Anthem Blue Cross Blue Shield of California policy
SURG.00155 Cryosurgery of Peripheral Nerves
SURG.00155 Cryosurgery of Peripheral Nerves is a public Anthem Blue Cross Blue Shield of California policy (policy SURG.00155). It lists 8 CPT or HCPCS codes, 8 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.00155
- 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 |
|---|---|---|---|
| 0440T | On the list | Ablation, percutaneous, cryoablation, includes imaging guidance; upper extremity distal/peripheral nerve | Policies naming 0440T |
| 0441T | On the list | Ablation, percutaneous, cryoablation, includes imaging guidance; lower extremity distal/peripheral nerve | Policies naming 0441T |
| 0442T | On the list | Ablation, percutaneous, cryoablation, includes imaging guidance; nerve plexus or other truncal nerve (e.g., brachial plexus, pudendal nerve) | Policies naming 0442T |
| 64624 | On the list | Destruction by neurolytic agent, genicular nerve branches including imaging guidance, when performed | Policies naming 64624 |
| 64640 | On the list | Destruction by neurolytic agent; other peripheral nerve or branch | Policies naming 64640 |
| 64999 | On the list | Unlisted procedure, nervous system [when specified as implantation, revision, replacement, or removal of vagus nerve blocking neurostimulator electrode array or pulse generator at the esophagogastric junction] or [when specified as percutaneous neuromodulation therapy] or [when specified as introduction of Kebilidi into cranial cavity and brain] or [when specified as craniectomy or craniotomy for implantation of neurostimulator electrodes, cerebellar] or [when specified as percutaneous decompression or laser procedures of cervical or thoracic spine] or [when specified as epiduroscopy] or [when specified as pulsed radiofrequency treatment] or [when specified as cooled or pulsed RF therapy (not destruction) to genicular nerve(s)] or [when specified as cryoneurolysis] or [when specified as nanoparticle thermal ablation] or [when specified as adrenal tissue, fetal mesencephalic tissue or fetal xenograft tissue transplant to brain] or [when specified as harvesting or administration of stem cells for therapy to repair damaged cells or body tissues] | Policies naming 64999 |
| C9808 | On the list | Nerve cryoablation probe (e.g., cryoICE, cryosphere, cryosphere max, cryoICE cryosphere, cryoICE cryo2), including probe and all disposable system components, non- opioid medical device | Policies naming C9808 |
| C9809 | On the list | Cryoablation needle (e.g., Iovera system), including needle/tip and all disposable system components, non-opioid medical device | Policies naming C9809 |
All Anthem Blue Cross Blue Shield of California policies · Anthem Blue Cross Blue Shield of California prior authorization CPT list