ATTENTION:
Prior Authorization Update
Quantitative Drug Testing for Drugs of Abuse &
Molecular Diagnostic Testing
Effective November 1, 2014 Buckeye Community Health Plan will require as a condition of payment for
specified Quantitative Testing for Drugs of Abuse or Molecular Diagnostic Testing. These requirements
are applicable to all products offered by Buckeye Community Health Plan. Codes in these two
categories that require prior authorization may be confirmed by either referencing the attached
spreadsheets or by confirming through the Prior Authorization Needed tab/PreScreen Tool section of
our website.
Buckeye Community Health Plan will not pay claims for laboratory tests when a required prior
authorization has not been obtained by the ordering physician. We have sent notices to the ordering
physicians in our network reminding them how to obtain prior authorizations for the above-referenced
tests, and we intend to continue to educate ordering physicians regarding the importance of this matter.
As the laboratory rendering the service, you may also want to take steps to ensure that ordering
physicians obtain the required prior authorization for tests that they refer to you. Some suggestions
include:
• Making a field available on your requisition form for the referring physician to enter an approval
number, which would indicate that the test has been prior authorized by Buckeye Community
Health Plan.
• Outreaching to your referring physicians to remind them of the prior authorization
requirement.
• Notifying your referring physicians how you would like for them to confirm that prior
authorization has been obtained for the appropriate tests.
Should you have any questions regarding this notification please call Provider Services at 866-296-8731.
Thank you for your attention to this matter.
Buckeye Community Health Plan
Exhibit 1
When the services below are Covered Services, the services require Prior Authorization.
Prior Authorization for services designated as “New Codes” below shall be required
effective NOVEMBER 1, 2014.
CPT CODE
Quantitative Testing for Drugs of Abuse
DESCRIPTION
80154
DRUG SCREEN QUANTITATIVE BENZODIAZEPINES
80184
DRUG SCREEN QUANTITATIVE PHENOBARBITAL
82145
AMPHETAMINE OR METHAMPHETAMINE, CHEMICAL, QUANTITATIVE
82205
BARBITURATES; QUANTITATIVE
82520
COCAINE, QUANTITATIVE
82646
DIHYDROCODEINONE
82649
83805
DIHYDROMORPHINONE, QUANTITATIVE
MEPROBAMATE, BLOOD OR URINE
83840
METHADONE
83887
NICOTINE
83925
ASSAY OF OPIATES
83992
PHENCYCLIDINE (PCP)
