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Anthem Blue Cross Blue Shield of California prior authorization, page 10

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

Prior authorization codes
CodeDescriptionSource
A0431Ambulance service, conventional air services, transport, one way (rotary wing)California PPO Prior Authorization List, Pg 21 Original policy
A0435Fixed wing air mileage, per statute mileCalifornia PPO Prior Authorization List, Pg 21 Original policy
A0436Rotary wing air mileage, per statute mileCalifornia PPO Prior Authorization List, Pg 21 Original policy
A0888Noncovered ambulance mileage, per mile (e.g., for miles traveled beyond closest appropriate facility)California PPO Prior Authorization List, Pg 21 Original policy
A0999Unlisted ambulance serviceCalifornia PPO Prior Authorization List, Pg 21 Original policy
A2022InnovaBurn or InnovaMatrix XL, per square centimeterCalifornia PPO Prior Authorization List, Pg 21 Original policy
A2023InnovaMatrix PD 1 mgCalifornia PPO Prior Authorization List, Pg 21 Original policy
A2024Resolve Matrix or xenoPATCH, per square centimeterCalifornia PPO Prior Authorization List, Pg 21 Original policy
A2026Restrata MiniMatrix, 5 mgCalifornia PPO Prior Authorization List, Pg 21 Original policy
A2027Matriderm, per square centimeterCalifornia PPO Prior Authorization List, Pg 21 Original policy
A2028MicroMatrix Flex, per mgCalifornia PPO Prior Authorization List, Pg 21 Original policy
A2029MiroTract Wound Matrix sheet, per cubic centimeterCalifornia PPO Prior Authorization List, Pg 21 Original policy
A2036Cohealyx collagen dermal matrix, per square centimeterCalifornia PPO Prior Authorization List, Pg 21 Original policy
A2037G4Derm Plus, per milliliterCalifornia PPO Prior Authorization List, Pg 21 Original policy
A2038Marigen Pacto, per square centimeterCalifornia PPO Prior Authorization List, Pg 21 Original policy
A2039Innovamatrix FD, per square centimeterCalifornia PPO Prior Authorization List, Pg 22 Original policy
A2040Microlyte Painguard, per square centimeterCalifornia PPO Prior Authorization List, Pg 22 Original policy
A2041Foundation DRS+ Duo, per square centimeterCalifornia PPO Prior Authorization List, Pg 22 Original policy
A2042Foundation DRS+ Solo, per square centimeterCalifornia PPO Prior Authorization List, Pg 22 Original policy
A2043NovaShield or NovoGen wound matrix, per square centimeterCalifornia PPO Prior Authorization List, Pg 22 Original policy
A4438Adhesive clip applied to the skin to secure external electrical nerve stimulator controller, eachCalifornia PPO Prior Authorization List, Pg 22 Original policy
A4468Exsufflation belt, includes all supplies and accessoriesCalifornia PPO Prior Authorization List, Pg 22 Original policy
A4542Supplies and accessories for external upper limb tremor stimulator of the peripheral nerves of the wristCalifornia PPO Prior Authorization List, Pg 22 Original policy
A4575Topical hyperbaric oxygen chamber, disposableCalifornia PPO Prior Authorization List, Pg 22 Original policy
A4600Sleeve for intermittent limb compression device, replacement only, eachCalifornia PPO Prior Authorization List, Pg 22 Original policy
A4649Surgical supply, miscellaneous [no specific code for antimicrobial silver wound dressings (e.g., Acticoat, Actisorb, AQUACEL Ag, Promogran Prisma, Silversorb, Urgotul Silver)] or [when specified as supply of a medial knee implanted shock absorber]California PPO Prior Authorization List, Pg 22 Original policy
A4659Surgical supply, miscellaneous [no specific code for antimicrobial silver wound dressings (e.g., Acticoat, Actisorb, AQUACEL Ag, Promogran Prisma, Silversorb, Urgotul Silver)]California PPO Prior Authorization List, Pg 22 Original policy
A7025High frequency chest wall oscillation system vest, replacement for use with patient-owned equipment, eachCalifornia PPO Prior Authorization List, Pg 22 Original policy
A9268Programmer for transient, orally ingested capsuleCalifornia PPO Prior Authorization List, Pg 22 Original policy
A9269Programable, transient, orally ingested capsule, for use with external programmer, per monthCalifornia PPO Prior Authorization List, Pg 22 Original policy
A9279Monitoring feature/device, stand-alone or integrated, any type, includes all accessories, components and electronics, not otherwise classified [when specified as an ingestion event monitor, for example, ID-CAP System or Discover]California PPO Prior Authorization List, Pg 22 Original policy
B9999NOC for parenteral suppliesCalifornia PPO Prior Authorization List, Pg 22 Original policy
