Anthem Blue Cross Blue Shield of California prior authorization, page 2
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 |
|---|---|---|
| 21172 | Reconstruction superior-lateral orbital rim and lower forehead, advancement or alteration, with or without grafts (includes obtaining autografts) | California PPO Prior Authorization List, Pg 3 Original policy |
| 21175 | Reconstruction, bifrontal, superior-lateral orbital rims and lower forehead, advancement or alteration (e.g., plagiocephaly, trigonocephaly, brachycephaly), with or without grafts (includes obtaining autografts) | California PPO Prior Authorization List, Pg 3 Original policy |
| 21179 | Reconstruction, entire or majority of forehead and/or supraorbital rims | California PPO Prior Authorization List, Pg 3 Original policy |
| 21180 | Reconstruction, entire or majority of forehead and/or supraorbital rims | California PPO Prior Authorization List, Pg 3 Original policy |
| 21182 | Reconstruction of orbital walls, rims, forehead, nasoethmoid complex following intra-and extracranial excision of benign tumor of cranial bone (e.g., fibrous dysplasia), with multiple autografts (includes obtaining grafts) | California PPO Prior Authorization List, Pg 3 Original policy |
| 21183 | Reconstruction of orbital walls, rims, forehead, nasoethmoid complex following intra-and extracranial excision of benign tumor of cranial bone (e.g., fibrous dysplasia), with multiple autografts (includes obtaining grafts) | California PPO Prior Authorization List, Pg 3 Original policy |
| 21188 | Reconstruction midface, osteotomies (other than LeFort type) and bone grafts (includes obtaining autografts) | California PPO Prior Authorization List, Pg 3 Original policy |
| 21230 | Graft; rib cartilage, autogenous, to face, chin, nose or ear (includes obtaining graft) | California PPO Prior Authorization List, Pg 3 Original policy |
| 21235 | Graft; ear cartilage, autogenous, to nose or ear (includes obtaining graft) | California PPO Prior Authorization List, Pg 3 Original policy |
| 21247 | Reconstruction of mandibular condyle with bone and cartilage autografts (includes obtaining grafts) (e.g., for hemifacial microsomia) | California PPO Prior Authorization List, Pg 3 Original policy |
| 21255 | Reconstruction of zygomatic arch and glenoid fossa with bone and cartilage (includes obtaining autografts) | California PPO Prior Authorization List, Pg 3 Original policy |
| 21256 | Reconstruction of orbit with osteotomies (extracranial) and with bone grafts (includes obtaining autografts) (e.g., micro- ophthalmia) | California PPO Prior Authorization List, Pg 3 Original policy |
| 21270 | Malar augmentation, prosthetic material | California PPO Prior Authorization List, Pg 3 Original policy |
| 21275 | Secondary revision of orbitocraniofacial reconstruction | California PPO Prior Authorization List, Pg 3 Original policy |
| 21740 | Reconstructive repair of pectus excavatum or carinatum; open | California PPO Prior Authorization List, Pg 3 Original policy |
| 21742 | Reconstructive repair of pectus excavatum or carinatum; minimally invasive approach (Nuss procedure), without thoracoscopy | California PPO Prior Authorization List, Pg 3 Original policy |
| 21743 | Reconstructive repair of pectus excavatum or carinatum; minimally invasive approach (Nuss procedure), with thoracoscopy | California PPO Prior Authorization List, Pg 3 Original policy |
| 22899 | Unlisted procedure, spine [when specified as percutaneous intradiscal radiofrequency thermocoagulation (PIRFT) or intradiscal biacuplasty (IDB)] or [when specified as a percutaneous or endoscopic procedure for decompression for example DTRAX cage procedure] or [when specified as insertion of a dynamic intervertebral pedicle-based stabilization device] or [when specified as pre-sacral interbody arthrodesis lumbar. L4-L5 interspace with instrumentation, or pre-sacral interbody arthrodesis L4-L5 or L5-S1 interspace without instrumentation] or [when specified as insertion of a non-pedicle interspinous process fixation device] | California PPO Prior Authorization List, Pg 4 Original policy |
| 22999 | Unlisted procedure, abdomen, musculoskeletal system [when specified as repair of diastasis recti] | California PPO Prior Authorization List, Pg 4 Original policy |
| 27599 | Unlisted procedure, femur or knee [when specified as implantation of a medial knee implanted shock absorber] or [when specified as implantation of RETHYMIC into quadriceps muscle] | California PPO Prior Authorization List, Pg 4 Original policy |
| 28899 | Unlisted procedure, foot or toes [when specified as cryoablation of plantar fasciitis or plantar fibroma] or [when specified as subtalar arthroereisis] | California PPO Prior Authorization List, Pg 4 Original policy |
| 29999 | Unlisted procedure, arthroscopy [when specified as a tendon repair using BioBrace implant] or [when specified as thermal capsulorrhaphy of shoulder; elbow, wrist, hip, knee or ankle] or [when specified as surgery using Coblation technology] | California PPO Prior Authorization List, Pg 4 Original policy |
| 30120 | Excision or surgical planing of skin of nose for rhinophyma | California PPO Prior Authorization List, Pg 4 Original policy |
| 30400 | Rhinoplasty, primary; lateral and alar cartilages and/or elevation of nasal tip | California PPO Prior Authorization List, Pg 4 Original policy |
