Anthem Blue Cross Blue Shield of California prior authorization, page 19
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 |
|---|---|---|
| 22527 | Percutaneous intradiscal electrothermal annuloplasty [IDET], unilateral or bilateral including fluoroscopic guidance; 1 or more additional levels | California PPO Prior Authorization List, Pg 37 Original policy |
| 22586 | Arthrodesis, pre-sacral interbody technique, including disc space preparation, discectomy, with posterior instrumentation, with image guidance, includes bone graft when performed, L5- S1 interspace | California PPO Prior Authorization List, Pg 37 Original policy |
| 22867 | Insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; single level | California PPO Prior Authorization List, Pg 37 Original policy |
| 22868 | Insertion of interlaminar/interspinous process stabilization/distraction device, without fusion, including image guidance when performed, with open decompression, lumbar; second level (List separately in addition to code for primary procedure) | California PPO Prior Authorization List, Pg 37 Original policy |
| 22869 | Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; single level | California PPO Prior Authorization List, Pg 37 Original policy |
| 22870 | Insertion of interlaminar/interspinous process stabilization/distraction device, without open decompression or fusion, including image guidance when performed, lumbar; second level (List separately in addition to code for primary procedure) | California PPO Prior Authorization List, Pg 37 Original policy |
| 28890 | Extracorporeal shock wave, high energy, performed by a physician or other qualified health care professional, requiring anesthesia other than local, including ultrasound guidance, involving the plantar fascia | California PPO Prior Authorization List, Pg 37 Original policy |
| 24300 | Manipulation, elbow, under anesthesia | California PPO Prior Authorization List, Pg 37 Original policy |
| 25259 | Manipulation, wrist, under anesthesia | California PPO Prior Authorization List, Pg 37 Original policy |
| 26340 | Manipulation, finger joint, under anesthesia, each joint | California PPO Prior Authorization List, Pg 37 Original policy |
| 27275 | Manipulation, hip joint, requiring general anesthesia | California PPO Prior Authorization List, Pg 37 Original policy |
| 27860 | Manipulation of ankle under general anesthesia (includes application of traction or other fixation apparatus) | California PPO Prior Authorization List, Pg 37 Original policy |
| 30468 | Repair of nasal valve collapse with subcutaneous/submucosal lateral wall implant(s) | California PPO Prior Authorization List, Pg 37 Original policy |
| 30469 | Repair of nasal valve collapse with low energy, temperature- controlled (i.e., radiofrequency) subcutaneous/submucosal remodeling | California PPO Prior Authorization List, Pg 37 Original policy |
| 30520 | Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft | California PPO Prior Authorization List, Pg 37 Original policy |
| 30620 | Septal or other intranasal dermatoplasty (does not include obtaining graft) | California PPO Prior Authorization List, Pg 37 Original policy |
| 31660 | Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial thermoplasty, 1 lobe | California PPO Prior Authorization List, Pg 37 Original policy |
| 31661 | Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with bronchial thermoplasty, 2 or more lobes | California PPO Prior Authorization List, Pg 37 Original policy |
| 32994 | Ablation therapy for reduction or eradication of 1 or more pulmonary tumor(s) including pleura or chest wall when involved by tumor extension, percutaneous, including imaging | California PPO Prior Authorization List, Pg 37 Original policy |
| 32998 | Ablation therapy for reduction or eradication of 1 or more pulmonary tumor(s) including pleura or chest wall when involved by tumor extension, percutaneous, radiofrequency, unilateral | California PPO Prior Authorization List, Pg 37 Original policy |
| 33208 | Insertion or replacement of permanent pacemaker with transvenous electrode(s); atrial and ventricular | California PPO Prior Authorization List, Pg 37 Original policy |
| 33214 | Upgrade of implanted pacemaker system, conversion of single chamber system to dual chamber system (includes removal of previously placed pulse generator, testing of existing lead, insertion of new lead, insertion of new pulse generator) | California PPO Prior Authorization List, Pg 38 Original policy |
| 33216 | Insertion of a transvenous electrode; single chamber (1 electrode) permanent pacemaker or single chamber pacing cardioverter-defibrillator | California PPO Prior Authorization List, Pg 38 Original policy |
| 33217 | Insertion of a transvenous electrode; dual chamber (2 electrodes) permanent pacemaker or dual chamber pacing cardioverter-defibrillator | California PPO Prior Authorization List, Pg 38 Original policy |
| 33224 | Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, with attachment to previously placed pacemaker or pacing cardioverter- defibrillator pulse generator (including revision of pocket, removal, insertion, and/or replacement of existing generator) | California PPO Prior Authorization List, Pg 38 Original policy |
| 33226 | Repositioning of previously implanted cardiac venous system (left ventricular) electrode (including removal, insertion and/or replacement of generator) | California PPO Prior Authorization List, Pg 38 Original policy |
