Anthem Blue Cross Blue Shield of California prior authorization
CPT code lookup
Each row is one code from the public prior authorization list. The description is the procedure or service name on that source row. This is not a coverage decision.
Prior authorization codes
| Code | Description | Source |
|---|---|---|
| 00580 | Anesthesia for heart transplant or heart/lung transplant | California PPO Prior Authorization List, Pg 1 Original policy |
| 00796 | Anesthesia for intraperitoneal procedures in upper abdomen including laparoscopy; liver transplant (recipient) | California PPO Prior Authorization List, Pg 1 Original policy |
| 15825 | Rhytidectomy; neck with platysmal tightening (platysmal flap, P-flap) | California PPO Prior Authorization List, Pg 1 Original policy |
| 15828 | Rhytidectomy; cheek, chin, and neck | California PPO Prior Authorization List, Pg 1 Original policy |
| 15829 | Rhytidectomy; superficial musculoaponeurotic system (SMAS) flap | California PPO Prior Authorization List, Pg 1 Original policy |
| 15832 | Excision, excessive skin and subcutaneous tissue (includes lipectomy); thigh | California PPO Prior Authorization List, Pg 1 Original policy |
| 15833 | Excision, excessive skin and subcutaneous tissue (includes lipectomy); leg | California PPO Prior Authorization List, Pg 1 Original policy |
| 15834 | Excision, excessive skin and subcutaneous tissue (includes lipectomy); hip | California PPO Prior Authorization List, Pg 1 Original policy |
| 15835 | Excision, excessive skin and subcutaneous tissue (includes lipectomy); buttock | California PPO Prior Authorization List, Pg 2 Original policy |
| 15836 | Excision, excessive skin and subcutaneous tissue (includes lipectomy); arm | California PPO Prior Authorization List, Pg 2 Original policy |
| 15837 | Excision, excessive skin and subcutaneous tissue (includes lipectomy); forearm or hand | California PPO Prior Authorization List, Pg 2 Original policy |
| 15838 | Excision, excessive skin and subcutaneous tissue (includes lipectomy); submental fat pad | California PPO Prior Authorization List, Pg 2 Original policy |
| 15839 | Excision, excessive skin and subcutaneous tissue (includes lipectomy); other area | California PPO Prior Authorization List, Pg 2 Original policy |
| 15840 | Graft for facial nerve paralysis; free fascia graft (including obtaining fascia) | California PPO Prior Authorization List, Pg 2 Original policy |
| 15841 | Graft for facial nerve paralysis; free muscle graft (including obtaining graft) | California PPO Prior Authorization List, Pg 2 Original policy |
| 15842 | Graft for facial nerve paralysis; free muscle flap by microsurgical technique | California PPO Prior Authorization List, Pg 2 Original policy |
| 15845 | Graft for facial nerve paralysis; regional muscle transfer | California PPO Prior Authorization List, Pg 2 Original policy |
| 15876 | Suction assisted lipectomy; head and neck | California PPO Prior Authorization List, Pg 2 Original policy |
| 15878 | Suction assisted lipectomy; upper extremity | California PPO Prior Authorization List, Pg 2 Original policy |
| 15879 | Suction assisted lipectomy; lower extremity | California PPO Prior Authorization List, Pg 2 Original policy |
| 17999 | Unlisted procedure, skin, mucous membrane and subcutaneous tissue [when specified as other abdominoplasty, excision excessive skin and subcutaneous tissue, including lipectomy, of abdomen] or [when specified as permanent hair removal by laser] or [when specified as implantation of biologic implants for soft tissue reinforcement in tissues other than breast and trunk] or [when specified as aesthetic flat chest closure or chest wall reconstruction after breast surgery] or [when specified as laser treatment of onychomycosis] or [when specified as percutaneous ultrasound ablation of subcutaneous tissue] or [when specified as application of prademagene zamikeracel (Zevaskyn) genetically engineered autologous cell therapy] or [when specified as harvesting or administration of stem cells for therapy to repair damaged cells or body tissues] | California PPO Prior Authorization List, Pg 2 Original policy |
| 19316 | Mastopexy | California PPO Prior Authorization List, Pg 2 Original policy |
| 19325 | Breast augmentation with implant | California PPO Prior Authorization List, Pg 2 Original policy |
| 19328 | Removal of intact breast implant | California PPO Prior Authorization List, Pg 2 Original policy |
| 19330 | Removal of ruptured breast implant, including implant contents (e.g., saline, silicone gel) | California PPO Prior Authorization List, Pg 2 Original policy |
