ADVANCING CLINICALLY APPROPRIATE LAB TECHNOLOGY AND SERVICES

The Prior Authorization List For BlueCross BlueShield of South Carolina and BlueChoice HealthPlan 2018

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® ® 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 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) or by phone (844‐227‐5769), 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

New codes for 2018

Existing code now requiring PA

Existing code that will no longer require PA, not intended to imply coverage

Codes Requiring Prior Authorization Procedure Required PA Requires PA Code Description 1/1/2017 1/1/2018 IDH1 (isocitrate dehydrogenase 1 [NADP+], soluble) (eg, glioma), common 81120 N/A Yes variants (eg, R132H, R132C) IDH2 (isocitrate dehydrogenase 2 [NADP+], mitochondrial) (eg, glioma), 81121 N/A Yes common variants (eg, R140W, R172M) Dmd () (e.g., duchenne/becker muscular dystrophy) deletion 81161 Yes Yes analysis, and duplication analysis BRCA1, BRCA2 (breast cancer 1 and 2) (e.g., hereditary breast and ovarian 81162 cancer) analysis; full sequence analysis and full duplication/deletion Yes Yes analysis 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 ASXL1 (additional sex combs like 1, transcriptional regulator) (eg, 81175 myelodysplastic syndrome, myeloproliferative neoplasms, chronic N/A Yes myelomonocytic leukemia) gene analysis; full gene sequence ASXL1 (additional sex combs like 1, transcriptional regulator) (eg, myelodysplastic syndrome, myeloproliferative neoplasms, chronic 81176 N/A Yes myelomonocytic leukemia) gene analysis; targeted sequence analysis (eg, exon 12) ASPA (aspartoacylase) (e.g., Canavan disease) gene analysis, common 81200 Yes Yes variants (e.g., E285A, Y231X) APC (adenomatous polyposis coli) (e.g., familial adenomatosis polyposis 81201 Yes Yes [FAP], attenuated FAP) gene analysis; full gene sequence

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Procedure Required PA Requires PA Code Description 1/1/2017 1/1/2018 APC (adenomatous polyposis coli) (e.g., familial adenomatosis polyposis 81202 Yes Yes [FAP], attenuated FAP) gene analysis; known familial variants APC (adenomatous polyposis coli) (e.g., familial adenomatosis polyposis 81203 Yes Yes [FAP], attenuated FAP) gene analysis; duplication/deletion variants 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 81207 minor breakpoint, qualitative or quantitative Yes Yes 81208 other breakpoint, qualitative or quantitative Yes Yes BLM (Bloom Syndrome, RecQ helicase‐like) (e.g., Bloom Syndrome) gene 81209 Yes Yes analysis, 2281del6ins7 variant BRAF (v‐raf murine sarcoma viral oncogene homolog b1) (e.g., colon cancer), 81210 Yes Yes gene analysis, v600e variant BRCA1, BRCA2 (breast cancer 1 and 2) e.g., hereditary breast and ovarian cancer) gene analysis; full sequence analysis and common 81211 Yes Yes duplication/deletion variants in BRCA1 (ie, exon 13 del 3.835kb, exon 13 dup 6kb, exon 14‐20 del 26kb, exon 22 del 510bp, exon 8‐9 del 7.1 kb) 81212 185delAG, 5385insC, 6174delT variants Yes Yes 81213 Uncommon duplication/deletion variants (BRCA1, BRCA2 ) Yes Yes BRCA1 (breast cancer 1 e.g., hereditary breast and ovarian cancer) gene analysis; full sequence analysis and common duplication/deletion variants 81214 (i.e., exon 13 del 3.835kb, exon 13 dup 6kb, exon 14‐20 del 26kb, exon 22 Yes Yes del 510bp, exon 8‐9 del 7.1kb) *Note: when performing BRCA1 full sequence analysis with BRCA2 full sequence analysis, use procedure code 81211 81215 Known familial variant. Note BRCA 1 or BRCA 2 Specific Site Analysis. Yes Yes BRCA2 (breast cancer 2) (e.g., hereditary breast and ovarian cancer) gene analysis, full sequence analysis **Note: when performing BRCA2 full 81216 Yes Yes sequence analysis with BRCA1 full sequence analysis, use procedure code 81211 81217 Known familial variant Yes Yes CEBPA (CCAAT/enhancer binding [C/EBP], alpha) (e.g., acute myeloid 81218 Yes Yes leukemia), gene analysis, full gene sequence CALR (calreticulin) (eg, myeloproliferative disorders), gene analysis, common 81219 No Yes variants in exon 9 81221 known familial variants Yes Yes CFTR (cystic fibrosis transmembrane conductance regulator) (e.g., cystic 81222 Yes Yes fibrosis) gene analysis; duplication/deletion variants CFTR (cystic fibrosis transmembrane conductance regulator) (e.g., cystic 81223 Yes Yes fibrosis) gene analysis; full gene sequence CFTR (cystic fibrosis transmembrane conductance regulator) (e.g., cystic 81224 Yes Yes fibrosis) gene analysis; intron 8 poly‐T analysis (e.g., male infertility) Cyp2c19 (cytochrome p450, family 2, subfamily c, polypeptide 19) (e.g., drug 81225 Yes Yes metabolism), gene analysis, common variants (e.g., *2, *3, *4, *8, *17) Cyp2d6 (cytochrome p450, family 2, subfamily d, polypeptide 6) (e.g., drug 81226 metabolism), gene analysis, common variants (e.g., *2, *3, *4, *5, *6, *9, Yes Yes *10, *17, *19, *29, *35, *41, *1xn, *2xn, *4xn)

