Anthem Blue Cross Blue Shield of California policy
CG-MED-81 Ultrasound Ablation for Oncologic Indications
CG-MED-81 Ultrasound Ablation for Oncologic Indications is a public Anthem Blue Cross Blue Shield of California policy (policy CG-MED-81). It lists 7 CPT or HCPCS codes, 7 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
- CG-MED-81
- Line of business
- Commercial
- 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 |
|---|---|---|---|
| 19499 | On the list | Unlisted procedure, breast [when specified as destruction of breast tissue by high intensity focused ultrasound] or [when specified as radiofrequency or microwave ablation or laser ablation of breast tumor(s)] or [when specified as catheter lavage of a mammary duct or fiberoptic ductoscopy] | Policies naming 19499 |
| 20999 | On the list | Unlisted procedure, musculoskeletal system, general [when specified as high intensity focused ultrasound for pain palliation for bone metastases] or [No specific code for surgery using Coblation technology] or [when specified as radiofrequency or pulsed radiofrequency treatment of trigger points] or [when specified as percutaneous ultrasonic ablation of soft tissue] or [when specified as harvesting and injection of bone marrow aspirate concentrate or harvesting or administration of stem cells for therapy to repair damaged cells or body tissues] | Policies naming 20999 |
| 51721 | On the list | Insertion of transurethral ablation transducer for delivery of thermal ultrasound for prostate tissue ablation, including suprapubic tube placement during the same session and placement of an endorectal cooling device, when performed | Policies naming 51721 |
| 55880 | On the list | Ablation of malignant prostate tissue, transrectal, with high intensity-focused ultrasound (HIFU), including ultrasound guidance | Policies naming 55880 |
| 55881 | On the list | Ablation of prostate tissue, transurethral, using thermal ultrasound, including magnetic resonance imaging guidance for, and monitoring of, tissue ablation | Policies naming 55881 |
| 55882 | On the list | Ablation of prostate tissue, transurethral, using thermal ultrasound, including magnetic resonance imaging guidance for, and monitoring of, tissue ablation; with insertion of transurethral ultrasound transducer for delivery of thermal ultrasound, including suprapubic tube placement and placement of an endorectal cooling device, when performed | Policies naming 55882 |
| C9734 | On the list | Focused ultrasound ablation/therapeutic intervention, other than uterine leiomyomata, with or without magnetic resonance (MR) guidance | Policies naming C9734 |
All Anthem Blue Cross Blue Shield of California policies · Anthem Blue Cross Blue Shield of California prior authorization CPT list