| 33228 | Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator; dual lead system | California PPO Prior Authorization List, Pg 38 Original policy |
| 33229 | Removal of permanent pacemaker pulse generator with replacement of pacemaker pulse generator; multiple lead system | California PPO Prior Authorization List, Pg 38 Original policy |
| 33230 | Insertion of implantable defibrillator pulse generator only; with existing dual leads | California PPO Prior Authorization List, Pg 38 Original policy |
| 33231 | Insertion of implantable defibrillator pulse generator only; with existing multiple leads | California PPO Prior Authorization List, Pg 38 Original policy |
| 33240 | Insertion of single or dual chamber pacing cardioverter- defibrillator pulse generator | California PPO Prior Authorization List, Pg 38 Original policy |
| 33249 | Insertion or repositioning of electrode lead(s) for single or dual chamber pacing cardioverter-defibrillator and insertion of pulse generator | California PPO Prior Authorization List, Pg 38 Original policy |
| 33263 | Removal of implantable defibrillator pulse generator with replacement of implantable defibrillator pulse generator; dual lead system | California PPO Prior Authorization List, Pg 38 Original policy |
| 33264 | Removal of implantable defibrillator pulse generator with replacement of implantable defibrillator pulse generator; multiple lead system | California PPO Prior Authorization List, Pg 38 Original policy |
| 33270 | Insertion or replacement of permanent subcutaneous implantable defibrillator system, with subcutaneous electrode, including defibrillation threshold evaluation, induction of arrhythmia, evaluation of sensing for arrhythmia termination, and programming or reprogramming of sensing or therapeutic parameters, when performed | California PPO Prior Authorization List, Pg 38 Original policy |
| 33271 | Insertion of subcutaneous implantable defibrillator electrode | California PPO Prior Authorization List, Pg 38 Original policy |
| 33274 | Transcatheter insertion or replacement of permanent leadless pacemaker, right ventricular, including imaging guidance (e.g., fluoroscopy, venous ultrasound, ventriculography, femoral venography) and device evaluation (e.g., interrogation or programming), when performed | California PPO Prior Authorization List, Pg 38 Original policy |
| 33275 | Transcatheter removal of permanent leadless pacemaker, right ventricular, including imaging guidance (e.g., fluoroscopy, venous ultrasound, ventriculography, femoral venography), when performed | California PPO Prior Authorization List, Pg 38 Original policy |
| 33289 | Transcatheter implantation of wireless pulmonary artery pressure sensor for long-term hemodynamic monitoring, including deployment and calibration of the sensor, right heart catheterization, selective pulmonary catheterization, radiological supervision and interpretation, and pulmonary artery angiography, when performed | California PPO Prior Authorization List, Pg 39 Original policy |
| 36260 | Insertion of implantable intra-arterial infusion pump (e.g., for chemotherapy of liver) | California PPO Prior Authorization List, Pg 39 Original policy |
| 36261 | Revision of implanted intra-arterial infusion pump [when specified as replacement] | California PPO Prior Authorization List, Pg 39 Original policy |
| 36563 | Insertion of tunneled centrally inserted central venous access device with subcutaneous pump | California PPO Prior Authorization List, Pg 39 Original policy |
| 36583 | Replacement, complete, of a tunneled centrally inserted central venous access device, with subcutaneous pump, through same venous access | California PPO Prior Authorization List, Pg 39 Original policy |
| 37238 | Transcatheter placement of an intravascular stent(s), open or percutaneous, including radiological supervision and interpretation and including angioplasty within the same vessel, when performed; initial vein | California PPO Prior Authorization List, Pg 39 Original policy |
| 37239 | Transcatheter placement of an intravascular stent(s), open or percutaneous, including radiological supervision and interpretation and including angioplasty within the same vessel, when performed; each additional vein | California PPO Prior Authorization List, Pg 39 Original policy |
| 37248 | Transluminal balloon angioplasty (except dialysis circuit), open or percutaneous, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty within the same vein; initial vein | California PPO Prior Authorization List, Pg 39 Original policy |
| 37249 | Transluminal balloon angioplasty (except dialysis circuit), open or percutaneous, including all imaging and radiological supervision and interpretation necessary to perform the angioplasty within the same vein; each additional vein | California PPO Prior Authorization List, Pg 39 Original policy |
| 41512 | Tongue base suspension, permanent suture technique | California PPO Prior Authorization List, Pg 39 Original policy |
| 41530 | Submucosal ablation of the tongue base, radiofrequency, 1 or more sites, per session | California PPO Prior Authorization List, Pg 39 Original policy |
| 42145 | Palatopharyngoplasty (e.g., uvulopalatopharyngoplasty, uvulopharyngoplasty) | California PPO Prior Authorization List, Pg 39 Original policy |