Anthem Blue Cross Blue Shield of California policy
SURG.00111 Axial Lumbar Interbody Fusion
SURG.00111 Axial Lumbar Interbody Fusion is a public Anthem Blue Cross Blue Shield of California policy (policy SURG.00111). It lists 2 CPT or HCPCS codes, 2 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
- SURG.00111
- 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 |
|---|---|---|---|
| 22586 | On the list | Arthrodesis, pre-sacral interbody technique, including disc space preparation, discectomy, with posterior instrumentation, with image guidance, includes bone graft when performed, L5- S1 interspace | Policies naming 22586 |
| 22899 | On the list | Unlisted procedure, spine [when specified as percutaneous intradiscal radiofrequency thermocoagulation (PIRFT) or intradiscal biacuplasty (IDB)] or [when specified as a percutaneous or endoscopic procedure for decompression for example DTRAX cage procedure] or [when specified as insertion of a dynamic intervertebral pedicle-based stabilization device] or [when specified as pre-sacral interbody arthrodesis lumbar. L4-L5 interspace with instrumentation, or pre-sacral interbody arthrodesis L4-L5 or L5-S1 interspace without instrumentation] or [when specified as insertion of a non-pedicle interspinous process fixation device] | Policies naming 22899 |
All Anthem Blue Cross Blue Shield of California policies · Anthem Blue Cross Blue Shield of California prior authorization CPT list