Anthem Blue Cross Blue Shield of California policy
Bundled Services and Supplies - Professional
Bundled Services and Supplies - Professional is a public Anthem Blue Cross Blue Shield of California policy (policy C-08003, effective Jan 1, 2027). It lists 360 CPT or HCPCS codes, 47 of them on the Anthem Blue Cross Blue Shield of California prior authorization list. Not a coverage decision; the payer's own document governs.
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- Policy number
- C-08003
- Effective
- Jan 1, 2027
- Line of business
- Commercial
- States
- CA
- Source
- www.anthem.com
Codes in this policy
The CPT and HCPCS codes the policy names. A policy can name a code it excludes. Prior authorization status is from the Anthem Blue Cross Blue Shield of California prior authorization list.
| Code | Prior authorization | Description on the prior authorization list | Other Anthem Blue Cross Blue Shield of California policies |
|---|---|---|---|
| 08002 | Not listed | Policies naming 08002 | |
| 08003 | Not listed | Policies naming 08003 | |
| 08011 | Not listed | Policies naming 08011 | |
| 09001 | Not listed | Policies naming 09001 | |
| 09006 | Not listed | Policies naming 09006 | |
| 0902T | Not listed | Policies naming 0902T | |
| 0903T | Not listed | Policies naming 0903T | |
| 0904T | Not listed | Policies naming 0904T | |
| 0905T | Not listed | Policies naming 0905T | |
| 0945T | Not listed | Policies naming 0945T | |
| 12007 | Not listed | Policies naming 12007 | |
| 13005 | Not listed | Policies naming 13005 | |
| 19081 | Not listed | Policies naming 19081 | |
| 19101 | Not listed | Policies naming 19101 | |
| 19288 | Not listed | Policies naming 19288 | |
| 20550 | Not listed | Policies naming 20550 | |
| 20551 | Not listed | Policies naming 20551 | |
| 20552 | Not listed | Policies naming 20552 | |
| 20553 | Not listed | Policies naming 20553 | |
| 22558 | On the list | Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar | Policies naming 22558 |
| 22600 | On the list | Arthrodesis, posterior or posterolateral technique, single level; cervical below C2 segment | Policies naming 22600 |
| 22610 | On the list | Arthrodesis, posterior or posterolateral technique, single level; thoracic (with lateral transverse technique, when performed) | Policies naming 22610 |
| 22612 | On the list | Arthrodesis, posterior or posterolateral technique, single level; lumbar (with lateral transverse technique, when performed) | Policies naming 22612 |
| 22614 | On the list | Arthrodesis, posterior or posterolateral technique, single level; each additional vertebral segment (List separately in addition to code for primary procedure) | Policies naming 22614 |
| 22630 | On the list | Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbar | Policies naming 22630 |
| 22633 | On the list | Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace and segment; lumbar | Policies naming 22633 |
| 24002 | Not listed | Policies naming 24002 | |
| 24004 | Not listed | Policies naming 24004 | |
| 29806 | On the list | Arthroscopy, shoulder, surgical; capsulorrhaphy | Policies naming 29806 |
| 29807 | On the list | Arthroscopy, shoulder, surgical; repair of SLAP lesion | Policies naming 29807 |
| 29819 | On the list | Arthroscopy, shoulder, surgical; with removal of loose body or foreign body | Policies naming 29819 |
| 29820 | On the list | Arthroscopy, shoulder, surgical; synovectomy, partial | Policies naming 29820 |
| 29821 | On the list | Arthroscopy, shoulder, surgical; synovectomy, complete | Policies naming 29821 |
| 29822 | On the list | Arthroscopy, shoulder, surgical; debridement, limited | Policies naming 29822 |
| 29823 | On the list | Arthroscopy, shoulder, surgical; debridement, extensive | Policies naming 29823 |
| 29824 | On the list | Arthroscopy, shoulder, surgical; distal claviculectomy including distal articular surface (Mumford procedure) | Policies naming 29824 |
| 29825 | On the list | Arthroscopy, shoulder, surgical; with lysis and resection of adhesions, with or without manipulation | Policies naming 29825 |
| 29827 | On the list | Arthroscopy, shoulder, surgical; with rotator cuff repair | Policies naming 29827 |
| 29834 | Not listed | Policies naming 29834 | |
