CurrentBlue Cross Blue Shield - South CarolinaPolicy N/A

Prior Authorization List — Genetic and Molecular Pathology Codes

Lists CPT/HCPCS genetic and molecular pathology service codes that require prior authorization for BlueCross BlueShield of South Carolina and BlueChoice HealthPlan members; applies to providers submitting claims for these laboratory/genetic tests.

Policy Summary

PayerBlue Cross Blue Shield - South Carolina

PolicyPrior Authorization List — Genetic and Molecular Pathology Codes

Policy CodePolicy N/A

Change TypeNo material change

Effective DateApr 1, 2023

Next Review DateN/A

Key ActionObtain prior authorization for the listed genetic and molecular pathology procedure and proprietary test codes before submitting claims.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

~200+procedure codes listed

20+code entries in extract

Most = YesPA status (4/1/2023)

Coverage and Prior Authorization Criteria

Coverage stance for listed codes

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Prior authorization required code list

Codes listed require prior authorization; many entries include test descriptions, required gene content or analytic scope, and proprietary test/lab where applicable.

The listed CPT, HCPCS, PLA and proprietary test codes require prior authorization. Many entries specify the test purpose (eg, hereditary, oncology, fetal aneuploidy), minimum gene content or analytic scope (eg, >=9 genes, >=60 genes, cfDNA chromosomes 13/18/21), and proprietary test name and laboratory/manufacturer where applicable.

Status change examples

Examples of status changes and PA requirements within the chunk:

ANY of the following

0080U: PA on 12/1/2022 = No; PA on 4/1/2023 = Yes
0087U: PA on 12/1/2022 = Yes; PA on 4/1/2023 = No

These examples illustrate codes whose prior authorization status changed between the two dates shown.

Prior authorization coverage listing

The document enumerates CPT/HCPCS codes and proprietary tests that require prior authorization. PA status is shown for at least two dates (12/1/2022 and 4/1/2023) where provided.

This listing includes CPT molecular pathology levels (81400–81408), genomic panels (eg, 81410, 81430), proprietary multigene assays and PLA codes (eg, 0022U, 0239U, 0242U), red cell antigen genotyping panels, and other genetic test codes; each entry shows PA status for the dates provided.

Codes and Code Tables

Codes Requiring Prior Authorization (selected genetic/molecular CPT codes)CPTCovered

81120	IDH1 (isocitrate dehydrogenase 1) common variants (e.g., R132H, R132C) — PA for 4/1/2023 = Yes
81121	IDH2 (isocitrate dehydrogenase 2) common variants (e.g., R140W, R172M) — PA for 4/1/2023 = Yes
81161	DMD (dystrophin) deletion and duplication analysis — PA for 4/1/2023 = Yes
81162	BRCA1/BRCA2 full sequence and full duplication/deletion analysis — PA for 4/1/2023 = Yes
81163	BRCA1/BRCA2 full sequence analysis — PA for 4/1/2023 = Yes
81164	BRCA1/BRCA2 full duplication/deletion analysis — PA for 4/1/2023 = Yes
81200	ASPA (aspartoacylase) common variants (Canavan disease) — PA for 4/1/2023 = Yes
81201	APC full gene sequence (familial adenomatous polyposis) — PA for 4/1/2023 = Yes
81202	APC known familial variants — PA for 4/1/2023 = Yes
81203	APC duplication/deletion variants — PA for 4/1/2023 = Yes

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Provider Actions and Authorization Notes

Prior Authorization

Prior Authorization Required

Prior authorization is required for a broad set of molecular, genomic, cytogenetic, pathology, and proprietary laboratory tests. Submit PA requests per payer procedures prior to performing the service to avoid claim denials.

