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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 CodeEffective DateProcedure DescriptionComments
0258U10/1/2021Autoimmune (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
0260U10/1/2021Rare diseases (constitutional/heritable disorders), identification of copy number variations, inversions, translocations, and other structural variants by optical genome mapping.Preauthorization required
0262U10/1/2021Oncology (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
0264U10/1/2021Rare 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
0265U10/1/2021Rare 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
0266U10/1/2021Unexplained 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
0267U10/1/2021Rare 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
0268U10/1/2021Hematology (atypical hemolytic uremic syndrome [aHUS]), genomic sequence analysis of 15 genes, blood, buccal swab, or amniotic fluid.Preauthorization required
0269U10/1/2021Hematology (autosomal dominant congenital thrombocytopenia), genomic sequence analysis of 14 genes, blood, buccal swab, or amniotic fluid.Preauthorization required
0270U10/1/2021Hematology (congenital coagulation disorders), genomic sequence analysis of 20 genes, blood, buccal swab, or amniotic fluid.Preauthorization required
0271U10/1/2021Hematology (congenital neutropenia), genomic sequence analysis of 23 genes, blood, buccal swab, or amniotic fluid.Preauthorization required
0272U10/1/2021Hematology (genetic bleeding disorders), genomic sequence analysis of 51 genes, blood, buccal swab, or amniotic fluid, comprehensive.Preauthorization required
0273U10/1/2021Hematology (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
0274U10/1/2021Hematology (genetic platelet disorders), genomic sequence analysis of 43 genes, blood, buccal swab, or amniotic fluid.Preauthorization required
0276U10/1/2021Hematology (inherited thrombocytopenia), genomic sequence analysis of 23 genes, blood, buccal swab, or amniotic fluid.Preauthorization required
0277U10/1/2021Hematology (genetic platelet function disorder), genomic sequence analysis of 31 genes, blood, buccal swab, or amniotic fluid.Preauthorization required
0278U10/1/2021Hematology (genetic thrombosis), genomic sequence analysis of 12 genes, blood, buccal swab, or amniotic fluid.Preauthorization required
0282U10/1/2021Red 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 CodeEffective DateProcedure DescriptionComments
0258U10/1/2021Autoimmune (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
0260U10/1/2021Rare diseases (constitutional/heritable disorders), identification of copy number variations, inversions, translocations, and other structural variants by optical genome mapping.Preauthorization required
0262U10/1/2021Oncology (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
0264U10/1/2021Rare 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
0265U10/1/2021Rare 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
0266U10/1/2021Unexplained 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
0267U10/1/2021Rare 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
0268U10/1/2021Hematology (atypical hemolytic uremic syndrome [aHUS]), genomic sequence analysis of 15 genes, blood, buccal swab, or amniotic fluid.Preauthorization required
0269U10/1/2021Hematology (autosomal dominant congenital thrombocytopenia), genomic sequence analysis of 14 genes, blood, buccal swab, or amniotic fluid.Preauthorization required
0270U10/1/2021Hematology (congenital coagulation disorders), genomic sequence analysis of 20 genes, blood, buccal swab, or amniotic fluid.Preauthorization required
0271U10/1/2021Hematology (congenital neutropenia), genomic sequence analysis of 23 genes, blood, buccal swab, or amniotic fluid.Preauthorization required
0272U10/1/2021Hematology (genetic bleeding disorders), genomic sequence analysis of 51 genes, blood, buccal swab, or amniotic fluid, comprehensive.Preauthorization required
0273U10/1/2021Hematology (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
0274U10/1/2021Hematology (genetic platelet disorders), genomic sequence analysis of 43 genes, blood, buccal swab, or amniotic fluid.Preauthorization required
0276U10/1/2021Hematology (inherited thrombocytopenia), genomic sequence analysis of 23 genes, blood, buccal swab, or amniotic fluid.Preauthorization required
0277U10/1/2021Hematology (genetic platelet function disorder), genomic sequence analysis of 31 genes, blood, buccal swab, or amniotic fluid.Preauthorization required
0278U10/1/2021Hematology (genetic thrombosis), genomic sequence analysis of 12 genes, blood, buccal swab, or amniotic fluid.Preauthorization required
0282U10/1/2021Red blood cell antigen typing, DNA, genotyping of 12 blood group system genes to predict 44 red blood cell antigen phenotypes.Preauthorization required

