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2020 Q2 Lab Procedure Authorization Matrix

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2020 Q2 Lab Procedure Authorization Matrix ADVANCING CLINICALLY APPROPRIATE LAB TECHNOLOGY AND SERVICES The Prior Authorization List For BlueCross BlueShield of South Carolina and BlueChoice HealthPlan (July 1, 2020) 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 (PA) 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), by phone (844-227-5769), or online using Avalon’s Prior Authorization System, 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 Yellow – Existing codes that will no longer require PA, not intended to imply coverage Green – Codes added to the PA list Codes Requiring Prior Authorization Procedure PA for Description Code 11/1/2019 IDH1 (isocitrate dehydrogenase 1 [NADP+], soluble) (e.g., glioma), 81120 Yes Yes common variants (e.g., R132H, R132C) IDH2 (isocitrate dehydrogenase 2 [NADP+], mitochondrial) (e.g., glioma), 81121 Yes Yes common variants (e.g., R140W, R172M) DMD (dystrophin) (e.g., Duchenne/Becker muscular dystrophy) deletion 81161 Yes Yes analysis, and duplication analysis, if performed BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (e.g., hereditary breast and ovarian cancer) gene analysis; full 81162 Yes Yes sequence analysis and full duplication/deletion analysis (i.e., detection of large gene rearrangements) BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair 81163 associated) (e.g., hereditary breast and ovarian cancer) gene analysis Yes Yes (breast cancer 1 and 2) of full sequence BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair associated) (e.g., hereditary breast and ovarian cancer) gene analysis; full 81164 Yes Yes duplication/deletion analysis (i.e., detection of large gene rearrangements) BRCA1 (BRCA1, DNA repair associated) (e.g., hereditary breast and 81165 Yes Yes ovarian cancer) gene analysis; full sequence analysis BRCA1 (BRCA1, DNA repair associated) (e.g., hereditary breast and 81166 ovarian cancer) gene analysis; full duplication/deletion analysis (i.e., Yes Yes detection of large gene rearrangements) Confidential and Proprietary Information of Avalon Health Services, LLC, d/b/a Avalon Healthcare Solutions PA-TOOL-6032-V02-20170124-Prior Authorization List 1 Procedure PA for Description Code 11/1/2019 BRCA2 (BRCA2, DNA repair associated) (e.g., hereditary breast and 81167 ovarian cancer) gene analysis; full duplication/deletion analysis (i.e., Yes Yes detection of large gene rearrangements) 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 AFF2 (AF4/FMR2 family, member 2 [FMR2]) (e.g., fragile X mental 81171 retardation 2 [FRAXE]) gene analysis; evaluation to detect abnormal (e.g., Yes Yes expanded) alleles AFF2 (AF4/FMR2 family, member 2 [FMR2]) (e.g., fragile X mental 81172 retardation 2 [FRAXE]) gene analysis; characterization of alleles (e.g., Yes Yes expanded size and methylation status) AR (androgen receptor) (e.g., spinal and bulbar muscular atrophy, 81173 Kennedy disease, X chromosome inactivation) gene analysis; full gene Yes Yes sequence ASXL1 (additional sex combs like 1, transcriptional regulator) (e.g., 81175 myelodysplastic syndrome, myeloproliferative neoplasms, chronic Yes Yes myelomonocytic leukemia) gene analysis; full gene sequence ASXL1 (additional sex combs like 1, transcriptional regulator) (e.g., myelodysplastic syndrome, myeloproliferative neoplasms, chronic 81176 Yes Yes myelomonocytic leukemia) gene analysis; targeted sequence analysis (e.g., exon 12) ATN1 (atrophin 1) (e.g., dentatorubral-pallidoluysian atrophy) gene 81177 Yes Yes analysis, evaluation to detect abnormal (e.g., expanded) alleles ATXN1 (ataxin 1) (e.g., spinocerebellar ataxia) gene analysis, evaluation to 81178 Yes Yes detect abnormal (e.g., expanded) alleles ATXN2 (ataxin 2) (e.g., spinocerebellar ataxia) gene analysis, evaluation to 81179 Yes Yes detect abnormal (e.g., expanded) allele ATXN3 (ataxin 3) (e.g., spinocerebellar ataxia, Machado-Joseph disease) 81180 Yes Yes gene analysis, evaluation to detect abnormal (e.g., expanded) alleles ATXN7 (ataxin 7) (e.g., spinocerebellar ataxia) gene