha) (e.g., acute myeloid
81218 Yes Yes
leukemia), gene analysis, full gene sequence
CALR (calreticulin) (eg, myeloproliferative disorders), gene analysis, common
81219 No Yes
variants in exon 9
81221 known familial variants Yes Yes
CFTR (cystic fibrosis transmembrane conductance regulator) (e.g., cystic
81222 Yes Yes
fibrosis) gene analysis; duplication/deletion variants
CFTR (cystic fibrosis transmembrane conductance regulator) (e.g., cystic
81223 Yes Yes
fibrosis) gene analysis; full gene sequence
CFTR (cystic fibrosis transmembrane conductance regulator) (e.g., cystic
81224 Yes Yes
fibrosis) gene analysis; intron 8 poly‐T analysis (e.g., male infertility)
Cyp2c19 (cytochrome p450, family 2, subfamily c, polypeptide 19) (e.g., drug
81225 Yes Yes
metabolism), gene analysis, common variants (e.g., *2, *3, *4, *8, *17)
Cyp2d6 (cytochrome p450, family 2, subfamily d, polypeptide 6) (e.g., drug
81226 metabolism), gene analysis, common variants (e.g., *2, *3, *4, *5, *6, *9, Yes Yes
*10, *17, *19, *29, *35, *41, *1xn, *2xn, *4xn)
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PA‐TOOL‐6032‐V02‐20170124‐Prior Authorization List 2Procedure Required PA Requires PA
Code Description 1/1/2017 2/1/2018
Cytogenomic constitutional (genome‐wide) microarray analysis;
interrogation of genomic regions for copy number variants (e.g., bacterial
81228 Yes Yes
artificial chormosome [BAC] or oligo‐based comparative genomic
hybridization [CGH] microarray analysis
Interrogation of genomic regions for copy number and single nucleotide
81229 Yes Yes
polymorphism (SNP) variants for chromosomal abnormalities
EGFR (epidermal growth factor receptor) (e.g., non‐small cell lung gancer)
81235 gene analysis, common variants (e.g. exon 19 LREA deletion,L858R, T790M, Yes Yes
G719A, G719S, L861Q)
F9 (coagulation factor IX) (eg, hemophilia B) full gene sequence, CAM 166
81238 N/A Yes
General Genetic Testing, Germline Disorders
F5 (coagulation factor V) (eg, hereditary hypercoagulabulity) gene analysis,
81241 No Yes
Leiden variant
FANCC (Fanconi Anemia, complementation group C) (e.g., Fanconi Anemia,
81242 Yes Yes
type C) gene analysis, common variant (e.g.: IVS4+4a>T)
FMR1 (Fragile X mental retardation 1) gene analysis; evaluation to detect
81243 Yes Yes
abnormal (e.g., expanded) alleles
FMR1 (Fragile X mental retardation 1) gene analysis; characterization of
81244 Yes Yes
alleles (e.g., expanded size and methylation status)
FLT3 (fms‐related tyrosine kinase 3) (e.g., acute myeloid leukemia), gene
81245 Yes Yes
analysis; internal tandem duplication (ITD) variants (i.e., exons 14, 15)
81247 G6PD (glucose‐6‐phosphate dehydrogenase) (eg, hemolytic anemia,
jaundice) gene analysis; common variant(s) (eg, A, A‐), CAM 166 General N/A Yes
Genetic Testing, Germline Disorders
81248 G6PD (glucose‐6‐phosphate dehydrogenase) (eg, hemolytic anemia,
jaundice) gene analysis; known familial variant(s), CAM 166 General Genetic N/A Yes
Testing, Germline Disorders
81249 G6PD (glucose‐6‐phosphate dehydrogenase) (eg, hemolytic anemia,
jaundice) gene analysis; full gene sequence, CAM 166 General Genetic N/A Yes
Testing, Germline Disorders
G6PC (glucose‐6‐phosphatase, catalytic subunit) (e.g., Glycogen storage
81250 disease, Type 1a, von Gierke disease) gene analysis, common variants (e.g., Yes Yes
R83C, Q347X)
GBA (glucosidase, beta, acid) (e.g., Gaucher disease) gene analysis, common
81251 Yes Yes
variants (e.g., N370S, 84GG, L444P, IVS2+1G>A)
GJB2 (gap junction protein, beta 2, 26kDa, connexin 26) (e.g., nonsyndromic
81252 Yes Yes
hearing loss) gene analysis; full gene sequence
