Anthem Blue Cross Blue Shield of California prior authorization, page 12
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 |
|---|---|---|
| E1230 | Power operated vehicle (three- or four-wheel nonhighway) - specify brand name and model number | California PPO Prior Authorization List, Pg 24 Original policy |
| E1239 | Power wheelchair, pediatric size, not otherwise specified | California PPO Prior Authorization List, Pg 24 Original policy |
| E1399 | Durable medical equipment, miscellaneous | California PPO Prior Authorization List, Pg 24 Original policy |
| E1801 | Static progressive stretch/patient actualized serial stretch elbow device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories | California PPO Prior Authorization List, Pg 24 Original policy |
| E1806 | Static progressive stretch wrist device, flexion and/or extension, with or without range of motion adjustment, includes all components and accessories | California PPO Prior Authorization List, Pg 24 Original policy |
| E1811 | Static progressive stretch/patient actualized serial stretch knee device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories | California PPO Prior Authorization List, Pg 24 Original policy |
| E1816 | Static progressive stretch/patient actualized serial stretch ankle device, flexion and/or extension, with or without range of motion adjustment, includes all components and accessories | California PPO Prior Authorization List, Pg 24 Original policy |
| E1841 | Static progressive stretch/patient actualized serial stretch shoulder device, with or without range of motion adjustment, includes all components and accessories | California PPO Prior Authorization List, Pg 24 Original policy |
| E2298 | Complex rehabilitative power wheelchair accessory, power seat elevation system, any type | California PPO Prior Authorization List, Pg 24 Original policy |
| E3200 | Gait modulation system, rhythmic auditory stimulation, including restricted therapy software, all components and accessories, prescription only | California PPO Prior Authorization List, Pg 24 Original policy |
| G0176 | Activity therapy, such as music, dance, art or play therapies not for recreation, related to the care and treatment of patient’s disabling mental health problems, per session (45 minutes or more) | California PPO Prior Authorization List, Pg 24 Original policy |
| G0341 | Percutaneous islet cell transplant, includes portal vein catheterization and infusion | California PPO Prior Authorization List, Pg 24 Original policy |
| G0342 | Laparoscopy for islet cell transplant, includes portal vein catheterization and infusion | California PPO Prior Authorization List, Pg 24 Original policy |
| G0343 | Laparotomy for islet cell transplant, includes portal vein catheterization and infusion | California PPO Prior Authorization List, Pg 24 Original policy |
| G0460 | Autologous platelet rich plasma or other blood-derived product for non-diabetic chronic wounds/ulcers, including as applicable phlebotomy, centrifugation or mixing, and all other preparatory procedures, administration and dressings, per treatment | California PPO Prior Authorization List, Pg 25 Original policy |
| G0465 | Autologous platelet rich plasma (PRP) or other blood-derived products for diabetic chronic wounds/ulcers, using an FDA- cleared device for this indication (includes as applicable administration, dressings, phlebotomy, centrifugation or mixing, and all other preparatory procedures, per treatment) | California PPO Prior Authorization List, Pg 25 Original policy |
| G0681 | Application of a premarket approval (PMA), 510(k), 361 human cells, tissues or cellular and tissue-based products (HCT/P) non-sheet form skin substitute for a wound surface area up to 100 sq cm; first 25 sq cm or less of wound surface area | California PPO Prior Authorization List, Pg 25 Original policy |
| G0682 | Application of a premarket approval (PMA), 510(k), 361 human cells, tissues or cellular and tissue-based products (HCT/P) non-sheet form skin substitute for a wound surface area up to 100 sq cm; each additional 25 sq cm wound surface area, or part thereof | California PPO Prior Authorization List, Pg 25 Original policy |
| G0683 | Application of a premarket approval (PMA), 510(k), 361 human cells, tissues or cellular and tissue-based products (HCT/P) non-sheet form skin substitute graft for a wound surface greater than or equal to 100 sq cm; first 100 sq cm wound surface area, or 1% of body area of infants and children | California PPO Prior Authorization List, Pg 25 Original policy |
| G0684 | Application of a premarket approval (PMA), 510(k), 361 human cells, tissues or cellular and tissue-based products (HCT/P) non-sheet form skin substitute graft for a wound surface greater than or equal to 100 sq cm; each additional 100 sq cm wound surface area or part thereof, or each additional 1% of body area of infants and children, or part thereof | California PPO Prior Authorization List, Pg 25 Original policy |
