Policy Updates Prior AuthorizationAnthem Blue Cross and Blue Shield | CommercialAnthem Blue Cross and Blue Shield | Medicare AdvantageJune 5, 2023

Notice of material change/amendment to contract

Carelon Medical Benefits Management, Inc. genetic testing CPT code list update

Effective for dates of service on and after October 1, 2023, the following codes will require prior authorization through Carelon Medical Benefits Management, Inc.*

Note: On March 1, 2023, AIM Specialty Health® began operating as Carelon Medical Benefits Management, Inc.

CPT® code

Description

81418

APOL1 (apolipoprotein L1) (for example, chronic kidney disease), risk variants (G1, G2)

81441

Drug metabolism (for example, pharmacogenomics) genomic sequence analysis panel, must include testing of at least 6 genes, including CYP2C19, CYP2D6, and CYP2D6 duplication/deletion an

81449

Oncology (oropharyngeal), evaluation of 17 DNA biomarkers using droplet digital PCR (ddPCR), cell-free DNA, algorithm reported as a prognostic risk score for cancer recurrence

81451

Oncology (urothelial), mRNA, gene-expression profiling by real-time quantitative PCR of 5 genes (MDK, HOXA13, CDC2 [CDK1], IGFBP5, and CXCR2), utilizing urine, algorithm incor

81456

Inherited bone marrow failure syndromes (IBMFS) (for example, Fanconi anemia, dyskeratosis congenita, Diamond-Blackfan anemia, Shwachman-Diamond syndrome, GATA2 deficiency syndrome, co

0332U

Targeted genomic sequence analysis panel, solid organ neoplasm, 5-50 genes (for example, ALK, BRAF, CDKN2A, EGFR, ERBB2, KIT, KRAS, MET, NRAS, PDGFRA, PDGFRB, PGR, PIK3CA, PTEN, RET)

0355U

Targeted genomic sequence analysis panel, hematolymphoid neoplasm or disorder, 5-50 genes (for example, BRAF, CEBPA, DNMT3A, EZH2, FLT3, IDH1, IDH2, JAK2, KIT, KRAS, MLL, NOTCH1, NPM1

0356U

Targeted genomic sequence analysis panel, solid organ or hematolymphoid neoplasm or disorder, 51 or greater genes (for example, ALK, BRAF, CDKN2A, CEBPA, DNMT3A, EGFR, ERBB2, EZH2, FLT

0363U

Oncology (pan-tumor), genetic profiling of 8 DNA-regulatory (epigenetic) markers by quantitative polymerase chain reaction (qPCR), whole blood, reported as a high or low proba

81349

Cytogenomic (genome-wide) analysis for constitutional chromosomal abnormalities; interrogation of genomic regions for copy number and loss-of-heterozygosity variants, low-pass sequencing analysis

81355

Vkorc1 (Vitamin K Epoxide Reductase Complex, Subunit 1) (for example, Warfarin Metabolism), Gene Analysis, Common Variants (for example, -1639/3673)

As a reminder, ordering and servicing providers may submit prior authorization requests to Carelon Medical Benefits Management by accessing Carelon Medical Benefits Management’s ProviderPortalSM directly at www.providerportal.com.

  • Online access is available 24/7 to process orders in real-time and is the fastest and most convenient way to request authorization.

If you have questions related to guidelines, please contact Carelon Medical Benefits Management via email at MedicalBenefitsManagement.guidelines@Carelon.com. You can also download a copy of the current upcoming guidelines here: https://tinyurl.com/yjmjuesk.

* Carelon Medical Benefits Management, Inc. is an independent company providing utilization management services on behalf of the health plan.

MEAMH-CR-023058-23-CPN22845, MULTI-BCBS-CM-023064-23-CPN22845

ATTACHMENTS: GENE.00010 (pdf - 4.52mb), GENE.00049 (pdf - 8.24mb), CG-GENE-11 (pdf - 9.6mb)

PUBLICATIONS: July 2023 Provider Newsletter