CPT CODES REQUIRING PRIOR AUTHORIZATION

1 Metro Lab Ordering Unit CodeTest NameCPT Code Metro Lab Ordering Unit CodeTest NameCPT Code10149 Cystic Fibrosis 165 (RET) Gene ,Bld8140550045 FACTOR V LEIDEN (R506Q) MUTATION81241304376 Marfan Syndrome (FBN1) Sequencing8140850055 PROTHROMBIN G 20210A GENE MUTATION81240304420 Cytogenomic SNP(aCGH) Microarray81229157511 FLT3 & NPM1 MUTATION DETECTION81245304580 MCAD Deficiency(ACADM)Sequencing,P81479181403 Bill: RhD Varient Assay81403304585 MCAD(ACADM) 2 Mutations (PCR),P81401181479 Bill: RBC Molecular Phenotype81479305041 BCR-ABL1 Mutation Analysis/NGS81479226022 BILL: INMS Unlisted : DNA seq/pcr81403281240 Billing: F2 Gene81240305355Y Chromosome Microdeletion81403281310 BILL: NPM1 GENE ANALY EXON 12 VAR81310305455 Fragile X (FMR1) w/Rflx Methylation81244290467Y Chromosome Microdeletions/PCR81403305600 Prenatal Testing Fetal Aneuploidy81420292032 CYP2D6 Genotype81226305605 Spinobulbar Musc Atrophy,Kennedy's81401292035 JAK2 V617F Mutation Detect.

2 Rpt:81270305770 Plasminogen ,Genotype81400292331 CYP2D6 Genotype - Tamoxifen81226305900 bcr/abl,t(9;22) QN81206297102 SPINAL CARRIER TEST81401306016 MTHFR Mutation Detection-2 Mutation81291300184 Twin Zygosity Testing81265306150 Ashkenazi Jewish Pnl 16 Gene Rpt:81200300550 Rflx: Factor V Leiden(F5) R506Q81241306190 HLA-B*1502 Typing81381300566 Prothrombin (F2) G20210A Typing81381302481 Hemochromatosis (HFE) 3 Mutation81256306265 Ehlers-Danlos Type IV (COL3A1 Gene)81479302696 Celiac (HLA-DQ2 & DQ8) Genotyping81376306345 Ehlers-Danlos Syndr IV (COL3A1):81408302697 Billing: HLA DQB1 allele(s)81383306365 CYP450 2D6(CYP2D6) 15var,Gene Dup81226302891 HLA-B*57.

3 01,Abicavir Sensitivity81381306400 A1A Genotype /w Rflx Phenotype81332302964 JAK2 V617F QL, PCR81270306510 Platelet AG 1 Genotyping (HPA-1)81400302966 JAK2 V617F QL,Bld/Bone Marrow81270306745 FAP:APC,Seq,Del/Dup(MUTYH) 2 Mut81201303035 Narcolepsy (HLA-DQB1*06:02)Genotype81383306750 Connexin 26 (GJB2),Sequencing,Bld81252303341 HLA Class I (ABC) Sequencing81379306875T-Cell Clonality Screening by PCR81342303441 BCR/ABL1, Major (p210),Quantitative81206306990 CALR Exon 9 Mutation Analysis/PCR81219303651 HLA-DQB Genotyping81382307005 Aortopathy Panel Rpt:81410303861 Alpha Thalassemia, 7 Deletions81257307030 JAK2 Exon 12 Mutation Analysis/PCR81403303891 Huntington Disease (HD) by PCR81401307095 Renal Hereditary Cancer Pnl Rpt:81445303892 Billing: Target Seq Molec Path Proc81479307115 Pancreatitis,Pnl,Gene Seq.

4 Rpt:81223303921 Hemophilia A (F8) 2 Inversions81403307180 Angelman/Prader-Willi Syndr/M-S PCR81331303926 Hemophilia A (F8) Mutation Analysis/Sequencing81263304021 bcr/abl,t(9;22) Genotype (Prometheus)81401304050 FLT3 Mutation Detection by PCR81245307275 5-FU Mutations,Toxicity/Response81400304055 NPM1 Mutation Detection by PCR81310307345 Neurofibromatosis 1 Seq,DelDup81408304161 IL28B-Associated Variants,2 SNPs81400307350 HMBS Gene,Full Gene Analysis81479304301 Ankylosing Spondylitis Rpt:81374307425 HLA-B Genotype81380 Page 1 of 2 Printed 9/26/2017 CPT CODES REQUIRINGPRIOR AUTHORIZATIONB eginning November 1, 2017, UnitedHealthcare (UPC) has announced that the following CPT CODES will require PRIOR AUTHORIZATION before submitting the orders to the performing laboratory.