| G9012 | Other specified case management services not elsewhere classified | California PPO Prior Authorization List, Pg 25 Original policy |
| H0004 | Behavioral health counseling and therapy, per 15 minutes | California PPO Prior Authorization List, Pg 25 Original policy |
| H0006 | Alcohol and/or drug services; case management | California PPO Prior Authorization List, Pg 25 Original policy |
| H0023 | Behavioral health outreach service (planned approach to reach a targeted population) | California PPO Prior Authorization List, Pg 25 Original policy |
| H0031 | Mental health assessment by non-physician [when specified as functional assessment and treatment plan developed for Adaptive Behavioral Treatment (ABT) services by a Qualified Autism Service Provider (licensed clinician or Board Certified Behavioral Analyst (BCBA)] | California PPO Prior Authorization List, Pg 25 Original policy |
| H0032 | Mental health service plan development by non-physician [when specified as supervision of a Qualified Autism Service Professional or Paraprofessional by a Qualified Autism Service Provider] | California PPO Prior Authorization List, Pg 25 Original policy |
| H0036 | Community psychiatric supportive treatment, face-to-face, per 15 minutes | California PPO Prior Authorization List, Pg 25 Original policy |
| H0046 | Mental health services, not otherwise specified [when specified as direct ABT services by a Qualified Autism Service Professional] | California PPO Prior Authorization List, Pg 25 Original policy |
| H2012 | Behavioral health day treatment, per hour [when specified as direct ABT services by a Qualified Autism Service Provider] | California PPO Prior Authorization List, Pg 25 Original policy |
| H2014 | Skills training and development, per 15 minutes [when specified as skill development, social skills group activity] | California PPO Prior Authorization List, Pg 25 Original policy |
| H2015 | Comprehensive community support services, per 15 minutes | California PPO Prior Authorization List, Pg 25 Original policy |
| H2019 | Therapeutic behavioral services, per 15 minutes [when specified as direct ABT services by a Qualified Autism Service Paraprofessional] | California PPO Prior Authorization List, Pg 25 Original policy |
| H2020 | Therapeutic behavioral services, per diem | California PPO Prior Authorization List, Pg 25 Original policy |
| J1411 | Etranacogene dezaparvovec-drlb (Hemgenix) | California PPO Prior Authorization List, Pg 25 Original policy |
| J1412 | Injection, valoctocogene roxaparvovec-rvox, per mL, containing nominal 2 × 10^13 vector genomes (Roctavian) | California PPO Prior Authorization List, Pg 25 Original policy |
| J1413 | Injection, delandistrogene moxeparvovec-rokl, per therapeutic dose (ELEVIDYS) | California PPO Prior Authorization List, Pg 26 Original policy |
| J1414 | Fidanacogene elaparvovec-dzkt (Beqvez) | California PPO Prior Authorization List, Pg 26 Original policy |
| J3386 | Etuvetidigene autotemcel (Waskyra) | California PPO Prior Authorization List, Pg 26 Original policy |
| J3387 | Elivaldogene autotemcel (Skysona) | California PPO Prior Authorization List, Pg 26 Original policy |
| J3389 | Prademagene zamikeracel (Zevaskyn) | California PPO Prior Authorization List, Pg 26 Original policy |
| J3392 | Injection, exagamglogene autotemcel, per treatment (Casgevy) | California PPO Prior Authorization List, Pg 26 Original policy |
| J3393 | Injection, betibeglogene autotemcel, per treatment (Zynteglo) | California PPO Prior Authorization List, Pg 26 Original policy |
| J3394 | Injection, lovotibeglogene autotemcel, per treatment (Lyfgenia) | California PPO Prior Authorization List, Pg 26 Original policy |
| J3398 | Injection, voretigene neparvovec-rzyl, 1 billion vector genomes [Luxturna] | California PPO Prior Authorization List, Pg 26 Original policy |
| J3399 | Injection, onasemnogene abeparvovec-xioi, per treatment, up to 5x1015 vector genomes [Zolgensma] | California PPO Prior Authorization List, Pg 26 Original policy |
| J3391 | Injection, atidarsagene autotemcel, per treatment [Lenmeldy] | California PPO Prior Authorization List, Pg 26 Original policy |
| J3402 | Injection, remestemcel-L-rknd, per therapeutic dose [Ryoncil] | California PPO Prior Authorization List, Pg 26 Original policy |
| J3403 | Revakinagene taroretcel-lwey, per implant [Encelto] | California PPO Prior Authorization List, Pg 26 Original policy |
| J3405 | Itvisma (onasemnogene abeparvovec-brve) | California PPO Prior Authorization List, Pg 26 Original policy |
| J3406 | Injection, omidubicel-onlv, per therapeutic dose | California PPO Prior Authorization List, Pg 26 Original policy |