| 30410 | Rhinoplasty, primary; complete, external parts including bony pyramid, lateral and alar cartilages, and/or elevation of nasal tip | California PPO Prior Authorization List, Pg 4 Original policy |
| 30420 | Rhinoplasty, primary; including major septal repair | California PPO Prior Authorization List, Pg 4 Original policy |
| 30430 | Rhinoplasty, secondary; minor revision (small amount of nasal tip work) | California PPO Prior Authorization List, Pg 4 Original policy |
| 30435 | Rhinoplasty, secondary; intermediate revision (bony work with osteotomies) | California PPO Prior Authorization List, Pg 4 Original policy |
| 30450 | Rhinoplasty, secondary; major revision (nasal tip work and osteotomies) | California PPO Prior Authorization List, Pg 4 Original policy |
| 30999 | Unlisted procedure, nose [when specified as rhinophototherapy, intranasal application of ultraviolet and visible light] or [when specified as nasal valve suspension by any method] or [when specified as minimally invasive treatment of the posterior nasal nerve, for example using cryotherapy, radiofrequency therapy or laser] | California PPO Prior Authorization List, Pg 4 Original policy |
| 31299 | Unlisted procedure, accessory sinuses [when specified as application of self-expanding absorptive sinus ostial dilator (for example, SinuSys Vent-OS Sinus Dilation System)] or [when specified as insertion of a drug-eluting sinus stent] | California PPO Prior Authorization List, Pg 4 Original policy |
| 32850 | Donor pneumonectomy(s) (including cold preservation), from cadaver donor | California PPO Prior Authorization List, Pg 4 Original policy |
| 32851 | Lung transplant, single; without cardiopulmonary bypass | California PPO Prior Authorization List, Pg 4 Original policy |
| 32852 | Lung transplant, single; with cardiopulmonary bypass | California PPO Prior Authorization List, Pg 4 Original policy |
| 32853 | Lung transplant, double (bilateral sequential or en bloc); without cardiopulmonary bypass | California PPO Prior Authorization List, Pg 4 Original policy |
| 32854 | Lung transplant, double (bilateral sequential or en bloc); with cardiopulmonary bypass | California PPO Prior Authorization List, Pg 4 Original policy |
| 32855 | Backbench standard preparation of cadaver donor lung allograft prior to transplantation, including dissection of allograft from surrounding soft tissues to prepare pulmonary venous/atrial cuff, pulmonary artery, and bronchus; unilateral | California PPO Prior Authorization List, Pg 4 Original policy |
| 32856 | Backbench standard preparation of cadaver donor lung allograft prior to transplantation, including dissection of allograft from surrounding soft tissues to prepare pulmonary venous/atrial cuff, pulmonary artery, and bronchus; bilateral | California PPO Prior Authorization List, Pg 4 Original policy |
| 33141 | Transmyocardial laser revascularization, by thoracotomy; performed at the time of other open cardiac procedure(s) [add- on] | California PPO Prior Authorization List, Pg 4 Original policy |
| 33225 | Insertion of pacing electrode, cardiac venous system, for left ventricular pacing, at time of insertion of pacing cardioverter- defibrillator or pacemaker pulse generator (including upgrade to dual chamber system) | California PPO Prior Authorization List, Pg 4 Original policy |
| 33367 | Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; cardiopulmonary bypass support with percutaneous peripheral arterial and venous cannulation (e.g., femoral vessels) | California PPO Prior Authorization List, Pg 4 Original policy |
| 33368 | Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; cardiopulmonary bypass support with open peripheral arterial and venous cannulation (e.g., femoral, iliac, axillary vessels) | California PPO Prior Authorization List, Pg 4 Original policy |
| 33369 | Transcatheter aortic valve replacement (TAVR/TAVI) with prosthetic valve; cardiopulmonary bypass support with central arterial and venous cannulation (e.g., aorta, right atrium, pulmonary artery) | California PPO Prior Authorization List, Pg 5 Original policy |
| 33418 | Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when performed; initial prosthesis | California PPO Prior Authorization List, Pg 5 Original policy |
| 33419 | Transcatheter mitral valve repair, percutaneous approach, including transseptal puncture when performed; additional prosthesis(es) during same session | California PPO Prior Authorization List, Pg 5 Original policy |
| 33477 | Transcatheter pulmonary valve implantation, percutaneous approach, including pre-stenting of the valve delivery site, when performed | California PPO Prior Authorization List, Pg 5 Original policy |
| 33927 | Implantation of a total replacement heart system (artificial heart) with recipient cardiectomy | California PPO Prior Authorization List, Pg 5 Original policy |
| 33928 | Removal and replacement of total replacement heart system (artificial heart) | California PPO Prior Authorization List, Pg 5 Original policy |
| 33929 | Removal of a total replacement heart system (artificial heart) for heart transplantation | California PPO Prior Authorization List, Pg 5 Original policy |
| 33930 | Donor cardiectomy-pneumonectomy (including cold preservation) | California PPO Prior Authorization List, Pg 5 Original policy |