5 Metro Lab Ordering Unit CodeTest NameCPT Code Metro Lab Ordering Unit CodeTest NameCPT Code307560 PML-RARA (15:17),PCR/QNT81315381241 BILLING F5 GENE ANALY LEIDEN VAR81241307615 Neurofibromatosis NF2 Seq,Del/Dup81405381242 Billing: FANCC Gene Analysis81242307620 MPL Exon 10 Mutation Detection,Bld81403381244 BILL: FMR1 Methylation by mPCR81244307625 CYP21A2 Full Gene Analysis,Bld81405381246 BILL: TKD Varients81246307630 JAK2 V617F QNT,Bld81270381251 Billing: GBA Gene Analysis81251307690 Cytogenomic SNP Microarray-Oncology81406381253 Rflx:GJB2 Targeted Sequencing Bill81253307700 Breast & Ovarian(BRCA1/BRCA2)FGA81162381255 Billing: HEXA Gene Analysis81255307710 Cystic Var.

6 W/Rflx : IKBKAP Gene Analysis81260307715 MYD88 L265P Mutation : MCOLN1 Gene Analysis81290307730CF (CFTR)Seq/Rflx Del/Dup(2nd Tier)81223381292 BILL: MLH1 GENE ANALYS,FULL SEQ81292307755 MPL codon 515 :MLH1 Targeted Sequencing Bill81293307765 COL4A1 DNA Sequencing (CSVD),Bld81408381294 BILL: MLH1 GENE ANALY DUP/DEL VAR81294307855 Factor V,R2 Mutation by PCR81400381295 BILL: MSH2 FULL GENE/FULL SEQ81295308025 Von Hippel-Lindau(VHL) Gene :MSH2 Targeted Sequencing Bill81296308055 EGFR T790M Mutation Detection/PCR81235381297 BILL: MSH2 GENE ANALY,DUP/DEL VAR81297308065 Kit Mutations in AML, : MSH6 GENE ANALY,FULL SEQ81298308070 CEBPA Mutation Detection81218381299 Rflx:MSH6 Targeted Sequencing Bill81299308100 Beta Globin (HBB) Gene Sequencing81404381300 BILL: MSH6 GENE ANALY,DUP/DELET VAR81300308110 UGT1A1 Genotyping81350381303 Rflx:MECP2 Targeted Sequencing Bill81303308155 Epi proColon81327381318 Rflx:PMS2 Targeted Sequencing Bill81318308175 Charcot-Marie-Tooth(1A)HNPP Del/Dup81324381322 Rflx:PTEN Targeted Sequencing Bill81322308200 Marfan Syndrome(FBN1)Seq &Del/Dup81479381323 BILL.

7 PTEN GENE ANALY,DUP/DEL VAR81323308220 HLA-DP Genotyping81382381330 Billing: SMPD1 Gene Analysis81330308225 HLA-DQ Genotyping81382381401 Bill: Molecular Pathology,Level281401308235 TPMT Genotyping,4 Variants,Blood81401381402 BILL: MOPATH Procedure Level 381402308265 DPYD,3 Varients,Genotype,Blood81400381403 BILL: 481403308310 : Molecular Level 581404308320 HLA-DRB1 by Next Generation : Level 681405308325 HLA DRB 3-,4-,5-81382381406 Bill: Level 781406308390TP53 Somatic Mutation,Prognostic81405381407 BILL: MOLEC PATH PROCEDURE LEVEL 881407308445 MEN Type 1 Sequencing81405381408 Bill: Level 981408308465 Custom Sequencing by Consultation81479381411 BILL: AORTIC DYSF/DILAT 4 GENE81411371404 BILL: ALPHA GLOB(HBA1/HBA2)DEL/DUP81404381479 BILL: Unlisted MolecPath : Alpha Seq81405382205 BILL: BCKDHB GENE ANALYSIS81205371479 BILL: HGB LEPORE HBD/HBB 3 :CFTR TARGETED SEQUEN81221380403 BILL: BETA GLOB(HBB) DEL/DUP81403382250 BILL: G6PC GENE ANALYSIS81250381202 Rflx: APC Targeted Sequencing Bill81202382400 BILL: MOLECULAR PATH LEVEL I81400381203 BILL.

8 APC GENE DUPL/DEL VARIENTS81203382401 BILL: BILL: MOLECULAR PATH LEVEL II81404381207 Billing: BCR/ABL1 Minor Brkpt81207382479 BILL: UNLISTED : Bloom Gene Analysis81209391401 BILL: Beta Globulin Mutations81401381213 BILL: BRCA1&2 UNCOMM DUP DEL VAR81213391402 BILL: MEFV81404 Target Seq Gene81402381215 BILL: BRCA1 Target Seq Gene81215391403 BILL: HGB81403381217 BILL: BRCA2 Target Seq Gene81217391404 BILL: MOLEC PATH PROCEDURE LEVEL 581404381221 Rflx:CFTR Targeted Sequencing Bill81221391405 Bill: 681405381222 BILL: CFTR Deletion/Duplication81222391406 BILL: MOPATH Level 781406381223 BILL: Gene : Level 981408381240 BILLING F2 GENE ANALYS 20210G-A81240391479 BILL: Unlisted 2 of 2 Printed 9/26/2017 This list is supplied by UnitedHealthcare and may be subject to change.

9 Please refer to their website at for updates and more information on PRIOR AUTHORIZATION .