Anthem Blue Cross Blue Shield of California policy
Modifiers 59 and XE, XP, XS, and XU: Distinct Procedural Service - Professional
Modifiers 59 and XE, XP, XS, and XU: Distinct Procedural Service - Professional is a public Anthem Blue Cross Blue Shield of California policy (policy C-09006, effective Jul 1, 2026). It lists 130 CPT or HCPCS codes, 54 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-09006
- Effective
- Jul 1, 2026
- 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 |
|---|---|---|---|
| 01996 | Not listed | Policies naming 01996 | |
| 09006 | Not listed | Policies naming 09006 | |
| 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 |
| 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 |
| 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 | |
| 43281 | On the list | Laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, when performed; without implantation of mesh | Policies naming 43281 |
| 43282 | On the list | Laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, when performed; with implantation of mesh | Policies naming 43282 |
| 43283 | Not listed | Policies naming 43283 | |
| 43332 | Not listed | Policies naming 43332 | |
| 43333 | Not listed | Policies naming 43333 | |
| 43644 | On the list | Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and Roux-en-Y gastroenterostomy (roux limb 150 cm or less) | Policies naming 43644 |
| 43645 | On the list | Laparoscopy, surgical, gastric restrictive procedure; with gastric bypass and small intestine reconstruction to limit absorption | Policies naming 43645 |
| 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 |
| 43842 | On the list | Gastric restrictive procedure, without gastric bypass, for morbid obesity; vertical-banded gastroplasty | Policies naming 43842 |
| 43843 | On the list | Gastric restrictive procedure, without gastric bypass, for morbid obesity; other than vertical-banded gastroplasty | Policies naming 43843 |
| 43845 | On the list | Gastric restrictive procedure with partial gastrectomy, pylorus- preserving duodenoileostomy and ileoileostomy (50 to 100 cm common channel) to limit absorption (biliopancreatic diversion with duodenal switch) | Policies naming 43845 |
| 43846 | On the list | Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb (150 cm or less) Roux-en-Y gastroenterostomy | Policies naming 43846 |
| 43847 | On the list | Gastric restrictive procedure, with gastric bypass for morbid obesity; with small intestine reconstruction to limit absorption | Policies naming 43847 |
| 43848 | On the list | Revision, open, of gastric restrictive procedure for morbid obesity, other than adjustable gastric restrictive device (separate procedure) | Policies naming 43848 |
| 43886 | On the list | Gastric restrictive procedure, open; revision of subcutaneous port component only | Policies naming 43886 |
| 43887 | On the list | Gastric restrictive procedure, open; removal of subcutaneous port component only | Policies naming 43887 |
| 43888 | On the list | Gastric restrictive procedure, open; removal and replacement of subcutaneous port component only | Policies naming 43888 |
| 58140 | Not listed | Policies naming 58140 | |
| 58145 | On the list | Myomectomy, excision of fibroid tumor(s) of uterus, 1 to 4 intramural myoma(s) with total weight of 250 g or less and/or removal of surface myomas; vaginal approach | Policies naming 58145 |
| 58146 | Not listed | Policies naming 58146 | |
| 58545 | On the list | Laparoscopy, surgical, myomectomy, excision; 1 to 4 intramural myomas with total weight of 250 g or less and/or removal of surface myomas | Policies naming 58545 |
| 58546 | On the list | Laparoscopy, surgical, myomectomy, excision; 5 or more intramural myomas and/or intramural myomas with total weight greater than 250 g | Policies naming 58546 |
| 58561 | Not listed | Policies naming 58561 | |
| 58570 | On the list | Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less | Policies naming 58570 |
| 58571 | On the list | Laparoscopy, surgical, with total hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s) | Policies naming 58571 |