Codes requiring prior authorization include molecular/genetic CPT codes (e.g., 81120–81165 series and many others listed below) and molecular pathology levels (81400–81408).
Genomic panels and sequence analysis codes (examples): 81410–81419 (disease-specific panels and exome testing), 81420, 81430–81433, and many additional panel codes (see proprietary panels and large NGS panels below).
Proprietary multigene/molecular assays requiring prior authorization include, but are not limited to: 81507 (Harmony™ Prenatal Test), 81518 (Breast Cancer Index), 81519 (Oncotype DX®), 81520 (Prosigna®), selected PLA/proprietary tests (see list below), and numerous U‑codes (e.g., 0001U, 0005U, 0016U, 0022U, 0026U, 0037U, 0047U–0050U, 0084U, 0101U–0103U, 0118U, 0129U, 0155U, 0169U, 0171U, 0172U, and many more).
Additional PLA and specialty molecular test codes requiring prior authorization include many laboratory-developed and proprietary tests (examples: 0022U Oncomine™ Dx Target Test, 0026U Thyroseq, 0030U Warfarin Response Genotype, 0046U FLT3 ITD MRD by NGS, 0047U Oncotype DX® Genomic Prostate Score™, 0048U MSK-IMPACT, 0049U NPM1 MRD by NGS, 0050U MyAML NGS Panel).
Code 0046U (FLT3 ITD MRD by NGS — LabPMM/Invivoscribe) requires prior authorization as of 4/1/2023 (PA = Yes).
Red cell antigen genotyping tests (Navigator / BLOODchip / PrecisionBlood / Versiti panels) require prior authorization. Examples: 0001U (PreciseType® HEA), 0181U–0201U, 0221U–0222U, 0246U, 0282U (Versiti red cell panel) and other Navigator/NGS red cell antigen codes — PA = Yes as of 4/1/2023.
Comprehensive genomic and hematology tests requiring prior authorization include extensive NGS panels and targeted hematology panels (examples): 0037U (324‑gene solid tumor panel), 0171U (MyMRD® NGS Panel), 0172U (somatic BRCA/Homologous recombination testing), 0239U (FoundationOne® Liquid CDx), 0242U (Guardant360® CDx), 0244U (Oncotype MAP™ Pan-Cancer), 0250U (PGDx elio™ tissue complete), 0268U–0277U and 0276U–0277U (Versiti hematology panels), and many U‑codes in the 0231U–0270U range (Genomic Unity® and Variantyx proprietary gene analyses).
Selected codes requiring prior authorization (examples): 81120, 81121, 81161–81165 (BRCA/DMD panels), 81381 (HLA Class I typing), 81278–81284 (translocation, JAK2, IFNL3, FXN), 88363, 88399, 89240, 87999, 88240–88291 (cytogenetics and related services), and S‑codes/G‑codes listed (e.g., G9143, S3800, S3840–S3850).
Codes with PA status updates (examples): 0080U changed from PA = No (12/1/2022) to PA = Yes (4/1/2023); 0087U changed from PA = Yes (12/1/2022) to PA = No (4/1/2023); 0282U changed from PA = No (12/1/2022) to PA = Yes (4/1/2023); 0326U changed from PA = No (12/1/2022) to PA = Yes (4/1/2023).
When ordering any test listed or similar molecular/genomic/proprietary assays not explicitly listed here, verify PA requirements and current PA status with the payer prior to testing.
Failure to obtain prior authorization where required may result in claim denial or member liability.

Definitions and Legends

Legend for color coding

Yellow (legend)Codes being removed from prior authorization (PA). This does not imply coverage.

Green (legend)Codes being added to prior authorization (PA).

Molecular pathology procedure levels (81400–81408)

DefinitionMolecular pathology procedure levels (81400–81408): tests used to analyze nucleic acid for abnormalities; include cell lysis, nucleic acid stabilization, extraction, digestion, amplification, and detection. Selection depends on the gene and specific mutation examined.

Code range example81400 = Molecular pathology procedure level 1; 81408 = Molecular pathology procedure level 9 (PA for 4/1/2023 = Yes).

Reporting noteAny procedures prior to cell lysis may be reported separately.

Genomic sequence analysis panel

DefinitionGenomic sequence analysis panel: a multi-gene panel targeting listed genes for a specified clinical indication; some panels require sequencing of a minimum number of genes (e.g., 81410 must include ≥9 genes; 81413 must include ≥10 genes).

Examples81410 = Aortic dysfunction/dilation panel (must include FBN1, TGFBR1, TGFBR2, COL3A1, MYH11, ACTA2, SLC2A10, SMAD3, MYLK).

Panel scopeEntries may specify required genes or minimum gene counts to meet the panel definition.

Proprietary test

DefinitionProprietary test: a named, vendor- or lab-specific assay (e.g., Harmony™, Oncotype DX®, Guardant360® CDx) identified with manufacturer/lab and proprietary branding.

Examples in list81507 (Harmony™ Prenatal Test), 81519 (Oncotype DX®), 0242U (Guardant360® CDx).

DocumentationProprietary tests are listed with lab/manufacturer information where available.

PA (Prior authorization)

PA abbreviationPA = Prior authorization status for the listed code on the given date.

Status reportingPA status is shown for at least two dates in the document (e.g., 12/1/2022 and 4/1/2023).

InterpretationPA = Yes indicates prior authorization is required for that code on the specified date.

Proprietary test (definition)

Proprietary test (repeat)Proprietary test: named, manufacturer-specific assay (document lists example proprietary tests with lab/manufacturer).

ContextMany proprietary tests in the list include brand names and lab/manufacturer (e.g., Oncotype DX®, Harmony™).

ImplicationThese entries are treated the same as other codes for PA requirement purposes.

Red cell antigen genotyping

DefinitionRed cell antigen genotyping: gene analysis to determine red blood cell antigen genotype for specific blood group systems (examples include Colton, Cromer, Diego, Dombrock).

Example tests0181U = Colton (AQP1 exon 1) Navigator CO Sequencing test; 0182U = Cromer (CD55 exons 1–10) Navigator CROM Sequencing test.

Proprietary namingMany red cell antigen genotyping assays are proprietary (Navigator series) with specified lab/manufacturer.

Proprietary test (additional)

Proprietary test (additional segment)Proprietary test: vendor-branded genomic assays (e.g., Oncotype DX Genomic Prostate Score™, Guardant360® CDx, PGDx elio™) noted with manufacturer and PA status.

PurposeUsed for oncology, hematology, prenatal, and other clinical indications per individual test descriptions.

PA implicationProprietary tests listed require prior authorization as indicated by PA statuses in the document.

PA (interpretation)

PA label meaningPA indicates prior authorization required (Yes/No shown for specified dates).

Examples0242U (Guardant360® CDx) PA for 4/1/2023 = Yes; 0047U PA for 4/1/2023 = Yes.

Date-specificPA status entries are date-specific and the document shows PA on 12/1/2022 and 4/1/2023 where provided.