Medical Codes Requiring Prior Authorization
Advantage MD, Priority Partners, Johns Hopkins Employee Health Programs, and Johns Hopkins US Family Health Plan (USFHP)
Effective Date: October 1, 2021
The following list of procedure codes requiring prior authorization is provided for reference purposes only and may not be all inclusive. The listing of a code does not imply that the service described by the code is a covered or non-covered service. Benefit coverage for health services is determined by a member-specific benefit plan and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee claim payment. Other Policies and Guidelines may apply.
Please refer to the Johns Hopkins Prior Authorization Tool (JPAL), located in the HealthLINK portal, to check and verify preauthorization requirements for outpatient services and procedures. Please note that preauthorization requirements are subject to change.
Advantage MD
| Procedure Code | Effective Date | Procedure Description | Comments |
|---|---|---|---|
| 0258U | 10/1/2021 | Autoimmune (psoriasis), mRNA, next-generation sequencing, gene expression profiling of 50-100 genes, skin surface collection using adhesive patch, algorithm reported as likelihood of response to psoriasis biologics. | Preauthorization required |
| 0260U | 10/1/2021 | Rare diseases (constitutional/heritable disorders), identification of copy number variations, inversions, translocations, and other structural variants by optical genome mapping. | Preauthorization required |
| 0262U | 10/1/2021 | Oncology (solid tumor), gene expression profiling by real-time RT-PCR of 7 gene pathways (ER, AR, PI3K, MAPK, HH, TGFB, Notch), formalin-fixed paraffin-embedded (FFPE), algorithm reported as gene pathway activity score. | Preauthorization required |
| 0264U | 10/1/2021 | Rare diseases (constitutional/heritable disorders), identification of copy number variations, inversions, insertions, translocations, and other structural variants by optical genome mapping (Identical technology/clinical descriptor, see 0260U). | Preauthorization required |
| 0265U | 10/1/2021 | 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. | Preauthorization required |
| 0266U | 10/1/2021 | 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. | Preauthorization required |
| 0267U | 10/1/2021 | 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. | Preauthorization required |
| 0268U | 10/1/2021 | Hematology (atypical hemolytic uremic syndrome [aHUS]), genomic sequence analysis of 15 genes, blood, buccal swab, or amniotic fluid. | Preauthorization required |
| 0269U | 10/1/2021 | Hematology (autosomal dominant congenital thrombocytopenia), genomic sequence analysis of 14 genes, blood, buccal swab, or amniotic fluid. | Preauthorization required |
| 0270U | 10/1/2021 | Hematology (congenital coagulation disorders), genomic sequence analysis of 20 genes, blood, buccal swab, or amniotic fluid. | Preauthorization required |
| 0271U | 10/1/2021 | Hematology (congenital neutropenia), genomic sequence analysis of 23 genes, blood, buccal swab, or amniotic fluid. | Preauthorization required |
| 0272U | 10/1/2021 | Hematology (genetic bleeding disorders), genomic sequence analysis of 51 genes, blood, buccal swab, or amniotic fluid, comprehensive. | Preauthorization required |
| 0273U | 10/1/2021 | Hematology (genetic hyperfibrinolysis, delayed bleeding), genomic sequence analysis of 8 genes (F13A1, F13B, FGA, FGB, FGG, SERPINA1, SERPINE1, SERPINF2, PLAU), blood, buccal swab, or amniotic fluid. | Preauthorization required |
| 0274U | 10/1/2021 | Hematology (genetic platelet disorders), genomic sequence analysis of 43 genes, blood, buccal swab, or amniotic fluid. | Preauthorization required |
| 0276U | 10/1/2021 | Hematology (inherited thrombocytopenia), genomic sequence analysis of 23 genes, blood, buccal swab, or amniotic fluid. | Preauthorization required |
| 0277U | 10/1/2021 | Hematology (genetic platelet function disorder), genomic sequence analysis of 31 genes, blood, buccal swab, or amniotic fluid. | Preauthorization required |
| 0278U | 10/1/2021 | Hematology (genetic thrombosis), genomic sequence analysis of 12 genes, blood, buccal swab, or amniotic fluid. | Preauthorization required |
| 0282U | 10/1/2021 | Red blood cell antigen typing, DNA, genotyping of 12 blood group system genes to predict 44 red blood cell antigen phenotypes. | Preauthorization required |
Priority Partners
| Procedure Code | Effective Date | Procedure Description | Comments |
|---|---|---|---|
| 0258U | 10/1/2021 | Autoimmune (psoriasis), mRNA, next-generation sequencing, gene expression profiling of 50-100 genes, skin surface collection using adhesive patch, algorithm reported as likelihood of response to psoriasis biologics. | Preauthorization required |
| 0260U | 10/1/2021 | Rare diseases (constitutional/heritable disorders), identification of copy number variations, inversions, translocations, and other structural variants by optical genome mapping. | Preauthorization required |