81253 known familial variants Yes Yes
GJB6 (gap junction protein, beta 6, 30kDa, connexin 30) (e.g., nonsyndromic
81254 hearing loss) gene analysis, common variants (e.g., 309kb [del(GJB6‐ Yes Yes
D13S1830)] and 232 kb [del(GJB6‐D13S1854)])
HEXA (hexosaminidase A [alpha polypeptide]) (e.g., Tay‐Sachs disease) gene
81255 Yes Yes
analysis, common variants (e.g., 1278insTATC, 1421+1G>C,G269S)
HFE (hemochromatosis) (e.g., hereditary hemochromatosis) gene analysis,
81256 Yes Yes
common variants (e.g., C282Y, H63D)
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PA‐TOOL‐6032‐V02‐20170124‐Prior Authorization List 3Procedure Required PA Requires PA
Code Description 1/1/2017 2/1/2018
HBA1/HBA2 (alpha globin 1 and alpha globin 2) (e.g., alpha thalassemia, Hb
Bart hydrops fetalis syndrome, HbH disease) gene analysis, for common
81257 Yes Yes
deletions or variant (e.g., Southeast Asian, Thai, Filipino, Mediterrenean,
alpha3.7, alpha4.2 alpha20.5, constant spring)
HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia, Hb
81258 Bart hydrops fetalis syndrome, HbH disease), gene analysis; known familial N/A Yes
variant
HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia, Hb
81259 Bart hydrops fetalis syndrome, HbH disease), gene analysis; full gene N/A Yes
sequence
IKBKAP (inhibitor of kappa light polypeptide gene enhancer in B‐cells, kinase
81260 complex‐associated protein) (e.g., familial dysautonomia) gene analysis, Yes Yes
common variants (e.g., 2507+6T>C, R696P)
IGH@ (Immunoglobulin heavy chain locus) (e.g., leukemias amd lymphomas,
81261 B‐cell), gene rearrangement analysis to detect abnormal clonal Yes Yes
population(s); amplified methodology (e.g., polymerase chain reaction)
81262 direct probe methodology (e.g., Southern blot) Yes Yes
IGH@ (Immunoglobulin heavy chain locus) (e.g., leukemias amd lymphoma,
81263 Yes Yes
B‐cell), variable region somatic mutation analysis
IGK@ (Immunoglobulin kappa light chain locus) (e.g., leukemia and
81264 lymphoma, B‐cell) gene‐rearrangement analysis, evaluation to detect Yes Yes
abnormal clonal population(s)
Comparative analysis using Short Tandem Repeat (STR) makers; patient and
comparative specimen (e.g., pre‐transplant recipient and donor germline
81265 testing, post‐transplant non‐hematopoietic recipient germline [e.g., buccal Yes Yes
swab or other germline tissue sample] and donor testing, twin zygosity
testing, or maternal cell contamination of fetal cells)
each additional specimen )e.g., additional cord blood donor, additional fetal
81266 samples from different cultures, or additional zygosity in multiple birth Yes Yes
pregnancies) [List separately in addition to code for primary procedure]
Chimerism (engraftment) analysis, post transplantation specimen (e.g.,
81267 hematopoietic stem cell), includes comparison to previously performed Yes Yes
baseline analyses; without cell selection
81268 with cell selection (e.g., CD3, CD33), each cell type Yes Yes
HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia, Hb
81269 Bart hydrops fetalis syndrome, HbH disease), gene analysis; N/A Yes
duplication/deletion variants
JAK2 ( Janus kinase 2) (e.g., myeloproliferative disorder) gene analysis,
81270 Yes Yes
p.Val617Phe (V617F) variant
81275 KRAS (e.g. carcinoma) gene analysis, variants in codons 12 and 13 Yes Yes
KRAS (Kirsten rat sarcoma viral oncogene homolog) (e.g., carcinoma) gene
81276 Yes Yes
analysis; additional variant(s) (e.g., codon 61, codon 146)
MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (e.g., hereditary
81288 non‐polyposis colorectal cancer, Lynch syndrome) gene analysis; promoter Yes Yes
