Anthem Blue Cross Blue Shield of California policy
SURG.00165 Histotripsy
SURG.00165 Histotripsy is a public Anthem Blue Cross Blue Shield of California policy (policy SURG.00165). It lists 5 CPT or HCPCS codes, 5 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.00165
- 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 |
|---|---|---|---|
| 0686T | On the list | Histotripsy (i.e., non-thermal ablation via acoustic energy delivery) of malignant hepatocellular tissue, including image guidance | Policies naming 0686T |
| 0888T | On the list | Histotripsy (i.e., non-thermal ablation via acoustic energy delivery) of malignant renal tissue, including imaging guidance | Policies naming 0888T |
| 1037T | On the list | Histotripsy (ie, non-thermal ablation via acoustic energy delivery) of malignant pancreatic tissue, including imaging guidance | Policies naming 1037T |
| 47399 | On the list | Unlisted procedure, liver [when specified as histotripsy of nonmalignant lesion of liver] | Policies naming 47399 |
| 55899 | On the list | Unlisted procedure, male genital system [when specified as phalloplasty] or [when specified as image-guided focused ultrasound ablation of prostate tissue for non-oncologic indications, such as benign prostatic hyperplasia] or [when specified as intracavernous injection of autologous adipose- derived regenerative cells, e.g., for erectile dysfunction] or [when specified as nanoparticle thermal ablation] or [when specified as histotripsy of prostate tissue] | Policies naming 55899 |
All Anthem Blue Cross Blue Shield of California policies · Anthem Blue Cross Blue Shield of California prior authorization CPT list