analysis, evaluation to 81181 Yes Yes detect abnormal (e.g., expanded) alleles ATXN8OS (ATXN8 opposite strand [non-protein coding]) (e.g., 81182 spinocerebellar ataxia) gene analysis, evaluation to detect abnormal (e.g., Yes Yes expanded) alleles ATXN10 (ataxin 10) (e.g., spinocerebellar ataxia) gene analysis, evaluation 81183 Yes Yes to detect abnormal (e.g., expanded) alleles CACNA1A (calcium voltage-gated channel subunit alpha1 A) (e.g., 81184 spinocerebellar ataxia) gene analysis; evaluation to detect abnormal (e.g., No Yes expanded) alleles CACNA1A (calcium voltage-gated channel subunit alpha1 A) (e.g., 81185 No Yes spinocerebellar ataxia) gene analysis; full gene sequence CNBP (CCHC-type zinc finger nucleic acid binding protein) (e.g., myotonic 81187 dystrophy type 2) gene analysis, evaluation to detect abnormal (e.g., Yes Yes expanded) alleles Confidential and Proprietary Information of Avalon Health Services, LLC, d/b/a Avalon Healthcare Solutions PA-TOOL-6032-V02-20170124-Prior Authorization List 2 Procedure PA for Description Code 11/1/2019 CSTB (cystatin B) (e.g., Unverricht-Lundborg disease) gene analysis; 81188 Yes Yes evaluation to detect abnormal (e.g., expanded) alleles CSTB (cystatin B) (e.g., Unverricht-Lundborg disease) gene analysis; full 81189 Yes Yes gene sequence ASPA (aspartoacylase) (e.g., Canavan disease) gene analysis, common 81200 variants (e.g., E285A, Y231X) (ASPA genetic analysis, CANW, or Canavan Yes Yes disease mutation analysis) APC (adenomatous polyposis coli) (e.g., familial adenomatous polyposis 81201 Yes Yes [FAP], attenuated FAP) gene analysis; full gene sequence APC (adenomatous polyposis coli) (e.g., familial adenomatous polyposis 81202 Yes Yes [FAP], attenuated FAP) gene analysis; known familial variants APC (adenomatous polyposis coli) (e.g., familial adenomatous polyposis 81203 Yes Yes [FAP], attenuated FAP) gene analysis; duplication/deletion variants AR (androgen receptor) (e.g., spinal and bulbar muscular atrophy, 81204 Kennedy disease, X chromosome inactivation) gene analysis; Yes characterization of alleles (e.g., expanded size or methylation status) 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 BCR/ABL1 (t(9;22)) (e.g., chronic myelogenous leukemia) translocation 81207 Yes Yes analysis; minor breakpoint qualitative or quantitative BCR/ABL1 (t(9;22)) (e.g., chronic myelogenous leukemia) translocation 81208 Yes Yes analysis; other breakpoint, qualitative or quantitative BLM (Bloom Syndrome, RecQ helicase-like) (e.g., Bloom Syndrome) gene 81209 Yes Yes analysis, 2281del6ins7 variant BRAF (B-Raf proto-oncogene, serine/threonine kinase) (e.g., colon cancer, 81210 Yes Yes melanoma), gene analysis, V600 variants BRCA1 (BRCA1, DNA repair associated), BRCA2 (BRCA2, DNA repair 81212 associated) (e.g., hereditary breast and ovarian cancer) gene analysis; Yes Yes 185delAG, 5385insC, 6174delT variants BRCA1 (BRCA1, DNA repair associated) (e.g., hereditary breast and 81215 Yes Yes ovarian cancer) gene analysis; known familial variant BRCA2 (BRCA2, DNA repair associated) (e.g., hereditary breast and 81216 Yes Yes ovarian cancer) gene analysis; full sequence analysis BRCA2 (BRCA2, DNA repair associated) (e.g., hereditary breast and 81217 Yes Yes ovarian cancer) gene analysis; known familial variant CEBPA (CCAAT/enhancer binding protein [C/EBP], alpha) (e.g., acute 81218 Yes Yes myeloid leukemia), gene analysis, full gene sequence CALR (calreticulin) (e.g., myeloproliferative disorders), gene analysis, 81219 Yes Yes common variants in exon 9 CFTR (cystic fibrosis transmembrane conductance regulator) (e.g., cystic 81221 Yes Yes fibrosis) gene analysis; known familial variants CFTR (cystic fibrosis transmembrane conductance regulator) (e.g., cystic 81222 Yes Yes fibrosis) gene analysis; duplication/deletion variants Confidential and Proprietary Information of Avalon Health Services, LLC, d/b/a Avalon Healthcare Solutions PA-TOOL-6032-V02-20170124-Prior Authorization List 3 Procedure PA for Description Code 11/1/2019 CFTR (cystic fibrosis transmembrane conductance regulator) (e.g., cystic 81223 Yes Yes fibrosis) gene analysis; full
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