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Anthem Blue Cross Blue Shield of California prior authorization, page 24

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
0107TQuantitative sensory testing (QST), testing and interpretation per extremity; using vibration stimuli to assess large diameter fiber sensationCalifornia PPO Prior Authorization List, Pg 51 Original policy
0108TQuantitative sensory testing (QST), testing and interpretation per extremity; using cooling stimuli to assess small nerve fiber sensation and hyperalgesiaCalifornia PPO Prior Authorization List, Pg 51 Original policy
0109TQuantitative sensory testing (QST), testing and interpretation per extremity; using heat-pain stimuli to assess small nerve fiber sensation and hyperalgesiaCalifornia PPO Prior Authorization List, Pg 51 Original policy
0110TQuantitative sensory testing (QST), testing and interpretation per extremity; using other stimuli to assess sensationCalifornia PPO Prior Authorization List, Pg 51 Original policy
0207TEvacuation of meibomian glands, automated, using heat and intermittent pressure, unilateralCalifornia PPO Prior Authorization List, Pg 51 Original policy
0253TInsertion of anterior segment aqueous drainage device, without extraocular reservoir, internal approach, into the suprachoroidal spaceCalifornia PPO Prior Authorization List, Pg 51 Original policy
0274TPercutaneous laminotomy/laminectomy (intralaminar approach) for decompression of neural elements, (with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy) any method under indirect image guidance (e.g., fluoroscopic, CT), single or multiple levels, unilateral or bilateral; cervical or thoracicCalifornia PPO Prior Authorization List, Pg 51 Original policy
0278TTranscutaneous electrical modulation pain reprocessing (e.g., scrambler therapy), each treatment session (includes placement of electrodes)California PPO Prior Authorization List, Pg 51 Original policy
0329TMonitoring of intraocular pressure for 24 hours or longer, unilateral or bilateral, with interpretation and reportCalifornia PPO Prior Authorization List, Pg 51 Original policy
0330TTear film imaging, unilateral or bilateral, with interpretation and reportCalifornia PPO Prior Authorization List, Pg 51 Original policy
0331TMyocardial sympathetic innervation imaging, planar qualitative and quantitative assessmentCalifornia PPO Prior Authorization List, Pg 51 Original policy
0332TMyocardial sympathetic innervation imaging, planar qualitative and quantitative assessment; with tomographic SPECTCalifornia PPO Prior Authorization List, Pg 51 Original policy
0335TInsertion of sinus tarsi implantCalifornia PPO Prior Authorization List, Pg 51 Original policy
0338TTranscatheter renal sympathetic denervation, percutaneous approach including arterial puncture, selective catheter placement(s) renal artery(ies), fluoroscopy, contrast injection(s), intraprocedural roadmapping and radiological supervision and interpretation, including pressure gradient measurements, flush aortogram and diagnostic renal angiography when performed; unilateralCalifornia PPO Prior Authorization List, Pg 51 Original policy
0339TTranscatheter renal sympathetic denervation, percutaneous approach including arterial puncture, selective catheter placement(s) renal artery(ies), fluoroscopy, contrast injection(s), intraprocedural roadmapping and radiological supervision and interpretation, including pressure gradient measurements, flush aortogram and diagnostic renal angiography when performed; bilateralCalifornia PPO Prior Authorization List, Pg 51 Original policy
0351TOptical coherence tomography of breast or axillary lymph node, excised tissue, each specimen; real-time intraoperativeCalifornia PPO Prior Authorization List, Pg 52 Original policy
0352TOptical coherence tomography of breast or axillary lymph node, excised tissue, each specimen; interpretation and report, real-time or referredCalifornia PPO Prior Authorization List, Pg 52 Original policy
0353TOptical coherence tomography of breast, surgical cavity; real- time intraoperativeCalifornia PPO Prior Authorization List, Pg 52 Original policy
0354TOptical coherence tomography of breast, surgical cavity; interpretation and report, real-time or referredCalifornia PPO Prior Authorization List, Pg 52 Original policy
0378TVisual field assessment, with concurrent real time data analysis and accessible data storage with patient initiated data transmitted to a remote surveillance center for up to 30 days; review and interpretation with report by a physician or other qualified health care professionalCalifornia PPO Prior Authorization List, Pg 52 Original policy
0379TVisual field assessment, with concurrent real time data analysis and accessible data storage with patient initiated data transmitted to a remote surveillance center for up to 30 days; technical support and patient instructions, surveillance, analysis and transmission of daily and emergent data reports as prescribed by a physician or other qualified health care professionalCalifornia PPO Prior Authorization List, Pg 52 Original policy
0408TInsertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic parameters; pulse generator with transvenous electrodesCalifornia PPO Prior Authorization List, Pg 52 Original policy
0409TInsertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic parameters; pulse generator onlyCalifornia PPO Prior Authorization List, Pg 52 Original policy
0410TInsertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic parameters; atrial electrode onlyCalifornia PPO Prior Authorization List, Pg 52 Original policy
0411TInsertion or replacement of permanent cardiac contractility modulation system, including contractility evaluation when performed, and programming of sensing and therapeutic parameters; ventricular electrode onlyCalifornia PPO Prior Authorization List, Pg 52 Original policy
0412TRemoval of permanent cardiac contractility modulation system; pulse generator onlyCalifornia PPO Prior Authorization List, Pg 52 Original policy
