Anthem Blue Cross Blue Shield of California prior authorization, page 20
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 |
|---|---|---|
| 43229 | Esophagoscopy, flexible, transoral; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed) | California PPO Prior Authorization List, Pg 39 Original policy |
| 43270 | Esophagogastroduodenoscopy, flexible transoral; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed) [other than ablation related to Barrett’s esophagus] | California PPO Prior Authorization List, Pg 39 Original policy |
| 43284 | Laparoscopy, surgical, esophageal sphincter augmentation procedure, placement of sphincter augmentation device (i.e., magnetic band), including cruroplasty when performed | California PPO Prior Authorization List, Pg 39 Original policy |
| 43285 | Removal of esophageal sphincter augmentation device | California PPO Prior Authorization List, Pg 39 Original policy |
| 43290 | Esophagogastroduodenoscopy, flexible, transoral; with deployment of intragastric bariatric balloon | California PPO Prior Authorization List, Pg 39 Original policy |
| 43291 | Esophagogastroduodenoscopy, flexible, transoral; with removal of intragastric bariatric balloon(s) | California PPO Prior Authorization List, Pg 39 Original policy |
| 43770 | Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device (e.g., gastric band and subcutaneous port components) | California PPO Prior Authorization List, Pg 40 Original policy |
| 43772 | Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device component only | California PPO Prior Authorization List, Pg 40 Original policy |
| 43773 | Laparoscopy, surgical, gastric restrictive procedure; removal and replacement of adjustable gastric restrictive device component only | California PPO Prior Authorization List, Pg 40 Original policy |
| 43774 | Laparoscopy, surgical, gastric restrictive procedure; removal of adjustable gastric restrictive device and subcutaneous port components | California PPO Prior Authorization List, Pg 40 Original policy |
| 43842 | Gastric restrictive procedure, without gastric bypass, for morbid obesity; vertical-banded gastroplasty | California PPO Prior Authorization List, Pg 40 Original policy |
| 43886 | Gastric restrictive procedure, open; revision of subcutaneous port component only | California PPO Prior Authorization List, Pg 40 Original policy |
| 43887 | Gastric restrictive procedure, open; removal of subcutaneous port component only | California PPO Prior Authorization List, Pg 40 Original policy |
| 43888 | Gastric restrictive procedure, open; removal and replacement of subcutaneous port component only | California PPO Prior Authorization List, Pg 40 Original policy |
| 43999 | Unlisted procedure, stomach [when specified as bariatric arterial embolization, endoluminal gastric restrictive surgery, placement of intragastric balloon device, or aspiration therapy] or [when specified as transendoscopic (peroral) gastric myotomy G-POEM] | California PPO Prior Authorization List, Pg 40 Original policy |
| 46707 | Repair of anorectal fistula with plug (e.g., porcine small intestine submucosa [SIS]) | California PPO Prior Authorization List, Pg 40 Original policy |
| 46948 | Hemorrhoidectomy, internal, by transanal hemorrhoidal dearterialization, 2 or more hemorrhoid columns/groups, including ultrasound guidance, with mucopexy, when performed | California PPO Prior Authorization List, Pg 40 Original policy |
| 50542 | Laparoscopy, surgical; ablation of renal mass lesion(s) | California PPO Prior Authorization List, Pg 40 Original policy |
| 50592 | Ablation, 1 or more renal tumor(s), percutaneous, unilateral, radiofrequency | California PPO Prior Authorization List, Pg 40 Original policy |
| 50593 | Ablation, renal tumor(s), unilateral, percutaneous, cryotherapy | California PPO Prior Authorization List, Pg 41 Original policy |
| 53850 | Transurethral destruction of prostate tissue; by microwave thermotherapy | California PPO Prior Authorization List, Pg 41 Original policy |
| 53852 | Transurethral destruction of prostate tissue; by radiofrequency thermotherapy | California PPO Prior Authorization List, Pg 41 Original policy |
| 54360 | Plastic operation on penis to correct angulation | California PPO Prior Authorization List, Pg 41 Original policy |
| 55880 | Ablation of malignant prostate tissue, transrectal, with high intensity-focused ultrasound (HIFU), including ultrasound guidance | California PPO Prior Authorization List, Pg 41 Original policy |
| 55873 | Cryosurgical ablation of the prostate (includes ultrasonic guidance for interstitial cryosurgical probe placement) | California PPO Prior Authorization List, Pg 41 Original policy |