methylation analysis
MCOLN1 (mucolipin 1)(e.g., Mucolipidosis, type IV) gene analysis, common
81290 Yes Yes
variants (e.g.,, IVS3‐2A>G, del6, 4kb)
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PA‐TOOL‐6032‐V02‐20170124‐Prior Authorization List 4Procedure Required PA Requires PA
Code Description 1/1/2017 2/1/2018
MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (e.g., hereditary
81292 non‐polyposis colorectal cancer, Lynch syndrome) gene analysis; full Yes Yes
sequence analysis
81293 known familial variants Yes Yes
81294 duplication/deletion variants Yes Yes
MSH2 (mutS homolog 2, colon cancer, nonpolyposis type 1) (e.g., hereditary
81295 non‐polyposis colorectal cancer, Lynch syndrome) gene analysis; full Yes Yes
sequence analysis
81296 known familial variants Yes Yes
81297 duplication/deletion variants Yes Yes
MSH6 (mutS homolog 6 [E. Coli]) e.g., jeredotaru mpm‐polyposis colorectal
81298 Yes Yes
cancer, Lynch syndrome) gene analysis; full sequence analysis
81299 known familial variants Yes Yes
81300 duplication/deletion variants Yes Yes
Microsatellite instability analysis (e.g., hereditary non‐polyposis colorectal
cancer, Lynch syndrome) of markers for mismatch repair deficiency (e.g.,
81301 No Yes
BAT25, BAT26), includes comparison of neoplastic and normal tissue, if
performed
Mecp2 (methyl cpg binding protein 2) (e.g., rett syndrome) gene analysis;
81302 Yes Yes
full sequence analysis
Mecp2 (methyl cpg binding protein 2) (e.g., rett syndrome) gene analysis;
81303 Yes Yes
known familial variant
Mecp2 (methyl cpg binding protein 2) (e.g., rett syndrome) gene analysis;
81304 Yes Yes
duplication/deletion variants
NPM1 (nucleophosmin) (e.g., acute myeloid leukemia) gene analysis, exon
81310 Yes Yes
12 variants
NRAS (neuroblastoma RAS viral [v‐ras] oncogene homolog) (e.g., colorectal
81311 carcinoma), gene analysis, variants in exon 2 (e.g., codons 12 and 13) and Yes Yes
exon 3 (e.g., codon 61)
PML/RARalpha, (t(15;17)), (promyelocytic leukemia/retinoic acid receptor
81315 alpha) (e.g., promyelocytic leukemia) translocation analysis; common Yes Yes
breakpoints (e.g., intron 3 and intron 6), qualitative or quantitative
single breakpoint (e.g., intron 3, intron 6 or exon 6), qualitative or
81316 Yes Yes
quantitative
PMS2 (postmeiotic segregation increased 2 [S. cerevisiae]) (e.g., hereditary
81317 non‐polyposis colorectal cancer, Lynch syndrome) gene analysis; full Yes Yes
sequence analysis
81318 known familial variants Yes Yes
81319 duplication/deletion variants Yes Yes
PTEN (phosphatase and tensin homolog) (e.g., Cowden syndrome, PTEN
81321 Yes Yes
hamartoma tumor syndrome) gene analysis; full sequence analysis
81322 known familial variant Yes Yes
81323 duplication/deletion variant Yes Yes
Pmp22 (peripheral myelin protein 22) (eg, charcot‐marie‐tooth, hereditary
81324 neuropathy with liability to pressure palsies) gene analysis; No Yes
duplication/deletion analysis
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PA‐TOOL‐6032‐V02‐20170124‐Prior Authorization List 5Procedure Required PA Requires PA
Code Description 1/1/2017 2/1/2018
Pmp22 (peripheral myelin protein 22) (eg, charcot‐marie‐tooth, hereditary
81325 neuropathy with liability to pressure palsies) gene analysis; full sequence No Yes
analysis
Pmp22 (peripheral myelin protein 22) (eg, charcot‐marie‐tooth, hereditary
81326 neuropathy with liability to pressure palsies) gene analysis; known familial No Yes
variant
SLCO1B1 (solute carrier organic anion transporter family, member 1B1) (eg,
81328 adverse drug reaction) gene analysis, common variant(s) (eg, *5), CAM N/A Yes