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Procedure Required PA Requires PA Code Description 1/1/2017 1/1/2018 Cytogenomic constitutional (genome‐wide) microarray analysis; interrogation of genomic regions for copy number variants (e.g., bacterial 81228 Yes Yes artificial chormosome [BAC] or oligo‐based comparative genomic hybridization [CGH] microarray analysis Interrogation of genomic regions for copy number and single nucleotide 81229 Yes Yes polymorphism (SNP) variants for chromosomal abnormalities EGFR (epidermal growth factor receptor) (e.g., non‐small cell lung gancer) 81235 gene analysis, common variants (e.g. exon 19 LREA deletion,L858R, T790M, Yes Yes G719A, G719S, L861Q) F5 (coagulation factor V) (eg, hereditary hypercoagulabulity) gene analysis, 81241 No Yes Leiden variant FANCC (Fanconi Anemia, complementation group C) (e.g., Fanconi Anemia, 81242 Yes Yes type C) gene analysis, common variant (e.g.: IVS4+4a>T) FMR1 (Fragile X mental retardation 1) gene analysis; evaluation to detect 81243 Yes Yes abnormal (e.g., expanded) alleles FMR1 (Fragile X mental retardation 1) gene analysis; characterization of 81244 Yes Yes alleles (e.g., expanded size and methylation status) FLT3 (fms‐related tyrosine kinase 3) (e.g., acute myeloid leukemia), gene 81245 Yes Yes analysis; internal tandem duplication (ITD) variants (i.e., exons 14, 15) G6PC (glucose‐6‐phosphatase, catalytic subunit) (e.g., Glycogen storage 81250 disease, Type 1a, von Gierke disease) gene analysis, common variants (e.g., Yes Yes R83C, Q347X) GBA (glucosidase, beta, acid) (e.g., Gaucher disease) gene analysis, common 81251 Yes Yes variants (e.g., N370S, 84GG, L444P, IVS2+1G>A) GJB2 ( protein, beta 2, 26kDa, 26) (e.g., nonsyndromic 81252 Yes Yes hearing loss) gene analysis; full gene sequence 81253 known familial variants Yes Yes GJB6 (gap junction protein, beta 6, 30kDa, connexin 30) (e.g., nonsyndromic 81254 hearing loss) gene analysis, common variants (e.g., 309kb [del(GJB6‐ Yes Yes D13S1830)] and 232 kb [del(GJB6‐D13S1854)]) HEXA (hexosaminidase A [alpha polypeptide]) (e.g., Tay‐Sachs disease) gene 81255 Yes Yes analysis, common variants (e.g., 1278insTATC, 1421+1G>C,G269S) HFE (hemochromatosis) (e.g., hereditary hemochromatosis) gene analysis, 81256 Yes Yes common variants (e.g., C282Y, H63D) HBA1/HBA2 (alpha globin 1 and alpha globin 2) (e.g., alpha thalassemia, Hb Bart hydrops fetalis syndrome, HbH disease) gene analysis, for common 81257 Yes Yes deletions or variant (e.g., Southeast Asian, Thai, Filipino, Mediterrenean, alpha3.7, alpha4.2 alpha20.5, constant spring) HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia, Hb 81258 Bart hydrops fetalis syndrome, HbH disease), gene analysis; known familial N/A Yes variant HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia, Hb 81259 Bart hydrops fetalis syndrome, HbH disease), gene analysis; full gene N/A Yes sequence IKBKAP (inhibitor of kappa light polypeptide gene enhancer in B‐cells, kinase 81260 complex‐associated protein) (e.g., familial dysautonomia) gene analysis, Yes Yes common variants (e.g., 2507+6T>C, R696P)

