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Anthem Blue Cross Blue Shield of California prior authorization, page 16

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
Q4396Natalin, per square centimeterCalifornia PPO Prior Authorization List, Pg 30 Original policy
Q4397Summit AAA, per square centimeterCalifornia PPO Prior Authorization List, Pg 30 Original policy
Q4398Summit AC, per square centimeterCalifornia PPO Prior Authorization List, Pg 30 Original policy
Q4399Summit FX, per square centimeterCalifornia PPO Prior Authorization List, Pg 30 Original policy
Q4400Polygon3 membrane, per square centimeterCalifornia PPO Prior Authorization List, Pg 30 Original policy
Q4401Absolv3 membrane, per square centimeterCalifornia PPO Prior Authorization List, Pg 30 Original policy
Q4402Xwrap 2.0, per square centimeterCalifornia PPO Prior Authorization List, Pg 30 Original policy
Q4403Xwrap Dual Plus, per square centimeterCalifornia PPO Prior Authorization List, Pg 30 Original policy
Q4404Xwrap Hydro Plus, per square centimeterCalifornia PPO Prior Authorization List, Pg 30 Original policy
Q4405Xwrap Fenestra Plus, per square centimeterCalifornia PPO Prior Authorization List, Pg 30 Original policy
Q4406Xwrap Fenestra, per square centimeterCalifornia PPO Prior Authorization List, Pg 30 Original policy
Q4407Xwrap Tribus, per square centimeterCalifornia PPO Prior Authorization List, Pg 30 Original policy
Q4408Xwrap Hydro, per square centimeterCalifornia PPO Prior Authorization List, Pg 30 Original policy
Q4409AmnioMatrixF3X, per square centimeterCalifornia PPO Prior Authorization List, Pg 30 Original policy
Q4411AmnioMatrixF4X, per square centimeterCalifornia PPO Prior Authorization List, Pg 30 Original policy
Q4412Choriofix, per square centimeterCalifornia PPO Prior Authorization List, Pg 30 Original policy
Q4413Cygnus Solo, per square centimeterCalifornia PPO Prior Authorization List, Pg 30 Original policy
Q4414SimpliChor, per square centimeterCalifornia PPO Prior Authorization List, Pg 30 Original policy
Q4415AlexiGuard SL-T, per square centimeterCalifornia PPO Prior Authorization List, Pg 30 Original policy
Q4416AlexiGuard TL-T, per square centimeterCalifornia PPO Prior Authorization List, Pg 30 Original policy
Q4417AlexiGuard DL-T, per square centimeterCalifornia PPO Prior Authorization List, Pg 30 Original policy
Q4418BioLab Membrane Wrap Flow, per square centimeterCalifornia PPO Prior Authorization List, Pg 30 Original policy
Q4419BioLab Membrane Wrap Lite Flow, per square centimeterCalifornia PPO Prior Authorization List, Pg 30 Original policy
Q4420Nuform, per square centimeterCalifornia PPO Prior Authorization List, Pg 30 Original policy
Q4421BioLab Membrane Wrap Solo, per square centimeterCalifornia PPO Prior Authorization List, Pg 30 Original policy
Q4422A/C wrap, per square centimeterCalifornia PPO Prior Authorization List, Pg 30 Original policy
Q4423BioLab Tri-Membrane Wrap Flow, per square centimeterCalifornia PPO Prior Authorization List, Pg 30 Original policy
Q4424Revive FT, per square centimeterCalifornia PPO Prior Authorization List, Pg 30 Original policy
Q4425Revive TL, per square centimeterCalifornia PPO Prior Authorization List, Pg 30 Original policy
Q4426DermaBind TL + or Dermabind TL X, per square centimeterCalifornia PPO Prior Authorization List, Pg 30 Original policy
Q4427DermaBind DL N or DermaBind DL + or DermaBind DL X, per square centimeterCalifornia PPO Prior Authorization List, Pg 30 Original policy
Q4428DermaBind SL N or DermaBind SL + or DermaBind SL X, per square centimeterCalifornia PPO Prior Authorization List, Pg 30 Original policy
Q4429DermaBind CH N or DermaBind CH X, per square centimeterCalifornia PPO Prior Authorization List, Pg 30 Original policy
Q4435Renati membrane, per square centimeterCalifornia PPO Prior Authorization List, Pg 30 Original policy
Q4436Renati AC membrane, per square centimeterCalifornia PPO Prior Authorization List, Pg 30 Original policy
Q4437Revival AC, per square centimeterCalifornia PPO Prior Authorization List, Pg 30 Original policy
Q4438Pretect, per square centimeterCalifornia PPO Prior Authorization List, Pg 30 Original policy
Q4439InstaGraft, per square centimeterCalifornia PPO Prior Authorization List, Pg 30 Original policy
Q4440Curamatrix, per square centimeterCalifornia PPO Prior Authorization List, Pg 30 Original policy
S2053Transplantation of small intestine and liver allograftsCalifornia PPO Prior Authorization List, Pg 30 Original policy
S2054Transplantation of multivisceral organsCalifornia PPO Prior Authorization List, Pg 30 Original policy
S2055Harvesting of donor multivisceral organs, with preparation and maintenance of allografts; from cadaver donorCalifornia PPO Prior Authorization List, Pg 30 Original policy
S2060Lobar lung transplantationCalifornia PPO Prior Authorization List, Pg 30 Original policy
S2061Donor lobectomy (lung) for transplantation, living donorCalifornia PPO Prior Authorization List, Pg 30 Original policy
S2065Simultaneous pancreas kidney transplantationCalifornia PPO Prior Authorization List, Pg 30 Original policy
S2066Breast reconstruction with gluteal artery perforator (GAP) flap, including harvesting of the flap, microvascular transfer, closure of donor site and shaping the flap into a breast, unilateralCalifornia PPO Prior Authorization List, Pg 30 Original policy
S2067Breast reconstruction of a single breast with "stacked" deep inferior epigastric perforator (DIEP) flap(s) and/or gluteal artery perforator (GAP) flap(s), including harvesting of the flap(s), microvascular transfer, closure of donor site(s) and shaping the flap into a breast, unilateralCalifornia PPO Prior Authorization List, Pg 30 Original policy
S2068Breast reconstruction with deep inferior epigastric perforator (DIEP) flap or superficial inferior epigastric artery (SIEA) flap, including harvesting of the flap, microvascular transfer, closure of donor site and shaping the flap into a breast, unilateralCalifornia PPO Prior Authorization List, Pg 30 Original policy
S2102Islet cell tissue transplant from pancreas, allogeneicCalifornia PPO Prior Authorization List, Pg 30 Original policy
S2103Adrenal tissue transplant to brainCalifornia PPO Prior Authorization List, Pg 30 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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