New Laboratory codes that require Prior Authorization from eviCore for PPMCO as of 1/1/2022
Effective Jan. 1, 2022, providers in the Priority Partners (PPMCO) network must obtain prior authorization for medical necessity from eviCore for certain codes.
The prior authorization requirement applies to members of all ages. The list of CPT/HCPCS codes are for informational purposes and may not be all inclusive. Inclusion or exclusion of a CPT/HCPCS code(s) does not signify or imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member’s specific benefits plan document 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 of payment. Other policies and coverage may be applicable.
New Laboratory codes that require Prior Authorization from eviCore for PPMCO
| Codes | Effective Date | Procedure Description | Prior Authorization Required |
|---|---|---|---|
| 0090U | 1/1/2022 | Oncology (cutaneous melanoma), mRNA gene expression profiling by RTPCR of 23 genes (14 content and 9 housekeeping), utilizing formalin-fixed paraffinembedded tissue, algorithm reported as a categorical result (ie, benign, malignant) | YES |
| 0285U | 1/1/2022 | Oncology, cell-free DNA, quantitative branched chain DNA amplification, plasma, reported as a radiation toxicity score | YES |
| 0286U | 1/1/2022 | CEP72 (centrosomal protein, 72-KDa), NUDT15 (nudix hydrolase 15) and TPMT (thiopurine Smethyltransferase) (eg, drug metabolism) gene analysis, common variants | YES |
| 0287U | 1/1/2022 | Oncology (thyroid), DNA and mRNA, next generation sequencing analysis of 112 genes, fine needle aspirate or formalin fixed paraffin-embedded (FFPE) tissue, algorithmic prediction of cancer recurrence, reported as a categorical risk result (low, intermediate, high) | YES |
| 0288U | 1/1/2022 | 2 Oncology (lung), mRNA, quantitative PCR analysis of 11 genes (BAG1, BRCA1, CDC6, CDK2AP1, ERBB3, FUT3, IL11, LCK, RND3, SH3BGR, WNT3A) and 3 reference genes (ESD, TBP, YAP1), formalin-fixed paraffinembedded (FFPE) tumor tissue, algorithmic interpretation reported as a recurrence risk score | YES |
| 0289U | 1/1/2022 | Neurology (Alzheimer disease), mRNA, gene expression profiling by RNA sequencing of 24 genes, whole blood, algorithm reported as predictive risk score | YES |
| 0290U | 1/1/2022 | Pain management, mRNA, gene expression profiling by RNA sequencing of 36 genes, whole blood, algorithm reported as predictive risk score | YES |
| 0291U | 1/1/2022 | 22 Psychiatry (mood disorders), mRNA, gene expression profiling by RNA sequencing of 144 genes, whole blood, algorithm reported as predictive risk score | YES |
| 0292U | 1/1/2022 | Psychiatry (stress disorders), mRNA, gene expression profiling by RNA sequencing of 72 genes, whole blood, algorithm reported as predictive risk score | YES |
| 0293U | 1/1/2022 | Psychiatry (suicidal ideation), mRNA, gene expression profiling by RNA sequencing of 54 genes, whole blood, algorithm reported as predictive risk score | YES |
| 0294U | 1/1/2022 | Longevity and mortality risk, mRNA, gene expression profiling by RNA sequencing of 18 genes, whole blood, algorithm reported as predictive risk score | YES |
| 0296U | 1/1/2022 | Oncology (oral and/or oropharyngeal cancer), gene expression profiling by RNA sequencing at least 20 molecular features (eg, human and/or microbial mRNA), saliva, algorithm reported as positive or negative for signature associated with malignancy | YES |
| 0297U | 1/1/2022 | Oncology (pan tumor), whole genome sequencing of paired malignant and normal DNA specimens, fresh or formalin fixed paraffinembedded (FFPE) tissue, blood or bone marrow, comparative sequence analyses and variant identification | YES |
| 0298U | 1/1/2022 | 22 Oncology (pan tumor), whole transcriptome sequencing of paired malignant and normal RNA specimens, fresh or formalin-fixed paraffinembedded (FFPE) tissue, blood or bone marrow, comparative sequence analyses and expression level and chimeric transcript identification | YES |
| 0299U | 1/1/2022 | Oncology (pan tumor), whole genome optical genome mapping of paired malignant and normal DNA specimens, fresh frozen tissue, blood, or bone marrow, comparative structural variant identification | YES |
| 0300U | 1/1/2022 | Oncology (pan tumor), whole genome sequencing and optical genome mapping of paired malignant and normal DNA specimens, fresh tissue, blood, or bone marrow, comparative sequence analyses and variant identification | YES |
| 81349 | 1/1/2022 | Neurology (Alzheimer disease), mRNA, gene expression profiling by RNA sequencing of 24 genes, whole blood, algorithm reported as predictive risk score | YES |
| 81523 | 1/1/2022 | Oncology (breast), mRNA, next-generation sequencing gene expression profiling of 70 content genes and 31 housekeeping genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as index related to risk to distant metastasis | YES |