C1734Orthopedic/device/drug matrix for opposing bone-to-bone or soft tissue-to-bone (implantable)California PPO Prior Authorization List, Pg 22 Original policy
C1789Prosthesis, breast (implantable)California PPO Prior Authorization List, Pg 22 Original policy
C2614Probe, percutaneous lumbar discectomyCalifornia PPO Prior Authorization List, Pg 22 Original policy
C8003Implantation of medial knee extraarticular implantable shock absorber spanning the knee joint from distal femur to proximal tibia, open, includes measurements, positioning and adjustments, with imaging guidance (e.g., fluoroscopy)California PPO Prior Authorization List, Pg 22 Original policy
C9399Unclassified drugs or biologicals [when specified as lifileucel (Amtagvi)] or [when specified as eladocagene exuparvovec- tneq (Kebilidi)] or [when specified as an ocular gene therapy agent other than voretigene neparvovec-rzyl (Luxturna)] or [when specified as etuvetidigene autotemcel (Waskyra)] or [when specified as a gene therapy for hemophilia other than Hemgenix, Beqvez, or Roctavian] or [when describing a product with no specific code indicated as investigational and not medically necessary]California PPO Prior Authorization List, Pg 22 Original policy
C9762Cardiac magnetic resonance imaging for morphology and function, quantification of segmental dysfunction; with strain imagingCalifornia PPO Prior Authorization List, Pg 22 Original policy
C9763Cardiac magnetic resonance imaging for morphology and function, quantification of segmental dysfunction; with stress imagingCalifornia PPO Prior Authorization List, Pg 22 Original policy
C9785Gastric restrictive procedure, endoscopic sleeve gastroplasty, with esophagogastroduodenoscopy and intraluminal tube insertion, if performed, including all system and tissue anchoring componentsCalifornia PPO Prior Authorization List, Pg 22 Original policy
C9796Repair of enterocutaneous fistula small intestine or colon (excluding anorectal fistula) with plug (e.g., porcine small intestine submucosa [sis])California PPO Prior Authorization List, Pg 22 Original policy
C9808Nerve cryoablation probe (e.g., cryoICE, cryosphere, cryosphere max, cryoICE cryosphere, cryoICE cryo2), including probe and all disposable system components, non- opioid medical deviceCalifornia PPO Prior Authorization List, Pg 22 Original policy
C9809Cryoablation needle (e.g., Iovera system), including needle/tip and all disposable system components, non-opioid medical deviceCalifornia PPO Prior Authorization List, Pg 22 Original policy
D9914Administration of dermal fillersCalifornia PPO Prior Authorization List, Pg 22 Original policy
E0218Fluid circulating cold pad with pump, any typeCalifornia PPO Prior Authorization List, Pg 22 Original policy
E0236Pump for water circulating padCalifornia PPO Prior Authorization List, Pg 22 Original policy
E0481Intrapulmonary percussive ventilation system and related accessoriesCalifornia PPO Prior Authorization List, Pg 22 Original policy
E0483High frequency chest wall oscillation system with full anterior and/or posterior thoracic region receiving simultaneous external oscillation, includes all accessories and supplies, eachCalifornia PPO Prior Authorization List, Pg 23 Original policy
E0650Pneumatic compressor, non-segmental home modelCalifornia PPO Prior Authorization List, Pg 23 Original policy
E0651Pneumatic compressor, segmental home model without calibrated gradient pressureCalifornia PPO Prior Authorization List, Pg 23 Original policy

Sources

Disclaimer

The information provided on this page is for general informational purposes only and does not constitute billing, coding, or reimbursement advice. Nothing on this page should be relied upon as a substitute for clinician assessment, professional billing guidance, or as a definitive statement of any payor's billing requirements or policies.

Payor agreements, fee schedules, and billing policies vary and are subject to change. Before submitting any claims related to maternity care services, including claims affected by the 2027 CPT code revisions, please consult the applicable payor agreements, coverage policies, and billing guidelines to confirm current requirements for their specific payor contracts.

Substrate makes no representation or warranty regarding the accuracy, completeness, or timeliness of the payor-specific information presented here. Providers are solely responsible for ensuring that all claims are submitted in accordance with applicable payor requirements, and Substrate assumes no liability for claim denials, underpayments, or other adverse outcomes arising from reliance on this information.

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