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Procedure Required PA Requires PA Code Description 1/1/2017 1/1/2018 IGH@ (Immunoglobulin heavy chain locus) (e.g., leukemias amd lymphomas, 81261 B‐cell), gene rearrangement analysis to detect abnormal clonal Yes Yes population(s); amplified methodology (e.g., polymerase chain reaction) 81262 direct probe methodology (e.g., Southern blot) Yes Yes IGH@ (Immunoglobulin heavy chain locus) (e.g., leukemias amd lymphoma, 81263 Yes Yes B‐cell), variable region somatic mutation analysis IGK@ (Immunoglobulin kappa light chain locus) (e.g., leukemia and 81264 lymphoma, B‐cell) gene‐rearrangement analysis, evaluation to detect Yes Yes abnormal clonal population(s) Comparative analysis using Short Tandem Repeat (STR) makers; patient and comparative specimen (e.g., pre‐transplant recipient and donor germline 81265 testing, post‐transplant non‐hematopoietic recipient germline [e.g., buccal Yes Yes swab or other germline tissue sample] and donor testing, twin zygosity testing, or maternal cell contamination of fetal cells) each additional specimen )e.g., additional cord blood donor, additional fetal 81266 samples from different cultures, or additional zygosity in multiple birth Yes Yes pregnancies) [List separately in addition to code for primary procedure] Chimerism (engraftment) analysis, post transplantation specimen (e.g., 81267 hematopoietic stem cell), includes comparison to previously performed Yes Yes baseline analyses; without cell selection 81268 with cell selection (e.g., CD3, CD33), each cell type Yes Yes HBA1/HBA2 (alpha globin 1 and alpha globin 2) (eg, alpha thalassemia, Hb 81269 Bart hydrops fetalis syndrome, HbH disease), gene analysis; N/A Yes duplication/deletion variants JAK2 ( Janus kinase 2) (e.g., myeloproliferative disorder) gene analysis, 81270 Yes Yes p.Val617Phe (V617F) variant 81275 KRAS (e.g. carcinoma) gene analysis, variants in codons 12 and 13 Yes Yes KRAS (Kirsten rat sarcoma viral oncogene homolog) (e.g., carcinoma) gene 81276 Yes Yes analysis; additional variant(s) (e.g., codon 61, codon 146) Long QT syndrome gene analyses (e.g., KCNQ!, KCNH2, SCN5A, KCNE1, 81280 KCNE2, KCNJ2, CACNA1C, CAV3, SCN4B, AKAP, SNTA1, and ANK2); full No Yes sequence analysis 81281 known familial sequence variant No Yes 81282 duplication/deletion variants No Yes MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (e.g., hereditary 81288 non‐polyposis colorectal cancer, Lynch syndrome) gene analysis; promoter Yes Yes methylation analysis MCOLN1 (mucolipin 1)(e.g., Mucolipidosis, type IV) gene analysis, common 81290 Yes Yes variants (e.g.,, IVS3‐2A>G, del6, 4kb) MLH1 (mutL homolog 1, colon cancer, nonpolyposis type 2) (e.g., hereditary 81292 non‐polyposis colorectal cancer, Lynch syndrome) gene analysis; full Yes Yes sequence analysis 81293 known familial variants Yes Yes 81294 duplication/deletion variants Yes Yes MSH2 (mutS homolog 2, colon cancer, nonpolyposis type 1) (e.g., hereditary 81295 non‐polyposis colorectal cancer, Lynch syndrome) gene analysis; full Yes Yes sequence analysis 81296 known familial variants Yes Yes