Exhibit 2
When the services below are Covered Services, the services require Prior Authorization
MOLECULAR DIAGNOSTIC TESTING
CPT CODE
DESCRIPTION
81161
DMD DUPLICATION/DELETION ANALYSIS
81200
ASPA GENE
81201
APC GENE ANALYSIS FULL GENE SEQUENCE
81202
APC GENE ANALYSIS KNOWN FAMILIAL VARIANTS
81203
APC GENE ANALYSIS DUPLICATION/DELETION VARIANTS
81205
BCKDHB GENE
81206
BCR/ABL1 GENE MAJOR BP
81207
BCR/ABL1 GENE MINOR BP
81208
BCR/ABL1 GENE OTHER BP
81209
BLM GENE
81210
BRAF GENE
81211
BRCA1&2 SEQ & COM DUP/DEL
81212
BRCA1&2 185&5385&6174 VAR
81213
BRCA1&2 UNCOM DUP/DEL VAR
81214
BRCA1 FULL SEQ & COM DUP/DEL
81215
BRCA1 GENE KNOWN FAM VARIANT
81216
BRCA2 GENE FULL SEQUENCE
81217
BRCA2 GENE KNOWN FAM VARIANT
81220
CFTR GENE COM VARIANTS
81221
CFTR GENE KNOWN FAM VARIANTS
81222
CFTR GENE DUP/DELET VARIANTS
81223
CFTR GENE FULL SEQUENCE
81224
CFTR GENE INTRON POLY T
81225
CYP2C19 GENE COM VARIANTS
81226
CYP2D6 GENE COM VARIANTS
81227
CYP2C9 GENE COM VARIANTS
81228
CYTOGEN MICRARRAY COPY NMBR
81229
CYTOGEN M ARRAY COPY NO&SNP
81235
EGFR GENE ANALYSIS COMMON VARIANTS
81240
F2 GENE
81241
F5 GENE
81242
FANCC GENE
81243
FMR1 GENE DETECTION
81244
FMR1 GENE CHARACTERIZATION
81245
FLT3 GENE
81250
G6PC GENE
81251
GBA GENE
CPT CODE
81252
81253
81254
81255
81256
81257
81260
81261
81262
81263
81264
81265
81266
81267
81268
81270
81275
81280
81281
81282
81287
81290
81291
81292
81293
81294
81295
81296
81297
81298
81299
81300
81301
81302
81303
81304
81310
81315
MOLECULAR DIAGNOSTIC TESTING
DESCRIPTION
GJB2 GENE ANALYSIS FULL GENE SEQUENCE
GJB2 GENE ANALYSIS KNOWN FAMILIAL VARIANTS
GJB6 GENE ANALYSIS COMMON VARIANTS
HEXA GENE
HFE GENE
HBA1/HBA2 GENE
IKBKAP GENE
IGH GENE REARRANGE AMP METH
IGH GENE REARRANG DIR PROBE
IGH VARI REGIONAL MUTATION
IGK REARRANGEABN CLONAL POP
STR MARKERS SPECIMEN ANAL
STR MARKERS SPEC ANAL ADDL
CHIMERISM ANAL NO CELL SELEC
CHIMERISM ANAL W/CELL SELECT
JAK2 GENE
KRAS GENE
LONG QT SYND GENE FULL SEQ
LONG QT SYND KNOWN FAM VAR
LONG QT SYN GENE DUP/DLT VAR
MGMT (O-6-methylguanine-DNA methyltransferase) (eg, glioblastoma multiforme), methylation
analysis
MCOLN1 GENE
MTHFR GENE
MLH1 GENE FULL SEQ
MLH1 GENE KNOWN VARIANTS
MLH1 GENE DUP/DELETE VARIANT
MSH2 GENE FULL SEQ
MSH2 GENE KNOWN VARIANTS
MSH2 GENE DUP/DELETE VARIANT
MSH6 GENE FULL SEQ
MSH6 GENE KNOWN VARIANTS
MSH6 GENE DUP/DELETE VARIANT
MICROSATELLITE INSTABILITY
MECP2 GENE FULL SEQ
MECP2 GENE KNOWN VARIANT
MECP2 GENE DUP/DELET VARIANT
NPM1 GENE
PML/RARALPHA COM BREAKPOINTS
CPT CODE
81316
81317
81318
