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Anthem Blue Cross Blue Shield of California prior authorization, page 18

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
15793Chemical peel, nonfacial; dermalCalifornia PPO Prior Authorization List, Pg 34 Original policy
15820Blepharoplasty, lower eyelidCalifornia PPO Prior Authorization List, Pg 34 Original policy
15821Blepharoplasty, lower eyelid; with extensive herniated fat padCalifornia PPO Prior Authorization List, Pg 34 Original policy
15822Blepharoplasty, upper eyelidCalifornia PPO Prior Authorization List, Pg 34 Original policy
15823Blepharoplasty, upper eyelid; with excessive skin weighting down lidCalifornia PPO Prior Authorization List, Pg 34 Original policy
15824Rhytidectomy; foreheadCalifornia PPO Prior Authorization List, Pg 34 Original policy
15826Rhytidectomy; glabellar frown linesCalifornia PPO Prior Authorization List, Pg 34 Original policy
15830Excision, excessive skin and subcutaneous tissue (includes lipectomy); abdomen, infraumbilical panniculectomyCalifornia PPO Prior Authorization List, Pg 34 Original policy
15847Excision, excessive skin and subcutaneous tissue (includes lipectomy), abdomen (e.g., abdominoplasty) (includes umbilical transposition and fascial plication) (List separately in addition to code for primary procedure)California PPO Prior Authorization List, Pg 34 Original policy
15877Suction assisted lipectomy; trunkCalifornia PPO Prior Authorization List, Pg 34 Original policy
17106Destruction of cutaneous vascular proliferative lesions (e.g., laser technique); less than 10 sq cmCalifornia PPO Prior Authorization List, Pg 34 Original policy
17107Destruction of cutaneous vascular proliferative lesions (e.g., laser technique); 10.0 to 50.0 sq cmCalifornia PPO Prior Authorization List, Pg 34 Original policy
17108Destruction of cutaneous vascular proliferative lesions (e.g., laser technique); over 50.0 sq cmCalifornia PPO Prior Authorization List, Pg 34 Original policy
17380Electrolysis epilation, each 30 minutesCalifornia PPO Prior Authorization List, Pg 34 Original policy
19105Ablation, cryosurgical, of fibroadenoma, including ultrasound guidance, each fibroadenomaCalifornia PPO Prior Authorization List, Pg 34 Original policy
19300Mastectomy for gynecomastiaCalifornia PPO Prior Authorization List, Pg 34 Original policy
19318Breast reductionCalifornia PPO Prior Authorization List, Pg 34 Original policy
20979Low intensity ultrasound stimulation to aid bone healing, noninvasive (nonoperative)California PPO Prior Authorization List, Pg 34 Original policy
20982Ablation, bone tumor(s) (e.g., osteoid osteoma, metastasis) radiofrequency, percutaneous, including computed tomographic guidanceCalifornia PPO Prior Authorization List, Pg 34 Original policy
20983Ablation therapy for reduction or eradication of 1 or more bone tumors (e.g., metastasis) including adjacent soft tissue when involved by tumor extension, percutaneous, including imaging guidance when performed; cryoablationCalifornia PPO Prior Authorization List, Pg 35 Original policy
21120GenioplastyCalifornia PPO Prior Authorization List, Pg 35 Original policy
21121GenioplastyCalifornia PPO Prior Authorization List, Pg 35 Original policy
21122GenioplastyCalifornia PPO Prior Authorization List, Pg 35 Original policy
21123GenioplastyCalifornia PPO Prior Authorization List, Pg 35 Original policy
21125Augmentation, mandibular body or angle; prosthetic materialCalifornia PPO Prior Authorization List, Pg 35 Original policy
21127Augmentation, mandibular body or angle; with bone graft, onlay or interpositional (includes obtaining autograft)California PPO Prior Authorization List, Pg 35 Original policy
21141Reconstruction midface, LeFort ICalifornia PPO Prior Authorization List, Pg 35 Original policy
21142Reconstruction midface, LeFort ICalifornia PPO Prior Authorization List, Pg 35 Original policy
21143Reconstruction midface, LeFort ICalifornia PPO Prior Authorization List, Pg 35 Original policy
21145Reconstruction midface, LeFort ICalifornia PPO Prior Authorization List, Pg 35 Original policy
21146Reconstruction midface, LeFort ICalifornia PPO Prior Authorization List, Pg 35 Original policy
21147Reconstruction midface, LeFort ICalifornia PPO Prior Authorization List, Pg 35 Original policy
21150Reconstruction midface, LeFort IICalifornia PPO Prior Authorization List, Pg 35 Original policy
21193Reconstruction of mandibular rami, horizontal, vertical, C, or L osteotomy; without bone graftCalifornia PPO Prior Authorization List, Pg 35 Original policy
21194Mandibular/Maxillary (Orthognathic) Surgery - Reconstruction of mandibular rami, horizontal, vertical, C or L osteotomy; with bone graftCalifornia PPO Prior Authorization List, Pg 36 Original policy
21195Reconstruction of mandibular rami and/or body, sagittal split; without internal rigid fixationCalifornia PPO Prior Authorization List, Pg 36 Original policy
21196Reconstruction of mandibular rami and/or body, sagittal split; with internal rigid fixationCalifornia PPO Prior Authorization List, Pg 36 Original policy
21198Osteotomy, mandible, segmentalCalifornia PPO Prior Authorization List, Pg 36 Original policy
21199Osteotomy, mandible, segmental; with genioglossus advancementCalifornia PPO Prior Authorization List, Pg 36 Original policy
21206Osteotomy, maxilla, segmental (e.g., Wassmund or Schuchard)California PPO Prior Authorization List, Pg 36 Original policy
21208Osteoplasty, facial bones; augmentation (autograft, allograft, or prosthetic implant)California PPO Prior Authorization List, Pg 36 Original policy
21209Osteoplasty, facial bones; reductionCalifornia PPO Prior Authorization List, Pg 36 Original policy
21210Graft, bone; nasal, maxillary or malar areas (includes obtaining graft)California PPO Prior Authorization List, Pg 36 Original policy
21215Graft, bone; mandible (includes obtaining graft)California PPO Prior Authorization List, Pg 36 Original policy
21244Reconstruction of mandible, extraoral, with transosteal bone plate (e.g., mandibular staple bone plate)California PPO Prior Authorization List, Pg 36 Original policy
21245Reconstruction of mandible or maxilla, subperiosteal implant; partialCalifornia PPO Prior Authorization List, Pg 36 Original policy
21246Reconstruction of mandible or maxilla, subperiosteal implant; completeCalifornia PPO Prior Authorization List, Pg 36 Original policy
21685Hyoid myotomy and suspensionCalifornia PPO Prior Authorization List, Pg 36 Original policy
22505Manipulation of the spine requiring anesthesia, any regionCalifornia PPO Prior Authorization List, Pg 36 Original policy
22526Percutaneous intradiscal electrothermal annuloplasty [IDET], unilateral or bilateral including fluoroscopic guidance; single levelCalifornia PPO Prior Authorization List, Pg 36 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.

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