Anthem Blue Cross Blue Shield of California prior authorization, page 17
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 |
|---|---|---|
| S2142 | Cord blood-derived stem cell transplantation, allogeneic | California PPO Prior Authorization List, Pg 31 Original policy |
| S2150 | Bone marrow or blood-derived peripheral stem cells (peripheral or umbilical), allogeneic or autologous, harvesting, transplantation, and related complications; including pheresis and cell preparation/storage, marrow ablative therapy, drugs, supplies, hospitalization with outpatient follow-up, medical/surgical, diagnostic, emergency, and rehabilitative services, and the number of days of pre- and post-transplant care in the global definition | California PPO Prior Authorization List, Pg 31 Original policy |
| S5108 | Home care training to home care client, per 15 minutes | California PPO Prior Authorization List, Pg 31 Original policy |
| S5110 | Home care training, family; per 15 minutes | California PPO Prior Authorization List, Pg 31 Original policy |
| S9002 | Intra-vaginal motion sensor system, provides biofeedback for pelvic floor muscle rehabilitation device | California PPO Prior Authorization List, Pg 31 Original policy |
| S9090 | Vertebral axial decompression, per session | California PPO Prior Authorization List, Pg 31 Original policy |
| S9123 | Nursing care in the home ; by registered nurse, per hour (use for general nursing care only, not to be used when CPT codes 99500-99602 can be used) | California PPO Prior Authorization List, Pg 31 Original policy |
| S9124 | Nursing care in the home; by licensed practical nurse, per hour | California PPO Prior Authorization List, Pg 31 Original policy |
| S9960 | Ambulance service, conventional air services, nonemergency transport, one way (fixed wing) | California PPO Prior Authorization List, Pg 31 Original policy |
| S9961 | Ambulance service, conventional air service, nonemergency transport, one way (rotary wing) | California PPO Prior Authorization List, Pg 31 Original policy |
| T1000 | Private duty/independent nursing service(s), licensed, up to 15 minutes | California PPO Prior Authorization List, Pg 31 Original policy |
| T1002 | RN services, up to 15 minutes | California PPO Prior Authorization List, Pg 31 Original policy |
| T1003 | LPN/LVN services, up to 15 minutes | California PPO Prior Authorization List, Pg 31 Original policy |
| T1030 | Nursing care, in the home, by registered nurse, per diem | California PPO Prior Authorization List, Pg 31 Original policy |
| T1031 | Nursing care, in the home, by licensed practical nurse, per diem | California PPO Prior Authorization List, Pg 31 Original policy |
| T2036 | Therapeutic camping, overnight, waiver; each session | California PPO Prior Authorization List, Pg 31 Original policy |
| T2037 | Therapeutic camping, day, waiver; each session | California PPO Prior Authorization List, Pg 31 Original policy |
| 11920 | Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation | California PPO Prior Authorization List, Pg 32 Original policy |
| 11921 | Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation | California PPO Prior Authorization List, Pg 32 Original policy |
| 11922 | Tattooing, intradermal introduction of insoluble opaque pigments to correct color defects of skin, including micropigmentation | California PPO Prior Authorization List, Pg 32 Original policy |
| 14040 | Adjacent tissue transfer or rearrangement, forehead, cheeks chin, mouth, neck, axillae, genitalia, hands and/or feet | California PPO Prior Authorization List, Pg 32 Original policy |
| 14041 | Adjacent tissue transfer or rearrangement, forehead, cheeks chin, mouth, neck, axillae, genitalia, hands and/or feet | California PPO Prior Authorization List, Pg 32 Original policy |
| 14060 | Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips | California PPO Prior Authorization List, Pg 32 Original policy |
| 14061 | Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips | California PPO Prior Authorization List, Pg 32 Original policy |
| 15150 | Tissue cultured skin autograft, trunk, arms, legs; first 25 sq cm or less | California PPO Prior Authorization List, Pg 32 Original policy |
| 15151 | Tissue cultured skin autograft, trunk, arms, legs; additional 1 sq cm to 75 sq cm | California PPO Prior Authorization List, Pg 32 Original policy |
| 15152 | Tissue cultured skin autograft, trunk, arms, legs; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof | California PPO Prior Authorization List, Pg 32 Original policy |
| 15155 | Tissue cultured skin autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; first 25 sq cm or less | California PPO Prior Authorization List, Pg 32 Original policy |
| 15156 | Tissue cultured skin autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; additional 1 sq cm to 75 sq cm | California PPO Prior Authorization List, Pg 32 Original policy |
| 15157 | Tissue cultured skin autograft, face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits; each additional 100 sq cm, or each additional 1% of body area of infants and children, or part thereof | California PPO Prior Authorization List, Pg 32 Original policy |
| 15271 | Application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area | California PPO Prior Authorization List, Pg 32 Original policy |
| 15272 | Application of skin substitute graft to trunk, arms, legs, total 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 32 Original policy |
| 15273 | Application of skin substitute graft to trunk, arms, legs, total wound surface area 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 33 Original policy |
| 15274 | Application of skin substitute graft to trunk, arms, legs, total wound surface area 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 33 Original policy |
| 15275 | Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area | California PPO Prior Authorization List, Pg 33 Original policy |
| 15276 | Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total 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 33 Original policy |
| 15277 | Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area 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 33 Original policy |
| 15278 | Application of skin substitute graft to face, scalp, eyelids, mouth, neck, ears, orbits, genitalia, hands, feet, and/or multiple digits, total wound surface area 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 33 Original policy |
| 15775 | Punch graft for hair transplant; 1 to 15 punch grafts | California PPO Prior Authorization List, Pg 33 Original policy |
| 15776 | Punch graft for hair transplant; more than 15 punch grafts | California PPO Prior Authorization List, Pg 33 Original policy |
| 15777 | Implantation of biologic implant (e.g., acellular dermal matrix) for soft tissue reinforcement (i.e., breast, trunk) | California PPO Prior Authorization List, Pg 33 Original policy |
| 15780 | Dermabrasion; total face (e.g., for acne scarring, fine wrinkling, rhytids, general keratosis) | California PPO Prior Authorization List, Pg 33 Original policy |
| 15781 | Dermabrasion; segmental, face | California PPO Prior Authorization List, Pg 33 Original policy |
| 15782 | Dermabrasion; regional, other than face | California PPO Prior Authorization List, Pg 33 Original policy |
| 15783 | Dermabrasion; superficial, any site (e.g., tattoo removal) | California PPO Prior Authorization List, Pg 33 Original policy |
| 15786 | Abrasion; single lesion | California PPO Prior Authorization List, Pg 33 Original policy |
| 15787 | Abrasion (lesions) | California PPO Prior Authorization List, Pg 33 Original policy |
| 15788 | Chemical peel, facial; epidermal | California PPO Prior Authorization List, Pg 33 Original policy |
| 15789 | Chemical peel, facial; epidermal | California PPO Prior Authorization List, Pg 33 Original policy |
| 15792 | Chemical peel, nonfacial; epidermal | California PPO Prior Authorization List, Pg 33 Original policy |