| 29835 | Not listed | Policies naming 29835 | |
| 29836 | Not listed | Policies naming 29836 | |
| 29837 | Not listed | Policies naming 29837 | |
| 29838 | Not listed | Policies naming 29838 | |
| 29876 | On the list | Arthroscopy, knee, surgical; synovectomy, major, 2 or more compartments (e.g., medial or lateral) | Policies naming 29876 |
| 29879 | On the list | Arthroscopy, knee, surgical; abrasion arthroplasty (includes chondroplasty where necessary) or multiple drilling or microfracture | Policies naming 29879 |
| 29880 | On the list | Arthroscopy, knee, surgical; with meniscectomy (medial AND lateral, including any meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty), same or separate compartment(s), when performed | Policies naming 29880 |
| 29887 | On the list | Arthroscopy, knee, surgical; drilling for intact osteochondritis dissecans lesion with internal fixation | Policies naming 29887 |
| 34839 | Not listed | Policies naming 34839 | |
| 36000 | Not listed | Policies naming 36000 | |
| 43235 | On the list | Esophagogastroduodenoscopy, flexible transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) | Policies naming 43235 |
| 43770 | On the list | Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device (e.g., gastric band and subcutaneous port components) | Policies naming 43770 |
| 43771 | On the list | Laparoscopy, surgical, gastric restrictive procedure; revision of adjustable gastric restrictive device component only | Policies naming 43771 |
| 43772 | On the list | Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device component only | Policies naming 43772 |
| 43773 | On the list | Laparoscopy, surgical, gastric restrictive procedure; removal and replacement of adjustable gastric restrictive device component only | Policies naming 43773 |
| 43774 | On the list | Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device and subcutaneous port components | Policies naming 43774 |
| 43775 | On the list | Laparoscopy, surgical, gastric restrictive procedure; longitudinal gastrectomy (i.e., sleeve gastrectomy) | Policies naming 43775 |
| 62310 | Not listed | Policies naming 62310 | |
| 62311 | Not listed | Policies naming 62311 | |
| 62319 | Not listed | Policies naming 62319 | |
| 62320 | On the list | Injection(s), of diagnostic or therapeutic substance(s) (e.g., anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic | Policies naming 62320 |
| 62321 | On the list | Injection(s), of diagnostic or therapeutic substance(s) (e.g., anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic | Policies naming 62321 |
| 62322 | On the list | Injection(s), of diagnostic or therapeutic substance(s) (e.g., anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral | Policies naming 62322 |
| 62323 | On the list | Injection(s), of diagnostic or therapeutic substance(s) (e.g., anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral | Policies naming 62323 |
| 62324 | Not listed | Policies naming 62324 | |
| 62325 | Not listed | Policies naming 62325 | |
| 62326 | Not listed | Policies naming 62326 | |
| 62327 | Not listed | Policies naming 62327 | |
| 63048 | On the list | Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [e.g., spinal or lateral recess stenosis]), single vertebral segment; each additional segment, cervical, thoracic, or lumbar (List separately in addition to code for primary procedure) | Policies naming 63048 |
| 63081 | On the list | Vertebral corpectomy (vertebral body resection), partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); cervical, single segment | Policies naming 63081 |
| 63088 | On the list | Vertebral corpectomy (vertebral body resection), partial or complete, combined thoracolumbar approach with decompression of spinal cord, cauda equina or nerve root(s), lower thoracic or lumbar; each additional segment (List separately in addition to code for primary procedure) | Policies naming 63088 |
| 64466 | Not listed | Policies naming 64466 | |
| 64469 | Not listed | Policies naming 64469 | |
| 64473 | Not listed | Policies naming 64473 | |
| 64474 | Not listed | Policies naming 64474 | |
| 69209 | Not listed | Policies naming 69209 | |
| 69210 | Not listed | Policies naming 69210 | |
| 74710 | Not listed | Policies naming 74710 | |
