Anthem Blue Cross Blue Shield of California prior authorization, page 25
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 |
|---|---|---|
| 0530T | Removal of intracardiac ischemia monitoring system, including all imaging supervision and interpretation; complete system (electrode and implantable monitor) | California PPO Prior Authorization List, Pg 53 Original policy |
| 0531T | Removal of intracardiac ischemia monitoring system, including all imaging supervision and interpretation; electrode only | California PPO Prior Authorization List, Pg 53 Original policy |
| 0532T | Removal of intracardiac ischemia monitoring system, including all imaging supervision and interpretation; implantable monitor only | California PPO Prior Authorization List, Pg 53 Original policy |
| 0546T | Radiofrequency spectroscopy, real time, intraoperative margin assessment, at the time of partial mastectomy, with report | California PPO Prior Authorization List, Pg 53 Original policy |
| 0563T | Evacuation of meibomian glands, using heat delivered through wearable, open-eye eyelid treatment devices and manual gland expression, bilateral | California PPO Prior Authorization List, Pg 53 Original policy |
| 0565T | Autologous cellular implant derived from adipose tissue for the treatment of osteoarthritis of the knees; tissue harvesting and cellular implant creation | California PPO Prior Authorization List, Pg 53 Original policy |
| 0566T | Autologous cellular implant derived from adipose tissue for the treatment of osteoarthritis of the knees; injection of cellular implant into knee joint including ultrasound guidance, unilateral | California PPO Prior Authorization List, Pg 54 Original policy |
| 0581T | Ablation, malignant breast tumor(s), percutaneous, cryotherapy, including imaging guidance when performed, unilateral | California PPO Prior Authorization List, Pg 54 Original policy |
| 0600T | Ablation, irreversible electroporation; 1 or more tumors per organ, other than liver or prostate, including imaging guidance, when performed, percutaneous | California PPO Prior Authorization List, Pg 54 Original policy |
| 0601T | Ablation, irreversible electroporation; 1 or more tumors, including fluoroscopic and ultrasound guidance, when performed, open | California PPO Prior Authorization List, Pg 54 Original policy |
| 0607T | Remote monitoring of an external continuous pulmonary fluid monitoring system, including measurement of radiofrequency- derived pulmonary fluid levels, heart rate, respiration rate, activity, posture, and cardiovascular rhythm (e.g., ECG data), transmitted to a remote 24-hour attended surveillance center; set-up and patient education on use of equipment | California PPO Prior Authorization List, Pg 54 Original policy |
| 0608T | Remote monitoring of an external continuous pulmonary fluid monitoring system, including measurement of radiofrequency- derived pulmonary fluid levels, heart rate, respiration rate, activity, posture, and cardiovascular rhythm (e.g., ECG data), transmitted to a remote 24-hour attended surveillance center; analysis of data received and transmission of reports to the physician or other qualified health care professional | California PPO Prior Authorization List, Pg 54 Original policy |
| 0615T | Automated analysis of binocular eye movements without spatial calibration, including disconjugacy, saccades, and pupillary dynamics for the assessment of concussion, with interpretation and report | California PPO Prior Authorization List, Pg 54 Original policy |
| 0620T | Endovascular venous arterialization, tibial or peroneal vein, 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 road mapping and imaging guidance necessary to complete the intervention, all associated radiological supervision and interpretation, when performed | California PPO Prior Authorization List, Pg 54 Original policy |
| 0655T | Transperineal focal laser ablation of malignant prostate tissue, including transrectal imaging guidance, with MR-fused images or other enhanced ultrasound imaging | California PPO Prior Authorization List, Pg 54 Original policy |
| 0658T | Electrical impedance spectroscopy of 1 or more skin lesions for automated melanoma risk score | California PPO Prior Authorization List, Pg 54 Original policy |
| 0671T | Insertion of anterior segment aqueous drainage device into the trabecular meshwork, without external reservoir, and without concomitant cataract removal, one or more | California PPO Prior Authorization List, Pg 54 Original policy |
| 0673T | Ablation, benign thyroid nodule(s), percutaneous, laser, including imaging guidance | California PPO Prior Authorization List, Pg 54 Original policy |
| 0689T | Quantitative ultrasound tissue characterization (nonelastographic), including interpretation and report, obtained without diagnostic ultrasound examination of the same anatomy (e.g., organ, gland, tissue, target structure) | California PPO Prior Authorization List, Pg 54 Original policy |