0413TRemoval of permanent cardiac contractility modulation system; transvenous electrode (atrial or ventricular)California PPO Prior Authorization List, Pg 52 Original policy
0414TRemoval and replacement of permanent cardiac contractility modulation system pulse generator onlyCalifornia PPO Prior Authorization List, Pg 52 Original policy
0415TRepositioning of previously implanted cardiac contractility modulation transvenous electrode, (atrial or ventricular lead)California PPO Prior Authorization List, Pg 52 Original policy
0416TRelocation of skin pocket for implanted cardiac contractility modulation pulse generatorCalifornia PPO Prior Authorization List, Pg 52 Original policy
0417TProgramming device evaluation (in person) with iterative adjustment of the implantable device to test the function of the device and select optimal permanent programmed values with analysis, including review and report, implantable cardiac contractility modulation systemCalifornia PPO Prior Authorization List, Pg 52 Original policy
0418TInterrogation device evaluation (in person) with analysis, review and report, includes connection, recording and disconnection per patient encounter; implantable cardiac contractility modulation systemCalifornia PPO Prior Authorization List, Pg 52 Original policy
0449TInsertion of aqueous drainage device, without extraocular reservoir, internal approach, into the subconjunctival space; initial device [XEN Gel Stent]California PPO Prior Authorization List, Pg 52 Original policy
0474TInsertion of anterior segment aqueous drainage device, with creation of intraocular reservoir, internal approach, into the supraciliary space; each additional device [XEN Gel Stent]California PPO Prior Authorization List, Pg 52 Original policy
0489TAutologous adipose-derived regenerative cell therapy for scleroderma in the hands; adipose tissue harvesting, isolation and preparation of harvested cells including incubation with cell dissociation enzymes, removal of non-viable cells and debris, determination of concentration and dilution of regenerative cellsCalifornia PPO Prior Authorization List, Pg 52 Original policy
0490TAutologous adipose-derived regenerative cell therapy for scleroderma in the hands; multiple injections in one or both handsCalifornia PPO Prior Authorization List, Pg 53 Original policy
0505TEndovenous femoral-popliteal arterial revascularization, with transcatheter placement of intravascular stent graft(s) and closure by any method, including percutaneous or open vascular access, ultrasound guidance for vascular access when performed, all catheterization(s) and intraprocedural roadmapping and imaging guidance necessary to complete the intervention, all associated radiological supervision and interpretation, when performed, with crossing of the occlusive lesion in an extraluminal fashionCalifornia PPO Prior Authorization List, Pg 53 Original policy
0510TRemoval of sinus tarsi implantCalifornia PPO Prior Authorization List, Pg 53 Original policy
0511TRemoval and reinsertion of sinus tarsi implantCalifornia PPO Prior Authorization List, Pg 53 Original policy
0512TExtracorporeal shock wave for integumentary wound healing, including topical application and dressing care; initial woundCalifornia PPO Prior Authorization List, Pg 53 Original policy
0515TInsertion of wireless cardiac stimulator for left ventricular pacing, including device interrogation and programming, and imaging supervision and interpretation, when performed; complete system (includes electrode and generator [transmitter and battery])California PPO Prior Authorization List, Pg 53 Original policy
0516TInsertion of wireless cardiac stimulator for left ventricular pacing, including device interrogation and programming, and imaging supervision and interpretation, when performed; electrode onlyCalifornia PPO Prior Authorization List, Pg 53 Original policy
0517TInsertion of wireless cardiac stimulator for left ventricular pacing, including device interrogation and programming, and imaging supervision and interpretation, when performed; both components of pulse generator (battery and transmitter) onlyCalifornia PPO Prior Authorization List, Pg 53 Original policy
0519TRemoval and replacement of pulse generator for wireless cardiac stimulator for left ventricular pacing; including device interrogation and programming; both components (battery and transmitter)California PPO Prior Authorization List, Pg 53 Original policy
0520TRemoval and replacement of pulse generator for wireless cardiac stimulator for left ventricular pacing; including device interrogation and programming; battery component onlyCalifornia PPO Prior Authorization List, Pg 53 Original policy
0525TInsertion or replacement of intracardiac ischemia monitoring system, including testing of the lead and monitor, initial system programming, and imaging supervision and interpretation; complete system (electrode and implantable monitor)California PPO Prior Authorization List, Pg 53 Original policy
0526TInsertion or replacement of intracardiac ischemia monitoring system, including testing of the lead and monitor, initial system programming, and imaging supervision and interpretation; electrode onlyCalifornia PPO Prior Authorization List, Pg 53 Original policy
0527TInsertion or replacement of intracardiac ischemia monitoring system, including testing of the lead and monitor, initial system programming, and imaging supervision and interpretation; implantable monitor onlyCalifornia PPO Prior Authorization List, Pg 53 Original policy
0528TProgramming device evaluation (in person) of intracardiac ischemia monitoring system with iterative adjustment of programmed values, with analysis, review, and reportCalifornia PPO Prior Authorization List, Pg 53 Original policy
0529TInterrogation device evaluation (in person) of intracardiac ischemia monitoring system with analysis, review, and reportCalifornia PPO Prior Authorization List, Pg 53 Original policy

Sources

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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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