81319
81321
81322
81323
81324
81325
81326
81330
81331
81332
81340
81341
81342
81350
81355
81370
81371
81372
81373
81374
81375
81376
81377
81378
81379
81380
81381
81382
81383
81400
81401
81402
81403
81404
81405
81406
MOLECULAR DIAGNOSTIC TESTING
DESCRIPTION
PML/RARALPHA 1 BREAKPOINT
PMS2 GENE FULL SEQ ANALYSIS
PMS2 KNOWN FAMILIAL VARIANTS
PMS2 GENE DUP/DELET VARIANTS
PTEN GENE ANALYSIS FULL SEQUENCE ANALYSIS
PTEN GENE ANALYSIS KNOWN FAMILIAL VARIANT
PTEN GENE ANALYSIS DUPLICATION/DELETION VARIANT
PMP22 GENE ANAL DUPLICATION/DELETION ANALYSIS
PMP22 GENE ANALYSIS FULL SEQUENCE ANALYSIS
PMP22 GENE ANALYSIS KNOWN FAMILIAL VARIANT
SMPD1 GENE COMMON VARIANTS
SNRPN/UBE3A GENE
SERPINA1 GENE
TRB@ GENE REARRANGE AMPLIFY
TRB@ GENE REARRANGE DIRPROBE
TRG GENE REARRANGEMENT ANAL
UGT1A1 GENE
VKORC1 GENE
HLA I & II TYPING LR
HLA I & II TYPE VERIFY LR
HLA I TYPING COMPLETE LR
HLA I TYPING 1 LOCUS LR
HLA I TYPING 1 ANTIGEN LR
HLA II TYPING AG EQUIV LR
HLA II TYPING 1 LOCUS LR
HLA II TYPE 1 AG EQUIV LR
HLA I & II TYPING HR
HLA I TYPING COMPLETE HR
HLA I TYPING 1 LOCUS HR
HLA I TYPING 1 ALLELE HR
HLA II TYPING 1 LOC HR
HLA II TYPING 1 ALLELE HR
MOPATH PROCEDURE LEVEL 1
MOPATH PROCEDURE LEVEL 2
MOPATH PROCEDURE LEVEL 3
MOPATH PROCEDURE LEVEL 4
MOPATH PROCEDURE LEVEL 5
MOPATH PROCEDURE LEVEL 6
MOPATH PROCEDURE LEVEL 7
CPT CODE
81407
81408
81479
81500
81503
81504
81506
81507
81508
81509
81510
81511
81512
81599
83890
83891
83892
83893
83894
83896
83897
83898
83900
83901
83902
83903
83904
83905
83906
83907
83908
83909
83912
83913
83914
83915
86812
MOLECULAR DIAGNOSTIC TESTING
DESCRIPTION
MOPATH PROCEDURE LEVEL 8
MOPATH PROCEDURE LEVEL 9
UNLISTED MOLELCULAR PATHOLOGY PROCEDURE
ONCO (OVARIAN) BIOCHEMICAL ASSAY TWO PROTEINS
ONCO (OVARIAN) BIOCHEMICAL ASSAY FIVE PROTEINS
Oncology (tissue of origin), microarray gene expression profiling of > 2000 genes, utilizing
formalin-fixed paraffin-embedded tissue, algorithm reported as tissue similarity scores
ENDOCRINOLOGY BIOCHEMICAL ASSAY SEVEN ANAL
Fetal aneuploidy (trisomy 21, 18, and 13) DNA sequence analysis of selected regions using
maternal plasma, algorithm reported as a risk score for each trisomy
FETAL CONGENITAL ABNOR ASSAY TWO PROTEINS
FETAL CONGENITAL ABNOR ASSAY 3 PROTEINS
FETAL CONGENITAL ABNOR ASSAY THREE ANAL
FETAL CONGENITAL ABNOR ASSAY FOUR ANAL
FETAL CONGENITAL ABNOR ASSAY FIVE ANAL
UNLISTED MULTIANALYTE ASSAY ALGORITHMIC ANALYSIS
MOLECULE ISOLATE
MOLECULE ISOLATE NUCLEIC
MOLECULAR DIAGNOSTICS
MOLECULE DOT/SLOT/BLOT
MOLECULE GEL ELECTROPHOR