| 19340 | Insertion of breast implant on same day of mastectomy (i.e., immediate) | California PPO Prior Authorization List, Pg 2 Original policy |
| 19342 | Insertion or replacement of breast implant on separate day from mastectomy | California PPO Prior Authorization List, Pg 2 Original policy |
| 19350 | Nipple/areola reconstruction | California PPO Prior Authorization List, Pg 2 Original policy |
| 19355 | Correction of inverted nipples | California PPO Prior Authorization List, Pg 2 Original policy |
| 19357 | Tissue expander placement in breast reconstruction, including subsequent expansion(s) | California PPO Prior Authorization List, Pg 2 Original policy |
| 19361 | Breast reconstruction with latissimus dorsi flap | California PPO Prior Authorization List, Pg 2 Original policy |
| 19364 | Breast reconstruction with free flap (e.g., fTRAM, DIEP, SIEA, GAP flap) | California PPO Prior Authorization List, Pg 2 Original policy |
| 19367 | Breast reconstruction; with single-pedicled transverse rectus abdominis myocutaneous (TRAM) flap | California PPO Prior Authorization List, Pg 2 Original policy |
| 19368 | Breast reconstruction; with single-pedicled transverse rectus abdominis myocutaneous (TRAM) flap, requiring separate microvascular anastomosis (supercharging) | California PPO Prior Authorization List, Pg 2 Original policy |
| 19369 | Breast reconstruction; with bipedicled transverse rectus abdominis myocutaneous (TRAM) flap | California PPO Prior Authorization List, Pg 2 Original policy |
| 19380 | Revision of reconstructed breast (e.g., significant removal of tissue, re-advancement and/or re-inset of flaps in autologous reconstruction or significant capsular revision combined with soft tissue excision in implant-based reconstruction) | California PPO Prior Authorization List, Pg 2 Original policy |
| 19396 | Preparation of moulage for custom breast implant | California PPO Prior Authorization List, Pg 2 Original policy |
| 19499 | Unlisted procedure, breast [when specified as destruction of breast tissue by high intensity focused ultrasound] or [when specified as radiofrequency or microwave ablation or laser ablation of breast tumor(s)] or [when specified as catheter lavage of a mammary duct or fiberoptic ductoscopy] | California PPO Prior Authorization List, Pg 2 Original policy |
| 20999 | Unlisted procedure, musculoskeletal system, general [when specified as high intensity focused ultrasound for pain palliation for bone metastases] or [No specific code for surgery using Coblation technology] or [when specified as radiofrequency or pulsed radiofrequency treatment of trigger points] or [when specified as percutaneous ultrasonic ablation of soft tissue] or [when specified as harvesting and injection of bone marrow aspirate concentrate or harvesting or administration of stem cells for therapy to repair damaged cells or body tissues] | California PPO Prior Authorization List, Pg 3 Original policy |
| 21083 | Impression and custom preparation; palatal lift prosthesis | California PPO Prior Authorization List, Pg 3 Original policy |
| 21086 | Impression and custom preparation; auricular prosthesis | California PPO Prior Authorization List, Pg 3 Original policy |
| 21087 | Impression and custom preparation; nasal prosthesis | California PPO Prior Authorization List, Pg 3 Original policy |
| 21137 | Reduction forehead; contouring only | California PPO Prior Authorization List, Pg 3 Original policy |
| 21138 | Reduction forehead; contouring and application of prosthetic material or bone graft (includes obtaining autograft) | California PPO Prior Authorization List, Pg 3 Original policy |
| 21139 | Reduction forehead; contouring and setback of anterior frontal sinus wall | California PPO Prior Authorization List, Pg 3 Original policy |
| 21151 | Reconstruction midface, LeFort II | California PPO Prior Authorization List, Pg 3 Original policy |
| 21154 | Reconstruction midface, LeFort III | California PPO Prior Authorization List, Pg 3 Original policy |
| 21155 | Reconstruction midface, LeFort III | California PPO Prior Authorization List, Pg 3 Original policy |
| 21159 | Reconstruction midface, LeFort III (extra and intracranial) with forehead advancement (e.g., mono bloc), requiring bone grafts (includes obtaining autografts) | California PPO Prior Authorization List, Pg 3 Original policy |
| 21160 | Reconstruction midface, LeFort III (extra and intracranial) with forehead advancement (e.g., mono bloc), requiring bone grafts (includes obtaining autografts) | California PPO Prior Authorization List, Pg 3 Original policy |