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Procedure Required PA Requires PA Code Description 1/1/2017 1/1/2018 81297 duplication/deletion variants Yes Yes MSH6 (mutS homolog 6 [E. Coli]) e.g., jeredotaru mpm‐polyposis colorectal 81298 Yes Yes cancer, Lynch syndrome) gene analysis; full sequence analysis 81299 known familial variants Yes Yes 81300 duplication/deletion variants Yes Yes Microsatellite instability analysis (e.g., hereditary non‐polyposis colorectal cancer, Lynch syndrome) of markers for mismatch repair deficiency (e.g., 81301 No Yes BAT25, BAT26), includes comparison of neoplastic and normal tissue, if performed Mecp2 (methyl cpg binding protein 2) (e.g., rett syndrome) gene analysis; 81302 Yes Yes full sequence analysis Mecp2 (methyl cpg binding protein 2) (e.g., rett syndrome) gene analysis; 81303 Yes Yes known familial variant Mecp2 (methyl cpg binding protein 2) (e.g., rett syndrome) gene analysis; 81304 Yes Yes duplication/deletion variants NPM1 (nucleophosmin) (e.g., acute myeloid leukemia) gene analysis, exon 81310 Yes Yes 12 variants NRAS (neuroblastoma RAS viral [v‐ras] oncogene homolog) (e.g., colorectal 81311 carcinoma), gene analysis, variants in exon 2 (e.g., codons 12 and 13) and Yes Yes exon 3 (e.g., codon 61) PML/RARalpha, (t(15;17)), (promyelocytic leukemia/retinoic acid receptor 81315 alpha) (e.g., promyelocytic leukemia) translocation analysis; common Yes Yes breakpoints (e.g., intron 3 and intron 6), qualitative or quantitative single breakpoint (e.g., intron 3, intron 6 or exon 6), qualitative or 81316 Yes Yes quantitative PMS2 (postmeiotic segregation increased 2 [S. cerevisiae]) (e.g., hereditary 81317 non‐polyposis colorectal cancer, Lynch syndrome) gene analysis; full Yes Yes sequence analysis 81318 known familial variants Yes Yes 81319 duplication/deletion variants Yes Yes PTEN (phosphatase and tensin homolog) (e.g., Cowden syndrome, PTEN 81321 Yes Yes hamartoma tumor syndrome) gene analysis; full sequence analysis 81322 known familial variant Yes Yes 81323 duplication/deletion variant Yes Yes Pmp22 (peripheral protein 22) (eg, charcot‐marie‐tooth, hereditary 81324 neuropathy with liability to pressure palsies) gene analysis; No Yes duplication/deletion analysis Pmp22 (peripheral myelin protein 22) (eg, charcot‐marie‐tooth, hereditary 81325 neuropathy with liability to pressure palsies) gene analysis; full sequence No Yes analysis Pmp22 (peripheral myelin protein 22) (eg, charcot‐marie‐tooth, hereditary 81326 neuropathy with liability to pressure palsies) gene analysis; known familial No Yes variant SMPD1 (sphingomyelin phosphodiesterase 1, acid lysosomal) (e.g., 81330 Niemann‐Pick disease, Type A) gene analysis, common variants (e.g., R496L, Yes Yes L302P, fsP330)

