Anthem Blue Cross Blue Shield of California prior authorization, page 21
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 |
|---|---|---|
| 62281 | Injection/infusion of neurolytic substance (e.g., alcohol, phenol, iced saline solutions), with or without other therapeutic substance; epidural, cervical or thoracic | California PPO Prior Authorization List, Pg 42 Original policy |
| 62282 | Injection/infusion of neurolytic substance (e.g., alcohol, phenol, iced saline solutions), with or without other therapeutic substance; epidural, lumbar, sacral (caudal) | California PPO Prior Authorization List, Pg 42 Original policy |
| 62287 | Decompression, percutaneous, of nucleus pulposus of intervertebral disc, any method utilizing needle based technique to remove disc material under fluoroscopic imaging or other form of indirect visualization, with discography and/or epidural injection(s) at the treated level(s), when performed, single or multiple levels, lumbar | California PPO Prior Authorization List, Pg 42 Original policy |
| 62291 | Injection procedure for discography, each level; cervical or thoracic | California PPO Prior Authorization List, Pg 42 Original policy |
| 62361 | Implantation or replacement of device for intrathecal or epidural drug infusion; nonprogrammable pump | California PPO Prior Authorization List, Pg 42 Original policy |
| 62362 | Implantation or replacement of device for intrathecal or epidural drug infusion; programmable pump, including preparation of pump, with or without programming | California PPO Prior Authorization List, Pg 42 Original policy |
| 64405 | Injection(s), anesthetic agent(s) and/or steroid; greater occipital nerve | California PPO Prior Authorization List, Pg 42 Original policy |
| 64415 | Injection(s), anesthetic agent(s) and/or steroid; brachial plexus, including imaging guidance, when performed | California PPO Prior Authorization List, Pg 42 Original policy |
| 64417 | Injection(s), anesthetic agent(s) and/or steroid; axillary nerve, including imaging guidance, when performed | California PPO Prior Authorization List, Pg 42 Original policy |
| 64447 | Injection(s), anesthetic agent(s) and/or steroid; femoral nerve, including imaging guidance, when performed | California PPO Prior Authorization List, Pg 42 Original policy |
| 64450 | Injection(s), anesthetic agent(s) and/or steroid; other peripheral nerve or branch | California PPO Prior Authorization List, Pg 42 Original policy |
| 64454 | Injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, including imaging guidance, when performed | California PPO Prior Authorization List, Pg 42 Original policy |
| 64510 | Injection, anesthetic agent; stellate ganglion (cervical sympathetic) | California PPO Prior Authorization List, Pg 42 Original policy |
| 64520 | Injection, Anesthetic Agent; Lumbar/Thoracic (Paravertebral Sympathetic) | California PPO Prior Authorization List, Pg 43 Original policy |
| 64553 | Percutaneous implantation of neurostimulator electrodes; cranial nerve | California PPO Prior Authorization List, Pg 43 Original policy |
| 64555 | Percutaneous implantation of neurostimulator electrodes; peripheral nerve (excludes sacral nerve) | California PPO Prior Authorization List, Pg 43 Original policy |
| 64561 | Percutaneous implantation of neurostimulator electrodes; sacral nerve (transforaminal placement) | California PPO Prior Authorization List, Pg 43 Original policy |
| 64568 | Open implantation of cranial nerve (e.g., vagus nerve) neurostimulator electrode array and pulse generator | California PPO Prior Authorization List, Pg 43 Original policy |
| 64569 | Revision or replacement of cranial nerve (e.g., vagus nerve) neurostimulator electrode array, including connection to existing pulse generator | California PPO Prior Authorization List, Pg 43 Original policy |
| 64575 | Open implantation of neurostimulator electrodes; peripheral nerve (excludes sacral nerve) [when specified as phrenic nerve stimulator for CG-MED-79] | California PPO Prior Authorization List, Pg 43 Original policy |
| 64581 | Open implantation of neurostimulator electrode array; sacral nerve (transforaminal placement) | California PPO Prior Authorization List, Pg 43 Original policy |
| 64585 | Revision or removal of peripheral neurostimulator electrode array [when specified as a sacral nerve stimulator] | California PPO Prior Authorization List, Pg 43 Original policy |
| 64590 | Insertion or replacement of peripheral, sacral, or gastric neurostimulator pulse generator or receiver, requiring pocket creation and connection between electrode array and pulse generator or receiver [when specified as phrenic nerve stimulator for CG-MED-79] or [when specified as sacral nerve stimulator for CG-SURG-95] | California PPO Prior Authorization List, Pg 43 Original policy |
| 64596 | Insertion or replacement of percutaneous electrode array, peripheral nerve, with integrated neurostimulator, including imaging guidance, when performed; initial electrode array | California PPO Prior Authorization List, Pg 43 Original policy |