| 0700T | Molecular fluorescent imaging of suspicious nevus; first lesion | California PPO Prior Authorization List, Pg 54 Original policy |
| 0701T | Molecular fluorescent imaging of suspicious nevus; each additional lesion | California PPO Prior Authorization List, Pg 54 Original policy |
| 0717T | Autologous adipose-derived regenerative cell (ADRC) therapy for partial thickness rotator cuff tear; adipose tissue harvesting, isolation and preparation of harvested cells, including incubation with cell dissociation enzymes, filtration, washing and concentration of ADRCs | California PPO Prior Authorization List, Pg 54 Original policy |
| 0718T | Autologous adipose-derived regenerative cell (ADRC) therapy for partial thickness rotator cuff tear; injection into supraspinatus tendon including ultrasound guidance, unilateral | California PPO Prior Authorization List, Pg 54 Original policy |
| 0736T | Colonic lavage, 35 or more liters of water, gravity-fed, with induced defecation, including insertion of rectal catheter | California PPO Prior Authorization List, Pg 54 Original policy |
| 0745T | Cardiac focal ablation utilizing radiation therapy for arrhythmia; noninvasive arrhythmia localization and mapping of arrhythmia site (nidus), derived from anatomical image data (e.g., CT, MRI, or myocardial perfusion scan) and electrical data (e.g., 12-lead ECG data), and identification of areas of avoidance | California PPO Prior Authorization List, Pg 54 Original policy |
| 0746T | Cardiac focal ablation utilizing radiation therapy for arrhythmia; conversion of arrhythmia localization and mapping of arrhythmia site (nidus) into a multidimensional radiation treatment plan | California PPO Prior Authorization List, Pg 55 Original policy |
| 0747T | Cardiac focal ablation utilizing radiation therapy for arrhythmia; delivery of radiation therapy, arrhythmia | California PPO Prior Authorization List, Pg 55 Original policy |
| 0766T | Transcutaneous magnetic stimulation by focused low- frequency electromagnetic pulse, peripheral nerve, with identification and marking of the treatment location, including noninvasive electroneurographic localization (nerve conduction localization), when performed; first nerve | California PPO Prior Authorization List, Pg 55 Original policy |
| 0767T | Transcutaneous magnetic stimulation by focused low- frequency electromagnetic pulse, peripheral nerve, with identification and marking of the treatment location, including noninvasive electroneurographic localization (nerve conduction localization), when performed; each additional nerve | California PPO Prior Authorization List, Pg 55 Original policy |
| 0770T | Virtual reality technology to assist therapy | California PPO Prior Authorization List, Pg 55 Original policy |
| 0771T | Virtual reality (VR) procedural dissociation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the VR procedural dissociation supports, requiring the presence of an independent, trained observer to assist in the monitoring of the patient's level of dissociation or consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older | California PPO Prior Authorization List, Pg 55 Original policy |
| 0772T | Virtual reality (VR) procedural dissociation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the VR procedural dissociation supports, requiring the presence of an independent, trained observer to assist in the monitoring of the patient's level of dissociation or consciousness and physiological status; each additional 15 minutes of intraservice time | California PPO Prior Authorization List, Pg 55 Original policy |
| 0773T | Virtual reality (VR) procedural dissociation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the VR procedural dissociation supports; initial 15 minutes of intraservice time, patient age 5 years or older | California PPO Prior Authorization List, Pg 55 Original policy |
| 0774T | Virtual reality (VR) procedural dissociation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the VR procedural dissociation supports; each additional 15 minutes of intraservice time | California PPO Prior Authorization List, Pg 55 Original policy |
| 0778T | Surface mechanomyography (sMMG) with concurrent application of inertial measurement unit (IMU) sensors for measurement of multi-joint range of motion, posture, gait, and muscle function | California PPO Prior Authorization List, Pg 55 Original policy |
| 0787T | Revision or removal of neurostimulator electrode array, sacral, with integrated neurostimulator | California PPO Prior Authorization List, Pg 55 Original policy |
| 0795T | Transcatheter insertion of permanent dual-chamber leadless pacemaker, including imaging guidance (e.g., fluoroscopy, venous ultrasound, right atrial angiography, right ventriculography, femoral venography) and device evaluation (e.g., interrogation or programming), when performed; complete system (i.e., right atrial and right ventricular pacemaker components) | California PPO Prior Authorization List, Pg 55 Original policy |
