Anthem Blue Cross Blue Shield of California prior authorization 22899
Anthem Blue Cross Blue Shield of California prior authorization for 22899: 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]
- Code
- 22899
- Description
- 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]
- Source
- California PPO Prior Authorization List, Pg 4 Original policy
Anthem Blue Cross Blue Shield of California prior authorization