USFHP

Procedure CodeEffective DateProcedure DescriptionComments
0258U10/1/2021Autoimmune (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
0260U10/1/2021Rare diseases (constitutional/heritable disorders), identification of copy number variations, inversions, translocations, and other structural variants by optical genome mapping.Preauthorization required
0262U10/1/2021Oncology (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
0264U10/1/2021Rare 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
0265U10/1/2021Rare 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
0266U10/1/2021Unexplained 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
0267U10/1/2021Rare 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
0268U10/1/2021Hematology (atypical hemolytic uremic syndrome [aHUS]), genomic sequence analysis of 15 genes, blood, buccal swab, or amniotic fluid.Preauthorization required
0269U10/1/2021Hematology (autosomal dominant congenital thrombocytopenia), genomic sequence analysis of 14 genes, blood, buccal swab, or amniotic fluid.Preauthorization required
0270U10/1/2021Hematology (congenital coagulation disorders), genomic sequence analysis of 20 genes, blood, buccal swab, or amniotic fluid.Preauthorization required
0271U10/1/2021Hematology (congenital neutropenia), genomic sequence analysis of 23 genes, blood, buccal swab, or amniotic fluid.Preauthorization required
0272U10/1/2021Hematology (genetic bleeding disorders), genomic sequence analysis of 51 genes, blood, buccal swab, or amniotic fluid, comprehensive.Preauthorization required
0273U10/1/2021Hematology (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
0274U10/1/2021Hematology (genetic platelet disorders), genomic sequence analysis of 43 genes, blood, buccal swab, or amniotic fluid.Preauthorization required
0276U10/1/2021Hematology (inherited thrombocytopenia), genomic sequence analysis of 23 genes, blood, buccal swab, or amniotic fluid.Preauthorization required
0277U10/1/2021Hematology (genetic platelet function disorder), genomic sequence analysis of 31 genes, blood, buccal swab, or amniotic fluid.Preauthorization required
0278U10/1/2021Hematology (genetic thrombosis), genomic sequence analysis of 12 genes, blood, buccal swab, or amniotic fluid.Preauthorization required
0282U10/1/2021Red blood cell antigen typing, DNA, genotyping of 12 blood group system genes to predict 44 red blood cell antigen phenotypes.Preauthorization required

EHP

Procedure CodeEffective DateProcedure DescriptionComments
0258U10/1/2021Autoimmune (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
0260U10/1/2021Rare diseases (constitutional/heritable disorders), identification of copy number variations, inversions, translocations, and other structural variants by optical genome mapping.Preauthorization required
0262U10/1/2021Oncology (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
0264U10/1/2021Rare 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
0265U10/1/2021Rare 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
0266U10/1/2021Unexplained 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
0267U10/1/2021Rare 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
0268U10/1/2021Hematology (atypical hemolytic uremic syndrome [aHUS]), genomic sequence analysis of 15 genes, blood, buccal swab, or amniotic fluid.Preauthorization required
0269U10/1/2021Hematology (autosomal dominant congenital thrombocytopenia), genomic sequence analysis of 14 genes, blood, buccal swab, or amniotic fluid.Preauthorization required
0270U10/1/2021Hematology (congenital coagulation disorders), genomic sequence analysis of 20 genes, blood, buccal swab, or amniotic fluid.Preauthorization required
0271U10/1/2021Hematology (congenital neutropenia), genomic sequence analysis of 23 genes, blood, buccal swab, or amniotic fluid.Preauthorization required
0272U10/1/2021Hematology (genetic bleeding disorders), genomic sequence analysis of 51 genes, blood, buccal swab, or amniotic fluid, comprehensive.Preauthorization required
0273U10/1/2021Hematology (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
0274U10/1/2021Hematology (genetic platelet disorders), genomic sequence analysis of 43 genes, blood, buccal swab, or amniotic fluid.Preauthorization required
0276U10/1/2021Hematology (inherited thrombocytopenia), genomic sequence analysis of 23 genes, blood, buccal swab, or amniotic fluid.Preauthorization required
0277U10/1/2021Hematology (genetic platelet function disorder), genomic sequence analysis of 31 genes, blood, buccal swab, or amniotic fluid.Preauthorization required
0278U10/1/2021Hematology (genetic thrombosis), genomic sequence analysis of 12 genes, blood, buccal swab, or amniotic fluid.Preauthorization required
0282U10/1/2021Red blood cell antigen typing, DNA, genotyping of 12 blood group system genes to predict 44 red blood cell antigen phenotypes.Preauthorization required