| 58572 | On the list | Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g | Policies naming 58572 |
| 58573 | On the list | Laparoscopy, surgical, with total hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s) | Policies naming 58573 |
| 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 |
| 63650 | On the list | Percutaneous implantation of neurostimulator electrode array, epidural | Policies naming 63650 |
| 63655 | On the list | Laminectomy for implantation of neurostimulator electrodes, plate/paddle, epidural | Policies naming 63655 |
| 75699 | Not listed | Policies naming 75699 | |
| 76511 | Not listed | Policies naming 76511 | |
| 76513 | Not listed | Policies naming 76513 | |
| 76603 | Not listed | Policies naming 76603 | |
| 76605 | Not listed | Policies naming 76605 | |
| 76707 | Not listed | Policies naming 76707 | |
| 76769 | Not listed | Policies naming 76769 | |
| 76777 | Not listed | Policies naming 76777 | |
| 76814 | Not listed | Policies naming 76814 | |
| 76816 | Not listed | Policies naming 76816 | |
| 76856 | Not listed | Policies naming 76856 | |
| 76858 | Not listed | Policies naming 76858 | |
| 76881 | Not listed | Policies naming 76881 | |
| 76883 | Not listed | Policies naming 76883 | |
| 76942 | Not listed | Policies naming 76942 | |
| 77002 | Not listed | Policies naming 77002 | |
| 77003 | Not listed | Policies naming 77003 | |
| 77012 | Not listed | Policies naming 77012 | |
| 77021 | Not listed | Policies naming 77021 | |
| 78265 | Not listed | Policies naming 78265 | |
| 78830 | Not listed | Policies naming 78830 | |
| 78835 | Not listed | Policies naming 78835 | |
| 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 | |
| 81005 | Not listed | Policies naming 81005 | |
| 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 |
| 82570 | Not listed | Policies naming 82570 | |
| 83516 | On the list | Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; qualitative or semiquantitative, multiple step method [when specified as ALCAT or Mediator Release Test (MRT)] | Policies naming 83516 |
| 83520 | On the list | Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; quantitative, not otherwise specified or [when specified as testing for food allergy or sensitivity (e.g., IgG testing)] or [when specified as tau protein, amyloid beta peptide testing] | Policies naming 83520 |
| 83789 | Not listed | Policies naming 83789 | |
| 83986 | Not listed | Policies naming 83986 | |
| 83992 | Not listed | Policies naming 83992 | |
| 84156 | Not listed | Policies naming 84156 | |
| 84311 | Not listed | Policies naming 84311 | |
| 95951 | Not listed | Policies naming 95951 | |
| 95953 | Not listed | Policies naming 95953 | |
| 95954 | Not listed | Policies naming 95954 | |
| 95956 | Not listed | Policies naming 95956 | |
| 95957 | Not listed | Policies naming 95957 | |
| 96365 | Not listed | Policies naming 96365 | |
| 96369 | Not listed | Policies naming 96369 | |
| 96372 | Not listed | Policies naming 96372 | |
| 96373 | Not listed | Policies naming 96373 | |
| 96374 | Not listed | Policies naming 96374 | |
| 96379 | Not listed | Policies naming 96379 | |
| 99281 | Not listed | Policies naming 99281 | |
| 99285 | Not listed | Policies naming 99285 | |
| G0138 | Not listed | Policies naming G0138 | |
| G0480 | Not listed | Policies naming G0480 | |
| G0481 | Not listed | Policies naming G0481 | |
| G0482 | Not listed | Policies naming G0482 | |
| G0483 | Not listed | Policies naming G0483 | |
| G0659 | Not listed | Policies naming G0659 | |
| J1202 | Not listed | Policies naming J1202 | |
| L8679 | On the list | Neurostimulator Implantation - Implantable neurostimulator, pulse generator, any type | Policies naming L8679 |
| L8680 | On the list | Neurostimulator Implantation - Implantable heurostimulator electrode, each | Policies naming L8680 |
| L8687 | On the list | Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension | Policies naming L8687 |
| Q3014 | Not listed | Policies naming Q3014 |
All Anthem Blue Cross Blue Shield of California policies · Anthem Blue Cross Blue Shield of California prior authorization CPT list