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Procedure Required PA Requires PA Code Description 1/1/2017 1/1/2018 SNRPN/UBE3A (small nuclear ribonucleoprotein polypeptide N and ubiquitin 81331 protein ligase E3A)(e.g., Prader‐Willi syndrome and/or Angelman syndrome), Yes Yes methylation analysis RUNX1 (runt related transcription factor 1) (eg, acute myeloid leukemia, 81334 familial platelet disorder with associated myeloid malignancy) gene analysis, N/A Yes targeted sequence analysis (eg, exons 3‐8) TRB@ (T cell antigen receptor, beta) (e.g., leukemia and lymphoma), gene 81340 rearrangement analysis to detect abnormal clonal population(s); using Yes Yes amplification methodology (e.g., polymerase chain reaction) 81341 using direct probe methodology (e.g., Southern blot) Yes Yes TRG@ ((T cell antigen receptor, gamma) (e.g., leukemia and lymphoma), 81342 gene rearrangement analysis, evaluation to detect abnormal clonal Yes Yes population(s) UGT1A1 (UDP glucuronosyltransferase 1 family, polypeptide A1) (e.g., 81350 Yes Yes irinotecan metabolism), gene analysis, common variants 81400 Mopath procedure level 1 Yes Yes 81401 Mopath procedure level 2 Yes Yes 81402 Mopath procedure level 3 Yes Yes 81403 Mopath procedure level 4 Yes Yes Molecular pathology procedure, Level 5 (e.g., analysis of 2‐5 exons by DNA sequence analysis, mutation scanning or duplication/deletion variants of 6‐ 81404 Yes Yes 10 exons, or characterization of a dynamic mutation disorder/triplet repeat by Southern blot analysis) 81405 Mopath procedure level 6 Yes Yes 81406 Mopath procedure level 7 Yes Yes 81407 Mopath procedure level 8 Yes Yes 81408 Mopath procedure level 9 Yes Yes Cardiac ion channelopathies‐genomic sequence analysis panel, must include 81413 at least 10 including ANK2, CASQ2, CAV3, KCNE1, KCNE2,, KCNH2, Yes Yes KCNJ2, KCNQ1, RYR2 AND SCN5A Cardiac ion channelopathies‐duplication/deletion gene analysis panel must 81414 Yes Yes include at least 2 genes, to include KCNH2 and KCNQ1 81415 Exome sequence analysis No Yes Exome (eg, unexplained constitutional or heritable disorder or syndrome); 81416 No Yes sequence analysis, each comparator exome Exome (eg, unexplained constitutional or heritable disorder or syndrome); 81417 No Yes re‐evaluation of previously obtained exome sequences Fetal chromosomal aneuploidy (e.g., trisomy 21, monosomy X) genomic 81420 sequence analysis panel, circulating cell‐free fetal DNA in maternal blood, Yes Yes must include analysis of 13, 18, and 21 81422 Fetal Chromosomal microdeletion genomic sequence analysis Yes No Hearing loss (eg, nonsyndromic hearing loss, Usher syndrome, Pendred syndrome); genomic sequence analysis panel, must include sequencing of at 81430 least 60 genes, including CDH23, CLRN1, GJB2, GPR98, MTRNR1, MYO7A, No Yes MYO15A, PCDH15, OTOF, SLC26A4, TMC1, TMPRSS3, USH1C, USH1G, USH2A, and WFS1

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Procedure Required PA Requires PA Code Description 1/1/2017 1/1/2018 Hearing loss (eg, nonsyndromic hearing loss, Usher syndrome, Pendred 81431 syndrome); duplication/deletion analysis panel, must include copy number No Yes analyses for STRC and DFNB1 deletions in GJB2 and GJB6 genes Hereditary breast cancer‐related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer); genomic 81432 sequence analysis panel, must include sequencing of at least 14 genes, No Yes including ATM, BRCA1, BRCA2, BRIP1, CDH1, MLH1, MSH2, MSH6, NBN, PALB2, PTEN, RAD51C, STK11, and TP53 Hereditary breast cancer‐related disorders (eg, hereditary breast cancer, hereditary ovarian cancer, hereditary endometrial cancer); 81433 No Yes duplication/deletion analysis panel, must include analyses for BRCA1, BRCA2, MLH1, MSH2, and STK11 Hereditary retinal disorders (eg, retinitis pigmentosa, Leber congenital amaurosis, cone‐rod dystrophy), genomic sequence analysis panel, must 81434 include sequencing of at least 15 genes, including ABCA4, CNGA1, CRB1, EYS, No Yes PDE6A, PDE6B, PRPF31, PRPH2, RDH12, RHO, RP1, RP2, RPE65, RPGR, and USH2A Hereditary colon cancer disorders (eg, Lynch syndrome, PTEN hamartoma syndrome, Cowden syndrome, familial adenomatosis polyposis); genomic 81435 sequence analysis panel, must include sequencing of at least 10 genes, No Yes including APC, BMPR1A, CDH1, MLH1, MSH2, MSH6, MUTYH, PTEN, SMAD4, and STK11 Hereditary colon cancer disorders (eg, Lynch syndrome, PTEN hamartoma syndrome, Cowden syndrome, familial adenomatosis polyposis); 81436 No Yes duplication/deletion analysis panel, must include analysis of at least 5 genes, including MLH1, MSH2, EPCAM, SMAD4, and STK11 Hereditary neuroendocrine tumor disorders (eg, medullary thyroid carcinoma, parathyroid carcinoma, malignant pheochromocytoma or 81437 No Yes paraganglioma); genomic sequence analysis panel, must include sequencing of at least 6 genes, including MAX, SDHB, SDHC, SDHD, TMEM127, and VHL Hereditary neuroendocrine tumor disorders (eg, medullary thyroid carcinoma, parathyroid carcinoma, malignant pheochromocytoma or 81438 No Yes paraganglioma); duplication/deletion analysis panel, must include analyses for SDHB, SDHC, SDHD, and VHL Inherited cardiomyopathy (e.g., hypertrophic cardiomyopathy, dilated cardiomyopathy, arrgythmogenic right ventricular cardiomyopathy) genomic 81439 Yes Yes sequence analysis panel, must include sequencing of at least 5 genes, including DSG2, MYBPC3, MYH7, PKP2 and TTN Noonan spectrum disorders (eg, Noonan syndrome, cardio‐facio‐cutaneous syndrome, Costello syndrome, LEOPARD syndrome, Noonan‐like syndrome), 81442 genomic sequence analysis panel, must include sequencing of at least 12 No Yes genes, including BRAF, CBL, HRAS, KRAS, MAP2K1, MAP2K2, NRAS, PTPN11, RAF1, RIT1, SHOC2, and SOS1 Targeted genomic sequence analysis panel, solid organ neoplasm, DNA analysis, and RNA analysis when performed, 5‐50 genes (e.g., ALK, BRAF, 81445 CDKN2A, EGFR, ERBB2, KIT, KRAS, NRAS, MET, PDGFRA, PDGFRB, PGR, Yes No PIK3CA, PTEN, RET), interrogation for sequence variants and copy number variants or rearrangements, if performed