| 76014 | Not listed | Policies naming 76014 | |
| 76019 | Not listed | Policies naming 76019 | |
| 76499 | On the list | Unlisted diagnostic radiographic procedure [when specified as 4-D or 5-D rendering of fetal ultrasound] | Policies naming 76499 |
| 76604 | Not listed | Policies naming 76604 | |
| 76705 | Not listed | Policies naming 76705 | |
| 76706 | Not listed | Policies naming 76706 | |
| 76770 | Not listed | Policies naming 76770 | |
| 76775 | Not listed | Policies naming 76775 | |
| 76776 | Not listed | Policies naming 76776 | |
| 76815 | Not listed | Policies naming 76815 | |
| 76881 | Not listed | Policies naming 76881 | |
| 76942 | Not listed | Policies naming 76942 | |
| 77002 | Not listed | Policies naming 77002 | |
| 77003 | Not listed | Policies naming 77003 | |
| 77012 | Not listed | Policies naming 77012 | |
| 77014 | Not listed | Policies naming 77014 | |
| 77021 | Not listed | Policies naming 77021 | |
| 77061 | Not listed | Policies naming 77061 | |
| 77062 | Not listed | Policies naming 77062 | |
| 77063 | Not listed | Policies naming 77063 | |
| 77280 | Not listed | Policies naming 77280 | |
| 77285 | Not listed | Policies naming 77285 | |
| 77290 | Not listed | Policies naming 77290 | |
| 80300 | Not listed | Policies naming 80300 | |
| 80301 | Not listed | Policies naming 80301 | |
| 80302 | Not listed | Policies naming 80302 | |
| 80303 | Not listed | Policies naming 80303 | |
| 80304 | Not listed | Policies naming 80304 | |
| 80305 | Not listed | Policies naming 80305 | |
| 80307 | Not listed | Policies naming 80307 | |
| 80320 | Not listed | Policies naming 80320 | |
| 80377 | Not listed | Policies naming 80377 | |
| 81000 | Not listed | Policies naming 81000 | |
| 81003 | Not listed | Policies naming 81003 | |
| 82541 | Not listed | Policies naming 82541 | |
| 82542 | On the list | Column chromatography, includes mass spectrometry, if performed (e.g., HPLC, LC, LC/MS, LC/MS-MS, GC, GC/MS- MS, GC/MS, HPLC/MS), non-drug analyte(s) not elsewhere specified, qualitative or quantitative, each specimen [when specified as testing for PFAS] | Policies naming 82542 |
| 82543 | Not listed | Policies naming 82543 | |
| 82544 | Not listed | Policies naming 82544 | |
| 82570 | Not listed | Policies naming 82570 | |
| 83986 | Not listed | Policies naming 83986 | |
| 83992 | Not listed | Policies naming 83992 | |
| 87913 | Not listed | Policies naming 87913 | |
| 88141 | Not listed | Policies naming 88141 | |
| 88155 | Not listed | Policies naming 88155 | |
| 88164 | Not listed | Policies naming 88164 | |
| 88167 | Not listed | Policies naming 88167 | |
| 88174 | Not listed | Policies naming 88174 | |
| 88175 | Not listed | Policies naming 88175 | |
| 91065 | Not listed | Policies naming 91065 | |
| 95700 | Not listed | Policies naming 95700 | |
| 95705 | Not listed | Policies naming 95705 | |
| 95726 | On the list | Electroencephalogram (EEG), continuous recording, physician or other qualified health care professional review of recorded events, analysis of spike and seizure detection, interpretation, and summary report, complete study; greater than 84 hours of EEG recording, with video (VEEG) | Policies naming 95726 |
| 95937 | Not listed | Policies naming 95937 | |
| 95940 | Not listed | Policies naming 95940 | |
| 95941 | Not listed | Policies naming 95941 | |
| 95942 | Not listed | Policies naming 95942 | |
| 95950 | Not listed | Policies naming 95950 | |
| 95951 | Not listed | Policies naming 95951 | |
| 95953 | Not listed | Policies naming 95953 | |
| 95954 | Not listed | Policies naming 95954 | |
| 95955 | Not listed | Policies naming 95955 | |
| 95956 | Not listed | Policies naming 95956 | |
| 95957 | Not listed | Policies naming 95957 | |
| 96360 | Not listed | Policies naming 96360 | |
| 96365 | Not listed | Policies naming 96365 | |
| 96374 | Not listed | Policies naming 96374 | |
| 96375 | Not listed | Policies naming 96375 | |
| 96376 | Not listed | Policies naming 96376 | |
| 96405 | Not listed | Policies naming 96405 | |
| 96406 | Not listed | Policies naming 96406 | |
| 96409 | Not listed | Policies naming 96409 | |
| 96413 | Not listed | Policies naming 96413 | |
| 96416 | Not listed | Policies naming 96416 | |
| 96440 | Not listed | Policies naming 96440 | |
