Anthem Blue Cross Blue Shield of California policy
CG-SURG-123 Autologous Fat Grafting and Injectable Soft Tissue Fillers
CG-SURG-123 Autologous Fat Grafting and Injectable Soft Tissue Fillers is a public Anthem Blue Cross Blue Shield of California policy (policy CG-SURG-123). It lists 17 CPT or HCPCS codes, 17 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-SURG-123
- 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 |
|---|---|---|---|
| 11950 | On the list | Subcutaneous injection of filling material (e.g., collagen); 1 cc or less | Policies naming 11950 |
| 11951 | On the list | Subcutaneous injection of filling material (e.g., collagen); 1.1 to 5.0 cc | Policies naming 11951 |
| 11952 | On the list | Subcutaneous injection of filling material (e.g., collagen); 5.1 to 10.0 cc | Policies naming 11952 |
| 11954 | On the list | Subcutaneous injection of filling material (e.g., collagen); over 10.0 cc | Policies naming 11954 |
| 15771 | On the list | Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; 50 cc or less injectate | Policies naming 15771 |
| 15772 | On the list | Grafting of autologous fat harvested by liposuction technique to trunk, breasts, scalp, arms, and/or legs; each additional 50 cc injectate, or part thereof | Policies naming 15772 |
| 15773 | On the list | Grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet; 25 cc or less injectate | Policies naming 15773 |
| 15774 | On the list | Grafting of autologous fat harvested by liposuction technique to face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet; each additional 25 cc injectate, or part thereof | Policies naming 15774 |
| 17999 | On the list | Unlisted procedure, skin, mucous membrane and subcutaneous tissue [when specified as other abdominoplasty, excision excessive skin and subcutaneous tissue, including lipectomy, of abdomen] or [when specified as permanent hair removal by laser] or [when specified as implantation of biologic implants for soft tissue reinforcement in tissues other than breast and trunk] or [when specified as aesthetic flat chest closure or chest wall reconstruction after breast surgery] or [when specified as laser treatment of onychomycosis] or [when specified as percutaneous ultrasound ablation of subcutaneous tissue] or [when specified as application of prademagene zamikeracel (Zevaskyn) genetically engineered autologous cell therapy] or [when specified as harvesting or administration of stem cells for therapy to repair damaged cells or body tissues] | Policies naming 17999 |
| 31574 | On the list | Laryngoscopy, flexible; with injection(s) for augmentation (e.g., percutaneous, transoral), unilateral | Policies naming 31574 |
| C1878 | On the list | Material for vocal cord medialization, synthetic (implantable) [e.g., RenuVoice, RenuGel] | Policies naming C1878 |
| D9914 | On the list | Administration of dermal fillers | Policies naming D9914 |
| G0429 | On the list | Dermal filler injection(s) for the treatment of facial lipodystrophy syndrome (LDS) (e.g., as a result of highly active antiretroviral therapy) | Policies naming G0429 |
| L8607 | On the list | Injectable bulking agent for vocal cord medialization, 0.1 ml, includes shipping and necessary supplies | Policies naming L8607 |
| L8699 | On the list | Prosthetic implant, not otherwise specified [when specified as hybrid cochlear device, including all internal and external components] or [when describing replacement components of an auditory brain stem implant] or [when specified as a hyaluronic acid gel agent such as Juvederm or Restylane] or [when describing a prefabricated, custom-fitted auricular implant] or [when describing a custom-fabricated auricular implant] or [when specified as testicular or penile prosthesis] | Policies naming L8699 |
| Q2026 | On the list | Injection, Radiesse, 0.1 ml | Policies naming Q2026 |
| Q2028 | On the list | Injection, Sculptra, 0.5 mg | Policies naming Q2028 |
All Anthem Blue Cross Blue Shield of California policies · Anthem Blue Cross Blue Shield of California prior authorization CPT list