20496 Genetic Testing for Statin Induced Myopathy
SMPD1 (sphingomyelin phosphodiesterase 1, acid lysosomal) (e.g.,
81330 Niemann‐Pick disease, Type A) gene analysis, common variants (e.g., R496L, Yes Yes
L302P, fsP330)
SNRPN/UBE3A (small nuclear ribonucleoprotein polypeptide N and ubiquitin
81331 protein ligase E3A)(e.g., Prader‐Willi syndrome and/or Angelman syndrome), Yes Yes
methylation analysis
RUNX1 (runt related transcription factor 1) (eg, acute myeloid leukemia,
81334 familial platelet disorder with associated myeloid malignancy) gene analysis, N/A Yes
targeted sequence analysis (eg, exons 3‐8)
81335 TPMT (thiopurine S‐methyltransferase) (eg, drug metabolism) gene analysis,
common variants (eg, *2, *3), CAM 20419 Pharmacogenomic and N/A Yes
Metabolite Markers for Patients Treated with Thiopurines
TRB@ (T cell antigen receptor, beta) (e.g., leukemia and lymphoma), gene
81340 rearrangement analysis to detect abnormal clonal population(s); using Yes Yes
amplification methodology (e.g., polymerase chain reaction)
81341 using direct probe methodology (e.g., Southern blot) Yes Yes
TRG@ ((T cell antigen receptor, gamma) (e.g., leukemia and lymphoma),
81342 gene rearrangement analysis, evaluation to detect abnormal clonal Yes Yes
population(s)
UGT1A1 (UDP glucuronosyltransferase 1 family, polypeptide A1) (e.g.,
81350 Yes Yes
irinotecan metabolism), gene analysis, common variants
81361 HBB (hemoglobin, subunit beta) (eg, sickle cell anemia, beta thalassemia,
hemoglobinopathy); common variant(s) (eg, HbS, HbC, HbE), CAM 166 N/A Yes
General Genetic Testing, Germline Disorders
81362 HBB (hemoglobin, subunit beta) (eg, sickle cell anemia, beta thalassemia,
hemoglobinopathy); known familial variant(s), CAM 166 General Genetic N/A Yes
Testing, Germline Disorders
81363 HBB (hemoglobin, subunit beta) (eg, sickle cell anemia, beta thalassemia,
hemoglobinopathy); duplication/deletion variant(s), CAM 166 General N/A Yes
Genetic Testing, Germline Disorders
81364 HBB (hemoglobin, subunit beta) (eg, sickle cell anemia, beta thalassemia,
hemoglobinopathy); full gene sequence, CAM 166 General Genetic Testing, N/A Yes
Germline Disorders
81400 Mopath procedure level 1 Yes Yes
81401 Mopath procedure level 2 Yes Yes
81402 Mopath procedure level 3 Yes Yes
81403 Mopath procedure level 4 Yes Yes
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PA‐TOOL‐6032‐V02‐20170124‐Prior Authorization List 6Procedure Required PA Requires PA
Code Description 1/1/2017 2/1/2018
Molecular pathology procedure, Level 5 (e.g., analysis of 2‐5 exons by DNA
sequence analysis, mutation scanning or duplication/deletion variants of 6‐
81404 Yes Yes
10 exons, or characterization of a dynamic mutation disorder/triplet repeat
by Southern blot analysis)
81405 Mopath procedure level 6 Yes Yes
81406 Mopath procedure level 7 Yes Yes
81407 Mopath procedure level 8 Yes Yes
81408 Mopath procedure level 9 Yes Yes
Cardiac ion channelopathies‐genomic sequence analysis panel, must include
81413 at least 10 genes including ANK2, CASQ2, CAV3, KCNE1, KCNE2,, KCNH2, Yes Yes
KCNJ2, KCNQ1, RYR2 AND SCN5A
Cardiac ion channelopathies‐duplication/deletion gene analysis panel must
81414 Yes Yes
include at least 2 genes, to include KCNH2 and KCNQ1
81415 Exome sequence analysis No Yes
Exome (eg, unexplained constitutional or heritable disorder or syndrome);
81416 No Yes
sequence analysis, each comparator exome
Exome (eg, unexplained constitutional or heritable disorder or syndrome);
81417 No Yes
re‐evaluation of previously obtained exome sequences