| 96446 | Not listed | Policies naming 96446 | |
| 96450 | Not listed | Policies naming 96450 | |
| 96542 | Not listed | Policies naming 96542 | |
| 97810 | Not listed | Policies naming 97810 | |
| 97814 | Not listed | Policies naming 97814 | |
| 98960 | Not listed | Policies naming 98960 | |
| 98961 | Not listed | Policies naming 98961 | |
| 98962 | Not listed | Policies naming 98962 | |
| 98966 | Not listed | Policies naming 98966 | |
| 98967 | Not listed | Policies naming 98967 | |
| 98968 | Not listed | Policies naming 98968 | |
| 99000 | Not listed | Policies naming 99000 | |
| 99001 | Not listed | Policies naming 99001 | |
| 99072 | Not listed | Policies naming 99072 | |
| 99151 | On the list | Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient younger than 5 years of age | Policies naming 99151 |
| 99152 | On the list | Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older | Policies naming 99152 |
| 99153 | On the list | Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; each additional 15 minutes of intraservice time | Policies naming 99153 |
| 99155 | On the list | Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; initial 15 minutes of intraservice time, patient younger than 5 years of age | Policies naming 99155 |
| 99156 | On the list | Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; initial 15 minutes of intraservice time, patient age 5 years or older | Policies naming 99156 |
| 99157 | On the list | Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; each additional 15 minutes of intraservice time | Policies naming 99157 |
| 99202 | Not listed | Policies naming 99202 | |
| 99215 | Not listed | Policies naming 99215 | |
| 99217 | Not listed | Policies naming 99217 | |
| 99220 | Not listed | Policies naming 99220 | |
| 99221 | Not listed | Policies naming 99221 | |
| 99224 | Not listed | Policies naming 99224 | |
| 99226 | Not listed | Policies naming 99226 | |
| 99233 | Not listed | Policies naming 99233 | |
| 99241 | Not listed | Policies naming 99241 | |
| 99242 | Not listed | Policies naming 99242 | |
| 99245 | Not listed | Policies naming 99245 | |
| 99251 | Not listed | Policies naming 99251 | |
| 99252 | Not listed | Policies naming 99252 | |
| 99255 | Not listed | Policies naming 99255 | |
| 99281 | Not listed | Policies naming 99281 | |
| 99285 | Not listed | Policies naming 99285 | |
| 99318 | Not listed | Policies naming 99318 | |
| 99324 | Not listed | Policies naming 99324 | |
| 99328 | Not listed | Policies naming 99328 | |
| 99334 | Not listed | Policies naming 99334 | |
| 99337 | Not listed | Policies naming 99337 | |
| 99339 | Not listed | Policies naming 99339 | |
| 99340 | Not listed | Policies naming 99340 | |
| 99354 | Not listed | Policies naming 99354 | |
| 99356 | Not listed | Policies naming 99356 | |
| 99357 | Not listed | Policies naming 99357 | |
| 99359 | Not listed | Policies naming 99359 | |
| 99360 | Not listed | Policies naming 99360 | |
| 99363 | Not listed | Policies naming 99363 | |
| 99364 | Not listed | Policies naming 99364 | |
| 99381 | Not listed | Policies naming 99381 | |
| 99383 | Not listed | Policies naming 99383 | |
| 99387 | Not listed | Policies naming 99387 | |
| 99393 | Not listed | Policies naming 99393 | |
| 99397 | Not listed | Policies naming 99397 | |
| 99415 | Not listed | Policies naming 99415 | |
| 99416 | Not listed | Policies naming 99416 | |
| 99420 | Not listed | Policies naming 99420 | |
| 99433 | Not listed | Policies naming 99433 | |
| 99441 | Not listed | Policies naming 99441 | |
| 99442 | Not listed | Policies naming 99442 | |
| 99444 | Not listed | Policies naming 99444 | |
| 99446 | Not listed | Policies naming 99446 | |
| 99447 | Not listed | Policies naming 99447 | |
| 99449 | Not listed | Policies naming 99449 | |
| 99451 | Not listed | Policies naming 99451 | |
| 99452 | Not listed | Policies naming 99452 | |
| 99459 | Not listed | Policies naming 99459 | |
| 99484 | Not listed | Policies naming 99484 | |
| 99487 | Not listed | Policies naming 99487 | |
| 99490 | Not listed | Policies naming 99490 | |
| 99495 | Not listed | Policies naming 99495 | |
| 99496 | Not listed | Policies naming 99496 | |
| 99497 | Not listed | Policies naming 99497 | |
| 99498 | Not listed | Policies naming 99498 | |