| 56810 | Perineoplasty, repair of perineum, nonobstetrical (separate procedure) | California PPO Prior Authorization List, Pg 41 Original policy |
| 58260 | Vaginal hysterectomy, for uterus 250 g or less | California PPO Prior Authorization List, Pg 41 Original policy |
| 58262 | Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s), and/or ovary(s) | California PPO Prior Authorization List, Pg 41 Original policy |
| 58263 | Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s), and/or ovary(s), with repair of enterocele | California PPO Prior Authorization List, Pg 41 Original policy |
| 58270 | Vaginal hysterectomy, for uterus 250 g or less; with repair of enterocele | California PPO Prior Authorization List, Pg 41 Original policy |
| 58290 | Vaginal hysterectomy, for uterus greater than 250 g | California PPO Prior Authorization List, Pg 41 Original policy |
| 58291 | Vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s) | California PPO Prior Authorization List, Pg 41 Original policy |
| 58292 | Vaginal hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s), with repair of enterocele | California PPO Prior Authorization List, Pg 41 Original policy |
| 58294 | Vaginal hysterectomy, for uterus greater than 250 g; with repair of enterocele | California PPO Prior Authorization List, Pg 41 Original policy |
| 58541 | Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less | California PPO Prior Authorization List, Pg 41 Original policy |
| 58542 | Laparoscopy, surgical, supracervical hysterectomy, for uterus 250 g or less; with removal of tube(s) and/or ovary(s) | California PPO Prior Authorization List, Pg 41 Original policy |
| 58543 | Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g | California PPO Prior Authorization List, Pg 41 Original policy |
| 58544 | Laparoscopy, surgical, supracervical hysterectomy, for uterus greater than 250 g; with removal of tube(s) and/or ovary(s) | California PPO Prior Authorization List, Pg 41 Original policy |
| 58545 | Laparoscopy, surgical, myomectomy, excision; 1 to 4 intramural myomas with total weight of 250 g or less and/or removal of surface myomas | California PPO Prior Authorization List, Pg 41 Original policy |
| 58546 | Laparoscopy, surgical, myomectomy, excision; 5 or more intramural myomas and/or intramural myomas with total weight greater than 250 g | California PPO Prior Authorization List, Pg 41 Original policy |
| 58550 | Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 g or less | California PPO Prior Authorization List, Pg 41 Original policy |
| 58553 | Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 g | California PPO Prior Authorization List, Pg 41 Original policy |
| 58580 | Transcervical ablation of uterine fibroid(s), including intraoperative ultrasound guidance and monitoring, radiofrequency | California PPO Prior Authorization List, Pg 42 Original policy |
| 58674 | Laparoscopy, surgical, ablation of uterine fibroid(s) including intraoperative ultrasound guidance and monitoring, radiofrequency | California PPO Prior Authorization List, Pg 42 Original policy |
| 61215 | Insertion of subcutaneous reservoir, pump or continuous infusion system for connection to ventricular catheter | California PPO Prior Authorization List, Pg 42 Original policy |
| 61715 | Magnetic resonance image guided high intensity focused ultrasound (MRgFUS), stereotactic ablation of target, intracranial, including stereotactic navigation and frame placement, when performed | California PPO Prior Authorization List, Pg 42 Original policy |
| 61885 | Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array | California PPO Prior Authorization List, Pg 42 Original policy |
| 62330 | Decompression, percutaneous, with partial removal of the ligamentum flavum, including laminotomy for access, epidurography, and imaging guidance (i.e., CT or fluoroscopy), bilateral; one interspace, lumbar | California PPO Prior Authorization List, Pg 42 Original policy |
| 62263 | Percutaneous lysis of epidural adhesions using solution injection (e.g., hypertonic saline, enzyme) or mechanical means (e.g., catheter) including radiologic localization (includes contrast when administered), multiple adhesiolysis sessions; 2 or more days | California PPO Prior Authorization List, Pg 42 Original policy |
| 62264 | Percutaneous lysis of epidural adhesions using solution injection (e.g., hypertonic saline, enzyme) or mechanical means (e.g., catheter) including radiologic localization (includes contrast when administered), multiple adhesiolysis sessions; 1 day | California PPO Prior Authorization List, Pg 42 Original policy |