Fetal chromosomal aneuploidy (e.g., trisomy 21, monosomy X) genomic
81420 sequence analysis panel, circulating cell‐free fetal DNA in maternal blood, Yes Yes
must include analysis of chromosomes 13, 18, and 21
81422 Fetal Chromosomal microdeletion genomic sequence analysis Yes No
Hearing loss (eg, nonsyndromic hearing loss, Usher syndrome, Pendred
syndrome); genomic sequence analysis panel, must include sequencing of at
81430 least 60 genes, including CDH23, CLRN1, GJB2, GPR98, MTRNR1, MYO7A, No Yes
MYO15A, PCDH15, OTOF, SLC26A4, TMC1, TMPRSS3, USH1C, USH1G,
USH2A, and WFS1
Hearing loss (eg, nonsyndromic hearing loss, Usher syndrome, Pendred
81431 syndrome); duplication/deletion analysis panel, must include copy number No Yes
analyses for STRC and DFNB1 deletions in GJB2 and GJB6 genes
Hereditary breast cancer‐related disorders (eg, hereditary breast cancer,
hereditary ovarian cancer, hereditary endometrial cancer); genomic
81432 sequence analysis panel, must include sequencing of at least 14 genes, No Yes
including ATM, BRCA1, BRCA2, BRIP1, CDH1, MLH1, MSH2, MSH6, NBN,
PALB2, PTEN, RAD51C, STK11, and TP53
Hereditary breast cancer‐related disorders (eg, hereditary breast cancer,
hereditary ovarian cancer, hereditary endometrial cancer);
81433 No Yes
duplication/deletion analysis panel, must include analyses for BRCA1,
BRCA2, MLH1, MSH2, and STK11
Hereditary retinal disorders (eg, retinitis pigmentosa, Leber congenital
amaurosis, cone‐rod dystrophy), genomic sequence analysis panel, must
81434 include sequencing of at least 15 genes, including ABCA4, CNGA1, CRB1, EYS, No Yes
PDE6A, PDE6B, PRPF31, PRPH2, RDH12, RHO, RP1, RP2, RPE65, RPGR, and
USH2A
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PA‐TOOL‐6032‐V02‐20170124‐Prior Authorization List 7Procedure Required PA Requires PA
Code Description 1/1/2017 2/1/2018
Hereditary colon cancer disorders (eg, Lynch syndrome, PTEN hamartoma
syndrome, Cowden syndrome, familial adenomatosis polyposis); genomic
81435 sequence analysis panel, must include sequencing of at least 10 genes, No Yes
including APC, BMPR1A, CDH1, MLH1, MSH2, MSH6, MUTYH, PTEN, SMAD4,
and STK11
Hereditary colon cancer disorders (eg, Lynch syndrome, PTEN hamartoma
syndrome, Cowden syndrome, familial adenomatosis polyposis);
81436 No Yes
duplication/deletion analysis panel, must include analysis of at least 5 genes,
including MLH1, MSH2, EPCAM, SMAD4, and STK11
Hereditary neuroendocrine tumor disorders (eg, medullary thyroid
carcinoma, parathyroid carcinoma, malignant pheochromocytoma or
81437 No Yes
paraganglioma); genomic sequence analysis panel, must include sequencing
of at least 6 genes, including MAX, SDHB, SDHC, SDHD, TMEM127, and VHL
Hereditary neuroendocrine tumor disorders (eg, medullary thyroid
carcinoma, parathyroid carcinoma, malignant pheochromocytoma or
81438 No Yes
paraganglioma); duplication/deletion analysis panel, must include analyses
for SDHB, SDHC, SDHD, and VHL
Inherited cardiomyopathy (e.g., hypertrophic cardiomyopathy, dilated
cardiomyopathy, arrgythmogenic right ventricular cardiomyopathy) genomic
81439 Yes Yes
sequence analysis panel, must include sequencing of at least 5 genes,
including DSG2, MYBPC3, MYH7, PKP2 and TTN
Noonan spectrum disorders (eg, Noonan syndrome, cardio‐facio‐cutaneous
syndrome, Costello syndrome, LEOPARD syndrome, Noonan‐like syndrome),
81442 genomic sequence analysis panel, must include sequencing of at least 12 No Yes
genes, including BRAF, CBL, HRAS, KRAS, MAP2K1, MAP2K2, NRAS, PTPN11,
RAF1, RIT1, SHOC2, and SOS1
Targeted genomic sequence analysis panel, solid organ neoplasm, DNA