MOLECULAR DX; NUCLEIC ACID PROBE EA
MOLECULE NUCLEIC TRANSFER
MOLECULAR DX AMPLIFICATION TARGET EA SEQUENCE
MOLECULAR DX AMP TARGET MULTIPLEX 1ST 2 SEQ
MOLECULAR DX AMP TARGET MULTIPLEX EA ADDL SEQ
MOLECULAR DX; REVERSE TRANSCRIPTION
MOLEC DX; MUTATION SCAN BY PHYS PROP-1 SEGMT EA
MOLEC DX; MUTATION ID-SEQUENCING-1 SGMT EA
MOLEC DX; MUTATION ID-ALLELE SPEC TRANSCRIP-1-EA
MOLEC DX; MUTATION ID-ALLELE SPEC TRANSLAT-1-EA
LYSE CELLS FOR NUCLEIC EXT
MOLECULAR DX AMPLIFICATION SIGNAL EA SEQUENCE
NUCLEIC ACID HIGH RESOLUTE
MOLECULAR DX; INTERPT & REPORT
RNA STABILIZATION
MUTATION ID ENZYMATIC LIG/PRIMER XTN 1 SGM EA
NUCLEOTIDASE 5'TISSUE TYPING; HLA TYPING, A, B, OR C (EG, A10, B7, B27), SINGLE ANTIGEN
CPT CODE
86813
86816
86817
86821
86822
86825
86826
86828
86829
86830
86831
86832
86833
86834
86835
88230
88233
88235
88237
88239
88240
88241
88245
88248
88249
88261
88262
88263
88264
88267
88269
88271
88272
88273
88274
88275
88280
88283
88285
MOLECULAR DIAGNOSTIC TESTING
DESCRIPTION
TISSUE TYPING; HLA TYPING, A, B, AND/OR C (EG, A10, B7, B27), MULTIPLE A
TISSUE TYPING; HLA TYPING, DR/DQ, SINGLE ANTIGEN
TISSUE TYPING; HLA TYPING, DR/DQ, MULTIPLE ANTIGENS
TISSUE TYPING; LYMPHOCYTE CULTURE, MIXED(MLC)
TISSUE TYPING; LYMPHOCYTE CULTURE, PRIMED(PLC)
HLA X-MATCH, NON-CYTOTOXIC
HLA X-MATCH, NON-CYT ADD-ON
HLA CLASS I&II ANTIBODY QUAL
HLA CLASS I/II ANTIBODY QUAL
HLA CLASS I PHENOTYPE QUAL
HLA CLASS II PHENOTYPE QUAL
HLA CLASS I HIGH DEFIN QUAL
HLA CLASS II HIGH DEFIN QUAL
HLA CLASS I SEMIQUANT PANEL
HLA CLASS II SEMIQUANT PANEL
TISS CULTURE NON-NEOPLAS DISORD; LYMPHOCYTE
TISS CULTURE NON-NEOPLAS DISORD; SKIN/SOLID TISS
TISS CULTURE NON-NEOPLAS DISORD; AMNIOTIC FLUID
TISS CULTURE NEOPLAS DISORD; MARROW/BLD CELLS
TISS CULTURE NEOPLAS DISORD; SOLID TUMOR
CRYOPRESERV-FREEZE & STORE CELLS EA CELL LINE
THAWING & EXPANSION FROZEN CELLS EA ALIQUOT
CHROMOSOME ANALY BREAK SYNDROM; SCE 20-25 CELLS
CHROMOSOME ANALY; BASELINE BREAKAGE
CHROMOSOME ANALY BREAK SYNDROM; CLASTOGEN STRESS
CHROMO ANALY; CT 5 CELLS 1 KARYOTYPE W/BANDING
CHROMO ANALY; CT 15-20 CELLS 2 KARYOTYPES W/BAND
CHROMO ANALY; CT 45 CEL MOSAICISM 2 KARYO W/BAND
CHROMOSOME ANALY; ANALY 20-25 CELLS
CHROMO ANALY AMNIO FLUID CT 15 CELLS 1 KARYOTYPE
CHROMO ANALY AMNIO FLUID CELLS CT 6-12 COLONIES
MOLEC CYTOGEN; DNA PROBE EA
MOLEC CYTOGEN; CHROMOSOM IN SITU HYBRID 3-5 CELL
MOLEC CYTOGEN; CHROMOSOM HYBRID 10-30 CELLS
MOLEC CYTOGEN; INTERPHASE IN SITU HYBRID 25-99
MOLEC CYTOGEN; INTERPHASE IN SITU HYBRID 100-300
