Anthem Blue Cross Blue Shield of California policy
Portable Normothermic Organ Perfusion Systems
Portable Normothermic Organ Perfusion Systems is a public Anthem Blue Cross Blue Shield of California policy (policy TRANS.00039). It lists 10 CPT or HCPCS codes, 10 of them on the Anthem Blue Cross Blue Shield of California prior authorization list. Not a coverage decision; the payer's own document governs.
Check eligibility for free
No account required. Sign a BAA to see plan details, coordination of benefits and more
- Policy number
- TRANS.00039
- 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 |
|---|---|---|---|
| 0494T | On the list | Surgical preparation and cannulation of marginal (extended) cadaver donor lung(s) to ex vivo organ perfusion system, including decannulation, separation from the perfusion system, and cold preservation of the allograft prior to implantation, when performed | Policies naming 0494T |
| 0495T | On the list | Initiation and monitoring marginal (extended) cadaver donor lung(s) organ perfusion system by physician or qualified health care professional, including physiological and laboratory assessment (e.g., pulmonary artery flow, pulmonary artery pressure, left atrial pressure, pulmonary vascular resistance, mean/peak and plateau airway pressure, dynamic compliance and perfusate gas analysis), including bronchoscopy and X ray when performed; first two hours in sterile field | Policies naming 0495T |
| 0496T | On the list | Initiation and monitoring marginal (extended) cadaver donor lung(s) organ perfusion system by physician or qualified health care professional, including physiological and laboratory assessment (e.g., pulmonary artery flow, pulmonary artery pressure, left atrial pressure, pulmonary vascular resistance, mean/peak and plateau airway pressure, dynamic compliance and perfusate gas analysis), including bronchoscopy and X ray when performed; each additional hour | Policies naming 0496T |
| 0894T | On the list | Cannulation of the liver allograft in preparation for connection to the normothermic perfusion device and decannulation of the liver allograft following normothermic perfusion | Policies naming 0894T |
| 0895T | On the list | Connection of liver allograft to normothermic machine perfusion device, hemostasis control; initial 4 hours of monitoring time, including hourly physiological and laboratory assessments (e.g., perfusate temperature, perfusate pH, hemodynamic parameters, bile production, bile pH, bile glucose, biliary bicarbonate, lactate levels, macroscopic assessment) | Policies naming 0895T |
| 0896T | On the list | Connection of liver allograft to normothermic machine perfusion device, hemostasis control; each additional hour, including physiological and laboratory assessments (e.g., perfusate temperature, perfusate pH, hemodynamic parameters, bile production, bile pH, bile glucose, biliary bicarbonate, lactate levels, macroscopic assessment) | Policies naming 0896T |
| 1072T | On the list | Liver allograft, normothermic machine perfusion; each additional hour of monitoring and management | Policies naming 1072T |
| 1073T | On the list | Liver allograft, normothermic machine perfusion; decannulation | Policies naming 1073T |
| 33999 | On the list | Unlisted procedure, cardiac surgery [when specified as percutaneous transmyocardial revascularization] or [when specified as transmyocardial transcatheter closure of ventricular septal defect, with implant, including cardiopulmonary bypass if performed] or [when specified as transcatheter replacement of tricuspid heart valve] or [when specified as autologous cell therapy for damaged myocardium, including harvesting and preparation of cells] or [when specified as use of a portable normothermic organ perfusion system for heart transplantation] | Policies naming 33999 |
| 53899 | On the list | Unlisted procedure, urinary system [when specified as transurethral MRI directional ultrasound ablation of prostate tissue (TULSA)] or [when specified as use of a portable normothermic organ perfusion system for kidney transplantation] | Policies naming 53899 |
All Anthem Blue Cross Blue Shield of California policies · Anthem Blue Cross Blue Shield of California prior authorization CPT list