| 0796T | Transcatheter insertion of permanent dual-chamber leadless pacemaker, including imaging guidance (e.g., fluoroscopy, venous ultrasound, right atrial angiography, right ventriculography, femoral venography) and device evaluation (e.g., interrogation or programming), when performed; right atrial pacemaker component (when an existing right ventricular single leadless pacemaker exists to create a dual- chamber leadless pacemaker system) | California PPO Prior Authorization List, Pg 55 Original policy |
| 0797T | Transcatheter insertion of permanent dual-chamber leadless pacemaker, including imaging guidance (e.g., fluoroscopy, venous ultrasound, right atrial angiography, right ventriculography, femoral venography) and device evaluation (e.g., interrogation or programming), when performed; right ventricular pacemaker component (when part of a dual- chamber leadless pacemaker system) | California PPO Prior Authorization List, Pg 55 Original policy |
| 0800T | Transcatheter removal of permanent dual-chamber leadless pacemaker, including imaging guidance (e.g., fluoroscopy, venous ultrasound, right atrial angiography, right ventriculography, femoral venography), when performed; right ventricular pacemaker component (when part of a dual- chamber leadless pacemaker system) | California PPO Prior Authorization List, Pg 56 Original policy |
| 0801T | Transcatheter removal and replacement of permanent dual- chamber leadless pacemaker, including imaging guidance (e.g., fluoroscopy, venous ultrasound, right atrial angiography, right ventriculography, femoral venography) and device evaluation (e.g., interrogation or programming), when performed; dual-chamber system (i.e., right atrial and right ventricular pacemaker components) | California PPO Prior Authorization List, Pg 56 Original policy |
| 0802T | Transcatheter removal and replacement of permanent dual- chamber leadless pacemaker, including imaging guidance (e.g., fluoroscopy, venous ultrasound, right atrial angiography, right ventriculography, femoral venography) and device evaluation (e.g., interrogation or programming), when performed; right atrial pacemaker component | California PPO Prior Authorization List, Pg 56 Original policy |
| 0803T | Transcatheter removal and replacement of permanent dual- chamber leadless pacemaker, including imaging guidance (e.g., fluoroscopy, venous ultrasound, right atrial angiography, right ventriculography, femoral venography) and device evaluation (e.g., interrogation or programming), when performed; right ventricular pacemaker component (when part of a dual-chamber leadless pacemaker system) | California PPO Prior Authorization List, Pg 56 Original policy |
| 0823T | Transcatheter insertion of permanent single-chamber leadless pacemaker, right atrial, including imaging guidance (e.g., fluoroscopy, venous ultrasound, right atrial angiography and/or right ventriculography, femoral venography, cavography) and device evaluation (e.g., interrogation or programming), when performed | California PPO Prior Authorization List, Pg 56 Original policy |
| 0824T | Transcatheter removal of permanent single-chamber leadless pacemaker, right atrial, including imaging guidance (e.g., fluoroscopy, venous ultrasound, right atrial angiography and/or right ventriculography, femoral venography, cavography), when performed | California PPO Prior Authorization List, Pg 56 Original policy |
| 0825T | Transcatheter removal and replacement of permanent single- chamber leadless pacemaker, right atrial, including imaging guidance (e.g., fluoroscopy, venous ultrasound, right atrial angiography and/or right ventriculography, femoral venography, cavography) and device evaluation (e.g., interrogation or programming), when performed | California PPO Prior Authorization List, Pg 56 Original policy |
| 0864T | Low-intensity extracorporeal shock wave therapy involving corpus cavernosum, low energy | California PPO Prior Authorization List, Pg 56 Original policy |
| 0935T | Cystourethroscopy with renal pelvic sympathetic denervation, radiofrequency ablation, retrograde ureteral approach, including insertion of guide wire, selective placement of ureteral sheath(s) and multiple conformable electrodes, contrast injection(s), and fluoroscopy, bilateral | California PPO Prior Authorization List, Pg 56 Original policy |
| 0951T | Totally implantable active middle ear hearing implant; initial placement, including mastoidectomy, placement of and attachment to sound processor | California PPO Prior Authorization List, Pg 56 Original policy |
| 0952T | Totally implantable active middle ear hearing implant; revision or replacement, with mastoidectomy and replacement of sound processor | California PPO Prior Authorization List, Pg 56 Original policy |