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Procedure Required PA Requires PA Code Description 1/1/2017 1/1/2018 Hereditary peripheral neuropathies panel (eg, Charcot‐Marie‐Tooth, spastic paraplegia), genomic sequence analysis panel, must include sequencing of at 81448 N/A Yes least 5 peripheral neuropathy‐related genes (eg, BSCL2, GJB1, MFN2, MPZ, REEP1, SPAST, SPG11, and SPTLC1) Targeted genomic sequence analysis panel, hematolymphoid neoplasm or disorder, DNA analysis, and RNA analysis when performed, 5‐50 genes (e.g., BRAF, CEBPA, DNMT3A, EZH2, FLT3, IDH1, IDH2, JAK2, KRAS, KIT, MLL, NRAS, 81450 Yes No NPM1, NOTCH1), interrogation for sequence variants, and copy number variants or rearrangements, or isoform expression or mRNA expression levels, if performed Whole mitochondrial genome (e.g., Leigh syndrome, mitochondrial encephalomyopathy, lactic acidosis, and stroke‐like episodes [MELAS], myoclonic epilepsy with ragged‐red fibers [MERFF], neuropathy, ataxia, and 81460 Yes No retinitis pigmentosa [NARP], Leber hereditary optic neuropathy [LHON]), genomic sequence, must include sequence analysis of entire mitochondrial genome with heteroplasmy detection Whole mitochondrial genome large deletion analysis panel (e.g., Kearns‐ 81465 Sayre syndrome, chronic progressive external ophthalmoplegia), including Yes Yes heteroplasmy detection, if performed 81479 Unlisted molecular pathology procedure Yes Yes Fetal aneuploidy (trisomy 21, 18, and 13) DNA sequence analysis of selected 81507 Yes Yes regions using maternal plasma, algorithm reported as a risk score Oncology (breast), mRNA, gene expression profiling by real‐time RT‐PCR of 81519 21 genes, utilizing formalin‐fixed paraffin embedded tissue, algorithm Yes Yes reported as recurrence score Oncology (high grade PSA), bioassay of four (Total PSA, Free PSA, 81539 Intact PSA and human kallikrein‐2 [hK2]), utilizing plasm or serum, Yes No prognostic algorithm reported as a probability score Oncology (thyroid), gene expression analysis of 142 genes, utilizing fine 81545 needle aspirate, algorithm reported as a categorical result (e.g., benign or No Yes supicious) 81599 Unlisted multianalyte assay with algorithmic analysis Yes Yes 84999 Unlisted chemistry panel Yes Yes 86849 Unlisted immunology procedure Yes Yes 87901 HIV‐1 reverse transcriptase and protease regions Yes Yes Infectious agent phenotype analysis by nucleic acid (DNA or RNA) with drug 87903 Yes Yes resistance tissue culture analysis, HIV1; first through 10 drugs tested each additional drug tested (list separately in addition to code for primary 87904 Yes Yes procedure) 87906 HIV‐1 other region (e.g., integrase, fusion) Yes Yes Each additional marker (listed separately in addition to code 88184 for the first marker). Dates of service before 5/1/2017 ‐ PA required only if greater 88185 Yes Yes than 29 unites are ordered. Dates of services on or after 5/1/2017 ‐ PA required only if greater than 24 units are ordered 88240 Cryopreservation, freezing and storage of cells, each cell line Yes Yes 88241 Thawing and expansion of frozen cells, each aliquot Yes Yes analysis for breakage syndrome; baseline Sister Chromatid 88245 Yes Yes Exchange (SCE), 20‐25 cells