analysis, and RNA analysis when performed, 5‐50 genes (e.g., ALK, BRAF,
81445 CDKN2A, EGFR, ERBB2, KIT, KRAS, NRAS, MET, PDGFRA, PDGFRB, PGR, Yes No
PIK3CA, PTEN, RET), interrogation for sequence variants and copy number
variants or rearrangements, if performed
Hereditary peripheral neuropathies panel (eg, Charcot‐Marie‐Tooth, spastic
paraplegia), genomic sequence analysis panel, must include sequencing of at
81448 N/A Yes
least 5 peripheral neuropathy‐related genes (eg, BSCL2, GJB1, MFN2, MPZ,
REEP1, SPAST, SPG11, and SPTLC1)
Targeted genomic sequence analysis panel, hematolymphoid neoplasm or
disorder, DNA analysis, and RNA analysis when performed, 5‐50 genes (e.g.,
BRAF, CEBPA, DNMT3A, EZH2, FLT3, IDH1, IDH2, JAK2, KRAS, KIT, MLL, NRAS,
81450 Yes No
NPM1, NOTCH1), interrogation for sequence variants, and copy number
variants or rearrangements, or isoform expression or mRNA expression
levels, if performed
Whole mitochondrial genome (e.g., Leigh syndrome, mitochondrial
encephalomyopathy, lactic acidosis, and stroke‐like episodes [MELAS],
myoclonic epilepsy with ragged‐red fibers [MERFF], neuropathy, ataxia, and
81460 Yes No
retinitis pigmentosa [NARP], Leber hereditary optic neuropathy [LHON]),
genomic sequence, must include sequence analysis of entire mitochondrial
genome with heteroplasmy detection
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PA‐TOOL‐6032‐V02‐20170124‐Prior Authorization List 8Procedure Required PA Requires PA
Code Description 1/1/2017 2/1/2018
Whole mitochondrial genome large deletion analysis panel (e.g., Kearns‐
81465 Sayre syndrome, chronic progressive external ophthalmoplegia), including Yes Yes
heteroplasmy detection, if performed
81479 Unlisted molecular pathology procedure Yes Yes
Fetal aneuploidy (trisomy 21, 18, and 13) DNA sequence analysis of selected
81507 Yes Yes
regions using maternal plasma, algorithm reported as a risk score
Oncology (breast), mRNA, gene expression profiling by real‐time RT‐PCR of
81519 21 genes, utilizing formalin‐fixed paraffin embedded tissue, algorithm Yes Yes
reported as recurrence score
Oncology (high grade PSA), bioassay of four proteins (Total PSA, Free PSA,
81539 Intact PSA and human kallikrein‐2 [hK2]), utilizing plasm or serum, Yes No
prognostic algorithm reported as a probability score
Oncology (thyroid), gene expression analysis of 142 genes, utilizing fine
81545 needle aspirate, algorithm reported as a categorical result (e.g., benign or No Yes
supicious)
81599 Unlisted multianalyte assay with algorithmic analysis Yes Yes
84999 Unlisted chemistry panel Yes Yes
86849 Unlisted immunology procedure Yes Yes
87901 HIV‐1 reverse transcriptase and protease regions Yes Yes
Infectious agent phenotype analysis by nucleic acid (DNA or RNA) with drug
87903 Yes Yes
resistance tissue culture analysis, HIV1; first through 10 drugs tested
each additional drug tested (list separately in addition to code for primary
87904 Yes Yes
procedure)
87906 HIV‐1 other region (e.g., integrase, fusion) Yes Yes
Each additional marker (listed separately in addition to code 88184 for the
first marker). Dates of service before 5/1/2017 ‐ PA required only if greater
88185 Yes Yes
than 29 unites are ordered. Dates of services on or after 5/1/2017 ‐ PA
required only if greater than 24 units are ordered
88240 Cryopreservation, freezing and storage of cells, each cell line Yes Yes
88241 Thawing and expansion of frozen cells, each aliquot Yes Yes
Chromosome analysis for breakage syndrome; baseline Sister Chromatid
88245 Yes Yes
Exchange (SCE), 20‐25 cells