| 0262U | 10/1/2021 | Oncology (solid tumor), gene expression profiling by real-time RT-PCR of 7 gene pathways (ER, AR, PI3K, MAPK, HH, TGFB, Notch), formalin-fixed paraffin-embedded (FFPE), algorithm reported as gene pathway activity score. | Preauthorization required |
| 0264U | 10/1/2021 | Rare diseases (constitutional/heritable disorders), identification of copy number variations, inversions, insertions, translocations, and other structural variants by optical genome mapping (Identical technology/clinical descriptor, see 0260U). | Preauthorization required |
| 0265U | 10/1/2021 | 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. | Preauthorization required |
| 0266U | 10/1/2021 | 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. | Preauthorization required |
| 0267U | 10/1/2021 | 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. | Preauthorization required |
| 0268U | 10/1/2021 | Hematology (atypical hemolytic uremic syndrome [aHUS]), genomic sequence analysis of 15 genes, blood, buccal swab, or amniotic fluid. | Preauthorization required |
| 0269U | 10/1/2021 | Hematology (autosomal dominant congenital thrombocytopenia), genomic sequence analysis of 14 genes, blood, buccal swab, or amniotic fluid. | Preauthorization required |
| 0270U | 10/1/2021 | Hematology (congenital coagulation disorders), genomic sequence analysis of 20 genes, blood, buccal swab, or amniotic fluid. | Preauthorization required |
| 0271U | 10/1/2021 | Hematology (congenital neutropenia), genomic sequence analysis of 23 genes, blood, buccal swab, or amniotic fluid. | Preauthorization required |
| 0272U | 10/1/2021 | Hematology (genetic bleeding disorders), genomic sequence analysis of 51 genes, blood, buccal swab, or amniotic fluid, comprehensive. | Preauthorization required |
| 0273U | 10/1/2021 | Hematology (genetic hyperfibrinolysis, delayed bleeding), genomic sequence analysis of 8 genes (F13A1, F13B, FGA, FGB, FGG, SERPINA1, SERPINE1, SERPINF2, PLAU), blood, buccal swab, or amniotic fluid. | Preauthorization required |
| 0274U | 10/1/2021 | Hematology (genetic platelet disorders), genomic sequence analysis of 43 genes, blood, buccal swab, or amniotic fluid. | Preauthorization required |
| 0276U | 10/1/2021 | Hematology (inherited thrombocytopenia), genomic sequence analysis of 23 genes, blood, buccal swab, or amniotic fluid. | Preauthorization required |
| 0277U | 10/1/2021 | Hematology (genetic platelet function disorder), genomic sequence analysis of 31 genes, blood, buccal swab, or amniotic fluid. | Preauthorization required |
| 0278U | 10/1/2021 | Hematology (genetic thrombosis), genomic sequence analysis of 12 genes, blood, buccal swab, or amniotic fluid. | Preauthorization required |
| 0282U | 10/1/2021 | Red blood cell antigen typing, DNA, genotyping of 12 blood group system genes to predict 44 red blood cell antigen phenotypes. | Preauthorization required |
USFHP
| Procedure Code | Effective Date | Procedure Description | Comments |
|---|---|---|---|
| 0258U | 10/1/2021 | Autoimmune (psoriasis), mRNA, next-generation sequencing, gene expression profiling of 50-100 genes, skin surface collection using adhesive patch, algorithm reported as likelihood of response to psoriasis biologics. | Preauthorization required |
| 0260U | 10/1/2021 | Rare diseases (constitutional/heritable disorders), identification of copy number variations, inversions, translocations, and other structural variants by optical genome mapping. | Preauthorization required |
| 0262U | 10/1/2021 | Oncology (solid tumor), gene expression profiling by real-time RT-PCR of 7 gene pathways (ER, AR, PI3K, MAPK, HH, TGFB, Notch), formalin-fixed paraffin-embedded (FFPE), algorithm reported as gene pathway activity score. | Preauthorization required |
| 0264U | 10/1/2021 | Rare diseases (constitutional/heritable disorders), identification of copy number variations, inversions, insertions, translocations, and other structural variants by optical genome mapping (Identical technology/clinical descriptor, see 0260U). | Preauthorization required |
| 0265U | 10/1/2021 | 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. | Preauthorization required |
| 0266U | 10/1/2021 | 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. | Preauthorization required |
| 0267U | 10/1/2021 | 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. | Preauthorization required |
| 0268U | 10/1/2021 | Hematology (atypical hemolytic uremic syndrome [aHUS]), genomic sequence analysis of 15 genes, blood, buccal swab, or amniotic fluid. | Preauthorization required |
| 0269U | 10/1/2021 | Hematology (autosomal dominant congenital thrombocytopenia), genomic sequence analysis of 14 genes, blood, buccal swab, or amniotic fluid. | Preauthorization required |
| 0270U | 10/1/2021 | Hematology (congenital coagulation disorders), genomic sequence analysis of 20 genes, blood, buccal swab, or amniotic fluid. | Preauthorization required |
