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. Rpt:81270305770 Plasminogen ,Genotype81400292331 CYP2D6 Genotype - Tamoxifen81226305900 bcr/abl,t(9.)

2 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*57:01,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.

3 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. 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.

4 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: 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.

5 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: 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.

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