baseline breakage, score 50‐110 cells, count 20 cells, 2 karotypes (e.g., for
88248 Yes Yes
ataxia telangiectasia, Fanconi anemia, Fragile X)
score 100 cells, clastogen stress (e.g., diepoxybutane, mitomycin C, ionizing
88249 Yes Yes
radiation, UV radiation)
88261 Chromosome analysis; count 5 cells, 1 karotype, with banding Yes Yes
88262 count 15‐20 cells, 2 karotypes, with banding Yes Yes
88263 count 45 cells, 2 karotypes, with banding Yes Yes
88264 analyze 20‐25 cells Yes Yes
Chromosome analysis, amniotic fluid or chorionic villus, count 15 cells, 1
88267 Yes Yes
karotype, with banding
Chromosome analysis, in situ for amniotic fluid cells, count cells from 6‐12
88269 Yes Yes
colonies, 1 karotype with banding
88271 Molecular cytogenetics; dna probe, each (e.g., fish) Yes Yes
Molecular cytogenetics; chromosomal in situ hybridization, analyze 3‐5 cells
88272 Yes Yes
(e.g., for derivatives and markers)
Confidential and Proprietary Information of Avalon Health Services, LLC, d/b/a Avalon Healthcare Solutions
PA‐TOOL‐6032‐V02‐20170124‐Prior Authorization List 9Procedure Required PA Requires PA
Code Description 1/1/2017 2/1/2018
Molecular cytogenetics; chromosomal in situ hybridization, analyze 10‐30
88273 Yes Yes
cells (e.g., for microdeletions)
88274 Molecular cytogenetics; interphase in situ hybridization, analyze 25‐99 cells Yes Yes
Molecular cytogenetics; interphase in situ hybridization, analyze 100‐300
88275 Yes Yes
cells
88280 Chromosome analysis; additional karyotypes, each study Yes Yes
88283 additional specialized banding technique (e.g., NOR, C‐banding) Yes Yes
88285 additional cell counted, each study Yes Yes
88289 additional high resolution study Yes Yes
Examination and selection of retrieval archival (ie.: previously diagnosed)
88363 Yes Yes
tissue(s) for molecular analysis (e.g.: KRAS mutational analysis)
88399 Unlisted surgical pathology procedure Yes Yes
89240 Unlisted miscellaneous pathology test Yes Yes
0009M Fetal aneuploidy trisom risk Yes Yes
S3800 Genetic testing for amyotrophic lateral sclerosis (ALS) Yes Yes
DNA analysis for germline mutations of the RET proto‐oncogene for
S3840 Yes Yes
susceptibility to multiple endocrine neoplasia type 2
S3841 Genetic testing for retinoblastoma Yes Yes
S3842 Genetic testing for Von Hippel‐Lindau disease Yes Yes
DNA analysis of the connexin 26 gene (GJB2) for susceptibility to congenital,
S3844 Yes Yes
profound deafness
S3845 Genetic testing for alpha thalassemia Yes Yes
S3846 Genetic testing for hemoglobin E beta‐thalassemia Yes Yes
S3849 Genetic testing for Niemann‐Pick disease Yes Yes
S3850 Genetic testing for sickle cell anemia Yes Yes
S3853 Genetic testing for muscular dystrophy Yes Yes
Gene expression profiling panel for use in the management of breast cancer
S3854 Yes Yes
treatment
Genetic testing, sodium channel, voltage‐gated, type v, alpha subunit
S3861 No Yes
(scn5a) and variants for suspected brugada syndrome
Comparative genomic hybridization (CGH) microarray testing for
S3870 Yes Yes
developmental delay, autism spectrum disorder and/or mental retardation
* Current Procedural Terminology© American Medical Association
2018 Code Revision Legend
New codes for 2018
Existing code now requiring PA
Existing code that will no longer require PA, Not intended to imply coverage.
Corporate Office Location
Avalon’s corporate headquarters is located in Tampa, Florida. For more information about Avalon, go to the Avalon web
site: www.Avalonhcs.com.
Confidential and Proprietary Information of Avalon Health Services, LLC, d/b/a Avalon Healthcare Solutions
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