| 0271U | 10/1/2021 | Hematology (congenital neutropenia), genomic sequence analysis of 23 genes, blood, buccal swab, or amniotic fluid. | Preauthorization required |
| 0272U | 10/1/2021 | Hematology (genetic bleeding disorders), genomic sequence analysis of 51 genes, blood, buccal swab, or amniotic fluid, comprehensive. | Preauthorization required |
| 0273U | 10/1/2021 | Hematology (genetic hyperfibrinolysis, delayed bleeding), genomic sequence analysis of 8 genes (F13A1, F13B, FGA, FGB, FGG, SERPINA1, SERPINE1, SERPINF2, PLAU), blood, buccal swab, or amniotic fluid. | Preauthorization required |
| 0274U | 10/1/2021 | Hematology (genetic platelet disorders), genomic sequence analysis of 43 genes, blood, buccal swab, or amniotic fluid. | Preauthorization required |
| 0276U | 10/1/2021 | Hematology (inherited thrombocytopenia), genomic sequence analysis of 23 genes, blood, buccal swab, or amniotic fluid. | Preauthorization required |
| 0277U | 10/1/2021 | Hematology (genetic platelet function disorder), genomic sequence analysis of 31 genes, blood, buccal swab, or amniotic fluid. | Preauthorization required |
| 0278U | 10/1/2021 | Hematology (genetic thrombosis), genomic sequence analysis of 12 genes, blood, buccal swab, or amniotic fluid. | Preauthorization required |
| 0282U | 10/1/2021 | Red blood cell antigen typing, DNA, genotyping of 12 blood group system genes to predict 44 red blood cell antigen phenotypes. | Preauthorization required |
EHP
| Procedure Code | Effective Date | Procedure Description | Comments |
|---|---|---|---|
| 0258U | 10/1/2021 | Autoimmune (psoriasis), mRNA, next-generation sequencing, gene expression profiling of 50-100 genes, skin surface collection using adhesive patch, algorithm reported as likelihood of response to psoriasis biologics. | Preauthorization required |
| 0260U | 10/1/2021 | Rare diseases (constitutional/heritable disorders), identification of copy number variations, inversions, translocations, and other structural variants by optical genome mapping. | Preauthorization required |
| 0262U | 10/1/2021 | Oncology (solid tumor), gene expression profiling by real-time RT-PCR of 7 gene pathways (ER, AR, PI3K, MAPK, HH, TGFB, Notch), formalin-fixed paraffin-embedded (FFPE), algorithm reported as gene pathway activity score. | Preauthorization required |
| 0264U | 10/1/2021 | Rare diseases (constitutional/heritable disorders), identification of copy number variations, inversions, insertions, translocations, and other structural variants by optical genome mapping (Identical technology/clinical descriptor, see 0260U). | Preauthorization required |
| 0265U | 10/1/2021 | 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. | Preauthorization required |
| 0266U | 10/1/2021 | 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. | Preauthorization required |
| 0267U | 10/1/2021 | 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. | Preauthorization required |
| 0268U | 10/1/2021 | Hematology (atypical hemolytic uremic syndrome [aHUS]), genomic sequence analysis of 15 genes, blood, buccal swab, or amniotic fluid. | Preauthorization required |
| 0269U | 10/1/2021 | Hematology (autosomal dominant congenital thrombocytopenia), genomic sequence analysis of 14 genes, blood, buccal swab, or amniotic fluid. | Preauthorization required |
| 0270U | 10/1/2021 | Hematology (congenital coagulation disorders), genomic sequence analysis of 20 genes, blood, buccal swab, or amniotic fluid. | Preauthorization required |
| 0271U | 10/1/2021 | Hematology (congenital neutropenia), genomic sequence analysis of 23 genes, blood, buccal swab, or amniotic fluid. | Preauthorization required |
| 0272U | 10/1/2021 | Hematology (genetic bleeding disorders), genomic sequence analysis of 51 genes, blood, buccal swab, or amniotic fluid, comprehensive. | Preauthorization required |
| 0273U | 10/1/2021 | Hematology (genetic hyperfibrinolysis, delayed bleeding), genomic sequence analysis of 8 genes (F13A1, F13B, FGA, FGB, FGG, SERPINA1, SERPINE1, SERPINF2, PLAU), blood, buccal swab, or amniotic fluid. | Preauthorization required |
| 0274U | 10/1/2021 | Hematology (genetic platelet disorders), genomic sequence analysis of 43 genes, blood, buccal swab, or amniotic fluid. | Preauthorization required |
| 0276U | 10/1/2021 | Hematology (inherited thrombocytopenia), genomic sequence analysis of 23 genes, blood, buccal swab, or amniotic fluid. | Preauthorization required |
| 0277U | 10/1/2021 | Hematology (genetic platelet function disorder), genomic sequence analysis of 31 genes, blood, buccal swab, or amniotic fluid. | Preauthorization required |
| 0278U | 10/1/2021 | Hematology (genetic thrombosis), genomic sequence analysis of 12 genes, blood, buccal swab, or amniotic fluid. | Preauthorization required |
| 0282U | 10/1/2021 | Red blood cell antigen typing, DNA, genotyping of 12 blood group system genes to predict 44 red blood cell antigen phenotypes. | Preauthorization required |