| 99601 | Not listed | Policies naming 99601 | |
| 99602 | Not listed | Policies naming 99602 | |
| A4215 | Not listed | Policies naming A4215 | |
| A4250 | Not listed | Policies naming A4250 | |
| A4281 | Not listed | Policies naming A4281 | |
| A4282 | Not listed | Policies naming A4282 | |
| A4283 | Not listed | Policies naming A4283 | |
| A4284 | Not listed | Policies naming A4284 | |
| A4285 | Not listed | Policies naming A4285 | |
| A4556 | Not listed | Policies naming A4556 | |
| A4557 | Not listed | Policies naming A4557 | |
| A4558 | Not listed | Policies naming A4558 | |
| A4580 | Not listed | Policies naming A4580 | |
| A4590 | Not listed | Policies naming A4590 | |
| A4595 | Not listed | Policies naming A4595 | |
| A4648 | Not listed | Policies naming A4648 | |
| C9032 | Not listed | Policies naming C9032 | |
| C9257 | On the list | Bevacizumab, 0.25 mg intravitreal (Avastin) | Policies naming C9257 |
| E0602 | Not listed | Policies naming E0602 | |
| E0603 | Not listed | Policies naming E0603 | |
| E0604 | Not listed | Policies naming E0604 | |
| E0776 | Not listed | Policies naming E0776 | |
| G0101 | Not listed | Policies naming G0101 | |
| G0180 | Not listed | Policies naming G0180 | |
| G0268 | Not listed | Policies naming G0268 | |
| G0276 | Not listed | Policies naming G0276 | |
| G0279 | Not listed | Policies naming G0279 | |
| G0310 | Not listed | Policies naming G0310 | |
| G0318 | Not listed | Policies naming G0318 | |
| G0402 | Not listed | Policies naming G0402 | |
| G0431 | Not listed | Policies naming G0431 | |
| G0434 | Not listed | Policies naming G0434 | |
| G0438 | Not listed | Policies naming G0438 | |
| G0439 | Not listed | Policies naming G0439 | |
| G0453 | Not listed | Policies naming G0453 | |
| G0466 | Not listed | Policies naming G0466 | |
| G0470 | Not listed | Policies naming G0470 | |
| G0477 | Not listed | Policies naming G0477 | |
| G0478 | Not listed | Policies naming G0478 | |
| G0479 | Not listed | Policies naming G0479 | |
| G0480 | Not listed | Policies naming G0480 | |
| G0483 | Not listed | Policies naming G0483 | |
| G0498 | Not listed | Policies naming G0498 | |
| G0500 | Not listed | Policies naming G0500 | |
| G0501 | Not listed | Policies naming G0501 | |
| G0502 | Not listed | Policies naming G0502 | |
| G0503 | Not listed | Policies naming G0503 | |
| G0504 | Not listed | Policies naming G0504 | |
| G0505 | Not listed | Policies naming G0505 | |
| G0507 | Not listed | Policies naming G0507 | |
| G0519 | Not listed | Policies naming G0519 | |
| G0531 | Not listed | Policies naming G0531 | |
| G0543 | Not listed | Policies naming G0543 | |
| G0550 | Not listed | Policies naming G0550 | |
| G0551 | Not listed | Policies naming G0551 | |
| G0554 | Not listed | Policies naming G0554 | |
| G0555 | Not listed | Policies naming G0555 | |
| G0565 | Not listed | Policies naming G0565 | |
| G0659 | Not listed | Policies naming G0659 | |
| G0908 | Not listed | Policies naming G0908 | |
| G0913 | Not listed | Policies naming G0913 | |
| G0918 | Not listed | Policies naming G0918 | |
| G0922 | Not listed | Policies naming G0922 | |
| G2212 | Not listed | Policies naming G2212 | |
| G9038 | Not listed | Policies naming G9038 | |
| G9481 | Not listed | Policies naming G9481 | |
| G9490 | Not listed | Policies naming G9490 | |
| G9678 | Not listed | Policies naming G9678 | |
| G9999 | Not listed | Policies naming G9999 | |
| H0048 | Not listed | Policies naming H0048 | |
| J2001 | Not listed | Policies naming J2001 | |
| J2004 | Not listed | Policies naming J2004 | |
| J3490 | On the list | Unclassified drugs or biologicals [when specified as eladocagene exuparvovec-tneq (Kebilidi)] or [when specified as an ocular gene therapy agent other than voretigene neparvovec-rzyl (Luxturna)] or [when specified as elivaldogene autotemcel (Skysona)] or [when specified as etuvetidigene autotemcel (Waskyra)] or [when specified as a gene therapy for hemophilia other than Hemgenix, Beqvez, or Roctavian] | Policies naming J3490 |
| K1034 | Not listed | Policies naming K1034 |
And 60 more in the original policy.
All Anthem Blue Cross Blue Shield of California policies · Anthem Blue Cross Blue Shield of California prior authorization CPT list