| 64597 | Insertion or replacement of percutaneous electrode array, peripheral nerve, with integrated neurostimulator, including imaging guidance, when performed; each additional electrode array (List separately in addition to code for primary procedure) | California PPO Prior Authorization List, Pg 43 Original policy |
| 64624 | Destruction by neurolytic agent, genicular nerve branches including imaging guidance, when performed | California PPO Prior Authorization List, Pg 43 Original policy |
| 64628 | Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; first 2 vertebral bodies, lumbar or sacral | California PPO Prior Authorization List, Pg 43 Original policy |
| 64629 | Thermal destruction of intraosseous basivertebral nerve, including all imaging guidance; each additional vertebral body, lumbar or sacral (List separately in addition to code for primary procedure) | California PPO Prior Authorization List, Pg 43 Original policy |
| 64640 | Destruction by neurolytic agent; other peripheral nerve or branch | California PPO Prior Authorization List, Pg 43 Original policy |
| 64654 | Initial open implantation of baroreflex activation therapy (BAT) modulation system, including lead placement onto the carotid sinus, lead tunnelling, connection to a pulse generator placed in a distant subcutaneous pocket (i.e., total system), and intraoperative interrogation and programming | California PPO Prior Authorization List, Pg 43 Original policy |
| 64655 | Revision or replacement of baroreflex activation therapy (BAT) modulation system, with intraoperative interrogation and programming; lead only | California PPO Prior Authorization List, Pg 43 Original policy |
| 64656 | Revision or replacement of baroreflex activation therapy (BAT) modulation system, with intraoperative interrogation and programming; pulse generator only | California PPO Prior Authorization List, Pg 43 Original policy |
| 64657 | Removal of baroreflex activation therapy (BAT) modulation system; total system, including lead and pulse generator | California PPO Prior Authorization List, Pg 43 Original policy |
| 64658 | Removal of baroreflex activation therapy (BAT) modulation system; lead only | California PPO Prior Authorization List, Pg 43 Original policy |
| 64659 | Removal of baroreflex activation therapy (BAT) modulation system; pulse generator only | California PPO Prior Authorization List, Pg 44 Original policy |
| 64716 | Neuroplasty and/or transposition; cranial nerve (specify) | California PPO Prior Authorization List, Pg 44 Original policy |
| 64722 | Decompression; unspecified nerve(s) [for example, occipital nerve] | California PPO Prior Authorization List, Pg 44 Original policy |
| 64732 | Transection or avulsion of; supraorbital nerve | California PPO Prior Authorization List, Pg 44 Original policy |
| 64734 | Transection or avulsion of; infraorbital nerve | California PPO Prior Authorization List, Pg 44 Original policy |
| 64744 | Transection or avulsion of; greater occipital nerve | California PPO Prior Authorization List, Pg 44 Original policy |
| 64771 | Transection or avulsion of other cranial nerve, extradural | California PPO Prior Authorization List, Pg 44 Original policy |
| 64772 | Transection or avulsion of other spinal nerve, extradural | California PPO Prior Authorization List, Pg 44 Original policy |
| 66174 | Transluminal dilation of aqueous outflow canal (e.g., canaloplasty); without retention of device or stent | California PPO Prior Authorization List, Pg 44 Original policy |
| 66175 | Transluminal dilation of aqueous outflow canal (e.g., canaloplasty); with retention of device or stent | California PPO Prior Authorization List, Pg 44 Original policy |
| 66183 | Insertion of anterior segment aqueous drainage device, without extraocular reservoir, external approach [when specified as Ex-PRESS Glaucoma Filtration Device] | California PPO Prior Authorization List, Pg 44 Original policy |
| 66683 | Implantation of iris prosthesis, including suture fixation and repair or removal of iris, when performed | California PPO Prior Authorization List, Pg 44 Original policy |
| 66833 | Implantation of iris prosthesis, including suture fixation and repair or removal of iris, when performed | California PPO Prior Authorization List, Pg 44 Original policy |
| 66989 | Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract surgery (e.g., iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage; with insertion of intraocular (e.g., trabecular meshwork, supraciliary, suprachoroidal) anterior segment aqueous drainage device, without extraocular reservoir, internal | California PPO Prior Authorization List, Pg 44 Original policy |
| 66991 | aEpxptrraocaacphs, uolanre coart amraocret removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (e.g., irrigation and aspiration or phacoemulsification); with insertion of intraocular (e.g., trabecular meshwork, supraciliary, suprachoroidal) anterior segment aqueous drainage device, without extraocular reservoir, internal approach, one or more | California PPO Prior Authorization List, Pg 44 Original policy |
| 67900 | Repair of brow ptosis (supraciliary, mid-forehead or coronal approach) | California PPO Prior Authorization List, Pg 44 Original policy |