CHROMOSOME ANALY; ADD KARYOTYPES EA STUDY
CHROMOSOME ANALY; ADD SPECIALIZED BANDING TECH
CHROMOSOME ANALY; ADD CELLS COUNTED EA STUDY
CPT CODE
88289
88291
88299
88384
88385
88386
S3713
S3800
S3818
S3819
S3820
S3822
S3823
S3828
S3829
S3830
S3831
S3833
S3834
S3835
S3837
S3840
S3841
S3842
S3843
S3844
S3845
S3846
S3847
S3848
S3849
S3850
S3851
S3852
S3853
S3854
S3855
S3860
S3861
MOLECULAR DIAGNOSTIC TESTING
DESCRIPTION
CHROMOSOME ANALY; ADD HIGH RESOLUTION STUDY
CYTOGEN & MOLEC CYTOGEN INTERPT & REPORT
UNLISTED CYTOGENETIC STUDY
RA-BASED EVAL MLT MOLEC PRBS 11 THRU 50 PRBS
RA-BASED EVAL MLT MOLEC PRBS 51 THRU 250 PRBS
RA-BASED EVAL MLT MOLEC PRBS 251 THRU 500 PRBS
KRAS MUTATION ANALYSIS
GENETIC TESTING FOR AMYOTROPHIC LATERAL SCLEROSIS (ALS)
COMPLETE GENE SEQUENCE ANALYSIS
COMPLETE GENE SEQUENCE ANALYSIS
COMPLETED BRCA1 AND BRCA2 GENE SEQUENCE ANALYSIS FOR SUSCEP
SINGLE MUTATION ANALYSIS FOR SUSCE TO BREAST AND OVARION CANCER
3-MUTATION ANALYSIS FOR SUSCEP/BREAST &OVARION CANCER IN ASHKENAZI INDI
COMPLETE GENE SEQUENCE ANALYSIS, MLH1 GENE
COMPLETE GENE SEQUENCE ANALYSIS, MLH2 GENE
COMPLETE MLH1 AND MLH2 GENE SEQUENCE ANALYSIS
SINGLE MUTATION ANALYSIS
COMPLETE APC GENE SEQUENCE ANAL/SUSCEPTIBILITY TO (FAP)
SINGLE-MUTATION ANALYSIS /SUSCEPTIBILITY TO (FAP)&ATTENUATED FAP
COMPLETE GENE SEQUENCE ANALYSIS FOR CYSTIC FIBROSIS GENETIC TESTING
COMPLETE GENE SEQUENCE ANALYSIS FOR HEMOCHROMATOSIS GENETIC TESTING
DNA ANALYSIS FOR GERMLINE MUTATIONS OF THE RET PROTO-ONCOGENE
GENETIC TESTING FOR RETINOBLASTOMA
GENETIC TESTING FOR VON HIPPEL-LINDAU DISEASE
DNA ANALYSIS OF THE F5 GENE FOR SUSCEP TO FACTOR V LEIDEN THROMBOPHILIA
DNA ANLYSS/CONNEXIN 26 GENE (GJB2)/SUSCEP/CONGENITAL, PRFND DEAFNESS
GENETIC TESTING FOR ALPHA-THALASSEMIA
GENETCI TESTING FOR HEMOGLOBIN E BETA-THALASSEMIA
GENETIC TESTING FOR TAY-SACHS DISEASE
GENETIC TESTING FOR GAUCHER DISEASE
GENETIC TESTING FOR NIEMANN-PICK DISEASE
GENETIC TESTING FOR SICKLE CELL ANEMIA
GENETIC TESTING FOR CANAVAN DISEASE
DNA ANLYS/APOE EPILSON 4 ALLELE FOR SUSCEP ALZHEIMER'S DISEASE
GENETIC TESTING FOR MYOTONIC MUSCULAR DYSTROPHY
GENE EXPRESSION PROFILING PANEL FOR US IN MGMT OF BREAST CANCER TRTMNT
GENETIC TESTING FOR DETECTION OF MUTATIONS IN THE PRESENILIN - 1 GENE
GENET TEST CARDIAC ION-COMP
GENETIC TEST BRUGADA
CPT CODE
S3862
S3865
S3866
S3870
S3890
MOLECULAR DIAGNOSTIC TESTING
DESCRIPTION
GENET TEST CARDIAC ION-SPEC
COMP GENET TEST HYP CARDIOMY
SPEC GENE TEST HYP CARDIOMY
CGH TEST DEVELOPMENTAL DELAY
DNA ANALYSIS FECAL COLORECTAL CANCER SCREENING