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Procedure Required PA Requires PA Code Description 1/1/2017 1/1/2018 baseline breakage, score 50‐110 cells, count 20 cells, 2 karotypes (e.g., for 88248 Yes Yes ataxia telangiectasia, Fanconi anemia, Fragile X) score 100 cells, clastogen stress (e.g., diepoxybutane, mitomycin C, ionizing 88249 Yes Yes radiation, UV radiation) 88261 Chromosome analysis; count 5 cells, 1 karotype, with banding Yes Yes 88262 count 15‐20 cells, 2 karotypes, with banding Yes Yes 88263 count 45 cells, 2 karotypes, with banding Yes Yes 88264 analyze 20‐25 cells Yes Yes Chromosome analysis, amniotic fluid or chorionic villus, count 15 cells, 1 88267 Yes Yes karotype, with banding Chromosome analysis, in situ for amniotic fluid cells, count cells from 6‐12 88269 Yes Yes colonies, 1 karotype with banding 88271 Molecular cytogenetics; dna probe, each (e.g., fish) Yes Yes Molecular cytogenetics; chromosomal in situ hybridization, analyze 3‐5 cells 88272 Yes Yes (e.g., for derivatives and markers) Molecular cytogenetics; chromosomal in situ hybridization, analyze 10‐30 88273 Yes Yes cells (e.g., for microdeletions) 88274 Molecular cytogenetics; interphase in situ hybridization, analyze 25‐99 cells Yes Yes Molecular cytogenetics; interphase in situ hybridization, analyze 100‐300 88275 Yes Yes cells 88280 Chromosome analysis; additional karyotypes, each study Yes Yes 88283 additional specialized banding technique (e.g., NOR, C‐banding) Yes Yes 88285 additional cell counted, each study Yes Yes 88289 additional high resolution study Yes Yes Examination and selection of retrieval archival (ie.: previously diagnosed) 88363 Yes Yes tissue(s) for molecular analysis (e.g.: KRAS mutational analysis) 88399 Unlisted surgical pathology procedure Yes Yes 89240 Unlisted miscellaneous pathology test Yes Yes 0009M Fetal aneuploidy trisom risk Yes Yes S3800 Genetic testing for amyotrophic lateral sclerosis (ALS) Yes Yes DNA analysis for germline mutations of the RET proto‐oncogene for S3840 Yes Yes susceptibility to multiple endocrine neoplasia type 2 S3841 Genetic testing for retinoblastoma Yes Yes S3842 Genetic testing for Von Hippel‐Lindau disease Yes Yes DNA analysis of the connexin 26 gene (GJB2) for susceptibility to congenital, S3844 Yes Yes profound deafness S3845 Genetic testing for alpha thalassemia Yes Yes S3846 Genetic testing for hemoglobin E beta‐thalassemia Yes Yes S3849 Genetic testing for Niemann‐Pick disease Yes Yes S3850 Genetic testing for sickle cell anemia Yes Yes S3853 Genetic testing for muscular dystrophy Yes Yes Gene expression profiling panel for use in the management of breast cancer S3854 Yes Yes treatment Genetic testing, sodium channel, voltage‐gated, type v, alpha subunit S3861 No Yes (scn5a) and variants for suspected brugada syndrome Comparative genomic hybridization (CGH) microarray testing for S3870 Yes Yes developmental delay, autism spectrum disorder and/or mental retardation

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* Current Procedural Terminology© American Medical Association

2018 Code Revision Legend

New codes for 2018

Existing code now requiring PA

Existing code that will no longer require PA, Not intended to imply coverage.

Corporate Office Location

Avalon’s corporate headquarters is located in Tampa, Florida. For more information about Avalon, go to the Avalon web site: www.Avalonhcs.com.

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